European Journal of Obstetrics & Gynecology and Reproductive Biology - Articles in Press

Uncorrected Proof

J. Drife — 2010-03-11

In a few days’ time the 21st European Congress of Obstetrics and Gynaecology will open in Antwerp. We expect it to be a great success and we are particularly pleased by the close co-operation between EBCOG and its affiliated subspecialty societies, whose logos form a colourful footnote to the http://www.ebcog2010.be webpage. In the past the problem for our specialty in Europe has been poor communication between national societies but our future challenge will be to avoid fragmentation into subspecialty groupings. The Congress addresses both of these issues, not only incorporating subspecialty sessions in the scientific programme but also bringing together participants from all of EBCOG's 36 member countries. Personal interaction is essential in building a Europe-wide identity for our specialty and enabling EBCOG to act effectively as advocate for women's health at the highest political levels in the EU. This is why this Journal repeatedly draws attention to its meetings. Perhaps it is not too early to mention that the 22nd European Congress will be in Tallinn, Estonia, on 9–12th May 2012.

Diagnosis and management of adult female stress urinary incontinence: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians - Uncorrected Proof

2010-03-08

Abstract: Urinary incontinence is a frequent affliction in women and may be disabling and costly {LE1}. When consulting for urinary incontinence, it is recommended that circumstances, frequency and severity of leaks be specified {Grade B}. The cough test is recommended prior to surgery {Grade C}. Urodynamic investigations are not needed before lower urinary tract rehabilitation {Grade B}. A complete urodynamic investigation is recommended prior to surgery for urinary incontinence {Grade C}. In cases of pure stress urinary incontinence, urodynamic investigations are not essential prior to surgery provided the clinical assessment is fully comprehensive (standardised questionnaire, cough test, bladder diary, post-void residual volume) with concordant results {PC}. It is recommended to start treatment for stress incontinence with pelvic floor muscle training {Grade C}. Bladder training is recommended at first intention in cases with overactive bladder syndrome {Grade C}. For overweight patients, loss of weight improves stress incontinence {LE1}. For surgery, sub-urethral tape (retropubic or transobturator route) is the first-line recommended technique {Grade B}. Sub-urethral tape surgery involves intraoperative risks, postoperative risks and a risk of failure which must be the subject of prior information {Grade A}. Elective caesarean section and systematic episiotomy are not recommended methods of prevention for urinary incontinence {Grade B}. Pelvic floor muscle training is the treatment of first intention for pre- and postnatal urinary incontinence {Grade A}. Prior to any treatment for an elderly woman, it is recommended to screen for urinary infection using a test strip, ask for a bladder diary and measure post-void residual volume {Grade C}. It is recommended to carry out a cough test and look for occult incontinence prior to surgery for pelvic organ prolapse {Grade C}. It is recommended to carry out urodynamic investigations prior to pelvic organ prolapse surgery when there are urinary symptoms or occult urinary incontinence {Grade C}.

A pilot study comparing efficacy of a cervical intraepithelial neoplasia excisor with loop electrosurgical excision procedure - Uncorrected Proof

Olaleye Sanu, Alak Pal, Samuel George — 2010-03-08

Abstract: Objective: To determine whether the proportion of incomplete resection of cervical intraepithelial neoplasia (CIN 1–3) may be reduced by CIN Excisor compared with loop excision of the transformation zone (LLETZ).Study design: A prospective trial during a 2-year period at a district general hospital in London, United Kingdom, including 420 women scheduled for treatment due to CIN, after colposcopy guided biopsy results. This study was expected to demonstrate a statistically significant difference (p<0.05) in the proportion of women with clear histopathological resection margins after treatment with CIN Excisor compared with LLETZ. Chi-square or Fisher's exact test were used to compare histopathological resection margins in the CIN Excisor and LLETZ groups.Results: Overall, there is strong evidence of a difference in the proportion of histopathological specimens with clear resection margins for the CIN Excisor group, compared with the LLETZ group (201/210, 95.7% versus 180/210, 85.7%: p<0.001). Sub-analysis within the two groups, of the proportion of histopathological specimens with clear resection margins in relation to CIN grades, revealed a statistically significant difference in favour of the CIN Excisor group for CIN 1 (99/103, 96.1% versus 82/95, 86.3%: p=0.01), and CIN 2 (73/77, 94.8% versus 68/80, 85%: p=0.04). There is a numerical difference in the proportion of clear resection margins in favour of the CIN Excisor for CIN 3 (29/30, 96.7% versus 30/35, 85.7%), but this difference was not statistically significant (p=0.21). Perioperative complications were similar between the two groups.Conclusion: CIN Excisor achieved better results than LLETZ for treatment of CIN 1–3 with respect to clear histopathological resection margins. However, further studies including a larger number of women treated for CIN 3 are needed before firm conclusions are drawn.

Isolated torsion of the fallopian tube in a patient with polycystic ovarian syndrome (PCOS) - Uncorrected Proof

Jasmine Tay, Helen Parker, Pallavi Dhange, Calum Paton-Forrester, William Atiomo — 2010-03-08

We present a case of chronic severe pelvic pain in a 31-year-old woman with known polycystic ovarian syndrome, later found to have isolated torsion of her left fallopian tube at laparoscopy. Following de-torsion, she became pain free.

Prevalence of cysts in epithelial ovarian cancer - Uncorrected Proof

2010-03-08

Abstract: Objective: Ovarian carcinomas mostly appear as large cystic masses. However, the exact prevalence of cysts in epithelial ovarian cancer (EOC) has never been documented as well as the tumor factors that are related to the presence of cysts. Demonstrating the prevalence of cysts in EOC is essential for research focused on predictive and prognostic biomarkers in ovarian cyst fluid.Study design: From 233 patients with primary EOC who underwent surgery, pathological data were collected from pathology reports. Univariate and multivariate logistic regression were used to analyze the relationship between the presence of cysts and other tumor characteristics.Results: Cysts in EOC were present in 83.7% of the patients and were mostly (61%) multilocular. The most common histological subtypes (serous, mucinous, endometrioid, clear cell) contained cysts in more than 85% of the cases. In univariate regression analysis, early FIGO stage, low tumor grade and a large tumor size were significantly associated with the presence of cysts (OR (95% CI)=5.312 (1.81–15.57), 6.906 (2.31–20.66) and 1.169 (1.08–1.27), respectively). In multivariate regression analysis, apart from tumor size, only tumor grade was independently associated with the presence of cysts (adjusted OR (95% CI)=4.234 (1.36–13.22)).Conclusions: The large majority of all EOCs contained cysts. Histological subtype, FIGO stage, tumor necrosis and age were not associated with the presence of cystic EOC. In contrast, tumor grade and tumor size were independently related to the presence of cystic EOC. This means that cystic EOCs represent a subgroup of larger and more well-differentiated tumors. The evident relationship between the presence of cysts and differentiation grade is interesting from a clinical point of view as grading is especially important for the prognosis and treatment of patients with stage I EOC.

Occurrence of endometrial cancer six years after treatment with thermal balloon ablation (Thermachoice®): First case report - Uncorrected Proof

2010-03-08

We report a case of endometrial cancer occurring de novo six years after a Thermachoice® procedure for dysfunctional uterine bleeding. To our knowledge, this is the first case described in the literature. A 48-year-old multiparous patient attended our outpatient clinic for uterine bleeding (menorrhagia and metrorrhagia). She had a past history of bilateral breast cancer treated with mastectomy and axillary lymph node dissection, and breast-conserving surgery without adjuvant hormone therapy. On physical examination, her height was 165cm and weight 86kg. She had no other risk factors for endometrial cancer. The uterine bleeding was diagnosed as functional after normal ultrasound examination of the endometrium and myometrium. A hysteroscopy (revealing a normal uterine cavity) was performed with biopsy-curettage. Pathological examination showed endometrium in the proliferative phase without atypia. She underwent Thermachoice® therapy (controlled 83°C intracavitary heating of the uterus for eight minutes using a balloon technique) by an experienced surgeon. Metrorrhagia recurred six years later. A hydrosonography examination revealed an abnormal endometrial/uterine image (myoma and/or polyp) and an irregular thickening of the uterine fundus confirmed by hysteroscopy. Biopsy-curettage revealed atypical endometrial hyperplasia with a few clusters of grade 2 endometrioid endometrial adenocarcinoma cells. Treatment consisted of Piver type I hysterectomy with pelvic lymph node dissection. The final histological examination revealed a FIGO stage IA, grade 2, endometrioid adenocarcinoma without lymph node involvement (right side: 0/7 and left side: 0/9) and with negative peritoneal cytology, associated with atypical endometrial epithelial hyperplasia lesions (no adenomyosis) mainly observed in the fundus.

Stress urinary incontinence six months after first vaginal delivery - Uncorrected Proof

2010-03-04

Abstract: Objective: To determine the prevalence, severity and impact on quality of life of stress urinary incontinence (SUI) six months after the first vaginal delivery, as well as to investigate the risk factors associated with it.Study design: We designed a prospective study that included 396 women who had their first vaginal delivery in the Hospital Donostia. Diagnosis and identification of the type of urinary incontinence were carried out considering the 2002 ICS definitions. Women were interviewed and examined twice, at term and six months after delivery. The severity of the symptoms was evaluated with the Incontinence Severity Index (ISI) and the impact on quality of life was evaluated with the International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form. The statistical analysis included comparison of means (Student's t-test or analysis of variance) and proportions (Chi square and Fisher's exact tests). Multiple logistic regression analysis was performed using variables that were close to statistical significance.Results: 15.1% of the women reported SUI six months after their first vaginal delivery. The ISI was slight or moderate in the majority of the cases and the impact on quality of life was low. The presence of SUI in pregnant women at term was the only independent risk factor associated with SUI after delivery (OR: 3.71; 95% IC: 1.95–7.06). The type of vaginal delivery did not influence in SUI six months after the birth, not even in women who were continent during pregnancy.Conclusions: Slight or moderate SUI was common after the first vaginal delivery and the impact on quality of life was low. Urinary incontinence during pregnancy was the only risk factor independently associated with the presence of SUI six months after the first vaginal delivery.

