Controversies in O&B and Infertility (Athens 14-17 April 2005)

Controversies in Obstetrics
Gynecology and Infertility
Editors:
Z. Ben-Rafael
G. Creatsas
Z. Shoham
Oren Publisher Ltd.

International Proceedings Division
2005
Digitally signed by
DN: CN = , C = IL, O = .
, OU =
Reason: ''. :
Date: 2005.03.20 12:29:30 +02'00'
Proceedings of the congress:
Controversies in Obstetrics
Gynecology and Infertility
Athens, Greece, April 14-17, 2005
Editors:
Z. Ben-Rafael
G. Creatsas
Z. Shoham
Oren Publisher Ltd.

International Proceedings Division
2005
Proceedings of the 7th world Congress Athens Greece. April 14-17 2005
Copyright 2005
E. Oren Publisher Ltd.
All rights reserved. No part of this publication may be reproduced, stored in
retrieval system, or transmitted, in any form, or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission, in
writhing, from the publisher.
Graphic Layout by E. Oren Ltd.
E-mail: oren_e@bezeqint.net
Printed in Israel by E. Oren Ltd. March 2005
Foreword
This is the 7th book of proceedings of Controversies in Obstetrics,
Gynecology and Infertility, which summarizes the 7th World Congress in
Athens, Greece. This book like the congress is solely devoted to controversial issues in the eld and represents a unique source of cutting edge
knowledge for the general practitioner as well as for the expert.
As evident from the content of the book the controversies presented encompass the main unresolved issues of our profession. The various chapters
presented here consolidate the knowledge through evidence-based medicine
but also indicate the gaps and lack of evidence to support certain clinical
practices.
We believe that readers will nd the chapters stimulating as a source
for updating their knowledge and helpful for practical handling of their
patients.
Z. Ben-Rafael
G. Creatsas
Z. Shohamn
CONTENTS
But Surely Not Me: Snakes, Bugs and Us
C. O. Granai . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Gamete cryopreservation
Ovarian freezing - are we progressing? What are the gaps?
Mara Snchez . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Transplantation of cryopreserved ovarian tissue
J. Donnez, M.M. Dolmans, D. Demylle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
PCOS
Risks of Controlled Ovarian Hyperstimulation
Z. Ben-Rafael . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Why Give LH if FSH Works?
T. Child. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Overweight women: profertility effect of weight reduction.

A prospective study
P.G. Crosignani, M. Colombo, W. Vegetti, E. Somigliana, A. Gessati, G. Ragni. . . . . . . . . . . . . 60
Do we need insulin sensitizers?
B.C. Tarlatzis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Risks of ovarian stimulation

In vitro fertilization, ovulation induction and the risk of cancer
C.W. Burger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Is endometrial receptivity altered in COH cycles?
J. A. Horcajadas, C. Simn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Increased risks of health problems in singleton ART babies:

Is it the procedure, the ovarian stimulation or infertility itself?
J. Cohen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Hot controversies in infertility

Why should we treat PCOS women with no infertility problem ?
L. Pawelczyk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Metformin and PCOS: Should they always go together?
E. Diamanti-Kandarakis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Controversies in Obstetrics, Gynecology and Infertility
Fresh ovarian tissue transplant: a propose of a place to implant it
A. Morales, G. Pons, O. Vidal, E. Trevio, D. Saldivar, L. Sordia, M. Merino,

F. Gonzlez, O. Barbosa, J. Vzquez . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
A structured literature review to establish the effectivity

of metformin in the clomiphene-resistant patient
T. Siebert, T.F. Kruger, D.W. Steyn, S. Nosarka . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Pollution, infertility and carcinogenesis

Ecological aspects of Environmental Pollution, Focusing on Carcinogenesis
P. Nicolopoulou-Stamati. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Other Health Hazards of Hormone Disrupters and how to ght them.

F. Comhaire, W. Dhooge, A. Mahmoud . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Impact of the environment on reproductive health: a bitter lesson from Athens
D.A. Adamopoulos, E. Koukkou. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Ovarian stimulation
New trends in IVF. Is there any evidence?
J. Serna, A. Pellicer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Induction of monoovulatory cycles for assisted

reproductive technology (ART)
P. G. Crosignani, E. Somigliana, M. Colombo, A. Riccaboni, G. Ragni . . . . . . . . . . . . . . . . . 145
Neuroendocrine aspects of amenorrhea related to stress
A.D. Genazzani, C. Lanzoni, C. Strucchi, H. Mehemeti, F. Ricchieri,

M. Ngo Mbusnum, O. Gamba, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
IVF or surgery first?

Fibroids and IVF: Which Comes First?
B.W. Rackow, A. Arici, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Treatment of tubal pathology or IVF?
J. Bontis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Uterine septum resection or IVF - which comes rst ?
P.Cline, L. Pascale, J. Donnez . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
In vitro maturation
In vitro maturation of human oocytes, potential benet of in vivo
priming with FSH/hCG before aspiration and priming of the endometrium
A.L. Mikkelsen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
IVM as an alternative in poor and over responders.

Hananel E.G Holzer, William M Buckett, Seang Lin Tan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Health status and development of children who are born after IVM
A. L. Mikkelsen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Hot controversies in Infertility

Investigation and Treatment of repeated implantation
failure following IVF and ET
E.J. Margalioth, T. Eldar-Geva, M. Gal, A. Ben-Chetrit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Is There a Life for IUI after the Advent of ICSI?
M. Yemini , J. Hade, A. Birkenfeld . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Does PGD help in patients with repeated IVF Failure?
G.B. Maroulis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Factors affecting Frozen Embryo Transfer program
H. Hashim, F. Al Salman , A. Felemban, H. Al Fozan., S. Hassan, M. Bugnah . . . . . . . . . . . . 231
The Use of Advanced Reproductive Technologies in Israel:

Are the professional partners seeing eye to eye?
Y. Simon, B. Kaplan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Review of non-surgical and surgical treatment, and the role of insulin-sensitizing

agents in the management of infertile women with polycystic ovary syndrome
A.M. Saleh, H.S. Khalil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
The peritoneal uid. A cause or a consequence of endometriosis?
J. Szamatowicz, P. Laudaski . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Should treatment with clomiphene citrate continue?

What should we offer to failures?
A. Weissman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Prevention of pregnancy failure in IVF

Aspirin and other adjuvants in assisted reproduction
S. Daya. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
Prevention of multiple pregnancies attributable to IVF/ICSI
D. Loutradis, P. Drakakis, A. Makrigiannakis, A. Antsaklis . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
Embryo transfer
Luteal phase support in assisted reproductive technologies
S. Daya. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
New technology and techniques

Virtual Hysteroscopy to Submucosal Myomas
K. Isaka . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Immune testing in fertility practice: Truth or Deception?
C. Kallen, A. Arici . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Sexual dysfunction
Vestibulitis-Conservative Treatment or Surgery?
J. Paavonen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
10
Androgen insufciency in women: Does it exist?
G. Mastorakos , C. Marios C. Markopoulos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
Surgical practice
The ten steps vaginalhysterectomy
M. Stark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344
Laparoscopic hysterectomy: Should we remove the cervix?
J. Donnez, J. Squifet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350
Laparoscopic myomectomy/myolysis : To whom should it be proposed ?
P. Jadoul, J. Donnez. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
Hot controversies in Gynecology

A new safer bipolar intelligent coagulation system
C. Wallwiener, E. Neunhoeffer, M. Wallwiener, R. Klein, M. Menger, M. Zubke . . . . . . . . . . . . 373
Uterine artery embolization in the treatment of hemorrhage

in obstetrics and gynaecology
J. Kowalski, R. Tarkowski, A. Nowakowski . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
In vivo proton magnetic resonance spectroscopy: A novel non-invasive

discriminatory test for ovarian tumors ?
E.A. Boss, R.D. Kok, D.W.J. Klomp, U.F.H. Engelke, H. Boonstra, R.A. Wevers,
J.O. Barentsz, A. Heerschap, L.F.A.G. Massuger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390
Choriocarcinoma-ultrasonographic models
B. Nikolic, A. Mitrovic, V. Lackovic, B. Nikolic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
Screening and treatment of ovarian cancer

Prophylactic oophorectomy, salpingectomy and omentectomy
in BRCA carriers with or without hysterectomy
P.E. Schwartz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404
Lymphadenectomy in Ovarian Cancer: A waste of time?
S. Fotiou. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410
WHI Whats next?

HT and heart disease: Is it still an unsettled issue?
G.E. Christodoulakos. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415
The million women study A critique
R. Farmer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420
Family planning
Newer progestogens. Progesterone-only pill (POP).
Do they offer any advantage?
S. Rozenberg, R. Gevers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
11
Prolonged use of OCs for symptomatic women
P.G. Crosignani . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430
Adolescent contraception. Is there one solution?
G. Creatsas, A. Deliveliotou . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434
Hormonal treatment for males and females

Hormone Therapy in 2005 for Men and Women: Where Are We?
M.J. Legato . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443
Hormone replacement therapy in the aging male and nutriceutical alternatives
F. Comhaire, A. Mahmoud . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447

Oophorectomy using hysterectomy At what age?
The special case of endometriosis
A.E. Schindler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458
Endometrial biopsy vs transvaginal ultrasound as a rst line test in patients

with pathologically proven endometrial polyps
J.P. Lerner, D. Smok. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
HIV infections in women How to deal with them?
T. Niemiec . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
Rationale for a safe alternative to conventional hormone

replacement therapy
D. Wildemeersch, D. Janssens, E. Schacht, K. Pylyser, N. De Wever . . . . . . . . . . . . . . . . . . . . 476
Gender-based Medicine
How Sex Impacts Normal Human Function and the Experience of Disease
M.J. Legato . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 486
Sleep disturbances - Why women are different from men?
Y. Dagan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
The Impact of Gender on the Experience of Coronary Artery Disease
M.J. Legato . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496
Urogynecology
Can SUI be treated medically? How to treat
A. Liapis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503
Endoscopy
Robotics in Gynecology Surgery
T. Falcone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513
Laparoscopic Hysterectomy why is it not more popular
G. Pantos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 517
12
Complications of Laparoscopic surgery-can they ever be eliminated?
T. Falcone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523
High and low-risk pregnancies

Should all twins be delivered by cesarean section?
I. Blickstein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 526
Antepartum fetal surveillance in pregnancies complicated by diabetes mellitus
A.M. Vintzileos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532
Second trimester miscarriage

Pregnancy loss: Evaluation and Treatment
A.M. Vintzileos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 536
The use of new ultrasonographic technologies in the evaluation

of uterine anomalies
G. Nazzaro, M. Locci, G. De Placido . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 540
Clinical controversies in the management of Preterm Labor

Tocolytic efcacy what is the evidence?
K.S. Khan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 542
Fetal growth: Implication for perinatal care

Cerebral Palsy and Fetal Growth
B. Jacobsson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547
Intrauterine growth in twin pregnancies
S. M. Kady, A. Francis, J. Gardosi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 554
Hot controversies in Obstetrics

Performances of dinoprostone slow release in the induction of labor
F. Facchinetti, P. Venturini, A. Volpe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 562
Use of b-lynch suture technique for postpartum haemorrhage a case report and review of literature
B.Vijayalakshmi, T.Doherty, P.Borrelli, D.Patil, S.F.Reynolds . . . . . . . . . . . . . . . . . . . . . . . . . 569
Growing importance of laparoscopic procedures during pregnancy
M. Klimek, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 573
Pre-eclampsia
The mode of delivery and Anesthesia in Preeclampsia
T. Sener . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 578
Prenatal screening and diagnosis

3D/4D: contribution to anomaly detection
or scan for parental entertainment?
N. Vrachnis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 588
13
Ethics of First-Trimester Risk Assessment for Down Syndrome
S. T. Chasen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 573
Breast cancer
Consensus and controversies regarding screening for breast cancer.
P. Neven, E. Van Limbergen, C Van Ongeval, A. Van Steen. . . . . . . . . . . . . . . . . . . . . . . . . . . . 597
Breast cancer and pregnancy
C. Markopoulos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610

Neonatal sepsis after single vs. multiple courses
of antenatal betamethasone therapy
S.Landolfo, S.Porcaro, A.Scarcella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
New objective method for the continuous assessment of fetal activity
K. Krzysztof, C. Krzysztof, K. Tomasz, S. Jacek, P. Tadeusz, L. Beata. . . . . . . . . . . . . . . . . . . . 620
Intrauterine growth restriction, angiogenic factors

and their possible role in post-partum catch-up growth of the neonate
A. Malamitsi-Puchner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 629
Womens views of and preferences regarding three approaches

to hospital care following rst trimester miscarriage
J. Shelley, S. Grove , D. Healy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 638
Modication of preterm uterine contractile activity by inammation:

Should we combine anti inammatory drugs with anti-oxytocics
T. Laudanski, P. Pierzynski . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 644
Does Antenatal Iron-deciency Anemia Have an Adverse

Effect on Pregnancy Outcome?
T.T. Lao, Ben C.P. Chan, Wing-Cheong Leung , Lai-Fong Ho . . . . . . . . . . . . . . . . . . . . . . . . . 650
Thrombophilia in Obstetrics and Gynecology

Thrombophilia 2005 - Overview
T. Hatzis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 656
Thrombophilia: What is the evidence for the relation with adverse pregnancy
outcomes?
B. Brenner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 665
The value of LMWH treatment in OB/GYN
D. Blickstein. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 673
Emergency cases in pregnancy

Delivery of the impact fetal head: Instrumental vs. CS
I. Blickstein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 678
Condition-specic antepartum fetal testing
A.M. Vintzileos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 683
14
15
But Surely Not Me:

Snakes, Bugs and Us
C. O. Granai, MD
Director, Program in Womens Oncology, Women & Infants Hospital/Brown University,
Associate Professor, Brown University School of Medicine, Providence,
Rhode Island U.S.A.
sgranai@wihri.org
Snakes, Bugs and Us; surely not me. Or is it the other way around? Odd title,
wouldnt you agree? Meaningless? Possibly. In any case, thanks for considering
the possibilities, and how we proceed when there are no answers. Once after
making a similarly obscure, oral presentation, I was invited to put aspects of
what was said on paper. My failed attempts to do so have curiously validated
one of the talks paradoxical, yet ironically unifying themes . . . having to do
with stumbling, if not falling at on ones face; and then, what happens (next).
The subject of this presentation is still not clear, is it?! How great the audacity,
then, that leaving you in such unclearness, I nevertheless ask the honor of
your (personal) company for the talk itself. But, your indulgence has been
sought by my sort before, and youve always been kind. So, lets make a deal.
Below are my above alluded-to editorials of August, 2003 and January,
2005, and a poem . . . they neednt be read, but if they are, their context may be
best saved for after the oral presentation. The potential reading thing would
be your part of the deal. For my part, Ill do my best to make your April 15,
Athens conference-morning colorful, dramatic, briey sad, musical, and fun.
Will the transaction be worth it? In the end, you be the judge . . . and you can
tell me in no minced words. Thanks for the chance.
16
What Matters Matter?

(p-values, h-values, leadership and us)
Prhcis: As overwhelming as the dismay, anger and resignation are, is there

really no meaningful difference individual physician-leadership can make for
patients, health care, society, and doctors themselves?
Abstract: Framed by the question, what matters matter, the essay considers
todays tired physicians, their needed leadership, the historic, principled-road
they embarked, and the reasons to continue. Taken as a whole, the vast problems
of health care are insolvable; but approached in small tangible steps, if not cure,
could direction, even inspiration appear? When sick, people look to physicians.
From their distinctive tradition of being present with patients, physicians have
earned trust and learned, scientically and artfully, about life in ways distantothers cannot. Homage to rational proof has separated physicians from alternatives, as homage to irrational human-values has distinguished them from pure
scientists. Both perspectives have proven vital since meaningful patient-centered care occurs at the brackish junction of logical science and tenuous human
needs, p-values and h-values long compelling of physicians. Along with the
privileged understanding gained privately with patients, comes the responsibility to stand publicly for the rights of all patients to private moments. Standing
up in these ways can never be easy, then again, it never was. Its the continued
journey towards historic ideals, somewhere in the paradox of mathematics and
mystery. Its an imprecise place of struggle where caring leadership has always been most needed, fullling and dening of physicians. And its there,
despite todays insurmountable everything else, each physician will nd ways to
re-energize around what matters matter. Heres one way to consider
What is more important, science or art? the admired senior physician was
asked near the end. The Im not sure startled the junior prothgh. Why merely
consider the reduced suffering brought by vaccines, antibiotics, anesthesia,
surgery, Watson and Crick and randomized trials, and the answer is quickly
apparent the young doctor surmised.1,2,3,4 The old physician was less certain,
instead quietly hoped for the sake of patients and the morale of doctors that a
choice between the two would not have to be made.
Science or art? Sometimes equal sometimes not, doesnt it all depend? But
in this assuredly nite world, real limitations everywhere, the opportunity not
to choose either/or is increasingly rare. In health care then, the germane question becomes: in choices of science or art, who chooses what matters matter?
Many it would seem. Joining the fabled third parties are administrations, administrators, lawyers, medical bureaucrats, biostatisticians, consultants, regula-
17
tors, fraud investigators, agencies, and numerous odd self-appointed multi-initialed certifying groups.5 Flaunting threats and ever-pending missing-the-point
inspections, they choose, and worse, they dictate, though each is further and
further removed, physically and experientially, from actual caring.6
But what about physicians, do they inuence the debate on what matters
matter too? While resisting a simple answer, todays convoluted health care
system makes it easy for doctors to feel (and self-righteously cop) me,
the individual physician, up against giant, powerful them; why thats a futile mismatch even Dr. Don Quixote would demur.7 From such a demoralized
mindset a fatal spiral naturally follows. Yet, as overwhelming as the dismay,
frustration, anger and resignation are, is there really no meaningful difference
individual physician-leadership can make for patients, heath care, society, and
their own essential direction and self-worth? Remarkably, among the smallsteps-possibilities emerge values-based ruminations, like those perplexing the
senior doctor, about science or art and what matters matter.
Few are drawn to being a physician intending to forego art for science, or
vice versa. Rather, physicians have offered what meager theyve known about
both, at difcult occasions of tandem medical and human need.8 Suddenly,
however, does maintaining modern relevance require physicians to proceed
differently?9 Or, business school axioms on the essentialness of continuous
change aside, are some things, framing questions among them, timeless? 10
Silently asked each step along the way, introspective-questions like What
would you want done for your loved one under those circumstances? have
guided physicians to patient-centered recommendations evidence-based medicine alone never could/will.11 Found confronting lifes truly threatening health
problems, most want the best of medical science and more.12 The more might
be best understood as art, in any of its wide expressions including: unscientic life-experience, intuitiveness, caring, touch, even weakness, failure and
poetry all part of elusive human values. Homage to inexplicable h-values
has distinguished physicians from pure scientists, just as homage to rational
proof and evidence-based p-values has separated physicians from alternative
practitioners, philosophers, and bureaucrats.13, 14 Both perspectives have proved
invaluable, for the best patient-centered care seems to occur at the imprecise
balance of p-values and h-values, a brackish tenuous junction of logical
science and less logical human needs long compelling of physicians.15
Few have been so honored to share in humanities uncertain moments, as
have physicians. From the eons of days and nights of being directly present, just
there, just then, physicians have gently earned trust. And from observational
science physicians have come to learn about life, death, suffering and the
18
importance of time, in ways that the others who-would-choose-about-healthcare-on-behalf-of-patients cannot. Surely its not the case that only physicians
see, or for that matter all of any one group does. There are, of course, kind and
vital people of all stripes working to make a difference. Seeking them out is
part of individual physician leadership.
Whether many or few, physicians can gratefully team with kindred-spirits
from nursing, social work, administration, trustees, CPAs, business leaders,
third parties, politicians, and yes honest lawyers, to confront the macro
level problems of health care. Only a team with shared ideals and diverse
expertise could hope to contend with such vast complexities, be they cynical
or unintended. One ailment ensnaring health care might analogously be dubbed
f-values. Seemingly remote and less honorable than p and h values,
nancial-values are in reality critical to both. Without appropriate distribution
of resources, including currently misaligned f-values, even the grandest ideas
will remain just that.
What would physician leadership bring the health care problem-solving
team, skeptics will ask? Absurd on its face, the question must still be answered:
With proud tradition physicians bring the core that others cannot; the distinctive
alternative of having learned scientically and artfully from patientsnot from
the abstract. Turning the question, is it conceivable that the best leadership of any
great human endeavor could come from outside cum laude theorists, unbalanced by those rooted to the front-line? Can a journeyman trade be learned from
books? Since the heart of health care is with patients, roots from that front-line
are fundamental to its best leadership. Roots alone, however, are not enough.
Lineage, in itself, is of perversely little value, if those so fortunate to have
it are otherwise swept away by the ow of popular currents. For example, in the
momentary stream of medicine, it is difcult not to be overcome by a mathematical, biostatistical reverence so forceful as to submerge common sense. Could this
obfuscation explain why: knowing the literature, not the patient, is that most revered, rewarded and taught by academia. Another example of wayward political
currents drowning reason is the one size ts all educational philosophy being
advanced with an appeasing-arrogance by bureaucratic medicine. No matter that
Socrates himself was unable to do so, todays medical organizations, unbecomingly dancing to the off-key music of outside fears, have obviously dened (and
formatted) what education and work are including how long is too long.
Such silliness not withstanding, more concerning is that the unique value of lineage can be so easily nullied, with consequences remaining to be seen.
All the wounds in health care, however, are not self-inicted. Entering the
negative mix largely from the outside are the, Im-not-sure-where-youve-hid-
19
den-it-but-I-know-you-did-it-wrong-and-Ill-nd-it, groups. These politically

sensitive rampaging agents believe in inscrutable and sanctimonious regulation rst and foremost. More dubious yet is their zealous sense that fraud
is the stealth overarching motivation for everything doctors do.16 Admittedly,
these perspectives occasionally have their place. But, more often, when linearly
applied by CMEs, IRBs, HICFA/CMS, HIPAA or as physician behavior
policies,17, 18 without context or exception, slowly passion, creativity, health
care and society lose. And, in the midst of it all, is it any wonder why physicians are tired, confused and demoralized in ways they cant fully understand.
A call to action seems clear.
Always having been ready to stand privately with patients during their sacred
moments, more than ever physicians today are called to stand publicly for the
sanctity of those same moments.19 Though a one-dimensional analysis reexively judges such moments too expensive, more fairly physicians know them to
be extraordinary human-instances defying economic quantication. They are
incredible occasions where science and art imperfectly come together in service
to people. Concerns about costs are dwarfed by the amazing good that can ripple
from even a short time focused on lifes most meaningful things usually
otherwise deferred.20, 21 Medicine, awed as it is, can facilitate (for patients and
families) the opportunity to reect and take stock. Often this invokes a coming
home to old roads and rusted station wagons unwittingly traded for superhighways and slick turbos nally encountering toll booths, speed traps and at tires.
The special-chance to return, regardless of age, to say Im sorry or I love
you is an elegantly simple, if unscientic, uneconomic, example of expenses
justied. But is an insight society only comes to have in time, one at a time.
Advocating for the rights to simple things, like lifes special chances, is
powerful physician-ship and in the reach of each physician. Standing against
shrill unseeing voices espousing armchair-conclusions deduced from trendy
cost: benet formulas will never be easy however. But easy was never
promised as part of the high road physicians chose to embark. An incredible
road it is nevertheless, where fortune holds that doing whats right is, at the
same time, uncommon (individual) leadership. Where humbly going forward,
in service to others, in a world which can never be fully understood, is the most
earnest advocacy, and surely thats worth of celebrating.22
Naive? Jousting at windmills? Possibly so. But even in failure comes good,
or so say the poets. They remind us that, win or lose, real peace resides in the
meaningfulness of choices made and values stood for. For physicians the current
paradox is one of ethical, hard work and science beyond business; of mystery
and non-rational ordinary virtues elite statistical universities and the young
20
doctor prothgh cannot abide.23 It is a commitment to something bigger than

self, bigger even than math or sculpture, where ironically and without fanfare
all the little things, scientic and not, add up as what matters matter.
P-values, h-values, leadership and us

what can the individual physician do?
Contrary to any dark sounds, by its nature the potential for caring is undiminishable. How lucky physicians are to be able to believe in that future as well
as the patient-centered good they do now. Though the fog will never lift to
clearly show the illogical curves ahead, this twisting road is nothing new for
physicians. Differing nuances era to era, sure, but in the greater sense todays
road is the extension connecting physicians in time. Sensing this struggle as
an experience in common is helpful, but even such profoundness cant totally
ameliorate disorienting pain. Especially then, and for everyones sake, physicians need a simple means to remain grounded.
While tugging at the juggernaut of macro health care, it remains at the
micro level, directly involving doctors and patients, where caring leadership
will always be most needed, fullling and dening of physicians. It is there
where physicians will always nd space to take measure and re-energize.
Though ethereal in nature, this nourishing location can be made more cognizant
with paper and pencil, a dear colleague or two, a beautiful space, (and likely a
glass of wine). Heres one way how
On a large sheet of paper create a ledger of a type most antithetical to the
Enrons. Title the ledger what matters matter setting up two simple columns,
one headed p-values the other h-values. Then, from your mind-of-science
and heart-of-art, under the corresponding column ll in the blanks with those
theorems, elements, data sets, therapies, trials, treatments, techniques, skills,
procedures, principles, concepts, values, ideals, metaphors, kindnesses, pills
and poems you would wish to bring the patients and families entrusting you
with their care. Sounds silly, its not. To the contrary, approached sincerely the
experience is hard, if not at times scary and painful (but in the end gratifying).
Its completion will be drawn from the totality of what you have come to know
scientically, and from what you have come to believe truly important in life.
When you are nished, along with some new, much of what is discovered
may be that which brought you/physicians here in the rst place. Either way,
it is likely that if ledger sheets are compared, the p-values listed will differ by medical discipline, but the h-values will hold much in common and
reinvigorating of us all.
21
That certain age

Old, older, too old. A categorizing of age or of medical thinking about age?
At different times and from the different vantages, like those of sincere caring,
lesser technologies, and relative ignorance, patients of that certain age have
been assumed non-candidates for certain treatments (i.e. that treatments risks
are too much, benets too little at that age). Sometimes we have been right
in this, of course. But increasingly, when depending on arbitrary thinking, were
not. Further, and as Wrights article opens the door to considering, the consequences of well-intended but misplaced assumptions could compromise the
health of the very patients we wish to serve/protect. For reasons ranging from
evidence-based to philosophic, historically based pessimistic medical thinking
deserves reassessment (1). While this continuously applies across medicine,
the focus here will be oncology; along with perceptions of treatment-tolerance
in the elderly, their spin-off implications, and other inuences affecting cancer
treatment decisions in older age groups. If the premises underlying current perceptions are earnestly re-evaluated, it is likely the conclusion will be: contrary
to traditionally held negative presumptions, the only thing certain is, we should
no longer be so certain (2,3). Pragmatically, however, as it is with most truisms
(e.g. elderly patients do not do as well with cancer or cancer treatments), just
considering alternative possibilities is hard enough; but translating them into
clinical behavior, well. thats an age-old high hurdle, made all the higher
when the denitions, resources, and engulng politics are constantly moving.
First off, in 2004, what denes old? I will leave it to Wright et al to
defend their denition of elderly as being from seventy years on. Sufce
it to say, there is ample room for social disagreement, and where the line is
nally drawn, will signicantly affect the conclusions of any analysis. Another
cogent yet amorphous, moving target is the denition of quality of life(4).
With inferences to both, we receive sardonic crape-hanging milestone birthday
cards that proclaim ageits only a number. Still, and as those of us of that
certain number soon come to know, in this linear world, numbers count, and
carry far-reaching impact, right and wrong (5). The stigma of the early-birdspecial, and corresponding service, or lack there of, seems instructive here.
True in all spheres of life, including medicine, the possibility of subtle inuence on (medical) decisions, caused by mere chronologic numbers, is not
something to be casually dismissed. Though not sinister in origin, the ramications of such inuence can bring sub par results. Aware that ageism is ever
lurking how could it still happen in health care (2,3)? The reasons, obviously
complex, may start quite simply, in doctors being human, thus not immune
to the shallowness of culture and pop images celebrating revered-life as pos-
22
sessing 20-year-old airbrushed skin and thick, non-grey Hollywood hair (i.e.
denitions of old and quality-of-life compliments of Cosmo; a vanity that
some in medicine also prot from as purveyors of expanding arsenals of youthstimulating drugs and cosmetic surgery).
It would, however, be unfair to point accusatory ngers at dazzling media
and reactionary consumerism as the prime explanations for medical distortions
about age as a treatment criterion (6). Many elements, some occult, doubtlessly
contribute; and we, in medicine, are complicit in most, if only through passivity. Lets look at examples of negative inuence taken from various categories,
beginning with a seemingly facetious one close to home: the way we clinicians formally communicate to each other about patients (but only to the extent
HIPPA permits useful communication, needless to say). Everyday virtually
every case-presentation begins: Mr./Ms. X is a (insert number here) year old
presenting with. There it is, right up front, the number, blazing with all the
drama afforded by juxtapositional primacy. How far behind could bias be?
So as not to be completely absurd, yes, in a general sense, age is an
important, long-recognized component in differentiating suitability for various
medical and surgical managements. Obviously not all patients of any age are
candidates for all treatments (7). Aging brings well-documented changes in
multiple functional capacities (8), many having meaningful implications about
treatment tolerance, quality of living, and life expectancy (9). But age is also
non-specic. Whatever the shared number, it's clear that chronologically
identical people do not constitute a biologically homogeneous group (4,5).
Some people at that age are physiologically younger, others of us older (10).
Biologic context is critical in determining physiologic endurance, longevity
and other matters for the individual patient (2). So too are the medical capabilities of the era and institution in question (11).
Even at this, there is much more that effects the therapeutic-choices made in
the care of elderly cancer patients. Physicians and hospitals are not alone in that
responsibility. Negative stereotypes about age and treatments are deep and
far-ung. Paradoxically, some of the strongest pessimism coming into play is
held by the elderly themselves and their families (12). Whatever their origins,
be it common sense, past realities, myths, stories from friends, depression, or
ordinary misinformation, each can narrow the vision of current potentials (13).
Much of the hope for fairly re-balancing the score card relies on physicians educating patients, families, society, and ourselves, about the pros and cons of stateof-the-art treatments, along with their alternatives including the option of no
treatment and its consequences (6). Maximal palliation is always a given.
Okay then, what is new in cancer care for the elderly? Fortunately a lot. For
23
instance, once insurmountable physiologic risk factors often accompanying

