Menachem P. David

Prevalence and characteristics of voiding difficulties in women: are subjective symptoms substantiated by objective urodynamic data?

OBJECTIVES To examine the prevalence and characteristics of voiding difficulties in women. METHODS Two hundred six consecutive female patients who attended a urogynecology clinic were recruited. Patients were interviewed regarding the presence and severity of symptoms that would suggest voiding difficulties (ie, hesitancy, straining to void, weak or prolonged stream, intermittent stream, double voiding, incomplete emptying, reduction, and positional changes to start or complete voiding). Urodynamic evidence of voiding difficulty was considered as a peak flow rate less than 12 mL/s (voided volume greater than 100 mL), or residual urine volume greater than 150 mL, on two or more readings. Residual urinary volume, flow patterns, and pressure-flow parameters were analyzed and compared between symptomatic and asymptomatic patients who had urodynamic parameters of voiding difficulties. RESULTS One hundred twenty-seven (61.7%) women reported having voiding difficulty symptoms; 79 others (38.3%) were free of such symptoms. Urodynamic diagnosis of voiding difficulty was made in 40 women (19.4% of the study population): 27 in the symptomatic group and 13 in the asymptomatic group (21.2% and 16.5%, respectively). Only 1 patient had voiding difficulty due to bladder outlet obstruction. All other cases of low flow rate were due to impaired detrusor contractility. CONCLUSIONS Objective evidence of voiding difficulty may be found in both symptomatic and asymptomatic patients and is usually due to impaired detrusor contractility. The clinical significance of the abnormal flow parameters in asymptomatic patients is unclear.

Sexual function in women attending a urogynecology clinic.

Abstract: The study prospectively evaluated the relationship between sexual dysfunction and urodynamic diagnoses in 100 consecutive female patients referred for urogynecologic evaluation. Sexual function was evaluated by a detailed questionnaire that addressed four phases of the sexual cycle: desire, arousal, orgasm and satisfaction. Each phase of the sexual cycle was assessed separately using a score of 1–4. Total sexual function (TSF) score was calculated by combining the scores of the four examined parameters (range 4–16). Analysis revealed statistically significant (P<0.05) lower TSF scores in patients with detrusor instability (DI) than in those with genuine stress incontinence, sensory urge or mixed urodynamic diagnoses (8.65 ± 4 versus 12.22 ± 3.6, 10.25 ± 4.1 and 11.47 ± 4.1, respectively). Three per cent of the elderly women (>60 years) compared to 29% of the younger women (≤60 years) reported urinary incontinence during sexual activity. Sexual function should therefore be routinely evaluated in women presenting with urinary symptoms.

Stress urinary incontinence: Prevalence among nulliparous compared with primiparous and grand multiparous premenopausal women

The study was conducted to assess the prevalence of stress urinary incontinence in premenopausal nulliparae, primiparae, and grand multiparae, and to examine possible obstetric risk factors. Three hundred consecutive nulliparae, primiparae, and grand multiparae, 20 to 43 years of age, were interviewed during the third postpartum day of their consequent delivery about the symptom of stress urinary incontinence. Women were asked whether they had experienced stress urinary incontinence before, during, or after previous pregnancies and how troubled they were by their incontinence. Details of general and gynecologic history, parity, mode of previous deliveries, and birth weights were sought. Main outcome measures included prevalence of pregnancy‐related and (persistent) nonpregnancy‐related stress urinary incontinence. Prevalence of persistent stress urinary incontinence was significantly higher in grand multiparae compared with nulliparae (21% vs. 5%, respectively; P = 0.0008). Prevalence of persistent stress urinary incontinence among grand multiparae who had been delivered of at least one baby weighing more than 4,000 g was significantly higher than in those who did not (29.4% vs. 16.7%, respectively). The birth weight of the first newborn and operative vaginal delivery were not found to be associated with increased risk of stress urinary incontinence. Grand multiparity was found to be associated with an increased risk of developing persistent stress urinary incontinence during reproductive ages. The delivery of at least one baby weighing more than 4,000 g seems to be a predominant factor. Neurourol. Urodynam. 18:419–425, 1999.