Prevalence of genital human papillomavirus infection and genotypes among women from Fujian province, PR China - Uncorrected Proof

Dongmei Wu, Lin Cai, Meng Huang, Yizhen Zheng, Jiang Yu — 2010-03-04

Abstract: Objective: The prevalence and distribution of oncogenic human papillomavirus (HPV) genotypes in women who underwent screening for cervical cancer in Fujian province, China, were assessed and the correlation of genotypes with the histological results was evaluated.Study design: Cervical samples were collected from 2338 women for cervical cancer screening. Participants were screened by liquid-based cytology and HPV genotyping using DNA Chip and referred to colposcopy and biopsy samples for further analyses if cytology results indicated undetermined significance (ASCUS) or higher.Results: The prevalent types with cervical intraepithelial neoplasia 1 (CIN 1) were HPV-52 (22.5%), HPV-16 (11.6%) and HPV-CP8304 (10.1%). The prevalent types with cervical intraepithelial neoplasia 2 or 3 (CIN2/3) were HPV-16 (24.5%), HPV-33 (21.6%), and HPV-52 (19.6%). The prevalent types with carcinoma, including squamous cell carcinoma (SCC) and adenocarcinoma (ADCA), were HPV-16 (42.7%), HPV-18 (20.8%) and HPV-33 (12.5%). Analysis by odds ratio (OR) revealed that HPV-66, -68, and -CP8304 (HPV-CP8304: OR, 7.34; 95% confidence interval (CI)=3.73–14.46) were associated with CIN 1; HPV-52 was CIN 2/3-associated type (OR, 7.25; 95%CI=4.19–12.53); HPV-16, -18, -31, -33, -45, -53, -58, and -59 were associated with carcinoma (HPV-45: OR, 54.78; 95%CI=10.49–286.16).Conclusion: It was concluded that HPV infection in Chinese women in Fujian province showed higher frequencies of HPV-52 and HPV-33. However, HPV-16 was still the most common type in CIN2/3 and carcinoma. HPV-16, -18, -31, -33, -45, -53, -58 and -59 have more dominant oncogenic risk over other types in this area.

Awareness and perception of intra-abdominal adhesions and related consequences: Survey of gynaecologists in German hospitals - Uncorrected Proof

2010-03-02

Abstract: Objective: Intra-abdominal adhesion formation after abdominal surgery is the most common postsurgical complication, and the consequences are a considerable burden for patients, surgeons and health systems. Since a wide variety of factors influence adhesion formation, it is difficult to define clear guidelines on how to reduce adhesion formation in daily practice. Given this dilemma, this study assessed the awareness and perception of adhesion formation among gynaecologists in Germany in order to define a baseline for further research and education.Study design: The Clinical Adhesion Research and Evaluation (CARE) group of the University of Giessen designed a questionnaire that was sent to the heads of all gynaecological departments in Germany. The director or one of the surgical consultants was asked to complete the questionnaire and return it for evaluation.Results: The completed questionnaire was returned by 279 of 833 gynaecological departments. Interviewed surgeons expected adhesions to form in 15% of cases after laparoscopy and 40% after laparotomy. Before surgery, 83.1% of the respondents told their patients about the risk of prior adhesion formation. More than 60% believed that postsurgical adhesion accounts for major morbidity. Infections within the abdomen, previous surgery and extensive tissue trauma were thought to have the most influence on adhesion formation. Risk of adhesion formation was thought to be highest in endometriosis and adhesiolysis surgery. The respondents agreed on performing adhesiolysis in symptomatic but not in all patients. Only 38.4% used adhesion reduction agents regularly. A total of 65.1% of a repertoire of adhesion prevention agents were familiar to the interviewed surgeons. Only 22.0% of them used anti-adhesion products in clinical practice. In general, the respondents were uncertain whether these products play an important role in adhesion reduction, represented by a range of 1.97±0.98% on a scale from 0 to 4.Conclusions: Even though postoperative adhesions are recognized as a major cause for morbidity, and it is widely agreed that infections, extensive tissue trauma and surgery lead to adhesion formation, there is uncertainty about the treatment and prophylactic strategies for dealing with adhesions. This dilemma reflects the awareness and perception of gynaecologists in Germany and is an initial point for further research.

Substance abuse during pregnancy: effect on pregnancy outcomes - Uncorrected Proof

S.M. Pinto, S. Dodd, S.A. Walkinshaw, C. Siney, P. Kakkar, H.A. Mousa — 2010-03-02

Abstract: Objective: To determine the contribution of drug use to maternal and perinatal complications, controlling for social confounders.Study design: This is a retrospective cohort study of 247 drug-using women and 741 controls over a 4-year period from 1997 to 2000. Cases were identified from the drug dependency register. Three controls for each woman with substance abuse were selected from the delivery suite records, with calliper matching by year of delivery (any control patient who delivered within 6 months before or after the date of delivery of a drug-using woman was considered as a potential match) and district of residence (post code). The primary outcomes of interest were preterm birth, abruption, pre-eclampsia, intrauterine growth restriction and low birth weight.Results: There were statistically significantly more preterm births amongst drug-using women (relative risk (RR) 2.5, 95% confidence interval (CI) 1.6–3.8), with preterm births complicating 25% of births amongst drug users. The incidence of low birth weight was 30.8% amongst drug-using women compared to 8% in control women (RR 3.6, CI 2.4–5.4), and the incidence of growth restriction was 25%, significantly higher than the control group (RR 3.82, CI 2.4–6.1). The risk of abruption was also higher (RR 2.74, CI 1.1–7.0). Of note is the extremely low incidence of pre-eclampsia among drug users, even after controlling for the confounder effects of parity and smoking.Conclusions: Despite multidisciplinary co-ordinated antenatal care, women with substance abuse during pregnancy are at significant risk of adverse obstetric and perinatal outcome, controlling for social confounders. A limitation of the study is that the sample size was not large enough to clearly assess individual drugs. This is the first study to highlight low incidence of pre-eclampsia among drug users over and above the effect of smoking. Further research is needed to elucidate the underlying biological reason for the lack of pre-eclampsia in women with substance abuse during pregnancy.

The functional reconstruction of fertility-sparing radical abdominal trachelectomy for early stage cervical carcinoma - Uncorrected Proof

Tingting Yao, Shaomin Mo, Zhongqiu Lin — 2010-03-02

Abstract: Objective: To study the feasibility and outcome of functional reconstruction during radical abdominal trachelectomy in the treatment of early stage cervical carcinoma.Study design: Ten cervical cancer patients (FIGO stage IA2 or IB1 with tumours less than 2cm in diameter) who desired to preserve their fertility underwent abdominal radical trachelectomy with functional reconstruction, including preserving the ascending uterine artery, placing a stent to avoid intrauterine adhesions and using three pieces of mesh to prevent cervical incompetence and uterine prolapse.Results: The mean age of the patients was 29 years (range 28–30). The average operative time was 261min (range 204–345), with a mean blood loss of 370ml (range 150–500). The mean time to remove the urinary catheter was 12 days (range 8–14) after surgery and the mean time to remove pelvic drainage was 4 days (range 2–8). During the follow-up (range 4–68 months), no recurrence was detected and a normal menstrual pattern resumed within 8 weeks after surgery. No abnormality was noted in the preserved ascending branches of the uterine arteries, and no intrauterine adhesion was found. One patient successfully conceived without reproductive assistance and another patient conceived with in vitro fertilization. There was no cervical incompetence or premature rupture of membrane in their pregnancies, and cesarean sections were done as in normal women at a gestation of 38+5 weeks and 34+3 weeks, respectively.Conclusion: We conclude that the functional reconstruction is a good choice of fertility-sparing surgery for patients with early stage cervical carcinoma.

Effect of female nargile smoking on in vitro fertilization outcome - Uncorrected Proof

Antoine Hannouna, Anwar H. Nassar, Ihab M. Usta, Antoine Abu Musa — 2010-03-02

Abstract: Objective: Smoking is a significant health hazard that has been associated with poor reproductive outcome and reduced fertility in reproductive age women. The aim of this study was to assess the effect of nargile smoking on intra-cytoplasmic sperm injection (ICSI) outcome.Study design: A prospective analysis of the outcomes of 297 women who underwent ICSI treatment at the ART Unit at the American University of Beirut Medical Center between January 1, and December 31, 2006 was done. The patients were divided into 3 groups based on their smoking status: cigarette smokers (n=42), nargile smokers (n=51) and non-smokers (n=204).Results: The mean age of nargile smokers was significantly lower than the other groups; however, the 3 groups were similar with respect to the cause of infertility, total dose of follicular stimulating hormone (FSH), number of oocytes and embryos obtained, and number and quality of embryos transferred. There was no significant difference in the clinical pregnancy rate between nargile smokers and non-smokers (51.0% vs 43.6%). However, cigarette smokers had a significantly lower clinical pregnancy rate compared to non-smokers (23.8% vs 43.6%, p=0.0238). On multiple logistic regression analysis, factors that decreased the clinical pregnancy rates were cigarette smoking and maternal age.Conclusion: Although this study did not find a deleterious effect of nargile smoking on ICSI outcome, the results need to be confirmed in prospective studies that would include larger number of women with more objective measures of nargile smoke exposure.

