Marjan Attaran

Vitamin C and vitamin E supplementation reduce oxidative stress–induced embryo toxicity and improve the blastocyst development rate

To evaluate the adverse effects of exogenously induced reactive oxygen species (ROS) on mouse embryo development by using the 12-phorbol 13-myristate acetate (PMA)-activated leukocyte model as a source of ROS, and to examine the protective effect of antioxidant supplementation (vitamin C and vitamin E). Prospective study. Research laboratory. Effects of ROS on the blastocyst development rate in the presence and absence of antioxidant supplementation. After incubation with the PMA-activated leukocyte supernatant, the median (25th, 75th percentile) rate of blastocyst development significantly decreased from 73% (60%, 80%) after 3 hours to 30% (20%, 40%) after 6 hours compared with control reactions (86% [80%, 100%]). Co-incubating the embryos with vitamin C (50 microM) and the PMA-activated supernatant significantly increased the blastocyst development rate from 73% (60%, 80%) to 90% (80%, 91%) at 3 hours and from 30% (20%, 40%) to 91% (89%, 91%) at 6 hours-a level similar to that of control reactions. The blastocyst development rate increased after vitamin E supplementation (400 microM) at 6 hours, but not significantly and not by as much as after vitamin C supplementation. Exposure of mouse embryos to ROS for extended periods results in embryotoxicity. Vitamin C is more effective than vitamin E in reversing ROS-induced mouse embryo toxicity.

Robotically assisted laparoscopic microsurgical uterine horn anastomosis

OBJECTIVE To evaluate the feasibility, safety, and sterility issues with regard to the use of a robotic device to perform uterine horn anastomosis in a live porcine model. DESIGN Prospective animal study. SETTING Landrace-Yorkshire pigs in a conventional laboratory setting. INTERVENTION(S) Six female pigs underwent laparoscopic bipolar electrocoagulation of the distal uterine horns. Two weeks later, the uterine horns were reanastomosed laparoscopically with use of a robotic system for microsuturing. Necropsy was performed 4 weeks later to assess postoperative adhesions and anastomosis patency. MAIN OUTCOME MEASURE(S) Tubal patency; secondary measures were operative time, complications, and surgeon fatigue. RESULT(S) The mean (+/-SD) total operative time per animal was 170+/-34 minutes including setting up and dismantling the robotic arms. The robot functioned well with only minor technical problems. All pigs survived both surgeries with no perioperative complications related to the use of the robot. Patency was confirmed after completing each anastomosis (12 anastomoses; 100% patency). Four weeks later, necropsy showed that eight anastomoses were still patent (67%). Only one pig had bilateral occlusion. Surgeons fatigue was mild for each animal study. CONCLUSION(S) Robotic technology can be used safely in creating laparoscopic microsurgical anastomoses. The robot functioned properly in a sterile operating room environment. Adequate patency rates were achieved during the acute phase and at 4-week follow-up. Robotic technology has the potential to make laparoscopic microsuturing easier.

Protein supplementation and the incidence of apoptosis and oxidative stress in mouse embryos.

OBJECTIVE: To estimate the effect of protein supplementation of culture media on reactive oxygen species production and incidence of apoptosis in preimplantation mouse embryos. METHODS: A total of 72 two-cell mouse embryos were cultured in human tubal fluid (HTF) alone (HTF-alone, control) and 71 embryos in HTF with protein supplementation (10% serum substitute supplement; HTF-SSS) for 72 hours. Total cell number per embryo was determined by staining with Hoechst 33258. Allocation of inner cell mass and trophectoderm in blastocysts and incidence of apoptosis were determined by confocal microscopy. Levels of reactive oxygen species in culture media were measured by chemiluminescence assay using luminol as probe. RESULTS: Blastocyst development, total cell number, and the inner cell mass/trophectoderm ratio were similar between the 2 groups. The blastocyst hatching rate was significantly higher in the HTF-SSS group than in the HTF-alone group (20% compared with 4%, P = .007). Level of reactive oxygen species was significantly higher in HTF-alone compared with HTF-SSS at 24 hours (median and interquartile range 28 [13, 43] compared with 0 [0, 1], P = .02), 48 hours (24 [21, 26] compared with 2 [1, 2], P = .02), and 72 hours (26 [9, 32] compared with 2 [2, 3], P = .03). The incidence of apoptosis in blastocysts cultured in HTF-SSS was significantly lower than those in HTF-alone group (mean ± standard deviation 2.38 ± 0.68 and 5.81 ± 1.11, respectively, P = .001). CONCLUSION: Protein supplementation of culture media improves the hatching rate and reduces reactive oxygen species levels and the incidence of apoptosis in mouse preimplantation embryos.