age, can now be proactively screened-for with CGA(comprehensive geriatric
assessments) -like tools (14,15), diagnosed and accurately monitored before,
during and after treatment (5,7). If encountered, such risks have relevance for
treatment, treatment modication, and outcome including survival. At the extreme, if the frailty syndrome is proven, it may preclude most semblances of
standard cancer management (16,17). Fortunately, contrary to pessimistic stereotypic notions, absolute contraindications to treatment are very rare. Further,
the lesser risks that are more commonly present, though once limiting, are
today resolvable or increasingly better managed thus affording effective cancer
interventions to go forward. Beyond the purely medical, we now recognize
that all constituencies have unique psychosocial-needs that must be addressed
as well to maximize outcome. The elderly as a group are no exception, and their
optimal oncologic care, which is the balance of so much, and much so unique,
depends our learning about all and working to help in all areas. Contributing
to the remarkable overall success are new insights, more specic and effective
treatments with less toxicity, and an array of side-effect antidotes (18) and the
prospective multidisciplinary team approach to oncology care . As they do
today, stunning evolution in knowledge and technology will constantly alter
the risk:benet ratio, opening unprecedented horizons for all ages.
Thus far so good, at least technically; but having new medical abilities, and
deciding to employ them, are two different things. The latter is less predictable,
being nuanced by human behavior and what motivates and demoralizes it. In
this vast world of forces, it is easy to understand why individual clinicians
feel tiny and incapable of inspiring broad meaningful change. While some
power-venues do require larger organizational advocacy, the cry, let the ACS
or ASCO handle it, is dangerously near a cop out. Rather, as the poets suggest,
slowly each small thing adds up. Herein lies the call for personal involvement
despite few guarantees of conspicuous achievement. Since our own physicianbehavior is the one thing we can predictably control, introspection informing
personal vigilance, is a good and pragmatic place to begin.
Germaine to the implications of the Wright paper (where similar cancer
patients in different age groups often received different cancer treatments) in
our reective self-scrutiny, we should seriously wonder about what we do, if it
differs from todays medical potentials (8). Every discrepancy between actions
and possibilities should be seen as a red ag marking the need for deeper
digging as to merit. Much of what personal exploration may nd, is not likely
to be earth shaking, however (6). Indeed, compared to the shiny-commotion of
super medical technologies, or the drama of the smoking gun that exposes de-
24
vious agendas, the relevant inuences on individual behavior may seem, at rst
blush, small, insignicant, or rather silly. But, as fortune cookies aptly warn,
left to their own devices, the mundane can mysteriously morph into insidious.
The example of syntax in medical case presentations, may again pertain. In that
ubiquitous medical construct, is age, per se, worthy of its headliner prominence,
as if lifes foremost characteristic and/or determinant of treatment? Further,
does having age so eminently sequenced, innocently create a quiet bias now
part of the medical day-to-day? No! we would quickly voiceat least to the
bias aspect; but is this being naive (19)? Either way, quasi-ageism nds ways
into health care from other quarters.
Joining the distortions of pervasive pop culture, subtle medical convention,
and those held about themselves by the elderly, are other diverse inuences.
In the best of worlds, having additional thoughtful perspectives is invaluable
in shaping health care (11). Under lesser ideal circumstances, the milieu of:
healthcare, money, votes, and power, forms a perfect morass for demigods
and catastrophe. While different in origin and impetus, together the dispirit
inuences can dampen the likelihood of older patients receiving complex and
state-of-the art cancer treatments. Though at moments heart-felt and valid,
at other times the opposition dubiously propagandizes todays best cancer
modalities as not clearly superior or too aggressive sprouting anxiety
and reluctance about that treatment; for who among us would self-inict
those risky fates (11,20)?! An example of this deceptive posturing is seen in
cost-rst priorities veiled as otherwise appropriate patient-centered concerns
(20). Whatever the full motivation behind these espousals often made by
non-clinical groups (e.g. third parties, health care administrators, politicians),
an intention to retard medical expense is usually part (19). Quite different is
their holistic public persona, however. Still, their bellicose thesis on economic
cost, and its consequences, is a rightful concern to a society with limited
resources.
Just beneath the specter of warm platitudes, their scal-reasoning about health
care goes something like this. Since there is an inevitable and costly correlation
between: aging, illness, health needs and dying; and because major scal expenditures for medical treatment are not likely to be recouped from an elderly, a
non-tax paying constituency; expensive (a.k.a. aggressive) interventions are best
invested in a more youthful, longer-living stratum (20). Logical enoughthe
young-eyed, one-dimensional, quick-x, mathematician will conclude (21). A
factual deduction made only clearer from the abstract of never-having-sat-atthe-bedside. Yet if literally applied, beyond short-sighted and hurtful, such a
policy would be wrong on virtually all important counts (19).
25
This is not an argument against hospice. Depending on many factors,

the fullness of supportive-care-only near the end of life can be a wise choice
for anyone (22). Still, in the example of the Wright paper, it is curious that the
hospice-like, no treatment option, was selected nine-times more frequently
by the older group. Empiric explanations, relating to: age, more advanced stage
at diagnosis and otherwise more limited expectation, seems most plausible
(23). Standing in opposition to the no treatment selection, are the effective
therapies and long-term palliations now available, even for advanced stage
cancer (19,24). Though once considered an anathema of medical care and ethics, today, formerly end stage cervical cancer patients primarily presenting
with urethral obstruction, are readily unblocked with minimum morbidity via
interventional radiology. The restored renal function then facilitates platinum
chemotherapy alone, or more often as a radiation sensitizer. Compared to the
dire outcomes of the past, let alone the consequences of no treatment, relatively superb results now follow present-day aggressive interventions (8).
Concerns about costs are important, nevertheless. They are not the proprietary interest of the non-medical community with their magnanimous balanced
vision (25). To the contrary, all agree about the responsibility to engage nite
economic and medical resources, thoughtfully (26). But, in the spectrum of real
health care needs, where are these assets more justly accorded than to the sick
(who are, by laws of nature and probability, often aged; not to mention their
having been long-paying taxpayers who similarly supported those preceding
them)? As for notions of return on investment, the cold question has many
validating retorts, none more fundamental than the humanistic inquiry in return:
What is the value of living (to patients, family, and society; for six months, let
alone six years)? Imperfect by many criteria, todays cancer management, even
when not literally curative, can allow people of all ages to live, in relative,
if not excellent, quality; and, in that, have time to address all-too-forgotten
priorities. Sadly, this is more than most of us who die suddenly, will ever get
around to doing. What a wonderful difference this makes in the lives of real
people, as can be readily seen in those left behind.
Standing for precious opportunities like this, is central to physician-ship and
the type of caring society we should want to live in. A society which is proud
to invest its resources in human-needs, at the age/ time they actually occur.
Yet, when it comes to investing in elderly cancer patients, optimal therapies
may not rise to activation (27). This is cause for ongoing concern and introspection about validity, priorities, complicity, and change (21). While there
is no absolution, amid the harsh mix of diverse negative inuences and old
data, understandably physician-perceptions about what treatments to suggest
26
at certain ages may be misaligned with the best of today. This stark possibility
is Wrights indirect red ag for us.
Purportedly just another paper cataloging cervical cancer treatments and
their tolerance in different cohorts a worthy endeavor in itself the studys
more far reaching value is in stimulating contemplation about the ndings.
Specically, what accounts for the: lower rates of surgery, lower doses of
radiation, less use of adjuvant therapy, higher rates of post-treatment persistent disease, and the previously mentioned more frequent opting of no
treatment, all by the studys similarly-staged elderly sub-group? Like other
authors, Wrights data shows that many older patients can successfully endure
comparable oncologic interventions (8,28,29). Despite their proven treatmenttolerance, the older patients frequently underwent different, typically lesser,
cancer treatments. Among the multifactorial reasons behind the variation,
some may be attributable to the studys duration (1986-2003). After all, the
value and superiority of using sensitizing chemotherapy with radiation in
advanced cervical cancer, was not nally established until 1999, thirteen years
into Wrights data base. Another reason for the studys lopsided treatment
distribution is ascribed to enrollment onto prospective protocols that dictated
therapy. There are, undoubtedly, many medically sound reasons behind
the treatment-choices made here, or anywhere in general. More important
yet is the patients preeminent right to choose any way they wish; and that
as physicians we accept, that true to human nature, subjective reasoning will
often trump objective (30). All this being so, the nagging question still lingers:
why, in the majority with early cervical cancers no less, did the elderly make
so many seemingly negative treatment decisions when more effective, well
tolerated alternatives existed?
Hysterectomy, including radical hysterectomy and pelvic lymphadenectomy,
has been proven tolerable in all age groups (31,32). In the clinical setting of
early cervical cancer, where its cure-rates are at least equivalent to radiation,
surgery offers important advantages including: shorter treatment time, accurate
surgical-pathologic staging furthering treatment to the specic patient, less
long-term morbidity, better sexual function (33) (and yes, shocking as it is
to generation X, us old people do have, and enjoy, sex too (16)). Nevertheless,
in Wrights study, the early stage, older patients were three times more likely
to forego surgery and its benets. Again, reasons from physiologic to psychosocial are likely (34). But, could some portion reect a pessimistic, passh
experience when the surgical option was indeed less tenable in that age range;
or worse, could it be a narrow one-sided reaction to a mere chronologic (age)
number (29)?
27
Despite its advantages, surgery is not always the best recommendation for
patients with early cervical cancer, of course (35). Future studies may someday
show radiation with sensitizing chemotherapy is generally superior to surgery,
even in this setting (36). In the fast world of exploding science, all clinicians
are obligated to stay-tuned for breaking insights, and this surely applies to
subspecialty oncologists at centers where relatively esoteric cancers are more
frequently seen thus they are appropriately sought-out for their academic and
clinical expertise (11). However the dynamic medical facts lay over time, two
broad concepts will likely remain constant. To the extent possible, the best
treatment of that moment is what should be employed for all patients (29).
And, to meet this challenge, difcult as it is, health care must continue shaking
ingrained, out-dated perceptions such as radical pelvic surgery is too much for
elderly patients to endure a standard teaching in Gynecologic Oncology
and Radiation Oncology fellowship programs not long ago. Fortunately realizations about this and similar matters are changing, to where the optimal use of
surgery, radiation, chemotherapy, adjuvant treatments, etc., can occur into the
tenth decade (3,9.37,38).
Maybe so, the skeptics respond, but the question of treatment-tolerance is
moot (18), since the elderly do intrinsically worse with cancer. Well admittedly, with certain cancers, at certain ages, there is biologic-reality to this dark
truism (39). Even assuming that the incomprehensible maze of confounding
variables could somehow be perfectly controlled-for, there would still likely be
oncologic-instances where older patients just fare fundamentally worse (4030).
In fact, Wrights data supports this perception, though in reection the authors
seem to question the conclusion. Then again, considering the physiology of aging, isnt this observation both logically inevitable, and yet, a false comparison
(1)? The more relevant contrast would be between like-aged, older patients
treated differently (8). When up against younger, healthier counterparts, the
older group may inevitably have an inferior outcome; but there should also be
relative outcome-differences within the elderly cohort itself, according to their
treatment (10). That benet, mathematically smaller though it may be, is just
as important humanistically as any other, especially to the patient and family
involved.
When available, biologic factors effecting oncologic-prognosis surely become key ingredients in the decision-making (4,38). At the same time, while
integrating different sources of information into the equation, we must not fall
prey to undue pessimism spinning from disorienting circular arguments (26). In
the realm of potential reasons for the inferior oncologic-outcomes in the older
population, it is the self-fullling prophecy that looms most ominous. Could a
28
subtle circular-fatalism be positively reinforcing an otherwise iffy proposition? To paraphrase an established therapeutic principle half treatments, well
intended as they are, rarely yield even half results. What then, do we expect
to occur with "half" oncologic treatments, the types more typically received
by older groups (8,37)? The virtues of extreme dose intensity notwithstanding,
treatments administered to established therapeutic thresholds continue to carry
the best chance for a good outcome regardless of age (8). This is quality cancer
care, the kind to be encouraged for its direct value to individuals, and its ripple
effects that, not unlike NASA, drive learning and progress for a wholly better
future.
While collectively championing the right of all patients to receive the best
treatment (25), what can we also do, personally, to improve the everyday? Many
ideas, and hearts, will apply here. One is working to diminish any skewed ageoriented "medical thinking". Remembering the age-old principle, rst things
rst is one practical, easy step, taken. In vitalizing the simple phrase into the
formulation of real-life patient-centered recommendations, our best rst-question would seem: what is the optimal treatment for this (oncologic, cardiac,
GI, etc) problem? With that universal answer in mind, secondary questions,
like those relating to a specic patients physiologic risk factors, take their
place in sequence to create the appropriate, patient-specic context for the nal
conclusion. Could a minor change in the order of deductive questions, or in the
juxtaposition of age within medical case presentations, actually reduce biasrelated blind spots to therapeutic choices? Wellokay, the syntax-thing may
be pushing it a bit, or even sillythen again, are we so sureand either way,
what is the downside risk of trying? But, whats actually most important, is
our simply thinking about these matters, and realizing that without fanfare, the
seemingly little things within our control, add up and make a big difference.
As much as it does upon new technologies and new understandings often
about old ideas genuinely better health care depends on us for this vital,
incremental change. The defrocked arbitrary mantra too old for the best
treatments after that certain age is an example of just such old thinking
now thankfully at rest for lack of a priori foundation.
29
Snakes, Bugs & Us

Why do we do what we dooooo
stars in the sky, more than a few.
Logic, science, proofs in season,
mostly though others the actual reasons.
Encouraged today to quietly think,
of why we doo and possible links.
Snakes and bugs here said to be
much like us (you) but surely not me.
For I am human, elite and evolved,
in charge of the issues each easily solved.
And too my choices, well those Im seeing,
dont ask of the others affecting my being.
Mysterious instincts, inkling, genes,
intuitions contribute, but what does this mean?
To knowledge amazing built by mankind,
to vaccines and astronauts born of our minds.
Intelligence vital, impressive for sure,
but also explaining why humans are bores.
More than blind to matters of fun,
are we fooling ourselves on what makes us run?
Biology, hormones, stealth pheromones make
all creatures in common thus you like a snake.
Or is it bug-like, fall/summer nights same,
dancing, no choice has drawn to the ame.
Scaly reptiles, with scary, forked-tongues,
scientists, doctors all suddenly one.
Each on their journey cross unchosen rhymes,
few concrete answers at just the right time.
Okay ... grand drama, hyperbole here,
but differences major would also seem clear.
For humans have free-will their choices can make
less bothered by vagueness propelling the snake.
How sorry the species that knows not its role

worse yet to imagine a lack of control.
But ask not the end of my why-do-I stew ?
or through me to others in that that I do.
Id rather seem certainlet mighty me reign
Bravado lifes opera heir surgeon still feigned.
Less lofty, such reasons in public, my fame
I wonder if others would cause me shame?
My wishful eyes see me not easily ruled,
pray others not witness an obvious fool.
But what purpose crude questions which push to the
brink
suggesting a kindred or possible link.
Exploring for common what good could then come,
from seeing us similar under one sun?
Or could being aware of more things that affect
bring humbling insight, best choices expect.
Thus rather than fearsome could forked-tongues be
seen
as searching for answers about what life means.
Each probing forked-tongue just trying to learn,
what this world is and which way to turn.
Armed with kind-knowledge, Isaac Newton august,
still mysterious forces link snakes, bugs, and us.
With fear, inch inch forward, dark skies should not
bar,
good service to others as metaphor stars.
Incomplete answers, the most we can know,
yet stars out this night, so each must still go.
For what now is here, over that which seems not,
for what now is clear and that which weve got.
For each need, all creatures, so real on this day
in darkness, few answers forked-tongue show the
way.
Then as to the question, why do we dooooo ...
stars in the sky, choices known left to you.
C. O. Granai, MD 12/13/2000
Copyright 2000 by Womens Oncology
All Rights of reproduction in any form reserved.
30
References
What Matters Matter:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
Crease RP. The most beautiful experiment. Physics World 2002;15:9:2.

Rossouw JL, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, et al. Risk
and benets of estrogen plus progestin in healthy postmenopausal women: principal results
from the Womens Health Initiative randomized controlled trial. JAMA 2002;288:321-333.
Watson JD, Crick FHC. Molecular structure of nucleic acids A structure for deoxyribose
nucleic acid. Nature 1953;171:737-738.
Venter JC, Adams MD, Myers EW, Li PW, Mural RJ, Sutton GG, et al. The sequence of the
human genome. Science 2001Human Genome Special Issue; 291:1304-1351.
Oberlander J. The US health care system: On a road to nowhere? CMAJ 2002;167:163-8.
Duff S. The best things in life are free; 2 Vermont hospitals abandon JCAHO accreditation.
Modern Healthcare 2002;32(33):20-1.
Cervantes Saavedra, Miguel de. The History of that Ingenious Gentleman, Don Quijote de la
Mancha (translated from the Spanish by Burton Raffell). New York: Norton, 1995.
Hippocrates. The genuine works of Hippocrates; trans. from the Greek, by Francis Adams.
Baltimore: Williams and Wilkins, 1939.
James B. Making it easy to do it right. N Engl J Med 2001;345(13):965-70.
Osler W. Aequanimitas and other papers that have stood the test of time with an introduction
by Paul Dudley White. New York: Norton, 1963.
Hundert EM. A Golden Rule: Remember the Gift. JAMA 2001;286(6):648-50.
Fried TR, Bradley EH, Towle VR, Allore H. Understanding the treatment preferences of seriously ill patients. N Engl J Med 2002;346:1061-6.
Peipert JF. The economic value of medical research: Is it worth the investment? Obstet Gynecol
2002;99:835-840.
Grimes D. The CONSORT guidelines for randomized controlled trials in Obstetrics &
Gynecology. Obstet Gynecol 2002;100(4):631-2.
Frankel F, Malin D, Shuett L. Scientic Photography from Talk of the Nation. National Public
Radio, September 27, 2002. Available at: http://search.npr.org/cf/cmn/segment_display.
cfm?segID=150686
Neuwirth ZE. Reclaiming the lost meanings of medicine. Medical Journal of Australia
2002;176(2):77-79.
HIPAA (Health Insurance Portability and Accountability Act). For detailed information, visit
their website at www.hipaa.org.
Physician Behavior Policy. (Pamphlet and Mousepad) Medical Staff Services, CORO Building,
Room 190, 167 Point Street, Providence, RI 02903.
Cohen JJ, Gabriel LA. Not just another business: Medicines struggle to preserve professionalism in a commercialized world. Obstet Gynecol 2002;100:168-9.
The Advisory Board Company. The new economics of cancer care. Washington: Oncology
Roundtable, 2000.
Donovan KA, Greene PG, Shuster JL, Partridge EE, Tucker DC. Treatment preferences in
recurrent ovarian cancer. Gynecologic Oncology 2002;86:200-211.
Granai C: "Snakes, Bugs, and Us." SGO Issues (The Editor's Corner) vol. 20 no. 3: Society of
Gynecologic Oncologists, 2001.
Varnadoe K. Entering the software century. Art News 1992;91:57.
31
That Certain Age

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Too old to care? Penson RT, Daniels KJ, Lynch TJ Jr. Oncologist. 2004;9(3):343-52.
Geriatric oncology: challenges for the new century. Balducci, L. Eur J Cancer. 2000
Sep;36(14):1741-54/
You may think Im old, but cant you treat my cancer? DiSilvestro PA, Granai CO, Gajewski
WH, Falkenberry SS. RI Med. 1995 May;78(5):143-4.
Quality of life in elderly cancer patients. Repetto L, Ausili-Cefraro G, Gallo C, Rossi A,
Manzione L.Oncol. 2001;12 Suppl 3:S49-52.
Care of breast cancer in elderly women what does comprehensive geriatric assessment
(CGA) help? Wedding U, Hoffken K. Support Care Cancer. 2003 Dec;11(12):769-74.
Physician-older patient communication about cancer. Greene MG, Adelman RD. Patient Educ
Couns. 2003 May;50(1):55-60/
Perioperative risk assessment in elderly and high-risk patients. Richardson JD, Cocanour CS,
Kern JA, Garrison RN, Kirton OC, Cofer JB, Spain DA, Thomason MH. J Am Coll Surg. 2004
Jul;199(1):133-46.
Physiological aspects of aging. Implications for the treatment of cancer. Lichtman, SM. Drugs
Aging. 1995 Sep;7(3):212-25.
Pharmacology of Chemotherapy in the older cancer patient. Balducci L, Beghr C. Cancer
Control. 1999 Oct;6(5):466-470.
Treatment of cancer in old age, shortcomings and challenges. Wymenga AN, Slaets JP, Sleijfer
DT. Neth J Med. 2001 Nov;59(5):259-66.
You're never too old. Surgery on patients of 80, 90, and up? It's gaining acceptance. Comarow
A. US News World Rep. 2004 Jul 12;137(1):83-4, 87-8.
Cancer treatment and age: patient perspectives. Newcome PA, Carbone PP. J Natl Cancer Inst.
1993 Oct 6;85(19):1580-4.
Cancer control and the older person. Psychosocial issues. Vachon ML, Robinovitch A, Burlow
J, Ganz P, Hermann J, Joseph R, Kane RA. Cancer. 1991 Dec 1;68(11 Suppl):2534-9.
Comprehensive assessment of the elderly cancer patient: the feasibility of self-report methodology. Ingram SS, Seo PH, Martell RE, Clipp EC, Doyle ME, Montana GS, Cohen HJ. J Clin
Oncol. 2002 Feb 1;20(3):770-5.
Studies of comprehensive geriatric assessment in patients with cancer. Extermann M. Cancer
Control. 2003 Nov-Dec;10(6):463-8.
Sexuality and sexual capacities of elderly people. Drench ME, Losee RH. Rehabil Nurs. 1996
May-Jun;21(3):118-23.
The frailty syndrome: a critical issue in geriatric oncology. Ferrucci L, Guralnik JM, Cavazzini
C, Bandinelli S, Lauretani F, Bartali B, Repetto L, Longo DL. Crit Rev Oncol Hematol. 2003
May;46(2):127-37.
Cancer chemotherapy in older adults. A tolerability perspective. Kimmick GG, Fleming R,
Muss HB, Balducci L. Drugs Aging. 1997 Jen;10(1):34-49.
Age as a bias for healthcare rationing. Arguments against ageism. Scharf S, Flamer H,
Christophidis N. Drugs Aging. 1996;9(6):399-402.
Should the elderly receive chemotherapy for node-negative breast cancer? A cost-effectiveness
analysis examining total and active life-expectancy outcomes. Desch CE, Hillner BE, Smith
TJ, Retchin SM. J Clin Oncol. 1993 Apr;11(4):777-82.
Ageism and the abuse of older people in health and social care. Ward D. Br J Nurs. 2000 May
11-24;9(9):560-3.
Increasing aggressiveness of cancer care near the end of life. Is it a quality care issue? Earle
CC, Neville BA, Landrum MB, Ayanian JZ, Block SD, Weeks JC. Am J Oncol Rev. 2004 July
3;7:401-404.
32
23.
Geriatric oncology. Medical and psychosocial perspectives. Wells NL, Balducci L. Cancer
Pract. 1997 Mar-Apr;5(2):87-91.
Psychosocial aspects of cancer in the elderly. Walker LG, Kohler CR, Heys SD, Eremin O. Eur
J Surg Oncol. 1998 Oct;24(5):375-8.
Cancer in America, 2004. Bosserman LD, Henderson IC. Comm Oncol 2004;1:30-35.
Cancer screening in elderly patients: a framework for individualized decision making. Walter
LC, Covinski KE. JAMA. 2001 Jun 6;285(21):2750-6.
The outcomes and costs of acute myeloid leukemia among the elderly. Mensin J, Lang K, Earle
CC. Arch Intern Med. 2002 Jul 22;162(14):1597-603.
Older age underwriting: frisky vs frail. Bennett AK. J Insur Med. 2004;36(1):74-83.
Variations in the use of chemotherapy for elderly patients with advanced ovarian cancer:
a population-based study. Sundarajan V, Hershman D, Grann VR. J Clin Oncol. 2002 Jan
1;20(1):173-8.
Psychosocial issues. Psychological and social issues for older people with cancer. Kane RA.
Cancer. 1991 Dec 1;68(11 Suppl):2514-8.
Radical hysterectomy in the elderly patient: analysis of morbidity. Fuchtner C, Manetta A,
Walker JL. Am J Obstet Gynecol. 1992 Feb;166(2):593-7.
Radical hysterectomy in patients 65 years of age and older. Levrant SG, Fruchter RG, Maiman
M. Gynecol Oncol. 1994 May;53(2):208-11.
Radical hysterectomy followed by tailored postoperative therapy in the treatment of stage
IB2 cervical cancer: feasibility and indications for adjuvant therapy. Yessaian A, Magistris A,
Burger RA, Monk BJ. Gynecol Oncol. 2004 Jul;94(1):61-6.
Psychosocial issues. Psychological and social issues for older people with cancer. Kane RA.
Cancer. 1991 Dec 1;68(11 Suppl):2514-8.
Surgical-pathological predictors of disease-free survival and risk groupings for IB2 cervical
cancer: do the traditional models still apply? Kamelle SA, Ruteledge TL, Tillmanns TD, Gould
NS, Cohn DE, Wright J, Herzog TJ, Rader JS, Gold MA, Johnson GA, Walker JL, Mannel RS,
McMeekin DS. Gynecol Oncol. 2004 Aug;94(2):249-55.
FIGO Stage IB2 cervix cancer and putting all your eggs in one basket. Ackerman I. Gynecol
Oncol. 2004 Aug;94(2):245-6.
Breast cancer in older patients. Kimmick G, Muss HB. Semin Oncol. 2001 Apr;31(2):23448.
Life expectancy, co morbidity and quality of life: the treatment equation in older cancer patients
Repetto L, Comandini D, Mammoloiti S. Crit Rev Oncol Hematol. 2001 Feb;37(2):147-52.
FIGO stage, histology, histologic grade, age and race as prognostic factors in determining
survival for cancers of the female gynecological system: an analysis of 1973-87 SEER cases of
cancers of the endometrium, cervix, ovary, vulva, and vagina. Kosary CL. Semin Surg Oncol.
1994 Jan-Feb;10(1):31-46.
Geriatric assessments it useful in the selection of elderly tumour patients for a difcult therapy?Krege S, Friedrich C, Lummen G, Pientka L, Rubben H. Urologe A. 2004
Aug;43(8):922-9.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
* Permission granted by Lippincott, Williams & Wilkins: What matters matter? C. O. Granai, MD
P values, H values, Leadership, and Us. Obstet Gynecol. 2003 Aug; 102(2):393-396
* Permission granted by John Wiley & Sons, Inc.: That Certain Age. C. O. Granai, MD, Cancer,
2005 Jan 1;103(1):5-10.
33
Gamete cryopreservation
Ovarian freezing - are we progressing?
What are the gaps?
Mara Snchez
Hospital Universitario Doctor Peset, Valencia.
e-mail: mariasanchez@ivi.es
It is estimated that in 2010 one of every 250 youngster between 20 and 29 years
of age will be a cancer survivor, due to two major causes; in rst place, the
incidence of cancer is growing; in second place, the therapies are improving
survival. As survival rates keep on improving, protection against iatrogenic
sterility, caused by chemotherapy (ChT) and/or radiotherapy (RT) is becoming
a main concern in medical research (1). Premature ovarian failure (POF) is a
likely long term consequence of ChT and RT, as gonads are particularly sensible to them. Increasing doses of ChT agents causes progressive destruction of
oocytes and follicles, suggesting a direct relationship between doses and POF
(2). The recent report of the rst human live birth after cryopreserved ovarian
tissue autotransplantation (3), has unlocked the debate about its indications,
efcacy and ethical considerations (4,5). Additionally, it brings an opening
to community about a subject so far almost restricted to research. Nowadays,
oncologycal patients themselves are searching for information concerning their
reproductive chances and their hormonal function. Once they or their parents
are informed, they usually demand these possibilities to become a reality. It
is our task to offer them, both, the information and the solutions. The solutions
for their reproduction include immature oocyte retrieval, in vitro maturation
of oocytes, oocyte vitrication, and embryo cryopreservation. For being able
to achieve both, reproduction and ovarian hormonal function, ovarian tissue
cryopreservation seems the option; though this option is not free of risks, and
autografting could be hampered by tumour cell contamination. Technologies
are being developed for detecting residual disease (6). At present time, embryo
34
cryopreservation is the only clinically well established option.