Change in the ovarian environment after hysterectomy as assessed by ovarian arterial blood flow indices and serum anti-Müllerian hormone levels - Corrected Proof

2010-03-02

Abstract: Objective: The aim of this prospective study was to evaluate the changes in the ovarian environment after hysterectomy based on ovarian arterial blood flow indices and serum anti-Müllerian hormone (AMH) levels.Study design: Ovarian arterial blood flow indices (pulsatile and resistance indices) by Doppler ultrasonography and serum AMH levels were measured at baseline and 1 week, 1 month, and 3 months after hysterectomy in 32 women ranging in age from 38 to 49 years, or at the time of screening in 21 age-matched controls. The study subjects underwent hysterectomy with conservation of both ovaries for benign diseases of the uterus (laparoscopy-assisted vaginal hysterectomy [LAVH], n=26; and total abdominal hysterectomy [TAH], n=6). The study subjects and controls were analyzed using a t-test or one-way analysis of variance.Results: No differences existed in demographic profiles, ovarian arterial blood flow indices, and serum AMH levels at baseline between the hysterectomy and control groups. Ovarian arterial blood flow indices did not change before and after surgery, and there were no serial changes in the mean levels of serum AMH at each time point (1.80±1.81ng/mL [pre-operatively], 1.69±1.62ng/mL [1 week post-hysterectomy], 1.42±1.34ng/mL [1 month post-hysterectomy], and 1.52±1.72ng/mL [3 months post-hysterectomy]; p=0.805). In addition, no significant differences in ovarian arterial blood flow indices and serum AMH levels existed between the LAVH and TAH groups.Conclusion: This preliminary study suggests that hysterectomy does not affect the ovarian environment for up to 3 months post-operatively, as assessed by ovarian arterial blood flow indices and serum AMH levels.

Vaginal progesterone supplementation has no effect on ongoing pregnancy rate in hCG-induced natural frozen–thawed embryo transfer cycles - Corrected Proof

2010-03-02

Abstract: Objective: The purpose of this study is to assess the effect of luteal phase supplementation (LPS) on pregnancy rates in human chorionic gonadotropin (hCG)-induced natural frozen–thawed (FET) cycles.Study design: All performed hCG-induced natural FET cycles from January 2006 until August 2007 were retrospectively identified. The study group consisted of 452 cycles: 243 supplemented with progesterone administration (600mg natural micronized progesterone in three separate doses) and 209 without progesterone. Analysis was limited to cycles where embryos were cryopreserved on day 3. Final oocyte maturation was achieved by hCG when endometrial thickness of ≥7mm and a follicle of 17mm were present on ultrasound.Results: No statistically significant differences were observed in ongoing pregnancy rate between the two groups (22% versus 21%, p=0.8; difference +1%; 95% confidence interval (CI): −6.5 to +8.7). The non-significant effect of the presence or not of luteal support on pregnancy rate was confirmed by logistic regression (odds ratio (OR): 0.9, 95% CI: 0.54–1.47, P=0.64). A previous pregnancy following fresh embryo transfer (OR: 6.04, 95% CI: 3.63–10.02, P=0.001) and increased endometrial thickness (OR: 1.25, 95% CI: 1.11–1.41, P=0.001) significantly affected the achievement of ongoing pregnancy, whereas the association between embryo score and achievement of pregnancy was marginally significant (OR:0.28, 95% CI: 0.08–0.97, P=0.05).Conclusion: There is no convincing evidence to support the use of LPS in hCG-induced natural FET cycles, since there is no luteal phase defect. Further prospective randomized studies are necessary to confirm these findings.

The use of anti-Müllerian hormone and antral follicle count to predict the potential of oocytes and embryos - Uncorrected Proof

Kingshuk Majumder, Tarek A. Gelbaya, Ian Laing, Luciano G. Nardo — 2010-02-26

Abstract: Objective: To investigate whether anti-Müllerian hormone (AMH) is better than antral follicle count (AFC) in predicting oocyte yield and embryo quality after controlled ovarian hyperstimulation for in vitro fertilization (IVF).Study design: This is a prospective observational study involving 162 women (<40 years old) undergoing their first IVF cycle at an IVF unit within a university hospital. AMH and AFC measurements were made on day 3 of the cycle within 3 months of starting ovarian stimulation. A standard long down-regulation protocol using gonadotrophin releasing hormone agonist and recombinant follicle stimulating hormone was used. A maximum of two embryos were transferred on day 2 or 3 following oocyte retrieval. The primary outcome was the number of good quality embryos available for transfer and freezing. Embryos were graded according to the number of blastomeres, the difference in blastomere size and the degree of fragmentation, into grades 1–4. Secondary outcomes included the number of oocytes retrieved and fertilized and the live birth rate. Correlation between different parameters was calculated using Spearman's correlation coefficient. Receiver operating characteristic (ROC) curves were generated for AMH and AFC to compare ability of parameters to predict top quality or frozen embryos and the occurrence of a live birth.Results: Of the 137 women who had fresh embryo transfer, 52 became pregnant (32.1% pregnancy rate per cycle started) and 38 had a live birth (23.5% live birth rate per cycle started). Both AMH and AFC had highly significant correlations with the number of oocytes retrieved and the number of oocytes fertilized (P<0.001). The two markers were also significantly associated with the number of top quality embryos available for transfer and the number of embryos frozen (P<0.01). With regard to live birth, AMH performed better than AFC (P<0.01 and P<0.05, respectively), but both markers were more valuable in predicting the absence rather than the occurrence of live birth (negative predictive value 84%).Conclusions: AMH and AFC are comparable predictors of oocytes retrieved and of the number of good quality embryos available for transfer and freezing. Prediction of live birth may help clinicians selecting patients suitable for single embryo transfer.

Prevalence and risk factors for early postpartum anemia - Uncorrected Proof

Renate L. Bergmann, Rolf Richter, Karl E. Bergmann, Joachim W. Dudenhausen — 2010-02-26

Abstract: Objective: To assess the prevalence and evaluate the most important risk factors for early postpartum anemia.Study design: The perinatal process data of 43807 women delivering between 1993 and 2008 (90.1% of all deliveries) in the largest university obstetric department in Germany were analyzed, and the associations of Hb<8g/dl with maternal characteristics, pregnancy risks, delivery mode and estimated delivery blood loss were calculated. Multivariable logistic regression models were applied to compute odds ratios. Additionally, the impact of these risk factors for delivery blood loss was estimated with multivariable linear regression analysis.Results: Twenty-two percent of mothers had Hb<10g/dl, and 3% had Hb<8g/dl. The adjusted odds ratios (OR) for Hb<8g/dl were 4.8 (p=0.001) for placenta previa, 2.9 (p<0.001) for mothers of African origin, 2.7 (p<0.001) for diagnosed anemia in pregnancy, 2.2 (p<0.001) for multiple pregnancy, and 2.1 (p=0.021) for bleeding in late pregnancy. However, the delivery blood loss was the most important risk factor for postpartum anemia. The adjusted OR for an estimated blood loss of 500–1000ml was 15.3 (p<0.001), and for a loss of >1000ml was 74.7 (p<0.001).Conclusion: The estimated obstetric blood loss is the most important risk factor for severe postpartum anemia, and the volume of blood lost is especially high in cesarean deliveries, which should be considered when electing delivery procedures. Also, measures to boost iron stores in pregnancy should be established.

Renin-angiotensin system dysregulation in fetuses with hydronephrosis - Uncorrected Proof

2010-02-26

Abstract: Objectives: To evaluate if fetal hydronephrosis is associated with dysregulation of the renin-angiotensin system (RAS), and if it could represent an early predictor of future renal damage or arterial hypertension.Study design: The study consisted of 26 pregnant women and their fetuses. Ultrasound scans were performed to evaluate the renal pelvis in fetuses. Four fetuses with hydronephrosis were included in the study, while the rest were found to have normal renal pelvis. Active and inactive renin was calculated by IRMA method in fetal and maternal blood, during the second trimester of pregnancy.Results: A comparison of plasma active and inactive renin levels was made between pregnant women and their fetuses, as well as between fetuses with and without hydronephrosis. Active and inactive renin levels obtained from fetuses with hydronephrosis were significantly higher compared to those obtained from fetuses with normal kidneys.Conclusions: Dilatation of renal pelvis in the second trimester of pregnancy seems to up-regulate the renin and prorenin system in fetal blood. Both factors are indicative of possible future renal pathology.

Physiology and clinical value of glycosuria after a glucose challenge during pregnancy - Corrected Proof

Johanna C.G. Coolen, Johan Verhaeghe — 2010-02-26

Abstract: Objective: Urine testing for glucose is commonly performed during pregnancy but little is known about the regulation and clinical value of glycosuria because studies are hampered by its low prevalence and intermittent nature. The aim of this study was to compare the urine and plasma response 60min after a 50g oral glucose challenge in the setting of gestational diabetes mellitus (GDM) screening.Study design: Of 338 consecutively enrolled gravidas, 325 completed the study. Glycosuria was measured semi-quantitatively (0, 1, 2 or 3+) and venous plasma glucose was measured.Results: Post-challenge glycosuria occurred in 26.2% of gravidas. Women with 2 or 3+ glycosuria showed higher plasma glucose (p<0.001), lower height (p=0.004) and lower body weight throughout pregnancy (p=0.014); however, glycosuria was not related to age, parity, body mass index (BMI), highest blood pressure or newborn size at birth. The sensitivity for a GDM diagnosis was 8.2%. Comparison of pure “urine” responders (i.e., any glycosuria but glucose <130mg/dl, n=50) with “plasma” responders (no glycosuria but plasma glucose ≥140mg/dl, n=29) showed that urine responders were younger and had a lower body weight and BMI than plasma responders.Conclusion: Glycosuria after an oral glucose challenge depends on the plasma glucose excursion, and is more pronounced in gravidas with lower height and body weight, who presumably have a smaller plasma distribution volume. Post-load glycosuria is a poor predictor of GDM, pre-eclampsia and newborn size at birth, and therefore has limited clinical benefit.

