Yuval Lavy

Fetal head circumference and length of second stage of labor are risk factors for levator ani muscle injury, diagnosed by 3-dimensional transperineal ultrasound in primiparous women.

OBJECTIVE We evaluated rate of levator ani muscle (LAM) avulsion among primiparae using 3-dimensional transperineal ultrasound to identify possible risk factors for such trauma. STUDY DESIGN We conducted a prospective observational study. Three-dimensional transperineal ultrasound was performed on all subjects. Primiparae were evaluated 24-72 hours after vaginal delivery. In all, 32 nulliparous gravidae (35-41 weeks) and 15 elective cesarean delivery primiparae were evaluated as methodological controls. We compared newborn head circumference (HC), birthweight, second stage duration, maternal age, baby sex, episiotomy, and instrumental delivery. RESULTS LAM trauma was observed in 39 of 210 (18.8%) patients and no controls. Odds ratio for LAM trauma when newborn HC >or= 35.5 cm was 3.343 (95% confidence interval, 1.33-8.42); when second stage duration >or= 110 minutes, odds ratio was 2.27 (95% confidence interval, 1.07-4.81). Logistic regression showed that HC >or= 35.5 and second stage duration >or= 110 minutes increased odds of LAM trauma by a factor of 5.32. CONCLUSION Large HC and prolonged second stage duration are risk factors in LAM trauma. Elective cesarean delivery may prevent LAM trauma.

Pivotal role of CEACAM1 protein in the inhibition of activated decidual lymphocyte functions

Lymphocytes in direct contact with embryonic extravillous trophoblasts constitute more than 40% of decidual cells and appear to play major roles in implantation and early gestation. A unique subset of NK cells, making up 70-80% of decidual lymphocytes, express high levels of CD56 but lack CD16. We have recently demonstrated a novel class I MHC-independent inhibitory mechanism of NK cell cytotoxicity that is mediated by CEACAM1 homotypic interactions. This mechanism is used by some melanoma cells to avoid attack, mainly by CD16(-) NK cells. We now demonstrate that CEACAM1 is expressed on primary extravillous trophoblasts and is upregulated on the vast majority of IL-2-activated decidual lymphocytes, including NK, T, and NKT cells. Importantly, we present evidence that CEACAM1 interactions inhibit the lysis, proliferation, and cytokine secretion of activated decidual NK, T, and NKT cells, respectively. In vivo analysis of decidual lymphocytes isolated from cytomegalovirus-infected (CMV-infected) pregnant women revealed a dramatic increase in the expression of CEACAM1. Finally, we suggest that a novel ligand for this adhesion molecule is present on the surface of CMV-infected fibroblasts. These combined results demonstrate a major role for the CEACAM1 protein in controlling local decidual immune responses.

Polymorphism in a gene coding for the inflammasome component NALP3 and recurrent vulvovaginal candidiasis in women with vulvar vestibulitis syndrome.

OBJECTIVE Patients with vulvar vestibulitis syndrome (VVS) and control subjects were tested for a polymorphism in the gene coding for the NALP3 component of inflammasomes, cytoplasmic structures regulating interleukin (IL)-1beta production. STUDY DESIGN DNA from 143 women with VVS and 182 control women were tested for a length polymorphism in intron 4 of the gene (CIAS1) that codes for NALP3. Vestibular tissue was examined for NALP3 expression. Whole blood cultures were tested for Candida albicans-induced IL-1beta production. RESULTS The allele 12 frequency was higher in control subjects than in the patients with VVS (P = .02). Among patients with VVS and a self-reported history of recurrent vulvovaginal candidiasis (RVVC), the allele 7 frequency was 43.9% as compared with 30.8% in patients with no history of RVVC and 26.9% in control women (P = .035 vs other patients and .001 vs control subjects). NALP3 was identified in vestibular tissue. C albicans-induced IL-1beta production was reduced in samples from women with the 7,7 genotype (P = .030). CONCLUSION Polymorphism in the CIAS1 gene may play a central role in the triggering of VVS in a subset of patients.