Medical advances during last decades bring us to the fact that medical success obtained with the resolution of cancer, at present must be accompanied
by the accomplishment of patients quality of life. In children, teenagers and
young women this quality of life will probably include gonadal hormonal
function and maternity safeguard. Poirot suggested in 2002 that ovarian tissue
cryopreservation should be offered to these patients (7). The idea of ovarian
transplantation is not new, the rst report about this issue is more than a century
old (8). Studies in small laboratory rodents have demonstrated that fertility can
be restored by transplanting whole cryopreserved ovaries (9), and also using
vascular anastomosis in dogs, sheep and rabbits (10, 11); but this ideal solution
is not feasible at this time in humans. Thus, transplantation of cryopreserved
ovarian tissue offers a means of preserving reproductive function. Provided the
appropriate cryopreservant is used, primordial oocytes in ovarian tissue tolerate
freezing/thawing surprisingly well. (Liu J, Van Der Elst J, Van der Broecke R,
Early massive follicle loss and apoptosis in heterotopically grafted newborn
mouse ovarios. Hum Reprod 2002;17:605-611). The major problem affecting
autograft success is the ischaemia reperfusion. Ovarian allografting requires
the use of toxic drugs which preclude its clinical application; egg donation is
a simpler and well established alternative.
We are cautiously progressing on ovarian freezing due to a certain extent to
the tremendous biological value of ovarian tissue samples which mess up with
the performance of long studies. The best way to try to answer these questions
is to present our work.
Initially, we experimented with two slow freezing protocols for ovarian
tissue as well as with vitrication of embryos at different stages. Viability of
ovarian tissue after thawing was also assessed.
Then, we autotransplanted fresh left ovarian cortex orthotopically onto
right medulla after extracting whole right cortex, to twelve 39 - 42 old aged
women undergoing abdominal hysterectomy. Particular care was taken to avoid
ischemia and to remove all cortical tissue except the transplantated one. There
was evidence of function of grafts. With different patterns, FSH levels showed
ovarian function in all twelve women and we were amazed to nd ovulation
(settled on vaginal ultrasound and progesterone serum levels) in ten patients.
These studies established that the technique of surgical transplantation was
technically feasible and ovarian function could be restored.
Recently, we have obtained the accreditation for the extraction and implant
of autologous ovarian tissue (Doctor Peset Universitary Hospital, Valencia
Spain), in coordination with the creation of an ovarian tissue bank (Transfusion
35
Centre of Valencia Autonomic Community, Valencia Spain), within the Public

Health System. This is a pioneer experience in our country, where only our
group is allowed to in Spain.
At the moment, besides managing the programme of extraction and implant
of autologous ovarian tissue, we are performing xenotransplantation on male
nude mouses. We subcutaneously insert pieces of ovarian cortex from fertile
age donors on nude male mousses, and different experiments are carried out.
All these protocols and studies will be presented and discussed at COGI
2005.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Blumemfeld Z, Avivi I, Ritter M, Rowe JM. Preservation of fertility and ovarian function and
minimizing chemotherapy-induced gonadotoxicity in young women. J Soc Gynecol Investig
1999;6:229-239.
Clark ST, Radford JA, Crowther D, Swindell R, Shalet SM. Gonadal function following chemotherapy for Hodgkin`s disease: a comparative study of MVPP and a seven drug hybrid
regimen. J Clin Oncol 1995;13:134-139.
Donnez J, Dolmans MM. Livebirth after cryopreserved ovarian tissue autotransplantation.
Lancet. 2004 Dec 11;364(9451):2092-3.
Oktay K, Sonmezer M. Ovarian tissue banking for cancer patients: fertility preservation, not
just ovarian cryopreservation. Hum Reprod. 2004 Mar;19(3):477-80.
Revel A, Schenker J. Ovarian tissue banking for cancer patients: is ovarian cortex cryopreservation presently justied? Hum Reprod. 2004 Jan;19(1):14-9.
Schreder C.P et al. An in vitro model for purging of tumour cells from ovarian tissue. Hum
Reprod 2004; 19:1069-1065.
Poirot C, Vacher-Lavenu M-C, Helardot P, Guibert J, Brugires L, Jouannet P. Human ovarian
tissue cryopreservation: indications and feasibility. Hum Reprod 2002;17:1447-1452.
R.T. Morris, The ovarian graft. N Y Med J. 1985;62:436.
Wang X et al. Fertility after intact ovary transplantation. Nature 2002;415:385.
W.J. Dempster. A technique for the study of the behaviour of the autotransplanted kidney,
adrenal gland and ovary of the dog. J. Physiol. 1954;124:1516.
J.R. Goding, J.A. McCracken and D.T. Baird, The study of ovarian function in the ewe by
means of a vascular autotransplantation technique. J. Endocrinol 1967;39:3752.
36
Transplantation of cryopreserved
ovarian tissue
Jacques Donnez, MD, PhD*, Marie-Madeleine Dolmans, MD,
Dominique Demylle, BS, PhD
Gynecology Research Unit, Universit Catholique de Louvain, Brussels, Belgium
*Department of Gynecology, Cliniques Universitaires St. Luc, Universit Catholique de
Louvain, Avenue Hippocrate, 10, B-1200 Brussels Belgium
The lifesaving treatment endured by cancer survivors provokes, in many cases,

early menopause and subsequent infertility. In clinical situations where there
is often a pressing need to start chemotherapy, ovarian tissue cryopreservation
looks to be a promising option to restore fertility.
It has been estimated that, by 2010, one in 250 people in the adult population
will actually be childhood cancer survivors [1].
The treatment of childhood malignancy is becoming increasingly effective.
Aggressive chemotherapy and radiotherapy, as well as bone marrow transplantation, can cure more than 90 percent of girls and young women affected by such
malignancies. However, the ovaries are very sensitive to cytotoxic treatment,
especially to alkylating agents and ionizing radiation, generally resulting in the
loss of both endocrine and reproductive function [2]. Moreover, it is known that
uterine irradiation at a young age reduces adult uterine volume [3].
There are several potential options available to preserve fertility in patients
facing premature ovarian failure, including immature and mature oocyte
cryopreservation, embryo cryopreservation and cryopreservation of ovarian
tissue[4,5].
For those patients who require immediate chemotherapy, cryopreservation
of ovarian tissue is a possible alternative [4,6,7].
37
History of experimental and clinical studies

To date, ovarian tissue has been successfully cryopreserved and transplanted in
mice and rodents, as well as large animals like sheep and marmoset monkeys
[8-10]. The rst successful fertilization and pregnancy following egg collection
from fresh transplanted ovarian tissue in a primate was recently described [11].
The grafted tissue functioned without any surgical connection to major blood
vessels. Experimental studies have indicated that the decrease in the number
of primordial follicles in grafted tissue is due to hypoxia and the delay before
reimplanted cortical tissue becomes revascularized. The loss of primordial follicles in cryopreserved ovarian tissue after transplantation is estimated to be 50
to 65 percent in some experimental studies [7,8,12]. In one experimental study,
in which ovarian cortex was grafted onto the uterine horn and under the skin,
the loss was found to be more than 90 percent [13].
Oktay et al have reported laparoscopic transplantation of frozen-thawed
ovarian tissue to the pelvic side wall [14], to the forearm [15] and, more recently, beneath the skin of the abdomen. A four-cell embryo was obtained from
20 oocytes retrieved from tissue transplanted to the latter site, but no pregnancy
occurred after transfer [16]. Radford et al reported on a patient with a history of Hodgkins disease treated by chemotherapy, in whom ovarian tissue
had been biopsied and cryopreserved four years after chemotherapy and later
reimplanted [17]. In this case, histological section of ovarian cortical tissue
revealed only a few primordial follicles because of the previous chemotherapy.
After reimplantation, the patient had only one menstrual period.
Very recently, the rst livebirth after a fresh ovarian tissue transplant in a
primate was reported [11].
We have described a livebirth after orthotopic autotransplantation of cryopreserved ovarian tissue. Our ndings suggest that cryopreservation of ovarian
tissue should be offered to all young women diagnosed with cancer [18].
Freeze-thawing
Freezing of ovarian tissue was carried out according to the protocol described
by Gosden et al [6]. The biopsies were immediately transferred to the laboratory in Leibovitz L-15 medium supplemented with Glutamax (GIBCO, Paisley,
Scotland). There, the remaining stromal tissue was gently removed.
Four biopsies of the cortex were then cut into 70 small cubes of 2x2mm.
One strip of 12x4mm was left whole.
Fragments (cubes and a strip) of ovarian tissue were suspended in the cryo-
38
protective medium. All the fragments were placed into precooled 2ml cryogenic
vials (Simport, Quebec, Canada) lled with Leibovitz medium supplemented
with 4mg/ml of human serum albumin (Red Cross, Brussels, Belgium) and
1.5mM DMSO (Sigma, St. Louis, MO). The cryotubes were cooled in a programmable freezer (Kryo 10, Series III; Planer, Sunbury-on-Thames, United
Kingdom) using the following program: (1) cooled from 0C to 8C at 2C/
min; (2) seeded manually by touching the cryotubes with forceps prechilled
in liquid nitrogen; (3) cooled to 40C at 0.3C/min; (4) cooled to 150C
at 30C/min, and (5) transferred to liquid nitrogen (-196C) immediately for
storage.
Reimplantation of ovarian cortical tissue

In 1997, a 25-year-old woman presented with clinical stage IV Hodgkins lymphoma. Ovarian tissue cryopreservation was carried out before chemotherapy.
Written informed consent was obtained. Using laparoscopy, 5 biopsies, about
1.2-1.5cm long and 5mm wide, were taken from the left ovary. Removing the
whole ovary was not an option, as one can never completely exclude recovery
of ovarian function after chemotherapy. Indeed, premature ovarian failure after
chemotherapy is age-, drug- and dose-dependent and does not occur in 100%
of cases.
After laparoscopy, the patient received MOPP/ABV hybrid chemotherapy
(mechlorethamine, vincristine, procarbazine, prednisone, adriamycin, bleomycin, vinblastine) from August 1997 to February 1998, followed by radiotherapy
(38 grays).
She became amenorrheic shortly after the initiation of chemotherapy. The
levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH) and
estradiol (E2) following chemo- and radiotherapy were, respectively, 91.1 mIU/
ml, 85 mIU/ml and 17 pg/ml, conrming castration. This ovarian failure prole
was conrmed three months later. Hormone replacement therapy (HRT) was
started in June 1998 and then stopped in January 2001, as the patient wished
to become pregnant. A thorough evaluation by oncologists demonstrated that
she was disease-free.
After cessation of HRT, FSH, LH and 17 -estradiol levels returned to levels
consistent with ovarian failure. From January 2001 to December 2002, the
patient experienced only one ovulatory cycle proved by a progesterone level
of 10 ng/ml and the presence of a corpus luteum on the left ovary, diagnosed
by vaginal echography. The decision to reimplant was therefore taken.
A rst laparoscopy was carried out 7 days before reimplantation in order to
39
create a peritoneal window by means of a large incision just beneath the right
ovarian hilus, followed by coagulation of the edges of the window. The goal
was to induce angiogenesis and neovascularization in this area. Both ovaries
looked atrophic. Nevertheless, a small corpus luteum was visible on the left
ovary. A decrease in LH and FSH was observed and the concentrations then
returned to castrated levels.
A second laparoscopy was carried out seven days after the creation of the
peritoneal window. A biopsy of 4-5mm in size was taken from each of the
atrophic ovaries in order to check for the presence or absence of primordial
follicles.
The thawed ovarian cortical tissue was then placed in sterile medium and
immediately transferred to the operating theatre. The large strip and 35 small
cubes of frozen-thawed ovarian tissue were pushed into the furrow created
by the peritoneal window very close to the ovarian vessels and mbria on the
right side. No suture was used. An extensive neovascular network was clearly
visible in this space
A third laparoscopy was carried out four and a half months after reimplantation to evaluate the survival of the graft. A follicle was visible at the site of
reimplantation. Biopsy was performed.
The grafted tissue was biopsied and histology and uorescent probe staining
revealed the presence of viable primordial follicles and a follicular structure
with inhibin A-marked cells. Follicles at an early growth stage require more
than 85 days to reach the antral stage [19]. Primordial follicles obviously require even more. The appearance of the rst follicle in the grafted tissue ve
months after reimplantation is totally consistent with the expected time course.
This time interval observed in our study between implantation of cortical tissue
and the rst estradiol peak (5 months) is also consistent with data obtained from
sheep and human beings [8,17].
From ve to nine months after reimplantation, ultrasonography revealed the
development of a follicle followed by corpus luteum formation with each cycle,
at the site of reimplantation. This corresponded to an estradiol level of more
than 100 pg/ml and a progesterone level ranging from 12 to 37 ng/ml. The LH
and FSH levels were signicantly (p<0.05) lower than those observed before
reimplantation. This led to the restoration of consecutive menstrual bleeding
each month.
At nine and a half months, FSH levels increased to 78.7 mIU/ml and returned to normal values seven days later. Three weeks later, a follicle of 2.6cm
in size had developed on the right side, clearly outside the right ovary. Both native ovaries were well visualized and found to be obviously atrophic. Eighteen
40
days after ovulation, calculated by basal body temperature, the hCG level was
2,853 mIU/ml.
We cannot explain this sudden and temporary surge in FSH. It is possible
that it was associated with a decline in inhibin secretion, as suggested in the
sheep model [20,21] or with slower follicular growth from a poor follicular
reserve in the graft. Indeed, due to the loss of primordial follicles in the transplant, the follicular density per mm3 was low but, in any case, the total amount
of cortical tissue transplanted is relatively unimportant. After transplantation,
the patient would have been considered a poor responder as, of the 500 to 1000
primordial follicles that would have been transplanted, more than 50 percent
would have been lost due to hypoxia [12].
Is it risky?
Unfortunately, in the majority of cases, aggressive chemotherapy and radiotherapy lead to ovarian failure. The restoration of ovarian function after
chemotherapy or radiotherapy has two main goals: to improve quality of life
and restore reproductive function. For those patients who require immediate
chemotherapy, ovarian tissue cryopreservation, performed before cancer treatment is begun, may be a means of preserving fertility without delaying the
initiation of chemotherapy. However, one major concern surrounding the use
of ovarian cortical strips for orthotopic autotransplantation is the potential risk
that the frozen-thawed ovarian cortex might harbour malignant cells which
could induce a recurrence of the disease after reimplantation. Shaw et al reported that ovarian grafts from AKR mice could transfer lymphoma to recipient
animals [22]. Nevertheless, more recent studies have suggested that ovarian
tissue transplantation in Hodgkins disease is safe [23-25].
In our study, histological evaluation of ovarian cortex before and after reimplantation demonstrated the absence of disease. But conrming the absence
of malignant cells by light microscopy may not be sufcient, especially in
other types of cancer (especially hematogenous or systemic neoplasms)[9].
Screening methods to detect minimal residual disease must be developed to
eliminate the risk of cancer cell transmission with reimplantation [5].
Lines of evidence:
1.The patient experienced, in total, 3 ovulatory cycles over a period of more
than two years. All of them originated from the left native ovary. This was
proved by laparoscopy and/or echography.
41
2. The native right ovary never demonstrated any ovarian activity at all (no
follicles, no corpus luteum).
3. Even if we cannot absolutely exclude the presence of isolated follicles in
the atrophic ovary, their density must be very low since serial sections of 4
large biopsies of atrophic ovaries failed to detect any.
4. Laparoscopy proved, by direct visualization, the development of a follicle
from the grafted tissue ve months after reimplantation.
5. Biopsy proved, by histologic examination, not only the survival of primordial
follicles in the grafted tissue, but also the maturation of a follicle (granulacells marked by inhibin-A). This is the rst time that survival of primordial
follicles has been histologically proved after cryopreserved ovarian tissue
transplantation.
6. After follicular development was proved by laparoscopy and histology, the
patient experienced regular menstrual bleeding. The progesterone level was
systematically more than 10ng/ml in the mid-luteal phase, calculated on the
basis of BBT.
During each ovulatory cycle (from 5 to 9 months), vaginal echography demonstrated a corpus luteum on the grafted tissue outside the right atrophic
ovary, which had demonstrated no ovarian activity for almost 3 years.
7. Finally, vaginal echography revealed the presence of a preovulatory follicle
at the reimplantation site during the cycle leading to the pregnancy, but no
follicles were seen on either of the native ovaries. This argument is a crucial
one.
Conclusion
This is the rst report of the birth of a healthy infant, obtained after orthotopic
autotransplantation of cryopreserved ovarian tissue. It opens new perspectives
for young cancer patients facing premature ovarian failure. Ovarian tissue cryopreservation should be an option offered to all young women diagnosed with
cancer, in conjunction with other existing options for fertility preservation such
as immature oocyte retrieval, in vitro maturation of oocytes, oocyte vitrication
or embryo cryopreservation.
Even if more and more papers are now describing the restoration of ovarian
function after orthotopic transplantation of fresh and frozen ovarian tissue and
the rst livebirth has recently been reported, we should still bear in mind that
many questions remain unanswered. In our department, research is presently
under way on freezing an entire ovary. A recent paper by our group described
not only the technique, but also the high rate of survival of primordial follicles
42
after freeze-thawing an entire ovary [26,27]. This could lead to the transplantation of an intact ovary, with microvascular anastomosis carried out to restore
immediate vascularization and minimize post-transplantation ischemia responsible for the reduction in follicular density.
A major limitation of intact organ transplantation, which needs to be investigated, is the problem of storage of an intact ovary with its vascular tissue.
Other issues, like the question of the optimum number of grafts and hence
oocytes, how long the graft will last and the optimum technique and site, must
be addressed.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Blatt J. Pregnancy outcome in long-term survivors of childhood cancer. Med Pediatr Oncol
1999; 33:2933.
Donnez J, Godin PA, Qu J, Nisolle M. Gonadal cryopreservation in the young patient with
gynaecological malignancy. Current Op Obstet Gynecol 2000; 12:19.
Larsen EC, Schmiegelow K, Rechnitzer C et al. Radiotherapy at a young age reduces uterine
volume of childhood cancer survivors. Acta Obstet Gynecol Scand 2004; 83:96-102.
Donnez J, Bassil S. Indications for cryopreservation of ovarian tissue. Hum Reprod 1998;
4:248259.
Rao GD, Chian RC, Son WS et al. Fertility preservation in women undergoing cancer treatment. Lancet 2004; 363:1829-1830.
Gosden RG, Baird DT, Wade JC, Webb R. Restoration of fertility to oophorectomised sheep
by ovarian autografts stored at 196C. Hum Reprod 1994; 9:597603.
Meirow D, Fasouliotis SJ, Nugent D et al. Laparoscopic technique for obtaining ovarian cortical biopsy specimens for fertility conservation in patients with cancer. Fertil Steril 1999;
71:94891.
Baird DT, Webb R, Campbell BK et al. Long-term ovarian function in sheep after ovariectomy
and transplantation of autografts stored at -196C. Endocrinology 1999; 140:46241.
Meirow D, Yehuda DB, Prus D et al. Ovarian tissue banking in patients with Hodgkins disease: is it safe? Fertil Steril 1998; 69:996998
Candy CJ, Wood MJ, Whittingham DG. Restoration of a normal reproductive lifespan after
grafting of cryopreserved mouse ovaries. Hum Reprod 2000; 15:13001304.
Lee DM, Yeoman RR, Battaglia DE et al. Live birth after ovarian tissue transplant. Nature
2004; 428:137138.
Nisolle M, Casanas-Roux F, Qu J et al. Histologic and ultrastructural evaluation of fresh and
frozen-thawed human ovarian xenografts in nude mice. Fertil Steril 2000; 74:1229.
Aubard Y, Piver P, Cogni Y et al. Orthotopic and heterotopic autografts of frozen-thawed
ovarian cortex in sheep. Hum Reprod 1999; 14:2149-2154.
Oktay K, Karlikaya G. Ovarian function after transplantation of frozen, banked autologous
ovarian tissue. N Engl J Med 2000; 342:1919.
Oktay K, Economos K, Kan M et al. Endocrine function and oocyte retrieval after autologous
transplantation of ovarian cortical strips to the forearm. Jama 2001; 286:14901493.
Oktay K, Buyuk E, Veeck L et al. Embryo development after heterotopic transplantation of
cryopreserved ovarian tissue. Lancet 2004; 363:837840.
Radford JA, Lieberman BA, Brison D et al. Orthotopic reimplantation of cryopreserved
43
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
ovarian cortical strips after high-dose chemotherapy for Hodgkins lymphoma. Lancet 2001;
357:11721175.
Donnez J, Dolmans MM, Demylle D et al. Livebirth after orthotopic transplantation of cryopreserved ovarian tissue. Lancet 2004; 364:1405-1410
Gougeon A. Dynamics of follicular growth in the human: a model from preliminary results.
Hum Reprod 1986;1:8187.
Callejo J, Salvador C, Miralles A et al. Long-term ovarian function evaluation after autografting by implantation with fresh and frozen-thawed human ovarian tissue. J Clin Endocrinol
Metab 2001; 86:44894494.
Campbell BK, Telfer EE, Webb R, Baird DT. Ovarian autografts in sheep as a model for
studying folliculogenesis. Mol Cell Endocrinol 2000; 163:131139.
Shaw JM, Bowles J, Koopman P et al. Fresh and cryopreserved ovarian tissue samples from
donors with lymphoma transmit the cancer to graft recipients. Hum Reprod 1996; 11:1668
1673.
Kim SS, Radford JA, Harris M et al. Ovarian tissue harvested from lymphoma patients to
preserve fertility may be safe for autotransplantation. Hum Reprod 2001; 16:2056-2060.
Kim SS, Battaglia DE, Soules MR. The future of human ovarian cryopreservation and transplantation: fertility and beyond. Fertil Steril 2001; 75:10491056.
Kim SS. Ovarian tissue banking for cancer patients. To do or not to do? Hum Reprod 2003;
18:17591761.
Martinez-Madrid B, Dolmans MM, Van Langendonckt A, Defrre S, Donnez J. Freeze-thawing intact human ovary with its vascular pedicle with a passive cooling device. Fertil Steril
2004; 82: 1390-1394.
Martinez-Madrid B, Dolmans MM, Van Langendonckt A, Defrre S, Van Eyck AS, Donnez
J. Ficoll density gradient method for recovery of isolated human ovarian primordial follicles.
Fertil Steril 2004; 82:1648-1653.
44
PCOS
Risks of Controlled Ovarian
Hyperstimulation
Zion Ben-Rafael
Sackler Faculty of Medicine and the Tarnensby Chair of Fertility Regulation,
Tel Aviv University, Israel
e-mail:brafael@zahav.net.il
Introductions to most articles on ovarian hyperstimulation syndrome (OHSS)

claim that OHSS is a potentially life-threatening complication of controlled
ovarian hyperstimulation (COH). However, it appears that in daily practice
clinicians do not give much credence to this contestation. In Delvingne and
Rosenbergs (2001) elegant study regarding physicians attitudes towards
prevention of OHSS, 573 members of ESHRE were asked if they would: a)
cancel a cycle; b) take preventive measures; or c) proceed to regular IVF, in
several case scenarios, including an extreme case of a lean PCOS patient with
multiple allergies (a predisposition to OHSS), protein C deciency (and thus
at increased risk of thrombo-embolic phenomena), and estradiol (E2) level of
6590 pg/ml. Only 20% of the physicians suggested abandoning the cycle before
hCG administration, despite the fact that hCG is the major factor triggering
OHSS, whereas 80% either proceeded to regular IVF (20%), or chose some,
albeit unproven preventive measures (60%), mainly coasting and albumin infusion (as well as freezing, which is well-established). What is the origin of these
variances in clinicians attitudes towards the risk of OHSS? Is it because physicians are reluctant to cancel a costly cycle in which the couple has invested high
hopes, or is it because their daily practical experience is different?
Ovarian hyperstimulation syndrome is an iatrogenic side effect of ovulation induction that subsides spontaneously in most cases unless a pregnancy
is established. The cardinal features of the syndrome are marked ovarian en-
45
largement and an acute third space uid sequestration. The uid shift from the
intra- to the extravascular spaces in response to the increase in capillary permeability leads to ascites, pleural and pericardial effusion, with hypovolemia,
hyperviscosity, hypercoagulability, electrolyte disturbances, oliguria, and very
rarely, ARDS and renal failure (Golan et al. 1989; Navot et al. 1996). The latter
study contributed most data to the morbidity associated with OHSS.
Incidence of OHSS
The incidence of all forms of OHSS is high, but the majority of cases are mild
(15%-30%), characterized by high E2 levels and ovarian enlargement, both of
which could be viewed as falling within the desired goals of the routine COH
protocols for IVF. Moderate OHSS is rare (2-6%), but usually requires no hospitalization, or special treatment, except for increased uid intake. Conversely,
the incidence of severe and critical forms of IVF-OHSS is very low and in a
busy program is only rarely encountered. Furthermore, severe cases are usually associated with multiple pregnancies and cannot be predicted by ovarian
stimulation.
The exact incidence of severe OHSS worldwide has not been determined,
as most of the studies conducted to date have contained relatively small series.
However, the data available suggest a 0.22.0% incidence of severe OHSS for
all assisted conception cycles (Smitz et al., 1990; Asch et al., 1991; Brinsden
et al., 1995; Roest et al., 1996). In an attempt to establish the frequency of
complications of IVF treatment, Bergh and Lundkvist (1992) surveyed 12
IVF clinics in Nordic countries. Of the 10,125 treatment cycles started, 0.7%
were associated with OHSS, severe enough to warrant patient hospitalization.
Similar ndings were noted in an analysis of 2,495 IVF cycles at a single Dutch
clinic (Roest et al., 1996). Neither of these studies reported fatal complications
of IVF treatment.
Abramov et al. (1998) documented an increase in the annual incidence of
severe OHSS in Israel (from 0.06 to >0.2% of IVF cycles) over a 10-year
period (1987-1997) that superseded the increase in total IVF activity (20-fold
versus 6-fold, respectively) during the same period, and was coincidental with
disproportionate nationwide increases in severe cases of OHSS. Yet again there
was not a single fatality due to OHSS in the 73,492 cycles studied by these
authors.
The reported incidence of OHSS is far lower than the high incidence of
ectopic and multiple pregnancies, and surgical procedures associated with IVF
and related assisted reproduction technologies (ART), all of which carry a
46
considerably higher risk of maternal morbidity. The ASRM reports from 1999
indicated that ectopic pregnancies accounted for 0.4% of all pregnancies and
0.1% of all IVF cycles. Accordingly, in 1998, Serour et al. found a corresponding rate of 0.6% in ectopic pregnancies of IVF cycles.
Venn et al. (2001) compared mortality rates between women referred for
IVF (treated and untreated) and the same age-matched females in the general
population in Australia. All-cause- mortality in the IVF group was found to be
signicantly lower than in the general population. Ovarian hyperstimulation
syndrome could not be directly related to any of the deaths identied in this
cohort.
Our search of the literature revealed only two fatalities associated with OHSS
in ART: one due to massive pulmonary edema and pleural effusion reported in a
study from Japan (Semba et al. 2000), and the other due to cerebral infarction
in a patient from New Zealand (Cluroe and Synek, 1995). This extremely low
fatality rate, less than one in several hundreds of thousands of ART cycles, is
negligible compared to the reported maternal mortality rate after the aforementioned complications associated with the much desired pregnancy.
Pathophysiology of OHSS
The direct action of gonadotropins on ovarian tissue triggers ovarian enlargement; however, the factor responsible for triggering third-space uid shifting,
similar to the well-known vascular leak syndrome, remains elusive.
Recently, evidence has been accumulated concerning interaction between
the immune and reproductive systems that results from sharing certain cytokines and their receptors (Orvieto and Ben-Rafael,1998). As many cases of
OHSS occur in the presence of normal or low estrogen levels, whereas high
estrogen levels only infrequently lead to severe OHSS, it is assumed that a
certain inherent factor, such as allergy, is also involved.
Prediction and Prevention of OHSS

Several articles have reviewed the epidemiologic, hormonal, and ultrasonographic characteristics of patients susceptible to OHSS (Blankstein et al., 1987;
Asch et al. 1991; Navot et al. 1992,1996; Morris et al., 1995; Zalel et al., 1995;
Levy et al., 1996 ). Despite numerous years of clinical experience, the pathophysiology of OHSS remains inadequately understood, and there is no reliable
test to predict which patients will develop severe OHSS. Young age, low body
weight, high E2 levels, number of follicles, number of oocytes retrieved, and
47
evidence of PCO were all found to be associated with OHSS, but the majority
of these factors have been regarded as debatable in follow-up studies (Whelan
and Vlahos, 2000).
The common use of excessive E2 levels and number of follicles as predictors
of severe OHSS was challenged in a recent study. The signicance of these
variables, which are more a consequence of the high physiological level at
which the ovary functions, as independent factors for the development of the
syndrome remains uncertain (Whelan and Vlahos, 2000).
Morris et al. (1995) did not nd any incident of OHSS among 72 donors
with E2 levels >4000 pg/ml, and 25 eggs. With E2 levels of 6000-12000 pg/ml
and 30 eggs, 10% developed OHSS, compared to only 3% of the non-pregnant women. The relative risk of OHSS with pregnancy was 12. The authors
concluded that the risk of OHSS even at high levels of stimulation is lower
than previously believed, and that donors have a very low risk of OHSS,
probably because of the absence of pregnancy. As such, cryopreservation of
all oocytes in IVF cycles is a reasonable alternative to cycle cancellation,
or use of adjunctive medication. These ndings were supported by Mathur
et al., (1995) who observed that OHSS may be more probable if multiple
pregnancies occur after assisted conception. However, other studies showed
that when there is serious risk of severe OHSS, cryopreservation of all resulting embryos may prevent pregnancy-associated late OHSS, but not early
onset OHSS, which is precipitated with the trigger hCG dose (Lyons et al.,
1994; Queenan et al., 1997). It follows that postponing transfer until day 7
post-hCG (blastocyst stage) to check for early signs of OHSS, is a strategy
that prevents abandoning a cycle while maintaining maximal security before
transfer (Navot et al., 1996).
Orvieto and Ben-Rafael (1998) and Orvieto (2003) have demonstrated a
considerable variability in E2 levels in patients who developed OHSS (Orvieto,
2003). In addition, the latter author presented pathophysiological evidence supporting a preventive, rather than a detrimental effect of E2 in OHSS. In a related
study, when all the accepted predictive variables were combined, the prevalence of severe OHSS in the ostensibly high-risk patients was approximately
20% (Orvieto and Ben-Rafael, 1998) - an extremely low value for reliable
prediction.
Secondary prevention by treatment, such as albumin, requires not only
knowledge of the pathophysiological mechanisms of the disease and means of
intervention to correct the pathophysiological changes, but also the availability
of early detection methods (Orvieto et al., 1993). As studies of the prevention
of severe OHSS have been limited by the low sensitivity and predictive values
48
of the factors currently used to dene high risk (Levy et al., 1996), evaluation
of secondary prevention strategies is also limited.
Controlled ovarian hyperstimulation for IVF was designed to obtain as
many follicles and oocytes as possible in order to yield the maximal number
of embryos in a single treatment cycle. With the introduction in 1987 of gonadtropin-releasing hormone agonists (GnRH-a) to the COH protocols, clinicians initiated treatment with higher doses of gonadotropins for retrieval of
a higher number of mature oocytes. These protocols came into widespread use
because of their higher conception and lower cancellation rates (Fleming et al.,
1988). Unfortunately, they were also associated with an increased occurrence
rate of OHSS (Forman et al., 1990).
In the late 90s COH protocols tended to be more aggressive, relying on
numerous prevention tactics which were never proven, such as albumin infusion, early ascites aspiration, follicular reduction, respiration of the corpora
lutea, GnRH-a administration as surrogate to hCG, and others. Common protocols employed high doses of gonadotropins (3-6 ampoules daily) combined
with GnRH-a down-regulation, a compound that blocks the self-protecting
mechanism (spontaneous luteinization) thus preventing further stimulation.
The widespread use of routine GnRH-a protocols have restricted its applicability as a surrogate to hCG to induce nal oocyte maturation and ovulation
(Balasch et al., 1994). However, with the introduction of GnRH antagonists to
the protocols (reviewed by Kol, 2004) it may be prudent in high risk cases to
perform COH with a GnRH-antagonist in combination with GnRH-a to trigger
ovulation.
The period of the 90s was not only the decade when the limits of stimulation in high- and low-responders were tested, but also the years of frustration
arising from the diverse preventive measures. It was soon realized that the lack
of reliable tests to predict development of the syndrome limited the accurate
evaluation of the preventive steps which, per se, were largely unreliable.
Early Versus late OHSS