Laparoscopy for Adnexal Masses in the Second Trimester of Pregnancy

STUDY OBJECTIVE To assess the safety of laparoscopic treatment of adnexal masses in the second trimester of pregnancy. DESIGN Retrospective chart review (Canadian Task Force classification II-3. SETTING Large tertiary care medical center. PATIENTS Eleven women. INTERVENTION Laparoscopic surgery. MEASUREMENTS AND MAIN RESULTS All masses were identified by ultrasound. The average gestational age at the time of surgery was 17 weeks, 4 days. In seven women the primary cannula was inserted in the left upper quadrant of the abdomen. Procedures were eight ovarian cystectomies, two oophorectomies, and one exploratory laparoscopy. Average operating time was 135 minutes (range 95-195 min). Average time exposed to carbon dioxide was 78 minutes (range 59-135 min). None of the masses was malignant. There were no fetal complications or malformations. No patients had preterm labor and all delivered at term. CONCLUSIONS The increasing number of reported cases and our experience suggest that laparoscopic treatment of adnexal masses in the second trimester is safe and effective, but the surgeon must be skilled in advanced techniques of laparoscopic surgery.

Comparison of intrauterine and intracervical insemination with frozen donor sperm: a meta-analysis.

OBJECTIVE To determine whether artificial insemination with frozen donor sperm yielded a higher pregnancy rate per cycle by intracervical (ICI) or intrauterine (IUI) techniques. A meta-analysis was performed. DATA IDENTIFICATION A computerized MEDLINE search of the English-language literature on artificial insemination with donor sperm was performed and augmented by a review of meeting abstract books and references in published papers. STUDY SELECTION Only prospective randomized studies that reported monthly fecundity rates for IUI and ICI with frozen donor sperm were included. DATA ANALYSIS Seven studies were identified. The odds ratios (OR) and 95% confidence intervals (CI) were determined with use of the general estimating equation method for the three studies for which raw data could be obtained. For the remaining four studies, the OR and CI were assessed with use of the published summary data. A random-effects meta-analysis was then performed. RESULT Intrauterine insemination resulted in a significantly higher monthly fecundity rate with a common OR of 2.4 (CI 1.5-3.8). CONCLUSION On the basis of this meta-analysis of the seven prospective studies, IUI results in higher pregnancy rates than ICI for frozen donor insemination.

Delayed blastulation, multinucleation, and expansion grade are independently associated with live-birth rates in frozen blastocyst transfer cycles

OBJECTIVE To identify blastocyst features independently predictive of successful pregnancy and live births with vitrified-warmed blastocysts. DESIGN Retrospective study. SETTING Academic hospital. PATIENT(S) Women undergoing a cycle with transfer of blastocysts vitrified using the Rapid-i closed carrier (n = 358). INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Clinical pregnancy and live-birth rates analyzed using logistic regression analysis. RESULT(S) A total of 669 vitrified-warmed blastocysts were assessed. The survival rate was 95%. A mean of 1.7 ± 0.5 embryos were transferred. The clinical pregnancy, live-birth, and implantation rates were 55%, 46%, and 43%, respectively. The odds of clinical pregnancy (odds ratio [OR] 3.08; 95% confidence interval [CI], 1.88-5.12) and live birth (OR 2.93; 95% CI, 1.79-4.85) were three times higher with day-5 blastocysts versus slower-growing day-6 vitrified blastocysts, irrespective of patient age at cryopreservation. Blastocysts from multinucleated embryos were half as likely to result in a live birth (OR 0.46; 95% CI, 0.22-0.91). A four -fold increase in live birth was observed if an expanded blastocyst was available for transfer. The inner cell mass-trophectoderm score correlated to positive outcomes in the univariate analysis. The implantation rate was statistically significantly higher for day-5 versus day-6 vitrified blastocysts (50% vs. 29%, respectively). CONCLUSION(S) The blastocyst expansion grade after warming was predictive of successful outcomes independent of the inner cell mass or trophectoderm score. Delayed blastulation and multinucleation were independently associated with lower live-birth rates in frozen cycles. Implantation potential of the frozen blastocysts available should be included in the decision-making process regarding embryo number for transfer.

Previous fertilization failure with conventional in vitro fertilization is associated with poor outcome of intracytoplasmic sperm injection

OBJECTIVE To evaluate the outcome of intracytoplasmic sperm injection (ICSI) in patients with a history of fertilization failure with conventional IVF. DESIGN Retrospective analysis of 2 years of clinical experience with ICSI. SETTING Clinical IVF-ET program in a tertiary care referral center. PATIENT(S) The results of ICSI performed between January 1995 and December 1996 were compared between patients with normal semen parameters and a history of fertilization failure (< 20% of oocytes) with conventional IVF and patients with male factor infertility. INTERVENTION(S) In vitro fertilization with ICSI. MAIN OUTCOME MEASURE(S) Parameters examined included oocyte survival, fertilization, embryo cleavage, implantation rates, and clinical pregnancy rates. RESULT(S) Fertilization was achieved with ICSI for all patients during the study period. Although oocyte survival and fertilization did not differ between groups, the pregnancy and implantation rates for patients with a history of idiopathic fertilization failure (20% and 6%, respectively) were significantly lower than those for other patients undergoing ICSI (47% and 22%, respectively). CONCLUSION(S) The outcome of ICSI varied depending on the indication for treatment. Patients who had a history of failed or poor fertilization in vitro with apparently normal semen parameters had significantly lower pregnancy and implantation rates than did patients with either obstructive azoospermia or impaired semen quality.