DEVELOPMENT OF POSTOPERATIVE URINARY STRESS INCONTINENCE IN CLINICALLY CONTINENT PATIENTS UNDERGOING PROPHYLACTIC KELLY PLICATION DURING GENITOURINARY PROLAPSE REPAIR

The present study was undertaken to evaluate the efficacy of Kelly plication in preventing postoperative urinary stress incontinence in clinically continent patients undergoing surgery for genitourinary prolapse. Thirty clinically continent patients with grade‐3 genitourinary prolapse were found to have a positive stress test with repositioning of the prolapse during preoperative urodynamic evaluation. In addition to the genitourinary prolapse repair, these patients underwent a Kelly plication as a preventive measure against possible development of postoperative urinary stress incontinence. Postoperative follow‐up included a detailed urogynecologic questionnaire, pelvic examination, urine culture, Q‐tip cotton swab test, and a full urodynamic evaluation. The mean duration of follow‐up was 25.5 ± 14.1 months. Fifteen (50%) patients developed subjective and objective postoperative stress incontinence. Eleven (37%) patients developed objective postoperative stress incontinence (proven by urodynamic evaluation) with no subjective complaints of stress incontinence. Prophylactic Kelly plication as performed by the method described does not appear to be effective in preventing postoperative urinary stress incontinence in clinically continent patients who undergo surgery for genitourinary prolapse. Neurourol. Urodynam. 18:193–198, 1999.

High progesterone levels adversely affect embryo quality and pregnancy rates in in vitro fertilization and oocyte donation programs

OBJECTIVE To assess the effect of P levels on oocyte and embryo quality and pregnancy rates (PRs) in IVF and oocyte donation. DESIGN Retrospective analysis of PRs in ovum donors and their recipients with regard to P levels on day of hCG administration. SETTING In Vitro Fertilization Units, oocyte donation programs. PATIENTS In vitro fertilization patients who agreed to donate oocytes were treated by hMG alone (53 cycles) or in combination with a GnRH analog (122 cycles). INTERVENTIONS Uterine preparation in oocyte recipients consisted of 6 mg/d E2 valerate. Progesterone (100 mg/d) was added when oocytes became available. Hormonal treatment was continued until 12 weeks of gestation. RESULTS Using a series of Fishers Exact Tests, a critical threshold for P was identified at 1.9 ng/mL (conversion factor to SI units, 3.185). With elevated P levels (> 1.9 ng/mL), lower PRs were noted for the donors (7.1% versus 17%), as well for the recipients (8.3% versus 26.7%). CONCLUSIONS Exposure to elevated P levels resulted in lower PRs for the donors and significantly lower PRs in the recipients. Because the endometria in the recipients were prepared uniformly, we conclude that this is the result of detrimental effects of P on oocyte or embryo quality.

Endometrial receptivity in the light of modern assisted reproductive technologies.

OBJECTIVE To review the different aspects of endometrial receptivity as it is reflected in the various modalities of modern assisted reproductive technologies. DESIGN The importance of endometrial receptivity and the factors that affect it such as the type of treatment, age, and ovarian function are discussed in this review. Novel approaches to determine receptivity such as Doppler ultrasonography and molecular biology are considered; assisted hatching is also discussed. CONCLUSIONS Endometrial receptivity cannot, as yet, be directly assessed. Circumstantial evidence suggests that receptivity declines with age, is adversely affected by controlled ovarian hyperstimulation, and is possibly affected by ovarian function. Future studies will have to focus on molecular cell biology and physiology of the endometrium.

Transfer of six or more embryos improves success rates in patients with repeated in vitro fertilization failures.

OBJECTIVE To examine the results of six or more embryos transferred to patients whose IVF-ET cycles repeatedly met with failure. DESIGN Prospective clinical evaluation of pregnancy rates and pregnancy outcome. SETTING IVF-ET Unit. PATIENTS Seventy-two IVF patients who had failed at least four previous IVF cycles. INTERVENTIONS Forty-one patients (group A) received six or more embryos, and 31 patients (group B) chose to receive five embryos. MAIN OUTCOME MEASURES Per embryo implantation rate, pregnancy rate, multiple pregnancies, and outcome were evaluated. RESULTS With the transfer of six or more embryos, the pregnancy rate was significantly higher than with the transfer of five embryos (56% versus 29%, respectively). This was associated with a slight, but insignificant, increase in multiple gestations. No difference in pregnancy outcome was noted among the groups. CONCLUSIONS Patients who have had repeated IVF failures may have higher pregnancy rates if six or more embryos are transferred in subsequent cycles.