The syndrome presents either 3-7 days after hCG administration in susceptible
patients (early-onset), or more commonly during early pregnancy, 12-17 days
after hCG administration (late-onset). Early OHSS can, to some extent, be
predicted by preovulatory indices of ovarian response, early enough to institute preventive measures, all of which are unproven, except for cancellation
and freezing of all embryos. However, in late OHSS preovulatory indices of
ovarian response are similar to that in the control group, making it difcult
49
for clinicians to identify the cycles in which it is likely to occur (Mathur et

al., 1997). In the original description of OHSS, the late form was observed
only in cycles with multiple gestations (Dahl Lyons et al., 1994). Thereafter,
OHSS was observed also in singleton gestations, but the risk remained higher
for multiple gestations with a trend towards a rise in severity of disease with
increase in the number of gestational sacs (Mathur et al., 1995). The present
trend of transferring blastocysts allows monitoring the cycle for signs of early
OHSS before transfer; if such signs occur, freezing of all embryos could be
offered. Furthermore, the tendency to reduce the number of embryo transfers
to one or two, further decreases the risk of developing severe late OHSS.
In Summary
The desire of some couples for children is so strong that they are willing to
accept a modicum of risk to treat their infertility. Ideally, ART practitioners
seek a balance between optimum ovarian stimulation and successful treatment outcome with minimal rate of severe OHSS, or multiple pregnancies.
While the absence of OHSS-related mortality in the studies conducted to date
is reassuring, severe OHSS can still lead to some complications, especially in
susceptible patients, such as thrombophilia carriers.
Although there are no precise methods to predict, and hence to completely
prevent severe OHSS, individualization of treatment according to the specic
risk factor and the specic response in the current cycle with the option of
freezing of all embryos, or replacement of only a single embryo, has the potential of reducing the risk and the severity of the syndrome in susceptible cases.
Thus, in high-risk patients, who usually possess a higher number of embryos, an attempt should be made to transfer only one blastocyst. Follow-up of
the patients for signs of early severe OHSS, for 7 days after hCG administration, can assist clinicians to determine whether it is safe to proceed with embryo
transfer, or if transfer should be withheld combined with cryopreservation of
all resulting embryos. This regimen can limit early OHSS, if it appears, to a
milder and shorter form. If early OHSS does not develop, the transfer of one
blastocyst will decrease the risk of multiple pregnancies to almost zero, thereby
eliminating the occurrence of late-OHSS.
The recent contestation (Dulitzky et al 2002) that patient with severe OHSS
had more positive markers for thrombophilia (17/20=80%) than matched controls with similarly estradiol levels but without OHSS (11/41=26.8%) might
further direct towards inherent sensitivity of OHSS patients.
50
References
Abramov, Y., Elchalal, U. and Schenker, J. (1998). Febrile morbidity in severe and critical
ovarian hyperstimulation syndrome: a multicenter study. Hum. Reprod., 13, 3128
3131.
Asch, R.H., Li, H., Balmaceda, J.P. et al. (1991). Severe ovarian hyperstimulation syndrome
in assisted reproductive technology: denition of high risk groups. Hum. Reprod., 6,
13951399.
Balasch, J., Tur, R., Creus, M. et al. (1994). Triggering of ovulation by gonadotropin
releasing hormone agonist in gonadotropin-stimulated cycles for prevention of ovarian
hyperstimulation syndrome and multiple pregnancy. Gynecol. Endocrinol., 8, 712.
Bergh, T. and Lundkvist, O. (1992). Clinical complications during in-vitro fertilization
treatment. Hum. Reprod., 7, 625626.
Blankstein, J., Shalev, J., Saadon, T., Kukia, E.E., Rabinovici, J., Pariente, C., Lunenfeld,
B., Serr, D.M. and Mashiach, S. (1987) Ovarian hyperstimulation syndrome: prediction
by number and size of preovulatory ovarian follicles. Fertil. Steril., 47, 597602.
Brinsden, P.R., Wada, I., Tan, S.L. et al. (1995) Diagnosis, prevention and management of
ovarian hyperstimulation syndrome. Br. J. Obstet. Gynaecol., 102, 767772.
Cluroe, A. and Synek, B. (1995) A fatal case of ovarian hyperstimulation syndrome with
cerebral infarction. Pathology, 27, 344346.
Dahl Lyons, C.A., Wheeler, C.A., Frishman, G.N. et al. (1994) Early and late presentation
of the ovarian hyperstimulation syndrome: two distinct entities with different risk factors. Hum. Reprod., 9, 792799.
Delvigne, A., and Rozenberg, S. (2001). Preventive attitude of physician to avoid OHSS
in IVF patients. Hum. Reprod., 16, 2491-2495
Dulitzky M, Choen SB, Inbal A, Seideman DS, Soriano D, Lidor A, Mashiach S, Rabinovici
J, (2002) Increased prevalence of thrombophilia among women with severe ovarian
hyperstimulation syndrome. Fertil. Steril. 77, 463-467.
Fleming, R., Haxton, M.J., Hamilton, M.P.R. et al. (1988) Combined gonadotropin-releasing hormone analog and exogenous gonadotropins for ovulation induction in infertile
women: Efcacy related to ovarian function assessment. Am. J. Obstet. Gynecol., 159,
376381.
Forman, R.G., Frydman, R., Egan, D. et al. (1990) Severe hyperstimulation syndrome
using agonists of gonadotropin-releasing hormone for in vitro fertilization: a European
series and a proposal for prevention. Fertil. Steril., 53, 502509.
Golan, A., Ron-El, R., Herman, A. et al. (1989) Ovarian hyperstimulation syndrome: an
update review. Obstet. Gynecol. Surv., 44, 430440.
Kol, S. (2004) Luteolysis induced by a gonadotropin-releasing hormone agonist is the key
to prevention of ovarian hyperstimulation syndrome. Fertil. Steril., 81, 1-5
Levy, T., Orvieto, R., Homburg, R., Dekel, A., Peleg, D. and Ben-Rafael, Z. (1996) Severe
ovarian hyperstimulation syndrome despite low plasma estrogen levels in a hypogo-
51
nadotropic hypogonadal patient. Hum. Reprod., 11, 11771179.
Lyons, C.A., Wheeler, C.A., Frishman, G.N. et al. (1994) Early and late presentation of
ovarian hyperstimulation syndrome: two distinct entities with different risk factors.
Hum. Reprod., 9, 792799.
Mathur, R.S., Joels, L.A., and Jenkins, J.M. (1995) Ovarian hyperstimulation syndrome
may be more likely if multiple pregnancy follows assisted conception. Acta Genet.
Med. Gemellol., 44, 233235.
Mathur, R.S., Akande, A.V., Keay, S.D. et al. (1997) Late onset OHSS after ovarian stimulation is poorly predicted by peak oestradiol concentration and number of oocytes
collected. Hum. Reprod., 12, (Abstr. Book 1), R-229.
Morris, R.S., Paulson, R.J., Sauer, M.V. and Lobo, R.A. (1995) Predictive value of serum
oestradiol concentrations and oocyte number in severe ovarian hyperstimulation syndrome. Hum. Reprod., 10, 811814.
Navot, D., Bergh, P.A. and Laufer, N. (1992) Ovarian hyperstimulation syndrome in novel
reproductive technologies: prevention and treatment. Fertil. Steril., 58, 249261.
Navot, D., Bergh, P.A. and Laufer, N. (1996) The ovarian hyperstimulation syndrome. In
E. Adashi., J.A. Rock, and Z. Rosenwaks (eds). Reproductive Endocrinology, Surgery,
and Technology. Lippincott-Raven Publishers, Philadelphia, pp. 22152232.
Orvieto, R., Achiron, A., Ben-Rafael, Z., Hagay, Z. and Achiron, R. (1993) The possible
role of intravenous immunoglobulin in preventing preeclampsia. Med. Hypotheses,
41,160-164.
Orvieto, R. and Ben-Rafael, Z. (1998) Role of intravenous albumin in the prevention of
severe ovarian hyperstimulation syndrome. Hum. Reprod., 13, 33063309.
Orvieto, R (2003) Prediction of ovarian hyperstimulation syndrome: challenging the estradiol mythos. Hum. Reprod., 18, 665-7.
Queenan, J.T., Veeck, L.L., Toner, J.P. et al. (1997) Cryopreservation of all prezygotes
in patients at risk of severe hyperstimulation does not eliminate the syndrome, but
the chances of pregnancy are excellent with subsequent frozen-thaw transfers. Hum.
Reprod., 12, 15731576.
Roest, J., Mous, H., Zeilmaker, G. et al. (1996) The incidence of major clinical complications in a Dutch transport IVF programme. Hum. Reprod. Update, 2, 345353.
Serour, G.I., Aboulghar, M., Mansour, R. et al. (1998) Complication of medically-assisted
conception in 3,500 cycles. Fertil. Steril., 70, 638642
Semba, S., Moriya, T., Youssef, E.M. and Sasano, H. (2000) An autopsy case of ovarian hyperstimulation syndrome with massive pulmonary edema and pleural effusion.
Pathol. Int., 50, 549-552.
Smitz, J., Camus, M., Devroey, P. et al. (1990) Incidence of severe ovarian hyperstimulation syndrome after GnRH agonist/HMG superovulation for in-vitro fertilization. Hum.
Reprod., 5, 933937.
Society for Assisted Reproductive Technology/The American Society for Reproductive
Medicine (1999) Assisted Reproductive Technology in the United States: 1996 results
generated from the American Society for Reproductive Medicine/Society for Assisted
52
Reproduction Technology Registry. Fertil. Steril., 71, 798807.

Venn, A., Hemminki, E., Watson, L., Bruinsma, F. and Healy, D. (2001) Mortality in a
cohort of IVF patients. Hum. Reprod., 16, 2691-2696
Whelan, J.G. and Vlahos, N.F. (2000) The ovarian hyperstimulation syndrome. Fertil.
Steril., 73, 883-896
Zalel, Y., Orvieto, R., Ben-Rafael, Z., Homburg, R., Fisher, O. and Insler, V. (1995)
Recurrent spontaneous ovarian hyperstimulation syndrome associated with polycystic
ovary syndrome. Gynecol. Endocrinol., 9, 313315.
53
Why Give LH if FSH Works?

Tim Child MA MRCOG
John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK
Introduction
The aims of this presentation are to:
1.
review the role of luteinizing hormone (LH) in follicular/ovarian
maturation and ovulation
2.
review the evidence for LH effects during ovarian stimulation under
the following circumstances
a. anovulation due to WHO Type I disorders
(hypogonadotrophic hypogonadism)
b. anovulation due to WHO Type II disorders (mainly PCOS)
c. long protocol IVF using GnRH-agonist
Background
Gonadotropins and ovarian function.
Within ovarian follicles, luteinizing hormone (LH) stimulates theca cells (TC)
to produce androgens. The androgens are then transferred to granulosa cells
(GC) where, under the follicle stimulating hormone (FSH)-controlled aromatase pathway, they are turned into estrogens. These estrogens have a vital role in
follicular and oocyte maturation and endometrial priming. This is the two-cell
two-gonadotropin model. During the early follicular phase TC express LH
receptors and GC express FSH receptors in keeping with the model. However,
by the mid to late follicular phase increasing estrogen levels in the presence of
FSH induce the formation of LH receptors on GC. Consequently towards the
end of the follicular phase LH is able to act independently of FSH through TC
androgen production followed by GC aromatization into estrogens.
54
During the very early follicular phase the intercycle FSH rise induces the
recruitment of a number of follicles. The increasing LH levels later in the follicular phase act on the LH receptors within GC of larger follicles to allow one
to continue its growth through dominance, independent of FSH. The absence
of LH receptors on the GC of smaller follicles and the fall in FSH levels leads
to their regression.
Gonadotropin preparations.
A number of gonadotropin preparations are available which are either urinary
derived or recombinant. Human menopausal gonadotropin (hMG) contains
equivalent amounts (75 IU) of FSH and LH. Some of the LH activity of these
preparations is due to the presence of hCG. In general, gonadotropin preparations are quantied by their biological activity, not the amount of hormone
contained, an exception being ll-by-mass Gonal-F (Serono). More highly
puried urinary preparations are available that contain 75 IU activity of FSH
but lesser amounts e.g. <1 IU or <0.1 IU of LH. Urinary derived chorionic
gonadotropin (CG) is also available.
Recombinant preparations of FSH, LH and CG are available. The development of these preparations has permitted investigators to study of the role of
gonadotropins by the specic addition or subtraction of a particular hormone.
Anovulation due to hypogonadotrophic hypogonadism

The absence of adequate concentrations of FSH and LH mean that women with
profound hypogonadotrophic hypogonadism (HH) are ideal models for studying the requirements for and doses of gonadotropins during ovarian stimulation. In general, studies suggest that the administration of highly puried or
recombinant FSH (i.e. very low or no LH activity) to HH patients results in
follicular development but inadequate androstenedione and estrogen production and poor endometrial development. These observations are in keeping with
the two-cell two-gonadotropin model. Furthermore, addition of LH activity,
whether by using hMG instead of rec-FSH, or by adding rec-LH or CG to recFSH improves the outcome of ovulation induction in HH. It appears that the
minimum dose of LH activity required in addition to FSH is around 75 IU per
day (The European Recombinant Human LH Study Group 1998).
This threshold concept has been extended to the idea of a LH window. The
level of LH for optimal follicular development lies within a range, the lower
point of which is equivalent to serum levels obtained by exogenous administration of 75IU LH per day. Recent studies have attempted to identify the upper
55
threshold beyond which LH can cause follicular regression. In a pilot study 20

women with HH receiving rec-FSH for ovulation induction were randomized
when the largest follicle was 10-13mm diameter to one of three groups and
continued treatment with: 1. rec-FSH alone, 2. rec-LH alone, or 3. rec-FSH
and rec-LH (Loumaye et al. 2003). Recombinant-LH was administered at a
dose of 250 IU. Withdrawal of rec-FSH (group 2) resulted in a high rate of
follicular regression due to the absence of endogenous FSH in HH. Addition
of rec-LH to rec-FSH appeared to promote monofollicular development when
compared to the rec-FSH alone group. Interestingly, serum LH levels were not
different between the groups regardless of whether rec-LH was given even
though biological effects were demonstrated. This observation has relevance
when one considers the prospective studies showing lack of predictive power
of serum LH levels during IVF cycles (see below).
Anovulation due to PCOS.

Studies comparing different gonadotropin preparations for ovulation induction
in PCOS patients have not shown benets of puried FSH over hMG in terms
of pregnancy rate though puried FSH may be associated with lower rates of
OHSS (van Wely et al. 2003a)
A recent multicentre study examined the ability of rec-LH given in addition
to low dose rec-FSH to reduce the number of developing follicles in PCOS
patients over-responding to ovulation induction (Hugues et al. 2005). Patients
were randomized to receive placebo or one of 4 rec-LH doses in addition to
37.5 IU of rec-FSH. Doses of up to 660 IU rec-LH appeared to increase the
proportion of patients developing a single dominant follicle of 16mm diameter
or more. LH doses above this resulted in premature luteinization and possibly
a lower pregnancy rate.
Long protocol IVF-ICSI with pituitary suppression

The majority of IVF cycles use the long-protocol regime in which pituitary suppression is achieved with 2-3 weeks of GnRH-agonist administration beginning
in the mid-luteal or early follicular phase. Different agonists are available and,
importantly, they may be given in a daily short-acting nasal or sub-cutaneous
form or a long-acting depot preparation. Use of depot GnRH-agonists for IVF
results in a deeper pituitary suppression compared to daily administration as
demonstrated by a greater requirement for ampoules of FSH, fewer retrieved
oocytes, and a longer duration of stimulation though similar pregnancy rates
56
(Dal Prato et al. 2004). A number of the trials examining the effects of additive
LH during ovarian stimulation for IVF use protocols using depot agonist. The
greater degree of LH suppression in such protocols may tend to overemphasize
the benets of LH supplementation.
Comparisons of urinary versus recombinant FSH
A number of trials have compared hMG against puried urinary FSH and/or
rec-FSH. The main difference between these preparations is the amount of LH
activity. Recent meta-analyses have given conicting results dependent on the
particular trials selected for inclusion. The meta-analysis of Daya suggested a
signicantly higher pregnancy rate for rec-FSH (Gonal-F, Serono) compared
to urinary products (Daya 2002). However, a more recent meta-analysis including fewer trials suggested a higher clinical pregnancy rate in patients treated
with hMG versus rec-FSH though livebirth rates were similar (van Wely et al.
2003b). The different protocols used in different trials and different selection
criteria for inclusion into meta-analyses are problematic. A multicentre randomised open label study suggested no difference in efcacy between highly
puried hMG containing equivalent amounts of FSH and LH and rec-FSH
(European and Israeli Study Group 2000). A later subgroup reanalysis suggested that patients undergoing IVF had a signicantly greater pregnancy rate with
highly puried hMG compared to rec-FSH whilst there was no advantage for
those undergoing ICSI (Platteau et al. 2004). Consequently the pros and cons
of urinary versus recombinant gonadotropins are still a matter for debate.
Addition of LH to rec-FSH protocols
Prospective trials have been performed to examine the effect of adding exogenous LH to FSH during long-protocol IVF. Three different clinical situations
are considered:
1. LH could be added to all cycles using rec-FSH. This would tend to recreate
the hMG scenario. Such an approach has not been shown to be benecial
(Marrs et al. 2004).
2. LH could be added to cycles demonstrating a poor response. This approach would assume that in a proportion of women the degree of pituitary
suppression is such that insufcient LH is present for optimal follicularoocyte maturation. A recent study randomized normogonadotrophic hyporesponsive women taking rec-FSH for IVF stimulation to 1) increased
rec-FSH, 2) addition of rec-LH (75-150 IU), or 3) an additional ampoule
of hMG (i.e. FSH and LH) (Ferraretti et al. 2004). The addition of recLH or hMG resulted in signicantly more oocytes collected. However, a
57
mean of 8.2 oocytes were collected in the patients who did not receive any
LH implying that the study patients were not particularly poor responders. The obvious biological effect of adding LH during stimulation however is of interest and demonstrates that further investigation is warranted.
A further study randomized 130 women undergoing rec-FSH stimulation
who had an initial inadequate ovarian response to the addition of either
150 IU of rec-LH or 150 IU of rec-FSH (De Placido et al. 2005). LH supplementation resulted in a signicant increase in numbers of oocytes retrieved
compared to FSH supplementation (9.0 versus 6.1). However, depot GnRHagonist was used in all patients which may limit the studies applicability to
regimes using daily low-dose agonist.
3. Cycles with a low serum LH following pituitary suppression could be
identied and exogenous LH administered from day 1 of stimulation.
Unfortunately a relationship between serum LH levels and outcome
was not established in a prospective study of 246 women undergoing
rec-FSH stimulation for IVF (Penarrubia et al. 2003). All patients had
serum LH measurements taken frequently before and during ovarian
stimulation. The treatment protocols used daily GnRH-agonist. The authors suggested that there would be no physiological reason to supplement cycles with LH since serum levels are not related to outcome.
However, a prospective study has been reported in which oocyte donors
were randomized to receive FSH alone or FSH and LH (in the form of recFSH and hMG) (Tesarik & Mendoza 2002). All patients received a powerful
pituitary suppression regime with oral norethisterone followed by depot
GnRH-agonist. Cycles were stratied depending on whether the initial LH
level was less or greater than 1.0 IU/L. Patients with a low LH <1 IU/L beneted from LH supplementation with a signicant increase in the number of
mature oocytes and a higher implantation rate. Conversely, the inclusion of
exogenous LH in the stimulation regime of those with a normal initial LH
of 1.0 IU/L or more lowered the implantation rate although the number of
mature oocytes retrieved increased. The authors interpreted their ndings
as further evidence of the LH window.
Conclusions
The development of recombinant preparations has signicantly improved our
ability to examine gonadotropin requirements during spontaneous and stimulated cycles. It appears that a minimum threshold of LH activity is required for
58
normal follicular function as shown in the HH patient studies (The European

Recombinant Human LH Study Group 1998). The ability of higher LH concentrations to cause follicular regression is an area of great interest with potential
use in the renement of ovulation induction regimes. Whether urinary gonadotropin preparations containing LH activity are better, equivalent or worse than
rec-FSH for IVF in general or under particular conditions is not entirely clear.
Similarly unclear are the benets of LH supplementation during IVF ovarian
stimulation with rec-FSH apart from, perhaps, in low responders using depot
agonist cycles. Further randomised trials in IVF cycles using regimes with less
profound pituitary suppression regimes are warranted.
59
References
Dal Prato L, Borini A, Coticchio G et al. Half-dose depot triptorelin in pituitary suppression for multiple ovarian stimulation in assisted reproduction technology: a randomized study. Hum Reprod
2004 Oct;19(10):2200-5.
Daya S. Updated meta-analysis of recombinant follicle-stimulating hormone (FSH)versus urinary
FSH for ovarian stimulation in assisted reproduction. Fertil Steril 2002 Apr;77(4):711-4.
De Placido G, Alviggi C, Perino A et al. Recombinant human LH supplementation versus recombinant human FSH (rFSH) step-up protocol during controlled ovarian stimulation in normogonadotrophic women with initial inadequate ovarian response to rFSH. A multicentre, prospective,
randomized controlled trial. Hum Reprod 2005 Feb;20(2):390-396.
European and Israeli Study Group on Highly Puried Menotropin versus Recombinant FollicleStimulating Hormone. Efcacy and safety of highly puried menotropin versus recombinant
follicle-stimulating hormone in in vitro fertilization/intracytoplasmic sperm injection cycles: a
randomized, comparative trial. Fertil Steril. 2002 Sep;78(3):520-8.
Ferraretti AP, Gianaroli L, Magli MC et al. Exogenous luteinizing hormone in controlled ovarian
hyperstimulation for assisted reproduction techniques. Fertil Steril 2004 Dec;82(6):1521-6.
Hugues JN, Soussis J, Calderon I et al. Does the addition of recombinant LH in WHO group II anovulatory women over-responding to FSH treatment reduce the number of developing follicles?
A dose-nding study. Hum Reprod. 2005 Mar;20(3):629-635.
Loumaye E, Engrand P, Shoham Z et al. Clinical evidence for an LH 'ceiling' effect induced by
administration of recombinant human LH during the late follicular phase of stimulated cycles in
World Health Organization type I and type II anovulation. Hum Reprod. 2003 Feb;18(2):31422.
Marrs R, Meldrum D, Muasher S et al. Randomized trial to compare the effect of recombinant human
FSH (follitropin alpha) with or without recombinant human LH in women undergoing assisted
reproduction treatment. Reprod Biomed Online 2002;8:175-82.
Penarrubia J, Fabregues F, Creus M et al. LH serum levels during ovarian stimulation as predictors of
ovarian response and assisted reproduction outcome in down-regulated women stimulated with
recombinant FSH.Hum Reprod 2003 Dec;18(12):2689-97.
Platteau P, Smitz J, Albano C, Sorensen P, Arce JC, Devroey P. Exogenous luteinizing hormone
activity may inuence the treatment outcome in in vitro fertilization but not in intracytoplasmic
sperm injection cycles. Fertil Steril. 2004 May;81(5):1401-4.
Tesarik J and Mendoza C. Effects of exogenous LH administration during ovarian stimulation of
pituitary down-regulated young oocyte donors on oocyte yield and developmental competence.
Hum Reprod. 2002 Dec;17(12):3129-37.
The European Recombinant Human LH Study Group. Recombinant human luteinizing hormone
(LH) to support recombinant human follicle-stimulating hormone (FSH)-induced follicular development in LH- and FSH-decient anovulatory women: a dose-nding study. J Clin Endocrinol
Metab 1998 May;83(5):1507-14.
van Wely M, Bayram N, van der Veen F. Recombinant FSH in alternative doses or versus urinary gonadotrophins for ovulation induction in subfertility associated with polycystic ovary syndrome: a
systematic review based on a Cochrane review. Hum Reprod. 2003a Jun;18(6):1143-9.
van Wely M, Westergaard LG, Bossuyt PM, van der Veen F. Effectiveness of human menopausal gonadotropin versus recombinant follicle-stimulating hormone for controlled ovarian hyperstimulation in assisted reproductive cycles: a meta-analysis. Fertil Steril. 2003b Nov;80(5):1086-93.
60
Overweight women:
Profertility effect of weight reduction.
A prospective study
P.G. Crosignani, M. Colombo, W. Vegetti, E. Somigliana,
A. Gessati, G. Ragni
First Department of Obstetrics and Gynecology, University of Milan, Italy
Introduction
Irregular menstrual cycles, reduced spontaneous and induced fertility and an
increased risk of miscarriages are conditions associated with obesity (1,2).
Excessive weight and central distribution of body fat are both related to an
increased risk of normogonadotropic anovulation (2). The mechanism through
which weight impairs fertility is still not understood, but these patients have
a lower concentration of sex hormone-binding globulin (SHBG) (4) and increased androgens, insulin secretion and insulin resistance (5). However, a
positive signicant correlation has been reported between ovarian volume and
BMI in patients with PCOS (6).
Weight loss in obese PCOS patients reduces circulating androgens and raises
SHBG (4,7), enhances insulin sensitivity (8-11) and signicantly improves
menstrual cyclicity and fertility rates (12-14). On clinical grounds weight loss
can re-establish ovulation in obese anovulatory patients or improve their response to ovulation induction (15-18). No data are available on ovarian morphology systematically checked during weight loss.
The study
The aim of the study was to correlate weight reduction and anthropometric
indices, ovarian morphology, menstrual cyclicity and spontaneous fertility in
61
overweight PCOS patients following a diet, combined with a program of physical exercise.
Patients and methods

Thirty-three anovulatory overweight patients with PCOS were enrolled. All
had patent Fallopian tubes and chronic anovulation: 27 were oligo-amenorrheic. The partners were normospermic. Patients were prescribed a 1200 kcal/
day diet, and physical exercise was recommended. Anthropometric indices and
ovarian imaging parameters were assessed at baseline and after 5% and 10%
weight loss.
Results
Twenty-ve patients (76%) lost at least 5% of their body weight. Eleven of
these (33%) reached a 10% decrease. Waist circumference at the umbilical
level, hip circumference, four skin folds, body mass index (BMI) and fatty
mass ratio were signicantly reduced after 5% and 10% weight loss.
Ovarian morphology changed during the diet, with signicant reductions in
ovarian volume and in the number of microfollicles per ovary. Among the 27
patients with oligo-amenorrhea, 18 had a resumption of regular cycles and 15
experienced spontaneous ovulation; 10 spontaneous pregnancies occurred in
patients who had lost at least 5% of their weight.
Discussion
This study found a prompt improvement in the indices of body fat and its distribution, and rapid reduction of ovarian volume and the number of microfollicles. A possible criticism of the study may be related to the study design since
the trial was not randomized. Therefore the lack of controls mean we cannot
rule out that observed effects were period- or observer-related. However, in
the light of current literature on this topic clearly demonstrating the benets of
diet (12-16), we believe that a randomized trial is no longer ethically acceptable
or even feasible. Overall, although we are unable to assess the importance of
this aspect, it seems highly unlikely that our study design played a major role
in explaining the substantial changes in our study population.
The mechanism through which body weight reduction modies ovarian
morphology can only be guessed: it might involve the more favorable endocrine environment after a rise in SHBG and a reduction in free androgens,
62
and improved insulin sensitivity. The decrease in volume might be due to

the reductions in microfollicles and ovarian stroma. The amount of ovarian
stroma is correlated with overproduction of theca-derived steroids, particularly
androstenedione (19) in PCOS patients: a reduction in ovarian volume and in
the number of microfollicles could therefore be involved in lowering circulating androstenedione and improving the clinical picture of these patients during
diet treatment.
Conclusions
Weight loss through a controlled low-calorie diet improved anthropometric
indices in obese PCOS patients, reducing ovarian volume and microfollicle
number, and restored ovulatory cycles, allowing spontaneous pregnancy.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Grodstein, F., Goldman, M.B. and Cramer, D.W. (1994) Body mass index and ovulatory infertility. Epidemiology, 5, 247-250.
Barbieri, R.L. (2001) The initial fertility consultation: recommendations concerning cigarette
smoking, body mass index and alcohol and caffeine consumption. Am. J. Obstet. Gynecol.
185, 1168-1173.
Zaadstra, B.M., Seidell, J.C., Van Noord, P.A., Te Velde, E.R., Habbema, J.D., Vrieswijk,
B. and Karbaat, J. (1991) Fat and female fecundity: prospective study of effect of body fat
distribution on conception rates. Br. Med. J., 306, 484-487.
Kiddy, D.S., Sharp, P.S., White, D.M., Scanlon, M.F., Mason, H.D., Bray, C.S., Polson, D.W.,
Reed, M.J. and Franks, S. (1990) Differences in clinical and endocrine features between obese
and non obese subjects with polycystic ovary syndrome: an analysis of 263 consecutive cases.
Clin. Endocrinol., 32, 213-20.
Barbieri, R.L., Smith, S. and Ryan, K.J. (1988) The role of hyperinsulinemia in the pathogenesis of ovarian hyperandrogenism. Fertil. Steril., 50, 197-212.
Balen, A.H., Conway, G.S., Kaltsas, G., Techatraisak, K., Manning, P.J., West, C. and Jacobs,
H.S. (1995) Polycystic ovary syndrome: the spectrum of the disorder in 1741 patients. Hum.
Reprod., 8, 2107-2111.
Hollmann, M., Runnebaum, B., Gerhard, I. (1996) Effects of weight loss on the hormonal
prole in obese, infertile women. Hum. Reprod., 11, 1884-1891.
Guzick, D.S., Wing, R., Smith, D., Berga, S.L. and Winters, S.J. (1994) Endocrine consequences of weight loss in obese, hyperandrogenic, anovulatory women. Fertil. Steril., 61,
598-604.
Andersen, P., Seljeot, I., Abdelnoor, M., Arnesen, H., Dale, P.O., Lovik, A. and Birkeland, K.
(1995) Increased insulin sensitivity and brinolytic capacity after dietary intervention in obese
women with polycystic ovary syndrome. Metabolism, 44, 611-616.
Holte, J., Bergh, T., Berne, C., Wide, L. and Lithell, H. (1995) Restored insulin sensitivity but
persistently increased early insulin secretion after weight loss in obese women with polycystic
ovary syndrome. J. Clin. Endocrinol. Metab., 80, 2586-2593.
63
11.
12.
13.
14.
15.
16.
17.
18.
19.
Huber-Buchholz, M.M., Carey, D.G. and Norman, R.J. (1999) Restoration of reproductive
potential by lifestyle modication in obese polycystic ovary syndrome: role of insulin sensitivity and luteinizing hormone. J. Clin. Endocrinol. Metab., 84, 1470-1474.
Bates, G.W. and Whitworth, N.S. (1982) Effect of body weight reduction on plasma androgens
in obese, infertile women. Fertil. Steril., 38, 406-409.
Franks, S., Kiddy, D., Sharp, P., Singh, A., Reed, M., Seppala, M., Koistinen, R. and HamiltonFairley, D. (1991) Obesity and polycystic ovary syndrome. Ann. N. Y. Acad. Sci., 626, 201206.
Pasquali, R., Casimirri, F. and Vicennati, V. (1997) Weight control and its benecial effect on
fertility in women with obesity and polycystic ovary syndrome. Hum. Reprod., 12(Suppl 1),
82-87.
Clark, A.M., Ledger, W., Galletly, C., Tomlinson, L., Blaney, F., Wang, X. and Norman, R.J.
(1995) Weight loss results in signicant improvement in pregnancy and ovulation rates in
anovulatory obese women. Hum. Reprod., 10, 2705-2712.
Clark, A.M., Thornley, B., Tomlinson, L., Galletley, C. and Norman, R.J. (1998) Weight loss in
obese infertile women results in improvement in reproductive outcome for all forms of fertility
treatment. Hum Reprod., 13, 1502-1505.
Crosignani P.G., Piloni, S., Gessati, A., Colombo, M., Vegetti, W., Comi, D. and Ragni, G.
(1999) Resuption of fertility with diet in PCOS patients. Fertil. Steril., (ASRM/CFAS Conjoint
Annual Meeting, September 25-30; Toronto, Ontario, Canada, Abstract Book, S233.
Crosignani, P.G., Vegetti, W., Colombo, M., Ragni, G. Resuption of fertility with diet in overweight women. (2002) Reprod. Med. Online, 5, 60-64.
Kyei-Mensah, A.A., LinTan, S., Zaidi, J. and Jacobs, H.S. (1998) Relationship of ovarian
stromal volume to serum androgen concentrations in patients with polycystic ovary syndrome.
Hum. Reprod., 13, 1437-1441.
64
Do we need insulin sensitizers?

