Olga Ramón

Epidemiology of endometriosis in infertile women

OBJECTIVE To assess the epidemiological factors linked to endometriosis in infertile women. SETTING Academic tertiary hospital. DESIGN Case-control study. PATIENTS One hundred seventy-four infertile women with endometriosis and 174 infertile women without endometriosis, all of them studied by laparoscopy. RESULTS Women with endometriosis and infertility had a higher frequency of cycles < or = 27 days (26.4% versus 16.7%). A trend to a protective effect of smoking was detected. Social class, reproductive history, infertility history, previous abortions, age, family history, age at menarche, and duration of menstrual flow were similar in both groups. CONCLUSION Cycles < or = 27 days was the only risk factor that seemed to be associated to endometriosis in infertile patients. However, predictive values were low. A trend to a protective effect of smoking was detected.

Recurrence of endometriosis in women with bilateral adnexectomy (with or without total hysterectomy) who received hormone replacement therapy

OBJECTIVE To estimate the risk of recurrence after administration of hormone replacement therapy (HRT) among women who have had endometriosis and who underwent bilateral salpingo-oophorectomy (BSO). DESIGN Prospective randomized trial (115 women receiving HRT and 57 not receiving HRT). SETTING; Public university hospital. PATIENT(S) Women with a histologic diagnosis of endometriosis in whom BSO was performed; 91.8% had a total hysterectomy. INTERVENTION(S) Periodical clinical examination, vaginal ultrasound, and CA-125 levels; surgical evaluation and histologic study. MAIN OUTCOME MEASURE(S) Recurrence rate, prognostic factors, and a mean follow-up time of 45 months. RESULT(S) There was no recurrence among women who did not receive HRT, versus a 3.5% rate (4 out of 115), or 0.9% per year, in women who received HRT. Two recurrences required abdominal surgery. There was one additional patient who required surgery, but the relationship to the endometriosis recurrence was controversial. Among women receiving HRT, the following risk factors were detected: peritoneal involvement > 3 cm (2.4% recurrence per year vs. 0.3%) and incomplete surgery (22.2% per patient vs. 1.9%). CONCLUSION(S) Patients with a history of endometriosis in whom total hysterectomy and bilateral salpingo-oophorectomy have been performed have a low risk of recurrence when HRT is administered. In those patients, HRT is a reasonable option. However, in cases with peritoneal involvement > 3 cm, the recurrence rate makes HRT a controversial option; if HRT is indicated, it should be monitored closely.

Are there any clinical signs and symptoms that are related to endometriosis in infertile women

OBJECTIVE Our purpose was to assess the physical signs and clinical symptoms associated with endometriosis in infertile women. STUDY DESIGN This case-control study was carried out in an academic tertiary hospital. There were 174 infertile women with endometriosis and 174 infertile women without endometriosis, all of them studied by laparoscopy. Before laparoscopy a standard interview and a standard physical examination were performed. RESULTS Cul-de-sac nodularity was more frequent in infertile women with endometriosis than in infertile women without endometriosis (6.3% vs 0%). Although uterosacral tenderness was also more frequent in infertile women with endometriosis (7.5% vs 1.7%), uterosacral tenderness without nodularity was similar in both populations. Uterine retroversion and cul-de-sac obstruction frequencies were somewhat higher in the endometriosis group (p<0.10). The remaining signs and symptoms analyzed, including pelvic pain and dysmenorrhea, were similarly frequent in both populations. Symptoms were similarly frequent in all American Fertility Society stages, although adnexal mass was higher in stage IV. CONCLUSION Uterosacral nodularity was pathognomonic of endometriosis in infertile women. Uterosacral nodularity and uterosacral tenderness (associated with uterosacral nodularity) were the only symptoms or signs of value to indicate endometriosis in infertile patients. The remaining clinical signs, as well as clinical symptoms, were of no value in diagnosing endometriosis in infertile women.

Endometriosis and spontaneous abortion rate: a cohort study in infertile women

OBJECTIVE To ascertain if there is an association between endometriosis and spontaneous abortion. DESIGN Prospective cohort study. SETTING Medical School Hospital. POPULATION 174 infertile women laparoscopically diagnosed with endometriosis and 174 infertile women in which endometriosis was ruled out by laparoscopy, in the same period of time. MAIN OUTCOME MEASURE Spontaneous abortion. Non-progressive gestational sac and/or histological study. RESULTS Per woman abortion rate was 7.47% (13/174) in the endometriosis group, similar to 5.74% (10/174) in the infertile women without endometriosis (RR=1.32: CI=0.53-3.36). Nor were there any differences in the per pregnancy abortion rate: 20.96% (13/62) in endometriosis vs. 16.94% (10/59) in non-endometriosis (RR=1.3; CI=0.47-3.57). The abortion rate was similar in the different AFS stages: 22.86% (8/35) in stage I, 16.67% (3/18) in II, 25% (1/4) in III and 20% (1/5) in IV. In stage I no differences were observed in patients who were managed expectantly or with medical treatment. CONCLUSION Endometriosis is not associated with an increased abortion rate. The severity of disease expressed by AFS staging is not associated with an increase in the abortion rate. In stage I the treatment of endometriosis did not decrease abortion rates.