Cyclo-oxygenase type 2 is dysregulated in breast ductal carcinoma in situ and correlates with poor outcome - Uncorrected Proof

2010-02-26

Abstract: Objective: Clinico-pathologic data on microinvasive carcinoma of the breast (MICB) as defined by the 2003 TNM criteria (T1mic≤1mm) are scarce. Nowadays, we do not know the percentages of Ductal Carcinoma in situ (DCIS) that will progress to invasion and predictive markers are not available. Cyclo-oxygenase type-2 (COX-2) is overexpressed in many human malignant tumours and has been linked to the processes of carcinogenesis, cell survival, invasion and metastasis. Despite the data on elevated COX-2 expression in breast neoplasia, the mechanism of upregulation remains unclear. This study aims to evaluate COX-2 expression in DCIS in comparison to MICB in order to establish the importance of this marker as a predictor of microinvasion and the correlation with Van Nuys classification.Study design: A retrospective study was performed on archival paraffin-embedded formalin-fixed tissue samples of DCIS and MICB from women who had undergone surgery. The COX-2 expression was assayed by immunohistochemistry using a specific polyclonal anti-human COX-2 antibody. Expression was scored in a scale 0 (absent) to 4 (strong) based on the extent and intensity of tumour cell staining.Results: Fifty-two cases of DCIS and 40 of MICB were studied. In all cases, COX-2 was detected in the cytoplasm of tumour cells, and elevated COX-2 expression was observed in Van Nuys high-grade CDIS cases compared with low and intermediate grades (p<0.05). In addition, enhanced COX-2 expression was significantly higher in DCIS component from MICB patients (82% cases) than in DCIS pure patients (40.4%) (p<0.05). In a multivariate model which includes age, tumour size, mammography, histological grade and COX-2 expression, we found COX-2 positivity to be an independent factor for microinvasion (OR 3.90; 95% CI 1.88–14.3).Conclusions: COX-2 is associated to higher Van Nuys grades of breast CDIS, and could be a molecular marker to identify the cases of DCIS which could progress to MICB.Condensation: COX-2 as a molecular marker in microinvasive carcinoma of the breast.

Unbalanced translocation 6p/16q (partial monosomy 6p and trisomy 16q): Prenatal diagnosis and cytogenetics - Corrected Proof

2010-02-26

Abstract: Unbalanced translocation 6p/16q in one fetus is a very rare event and the prenatal sonographic findings have never been published before. We will give a short overview of the literature along with a case report focussing on prenatal ultrasound features and molecular cytogenetic analysis.Case description: A 21-year-old primigravid woman presented with a singleton pregnancy at 19 weeks’ gestation. The fetus revealed a mild hydrocephalus, a ventricular septal defect (VSD), a Dandy–Walker malformation as well as an intrauterine growth retardation (IUGR) and limb anomalities. MLPA analysis from amniotic fluid cells showed an unbalanced translocation from the subtelomeric region of chromosome 6p to the subtelomeric region of chromosome 16q. Karyotype of the fetus was 46, XX.ishder(6)t(6;16)(p2?5;q?13)(pVYS246A+, pVYS228B−, pVYS229A+). Despite the karyotype the mother decided not to interrupt pregnancy. The fetus died in utero within the 39th week of gestation and was delivered vaginally after labour induction, with a birth weight of 1815g.Prenatal FISH and MLPA studies can be very important to help outline the chromosomal area of deletion and duplication and the sonographic findings forebode the cytogenetic region of interest.Subsequent to the processing of the case, a complete Medline search was conducted to review previous cases with similar genetic alterations.

Response to Letter to the Editor Re: “Preterm birth and low birth weight among in vitro fertilization singletons: A systematic review and meta-analyses” - Uncorrected Proof

Sarah D. McDonald — 2010-02-25

Thank you for your interest in our manuscript Preterm birth and low birth weight among in vitro fertilization singletons: A systematic review and meta-analyses. Our inclusion criteria as stated in the Methods section required a control group of spontaneously-conceived singletons and studies not meeting this, including yours, were not eligible for inclusion. Thank you again for your attention to our meta-analysis.

Coagulation versus excision of primary superficial endometriosis: A 2-year follow-up - Uncorrected Proof

2010-02-24

Abstract: Objective: Even the common mild forms of endometriosis can strongly affect quality of life due to dysmenorrhea, dyspareunia, dyschezia, or subfertility. We compared the effectiveness of the two laparoscopic methods, coagulation versus excision, for intraperitoneal superficial endometriosis with regard to recurrence and symptom control.Study design: In a retrospective analysis we evaluated the postoperative follow-up of 79 patients, aged 16–42, with superficial manifestation of endometriosis (median rASRM score 9.2) operated on in the Department of Gynecology and Obstetrics at the University Hospital of Jena. Forty-three patients were treated by electrocoagulation and 36 underwent sharp excision. Therapy success was evaluated by using a questionnaire after a mean follow-up of 29 months. Patients were interviewed about pain associated with endometriosis such as dysmenorrhea, dyspareunia, dyschezia and possible medical treatment after surgery. We evaluated the number of surgically proven relapses and questionnaire results using a pain score on an ordinal scale (1–5) for the three categories dysmenorrhea, dyspareunia, and dyschezia.Results: Both treatment methods resulted in a low number of endometriosis-related symptoms after surgical intervention and in recurrences of 2.8% in the coagulation group and 18.6% in the excision group. The recurrence rate in the coagulation group was lower (p=0.001). The coagulation group was also presented with a significantly lower postoperative pain score at our long-term follow-up (p=0.0067).Conclusion: In cases of superficial endometriosis, laparoscopic surgery achieved low recurrence rates and good symptom control. Compared to sharp excision the use of bipolar electrocoagulation might result in fewer endometriosis-related symptoms as well as fewer relapses with need for surgical re-intervention after a more than 2-year interval. Due to the retrospective, non-randomized character of this study the results should be interpreted carefully. Further prospective studies are needed to assess the value of both surgical approaches in the treatment of endometriosis.

Cabergoline versus bromocriptine for symptomatic treatment of premenstrual mastalgia: A randomised, open-label study - Corrected Proof

Yavuz Aydin, Alev Atis, Semih Kaleli, Seyfettin Uludağ, Nimet Goker — 2010-02-24

Abstract: Objective: To compare the effectiveness and side effects of cabergoline with bromocriptine for the symptomatic treatment of cyclic mastalgia as a part of the premenstrual syndrome.Study design: 140 women with premenstrual mastalgia were enrolled in this randomised, open-label trial. Two groups were created (bromocriptine and cabergoline) and consisted of 61 and 67 patients respectively at the end of trial. Bromocriptine was administered 5mg daily during second half of the menstrual cycle. Cabergoline was administered 0.5mg weekly during the second half of the cycle. Relief of pain was evaluated using a visual analog scale (VAS). The mean percentage decrease in score for all patients in each group was calculated. A 50% or greater decrease at the end of the third month from the basal VAS score was accepted as a positive response to drug therapy. Data regarding side effects were collected systematically with review of a symptom diary.Results: The positive response rates to treatment were similar (bromocriptine 66.6% and cabergoline 68.4%). The pain reduction rates for each month were also similar. Moreover, the pain reduction rate was maximum in the second month of treatment for both groups. Vomiting (28%), nausea (39%) and headaches (23%) recorded in the bromocriptine group were significantly more frequent than vomiting (4.5%), nausea (20.9%) and headache (6%) recorded in the cabergoline group (p=0.023, p=0.001, p=0.006 respectively). A difference in the rate of dizziness was not statistically significant (26.4% vs. 14.9%). There was no correlation between the baseline breast pain score and prolactin level but post-treatment pain reduction was well correlated with prolactin level.Conclusions: Cabergoline is as effective as bromocriptine for the treatment of cyclic mastalgia but has minimal side effects compared to bromocriptine.

Perinatal health of IVF and ICSI children - Corrected Proof

Reija Klemetti — 2010-02-24

We read with interest the review on preterm birth and low birth weight among in vitro fertilization (IVF) singletons . However, the review lacked our study, which is one of the largest (N=4559 including 2930 singletons) cohort studies on health of IVF children . Our study was based on health registers and included IVF and ICSI children. The findings were similar to those cited in the review. After adjusting for mother's age, living area, marital status, parity, and socioeconomic position, IVF/ICSI singletons had significantly increased risks for preterm birth, low birth weight, and some other adverse perinatal outcomes. The adjusted odds ratio (OR, 95% CI) for preterm birth (<37 gestational weeks) was 1.72 (1.51–1.96), for very preterm birth (<32 gestational weeks) was 2.06 (1.56–2.76), for low birth weight (<2500g) was 1.60 (1.37–1.87), and for very low birth weight (<1500g) was 2.17 (1.64–2.88). In addition, we found that IVF/ICSI singletons had increased risks for having special care (1.36, 1.21–1.53), respiratory treatment (1.76, 1.34–2.31), and hospitalization for 7 or more days after the birth (1.43, 1.26–1.61).