Basil C. Tarlatzis, M.D., Ph.D,
Unit for Human Reproduction, 1st Department of Obstetrics and Gynaecology,
Aristotle University of Thessaloniki, Greece
The polycystic ovarian syndrome (PCOS) is the most common cause of anovulation. Ovulation induction in women with PCOS is frequently associated
with an elevated risk for ovarian hyperstimulation syndrome (SS), multiple
pregnancies or rst trimester pregnancy loss. In addition, the high levels of insulin observed in some of the PCOS women contribute to the hyperproduction
of androgens from the ovaries (1, 2, 3) and have a negative effect on follicular
growth and development (4, 5).
Metformin is a biguanine used to control the glucose levels in non-insulin
dependent diabetic patients by decreasing its production in the liver and increasing its peripheral metabolism (6, 7). Moreover, it decreases the levels of
LH, insulin and androgens in plasma (8).
Recent studies have shown that metformin, as well as other insulin sensitizers (ISDs), normalize the menstrual cycle, increase the occurrence of spontaneous ovulation, as well as the pregnancy rates in anovulatory women (9, 10, 11,
12). Morgetti et al. (9) showed that metformin therapy (500 mg 3 times a day
for 26 months) managed to normalize the cycle in 17 out of 32 women (54%)
who participated in the study. Later, Nestler et al. (10), reviewing the above
study, suggested that an increase of the metformin dose to 1000 mg twice a
day, could possibly improve further these results. In the same study, Nestler et
al. (10) have used metformin alone in patients resistant to clomiphene citrate
(CC), and compared it with placebo, showing that metformin achieved signicantly higher ovulation rates (34% vs 4%, respectively, p<0.05). Consequently,
patients who did not ovulate continued their initial treatment, metformin or placebo, adding clomiphene citrate in both groups. The metformin group showed
90% ovulation rate, while the placebo group only 8% (p<0.05).
65
Recently, Vandermolen et al. (13) in a multicentre, double-blind, assessor

blind study, evaluated the coadministration of metformin with CC in women
previously resistant to CC. Thus, metformin or placebo was given for 7 weeks
and in those that did not respond CC was added, 50 mg / day, gradually increased up to 150 mg. Results showed that 9/12 (75%) women from the metformin group responded and 7/12 (58%) achieved a pregnancy, while the rates
in the placebo group were 27% and 13%, respectively.
Similar results were also reported by Heard et al. (14), who administered
metformin alone in anovulatory women achieving a 40% ovulation rate, while
in combination with CC the rates were increased to 67% and the total pregnancy rate to 42%.
Lord et al. performed a meta-analysis of 13 randomized controlled trials
(543 women) in order to assess the effectiveness of metformin in improving
clinical and biochemical features of polycystic ovary syndrome (15). The metaanalysis showed that metformin is effective in achieving ovulation in women
with polycystic ovary syndrome, with odds ratios of 3.88 (95% condence
interval 2.25 to 6.69) for metformin compared with placebo and 4.41 (2.37 to
8.22) for metformin and clomifene compared with clomifene alone. An analysis of pregnancy rates showed a signicant treatment effect for metformin and
clomifene (odds ratio 4.40, 1.96 to 9.85). In addition, metformin had an effect
in reducing fasting insulin concentrations, blood pressure, and low density
lipoprotein cholesterol. The authors concluded that metformin's choice as a rst
line agent seems justied, and there is some evidence of benet on variables
of the metabolic syndrome.
As mentioned before, PCOS women treated with FSH for ovulation induction are at higher risk for OHSS and multiple gestations. De Leo et al. (16)
studied recently the results of metformin administration together with gonadotropins for ovarian stimulation in PCOS patients. In this study, a group of 10
women received 500 mg metformin three times daily for a month, followed by
ovulation induction with FSH. A second group of 10 patients underwent two
cycles of ovarian stimulation with FSH, followed by a month of metformin
therapy, preceeding a third cycle of FSH therapy.
It was found that the administration of metformin was associated with
signicantly fewer follicles of > 15 mm in diameter and lower estradiol (2)
plasma levels, compared to FSH cycles without metformin. Hence, De Leo et
al. (16) suggest that the low 2 levels in plasma and the reduced multifollicular
growth achieved with the administration of metformin, may possibly decrease
the risk for the occurrence of OHSS and multiple pregnancies.
The co-administration of metformin in therapeutic cycles of ovarian stimu-
66
lation with GnRH analogues and gonadotropins for IVF was also evaluated
(17). The results of this study have shown that signicantly lower number of
follicles and 2 plasma levels, as well as signicantly higher number of mature
oocytes, fertilization rates and clinical pregnancy rates could be achieved.
Women with PCOS have higher miscarriage rates in the rst trimester of
pregnancy ranging from 30% to 50%, three times more as compared to the
general population (18), as hyperinsulinemia and insulin resistance seem to be
independent predisposal factors for rst trimester miscarriage.
Glueck et al. (19) showed that the continuation of metformin administration during the rst trimester of pregnancy in women with PCOS reduces signicantly the premature miscarriage rate. However, this assumption was not
conrmed by the Heard et al. study (14).
It is important to note that there is no contra-indication in the use of metformin during pregnancy, since no cases of teratogeneity have been reported
(14). Additional evidence was recently derived from a study conducted in
South Africa, where metformin was administered in pregnant women with
pre-existing type 2 diabetes or gestational diabetes mellitus (20). Furthermore,
metformin is characterized by the American Federal Drug Association (FDA)
as pharmaceutical substance type B, which means that it has been successfully
checked in pregnant animals for the danger of teratogenicity.
Metformin is well-tolerated with rare gastrointestinal disturbances that usually retreat after two weeks of administration. Contraindications to its administration are the existence of severe heart, liver or renal disease, due to the rare
cases of lactic acidosis that have been reported (21).
In conclusion, the results of the rst studies on metformin administration
for ovarian stimulation in women with PCOS are encouraging. In any case, before metformin is established as rst line therapeutic approach for anovulatory
women with PCOS, it is necessary to design extensive randomized controlled
trials, in order to assess its efcacy, safety and effect in the occurrence of OHSS
and multiple gestations.
References
1.
2.
3.
Dunaif A. Insulin resistance and the polycystic ovary syndrome. Mechanism and implication
for pathogenesis. End. Rev., 1997; 18:774-800.
Nestler JE, Jakubowicz DJ. Lean women with polycystic ovary syndrome respond to insulin reduction with decreases in ovarian P450c17 activity and serum androgens. J. Cl. End.
Metabl., 1997; 82: 4075-9.
Nestler JE, Powers LP, Matt DW, Steingold KA, Plymate SR, Rittmaster et al. A direct effect
on hyperinsulinemia on sex hormone binding globulin levels in obese women with polycystic
67
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
ovary syndrome. J. Clin. Endocr. Met., 1991; 72: 83-9.

Gyster MG, March CM, Mishell DR, Bailey EJ. Adecades experience with an individualized
clomiphene treatment regimen including its effect on postcoital test. Fertil. Steril., 1982; 37:
161-7.
Lobo RA, Granger LR, Davajan V, Mishell DR. An extended regimen of clomiphene citrate
in women unresponsibe to standard therapy. Fertil. Steril., 1982; 762-6.
Bailey CJ, Turner RC. Metformin drug therapy. N. Eng. J. Med., 1996; 334: 574-9.
Bailey CJ. Biguanides and NIDDU Diabetes Care. 1992; 15: 755-72.
Diamanti-Kandaraki E, Vouli C, Tsianateli T, Bergiele A. Therapeutic effects of metformin on
insulin resistant and hyperandrogenism in polycystic ovary syndrome. Eur. J. Endocr., 1998;
138: 269-74.
Morgeti P, Castello R, Negri C, Tossi F, Perrone F, Caputo M et al. Metformine effects on
clinical features, endocrine and metabolic proles and insulin sensitivity in polycystic ovary
syndrome. A randomized double blind placebo controlled 6 months trial followed by open
long term clinical evaluation. J. Clin. End. Metab., 2000; 85: 139-146.
Nestler JE, Jakubovicz DJ, Evans WS, Pascuali R. Effects of metformin on sponta-neus and
clomiphene induced ovulation in the polycystic ovary syndrome. N. Eng. J. Med., 1998; 338:
1876-80.
Velazquez E, Agosta A, Mendoza SG. Menstrual cyclicity after metformin therapy on insulin
resistance and hyperandrogenism in polycystic ovary syndrome. Eur. J. Endocr., 1998; 138:
269-74.
Morrin-Pappunen LC, Koivunen RM, Ruokonen A, Martikainen HK. Metformin therapy
improves the menstrual pattern with minimal endocrine and metabolic effects in women with
polycystic ovary syndrome. Fertil. Steril., 1998; 69: 691-96.
Vandermolen DT, Ratts VS, Evans WS, Stoval DW, Kauma SW, Nestler JE. Metformin
increases the ovulatory rate and pregnancy rate from treatment with clomiphene citrate in
patients with polycystic ovary syndrome who are resistant to clomiphene citrate alone. Fertil.
Steril., 2001; 75: 310-5.
Heard MJ, Pierce A, Carson SA, Buster JE. Pregnancies following use of metformin for ovulation induction in patients with polycystic ovary syndrome. Fertil. Steril., 2002; 77: 669-73.
Lord JM, Flight IHK, Norman RJ. Metformin in polycystic ovary syndrome: systematic review
and meta-analysis. BMJ, 2003; 327:951-3.
DeLeo V, La Marca A, Ditto A, Morgante G, Cianci A. Effects of metformin on gonadotrophin
induced ovulation in women with polycystic ovary syndrome. Fertil. Steril., 1999; 72: 2825.
Stadtmauer LA, Toma SK, Riehl RM, Talbert LM. Metformin treatment of patients with polycystic ovary syndrome undergoing IVF, improves outcomes associated with modulation of
insulin-like growth factors. Fertil. Steril., 2001; 75: 505-509.
Regan L, Braube PR, Trembath PL. Inuence of past reproductive performance on risk of
spontaneous abortion. BMJ, 1989; 299: 541-5.
Glueck CJ, Wang P, Kobayashi S, Phillier H, Smith LS. Metformin therapy through-out
pregnancy reduces the development of gestational diabetes in women with polycystic ovary
syndrome. Fertil. Steril., 2002; 77: 520-5.
Coetzce EJ, Jackson WPU. Metformin in management of pregnant insulin independent diabetics. Diabetologia, 1979; 16: 241-5.
ASRM. A practice committee report. Use of insulin sensitizing agents in the treatment of
polycystic ovary syndrome. April 2000.
68
Risks of ovarian stimulation

In vitro fertilization, ovulation
induction and the risk of cancer
Curt W. Burger
Dept of Ob&Gyn, Division of Gynaecological Oncology,
Erasmus University Medical Centre, Rotterdam, the Netherlands
Introduction
A Dutch study estimated that between 14% and 16.5% of couples seek medical
care for fertility problems during their reproductive life. More than 10% fullled the criteria for subfertility (1). In the United States, the number of women
treated annually with fertility drugs (FDs) has nearly doubled between 1973
and 1991 (2). It is estimated that almost 2.5% of all live births per year result
from Assisted Reproductive Technologies (3). In the past years, much attention has been focused on the possible association between the use of FDs and
the development of malignancies of the ovary, breast, and endometrium, and
melanoma (4, 5). FDs, temporarily raise serum levels of endogenous gonadal
hormones and gonadotrophins, and consequently increase the chances of multiple ovulations per menstrual cycle. Since hormonal and reproductive factors
are known to be involved in the aetiology of cancers of the female reproductive
system, a stimulating effect of FDs on the risk of these cancers is theoretically
possible. The precise mechanisms, however, involved in the pathogenesis of
hormone-related cancers remain unclear, and thus it is difcult to predict how
and to which extent FDs may affect the risk of various cancers.
This review discusses the potential long-term effects of FDs on the risk of
cancers of the ovary, breast and endometrium, but we will also discuss the possible effect of FDs on the risk of melanoma and thyroid cancer. Since women
receiving FDs may have disturbances in their metabolism of endogenous go-
69
nadal hormones we will specically discuss the possible associations between

various subfertility disorders and the risk of cancer, and subsequently address
the possible confounding effects of subfertility on the relationship between
FDs and cancer risk.
Subfertility and cancer risk

An important issue is to assess the risk of cancer in subfertile versus fertile
women before dealing with the risks of fertility drugs. Klip et al. (40) have
summarized the data for several types of malignancy in Table 1.
This question of subfertility has been studied in several case-control and cohort
studies. According to Klip et al. (4) ovarian cancer risk among nulliparous
or nulligravid women in most case-control studies was found to be weakly
associated with unsuccessful attempts to conceive, with a history of physiciandiagnosed subfertility, with expressed doubts about the ability to conceive or
with the number of years of unprotected intercourse.
For gravid or parous women, subfertility has generally not been found
to be associated with a signicantly increased risk of ovarian cancer. The
Collaborative Ovarian Cancer Group (13,14,15) has published a well-conducted meta-analysis of case-control studies. No signicant differences in
ovarian cancer risk were found according to marital status and gravidity, as
indicators of subfertility. However, after a total of 15 or more years of unprotected intercourse, nulligravid and gravid women experienced an increased risk
of ovarian cancer (Odds Ratio (OR) = 1.6; 95% Condence Interval (CI): 1.22.2) compared to women with less than two years of unprotected intercourse.
After the publication of Whittemores group in 1992 (14), a red alert appeared
to arise in the world since they found an extremely high correlation between
long-term subfertility in nulligravid women, trying to conceive for more than
15 years. The relative risk was 27 (95% CI 2.3-315.6) based on 12 cases and
one control. In view of the extreme CI this risk was clinically not signicant.
However, the commotion had started!
Klip et al. (4) stress the importance of limitation of the use of the SIR in the
above studies that are based on a comparison of cancer risk in subfertile women
with that of the general population. Since cohorts of subfertile women have
lower parity rates than the general population and nulliparity is a strong risk
factor for ovarian cancer, an increased SIR may be solely due to the confounding effect of nulliparity. Thus, results based only on the SIR are of little value
when determining the relationship between subfertility (treatment) and ovarian
cancer or other hormone-related cancers.
9,044
10
20,656
to IVF
and unexposed
subfertility
Evaluated for
exposed to IVF
subfertility and
Evaluated for
FDs
12
11$
11
Obs
5.2
0.7
1.5
7.2
1.9
1.8
4.3
8.6
1.9
Exp
1.2
0.9
1.4
0.7
1.6
1.6
1.7
2.5
1.3
2.1
SIR
0.5-2.6
0.4-1.8
0.0-7.5
0.0-3.8
0.8-2.9
0.5-5.1
0.6-5.3
1.3-4.5
n.s.
n.s.
95% CI
Ovarian cancer
Abbreviations: n.s.: not signicant; Obs: Observed cases; Exp: Expected cases
$ Invasive (n=4) or borderline tumor (n=5) and granulosa-cell tumors (n=2)
1999 Australia
Venn et al. 12
17.6
417
unexposed to
exposed to FDs
Infertile women
1999 Israel
18.0
780
subfertility
Diagnosed with
to IVF
and unexposed
subfertility
Evaluated for
exposed to IVF
subfertility and
Evaluated for
subfertility
Evaluated for
subfertility
Evaluated for
subfertility
Diagnosed with
Population
Infertile women
21.4
2,469
7.6
5.2
5,564
4,794
6.9
19.4
12.3
up (y)
3,837
2,335
2,575
size
Mean
follow
Potashnik et al. 11
1998 Israel
Modan et al. 10
1995 Australia
Venn et al. 9
1994 USA
Rossing et al. 8
1989 USA
Brinton et al. 7
1987 Israel
Ron et al. 6
year and country
Total
59.2
95.4
5.0
9.6
46.6
18.3
17.9
28.8
52.0
14.1
Exp
0.95
0.9
0.8
1.7
1.3
1.0
0.9
0.9
0.9
1.1
SIR
Body of the uterus

Median years of follow-up
56
87
16
59
18
16
27
49
15
Obs
Breast cancer
0.7-1.2
0.7-1.1
0.2-2.0
0.9-2.7
0.96-1.6
0.6-1.6
0.6-1.5
0.6-1.4
n.s.
n.s.
95% CI
21
11
Obs
2.5
1.1
3.0
4.8
3.5
2.2
0.9
4.8
SIR
1.2-5.2
0.5-2.6
0.3-10.9
3.0-7.4
1.1-10.8
0.6-8.9
n.s.
1.7-10.6
95% CI
12
Obs
adapted from Klip et al. (4)
2.8
4.6
0.4
0.7
4.3
0.9
0.9
12.8
1.1
Exp
Endometrial cancer
7.0
7.6
7.4
6.8
3.5
2.0
Exp
1.1
1.2
1.0
1.8
1.2
2.0
SIR
Melanoma
0.5-2.2
0.6-2.3
0.5-2.0
0.9-3.1
n.s
n.s
95% CI
Standardized Incidence Rates (SIR) for ovarian cancer, breast cancer, endometrial cancer and melanoma in cohorts of subfertile patients.
Author, reference,
Table 1:
70
71
For that reason a comparison of cancer risk within a cohort of subfertile

women is necessary to make a valid assessment of the independent effect
of cause of subfertility. Only two studies were large enough to analyze the
effect of the cause of subfertility on cancer risk. The results are shown in
Table 2.
Table 2:
Cause of subfertility and ovarian cancer risk: case-control studies.

Total
Total
Author, reference,
no.
no.
Type
year and country
cases
contr.
contr.
Comparison
OR
95% CI
2.1#
0.9-4.7
1.3#
0.6-2.8
0.8#
0.6-1.1
PCOS
2.4
1.0-5.9
Nulligravid women
1.19
0.91-1.55
Gravid women
1.16
1.02-1.31
Ovulatory factors vs. no

subfertility
Whittemore et al. 14
1992, USA
Tubal abnormalities vs. no

2,197
8,893
H/P
subfertility
Unexplained/other vs. no
subfertility
Schildkraut et al. 16
1996, USA
Ness et al. 17
2002, USA
476
4,081
4644
7182
Diagnosed with PCOS vs. no
Abbreviations: H: Hospital controls; P: Population controls; N: No; Y: Yes

* Other variables: s=study, v=age at diagnosis or interview, o=OC use, f=subfertility and e=education
The odds ratios for ovarian cancer were not signicantly increased in women
with subfertility either with tubal disease, idiopathic subfertility or ovulation
disorders. Schildkraut et al. (16) found a 2.4 nearly signicantly increased risk
for ovarian cancer in PCO patients.
The cohort studies that have presented data on ovarian cancer risk in relation
to different causes of subfertility are summarized in Table 3.
Two cohorts showed a signicantly increased risk of ovarian cancer relative to
the population rates for women with unexplained subfertility. Overall however,
the data presented in Table 3 do not favor a consistent risk increase or decrease
associated with any of the specied subfertility disorders. Despite the size of
the cohorts, due to the overall low incidence of ovarian cancer the numbers in
all of the above studies are small. Consequently, all studies have wide con-
72
dence intervals around the risk estimates. So, conclusions of risk changes in
subfertility alone must be made with caution.
Table 3: Cause of subfertility and ovarian cancer risk: cohort studies.
Mean
Total
Total
Author, reference,
follow
cohort
no.
year and country
up (y)
size
cases
Comparison
RR
95% CI
Ron et al. 6
12.3
2,575
Unexplained vs. GP
6.1||
1.0-20.0
19.4
2,335
11
Progesterone deciency vs. GP
1.6||
n.s.
Other causes vs. GP
1.1||
n.s.
Ovulatory factor vs. GP
3.7||
1.4-8.1
Ovulatory vs. non-ovulatory factors
2.2
0.6-8.2
2.5
0.4-14.1
fac.
2.2
0.3-13.5
PCOS vs. non-ovulatory factors
2.4
0.2-22.5
Unexplained vs. GP
7.0||
2.9-16.8
Unexplained vs. known causes
19.2
2.2-165
1987 Israel
Brinton et al. 7
1989 USA
Rossing et al. 8
6.9
3,837
11$
1994 USA
Anovulation vs. non-ovulatory

factors
Oligomenorrhea vs. non-ovulatory
Venn et al. 9
6.3
10,358
1995 Australia
Brinton et al. 18
11.4
20,686
29
Endometriosis vs. GP
1.9||
1.3-2.8
21.4
2,496
12
Progesterone deciency vs. GP
0.8||
0.1-2.9
Mechanical /male subfertility vs. GP
2.7||
1.0-6.0
Unexplained vs. GP
1.9
0.5-4.8
Female subfertility vs. no subfertility 2.2
1.1-4.6
Male infertility vs. no subfertility
0.9
0.2-3.8
Unexplained vs. no subfertility
1.3
0.7-2.3
Tubal vs. GP
0.96||
0.4-2.1
Male factor vs. GP
0.7
||
0.2-2.7
Endometriosis vs. GP
1.5||
0.5-4.6
Unexplained vs. GP
2.6
1.1-6.4
1997 Sweden
Modan et al. 10
1998 Israel
Rodriguez et al. 19
12.0
198,247 797
1998 USA
Venn et al. 12
1999 Australia
7.8
29,666
13
||
||
Abbreviations GP: general population; N: No; Y: Yes

* Other variables: v=calendar year at diagnosis, r=ethnicity/race/country of origin, w=weight, v=year of enrollment in study,
e=education, b=body mass index, m=age at menarche, o=years of OC use, t=tubal ligation, h=years of estrogen replacement
therapy use, p=menopausal status/age
|| SIR (Standardized Incidence Rate)
Median years of follow-up
$ Invasive (n=4) or borderline tumor (n=5) and granulosa-cell tumors (n=2)
Subcohort (n=135) used in analysis
73
Fertility drugs and ovarian cancer risk

The shortcomings of many studies on FDs are: retrospective study designs,
the focus on mainly ovarian cancers, small numbers of ovarian cancer cases,
inconsistent reporting of fertility drug use and inconsistent reporting of type
of infertility. Klip and (4) published an extensive review of this subject using
as methodology: identication of papers published between 1966 and 1999,
examination of FDs, specic causes of subfertility in relation to the risks of
cancers of the ovary, breast, endometrium, thyroid and melanoma. The cohort
studies are shown in Table 4.
Rossing et al. (8) studied the long time use of clomiphene citrate. A relative
risk of 11 was found with signicant CIs. Adjustment for the presence of
ovulatory abnormalities reduced the RR associated with the use of clomiphene
citrate for 12 cycles to 7.7 (95% CI: 1.0-60.1). The RR of ovarian cancer associated with long-term use (12 cycles) of clomiphene citrate was 9.1 (95%
CI: 1.0-86.5) among women without ovulatory abnormalities, and 7.4 (95% CI:
1.0-53.1) among women with ovulatory abnormalities (compared with use of 0
to 11 cycles). Thus, both among women with and without ovulatory abnormalities, an extended period of subfertility treatment with clomiphene citrate was
associated with an increased risk of ovarian malignancies.
Venn et al. (9,12) published a large cohort study on this subject in IVF
patients: seven ovarian cancer cases in the exposed group were observed, and
the SIR did not differ from that in the unexposed group (SIRs of 0.88 and 0.16,
respectively). In this publication, the authors stratied according to the number
of stimulated cycles and specic drugs that were used during IVF treatment.
Unfortunately, the numbers of ovarian cancers in the subgroups were too small
to yield reliable risk estimates.
Because of the lack of large studies with sufcient follow-up time since FD
use, the discussion about a possible association is mostly inspired by theories
concerning the pathogenesis of ovarian cancer. An increase risk of ovarian cancer after FD use is compatible with both the "incessant ovulation" theory and
the theory of "increased gonadotrophin levels". In addition, multiple punctures
as needed for IVF may, through repeated ruptures of the ovarian epithelium,
cause increased mitotic activity in the ovary. The etiology of ovarian cancer
is probably multi-factorial with genetic, environmental and endocrinological
factors interacting in various causal pathways.
74
Table 4:

Use of FDs and ovarian cancer risk: case-control studies.
Total
Total
Author, reference,
no.
no.
Type
year and country
cases
contr.
contr.
Comparison
OR
95% CI
Shu et al. 20
229
229
"hormones to help become
2.1
0.2-22.7
2.8
1.3-6.1
27.0
2.3-316
FD use vs. no subfertility
1.4
0.5-3.6
"ever having used FDs" vs. no
0.8
0.2-3.7
FD use vs. no FD use
1.3
0.6-2.7
CC vs. no FD use
0.9
0.3-2.3
HMG/CC vs. no FD use
1.4
0.7-3.1
HMG vs. no FD use
3.2
0.9-11.8
12 cycles CC vs. no FD use
1.4
0.3-5.8
1.1
0.4-3.3
< 6 cycles vs. no FD use
0.7
0.1-7.9
6 cycles vs. no FD use
1.0
0.2-3.8
0.8
0.4-2.0
CC vs. no FD use
0.7
0.2-2.0
CC/HCG vs. no FD use
1.2
0.3-4.0
HMG/HCG vs. no FD use
0.8
0.2-3.7
1989 China
pregnant" vs. no FD use
Whittemore et al. 14 2,197#
8,893#
H/P

nulligravid:
1992, USA

gravid:
Francheschi et al. 21 195
1,339
1994, Italy
Shushan et al. 22
FD use
200$
408
1996, Israel
Parazzini et al. 23
971
2,758
1997, Italy
Mosgaard et al. 24
1997, Denmark
684
1,721
Nulliparous
Abbreviations: N: No; Y: Yes; H: Hospital controls; P: Population controls

* Other variables: b=body mass index, r=region of birth, e=education, i=interviewer, n=area of residence,
o=use of OC, s=study, u=breastfeeding, c=ovarian cyst, m=age at menarche, a=previous cancer, d=intrauterine
device, p=menopausal status, h=HRT, v=age at diagnosis or interview
1. Clinically assessed cause of subfertility, classied in subtypes
# Meta-analysis based on three case-control studies
$ Invasive (n=164) or borderline tumor (n=36)
In case of a true association, ovulation induction agents (or their immediate

effects) may constitute a critical event in the multi-step process of ovarian
75
carcinogenesis, or alternatively, induce rapid growth of pre-existing malignant

cells in the ovary. It must be kept in mind that most subfertile women use
FDs for a period that is rather limited as compared to the total length of their
reproductive lives. Even if ovulation-inducing agents do exert a stimulatory
effect on ovarian cancer risk, it is questionable, therefore, whether such an
effect would be detectable.
Fertility drugs and borderline tumors of the ovary

The pathogenesis of borderline tumors of the ovary is similar to the etiology of
epithelial ovarian malignancies. A few studies specically examined subfertility
(treatment) in relation to the risk of developing borderline tumors of the ovary. In
the case-cohort study of Rossing et al. (8) a relative high frequency of borderline
tumors of the ovary was noted (5/11=45 % of all epithelial ovarian tumors). The
risk of a borderline tumor of the ovary was substantially higher than expected on
the basis of the general population rates (SIR=3.3; 95% CI: 1.1-7.8). Data of 327
women with a borderline tumor of the ovary and 4,144 hospital and population
controls were included in this study. Women with a history of subfertility were
found to be at increased risk (OR=1.9; 95% CI: 1.3-2.7) of a borderline tumor
of the ovary compared to women without such a history (25).
In another case-control study, Shushan et al. (22) also found a signicantly
increased risk of developing a borderline tumor for women who had used FDs
(OR=3.5); a particularly high risk was found in the subgroup of women who
had used HMG (OR=9.4). The ORs reported in those two case-control studies
were not adjusted for cause of subfertility. The high proportion of borderline
tumors relative to invasive ovarian cancer as reported in the study of Rossing
et al. (8) suggests that the increased risk might be attributed to the increased
medical surveillance of subfertile women. However, this appears to be unlikely
since most tumors were diagnosed after fertility treatment had been stopped.
Fertility drugs and breast cancer risk

Breast cancer is the most common malignancy in women in developed countries
and accounts for 30-35% of all malignancies in females. In the United States
recent estimates of approximately 178,700 new cases and more than 43,500
breast cancer deaths per year have been published (26), Table 1 summarizes
the SIRs from different cohort studies of subfertile populations. In none of
these studies is the risk of breast cancer signicantly different from that in the
general population. There is also no consistently observed increase or decrease
76
of breast cancer risk across studies. An important limitation of these studies is

that adjustment for nulliparity, an established risk factor for breast cancer, is not
possible. Since the various causes of subfertility may have different effects on
breast cancer risk, it is important to distinguish between them when examining
the association between breast cancer and subfertility.
A number of epidemiologic studies specically reported on the risk of breast
cancer associated with FD use (Table 5).
Table 5: Use of FDs and breast cancer risk.: cohort studies.
Mean
Total
Total
Author, reference, year
follow
cohort
no.
and country
up (y)
size
cases
Comparison
RR
95% CI
Ron et al. 6
12.3
2,575
15
Use of HMG vs. no FD use
no ass
n.s.
Use of CC vs. no FD use
no ass
n.s.
Other FDs vs. no FD use
no ass
n.s.
CC use vs. no CC use
0.5
0.2-1.2
1-5 cycles CC vs. no CC use
0.4
0.2-1.4
6-11 cycles CC vs. no CC use
0.5
0.1-1.7
12 cycles CC vs. no CC use
0.6
0.2-2.4
HCG use vs. no HCG use
0.5
0.2-1.8
1987, Israel
Rossing et al. 8
6.9
3,837
27
1994, USA
Venn et al. 9
6.3
10,358
34
IVF vs. no IVF
1.1
0.6-2.2
21.4
2,496
59
CC use vs. GP
1.2||
0.7-1.9
CC/HMG use vs. GP
1.6||
0.7-3.4
1-2 cycles CC vs. GP
2.6||
1.2-5.0
3-5 cycles CC vs. GP
1.3||
0.4-3.4
6 cycles CC vs. GP
0.9
||
0.2-2.7
1,000mg CC vs. GP
2.5||
1.2-4.6
1,001-2,000mg CC vs. GP
1.2
||
0.2-3.5
3,000mg CC vs. GP
2.1||
0.3-4.2
CC use vs. GP
0.9||
0.3-2.3
CC/HMG use vs. GP
1.2
0.9-1.6
HMG use vs. GP
0.99||
0.6-1.8
HMG/GnRH-AG use vs. GP
0.8
0.6-1.4
1995, Australia
Modan et al. 10
1998, Israel
Potashnik et al. 11
17.9
1,197
20
1999, Israel
Venn et al. 12
1999 Australia
7.2
20,656
87
||
||
77
Mean
Total
Total
Author, reference, year
follow
cohort
no.
and country
up (y)
size
cases
Comparison
RR
95% CI
5026
11
Treated 1981-92
0.69
0.46-1.66
Dor et al. 27
2002, Israel
Abbreviations: n/a: no information available; no ass: no association; N: No; Y: Yes; GP: general population
* Other variables: v=calendar year at diagnosis, r=ethnicity/country of origin, w=weight, d=year of enrollment
in study
Clinically assessed cause of subfertility, classied in subtypes
|| SIR (Standardized Incidence Rate)
In the rst Australian cohort of women referred for IVF, 34 cases of invasive
breast cancer were observed (9). After adjustment for age and subfertility
type, the RR was 1.1 in the group treated with IVF as compared with the
untreated group. In the second study (12), 87 cases of breast cancer occurred.
No signicant increased risk was observed for any form of FD use, number of
stimulated cycles, and number of oocytes per stimulated cycle. Signicantly
more breast cancers diagnosed within a year of IVF treatment were found in
the exposed group than was expected (Obs:17; Exp:8.7; SIR:2.0; 95%CI:1.223.15). In the case-cohort study by Rossing et al. (28) women receiving clomiphene citrate had a non-signicantly decreased risk of breast cancer of 0.5.
This risk estimate was based on 15 (of the 27) breast cancer cases and 87 (of
the 135) women in the sub cohort who had used clomiphene citrate. There
was no clear trend of decreasing risk of breast cancer with longer duration of
clomiphene citrate use. Also, subfertile women who had used HCG were less
likely to develop breast cancer than infertile women who never received this
drug were (RR=0.5). However, after adjustment for clomiphene citrate use,
this association became weaker. The authors suggested that clomiphene citrate
might be protective against breast cancer because of its structural similarity
with tamoxifen. No such association was found in the cohort study in Israel
(6). In the most recent update of this study, the risk in clomiphene citrate users
was compared to that of the general population and not with the women who
never used clomiphene citrate (10). The results of the latest study from Israel
(11) show no overall increase or decrease breast cancer risk among infertile
women treated with clomiphene citrate when compared with untreated women
or the female general population. However, women with 1-2 cycles clomiphene
citrate or women using 1,000mg clomiphene citrate had a signicantly increased risk of breast cancer compared to the general population (SIR=2.6 and
78
SIR=2.5, respectively). The most recent case control study is that of Dor et al.
(27) in which a non-signicantly reduced risk of breast cancer was found with
fertility drug use.
In conclusion: studies of subfertility in relation to breast cancer risk show
inconsistent results. This may partly reect methodological differences in the
assessment of cause of subfertility and the control of various confounders.
However, even the larger studies had inadequate power to reliably assess breast
cancer risk in relation to subfertility diagnosis. As yet, no increased risk of
breast cancer seems present for subfertile women, but larger studies have to
further elucidate this matter.
Only a few studies assessed breast cancer risk in relation to FD use, but
these studies are inconsistent and based on short follow-up. Ovulation induction exposes women to temporarily higher endogenous estrogen concentrations
than occur in natural menstrual cycles, sometimes for prolonged times. It is
possible that these high endogenous estrogen levels, or other hormonal changes
(e.g. elevations in gonadotrophin levels), provide a carcinogenic stimulus to
the breast. On the other hand, the suggestion from one cohort that clomiphene
citrate might be protective against breast cancer should be addressed in other,
larger studies. Clomiphene citrate is a non-steroid anti-estrogen that is structurally related to tamoxifen and DES, and that has been reported to exert anti-proliferative effects on human breast cancer cells (29). An interesting explanation
for the nding that women who had IVF showed signicantly more breast
cancers than expected diagnosed within one year of IVF treatment is that ovulation induction may promote the development of preexisting cancers (12). As
mentioned by the authors, a short-term increase in breast cancer risk is thought
to be related to the tumor promoting effects of high estrogen concentrations
during pregnancy or use of OC. Generally, the use of fertility drugs did not
increase the risk for breast cancer neither in these two large study groups, nor
in the other studies.
Fertility drugs and endometrial cancer