Young Low Responders Protected from Untoward Effects of Reduced Ovarian Response

OBJECTIVE(S) To correlate fertilization and clinical pregnancy rates (PRs) in low responders with their E2 levels (<500, 500-800, >800-1,000 pg/mL), age (20-30, 31-40, >40 years), number of follicles, and number of oocytes retrieved. DESIGN A retrospective study. SETTING The IVF unit of an academic hospital. PATIENT(S) One hundred forty-three women who failed to attain E2 levels of 1,000 pg/mL on the day of hCG administration. INTERVENTION(S) Controlled ovarian hyperstimulation, blood E2 and progesterone measurements, ultrasonographic scanning of ovarian follicles, oocyte retrieval after hCG administration, and ET. MAIN OUTCOME MEASURE Clinical PR. RESULT(S) Although E2 levels, fertilization rates, age, and number of oocytes did not differ significantly between the three age groups, the PR achieved in the youngest group was approximately three times as high (19.3%) as that achieved in the two older groups. CONCLUSION Young low responders represent a unique subset in that their age protects them from the deleterious effects of poor ovarian response.

Observer variability in the diagnosis and management of the hysterosalpingogram

OBJECTIVE To determine the reproducibility of hysterosalpingogram (HSG) interpretation and clinical management recommendations among trained observers. DESIGN Fifty HSG films were distributed to five fertility practitioners with a mean of 20 years clinical experience. Each observer evaluated components of uterine and tubal status and provided clinical recommendations for hysteroscopy and laparoscopy. SETTING University hospital-affiliated reproductive endocrine practice. INTERVENTION(S) None MAIN OUTCOME MEASURE(s): The level of agreement among observers for each uterine and tubal category as determined by the kappa(kappa) statistic. Determinants of clinical recommendation for further diagnostic studies were assessed. RESULT(S) The level of agreement between observers as determined by kappa ranged from 0.645 in the hydrosalpinx category, indicating fair reliability, to 0.111 for pelvic adhesions, indicating poor reliability. The composite kappa for uterine status was 0.345 whereas the composite kappa for tubal status was 0.430. Agreement among observers concerning management showed marginal reproducibility with a kappa of 0.261. Overall, more than one abnormality of either the cavity or the fallopian tubes led to a diagnostic recommendation for further workup in > or = 90% of cases. CONCLUSION(S) In a group of five experienced clinicians, there was considerable variability in the interpretation as well as the clinical management of the HSG. Physicians caring for infertile couples should be aware of this discrepancy and should, if possible, review carefully both the original films as well as the report of the attending radiologist in formulating their diagnostic evaluation and management plan.

The significance of intrauterine lesions detected by ultrasound in asymptomatic postmenopausal patients

A retrospective study on 82 women with an incidental sonographic finding suspected to be intrauterine polyps was undertaken to assess the histopathologic characteristics of such polyps utilising operative hysteroscopy. Endometrial polyps were found in 68 patients, submucousal myomas in 7, atrophic endometrium in 6 and thickened proliferative endometrium was found in 1 patient. Simple hyperplasia was found in one polyp but neither endometrial carcinoma nor complex hyperplasia was found. The total complication rate was 3.6%. It appears that the risk of endometrial carcinoma in postmenopausal women with asymptomatic endometrial polyps is low, although a larger series is required to confirm this finding.

Can pelvic floor injury secondary to delivery be prevented

The number of women suffering from pelvic floor disorders (PFD) is likely to grow significantly in the coming years with a growing older population. There is an urgent need to investigate factors contributing to the development of PFD and develop preventative strategies. We have reviewed the literature and analyzed results from our own study regarding the association between delivery mode, obstetrical practice and fetal measurements, and damage to the pelvic floor. Based on our findings, we have suggested a flowchart helping the obstetrician to conduct vaginal delivery with minimal pelvic floor insult. Primiparity, instrumental delivery, large fetal head circumference, and prolonged second stage of delivery are risk factors for PFD. Pelvic floor integrity should always be seriously considered in every primiparous woman. All efforts should be aimed at minimizing any insult, which might have a significant impact on the woman’s pelvic integrity and future quality of life.

Sexual Function and Quality of Life of Women with Stress Urinary Incontinence: A Randomized Controlled Trial Comparing the Paula Method (Circular Muscle Exercises) to Pelvic Floor Muscle Training (PFMT) Exercises