An epidemiological survey of bacterial vaginosis, vulvovaginal candidiasis and trichomoniasis in the Tibetan area of Sichuan Province, China - Corrected Proof

2010-02-24

Abstract: Objective: To determine the prevalence and risk factors of vaginitis in the Tibetan area of Sichuan Province in China.Study design: Between September and October 2007, 397 women were surveyed with a questionnaire and diagnosed with bacterial vaginosis (BV), vulvovaginal candidiasis (VVC) and trichomoniasis by Gram stain and microscopy of vaginal swabs.Results: The prevalence of BV, VVC, and trichomoniasis was 51.6%, 6.5%, and 2.5%, respectively. Multivariate logistic modeling showed that risk factors associated with having vaginitis due to any of the three infections were older age and Tibetan ethnicity.Conclusion: BV appears to be the predominant cause of vaginitis, followed by VVC, and trichomoniasis. Risk factors for vaginitis include being more than 49 years old and of Tibetan ethnicity.

A comprehensive assessment of outcomes in pregnancies conceived by in vitro fertilization/intracytoplasmic sperm injection - Corrected Proof

2010-02-24

Abstract: Objective: To assess the association between in vitro fertilization (IVF) with or without intracytoplasmic sperm injection (ICSI) and adverse birth outcomes.Study design: Retrospective cohort study involved IVF/ICSI patients who were treated in the Ottawa Fertility Centre from 1996 to 2005 with a viable pregnancy (>20 weeks of gestation) and mothers who conceived naturally.Results: Eleven of the 1044 infants conceived with IVF/ICSI (1.1%) and 7 of the 1910 naturally conceived infants (0.4%) had congenital heart defects (P<0.01). Five of the 138 infants (3.6%) born to mothers with a body mass index>30 and conceived by IVF/ICSI had congenital heart defects, compared with none in the 240 infants born to mothers with a body mass index>30 and conceived naturally (P<0.01).Conclusion: Infants conceived with use of IVF/ICSI have three times as high a risk of a congenital heart defect as naturally conceived infants.

Letrozole and norethisterone acetate in colorectal endometriosis - Uncorrected Proof

2010-02-23

Abstract: Objective: Up to now limited attention has been given to the medical treatment of bowel endometriosis. This study evaluates the efficacy of aromatase inhibitors and norethisterone acetate in treating pain and gastrointestinal symptoms caused by bowel endometriosis.Study design: This prospective pilot study included six women with colorectal endometriosis; all women had intestinal nodules infiltrating at least the muscularis propria of the bowel and did not have a stenosis of the bowel lumen >60%; the patients suffered from pain and intestinal symptoms. The study subjects received letrozole (2.5mg/day) and norethisterone acetate (2.5mg/day) continuously for 6 months. The presence and intensity of symptoms were evaluated before starting the treatment, and after 3 and 6 months of treatment.Results: The double-drug regimen improved pain, non-menstrual pelvic pain, deep dyspareunia, dyschezia, symptoms mimicking diarrhoea-predominant irritable bowel syndrome, intestinal cramping, abdominal bloating and passage of mucus in the stools, and 67% of the patients declared that the treatment improved their gastrointestinal symptoms.Conclusions: The administration of letrozole and norethisterone acetate reduces pain and gastrointestinal symptoms of women with colorectal endometriosis, particularly when patients suffer from symptoms mimicking diarrhoea-predominant irritable bowel syndrome.

Women with asymptomatic cervical polyps may not need to see a gynaecologist or have them removed: An observational retrospective study of 1126 cases - Corrected Proof

Mayada T.S. Younis, Samina Iram, Bilal Anwar, Ayman A.A. Ewies — 2010-02-19

Abstract: Objectives: (1) To determine the prevalence of pathology in cervical polyps and whether referring and/or removing them is justified, (2) to assess the frequency of associated endometrial pathology and whether investigating the uterine cavity is warranted, and (3) to estimate the financial costs of processing cervical polyps.Study design: Retrospective review of the histopathology database and case notes of women who had cervical polyps examined at the pathology department of Ipswich Hospital, UK, over a seven-year period from 01/01/2002 to 31/12/2008.Results: The number of cervical polyps removed from 988 women was 1126. Each case of polyps was considered as a separate episode. The recurrence rate was 15%. All polyps were benign except two (0.2%) symptomatic polyps that showed high grade cervical intraepithelial neoplasia. The cost of referring women with cervical polyps (excluding women aged >45 years with abnormal bleeding and those with abnormal smear) to see a gynaecologist and of examining polyps histologically was estimated to be £94816.40. Further investigations to assess the cervix and/or uterine cavity which were performed for 133 women (14.3%), because of the cervical polyps and for no other clinical indication, showed no significant pathology at cost of £41195.54.Conclusion: Our data do not justify referring women with asymptomatic cervical polyps to see a gynaecologist. Further, removing these polyps and investigating the uterine cavity is not warranted. A policy of removing polyps from only symptomatic women or those with abnormal smear and limiting histological examination to these polyps would result in significant savings.

Streptococcus agalactiae colonization and correlation with HIV-1 and HBV seroprevalence in pregnant women from Zimbabwe - Corrected Proof

Rooyen Tinago Mavenyengwa, Sylvester Rogers Moyo, Svein Arne Nordbø — 2010-02-19

Abstract: Objective: To estimate the frequency of coinfection of Streptococcus agalactiae or Group B streptococcus (GBS), hepatitis B virus (HBV) and HIV-1 in pregnant women and evaluate any association between them.Study design: Three health centres from rural, rural–urban and urban communities were selected and at least 369 pregnant women had samples available for simultaneous analysis of GBS colonization rates, and HIV and HBV seroprevalence rates. Swabs were collected at two different stages in the course of pregnancy and at delivery to isolate GBS. Serum samples were collected at recruitment for analysis of standard HBV seromarkers and the presence of HIV-1. The odds ratio (95% CI) and χ2 tests were used for analysis of the results at a level of significance set at ≤0.05.Results: Single infections with GBS, HBV and HIV-1 were found to be 35.7%, 3.3% and 20.1% respectively. The HIV-1 prevalence rate was 14.1%, 23.1% and 19.5% for the rural, rural–urban and urban communities respectively. The HBV prevalence rates were 3.3%, 3.0% and 3.7% for Chitsungo, Guruve and Harare respectively. There were no significant differences in HBV prevalence rates among the three communities. Simultaneous coinfection with GBS, HBV and HIV-1 was registered in only one (0.3%) of the women. The prevalence of coinfection with GBS/HBV, GBS/HIV-1 and HBV/HIV-1 was 0.5%, 9.2% and 0.8% respectively. The prevalence rate of GBS/HIV-1 coinfection was significantly higher in the rural–urban than the two other communities (p<0.001).Conclusions: There was a high prevalence of single infections with GBS and HIV-1 but a lower HBV prevalence among pregnant women studied compared to other studies in Zimbabwe. Coinfection with GBS/HIV-1 was more common than GBS/HBV and HBV/HIV-1. Coinfection with HIV-1 and HBV did not differ between GBS colonized and GBS negative women. There was no difference in GBS colonization rate between HIV-1 positive and HIV-1 negative pregnant women.

Effect of alfentanil dosage during oocyte retrieval on fertilization and embryo quality - Uncorrected Proof

Ann-Louise Gejervall, Kersti Lundin, Elisabet Stener-Victorin, Christina Bergh — 2010-02-18

Abstract: Objective: A possible negative effect of pain-relieving analgesics used during oocyte retrieval on fertilization and embryo development has been discussed. This study examines whether alfentanil dosage adversely affects fertilization and/or embryo quality.Study design: In a retrospective observational study the effect of different doses of alfentanil on two primary endpoints, fertilization rate and good quality embryo (GQE) rate, were compared in 663 women.Results: In group A (≤0.5mg alfentanil) and group B (>0.5mg alfentanil) mean fertilization rate was 0.6±0.3 versus 0.6±0.2 (P=0.678, adjusted P=0.937, 95% CI for the difference −0.041; 0.044) and mean GQE rate was 0.6±0.3 versus 0.5±0.3 (P=0.207, adjusted P=0.179, 95% CI for the difference −0.015; 0.078), respectively. A paired comparison of 65 women who underwent repeated IVF cycles found that, compared with ≤0.5mg alfentanil, doses of >0.5mg alfentanil had no adverse effects on fertilization rate (mean difference 0.05±0.3, P=0.231, 95% CI −0.02; 0.12) or GQE rate (mean difference −0.02±0.4, P=0.970, 95% CI −0.12; 0.09).Conclusion: The amount of alfentanil is not associated with adverse effects on fertilization rate, embryo development, or clinical pregnancy rate, which is reassuring and indicates that women can be offered adequate pain relief.