In most industrialized countries, cancer of the corpus uteri is about as frequent
as ovarian cancer, accounting for 6% of all new cancers. Recent estimates
from the US show that, yearly, 36,100 women are diagnosed with cancer of the
corpus uteri while, due to the relatively good prognosis, less than 6% (6,300)
will die from it (6). Recognized risk factors for endometrial cancer are nulliparity, late age at menopause, obesity, PCOS, and the presence of estrogen
secreting malignancies (30). Anovulation, infrequent ovulations and various
79
progesterone deciencies mostly characterize hormonal subfertility. Irregular

(long) menstrual cycles are often anovulatory, or have a prolonged follicular
phase. Both features result in prolonged exposure to "estrogen unopposed by
progesterone" and would thus be expected to raise the risk of endometrial
cancer (31). Obviously, progesterone deciency also results in prolonged exposure to "unopposed" estrogens. Similarly, FDs that prolong exposure of the
endometrium to "unopposed" estrogen might increase the risk of endometrial
cancer.
Several case-control and cohort studies have reported a moderate increase
in endometrial cancer risk after fertility problems (or prolonged time to achieve
pregnancy). The SIRs from different cohort studies are summarized in Table
1, generally showing a signicant positive association. The cohort study
conducted in Israel (6) reported an eight-fold increased risk of endometrial
cancer (95% CI: 2.5-19.3) among women with hormonal causes of subfertility
(based on four cases). After more than 21 years of follow-up of this cohort,
Modan et al. (10) reported a strong increase in risk among women with fertility
problems characterized by unopposed estrogen (adequate endogenous estrogen
and inadequate progesterone; SIR=9.4; 95% CI: 5.0-16.0). Subfertility due to
a specic cause such as the PCOS (32) has also been found to be associated
with increased risk of endometrial cancer. The large Australian cohort study
by Venn et al. (9) reported for women with unexplained subfertility a SIR of
8.3 (95% CI: 2.87-25.7) for cancer of the uterus. In the latest study published
by this group, a SIR of 4.6 (95% CI: 1.9-11.0) for cancer of the uterus was
reported (12).
Use of fertility drugs in relation to the risk of endometrial cancer has been
studied in only two papers. Ron et al (6) showed after 12 years of follow-up no
signicant increase in risk. An SIR of 6.8 only after 21 years of follow-up was
demonstrated. In the SIR of 6.8 is included the subgroup with subfertility but
without fertility drugs with a SIR of 3.3. According to Modan et al., (10) the
different causes of subfertility in the two groups largely explained the difference in risk estimates between the treated and untreated group. In the study by
Venn et al. (9,12) cancer of the uterus was not associated with IVF treatment
or any of the specic fertility drugs examined, but the risk estimate were based
on very small numbers (n=5).
In conclusion: Almost all published studies show an increased risk of endometrial cancer in subfertile women. This increase in risk is largely restricted to
women with hormonal disorders. Increased risk of endometrial cancer associated with hormonal subfertility (such as anovulatory periods, amenorrhea, and
progesterone deciency) is compatible with current insights into the pathogen-
80
esis of endometrial cancer. However, confounding factors such as nulliparity

and use of OC were not adequately controlled for in a number of studies. In
view of the magnitude of the risk increase associated with subfertility (range
of RRs=3-10) it is unlikely that this excess can be fully attributed to confounding.
The relation between FD use and endometrial cancer is suffering from low
power, short follow-up and lack of information on important confounders, such
as the cause of subfertility and/or parity. In future studies, it is crucial, therefore, to disentangle the effects of different types of medication and the cause
of subfertility.
Fertility drugs and melanoma risk

Increased risk of cutaneous melanoma in women has been associated with
delayed childbearing and low parity (33). However, these associations have
not been consistently observed (34). Risks data are summarized in Table 1. A
biological mechanism for an effect of FD use on the development of cutaneous
melanoma is unclear, some epidemiologic studies suggest a possible increase
in melanoma risk in relation to hormonal subfertility and/or its treatment. Due
to the small number of melanoma cases that occurred in the study by Rossing
et al. (8) and the Israeli cohort (6) the observed associations may be chance
ndings. The largest study so far, by Venn et al. (9,12) showed no increase in
melanoma risk due to subfertility.
Fertility drugs and thyroid cancer risk

Since incidence rates of thyroid cancer are much higher in females than in
males, a role of hormonal factors has long been suspected (35). In summary,
studies published to date do not show convincing evidence of an association
between thyroid cancer risk and subfertility (treatment).
General conclusion
Subfertility: Thus far, no convincing relation between fertility drugs and cancer (risks) has been demonstrated. A consistent observation is the increased risk
of endometrial cancer for women with infertility due to hormonal disorders. An
association between ovulation induction and ovarian cancer does not necessarily mean a causal effect. Infertility alone is an independent risk factor for the
development of ovarian cancer. Nulliparous women with refractory infertility
81
may harbor a particularly high risk of ovarian cancer, irrespective of their use
of fertility drugs.
In Vitro Fertilization: The shortcomings of the present data on cancer risk
and the use of fertility drugs are: retrospective study designs, relatively small
numbers of (ovarian) cancer cases, inconsistent reporting of fertility drug use
and inconsistent reporting of type of infertility. For these reasons no convincing relation between fertility drugs and risks for ovarian, breast, endometrial
and thyroid cancer. Also the risk for cutaneous melanoma is not amplied by
fertility drugs. However, fertility specialists must become aware that consistent
observations of increased risk of endometrial cancer for women with infertility
particularly due to hormonal disorders have been publicized.
From the data of the present literature it can be concluded that fertility
drugs and IVF do not increase the risk of breast and ovarian cancer. There is,
however, concern about the risk of endometrial cancer. The small increased risk
of endometrial cancer is apparently not correlated with hormone use but rather
with the polycystic ovary syndrome, and thus with subfertility.
82
References
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Koudstaal J, van Dop PA, Hogerzeil HV, Kremer JA, Naaktgeboren N, Van Os HC et al. Preg
nancy course and outcome in 2956 pregnancies after in-vitro fertilization in Netherlands]. Ned
Tijdschr Geneeskd 1999;143:2375-2380.
Wysowski DK. Use of fertility drugs in the United States, 1973 through 1991. Fertil Steril
1993; 60:1096-8
de Jong- van den Berg LTW, Cornel MC, van den Berg PB, et al. Ovulation-inducing drugs:
a drug utilization and risk study in the Dutch population. Int J Risk Safety Med 1992;3: 99112.
Klip H, Burger CW, Kenemans P, Leeuwen FE. Cancer risk associated with subfertility and
ovulation induction: a review. Cancer Causes and Control 2000;11:319-344
Venn A, Cancer risk associated with the diagnosis of infertility. Best Practice & Research
Clinical Obstet & Gynaecol 2003;17/2:343-67
Ron E, Lunenfeld B, Menczer J, Blumstein T, Katz L, Oelsner G et al. Cancer incidence in a
cohort of infertile women. Am.J Epidemiol 1987;125:780-90.
Brinton LA, Melton LJ, Malkasian Jr GD, Bond A, Hoover R. Cancer risk after evaluation for
infertility. Am J Epidemiol 1989;129:712-22.
Rossing, MA, Daling, JR and Weiss, NS, Moore DE, Self SG. Ovarian tumors in a cohort of
infertile women. N Engl J Med 1994;331:771-6
Venn A, Watson L, Lumley J, Giles G, King C, Healy D. Breast and ovarian cancer incidence
after infertility and in vitro fertilization. Lancet 1995;346:995-1000.
Modan B, Ron E, Lerner-Geva L, Blumstein T, Menczer J, Rabinovici J et al. Cancer incidence
in a cohort of infertile women. Am J Epidemiol 1998;147:1038-42
Potashnik G, Lerner-Geva L, Genkin L, Chetrit A., Lunenfeld E, Porath A. Fertility
drugs and the risk of breast and ovarian cancers: results of a long-term study. Fertil Steril
1999:71:853-9.
Venn A, Watson L, Bruinsma F, Giles, G, Healy D. Risk of cancer after use of fertility drugs
with in-vitro fertilisation Lancet 1999;354:1586-90
Whittemore, AS, Wu, ML, Paffenbarger, Jr, RS, Sarles, DL, Kampert, JB, Grosser, S et al.
Epithelial ovarian cancer and the ability to conceive. Cancer Res 1989;49:4047-52
Whittemore, AS, Harris, R, Itnyre, J. Characteristics relating to ovarian cancer risk: collabora
tive analysis of 12 US case-control studies. II. Invasive epithelial ovarian cancers in white
women. Collaborative Ovarian Cancer Group. Am J Epidemiol 1992;136:1184-1203
Whittemore, AS, Harris, R, Itnyre J, Halpern J Characteristics relating to ovarian cancer
risk: collaborative analysis of 12 US case-control studies. I. Methods. Collaborative Ovarian
Cancer
Group. Am J Epidemiol 1992;136:1175-83
Schildkraut, JM, Schwingl, PJ, Bastos, E, Evanoff, A, Hughes, C. Epithelial ovarian cancer
risk among women with polycystic ovary syndrome. Obstet Gynecol 1996;88:554-9
Ness RB, Cramer DW, Goodman MT et al. Infertility, fertility drugs, and ovarian cancer: a
pooled analysis of case control studies. Am J Epidemiology 2002;155:217-224
Brinton LA, Gridley G, Persson I, Baron J, Bergqvist A (1997) Cancer risk after a hospital
discharge diagnosis of endometriosis. Am J Obstet Gynecol 176: 572-579.
Rodriguez, C, Tatham, LM, Calle, EE, Thun, MJ, Jacobs, EJ, Heath, Jr CW . Infertility and
risk of fatal ovarian cancer in a prospective cohort of US women. Cancer Causes Control
1998;9:645-51
Shu XO, Brinton LA, Gao YT, Yuan JM. Population-based case-control study of ovarian can
cer in Shanghai Cancer Res 1989;49: 3670-3674
Franceschi S, La Vecchia C, Negri E, Guarneri S, Montella M, Conti E et al. Fertility drugs
83
22
23
24
25
26
27
28
29
30
31
32
33
34
35
and risk of epithelial ovarian cancer in Italy. Hum Reprod 1994;9:1673-1675.

Shushan A, Paltiel O, Iscovich J, Elchalal U, Peretz T, Schenker JG. Human menopausal
gonadotropin and the risk of epithelial ovarian cancer. Fertil Steril 1996;65: 13-18
Parazzini F, Negri E, La Vecchia C, Moroni S, Franceschi S, Crosignani PG. Treatment for
infertility and risk of invasive epithelial ovarian cancer. Hum Reprod 1997;12: 2159-2161
Mosgaard BJ, Lidegaard O, Kjaer SK, Schou G, Andersen AN. Infertility, fertility drugs, and
invasive ovarian cancer: a case-control study. Fertil Steril 1997;67: 1005-1012
Harris R, Whittemore, AS, Itnyre J. Characteristics relating to ovarian cancer risk: collaborative analysis of 12 US case-control studies. III. Epithelial tumors of low malignant potential
in white women. Collaborative Ovarian Cancer Group. Am J Epidemiol 1992;136:1204-11
Kelsey JL, Horn-Ross PL. Breast cancer: magnitude of the problem and descriptive epidemic
ology. Epidemiol Rev 1993;15: 7-16
Dor J, Lener-Geva L, Rabinovici J et al. Cancer incidence in a cohort of infertility women
who underwent in vitro fertilization. Fert Steril 2002;77:324-327
Rossing MA, Daling JR, Weiss NS. Risk of ovarian cancer after treatment for infertility. N
Engl J Med 1995;332:1302-8
Sutherland RL, Watts CK, Hall RE, Ruenitz PC. Mechanisms of growth inhibition by nonster
oidal antioestrogens in human breast cancer cells. J Steroid Biochem 1987;27: 891-897.
Brinton LA, Berman ML, Mortel R et al. Reproductive, menstrual, and medical risk factors
for endometrial cancer: results from a case-control study. Am J Obstet Gynecol 1992;167:
1317-1325
Key TJ, Pike MC. The dose-effect relationship between 'unopposed' oestrogens and endo
metrial mitotic rate: its central role in explaining and predicting endometrial cancer risk. Br J
Cancer 1988;57: 205-212
Escobedo LG, Lee NC, Peterson HB, Wingo PA. Infertility-associated endometrial cancer risk
may be limited to specic subgroups of infertile women. Obstet Gynecol 1991;77: 124-128.
Holly EA, Cress RD, Ahn DK. Cutaneous melanoma in women: ovulatory life, menopause,
and use of exogenous estrogens. Cancer Epidemiol Biomarkers Prev 1994;3: 661-668.
Holman CD, Armstrong BK, Heenan PJ (1984) Cutaneous malignant melanoma in women:
exogenous sex hormones and reproductive factors. Br J Cancer 50: 673-680.
Bernstein L, Ross RK, Henderson BE. Relationship of hormone use to cancer risk. J Natl
Cancer Inst Monogr 1992;137-147.
84
Is endometrial receptivity altered

in COH cycles?
J. A. Horcajadas and C. Simn
Instituto Valenciano de Infertilidad Foundation (FIVI)-Valencia University
c/ Guadassuar, 1 Bajo, 46015 Valencia, SPAIN.
e-mails: jhorcajadas@ivi.es, csimon@ivi.es
Summary
Controlled ovarian hyperstimulation (COH) used in IVF produces lower implantation rates per embryo transferred compared to natural cycles utilized in
ovum donation, suggesting a suboptimal endometrial development. After the
publication of several studies about the endometrial receptivity in the natural
cycle using microarray technology, we have investigated the impact of COH in
the gene expression pattern of the endometrium. In one hand, we have analyzed
the use of urinary gonadotrophins with a long protocol using GnRH agonists
without progesterone (P) supplementation (similar to the natural cycle) during
the window of implantation (WOI) by comparing the proles at day hCG+7
of COH versus LH+7 of a previous natural cycle in the same women. In the
other hand, the impact of a standard and a high dose GnRH antagonist on the
endometrial development in stimulated cycles, as compared with treatment
with a GnRH agonist or in natural cycles. We have used microarray technology
by Affymetrix (GeneChip HG_U133A) which allows more than 22,000 genes
to be tested simultaneously and we have validated the results by quantitative
PCR (Q-PCR) experiments. We have found that a high number of WOI genes
are dys-regulated showing a differential expression during the natural cycle
and the stimulated cycles and, moreover, that these changes depended on the
treatment used (GnRH agonist or antagonist). The large degree of gene expression changes found is surprising and highlights the need for further efforts to
85
optimize COH protocols.
Introduction
Assisted Reproductive Technologies (ART) have provided considerable insight
into the human reproductive processes. However, lower implantation rates per
transferred embryo than those in natural cycles remain a major problem that
is compensated for by increasing the number of transferred embryos (1) at the
cost of increased numbers of twin and triplet pregnancies. It is accepted that
the point that is altered in COH used for IVF is the uterine receptivity (2).
Furthermore it has been demonstrated that the endometrium suffers a morphological advancement in the early luteal phase demonstrated by histological
techniques (3-6), scanning electron microscopy (SEM) (7,8), down-regulation
of endometrial ER and PR (9) and biochemical changes in the endometrial uid
(10). This is not surprising considering that the aim of ovulation induction is to
recruit a sufcient number of oocytes, and as a side-effect supraphysiological
levels of steroid hormones and paracrine mediators are produced and received
by the endometrium.
Following completion of Human Genome sequence, the principal goal in this
eld of work has been to enumerate genes involved in physiological and pathological processes. Several genomics analyses of human endometrial receptivity
have recently been done using microarray technology that have demonstrated
that receptivity is an active process involving hundreds of up- and down-regulated genes (11-14). After these observations, our efforts have been focused in
investigating the genomic impact of COH using on the human endometrium
during IVF treatment. The aim of our studies was to analyze the impact of the
long protocol with GnRH agonist without progesterone supplementation and
to assess the inuence of standard and a high dose GnRH antagonist on the
endometrial development as compared with treatment with a GnRH agonist or
in natural cycles.
Methods
SUBJECTS: The study population was comprised of healthy, fertile women
with normal cycles (Caucasian, between the ages of 23 and 39) who served as
oocyte donors in our Institution. Volunteers signed an informed consent form
approved by the IRB of our Institution. Patients were followed-up during their
natural cycles and during the stimulated cycles performed for IVF.
FIRST STUDY: Endometrial biopsies were obtained from two groups of pa-
86
tients using different experimental designs. In the rst group, samples were
obtained at days LH+2 (n=5) and LH+7 (n=5) as determined by urinary LH
surge during the natural cycle from the same patient to reconrm previous
ndings. The second group, endometrial samples were obtained in the same
patient at day LH+7 (n=9) of the natural cycle and at day hCG+7 (n=5). The
protocol for ovarian stimulation used was a long protocol with GnRH agonist
(leuprolide acetate) without progesterone supplementation (15).
SECOND STUDY: 31 oocyte donors underwent rFSH treatment combined
with 0.25 mg/day ganirelix (standard-dose), 2 mg/day ganirelix (high-dose)
or; 0.6 mg/day buserelin (long protocol). Vaginal progesterone (200 mg/day)
was given in the luteal phase. Endometrial biopsies were taken 2 and 7 days
after hCG administration. In 12 subjects, additional biopsies were taken 2 and
7 days after the LH peak of the previous cycle (16).
In both studies, endometrial biopsies were obtained from the uterine fundus using a Pipelle catheter (Genetics, Namont-Achel, Belgium) under sterile
conditions and evaluated according to the criteria described by Noyes et al.
(17) by two assessors at CYTOPAT (Valencia, Spain). Results were validated
by Q-PCR in all cases.
Results
The rst data we obtained as a result of this study were the genes regulated
during the formation of a receptive endometrium (LH+2 versus LH+7, called
window of implantation (WOI genes). In this study we used the recently available HG-U133A genechip, which contains almost twice as many gene fragments. A large degree of overlapping was identied when we compared our
HG-U95A LH+7/LH+2 data (13) with the genes identied in this study. More
specically, of the top 40 up-regulated and top 30 down-regulated genes from
the HG-U95A set of data, 68 were also identied as being equally regulated
in this study conrming the reproducibility of microarray technique. In total,
in this study, we identied 504 genes that were down-regulated and 894 genes
that were up-regulated more than 2 fold at the time of implantation.
When comparing the data of the hCG+7 samples with that of the natural
cycle at LH+7 in the rst study (with GnRH agonist (leuprolide acetate) without
progesterone supplementation) we found to our surprise that the expression of a
large number of genes (558) was dys-regulated. We identied equal numbers of
up- and down-regulated genes, while more than 200 genes were dys-regulated
with a fold change of >3, of which 80 showed a fold change of >5. This unex-
87
pected result was conrmed for a number of genes by semi-quantitative and

quantitative PCR. The consistency of the individual endometrial expression
proles, demonstrated using microarray technology, is surprising. Of the 558
DNA fragments that were differentially expressed in hCG+7 and LH+7 groups,
351 were also regulated during the formation of a receptive endometrium.
Interestingly, genes that were normally down-regulated during the formation of
a receptive endometrium tended to be expressed at a higher level during COH,
whereas genes that were up-regulated in the WOI tended to be down-regulated
during COH (see table 1).
Table 1:
Number of genes with differential regulation between the natural cycle (day LH+7) and
the treatment regimens (at day hCG+7) and within the window of implantation for the
four treatment regimens.
Window of implantation genes
Typically
Regimen/direction of regulation
N of genes
o
upregulated
(n = 894)
Typically downregulated
(n = 504)
STUDY
FIRST
Leuprolide (agonist)
Up
281
115
Down
277
227
Up
22
Down
69
46
Up
88
Down
24
15
Up
22
Down
100
76
SECOND STUDY
Ganirelix 0.25 mg/day (antagonist)
Ganirelix 2 mg/day
(antagonist)
Buserelin long protocol (agonist)
In the second study, for each of the treatment regimens, a similar number of
88
genes were differentially expressed (fold change >2.0) between treated and
natural cycles: 91 genes for the standard-dosage ganirelix regimen, 112 genes
for the high-dosage ganirelix regimen, and 122 genes for the buserelin regimen. As we have mentioned, previous research had identied 1398 genes that
are differentially expressed within the window of implantation (between day
LH+2 and LH+7) and are therefore potentially important for the implantation
process and endometrial receptivity (14). Of the genes with differential expression between treated and natural cycles, 50 of the 91 genes in the standarddosage ganirelix specimens, 23 of the 112 genes in the high-dosage ganirelix
specimens, and 85 of the 122 genes in the buserelin specimens belong to the
window of implantation group (see Table I).
Conclusions
The fact that so many genes are dys-regulated suggests a shift in time in the
differentiation towards a receptive endometrium caused by COH treatment in
the rst stimulation protocol, rather than the direct dys-regulation of a limited
number of genes by the hormones used. Indeed, evidence can be found in the
literature that, on the day of oocyte retrieval (36 hours after hCG administration) the endometrium appears morphologically advanced (17-20), whereas
delayed, advanced and in phase endometrium is described during the window
of implantation following COH. Our study shows that, for many of the genes
that are regulated during the formation of the window of implantation, the
expression levels in hCG+7 samples are more comparable with those of LH+2
than with LH+7 patterns in the rst study using GnRH agonist (leuprolide
acetate) without progesterone supplementation. This observation suggests a
delay in the regulation of gene expression necessary for the formation of a
receptive endometrium due to this COH treatment. The altered gene expression
proles, strongly suggests that a COH endometrium is not optimally prepared
for implantation in this case. This could have negative effects on the implantation process and therefore could be one of the main cause of a low success rates
in COH in this protocol.
In the second study, the gene expression proles of the 3 different treatment
groups were largely comparable to that of the natural cycle. In each of the
treatment groups, expression of about 100 genes was different from that in the
natural cycle. When specically investigating for genes whose expression is
regulated during the window of implantation (WOI genes), more genes were
differentially expressed compared to the natural cycle in the buserelin group
than in either the low or the high dose ganirelix groups. This suggests that the
89
expression prole of WOI genes is closer to the natural cycle prole in the
ganirelix groups than in the buserelin group.
In all cases some of the dys-regulated genes are known to be implicated in
endometrial receptivity such as PP-14 (Glycodelin) (21) or LIF (22) but others
have more general functions. These works are very useful to deep into the gene
function of the WOI genes and to increase or decrease the relevance of the role
of these genes into implantation process.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
American Society for Reproductive Medicine. (2002) Assisted reproductive technology in the
United States and Canada: 1999 results generated from the American Society for Reproductive
Medicine/Assisted Reproductive Technology Registry. Fertil. Steril. 78, 5.
Paulson, R.J., Sauer, M.V. and Lobo, R.A. (1990) Embryo implantation after human in vitro
fertilization: importance of endometrial receptivity. Fertil. Steril. 53, 870-874.
Seif, M.W., Pearson, JM.., Ibrahim, Z.H. et al. (1992) Endometrium in in-vitro fertilization
cycles: morphological and functional differentiation in the implantation phase. Hum. Reprod.
7, 6-11.
Psychoyos, A. (1994) The implantation window; basic and aspects. In Mori et al., eds.
Perspectives on Assisted Reproduction. Ares-Serono Symposium 4, Roma, pp. 57-63.
Kolb, B.A. and Paulson, R.J. (1997) The luteal phase of cycles utilizing controlled ovarian
hyperstimulation and the possible impact of this hyperstimulation on embryo implantation.
Am. J. Obstet. Gynecol. 176, 1262-1267.Kolibianakis et al., 2003)
Nikas, G., Develioglu, O.H., Toner, J.P. et al. (1999) Endometrial pinopodes indicate a shift in
the window of receptivity in IVF cycles. Hum. Reprod. 14, 787-792.
Giudice, L.C. (2003) Elucidating endometrial function in the post-genomic era. Hum. Reprod.
Update 9, 223-235.
Develioglu, O.H., Hsiu, J.G., Nikas, G. et al. (1999) Endometrial estrogen and progesterone
receptor and pinopode expression in stimulated cycles of oocyte donors. Fertil. Steril. 71,
1040-1047.
Simn, C., Mercader, A., Francs, A., et al. (1996) Hormonal regulation of serum and endometrial IL-1, IL-1 and IL-1ra: IL-1 endometrial microenvironment of the human embryo at
the apposition phase under physiological and supraphysiological steroid level conditions. J.
Reprod. Immunol. 31, 165-184.
Kao, L.C., Tulac, S., Lobo, S. et al. (2002) Global gene proling in human endometrium during
the window implantation. Endocrinology 143, 2119-2138.
Carson, D., Lagow, E., Thathiah, A. et al. (2002) Changes in gene expression during the early
to mid-luteal (receptive phase) transition in human endometrium detected by high-density
microarray screening. Mol. Hum. Reprod. 8, 971-879.
Borthwick, J., Charnock-Jones, S., Tom, B. et al. (2003) Determination of the transcript prole
of human endometrium. Mol. Hum. Reprod. 9, 19-33.
Riesewijk, A., Martn, J., van Os, R. et al. (2003) Gene expression proling of human endometrial receptivity on days LH+2 versus LH+7 by microarray technology. Mol. Hum. Reprod. 9,
253-264.
Horcajadas, J. A., Riesewijk, A., Polman, J., van Os, R., Pellicer, A., Mosselman, S. and
Simn, C. (2005) Effect of Controlled Ovarian Hyperstimulation in IVF on Endometrial Gene
90
15.
16.
17.
18.
19.
20.
21.
22.

