Spiros Milingos

The effective cumulative pregnancy rate of different modes of treatment of male infertility

Summary The clinical efficacy of conventional and advanced methods of treatment was assessed in 814 couples with infertility due to a male factor. The monthly and effective cumulative rate of ongoing or term pregnancies was calculated during 4712 couple‐months. Treatment of varicocele by transcatheter embolization, resulting in 3.9% pregnancies per cycle and an effective cumulative pregnancy rate of 41% after 1 year, is more effective than counselling and timed intercourse (9% pregnancies after 12 months). Intrauterine insemination (IUI) of washed spermatozoa produced 17% pregnancies in the initial 4 months, but the success rate of the subsequent cycles (1.7% per cycle) was not different from that of the controls.

The value of semen characteristics and tests of sperm function in selecting couples for intra-uterine insemination.

In order to improve the selection of couples for intrauterine insemination (IUI) because of longstanding primary infertility of alleged male origin, we have performed a prospective study measuring conventional and advanced analysis of sperm characteristics, the hypoosmotic swelling test, the Shorr stain, the acidified aniline blue stain and alpha-glucosidase activity in seminal plasma, of 89 couples with no demonstrable abnormality of the female partner. Twenty-four couples attained spontaneous conception, 23 were successful within six cycles of IUI, and 42 remained without conception in spite of IUI during six unstimulated cycles. The proportion and concentration of spermatozoa with progressive motility was significantly lower (P < 0.01) in the successful IUI cases than in the couples attaining spontaneous conception, and the lower quartile value was lower in the former than in the latter. There were less pregnancies among IUI treated couples when sperm concentration and motility were within the range of normal fertile men, or when the concentration of white blood cells was elevated. More pregnancies occurred when markers of epididymal function, namely the result of the Shorr stain and alpha-glucosidase measurement, were normal. Total progressive motility and the result of the Shorr stain were the only independent variables selected by logistic regression to discriminate between successful and failed IUI cases. It is concluded that only a limited group of couples may benefit from IUI.

Laparoscopic Treatment of Ovarian Dermoid Cysts: Eleven Years' Experience

STUDY OBJECTIVE To compare laparoscopic and open approaches in the management of benign ovarian teratomas (dermoid cysts) with regard to operative outcome, complications, and postoperative follow-up. Factors that predispose to rupture of dermoid cysts during laparoscopic removal and rates of adhesion formation in women with and without cyst rupture during laparoscopic surgery also were considered. DESIGN Review of cases of women with dermoid cysts who underwent cystectomy either by laparoscopy or laparotomy in our department from 1992 through 2002 (Canadian Task Force classification III). SETTING The Infertility and Operative Laparoscopy units of the First Department of Obstetrics and Gynecology of the University of Athens, Alexandra Maternity Hospital, Athens, Greece. PATIENTS Two hundred twenty-two women with an ovarian mass requiring surgical management. Of these, 187 women with benign cystic teratomas underwent laparoscopic cystectomy, and 35 underwent cystectomy by laparotomy. INTERVENTIONS Cystectomy either by laparoscopy or laparotomy. MEASUREMENTS AND MAIN RESULTS Potential benefits of operative laparoscopy include reduced blood loss, less postoperative pain, shorter hospital stay, fast recovery, and an excellent cosmetic result. CONCLUSION Laparoscopy should be considered the method of choice for the removal of benign ovarian cystic teratomas as it offers the advantages of fewer postoperative adhesions, reduced pain, shorter hospital stay, and better cosmetic result. It should be performed by surgeons with considerable experience in advanced laparoscopic surgery.

Miliary Tuberculous Peritonitis Mimicking Advanced Ovarian Cancer

Primary peritoneal tuberculosis is a rare presentation of this disease. It is usually associated with ascites and raised CA-125 levels. Occasionally a pelvic mass may be present making the preoperative differential diagnosis from advanced ovarian cancer extremely difficult. Acid-fast stains and special cultures of the ascitic fluid for Mycobacterium tuberculosis are frequently negative, and confirmation of the diagnosis commonly requires histologic examination of biopsy specimens, in which epithelioid granulomas with central caseous necrosis can be identified. We present a case of unexplained pyrexial ascites in a postmenopausal woman in whom the diagnosis of miliary peritoneal tuberculosis was confirmed laparoscopically. The role of noninvasive tools such as measurement of ascitic fluid adenosine deaminase levels is also discussed.