Intrauterine insemination with frozen sperm increases pregnancy rates in donor insemination cycles under gonadotropin stimulation

OBJECTIVE To compare the efficacy of IUI donor and pericervical insemination donor in frozen sperm insemination cycles under gonadotropin stimulation. DESIGN Couples where infertility was caused by male conditions were randomized into two groups: IUI and pericervical insemination. Semen samples, gonadotropin stimulation, and ovarian monitoring were the same in both groups. One IUI was performed per cycle as against two pericervical inseminations. SETTING The donor insemination program at the Human Reproduction Unit at the Hospital of Cruces, Pais Vasco University. PATIENTS Eighty-eight women (47 IUI and 41 pericervical insemination) with at least one patent fallopian tube and < 40 years of age. MAIN OUTCOME MEASURE Intrauterine gestational sac observed by transvaginal ultrasound. RESULTS Per woman pregnancy rate (PR) was higher in IUI than in pericervical insemination (65.96% versus 41.46%, odds ratio [OR] = 2.73, confidence interval [CI] = 1.06 to 7.2). Pregnancy rates were always higher in IUI irrespective of woman and husbands status, but statistical significance was not reached in any subgroups analyzed independently. Per cycle PR was also significantly higher in IUI than in pericervical insemination: 24.03% (31/129) versus 11.89% (17/143) (OR = 2.34, CI = 1.17 to 4.71). Moreover, cumulative PR was higher in IUI (86% versus 49.5%) (OR = 6, CI = 1.98 to 18.80). CONCLUSION Per woman and per cycle PRs were significantly higher in IUI.

Ultrasound-guided artificial insemination: a randomized controlled trial

BACKGROUND The aim was to ascertain whether using ultrasound guidance during intrauterine insemination (IUI) could increase pregnancy rates (PRs). METHODS The population under study consisted of 73 consecutive couples subjected to IUI in our Human Reproduction Unit, between June and December 2006, with a total of 231 IUI cycles performed. The patients were randomized using a computer-generated random numeric table into two groups: ultrasound-guided IUI group (n = 33) and clinical IUI group (n = 40). RESULTS The PR was 16.0% per cycle in ultrasound-guided IUI and 16.8% in the control group, no statistically significant differences being observed between the groups. The 95% confidence interval for the difference in PRs of 0.8% was -8.8 to 10. There were no differences in PR per woman, nor in first-cycle PR. The cumulative PR was also similar in both populations. Although the initial intention was to perform a study involving a larger number of cases, after a first interim analysis, the study was interrupted due to its futility. There were no differences in PR according to the different cervico-uterine angles. CONCLUSIONS Ultrasound-guided IUI does not produce better results than blind insemination, because the PR per cycle is similar. ClinicalTrials.gov ID NCT00809952.

Prognostic value of serum progesterone and LH values on the day of hCG administration in IUI GnRH antagonist cycles.

Objetive: to evaluate the effect of LH surge and progesterone rise in IUI cycles under gonadotropin stimulation with GnRH antagonist coadministration on pregnancy rates (PR). Study Design: The population under study consisted of 152 women prospectively studied and subjected to IUI. Results The higher the progesterone cutoff value, the lower the PR were 26.5% and 10.9% when the cutoff was 1 ng/mL, 26.0% and 8.6% when the cutoff was 1.2 ng/mL, 25.6% and 7.1% when the cutoff was 1.4 ng/mL and 25.3% and 0% when the cutoff was 1.6 ng/mL. Conclusion: In IUI cycles under GnRH antagonist coadministration, serum progesterone levels over 1.0 ng/mL are associated with lower PR, the higher the progesterone levels, the lower the PR.

Failure of intrauterine insemination as rescue treatment in low responders with adequate HCG timing with no oocytes retrieved

In this retrospective study, the efficiency of carrying out rescue intrauterine insemination (IUI) in low-responder patients undergoing IVF when no oocytes were retrieved after follicular aspiration and when HCG timing was adequate was analysed. A historical control group was used. Over 13 years, women undergoing IVF with failure to obtain oocytes at follicular aspiration underwent rescue IUI if the following criteria were met: adequate HCG timing; one normal tube; motile sperm count after preparation over 3 million/ml; and ultrasound visualization of one to six follicles over 13 mm. The rescue IUI was carried out 1 h after follicular aspiration. Results were compared with those of a standard IUI population (5394 cycles) in the same period. Confidence intervals were calculated using Poisson 97.5% confidence upper tail limits when no event was observed in the study sample. No pregnancies were achieved among the 54 cases who underwent rescue IUI (confidence interval: 0 to 6.8%). This pregnancy rate was lower than that observed in the general IUI population (17.5%) (relative risk, 19.2). After adjusting for age and endometriosis, the relative risk was 11.7. The rescue IUI is an inefficient procedure. Its efficacy is unlikely to exceed 7% pregnancy rate per IUI.

Treatment of the Male With Follicle-Stimulating Hormone in Intrauterine Insemination With Husband's Spermatozoa: A Randomized Study

We have examined the potential of follicle-stimulating hormone (FSH) therapy for the male to improve pregnancy rates in intrauterine insemination (IUI) with husbands spermatozoa. A prospective randomized trial was performed in 148 couples undergoing IUI because of male subfertility. In the treatment group, 150 IU FSH were administered to the husbands, either i.m. or s.c., three times a week, starting 3 months before the beginning of IUI cycles and maintained until the fifth IUI cycle. In the control group no treatment was given. FSH therapy did not change semen parameters. The pregnancy rate per cycle was 13.47% in the FSH group versus 10.07% in the non-FSH group; the pregnancy rate per woman was 44.38% in the FSH group versus 37.18% in the non-FSH group. Although the pregnancy rate increase was > 30% per cycle and > 20% per woman, statistical significance was not achieved. The cumulative pregnancy rate was 59.20% in the FSH group versus 42.91% in the non-FSH group. The pregnancy rate outside the IUI cycle was 14.70% (10/68) in the FSH group versus 2.5% (2/80) in the non-FSH group, the difference being statistically significant. In conclusion, a non-significant trend towards higher pregnancy rates in IUI was observed in the FSH group.