Expression Proles. In Press. Mol. Human Reprod.
Simon C., Obery J., Bellver J., Vidal C., Bosch E., Horcajadas J. A., Murphy C., Adams S.,
Riesewijk A., Mannaerts B. and Pellicer A. (2005) Similar endometrial development in oocyte
donors treated with either high- or standard-dose GnRH antagonist compared to treatment with
a GnRH agonist or in natural cycles. Submitted to Human Reproduction.
Noyes RW, Hertig AT and Rock J (1950) Dating the endometrial biopsy. Fertil Steril 1, 3-25.
Seif, M.W., Pearson, JM.., Ibrahim, Z.H. et al. (1992) Endometrium in in-vitro fertilization
cycles: morphological and functional differentiation in the implantation phase. Hum. Reprod.
7, 6-11.
Psychoyos, A. (1994) The implantation window; basic and aspects. In Mori et al., eds.
Perspectives on Assisted Reproduction. Ares-Serono Symposium 4, Roma, pp. 57-63.
Kolb, B.A. and Paulson, R.J. (1997) The luteal phase of cycles utilizing controlled ovarian
hyperstimulation and the possible impact of this hyperstimulation on embryo implantation.
Am. J. Obstet. Gynecol. 176, 1262-1267.
Kolibianakis, E.M., Bourgain, C., Platteau, P. et al. (2003) Abnormal endometrial development
occurs during the luteal phase of nonsupplemented donor cycles treated with recombinant
folliclestimulating hormone and gonadotropin-releasing hormone antagonists. Fertil. Steril.
80, 464-466.
Julkunen, M., Koistinen, R., Sjberg, J. et al. (1986) Secretory endometrium synthesizes placental protein 14. Endocrinology 118, 1782-1786.
Stewart, C.L., Kaspar, P., Brunet, L.J. et al. (1992) Blastocyst implantation depends on maternal expression of leukaemia inhibitory factor. Nature 359, 76-9.
91
Increased risks of health problems

in singleton ART babies:
is it the procedure, the ovarian
stimulation or infertility itself?
Dr Jean Cohen
8 rue de Marignan, 75008 Paris, France
A.R.T. is an efcacious treatment in subfertile couples. So far, little attention

has been paid to its adverse effects and complications. The fact that most of
ART centers do not include obstetricians or pediatricians has led to evaluate
results in terms of pregnancy rates without being preoccupied by the condition
and the future of the child. We must now identify if the offsprings are at greater
risk, if they enter life with a greater burden of abnormalities than their naturally
conceived purs.
I. Effect of protocols or techniques

a) IVF babies. Most of the studies are reassuring but there are contradictory
results (HANSEN, ERICSON, STROMBERG, KOIVURA, etc)
b) Multiple pregnancies. There is an increased incidence of developmental disability, cerebral palsy, mental retardation, sensory impairments, language delays, etc and of depression of the mothers and family disruption. Prevention
is possible.
c) ICSI babies. Many studies conclude that neither lassitude nor over concern
about adverse effects are justied. But the category of genetic defects for which
concerns have most often been raised is chromosomal abnormalities. A cohort
of 1987 pregnancies in Brussels yielded a frequency of de novo autosomal
rearrangements of 0.36% and a de novo sex chromosomal abnormalities of
92
0.83%. Both rates are higher than expected in the general population. Various
explanations for these increased cytogenetic autosomal abnormalities will be
explored. In addition to arising from the procedure per se, a genetic or cytogenetic abnormality in offspring of an ICSI pregnancy could arise as result of
offspring inheriting the mutant gene or chromosomal abnormality conferring
paternal infertility : Y deletions (DAZ) in oligospermia males, cystic brosis in
offspring of males with congenital bilateral absence vas deferens (CBAVD), and
sex chromosomal abnormalities in offspring of Klinefelter syndrome (47,XXY).
d) Epigenetic risks. An increased risk of rare imprinting disorders such as
Beckwith-Wiedemann syndrome or Angelman syndrome has been reported.
e) Aetiology. 3 possible sources of increased risks of health problems in ART
babies will be discussed :
the IVF procedure
ovarian stimulatory drugs
infertility itself.
II. Specic parental situations
donor ART
homosexual parents
surrogate mothers will be discussed
III. The condition of infertility as a cause

If the observed differences were genuine, it is unclear either :
The ovarian stimulation
The lab. Technology
The condition of infertility itself were responsible.
This last etiology has never been considered correctly.
Many studies indicate that in absence of treatment infertile couples have more
abnormal children than the general population. Z.PANDIAN ( ) has shown that
women with idiopathic infertility have higher risks of pre-eclampsia, placental
abruption, and premature delivery. Infertile women have also an increased risk
of spontaneous abortion.
Azoospermic men have an increase of DNA replication incidence in testis
and spermatozoa. These abnormalies more than fertilization aberrations, may
induce long term neurological disorders as Huntington disease, spinocerebellar
ataxia, myotonic dystrophy, etc
So, it is possible that observed abnormalities would not be caused by AC
93
technics, but by parental factors. The comparaison of spontaneous pregnancies

with AC pregnancies in infertile couples is difcult because :
small number of controls

therapeutic abortion rate is unknown
spontaneous abortion rate is not always indicated
follow up is not done on a large scale.
For R.G. EDWARDS and M. LUDWIG (2003) the epidemiological identication of higher frequencies of abnormal births after ART as compared
with natural conception could be partly explained by factors independent of
assisted conception. Preliminary data from surrogate mothers indicates that
relative risks after ART or natural conception are similar, indicating the uterus
is a cause of increased anomalies. Unique factors in some infertile patients,
e.g. higher risks of pre-eclampsia, infections and placental insufciency could
enhance anomalies among offspring by a mistaken attribution to ART in epidemiological analyses. High steroid levels and other hormones in ART cycles
may impose specic risks absent under natural circumstances, and placental
function and gene expression have to be related to its fetal and maternal components. Imprinting defects, serious for individual families, currently seem
too rare to explain higher risks of birth anomalies with ART, although many
more may be identied with stricter protocols in follow-up studies. Exposing
early developmental stages to culture media and sera may be a major cause of
some impriting defects during ART, and is known to involve immediate stress
responses and metabolic modications in embryos. A detail awaiting solution
is why imprinting syndromes were not detected in original follow-up studies
after ART, and whether numerous but so far unidentied imprinted loci in the
genome may be affected in vitro.
R.D. LAMBERT (2003) conducted literature review on premature birth, low
birth weight, perinatal mortality and major birth defects in children conceived
from infertility treatments. Only 39 publications comparing the outcome of
pregnancy in an infertile group of patients to a matched control group were
selected. The analysis of the outcome of singleton pregnancies resulting from
IVF versus articial insemination, obtained with or without the used of ovarian stimulatory agents and obtained with or without the use of a semen donor,
suggests that female infertility is an important risk factor. Criteria for screening at-risk infertile women have not yet been identied. Prospective studies
designed to identify precisely the aetiology of health problems in singletons
ART babies will have to be conducted.
94
IV. Prevention and informed consent

New studies must concern follow up of children at 2 5 10 years old. (Many
abnormalities cannot be detected at birth). In France, follow up association
contacts parents by telephone. In UK, HFEA has started a follow up study of
children born after A.C.
The incidence of abnormalities remains small but we must not hide it.
Meanwhile parents must be informed and advised. They must know that the
absence of criteria correlating at-risk infertile women to health problems in
their children does not allow a gynaecologist the opportunity to offer infertility
treatments to the least susceptible patients.
Parents must know that we are not able to promise a normal child, even if all
investigations done are normal.
We must tell them that an infertile couple does not become a normal fertile
couple any may be the treatment.
95
Hot controversies in infertility

Why should we treat PCOS women
with no infertility problem?
Leszek Pawelczyk
Division of Infertility and Reproductive Endocrinology, Department of Gynecology and
Obstetrics, Poznan University of Medical Sciences, Poznan, Poland
Polycystic ovary syndrome (PCOS) is one of the most common endocrine

disorders affecting around 5-8% of reproductive age women. Rotterdam
Consensus PCOS Workshop held in 2003 under joined auspices of ESHRE
and ASRM redened diagnostic criteria of PCOS. The workshop expert group
concluded that PCOS is a syndrome of ovarian dysfunction, with oligomenorrhoea, hyperandrogenism and polycystic ovary morphology. Majority of young
women with PCOS seek medical assistance due to two major problems: i)
hirsutism and acne and ii) oligo-/anovulation leading to infertility. However
one should also focus on systemic abnormalities of PCOS patients that appear
early in their reproductive life and may have serious consequences later during
the perimenopausal period.
Pathogenesis of PCOS is still unclear but several lines of evidence indicate
role of insulin resistance and hyperinsulinemia predominant to possible abnormalities of hypothalamic and pituitary gonadotropin secretion. Compensatory
chronic hyperinsulinemia acts synergistically with LH, resulting in hyperandrogenemia and consequent anovulation.
Insulin resistance, as well as additional risk factors dyslipidemia and
obesity contribute considerably to the increased risk for cardiovascular
disorders and type II diabetes. It has been established that PCOS women have
more prevalent selected metabolic risk factors and higher morbidity from
polymetabolic syndrome. Hence selected modes of treatment and lifestyle
modications should be implemented in PCOS population, early in their reproductive life.
96
More than 25% of PCOS women have impaired glucose tolerance that is
detectable even in adolescence and has high conversion rates to type II diabetes. During menopause around 10% of PCOS patients are affected with type II
diabetes, more than in healthy age-matched controls. In a large Nurses Health
Study it was demonstrated that oligomenorrhoeic patients have more than 2fold increase in the risk of type II diabetes development.
Well designed studies assessing pharmacological and life-style interventions
on prevalence of type II diabetes in women with PCOS are missing. Diabetes
studies suggest that aerobic exercise improves insulin sensitivity and weight
loss with calorie restriction ameliorates menstrual regularity. Additionally treatment of PCOS women, with insulin sensitizers (including metformin) improves
glucose tolerance and may decrease risk of cardiovascular episodes and type II
diabetes. This therapy leads to a decrease in serum insulin and androgen levels
as well as an improvement in ovulatory function. Recent studies by Diabetes
Prevention Program Research Group exploring type II diabetes development
in non diabetic hyperglycemic individuals revealed even greater reduction
of frequency of diabetes with life style modications (>7 % weight loss and
intensive exercise) than with metformin therapy. Nevertheless data available
should encourage to implementation of lifestyle amendment with concomitant
application of insulin sensitizers in all PCOS women.
Epidemiological studies demonstrated that women with PCOS have signicantly increased risk for development of cardiovascular disease and myocardial infarction. Interestingly there are preliminary data that PCOS patients
have raised markers of chronic inammation directly related to severity of
insulin resistance. Moreover PCOS women have altered haemostatic and brinolytic parameters, endothelial dysfunction, impaired vascular compliance,
and increased oxidative stress. In line with these observations, increased atherosclerosis, including increased carotid intimal thickness on ultrasound and
abnormal coronarography, were reported. Both lean and obese PCOS women
have abnormal, atherogenic lipid prole, with elevated LDL cholesterol and
triglycerides and decreased HDL fraction. Up to 60% of PCOS women presents
with visceral obesity, that is an independent risk factor for development of
hypertension and cardiovascular disease. There is some evidence for moderate
elevation in blood pressure in these patients but even in studies demonstrating
no raise in blood pressure the risk for development of cardiovascular disease
notwithstanding remained higher. This leads to speculation that the differences
may be subtle and detectable at the levels of surrogate markers for arterial
stiffness. Long-term treatment with metformin decreased LDL cholesterol and
improved HDL-cholesterol fraction. These changes parallel improvement In
97
insulin sensitivity as well body mass loss. This may constitute an additional
argument for long term therapy in PCOS patients with this biguanide.
Several studies pointed out that long term unopposed estrogen action, obesity
and insulin resistance in PCOS women may lead to increased risk of selected
malignancies. An association between PCOS and endometrial cancer had been
suggested in several studies but data is inconclusive. Thus general screening
for endometrial hyperplasia is not recommended but these patients are advised
to receive hormonal treatment in the form of cyclic progestogen or combined
oral contraceptive pill. Relationship between PCOS and breast/ovarian cancer
is even more unclear and contradictory. Further large studies are required to
assess the possible increased risk of PCOS women for these malignancies.
In summary, we have rm evidence for increased prevalence of metabolic
risk factors and future development of type II diabetes and cardiovascular disorders in women with PCOS. Even though higher mortality from cardiovascular episodes and diabetes complications has not been denitely demonstrated
in this subpopulation, certain preventive health measures should be undertaken.
Insulin resistance should be improved with life style modications, including intensive exercise and calorie restrictive diet. Long term pharmacological
interventions with insulin sensitizers should be considered in high risk PCOS
patients in order to improve lipid prole, glucose intolerance and possible
cardiovascular disease. Hormonal therapy to promote regular endometrial
shedding should be administered and screening for endometrial cancer with
ultrasound may be considered.
98
Metformin and PCOS:

Should they always go together?
Evanthia Diamanti-Kandarakis MD
Associate Professor in medicine
Medical School University of Athens, Athens Greece
Doctors are men who prescribe medicines of which they know little, to cure
diseases of which they know less, in human beings of whom they know nothing.
Voltaire (1694-1778)
Polycystic ovary syndrome (PCOS) is a complex and heterogeneous disorder
presenting a challenge for clinical investigators. It is the most common endocrine disorder of the reproductive-aged women, yet the optimal therapeutic
approach is unknown because the pathophysiological and molecular basis of
the syndrome is not fully understood. Currently, the treatment is targeted to
the patients primary complaint. Treatment strategies focus on the reduction
of clinical manifestations of hyperandrogenism (e.g. hirsutism), restoration of
regular menses and achieving pregnancy. Pharmacological agents available
for the treatment of hirsutism include androgen-suppressors and peripheral
androgen blockers. Combined oral contraceptive pills are the most commonly
used androgen suppressor and the treatment of choice for menstrual dysfunction in PCOS patients who do not desire pregnancy. The rst-line treatment
for infertility in PCOS is clomiphene-citrate while parenteral gonadotropins
are commonly used in clomiphene-resistant patients. The benets of insulinsensitizing agents in PCOS patients have become increasingly clear over the
last decade.
Metformin is the most extensively used insulin-sensitizing agent in PCOS.
Metformin is a biguanide antihyperglycemic that has been used to treat type 2
99
diabetes for many years in Europe, and was introduced in the United States in
1995. The glucose-lowering effects of metformin are mainly a consequence of
reduced hepatic glucose output (primarily through inhibition of gluconeogenesis and, to a lesser extent, glycogenolysis) and increased insulin-stimulated
glucose uptake in skeletal muscle and adipocytes. By increasing insulin sensitivity, metformin reduces insulin resistance, insulin secretion and hyperinsulinemia. Metformin might lead to a decreased food intake and a modest amount
of weight loss in some patients.
The rst report of metformin use in PCOS was published by Velazquez et
al. in an uncontrolled study of 26 obese women showing that 1500 mg/day of
metformin for 8 weeks resulted in improvement in insulin resistance, decrease
in LH and androgen levels, and increase in SHBG, E.Diamanti Kandarakis et
all published the rst study in Europe for six months assessing the insulin sensitivity with the gold standard method of clamp. Restoration of regular menstrual
cycles was observed in seven patients while spontaneous pregnancies occurred
in three patients. Nestler and Jakubowicz , subsequently reported similar ndings in a placebo controlled trial of 24 obese women with PCOS. Since then,
several studies have shown a wide range of benecial effects in metabolic,
reproductive and clinical outcomes. However, most of those studies were observational cohorts or uncontrolled with small numbers of participants.
Recently, the effects of metformin in PCOS were assessed in a meta-analysis
including 13 randomized controlled trials of 543 participants The dose range
of the metformin used in these trials was 1500-1700 mg/day. There was a
signicant effect of metformin in achieving ovulation in women with PCOS
with odds ratios of 3.88 (95% CI 2.25-6.69) for metformin vs. placebo, and
4.41 (95% CI 2.37-8.22) for metformin and clomiphene vs. clomiphene alone.
The data in this meta-analysis suggested that metformin has its effect relatively
quickly with signicant treatment effects reported after two months. There was
a signicant correlation between trial length and proportion ovulating with
placebo (r=0.83, p<0.02) suggesting that the treatment effect will appear less
with the longer trials due to higher rate of spontaneous ovulation in the placebo
arm.
The speculation of the use of metformin as a rst-line agent for ovulation
induction, instead of clomiphene in women with PCOS remains to be tested in a
head-to-head randomized trial. There are currently no studies directly comparing metformin with clomiphene as initial therapy for anovulatory patients with
PCOS. However, there is an ongoing multi-center randomized trial in the U.S.
assessing the effects of metformin and gonadotropins for ovulation induction
in clomiphene-resistant PCOS patients.
100
Limited available data suggest that despite its benecial effects on spontaneous ovulation, metformin does not enhance ovulatory or pregnancy rates in
gonadotropin ovulation induction and in vitro fertilization.
Preliminary results from small, observational trials suggest that metformin
might also be helpful for hirsutism, puberty prevention of PCOS, gestational
diabetes mellitus, and prevention of recurrent miscarriage. These ndings need
conrmation in large trials from different centers.
Gastrointestinal side effects such as nausea and vomiting are common with
use of metformin but tend to improve with the initiation of the drug at low
doses and increasing the dose in a stepwise fashion. Importantly, metformin
is a category B medication and well-controlled studies evaluating the possible
adverse effects on metformin use in pregnancy are lacking. Current recommendation is to discontinue the drug once the pregnancy is established.
References
Diamanti-Kandarakis E, Kouli Cr, Bergiele At et al.: A survey of the polycystic ovary syndrome in
the Greek island of Lesbos: hormonal and metabolic prole. J Clin Endocrinol Metab (1999)
84(11):4006-4011
Azziz R, Woods Ks, Reyna R et al.: The prevalence and features of the polycystic ovary syndrome
in an unselected population. J Clin Endocrinol Metab (2004) 89(6):2745-2749.
Diamanti-Kandarakis E, Dunaif A 1996 New perspectives in PCOS. Trends in Endocrinology and
metabolism: 7:267-271
Diamanti-Kandarakis E, Couli C, Tsianateli T, Bergiele A. Therapeutic effects of metformin on
insulin resistance and hyperandrogenism in polycystic ovary syndrome. European Journal of
Endocrinology 1998;138:269-274
Rotterdam Eshre/Asrm-sponsored pcos consensus workshop group: Revised 2003 consensus on
diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril
(2004) 81(1):19-25
Moran Lj, Noakes M, Clifton Pm, Tomlinson L, Norman Rj: Dietary composition in restoring reproductive and metabolic physiology in overweight women with polycystic ovary syndrome. J Clin
Endocrinol Metab (2003) 88(2):812-819.
Velazquez Em, Mendoza S, Hamer T, Sosa F, Glueck Cj: Metformin therapy in polycystic ovary
syndrome reduces hyperinsulinemia, insulin resistance, hyperandrogenemia, and systolic blood
pressure, while facilitating normal menses and pregnancy. Metabolism (1994) 43(5):647-654.
Nestler Je, Jakubowicz Dj: Decreases in ovarian cytochrome P450c17 alpha activity and serum free
testosterone after reduction of insulin secretion in polycystic ovary syndrome. N Engl J Med
(1996) 335(9):617-623.
Lord J, Flight I, Norman R: Insulin-sensitising drugs (metformin, troglitazone, rosiglitazone, pioglitazone, D-chiro-inositol) for polycystic ovary syndrome. Cochrane Database Syst Rev (2003)
3:CD003053.
Single currently available meta-analysis assessing the role of insulin-sensitizing agents in the
treatment of PCOS.
Nestler Je, Stovall D, Akhter N, Iuorno Mj, Jakubowicz DJ: Strategies for the use of insulin-sensi-
101
tizing drugs to treat infertility in women with polycystic ovary syndrome. Fertil Steril (2002)
77(2):209-215.
Yarali H, Yildiz Bo, Demirol A et al.: Co-administration of metformin during rFSH treatment in
patients with clomiphene citrate-resistant polycystic ovarian syndrome: a prospective randomized trial. Hum Reprod (2002) 17(2):289-294.
Kjotrod Sb, Von During V, Carlsen SM: Metformin treatment before IVF/ICSI in women with polycystic ovary syndrome; a prospective, randomized, double blind study. Hum Reprod (2004)
19(6):1315-1322.
Harborne L, Fleming R, Lyall H, Sattar N, Norman J: Metformin or antiandrogen in the treatment of
hirsutism in polycystic ovary syndrome. J Clin Endocrinol Metab (2003) 88(9):4116-4123.
Glueck Cj, Wang P, Kobayashi S, Phillips H, Sieve-Smith L: Metformin therapy throughout pregnancy reduces the development of gestational diabetes in women with polycystic ovary syndrome.
Fertil Steril (2002) 77(3):520-525.
Glueck Cj, Awadalla Sg, Phillips H et al.: Polycystic ovary syndrome, infertility, familial thrombophilia, familial hypobrinolysis, recurrent loss of in vitro fertilized embryos, and miscarriage.
Fertil Steril (2000) 74(2):394-397.
102
Fresh ovarian tissue transplant:

A propose of a place to implant it
Morales Arturo MD, Pons Guillermo MD, Vidal Oscar MD,
Trevio Emilio MD, Saldivar Donato MD, Sordia Luis MD,
Merino Martha MC, Gonzlez Francisco MD, Barbosa Oralia MD,
Vzquez Juana MD.
Cancer affects millions of people around the world, no matter the age or gender
of the person. According to the 2003 cancer report from the American Cancer
Society, they estimated around 1,400,000 new cases of cancer in the United
States, 48% of them in women (1).
Statistics by the Mexican health department (2), reports this disease as the
second cause of death in the 2001, this represents about 60,000 deaths in that
year. In relation between the genders, maligns tumors were the 14.8% of the
causes of death in Mexican women, having the cervical cancer as the rst cause
with 4,260 deaths.
Actually the survival rate, after the cancer treatment, has increased up to an
80% at ve years, depending the kind of cancer (3)(4)(5)(6). Recent advances in
cancer treatment modalities, including aggressive chemotherapy , radiotherapy,
and bone marrow transplantation had a result of signicant increase in the survival rate. Unfortunately, these survivors often suffer of the late effects of their
own disease and the effects of the treatment they had. In the case of females
in the reproductive age, an aggressive treatment strategy for the management
of cancer in reproductive organs, often cause infertility and premature ovarian
failure. This is related to the damage to the ovarian tissue (7-16).
In the last few years, there has been many reports of successful cases of auto
transplantation of frozen-banked or fresh ovarian cortical strips (17-22). The
technique of transplant ovarian cortical strips, described by Oktay (23), in the
103
forearm has shown the restoration of the ovarian function in approximated 270
days. We believe that exist better places to transplant the grafts of the ovarian
tissue having a shorter period of time to revasculate and start working before
that period of time. One of this places is the anterior part of the upper arm,
because in this area the supercial branches of the braquial artery provide a
better blood supply for the tissue. Even more, this site is less exposed to an
accidental traumatism compared with the forearm region.
The objective of this study is to demonstrate the anterior part of the upper
arm as a better place to implant the ovarian tissue.
Design:
This is a prospective experimental study.
Materials and Methods

We select a 33 years old woman with stage IB1 squamous cell cervical carcinoma. She signed the consent for the procedure. She had a medical history of
a left ectopic pregnancy treated with salpingoophorectomy many years before.
Previous to the ovary transplant we obtain basal levels of FSH, LH, Estradiol,
TSH, PRL, Testosterone, DHEA-S and Androstenedione to probe the normal
hormonal function of the remaining ovary. We used the Blatt Kupperman scale
to evaluate the symptoms related to estrogen deciency. Once we probed
than she had a normal ovary function and does not had any perimenopausic
symptoms, an oophorectomy was made, ovarian cortical pieces were prepared.
The strips were 5 cm long, 0.5 cm wide and 3 mm thickness and preserved in a
EAGLE medium until the location of the transplant was ready (Figure 1).
Figure 1: Ovary tissue strips
104
At the anterior region of the right upper arm, approximately 5 cm above the
humero-cubital fosa, a 5 cm long transverse incision was made; using a blunt
dissection we created a pocket between the fascia and the subcutaneous tissue
where 8 cortical ovarian strips were inserted. After this, we closed and covered
the skin with a no pressure dressing. The patient was release to home 48 hrs
after the procedure without any complications.
She came to her follow-up at 7, 15 and 30 days after the procedure, after that
she began to come with us every month. In each consult, the Blatt Kupperman
scale and hormonal serum levels were done.
Figure 2: Incision and pocket in right upper arm.
Results
A 5-week radiotherapy cycle and a radical hysterectomy were done to complement her treatment. She came to every appointment without complies at the
graft site. The results of the hormonal levels are shown at the gure 3.
140,00
Hormonal Levels
120,00
100,00
80,00
60,00
40,00
20,00
0,00
Before Surgery
15
FSH
30
45
60
75
Figure 3: Hormonal
levels
LH
100
135
Estradiol
190
105
Between the three rst months, the hormonal levels of FSH and LH increased
and after that, they began to decrease. In relation with the estradiol, the hormonal serum levels decreased at the beginning and reach normal levels at the
190-day after the transplant. At this last appointment, she reported the presence
of a painless bulge at the site of the transplant. Ultrasound examination showed
a 7 mm follicle (Figure 4). At 170 days after the transplant.
Figure 4: Ultrasound in the site of transplant.

In relation with the menopause symptoms estimated by the Blatt Kupperman
scale, she presented a great number of symptoms at the beginning but after few
months later, the symptoms disappear almost to be nule (Figure 5).
35,00
30,00
25,00
20,00
15,00
10,00
5,00
0,00
Before Surgery
15
30
45
60
75
100
135
190
IBK 1
Figure 5: Blatt Kupperman Index results.
Comments and Conclusions

Ovarian tissue transplant is another option that we have to preserve not only
the endocrine function, but also the reproductive function in young women
before the treatment with pelvic radiotherapy and/or chemotherapy (17)(18)(
106
19)(20)(21)(22). Otkay evidence the feasibility of transplanting fresh cortical

ovarian strips at the forearm and reestablish its function in approximated 270
days (22)(23). Reviewing the anatomy of the arm, we noticed that the region of
the upper arm has more and better irrigation than the forearm due the presence
of multiple supercial branches of the braquial artery. So then, because of this
knowledge, we decided to reproduce the Otkay experience with the difference
of implanting the ovarian tissue at the anterior region of the upper arm. Our
results have been as favorable as the results reported by Otkay, with the difference of lesser days to prove the function of the transplant.
We believe that the reason for this is, as a matter of fact, due to the place of
the ovary tissue transplant, where the blood supply is grater than the forearm
and this improves the revascularization of the tissue.
107
Bibliography
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
16)
17)
18)
19)
20)
21)
22)
23)
Cancer Statistics 2003, The American cancer Society

Registro Histopatologico de Neoplasias Malignas. SSA. Mexico
Meirow D. The effects of radiotherapy and chemotherapy on female reproduction. Human
Reproduction Update 2001 (7);6:535-543
A strategy for fertility services for survivors of childhood cancer. Multidisciplinary working
group convened by the british fertility society
Blatt J. Pregnancy outcome in long-term survivors of childhood cancer. Med Pediatr Oncol
1999;33:29-33
Landis, S.H. cancer statistics 1998, CA cancer J. Clin 1998;48:6-29
Kim S. The future of human ovarian cryopreservation and transplantation: fertility and beyond.
Steril Fertil 2001;75:1049-1056
Donnez J. Indications for cryopreservation of ovarian tissue. Human Reproduction Update
1998 (4);3:248-259
Meirow D. An in-vitro study of the effects of chemotherapy on human primordial follicles.
Hum Reprod 1998; 13
Wallace W.H.B. Ovarian failure following ovarian irradiation in childhood. The radiosensitivity of human oocyte. Br. J. Radiol 1989;62:995-998
Lushbaugh C.C. The effects of gonadal irradiation in clinical radiation therapy: a review.
Cancer 1976;37:1111-1125
Thibaud E. Ovarian function after bone marrow transplantation during childhood. Bone
Marrow Transplant 1998;21:287-290
Chiarelli A.M. Early menopause and infertility in females after treatment for child hood cancer
diagnosed in 1964-1988 in Notario, Canada. Am J Epidemiol. 1999;150:245-254
Sanders J.E. Ovarian function following marrow transplantation for aplastic anemia or leukemia. J Clin. Oncol. 1988;6:813-818
Whitehead E. The effect of combination chemotherapy on ovarian function in women treated
for Hodgkings disease. Cancer 1983;52:988-993
Meirow D. Ovarian injury and modern options to persevere fertility in female cancer patients
treated with high dose radio-chemotherapy for hemato-oncological neoplasias and others cancers. Leuk Lymphoma 1999;33:65-76
Gunasena K. Live births after autologous transplant of cryopreserved mouse ovaries. Hum
Reprod 1997;12(1):101-106
Candy C.J. Restoration of a normal reroductive lifespan after grafting of cryopreserved mouse
ovaries. Hum Reprod 2000;15(6):300-304
Demerci B. Follicular viability and morphology of sheep ovaries after exposure to cryoprotectant and cryopresrvation with different freezing protocols. Fertil Steril 2003;75(4):754-762
Leporrier et al . A new technique to protect ovarian function before pelvic irradiation: heterotopic ovarian autotransplantion. Cancer 1987; 60(9):2201-4
Marconi et al.Accidental ovarian autograft after laparoscopic surgery: case report. Fertil Steril
1997; 68:364-5
Okay K. Endocrine Function and Oociyte Retrival After Autologous Transplantation of Ovarian
Cortical Strips to the Forearm. Jama 2001;286(12):1490-1493
Oktay K. A technique for transplantation of ovarian cortical strips to the forearm. Fertil Steril
2003; 80(1):1931-9
108
A structured literature review to

establish the effectivity of metformin in
the clomiphene-resistant patient
TI Siebert, TF Kruger, DW Steyn, S Nosarka
Aim :
Literature search to establish the effectivity of Metformin regarding ovulation
in the C/C resistant patient.
Methods:
Medline data base was searched from 1 January 1980 - 31 December 2003.
Inclusion criterIa was prospective randomised control trials where Metformin
was randomised either with placebo or C/C to induce ovulation in the C/C
resistant patient.
Results:
Group 1:
Four trials were prospective double-blind placebo controlled. When the data
of the 4 trials was pooled, the overall effect of the addition of Metformin in the
C/C patient was p = 0,0006 with a 95% CI of 1,81 - 8,84.
Group 2:
In two trials the randomisation was only prospective. When the data of these
two trials were pooled, the overall effect of the addition of Metformin in the
C/C resistant patient wat p < 0,0001 and a 95% CI of 6,24 - 70,27.
109
Group 1 & 2:
The combined data shows an overall effect of p< 0,0001 and a 95% CI of 3.59
- 12.96.
Conclusions:
The addition of Metformin in the C/C resistant patient is highly effective in
achieving ovulation induction.
1.Introduction
Polycystic ovarian syndrome (PCOS) is a very common endocrinopathy
among infertile female individuals and affects approximately 6% of the
general female population1. The most prominent presenting characteristics
are anovulation and hyperandrogenism.
The diagnosis of PCOS seems to be solved following the Rotterdam consensus statement2. This statement concluded that the diagnosis of PCOS can be
made if two of the following are present:- Chronic anovulation, polycystic
ovaries on ultrasound, and hyperandrogenism2.
Insulin resistance and concomitant hyperinsulinemia are frequently found
in obese PCOS women (65%)3. The incidence of insulin resistance among
lean PCOS women is nearly 20%3. This results in hyperinsulinemia and
enhances the LH driven production of androgens from ovarian theca cells4.
Hyperinsulinemia, insulin resistance and an increase in androgen production
are all linked together in PCOS patient4-5. It is also known that patients with
PCOS and insulin resistance are more resistant to ovulation induction. Is the
answer in the management of infertile PCOS women then the use of insulin
sensitisisers? Numerous articles have been published where insulin sensitisers
such as biguanides (metformin)6 and thiazolidinediones (troglitazone), have
been used and proven to improve metabolic abnormalities in PCOS patients7.
Unfortunately, nearly all of these studies were observational studies.
Metformin, a biguanide, is normally used in non-insulin dependent diabetes and the mechanism of action includes inhibition of gluconeogenesis in
the liver and increasing the peripheral uptake of glucose. Metformin also
reduces plasma levels of LH, hyperinsulinemia and also decrease ovarian
levels of androgen.8-9
Infertility secondary to chronic anovulation is one of the most common
clinical presenting features1. Clomiphene citrate(C/C)10 is the standard drug
used for ovulation induction in women with PCOS10-12. PCOS patients are
110
frequently resistant to C/C and this results in numerous cycles where C/C
is unsuccessfully used for ovulation induction. The continuous use of C/C
has also been linked to possible higher ovarian cancer risk13. . The possible
solution for an optimal protocol in ovulation induction is for the clincian
to know the optimal time when to introduce insulin sensitizers to improve
ovulation induction among PCOS patients.
The aim of this literature search is to establish the effectivity of Metformin
regarding ovulation induction in the C/C resistant patient.
2. Materials and methods

Studies were identied using several search strategies. The National Library
of Medicines MEDLINE data base was searched form 01 January 19802003. The following medical subject headings (MESH) were used: metformin, ovulation induction, C/C-resistance. The MEDLINE search was
performed on titles, abstracts and key words of the listed articles.
Clinical trials comparing two groups of patients were selected only if they
met the inclusion criteria and if the outcome data was provided to enable
statistical pooling of the data.
Our inclusion criteria was prospective randomised control trials where
Metformin was randomised either with placebo or C/C to induce ovulation
induction in the C/C-resistant patient.
The primary outcome of interest was ovulation.
i- Validity assessment and data extraction
A score was given to each trial using the same scoring system by Soliman
et al14 (1994). Six methodological variables namely, randomisation, group
demographics, placebo use, follow-up, co-intervention and patient cycle
differentiation were chosen (Table 1). Each trial was assessed and ranked
for its methodological rigor and its potential to introduce bias.
The methodological strength of each trial was evaluated in a systematic
fashion (Table 2). Trials were given scores that were divided by the maximum possible score and a percentage performance was given to each trial.
Performance scores ranged from 50% to 92% for the studies analysed.
ii- Statistical analysis
The data on the outcomes of each include trial was summarized in two-bytwo tables. The odds ratio (OR) was calculated for the use of Metformin
in the C/C-resistant patient. The overall combined OR, together with its
111
95% condence interval (CI) was calculated using the Mantel-Haentszel

method. Statistical signicance was inferred with a two-tailed p value of
0.05 or less.
3. Results
Twenty trials were evaluated. Eight trials compared the efcacy of metformin in the C/C-resistant patient regarding ovulation induction. Six trials
met the inclusion criteria and were selected for analysis. Table 3 lists the
methodological details of these trials.
Three groups were identied regarding the study structure.
Group 1
Four trials were prospective double-blind placebo controlled15-18. Each of
these trials randomised Metformin with placebo in the C/C-resistant patient.
In one trial (Hung Yu Ng)17 there was no difference in outcome. The other
three trials had a statistical signicant improvement when Metformin was
added to C/C in the C/C-resistant patient (Figure1). When the data of the
four trials were pooled the test for the overall effect was p=0.0006 with an
OR of 4 and 95%CI of 1.81-8.84.
Group 1: Four trials where the addition of Metformin was randomised in a prospective doubleblind placebo controlled fashion in the C/C resistant patient
Figure 1
Group 2:
In two of the trials the randomisation was only prospective and not double
blind19,20. Each of these trials prospectively randomised and compared the
addition of Metformin with placebo in the C/C-resistant patient. In both trials
there was a statistical improvement when Metformin was added (Figure 2).
When the data of the two trials were pooled the overall effect was p(smaller
as) 0.00001 with an OR of 20.94 and 95% CI of 6.24-70.27.
112
Group 2: Two trials where the addition of Metformin was prospectively randomised in the C/C
resistant patient
COMBINED ANALYSIS OF GROUP 1 AND GROUP 2.