AIM To compare the effectiveness of the Paula method (circular muscle exercises) vs. pelvic floor muscle training (PFMT) exercises on sexual function (SF) and quality of life (QoL) of women with stress urinary incontinence (SUI). METHODS A randomized controlled trial (RCT) was conducted in outpatient urban community clinics serving diverse socioeconomic populations between September 2004 and July 2005. The intervention included two exercise regimens: Paula method--12 weeks of private 45 minutes sessions; PFMT--12 weeks of group (up to 10 participants) sessions of 30 minutes in length once a week, for 4 weeks plus two additional sessions, 3 weeks apart. MAIN OUTCOME MEASURES The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire; the Incontinence Quality of Life Questionnaire; 1-hour clinic pad test; gynecological examination; demographic/health history. RESULTS Sixty-six women in the Paula group and 60 women in the PFMT group. The mean SF scores post interventions were 38.72 (5.35) in the Paula group and 38.07 (5.80) in the PFMT group. SF score improvement was found to be significant in both groups (Paula, P = 0.01; PFMT, P = 0.05), as was in the QoL scores (Paula, P < 0.001; PFMT, P ≤ 0.001), with no significant difference between groups. There was a significant correlation between the mean SF score and the mean QoL score after the intervention (Paula: r = 0.4, P = 0.002; PFMT: r = 0.4, P = 0.009). A mild to moderate significant correlation was also found between the SF score and pad test results in both groups post intervention (r = -0.3, P = 0.02; r = -0.3, P = 0.04, respectively). CONCLUSION This RCT study demonstrated the effectiveness of two exercise methods on SF and QoL in women suffering from SUI. The Paula method of exercise was presented for the first time in the literature as a conservative noninvasive treatment for SUI and SF.

Sexual function and quality of life for women with mild-to-moderate stress urinary incontinence.

INTRODUCTION Sexual function is affected by stress urinary incontinence with or without pelvic organ prolapse. The aim of the study was to describe the sexual function of women with mild-to-moderate stress urinary incontinence, with or without pelvic organ prolapse (up to stage 2) and examine correlations with symptoms and quality of life. This investigation was part of a large, randomized, clinical trial of women with stress urinary incontinence who participated in an exercise intervention. METHODS Women included in the study suffered from stress urinary incontinence as measured by a pad test and were interested in an exercise intervention. All participants underwent assessment for prolapse staging. Instruments included: the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), Incontinence Quality of Life Questionnaire (I-QOL), and a health and urinary leakage questionnaire. RESULTS One hundred and eighty-seven ambulatory women, aged 20 to 65 years, had a mean sexual function score of 36.9 (standard deviation [SD] 5.9). No significant correlation was found between the sexual function scores and quantity of urinary leakage. A significant correlation existed between the sexual function and I-QOL scores (P < .001). An additional finding was that women with urgency symptoms were older (P= .04) and had significantly lower sexual function scores (mean 35.7; SD 6.4) than those who did not report urgency (mean 38.7; SD 4.6; P < .001). DISCUSSION Women with mild-to-moderate stress urinary incontinence, without or with lower stages of pelvic organ prolapse, demonstrated good sexual function, which correlated with physical and psychosocial factors. Health professionals need to perform multifaceted intake assessments on women with urinary leakage to customize their health promotion regimen.

Human trophectoderm apposition is regulated by interferon γ-induced protein 10 (IP-10) during early implantation.

INTRODUCTION The first step in human implantation is the attraction of the blastocyst to the endometrium. We aimed to study attraction of the human blastocyst to the endometrium, and how this process is accomplished by chemokines secreted by the endometrium. MATERIALS AND METHODS Blastocyst trophectoderm cells and other trophoblast lineage cells were subjected to attraction assays by IP-10 and other chemokines using transwell migration and chemotaxis assays. Chemokine expression and secretion were investigated using immunohistochemistry, ELISA, FACS analysis, and RT-PCR on material from flushing of the uterine cavity in endometrial biopsies. Chemokine receptor expression by blastocyst trophectoderm following PGD biopsy, trophectoderm derived from hES, placental villi, and other trophoblast lineage cells were characterized by the same methods. RESULTS IP-10 dramatically attracted trophectoderm derived from hES cells and other lineages by interaction with CXCR3 chemokine receptors, as shown by both chemotaxis and transwell migration. High levels of IP-10 were detected throughout the menstrual cycle at flushing of the uterine cavity. Immunohistochemistry, FACS analysis, and RT-PCR of endometrial biopsy detected IP-10 in glandular and stromal cells of the endometrium. High levels of IP-10 were detected in condition medium of the endometrial stromal and glandular cells. Of all of the chemokine/chemokine receptor combinations examined, the IP-10/CXCR3 interaction was the only cytokine that was significantly elevated. DISCUSSION While they await the wandering blastocyst, IP-10 is produced by many cells of the endometrium, but not by endometrial natural killer cells. CONCLUSION Endometrial IP-10 may specifically attract human blastocyst trophectoderm cells early in implantation.