Intrauterine insemination in male subfertility: a comparative study of sperm preparation using a commercial percoll kit and conventional sperm wash

In order to evaluate the possible benefit of sperm preparation using a commercially available, ready-to-use Percoll gradient kit (PerWash, FertiPro, Belgium) for intrauterine insemination (IUI), a two-centre study was performed comparing this method with conventional sperm preparation by means of centrifugation-resuspension. In the Percoll group, 25 couples out of 52 (48%) achieved pregnancy requiring 136 cycles of insemination, with a per cycle success rate of 18.4%. This result was significantly better (P < 0.01) than the per cycle pregnancy rate of 8.9%, which is 23 pregnancies out of 65 cases treated during 259 cycles of insemination with conventionally prepared semen. Also, the 10th percentile of sperm characteristics among successful cases was lower for sperm concentration, proportion and concentration of grade (a) motile spermatozoa in the Percoll group as compared to couples inseminated with conventionally prepared semen. In contrast, cases with elevated proportion of grade (a) motility (> 22%) were significantly less likely (P < 0.001) to obtain pregnancy with IUI, using either sperm preparation method. It is concluded that sperm preparation for intrauterine insemination using the Percoll gradient kit gives a better success rate and can be applied in cases with more severe sperm deficiency.

Laparoscopic treatment of hydrosalpinx: factors affecting pregnancy rate.

STUDY OBJECTIVE To evaluate the efficacy of laparoscopic surgery in a series of women with hydrosalpinx. DESIGN Prospective, observational study (Canadian Task Force classification II-2). Setting. University-affiliated hospital. PATIENTS Sixty-one women undergoing bilateral neosalpingostomy and restoration of tubal ovarian anatomy laparoscopically, and followed for 24 months. INTERVENTION Video-controlled operative laparoscopy using standard four-puncture technique. MEASUREMENTS AND MAIN RESULTS During 24-month follow-up, cumulative intrauterine pregnancy rates at 6-month intervals were 6.8%, 13.6%, 20.5%, and 20.5% for patients with only distal tubal obstruction and 12%, 23%, 29%, and 29% for those with mild degree of tubal disease and periadnexal adhesions. Miscarriage rate for intrauterine pregnancies was zero in both groups. CONCLUSION Operative laparoscopy seems to be an effective treatment for hydrosalpinx in terms of pregnancy outcome.

Postoperative ascites developing after laparoscopic surgery can become a difficult diagnostic dilemma.

Postoperative ascites is a rare complication of laparoscopic surgery. Life-threatening and serious etiologies such as unrecognized bowel or urinary tract injury should be excluded promptly to avoid prolonged morbidity and even mortality. Occasionally, no definitive cause can be identified after an extensive diagnostic work-up. In such cases, idiopathic allergic or inflammatory peritoneal reaction may be the final diagnosis.

Hydrosalpinx Treatment: Comparison Between Laparoscopy and Laparotomy

Distal tubal obstruction continues to be a common cause of infertility. The choice of surgical or in vitro fertilization approach is still ambiguous. During the period January 1990 to June 1999, 144 cases of bilateral neosalpingostomy and restoration of the tubal-ovarian anatomy were carried out in our institution. In 61 cases, the neosalpingostomies were performed laparoscopically and, in the remaining 83, by microsurgery. After treatment, all patients attempted to conceive, and at the end of the 24-month follow-up, 21 (25%) and seven (8.4%) from the laparotomy group and 14 (23%) and two (3.3%) from the laparoscopy group have, respectively, achieved intrauterine and extrauterine pregnancies. In both groups, most pregnancies occurred during the first postoperative year. Pregnancies were achieved in all stages of the disease in the laparotomy group, while in the laparoscopy group no pregnancy was achieved in the severe stage. Hysterosalpingographies performed 2 years after in non-pregnant patients showed t...