Robotic hysterectomy versus conventional laparoscopic hysterectomy: Outcome and cost analyses of a matched case–control study - Corrected Proof

Dimitri Sarlos, LaVonne Kots, Nebojsa Stevanovic, Gabriel Schaer — 2010-02-18

Abstract: Objective: Robotic surgery, with its technical advances, promises to open a new window to minimally invasive surgery in gynaecology. Feasibility and safety of this surgical innovation have been demonstrated in several studies, and now a critical analysis of these new developments regarding outcome and costs is in place. So far only a few studies compare robotic with conventional laparoscopic surgery in gynaecology. Our objective was to evaluate our initial experience performing total robot-assisted hysterectomy with the da Vinci® surgical system and compare peri-operative outcome and costs with total laparoscopic hysterectomy.Study design: For this prospective matched case–control study at our institution, peri-operative data from our first 40 consecutive total robot-assisted hysterectomies for benign indications were recorded and matched 1:1 with total laparoscopic hysterectomies according to age, BMI and uterus weight. Surgical costs were calculated for both procedures. Surgeons’ subjective impressions of robotics were evaluated with a self-developed questionnaire.Results: No conversions to laparotomy or severe peri-operative complications occurred. Mean operating time was 109 (113; 50–170) min for the robotic group and 83 (80; 55–165) min for the conventional laparoscopic group. Mean postoperative hospitalisation for robotic surgery was 3.3 (3; 2–6) days versus 3.9 (4; 2–7) days for the conventional laparoscopic group. Average surgical cost of a robot-assisted laparoscopic hysterectomy was €4067 compared to €2151 for the conventional laparoscopic procedure at our institution. For the robotic group wider range of motion of the instruments and better ergonomics were considered to be an advantage, and lack of direct access to the patient was stated as a disadvantage.Conclusion: Robot-assited hysterectomy is a feasible and interesting new technique with comparable outcome to total laparoscopic hysterectomy. Operating times of total laparoscopic hysterectomy seem to be achieved quickly especially for experienced laparoscopic surgeons. However, costs of robotic surgery are still higher than for conventional laparoscopy. Randomised clinical trials need to be conducted to further evaluate benefits of this new technology for patients and surgeons and analyse its cost-effectiveness in gynaecology.

Poor prognosis in cycles following “genuine” empty follicle syndrome - Corrected Proof

2010-02-18

Abstract: Objectives: The aim of this study was to investigate the prognosis in future IVF cycles of patients with empty follicle syndrome (EFS).Study design: EFS cases and their future cycles were reviewed. Clinical pregnancy rate per started cycle was taken as the primary outcome in assessing the future outcome in IVF treatment cycles.Results: A total of 3023 patients underwent 5238 IVF treatment cycles. Twenty-six patients (1%) had a total of 58 (1%) cycles of EFS. Thirteen women went through 32 further IVF treatment cycles following the diagnosis of EFS, yielding only two clinical pregnancies, giving a clinical pregnancy rate of 6.25% per started cycle. In addition, four patients had recurrence in a total of 15 cycles.Conclusions: The occurrence of EFS will indicate poor IVF success in subsequent IVF cycles. Patients with “genuine EFS” should be counselled about the outcome of their future IVF cycles.

Sensorimotor neuropathy associated with endometrioid endometrial carcinoma - Corrected Proof

Hacer Durmuş, Erdem Tüzün, Sema İçöz, Gülşen Akman-Demir, Yeşim Parman — 2010-02-18

While neuropathies associated with uterine and endometrial cancers often arise due to medication side effects or infections, paraneoplastic neuropathy cases have also been rarely reported . A 77-year-old woman was admitted with an 11-month history of progressive numbness/tingling in limbs and difficulty in walking. Neurological findings included reduced vibration sense in the feet, reduced ankle reflexes, ataxic, wide-based gait and positive Romberg's sign. Both iliopsoas muscles were weak (4/5 at Medical Research Council scale). Light touch and pinprick sensations were preserved.

Recurrent miscarriage: Are three miscarriages one too many? Analysis of a Scottish population-based database of 151,021 pregnancies - Corrected Proof

Sohinee Bhattacharya, John Townend, Siladitya Bhattacharya — 2010-02-18

Abstract: Objective: To assess the risk of further miscarriage or preterm delivery in women with a history of miscarriages in previous pregnancies, adjusting for maternal age and smoking.Study design: Retrospective cohort study using all women with first pregnancies recorded between 1950 and 2000 in the Aberdeen Maternity and Neonatal Databank.Exposure was one or more spontaneous miscarriages, while outcomes assessed were further miscarriage or preterm delivery.Results: There were 143,595 pregnancies with none, 6,577 with one, 700 with two, 115 with three and 24 with four consecutive previous miscarriages. The odds of miscarriage were greater in pregnancies following one previous miscarriage than none {adj.O.R. 1.94 (95% C.I. 1.80, 2.09)}. The risk of miscarriage following two miscarriages was greater than in pregnancies following one {adj.O.R. 1.56 (95% C.I. 1.28, 1.90)}. However, there was no further significant increase in odds of miscarriage for pregnancies following three {adj.O.R. 1.37 (95% C.I. 0.86, 2.17)} previous consecutive miscarriages. Odds of spontaneous preterm delivery were greater following one miscarriage than none {adj.O.R. 1.52 (95% C.I. 1.36, 1.69)} but no further increases in risk were seen.Conclusion: After adjusting for age and smoking, the risk of a further miscarriage increased sequentially in women who had one and two miscarriages. Three miscarriages did not increase the odds any further. One miscarriage was associated with an increased chance of spontaneous preterm delivery, but two or three miscarriages did not increase the odds any further.

Detection of paternal alleles in maternal plasma for non-invasive prenatal diagnosis of β-thalassemia: A feasibility study in southern Chinese - Corrected Proof

Kaimin Chan, Irene Yam, K.Y. Leung, Mary Tang, T.K. Chan, Vivian Chan — 2010-02-18

Abstract: Objective: To evaluate in maternal plasma, the efficacy of detecting the paternal β-gene mutation and informative single nucleotide polymorphisms (SNPs) linked to the paternal-mutant or -normal allele in non-invasive prenatal diagnosis (NIPND).Study design: In 20 at-risk pregnancies, using the allele-specific arrayed primer extension (AS-APEX) technology of the previously published “Thalassemia” array, cyanine-5-deoxycytosine triphosphate (Cy5-dCTP) was incorporated into the extended strands to matched PCR-amplified maternal plasma DNA templates, to detect both the paternal β-gene mutation and informative paternal SNPs.Results: Sensitivity experiment showed that 5pg DNA as starting template gave detectable signals on the array. In 13 cases (65%), the paternal-derived β-gene mutation and/or informative mutant-associated SNP were detected. A subsequent invasive procedure was required to determine if the fetus had a β-thalassemia (thal) major or minor genotype. In 3 cases (15%), absence of the paternal mutant or mutant-associated SNP excluded a β-thal major fetus; while in 4 cases (20%), this approach was non-discriminative as both parents carry the same mutation without any informative SNP.Conclusion: This approach was useful in 16 out of 20 (80%) pregnancies at risk for β-thal in southern Chinese.

An increase in systolic blood pressure and abnormal circadian blood pressure regulation in lean women with polycystic ovary syndrome - Corrected Proof

Cemil Kaya, Gogsen Onalan, S. Dinçer Cengiz — 2010-02-18

We have studied 24-h ambulatory systolic blood presssure (SBP) in women with lean polycystic ovary syndrome (PCOS) and in controls. The study group consisted of 45 lean patients with PCOS (age, 24.2±4.4yr; body mass index (BMI), 24.9±6.1kg/m2) while the control group was composed of 45 age- and BMI-matched healthy subjects. The diagnosis of PCOS was made when ≥2 of the following 3 criteria existed, as proposed at the Rotterdam Consensus Meeting: oligomenorrhea or amenorrhea, clinical hyperandrogenism and/or hyperandrogenemia, and polycystic ovaries . All subjects gave written informed consent and the Ethics Committee of the University of Ufuk approved the study protocol.

Borderline serous papillary tumor arising in a paraovarian cyst - Corrected Proof

Tadashi Terada — 2010-02-17

Paraovarian cyst (PC) is a very common condition. However, tumors arising from PCs are very rare. A 45-year-old Japanese woman consulted our hospital because of abnormal bleeding. Imaging modalities including US, CT and MRI showed a cystic lesion (3.5cm in diameter) in the left adnexa (). MRI further identified a mural nodule measuring 0.8cm in diameter within the cystic lesion (). A cystectomy was performed under the clinical diagnosis of left ovarian malignancy. At operation, the cyst was a PC located in the mesosalpinx. It was remote from and did not attach to the ovary and fallopian tube. Frozen sections showed borderline serous papillary tumor within the PC. Further resection was not performed. The patient is now healthy 5 months after the operation.

Adnexal torsion: a literature review - Corrected Proof

Cyrille Huchon, Arnaud Fauconnier — 2010-02-17

Abstract: This review of the literature focuses on the diagnosis and surgical management of adnexal torsion. Diagnosis of adnexal torsion is difficult and is based on a range of elements obtained by questioning, clinical examination and additional investigations. Pelvic and Doppler ultrasonography are often incapable of revealing this pathology. When adnexal torsion is suspected and diagnosis can only be achieved by surgery, arrangements should be made for laparoscopy as soon as possible. Treatment consists essentially of untwisting the adnexa, even when necrosed, and completed as required by treatment of any cyst present and/or ligamentopexy.

Influence of habitual physical activity on body composition, fat distribution and metabolic variables in early postmenopausal women receiving hormonal therapy - Corrected Proof

S. Lara, G. Casanova, P.M. Spritzer — 2010-02-17

Abstract: Objective: To determine whether there is an association between the level of habitual physical activity, body composition and anthropometric and metabolic variables in postmenopausal patients before and after hormone replacement therapy (HRT).Study design: Thirty-four healthy, recent postmenopausal women (50±2.7 years; 23.8±10 months since menopause) consulting for symptoms of estrogen deficiency were included in the study. Anthropometric assessment, percent of body fat (BF) estimated by skinfold measures, and metabolic evaluation were performed before and 4 months after the start of HRT, which included non-oral or low-dose oral preparations. The status of physical activity was defined by counting steps with a pedometer. Patients were stratified as active (6000 steps ore more per day) or inactive (fewer than 6000 steps per day). Results are expressed as mean±SD or median and interquartile range. log 10 transformation was used to normalize the distribution of non-Gaussian variables. ANOVA for repeated measures was performed for the active and inactive groups, before and after HT. Pearson correlation coefficient was used to investigate the relationship between anthropometric and metabolic variables and habitual physical activity.Results: BMI and BF did not change with HRT in comparison with baseline. In contrast, a decline was observed in waist circumference (WC) and waist to hip ratio (WHR) after HRT in both active and inactive women (P<0.01). While triglycerides and glucose did not change after HRT, total and LDL-cholesterol decreased from baseline. In contrast, after HRT, active patients were found to have lower BF than inactive women (active: 25.4±2.5; inactive: 26.6±2, P=0.01). There was a significant negative correlation between habitual physical activity (number of steps per day) and BF (r=−0.36, P=0.04). After HRT, when only active patients were considered, a significant negative correlation was found between the number of steps and WC (r=−0.42, P=0.04) and WHR (r= −0.58, P=0.03).Conclusion: Habitual physical activity plays a major role in preserving a favorable cardiovascular profile in postmenopausal patients using HRT.