Relationship between cytokines and the embryotoxicity of hydrosalpingeal fluid

Objective: The exact chemical composition of hydrosalpingeal fluid is unknown. The objective of this study was to characterize cytokines in hydrosalpingeal fluid (HSF) and examine their possible role in the embryo development.Study Design: HSF was aspirated at laparoscopic salpingectomy in eight infertile women. Levels of IL-1β, IL-13, IL-8, IL-6 and TNF-α in the HSF were determined by quantitative immunoassay kits. Two-cell mouse embryos were incubated with 0, 25, 50 and 75% concentrations of HSF. The blastocyst development rate (BDR) of mouse embryos was measured at each HSF concentration.Result(s): The embryotoxicity of HSF was concentration dependent. An increase in the HSF concentration resulted in significant decrease in % BDR (p < 0.01). IL-1β was present in six of the eight HSF samples with a mean (± SD) concentration of 0.9 ± 0.8 pg/mL. IL-13 was not detected in any of the HSF samples. IL-8, IL-6 and TNF-α were detected in all samples with a mean (± SD) concentration of 4741.2 ± 6554.4 pg/mL, 204.8± 132.8 pg/ml and 12 ± 12.8 pg/mL respectively. IL-6 was positively correlated with BDR (r = 0.53; p < 0.04).Conclusion(s): We demonstrated for the first time the presence of IL-1β, IL-8, IL-6 and TNF-α and the absence of IL-13 in human hydrosalpingeal fluid. IL-6 was positively related to the BDR.

Residency Training in Pediatric and Adolescent Gynecology Across Obstetrics and Gynecology Residency Programs: A Cross-Sectional Study

STUDY OBJECTIVE To estimate the prevalence of Pediatric and Adolescent Gynecology formal training in the United States Obstetric and Gynecology residency programs. DESIGN Prospective, anonymous, cross-sectional study. PARTICIPANTS United States program directors of Obstetrics and Gynecology residency programs, N = 242; respondents 104 (43%). RESULTS 104 residency programs responded to our survey. Among the 104 residency programs, 63% (n = 65) have no formal, dedicated Pediatric and Adolescent Gynecology clinic, while 83% (n = 87) have no outpatient Pediatric and Adolescent Gynecology rotation. There is no significant difference in the amount of time spent on a Pediatric and Adolescent Gynecology rotation among residents from institutions with a Pediatric and Adolescent Gynecology fellowship (P = .359), however, the number of surgeries performed is significantly higher than those without a Pediatric and Adolescent Gynecology fellowship (P = .0020). When investigating resident competency in Pediatric and Adolescent Gynecology, program directors reported that residents who were taught in a program with a fellowship-trained Pediatric and Adolescent Gynecology faculty were significantly more likely to be able to interpret results of selected tests used to evaluate precocious puberty than those without (P = .03). CONCLUSIONS Residency programs without fellowship trained Pediatric and Adolescent Gynecology faculty or an established Pediatric and Adolescent Gynecology fellowship program may lack formal training and clinical exposure to Pediatric and Adolescent Gynecology. This information enables residency directors to identify deficiencies in their own residency programs and to seek improvement in resident clinical experience in Pediatric and Adolescent training.

Unusual presentation of lichen sclerosuis in an adolescent

Background: The presentation of lichen sclerosus has been described in detail in the adult literature. Typically present with symptoms of itching and soreness in the vulvar area at which time a vulvar evaluation reveals a specific appearance. The presentation is believed to be similar in prepubertal children and adolescents. In this case report we encountered an unusual initial presentation of this disease.Methods: Case presentation.Results: An 18-year-old female presented for the first time to her gynecologist with complaint of difficulty with complete emptying of bladder and dribbling. She had noted the onset of these symptoms two months prior to presentation. She denied any long-term history of vulvar itching or irritation. Her menses were normal with no complaints of dysmenorrhea. Onset of menarche and pubertal development were also normal. She denied any pre-pubertal history of labial adhesions or lichen sclerosis. The patient was not sexually active. She was diagnosed with labial adhesions and her first course of treatment included topical estrogen therapy for 8 weeks. Her second course of therapy included topical testosterone for 6 weeks without any improvement or side effects. On evaluation at our institution the posterior aspect of the labia minora could not be seen and the area of the vaginal introitus was completely obstructed (see picture). The clitoral hood could not be retracted and the surrounding vulva appeared atrophic and white. The degree of obstruction was such that the urethra could not be seen. In the operating room the labia minora were manually separated. The patient applied clobetasol.05% ointment for the next two weeks to the vulva and then switched to a less potent steroid. Follow-up evaluation 2 and 4 weeks after the procedure did not show any adhesions. Punch biopsy was consistent with diagnosis of lichen sclerosis.Conclusion: The presentation of lichen sclerosis may be variable in adolescents; thus, a high index of suspicion must be maintained to make this diagnosis.