The use of prophylactic Stamey bladder neck suspension to prevent post‐operative stress urinary incontinence in clinically continent women undergoing genitourinary prolapse repair

The present study was undertaken to evaluate the efficacy of Stamey bladder neck suspension in preventing post‐perative stress urinary incontinence in clinically continent women undergoing surgery for genitourinary prolapse. Thirty clinically continent women with severe genitourinary prolapse were found to have a positive stress test with re‐positioning of the prolapse. They all had significant urethrovesical junction hypermobility. In addition to the genitourinary prolapse repair, these patients underwent a prophylactic Stamey procedure to prevent the possible development of post‐operative stress urinary incontinence. The mean duration of follow‐up was 8 ± 4.5 months (range, 3–19 months). Seven (23.30%) patients developed overt post‐operative stress urinary incontinence that was confirmed urodynamically. Eleven (36.7%) other patients denied stress incontinence; however, post‐operative urodynamics demonstrated sphincteric incontinence. Post‐operative complications were uncommon and minor. In conclusion, continent patients with a positive stress test demonstrated on re‐positioning of the prolapse during pre‐operative urodynamic evaluation are considered to be at high risk of developing post‐operative stress urinary incontinence. In these patients, an additional, effective anti‐incontinence procedure should be considered during surgical correction of genitourinary prolapse. The Stamey procedure, although simple and safe, does not appear to be the optimal solution to this clinical problem. Neurourol. Urodynam. 19:671–676, 2000.

Uterine preparation with estrogen for oocyte donation: assessing the effect of treatment duration on pregnancy rates

OBJECTIVE To assess the effect of the duration of uterine preparation with E2 on pregnancy rates (PRs) in oocyte donation. DESIGN A retrospective study. SETTING IVF-ET Unit, oocyte donation program. PATIENTS Four hundred eleven patients undergoing 865 ET cycles after oocyte donation. Uterine preparation consisted of 6 mg/d E2 valerate. The duration of treatment varied according to the availability of the oocytes for donation. Progesterone, 100 mg/d, was added upon oocyte retrieval. Patients were divided into seven groups according to the duration of uterine preparation with E2, in 5-day ranks. MAIN OUTCOME MEASURES Pregnancy rates per ET according to the duration of uterine preparation. RESULTS No differences were noted in the mean age, number of oocytes received, fertilization rates, or number of embryos transferred when comparing all groups. Pregnancy rates ranged from 19% to 27% for E2 treatment of 5 to 35 days. CONCLUSION Endometrial preparation in anonymous oocyte donation programs is achieved with continuous administration of E2 until oocytes become available. Our results show that this treatment may be extended for as long as 5 weeks with no significant decrease in PRs.

In vitro fertilization and oocyte donation in women 45 years of age and older

OBJECTIVE To assess the reproductive potential in women > or = 45 years of age. DESIGN Retrospective analysis. SETTING In vitro fertilization-embryo transfer unit, standard IVF and oocyte donation programs. PATIENTS One hundred twenty-seven patients > or = 45 years old who applied for treatment of infertility. INTERVENTION Thirty-one patients underwent 52 treatment cycles in standard IVF. Ninety-six patients underwent 220 oocyte donation cycles. RESULTS Of the 52 standard IVF cycles, oocytes were retrieved successfully in only 32. Of these, fertilization and ET were performed in 21 cycles. None of these treatment cycles resulted in a clinical pregnancy. Of the 220 oocyte donation cycles, fertilization and ET were accomplished in 189 cycles. These resulted in 33 (17.5% per transfer) clinical pregnancies. CONCLUSIONS These results suggest that oocyte donation may extend the reproductive potential in women > or = 45 years old when little hope is offered by standard IVF.