Suffering in silence: pregnant women's experience of urinary incontinence in Zaria, Nigeria - Corrected Proof

2010-02-17

Abstract: Objective: To determine the prevalence and severity of urinary incontinence during pregnancy in Zaria, Nigeria.Study Design: This was a descriptive, cross-sectional study in which 204 apparently healthy pregnant women attending routine antenatal care (ANC) at the Ahmadu Bello University (ABU) Teaching Hospital in Zaria, Nigeria were screened for urinary incontinence using the International Consultation on Incontinence Questionnaire on Urinary Incontinence (ICIQ-UI Short Form) UK English Version. Nurses working in the antenatal clinic were trained on how to help respondents (most of whom were not literate) to respond to the questions. Uni- and bivariate analysis was performed on the data using SPSS version 15 for Windows.Results: The prevalence rate of all types of urinary incontinence during pregnancy was 21.1% in the study population. Stress urinary incontinence was the most common type accounting for 60.5%. The majority of the expectant mothers (74.4%) reported leaking no more than once a week; in 90% of them the volume was small in amount. The modal ICIQ score for urinary incontinence was 3 for the study population. The majority (83.4%) of the incontinent women felt their symptom did not interfere with their daily routines.Conclusions: About one-fifth of pregnant women in this setting experienced urinary incontinence which they did not report to their primary care providers. Awareness needs to be created for antenatal clients and providers on how to recognize symptoms and manage them. The ICIQ questionnaire has simplified this process.

Effect of ovarian stimulation with human menopausal gonadotropin and recombinant follicle stimulating hormone on the expression of integrins alpha(3), beta(1) in the rat endometrium during the implantation period - Corrected Proof

Fatih Sendag, Ayşin Akdogan, Kemal Ozbilgin, Gülşen Giray, Kemal Oztekin — 2010-02-17

Abstract: Objective: To investigate the effect of exogenous ovarian stimulation with human menopausal gonadotropin (hMG) and recombinant follicle stimulating hormone (rFSH) on the expression of integrins alpha(3), beta(1) in the rat endometrium during implantation.Study design: Following three successive normal estrous cycles the animals were divided into five groups: Group I (n=10, control group) received no medication; Group II (n=10) received 10 units of hMG; Group III (n=10) received 20 units of hMG; Group IV (n=10) received 10 units of rFSH; Group V (n=10) received 20 units of rFSH at midday of middiestrous. The rats were then mated with fertile males. The animals were sacrificed on the day of implantation. The uterine horns were placed in fixative and paraffin blocks of the tissue were cut in 5μm sections. The tissues were stained with primary antibodies; monoclonal anti-integrin alpha(3) and monoclonal anti-integrin beta(1) using immunohistochemical methods. The staining intensities of alpha(3) and beta(1) integrins were calculated separately for epithelium and stroma in each group.Results: Staining intensities of alpha(3) and beta(1) integrins in both the epithelium and the stroma were significantly lower in the treatment groups than the control group (p<0.05).Conclusion: Ovarian stimulation by low and high doses of HMG and rFSH may have an effect on endometrial receptivity, possibly via a decrease in expression of integrins in the endometrium during the implantation period.

Tumor necrosis factor α (−308), interleukin-6 (−174) and interleukin-10 (−1082) gene polymorphisms in polycystic ovary syndrome - Corrected Proof

Pervin Vural, Sevgin Değirmencioğlu, Neslihan Y. Saral, Cemil Akgül — 2010-02-17

Abstract: Objective: The imbalance between pro- and anti-inflammatory cytokines and polymorphism of cytokine genes may play a role in the etiology of the polycystic ovary syndrome (PCOS). The aim of this study was to investigate the association of polymorphisms of TNFα, IL-6 and IL-10 genes with the occurrence and the clinical/laboratory characteristics of PCOS in the Turkish population.Study design: Single nucleotide polymorphisms (SNPs) of TNFα (−308 G/A), IL-6 (−174 G/C), IL-10 (−1082 G/A) genes in DNA from peripheral blood leukocytes of 97 PCOS patients and 95 healthy control women were investigated.Results: There is a tendency toward lower frequency of the IL-6 CC genotype and C allele among PCOS women compared with healthy controls although the difference did not reach a significant level. No notable differences were observed in allele or genotype frequencies for TNFα and IL-10 genes between groups. The concomitant presence of wild homozygous TNFα genotype together with mutant IL-6 C allele has a protective effect against PCOS with an OR=0.45 (95% CI=0.23–0.86). While TNFα (−308) and IL-10 (−1082) genotypes did not influence clinical/laboratory parameters in PCOS, IL-6 (−174) CC or pooled CG+CC genotypes have lower glucose, insulin, HOMA, cholesterol, triglyceride, and LDL-C, and higher GIR and HDL-C values than GG genotypes.Conclusions: We suggest that the IL-6 promoter region polymorphism may be related to occurrence and metabolic abnormalities seen in PCOS in the Turkish population. However, more studies with larger sample size are necessary to support our findings in other populations before any statement can be made about the relationship between PCOS and cytokine polymorphism.

Suspicious axillary lymph nodes in patients with unremarkable imaging of the breast - Corrected Proof

F.D. Schwab, H. Burger, M. Isenschmid, A. Kuhn, M.D. Mueller, A.R. Günthert — 2010-02-17

Abstract: Objective: The aim of this study was to evaluate the pathological findings and the method of tissue harvesting in those patients who have both suspicious axillary lymph nodes and normal imaging of the breast.Study design: From January 2005 to June 2008 all female patients who underwent opportunistic screening mammography and ultrasound examination of the breast and the axilla, and who were found to have suspicious axillary lymph nodes seen on ultrasound examination, were retrospectively analysed. Tissue harvesting was done by fine needle aspiration, core needle biopsy, or open biopsy.Results: Out of approximately 7500 screened patients, 51 were found to have suspicious axillary lymph nodes on ultrasound with unremarkable breast ultrasound and mammography. Histopathology and/or cytology of these lymph nodes showed 33 benign and 18 malignant results. Of the malignant results only 1 case was an occult invasive lobular breast carcinoma detected afterwards on breast magnetic resonance imaging. Eleven cases were non-Hodgkin lymphomas, 4 were malignant melanomas, and 2 were metastases from the lower genital tract. Diffuse cortical thickening and complete loss of echo texture were the only features on ultrasound predicting malignancy. Palpation and mean size of the evaluated lymph nodes had no predictive value for malignancy. In the 33 cases of non-malignant pathology 9 patients showed patterns of specific infectious disease, including 4 patients with tuberculosis.Conclusion: Suspicious lymph nodes of the axilla seen on ultrasound rarely indicate occult breast cancer but show a variety of other malignancies and generalised infectious disease requiring further treatment. Fine needle aspiration and/or core needle biopsy are both sufficient methods for clarification in the majority of cases.

A comparison between monophasic levonorgestrel–ethinyl estradiol 150/30 and triphasic levonorgestrel–ethinyl estradiol 50–75–125/30–40–30 contraceptive pills for side effects and patient satisfaction: A study in Iran - Corrected Proof

Maryam Kashanian, Farangis Shahpourian, Omolbanin Zare — 2010-02-15

Abstract: Objective: Oral contraceptive pills (OCPs) are one of the most effective reversible and accessible contraceptives, and patient acceptance for their use depends partly on the unfavorable adverse effects. The present study compared the two kinds of OCPs (monophasic; levonorgestrel (LNG)–ethinyl estradiol (EE) 150/30 versus triphasic; LNG–EE 50–75–125/30–40–30) for adverse effects and patient satisfaction.Study design: A randomized clinical trial was performed on 314 women who used OCPs for the first time, as their contraception, for 6 months. Overall, 1884 cycles were studied. In the monophasic group (n=159 who finally finished the study), monophasic pills LNG–EE 150/30mcg, and in the triphasic group (n=155 who finally finished the study), triphasic pills LNG–EE 50–75–125/30–40–30 mcg were used. Statistical analysis was performed using SPSS 10: Chi square test, Fisher exact test and Student's t-test were used.Results: There were no significant differences between the two groups for common side effects, including nausea, headache, nervousness, facial hyperpigmentation (chloasma), and body weight (increase or decrease) but breakthrough bleeding and spotting (BTB/S) were less in the triphasic group, occurring in 30 cycles (18.86%) versus 10 cycles (6.45%), P=0.009*. Patient satisfaction for the two OCPs was similar and high. The rates of side effects were low.Conclusion: It seems that the monophasic and triphasic pills are similar according to patient satisfaction and side effects; therefore there is no benefit of one over the other except for BTB/S, for which triphasic is superior.

Exposure to herbal products during pregnancy and the risk of preterm birth - Corrected Proof

Krystel Moussally, Anick Bérard — 2010-02-15

Use of herbal products (HP) during pregnancy is common despite the lack of evidence on their safety during gestation . Furthermore, few human studies have specifically focused on the association between HP use during gestation and the risk of preterm birth despite the increasing rate of prematurity in recent years . Therefore we aimed to quantify the association between HP use, more specifically flax, chamomile, peppermint, and green tea – the most prevalent HP used in our study population – during the last two trimesters of pregnancy (>15th weeks of gestational age (GA)) and the risk of prematurity. Data were obtained from the Quebec Pregnancy Registry (including data on 109,344 women) and a self-administered questionnaire was mailed to 8505 women aged 15–45 years selected from the Registry. A detailed description of the Registry, the questionnaire from which information on HP use was obtained, and the methodology has been described previously . Briefly, the Quebec Pregnancy Registry put in place with the linkage between the databases of the Régie de l’assurance maladie du Québec (RAMQ), hospital discharge (MedEcho), and birth and death registry (ISQ) of Quebec, includes medical, pharmaceutical and hospital data on all pregnancies in Quebec. All diagnoses are physician-based, and gestational age is validated by ultrasound. The study has received ethics approval from Ste-Justine's Hospital ethics committee and the Commission d’accès à l’information du Québec.

Concurrent endometrial carcinoma following hysterectomy for atypical endometrial hyperplasia - Corrected Proof

2010-02-15

Abstract: Objective: To evaluate the prevalence of concurrent endometrial carcinoma in women diagnosed with atypical endometrial hyperplasia (AEH) by endometrial biopsy.Study design: We retrospectively analyzed the medical records of 126 patients who underwent hysterectomies for AEH diagnosed by endometrial biopsy from 1999 to 2008. AEH was initially diagnosed by dilatation and curettage (98 cases) or endometrial biopsy with a Z-sampler (24 cases). The remaining four cases were diagnosed by hysteroscopic polypectomy. The results of the endometrial biopsies were graded on an ordinal scale and were compared with pathologic features obtained at the hysterectomy.Results: In patients preoperatively diagnosed with AEH by biopsy, hysterectomy specimens revealed a rate of simple or complex endometrial hyperplasia without atypia of 27% with AEH and normal proliferative phases found in 54.7 and 7.9% of specimens, respectively. The incidence of endometrial carcinoma was considerably high (13/126, 10.3%). Eleven of 13 cases were confined to the endometrium and the remaining two were located at the adenomyosis without myometrial invasion. All patients with endometrial carcinoma displayed coexisting atypical complex hyperplasia following hysterectomy.Conclusions: Biopsy specimens showing AEH, particularly atypical complex hyperplasia, are associated with a risk of coexisting endometrial carcinoma. When considering management strategies for women with a biopsy diagnosis of AEH, clinicians should take into account the considerable rate of concurrent endometrial cancer and the discrepancy with pathologic diagnosis. Treatment modalities may differ depending on population as the rates of concurrent endometrial cancer with AEH and myometrial invasion vary by geographical location.

Prevention of postoperative peritoneal adhesions - Uncorrected Proof

Remah M. Kamel — 2010-02-15

Abstract: Adhesions are bands of tissue that connect organs together. They are frequently reported after surgery and remain a major problem for health and society. Efforts to prevent or reduce peritoneal adhesions mostly have been unsuccessful, hindered by their empirical basis, lack of a good predictive animal model, and complexity of adhesion pathogenesis. Although a good surgical technique is a crucial part of adhesion prevention, technique alone cannot effectively eliminate adhesions. Thus there remains room for further research. A literature review of published experimental and clinical studies of adhesion prevention was carried out at the University of Bristol library website (MetaLib®) with a cross-search of seven different medical databases (AMED—Allied and Complementary Medicine Database, BIOSIS Previews on Web of Knowledge, Cochrane Library, Embase, and the Medline on Web of Knowledge, OvidSP and PubMed) by using keywords to explore the progress in different surgical strategies and adjuvant materials used to prevent adhesion formation and reformation. By the end of the study, recommendations could be formulated for surgeons to follow during operations to prevent, as much as possible, postoperative adhesions.

Comparison of the effects of raloxifene and anastrozole on experimental endometriosis - Corrected Proof

Devrim Altintas, Arif Kokcu, Bedri Kandemir, Migraci Tosun, Mehmet B. Cetinkaya — 2010-02-15

Abstract: Objective: To compare the efficacies of anastrozole and raloxifene on endometriosis.Study design: A randomized, placebo-controlled, single-blind, experimental study was performed on 45 adult Wistar female rats in the Experimental Surgery Laboratory at Ondokuz Mayis University in Turkey. Endometrial tissues were implanted on the abdominal peritoneum in 45 rats. Six weeks later, the implant volumes were measured (volume-1) by performing a second laparotomy. Rats were randomized to one of three equal study groups. Saline solution (0.1cc/rat/week, subcutaneously) was administered to group 1 (control group), anastrozole (0.004mg/rat/day, orally) to group 2 (anastrozole group), and raloxifene (0.24mg/rat/day, orally) to group 3 (raloxifene group) for 8 weeks. At the end of administration, a third laparotomy was performed to remeasure implant volumes (volume-2), and implants were totally excised for histopathologic examination. Volume-1 and volume-2 within the groups, as well as stromal and glandular tissues between the groups, were compared.Result(s): In the anastrozole and raloxifene groups, volume-2 values were significantly lower than those of volume-1. When compared to the control group, in both anastrozole and raloxifene groups, while glandular tissue scores were found significantly lower, stromal tissue scores were not different than that of the control group. There was no significant difference between both the GT and ST scores of the anastrozole and raloxifene groups.Conclusion(s): Anastrozole and raloxifene were seen to have caused equally the regression of the experimental endometriosis statistically significantly.

Effect of palmitoylethanolamide–polydatin combination on chronic pelvic pain associated with endometriosis: Preliminary observations - Corrected Proof

Ugo Indraccolo, Fabrizio Barbieri — 2010-02-11

Abstract: Objective: Endometriosis is a chronic oestrogen-dependent gynaecological disorder, the most common symptom of which is pain. Inflammation can be considered one of the major causes of pain in endometriosis. In particular, degranulating mast cells have been found in significantly greater quantities in endometriotic lesions than in unaffected tissues. The increase in activated and degranulating mast cells is closely associated with nerve structures in painful endometriotic lesions. These observations indicate that inflammation due to mast cells may contribute to the development of pain and hyperalgesia in endometriosis. Controlling mast-cell activation may therefore relieve the pain associated with endometriotic lesions.Study design: Four patients presenting an endometriosis-related pain intensity ≥5 (visual analogue scale for pain, or VAS) were enrolled and monitored during 3 months of the following treatment: oral palmitoylethanolamide 400mg and polydatin 40mg, twice daily for 90 days. Deep dyspareunia, dyschezia, dysuria, dysmenorrhoea and analgesic drug use during the 3-month follow-up period were also monitored, with the aim of demonstrating a reliable reduction in chronic pelvic pain.Results: The preliminary results indicate that all patients enrolled experienced pain relief as early as 1 month after starting treatment. Furthermore, a reduction in the analgesic drugs usually employed for pain control was observed in all subjects treated. Additionally, some improvements in endometriotic lesions seemed to be demonstrated by imaging.Conclusions: The palmitoylethanolamide–polydatin combination seems to be very useful in controlling chronic pelvic pain associated with endometriosis. As a result of these findings we have initiated a multi-centre pilot study to verify the effectiveness of this treatment in controlling the chronic pelvic pain associated with endometriosis.

Comparison of day 2 embryo quality after conventional ICSI versus intracytoplasmic morphologically selected sperm injection (IMSI) using sibling oocytes - Corrected Proof

2010-02-10

Abstract: Objective: To evaluate whether intracytoplasmic morphologically selected sperm injection (IMSI) could influence early paternal effects by observing embryo quality at day 2.Study design: The study included 30 couples with at least one of the following criteria: male factor infertility, at least 2 previous failures of implantation or previous miscarriages after IVF/ICSI. Sibling oocytes of each patient were randomly assigned to either the ICSI group or the IMSI group. For IMSI, spermatozoa were selected at 8400× magnification through an inverted microscope equipped with Nomarski differential interference contrast optics, Uplan Apo 100× oil/1.35 objective lens and variable zoom lens. For conventional ICSI, spermatozoa were selected at 400× magnification. An embryo was defined as top quality if there were four identical blastomeres on day 2 with no fragments or multinucleation of blastomeres. Data were analysed using the Wilcoxon and chi-squared tests. The significance level was set at P<0.05. The variables were analysed in relation to the general population and the subpopulations with or without male factor.Results: A total of 331 MII oocytes (30 oocyte retrievals) were selected and injected by the ICSI (n: 172) or IMSI (n: 159) procedure. For IMSI, only spermatozoa classified as morphologically normal at high magnification were used. No differences (P>0.05) in fertilisation rate (ICSI: 70.9%; IMSI: 70.4%), early embryo cleavage rate (ICSI: 66.9%; IMSI: 60.4%) or cleavage rate (ICSI: 99.2%; IMSI: 99.1%) were observed. On day 2, as compared to ICSI, IMSI provided a similar proportion of top quality embryos (ICSI: 57.8%; IMSI: 52.2%; P>0.05). These results were not influenced by the presence or absence of male factor.Conclusion: In terms of embryo quality at day 2, IMSI had the same performance as conventional ICSI. However, we cannot exclude the possibility that IMSI effects occur only as a positive later paternal effect.