The data of these two groups were combined to increase the numbers and to give the metaanalysis more weight (figure 3). This combined data shows an overall effect, p<0.00001 and an
Combined analysis of group 1 and group 2.

The data of these two groups were combined to increase the numbers and to
give the meta-analysis more weight (gure 3). This combined data shows an
overall effect, p<0.00001 and an OR of 6.82 with a 95% CI of 3.59-12.96.
Group 3
The third group consisted of two trials21,22. In these two trials the investigator
looked prospectively at a cohort of C/C-resistant patients when Metformin
was added without randomisation.
Batukan21 added Metformin to 29 C/C-resistant patients. 65.2% of the patients got pregnant when Metformin was added. In the second study by
Parsanezhad22, he added Metformin to 41 C/C-resistant patients. None
of these patients were ovulating before the addition of Metformin and
13(39.39%) ovulated after treatment.
Group 3: Pool data of group 1 and 2.
113
4. Discussion
The fertility specialist cannot consider any medical treatment in PCOS patients with anovulation if lifestyle intervention is not practiced. In a study by
Norman et al23 they demonstrated that lifestyle modication led to increased
insulin sensitivity and also resulted in improved ovulation and fertility in
obese women with PCOS. This approach of lifestyle modication, which
includes weight-reducing diet and exercise, should be the rst step in the
management of the obese patient with PCOS24.
Two excellent review articles were published recently (Costello26, Lord25)
In the one review (Cos26), two important articles were not included in their
analysis and in the other (Lord25) only two articles were mentioned in
the C/C-resistant group with the data set very heterogenic. Based on the
above mentioned facts and the fact that C/C-resistance is a major problem
in the handling of the PCOS patient, we performed another meta-analysis
with more articles to our disposal and according to the selection criteria as
outlined. For the meta-analysis, we obtained data from four prospective
randomised double blind trials and two prospective randomised (not double
blind) trials. The data on the rst four articles15-18 clearly showed a statistical signicant effect in favour of ovulation with addition of Metformin.
When the data of the two prospective randomised articles19,20 were pooled
with the rst mentioned data set it further conrmed the positive effect on
ovulation with the addition of metformin in the C/C-resistant patient. (g.3)
Although the prospective randomised studies used in the meta-analysis are
strong pieces of evidence in favour of the use of Metformin in C/C-resistant
patients, it is interesting to note that this observation is further strengthened
by two cohort studies21,22 where C/C-resistant patients received metformin
with a positive effect.
In contrast with the above mentioned studies where Metformin was added
only after C/C- resistance was observed, Fleming et al27 performed the
only prospective double-blind placebo controlled trial where Metformin
was primarily randomised with placebo in women with oligo-amenorrhea
and PCOS. In this study 45 women used Metformin and 47 used placebo.
Twenty three percent of the Metformin treated group ovulated and only
thirteen percent in the placebo group ovulated. This difference was modest
but statistical signicant. It is however important to note that the dropout
rate in the Metformin group was 30% due to side-effects.
In a review article by Nestler28 et al the opinion was expressed that for practical purposes all patients should be regarded as insulin resistant. However,
if we compare on the one hand the signicant benet of the addition of
114
Metformin in the C/C-resistant patient with on the other hand the results of
Fleming et al27, it will be difcult to conclude that all PCOS women should
receive Metformin to achieve ovulation. It is our opinion that the side effects
must be taken in consideration before prescribing the drug. A percentage of
patients will denitely benet by simple lifestyle measures as well as C/C
alone as primary ovulation induction method.
Based on our study it can be concluded that Metformin is highly effective
in achieving ovulation in the C/C-resistant patient. We also recommend that
all obese PCOS patients, seeking fertility help, should be guided using a
lifestyle modication programme that should include weight-reducing diet
and exercises23,24. When this goal is achieved the patient can be started on
C/C and only if C/C-resistance is present Metformin should be added to
achieve ovulation.
Validity criteria and scoring for methodology assessment of studies
CATEGORY
A. Randomization
SCORE
METHOD
Randomized by central means (telephone and

pharmacy) or sealed accounted envelopes.
Alternating numbers.
Methods not described
B. Group Demographics
C. Placebo use
Demographics comparable.
Demographics not described.
Placebo or other treatment used in control group.

No placebo or other treatment
D. Follow-up
Outcome data for primary analysis complete.

Outcome data incomplete.
115
CATEGORY
E. Co-intervention
SCORE
METHOD
Other than for use of treatment versus control,

protocol involved same drugs.
Difference in protocols that may lead to

contaminated results.
F. Patient and cycle
Only rst treatment cycle included.
differentiation
Patients included for more than 1 cycle.
Cycles and patients not differentiated.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Polson DW, Adams J, Wadsworth J, Franks S. Polycystic ovaries-a common nding in normal
women. Lancet 1988; 1:870-2.
The Rotterdam ESHRE/ASRM sponsored PCOS consensus group. Revised 2003 consensus
on diagnostic criteria and long-term health risk related to polycystic ovary syndrome (PCOS).
Human Reproduction 2004; 19 (1):41-47.
Chang RJ, Nakamura RM, Judd HL, Kaplan SA. Insulin resistance in nonobese patients with
polycystic ovarian disease. J Clin Endocrinol Metab 1983; 57:356-9.
Dunaif A. Insulin resistance and the polycystic ovarian syndrome: mechanism and implications
for pathogenesis. Endocr Rev 1997; 18:774-800.
Burghen GA, Givens JR, Kitabchi AE. Correlation of hyperandrogenism with hyperinsulinemia
in polycystic ovarian disease. J Clin Endocrinol Metab 1980; 50:113-5.
Velazquez EM, Mendoza SG, Hamer T, Sosa F, Glueck CJ. Metformin therapy in polycystic ovary syndrome reduces hyperinsulinemia, insulin resistance, hyperandrogenaemia and
systolic blood pressure, while facilitating normal menses and pregnancy. Metabolism 1994;
43:647-54.
Erhmann D, Schneider DJ, Sobel BE, Cavaghan MK, Imperial J, Sturis J, et al. Troglitazone
improves defects in insulin action, insulin secretion, ovarian steroidogenesis, and brinolysis
in women with polycystic ovary syndrome. J Clin Endocrinol Metab 1997;82:2108-16.
Nestler JE, Jakubowicz D. Lean women with polycystic ovary syndrome respond to insulin
reduction with decreases in ovarian P450c17 alpha activity and serum androgens. J Clin
Endocrinol Metab 1997; 82:4075-9.
Williams G. Management of non insulin-dependent diabetes mellitus. Lancet 1994; 343:95100.
Shepard MK, Balmaceda JP, Leija CG. Relationship of weight to successful induction of
ovulation with Clomiphene citrate. Fetil Steril 1979;32:641-5.
OHerlihy C, Pepperell RJ, Brown JB, Smith MA, Sandri L, McBain JC. Incremental
Clomiphene therapy: a new method of treating persistent anovulation. Obstet Gynaecol 1981;
58:535-42.
92%
85%
92%
92%
Sturrock
Kocak
Vandermolen
78%
85%
57%
50%
SCORE
Hung Yu Ng
Not a-b
Malkawi
Not d-b
Nestler
cohort
Parsanezhad
cohort
Batukan
STUDY
generated
computer
sealed envelopes
envelopes
computer/sealed
RANDOMIZATION
Table 2.: Validity criteria score
DEMOGRAPHICS
OTHER
PLACEBO/
FOLLOW-UP
CO-INTERVENTION
CYCLES
13
13
12
13
11
12
TOTAL
116
117
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
Lobo RA, Gysler M, March CM, Goebelsmann U, Mishell DR Jr. Clinical and laboratory
predictors or Clomiphene response. Fertil Steril 1982;37:168-74.
Rossing MA, Daling JR, Weiss NS, Moore DE, Self SG. Ovarian tumours in a cohort of
infertile women. Br J Pharmacol 1994;331:771-776.
Soliman S, Daya S, Collind J et al. The role of luteal phase support in infertility treatment: a
meta-analysis of randomised trials. Fertil Steril 1994;61 (6):1068-1076.
Kocak M, Caliskan E, Simsir C, Haberal A. Metformin therapy improves ovulatory rates,
cervical scores, and pregnancy rates in clomiphene citrate-resistant women with polycystic
ovary syndrome. Fertil Steril 2002;77 (1):101-106.
Vandermolen DT, Ratts V, Evans WS, Stovall DW, Kauma SW, Nester JE. Metformin increases
the ovulatory rate and pregnancy rate from clomiphene citrate in patient with polycystic ovary
syndrome who are resistant to clomiphene citrate alone. Fertil Steril 2001;75(2):310-315.
Hung Yu Ng E, Ming Sun Wat N, Chung Ho P. Effects of metformin on ovulation rate,
hormonal and metabolic proles in women with clomiphene-resistant polycystic ovaries: a
randomized, double-blinded placebo-controlled trial. Hum Reprod.,2001;16(8):1625-1631.
Sturrock NDC, Lannon B, Fay TN. Metformin does not enhance ovulation induction in clomiphene resistant polycystic ovary syndrome in clinical practice. Br J Pharmacol.
Nestler J, Jakubowich DJ, Evans WS, Pasquali R. Effects of metformin on spontaneous and
clomiphene-induced ovulation in the polycystic ovary syndrome. N Engl J Med 1998; June
25:1876-1880.
Malkawi HY, Qublan HS. The effect of metformin plus clomiphene citrate on ovulation and
pregnancy rates in clomiphene-resistant women with polycystic ovary syndrome. Saudi Med
J 2002 Jun; 23(6):663-6.
Batukan C, Baysal B. Metformin improves ovulation and pregnancy rates in patient with
polycystic ovary syndrome. Arch Gynecol Obstet 2001 Aug;265(3):124-7.
Parsanezhad ME, Alborzi S, Zarei A, Dehbashi S, Omrani GH. Insulin resistance in Clomiphene
responders and non-responders with polycystic ovarian disease and therapeutic effects of metformin. Inter J of Obstet Gynecol 2001; 75:43-50.
Norman RJ, Davies MJ, Lord J, Moran IJ. The role of lifestyle modication in polycystic
ovary syndrome. Trends Endocrinol Metab 2002;13:251-7.
Clark Am, Thornley B, Tomlinson L, Galletley C, Norman RJ. Weight loss in obese infertile
women results in improvement in reproductive outcome for all forms of fertility treatment.
Hum Reprod 1998;13:1502-5.
Lord JM, Flight IHK, Norman RJ. Metformin in polycystic ovary syndrome: systematic
review and meta-analysis. Brit Med J 2003 25 Oct; 327:1-6.
Costello MF, Eden JA. A systematic review of the reproductive system effects of metformin
in patient with polycystic ovary syndrome. Fertil Steril 2003; Vol 79 (1):1-13.
Flemming R, Hopkinson ZE, Wallace AM, Greer IA, Sattar N. Ovarian Function and metabolic factors in women with oligomenorrhea treated with metformin in a randomized double
blind placebo-controlled trial. J Clin Endocinol Metab, Feb 2002;87(2):569-574.
Nestler JE, Stovall D, Akhter N, Luorno MJ, Jakubowicz DJ. Strategies for the use of insulinesensitizing drugs to treat infertility in women with polycystic ovary syndrome. Fertil Steril Feb
2002; Vol 77(2):209-215.
118
Pollution, infertility and carcinogenesis

Ecological aspects of Environmental
Pollution, Focusing on Carcinogenesis
Polyxeni Nicolopoulou-Stamati.
Associate Professor of Environmental Pathology
Medical School University of Athens, Department of Pathology,
75 Mikras Asias, 11527 Athens, Greece
e-mail: aspis@ath.forthnet.gr
Summary
In the past 50-60 year many millions of tones of man-made chemicals have
been produced and used, and consequently many of them have become widespread environmental contaminants throughout the world. There is now a
growing concern that some man-made chemicals are affecting the health of
human and wildlife populations. Some of these chemicals have the ability
to affect health interfering and upsetting the bodys hormone system. They
are known as endocrine disrupting substances or endocrine disrupters (EDs).
Exposure to EDs starts within the rst days of human life. The placenta cannot
prevent substances, as organochlorine compounds, acting as EDs from getting
into embryonic circulation, thus the fetus is exposed to EDs during a period
of life when organogenesis occurs. After birth, exposure continues through
lactation.
Chemicals released in the environment are known to have also the ability
to act as epigenetic or genotoxic carcinogens. Scientic evidence strongly
supports the implication of environmental factors in carcinogenesis. Twin
studies indicating that environmental factors predominate over genetic factors, Immigrants experiencing a rapid increase in breast cancer, incidental
exposure to dioxins, as it happened in Sevezo, and increase in hormone
119
dependent tumors of breast and prostate should be considered. Environmental

cancer studies are challenged to relate chemical exposure with the genome
of the individual and to continue to address new fundamental and applied
questions.
Introduction
In the past 50-60 years millions of tones of man made chemicals where released
and become widespread contaminants throughout the world. Impaired fertility
in humans and wildlife, congenital malformations, alternation of behaviour
increased incidence of hormone-related cancers have raised concern about
their relation with environmental pollution. Environmental hazards emerging
technologies, particularly genetically engineered food and milk production,
plus adverse impact of runaway petrochemicals and radionuclears with possible carcinogenic properties are considered as threats for public health. It is
recognized that there is an urgent need towards revisiting the impact of the
environment on health focusing on the major concern which is the alarming
raising of cancer incidence (Nicolopoulou et al., 2004).
Cancer is an extremely important recurring topic of discussion related to
the environment, not only amongst experts, but also in society as a whole.
Carcinogenesis is a multi-factor, multistage process which has been the subject
of an enormous amount of research. Many molecular mechanisms and processes have been proposed for cancer development; however the identication
of the initiating event leading to malignant transformation is still obscure. In
post-modern societies, people are constantly exposed to various potential carcinogens. Modern lifestyle, involuntary exposure to pollutants and radiation are
both implicated as causal factors of the disease. Can cancer be prevented?
Evidence from observations on wildlife but also well documented cases in the
literature including immigrant and twin studies, accidental exposure, intrauterine exposure of the foetus point to an association between environmental
pollution and carcinogenesis.
Despite the scientic efforts to understand the origin of cancer, to implement
curing and prevention there is hardly any real improvement. On the contrary
the globally rising incidence of cancer over the last one hundred years is undeniable (WHO, 2003). In the middle of the nineteenth century, cancer deaths
accounted for only 1.3 per cent of all deaths (Logan, 1982), while today cancer
is the second-leading cause of mortality in the developed world and fourth in
the developing world - accounting for 12 per cent of all deaths world-wide
(WHO, 2002).
120
Cancer and the Environment

Already in 1755 Perceival Pott recognised the association between cancer and
exposure to soot in the scrotum of chimney sweepers. Moreover, during the
19th and the 20th century, the association between occupational exposure to
carcinogens and cancer was described.
Nevertheless, mainly research of the 1970ies and 1980ies focussed on the
genetic background for cancer. Epidemiologists as Doll and Peto (1981) concluded that only a few per cent of cancers were attributable to environmental
exposure. This epidemiological nding was supported by the existence of
genetic aberrations in cancer cells and progress in knowledge on the role of
cancer genes.
If cancer is mainly attributed to genetic factors, then a set of other ndings
are difcult to interprete. The increase of cancer incidence, e.g., should be lower
and the rising trends in cancer incidence should be much smoother than what
is currently observed (Eaton, 2003). Evidence proving that cancer is related to
the environment has started from studies of wildlife settings (Carson, 2002).
Furthermore, it is based on the issue that certain types of cancer such as prostate
(Weir et al., 2003), testicular (Huyghe et al., 2003) and breast cancer (Weir et
al., 2003), which are hormone-depended cancers, are increasing constantly.
Their possible association with endocrine disrupters is extremely important.
Thyroid cancer rates are also under discussion especially after the Chernobyl
accident (Moysich et al., 2002).
Moreover the immigrants cancer rate adjusted to the rates of host countries
consists a strong argument of the environmental impact (Oppenheimer, 2001).
Childhood cancer which is also related to low dose exposure of carcinogens,
may be a source of scientic information concerning vulnerability of windows
of exposure and intrauterine effects of pollutants (Anderson et al., 2000).
Natural environment versus built environment with human made infrastructure is overwhelmed by products of industrial activities including chemicals
and radioactive substances. Institutional arrangements within society bring to
close relation industry with decision makers reecting their conict of interest of policy outcome, to citizens. Voluntary exposure due to lifestyle choices
versus imposed exposure due to industrial activity and policy decision is a
further complex issue.
Even though tremendous research activity is undertaken nanced by governments, the EU and industry, and despite the available experimental and epidemiological data, cancer experts generally cannot determine with condence
the specic cause of cancer in an individual (Montesanto and Hall, 2001). The
121
nearest they can get is the understanding of factors contributing to cancer rates
observed in large populations (Tomatis, 1993). It is clear that there is great difculty involved in the identication of cancer mechanisms and the evaluation
of data (Christoforou, 2001).
Towards New Concepts on Cancer

Prior to the development of molecular biology leading to knowledge of the structure of DNA and the alterations that are possible in the double helix, research on
cancer was limited to observations, experiments and epidemiological data.
Knowledge acquired from biology has altered the paths of research on cancer investigation. The understanding of the cellular and molecular events in
carcinogenesis has helped to clarify the issue. Cancer develops when normal
tissue cells no longer follow controlled growth. The reason for this is either
information included in the genetic planning of the cell or exogenous nonrepaired damage. More and more genetic information is being revealed by
genome techniques (Bishop and Schiestl, 2001). There is external impact on
cells through viruses, ultraviolet and ionising radiation, as well as by the large
amount of chemicals released into the environment during the last decades.
Cancer induction by chemicals is a highly complex multistage process that
is constantly revisited in the light of new scientic observations. They can
have genotoxic and non-genotoxic effect on cells. Genotoxic carcinogenicity
became a growing eld of study after the analysis revealing the structure of
DNA. The development of new methods not only gave an insight into the
reaction of metabolites with DNA, but also opened the path for the study of
the mechanisms of chemicals acting as non-genotoxics via receptor-mediated
mechanisms (peroxisome proliferators and dioxin) and via regenerative hyperplasia (Melnick et al., 1996). Recent research has begun to clarify the subject
by identifying key genes directly involved in carcinogenesis and demonstrating
how mutations in these genes allow cells to abandon cellular controls. By identifying the molecular basis of the differences between normal and malignant
cell, new opportunities have been created to observe the process by which
normal cells are progressively transformed into malignant ones. Sequential
acquisition of mutations which occur, result in endogenous processes such as
errors in replication of DNA, or free radicals generated during metabolism of
unstable DNA bases. Cells have evolved methods to repair such damage, but
for various reasons errors occur, and, due to permanent changes in the genome,
mutations are introduced. Identifying sources of such mutational damage can
lead to the identication of basic causes of human cancer.
122
The classication of chemicals as genotoxic and non-genotoxic has unfortunately proven inadequate for the evaluation of all potential contributing effects
on the actual relationship between exposure and cancer outcome. Human risk
is evaluated without the concept of a quantitative approach. Many chemicals
considered to be non-genotoxic carcinogens exhibit certain genotoxic behaviour. Limiting evaluations of carcinogenicity to their non-genotoxic effects can
be misleading. Some non-genotoxic activities may cause oxidative DNA damage and therefore initiate carcinogenesis without damaging the DNA directly.
Cell-replication may be involved in tumour development but cytotoxicity and
mutagenesis do not always reliably predict carcinogenesis. Threshold tumour
response is not always an inevitable result of a receptor-mediated mechanism
(Melnick et al., 1996). It is widely recognised that cell proliferation is a basic
and important mechanistic event that can be affected both by genotoxic and
non-genotoxic carcinogens (Tomatis, 1993; Rakitsky et al., 2000). Growth
factors are involved in this process and their role is underestimated in cancer
research (Jain, 2002).
Over the past thirty years, evidence has accumulated to show that a variety
of chemicals, including natural and synthetic hormones, pesticides, additives
used by the plastic industry, surfactants and persistent environmental pollutants
like polychlorinated aromatic hydrocarbons (PCBs and dioxins), can mimic
and disrupt hormone action. These 'endocrine disrupters', as they are called, can
interfere with the synthesis, secretion or action of the body's natural hormones
responsible for the maintenance of homeostasis, reproduction, development
and behaviour (Nicolopoulou-Stamati and Pitsos, 2001; Dorner et al., 2001).
The relationship between endocrine-related human malfunctions and cancer is
still poorly understood and has only recently been investigated. Gaps remain in
our knowledge of the mechanisms and substances involved and this is because
research protocols are based on traditional procedures.
Focusing on Carcinogenesis
The evidence of environmental impact through observations in the 18th century helped scientists in the 19th century to specify its particular relevance to
abnormal cell division in cancer. Early in the 20th century it was proposed that
cancer originates through uncontrolled division of somatically-mutated cells.
X-rays and viruses were also implicated in the etiology of cancer. While mutation in a single cell was assumed to be the primary causative mechanism in
carcinogenesis, the generally-observed logarithmic increase in incidence with
age reected a 'multiprocess' procedure requiring multiple successive muta-
123
tions in the progeny of the original mutation. It was also recognised that the
rate of proliferation of potentially cancerous cells inuences the probability of
their subsequent mutation.
The mutational theory of carcinogenesis seems to be dominant despite other
theories evolving that are attributing the cause of carcinogenesis to signalling mechanisms between cells and the surrounding tissue stroma. It has been
proposed that a neoplastic cell may be programmed to behave like a normal
cell within normal tissues. The organisation eld theory proposed a totally
new concept that should be implemented into research in order to be tested
(Sonnenschein and Soto, 2000).
Despite attempts to explain and understand carcinogenesis, the concept
remains that hereditary predisposition combined with environmental impacts
and lifestyle seems to be closely correlated with the onset of cancer (Knudson,
1997).
Epidemiological studies fail to prove a causal link in various human cancers.
It is obvious that voluntary or 'an acknowledged' exposure, such as smoking,
cannot ever reach the desired level of singling out the one and only causal effect in any given carcinogenesis. Even though exposures through, for example,
smoking, viral infections and occupation are linked with specic cancers, the
causal effect cannot be attributed to only one of them or even to their synergistic effect. As the molecular basis of carcinogenesis is studied, initiation and
promotion reveal that there are many trigger-points which do not necessarily
require the same event (Montesano and Hall, 2001). Parallel lines of basic
research, clinical studies and epidemiological studies highlight the multifactorial nature of the disease (Melnick et al., 1996).
Involuntary Exposure to Carcinogens in Early Life

Involuntary exposure to carcinogens - mainly chemicals but also different types
of radiation - in the uterus or early childhood requires particular attention. One
very well-known example is that of the synthetic oestrogen diethylstilbestrol
(DES), which was widely prescribed to pregnant women during the 1950s and
1960s in order to prevent miscarriage, but which was later discovered to be associated with an increased risk of clear-cell carcinoma of the vagina and cervix
in female offspring (Swan, 2000). This was the rst observation, but later more
adverse effects were found. It was found that intra-uterine exposure to DES
is associated with an increased risk of breast cancer among women aged 40
and older (Palmer et al., 2002), high-grade squamous neoplasia of the genital
tract (Hatch et al., 2001), hypospadias in male children (Klip et al., 2002) as
124
well as other reproductive abnormalities (Swan, 2000). There is also in vitro

evidence which suggests that women exposed to diethylstilbestrol have alterations in T-cell-mediated immunity (Burke et al., 2001). The identication of
adverse effects of DES indicated the endocrine involvement in carcinogenesis
even during prenatal exposure. This evidence raises concern over the long-term
effects of endocrine disrupters on developing foetuses. These substances are
transferred through the placenta to the foetus and by lactation to the infant
(Yang et al., 2002).
Children should not be considered as small adults when investigating the
impact of the environment (radiation, air-pollutants, endocrine disrupters, etc).
Their responses may be different from those of adults because they are in a state
of growth and development; or because of differences affecting toxicokinetics
or toxicodynamics including tissue structure, fat ratio and enzymes. Infants
and children are often assumed to be more susceptible to toxic effects, but this
generalisation is based on assumptions rather than on facts. The available data is
mostly concerned with toxicity and therapeutic effects of pharmaceuticals, while
the effects in children of industrial chemicals are less well-documented.
Toxicants may interfere with growth and development and therefore toxic
exposure may have more serious consequences for children than for adults,
irrespective of sensitivity. Immature physiological functions of the foetus and
young child theoretically make them more vulnerable to toxicants, at least
up to 1 year of age. The existing data on the effects of chemical exposure
in children suggests that susceptibility depends on the substance and on the
exposure situation. For a particular compound, children may be more sensitive than adults, or they may be less sensitive. Furthermore, the sensitivity of
children to a particular substance varies greatly with age. It is necessary to view
premature neonates, neonates, infants, and children of different ages as separate
risk groups. Methods which have special emphasis on reproductive cells, on the
foetus, and on the immature organism should be used to cover exposure during
all life-stages. However, some specic types of effects and delayed effects of
perinatal exposure are not always included in standard toxicity test protocols.
Exposure may also vary between children and adults as regards food intake.
The EU Scientic Committee for Food has recommended that intake assessment of children be considered separately from that of adults because patterns
of consumption are different (stergaard and Knudsen, 1998).
There is evidence from animal and epidemiologic studies for causal relationships for preconceptional, in utero, and childhood exposures and cancer
occurrence in children and adults. However, the evidence is incomplete and
all relevant critical windows may not have been identied. The comprehensive
125
evaluation of the relative importance of specic time windows of exposure is

limited. Improvements in the design of epidemiologic studies and additional
animal studies of mechanisms are warranted (Olshan et al., 2000).
The environmental exposure that occurs during the perinatal/postnatal
period is increasing and hence potentially increasing the risk of cancer. In
animal models, preconceptional carcinogenetic mechanisms have been demonstrated for a variety of types of radiation and chemicals. Sensitivity has been
demonstrated at all stages, from foetal gonocytes to postmeiotic germ cells.
Transplacental and neonatal carcinogenesis showed marked ontogenetic stage
specicity in some cases. The number of cells at risk, the rate of cell division,
the development of differentiated characteristics including the ability to activate and detoxify carcinogens, along with the presence of stem cells, should
all be taken into consideration (Anderson et al., 2000).
In addition, the rst evidence indicating heightened susceptibility of the
human foetus to DNA damage, compared to the mother, has recently been
shown. There is a molecular link between somatic mutation in the newborn and
transplacental exposure to common air pollutants, a nding that is relevant to
cancer risk assessment (Perera et al., 2002).
More experimental data comes from animal studies. It was found that mouse
mid-pregnancy exposure to polycyclic aromatic hydrocarbons (benzo[a]pyrene)
caused signicant deciencies of the immune system of the offspring resulting
from the formation of benzo[a]pyrene-DNA adducts in immature T-cells. This
could explain the observed T-cell immunosuppression and tumour susceptibility in mice exposed to benzo[a]pyrene in utero (Rodriguez, et al., 2002).
Bisphenol-A is a chemical substance with known oestrogenic action that
is used in the manufacture of a wide range of products. The low-dose in utero
exposure to bisphenol A of experimental animals caused striking morphological changes in the vagina of postpubertal offspring. In addition, the oestrogen
receptor alpha was not expressed during oestrus in the vagina of female offspring exposed to bisphenol-A and the altered vaginal morphology is attributed to the down regulation of oestrogen receptor alpha (Schonfelder et al.,
2002). Another experiment on mice after intra-uterine exposure to bisphenol-A
showed differences in the rate of ductal migration into the stroma at 1 month
of age and a signicant increase in the percentage of ducts, terminal ducts,
terminal end buds, and alveolar buds at 6 months of age. The changes in histoarchitecture, coupled with an increased presence of secretory product within
alveoli, resemble those of early pregnancy. This suggests a disruption of the
hypothalamic-pituitary-ovarian axis and/or misexpression of developmental
genes. It was concluded that the altered relationship in DNA synthesis between
126
the epithelium and stroma and the increase in terminal ducts and terminal end
buds are noteworthy, because these changes are associated with carcinogenesis
in both rodents and humans (Markey et al., 2001).
Smoking is a known risk factor which is associated with complications of
pregnancy such as low birth-weight and pre-term birth. Recently however, a
meta-analysis of prenatal exposure to passive smoking as well as maternal
active smoking and postnatal exposure to environmental tobacco smoke (ETS)
investigated the potential for enhanced incidence of childhood cancer. It was
shown that there is no strong association between maternal smoking in pregnancy and/or exposure to ETS and childhood cancer. However, several studies
found slightly increased relative risks, generally smaller than 1.5, i.e. the same
order of magnitude associated with some recognised hazards of exposure to
ETS (1.2 to 1.3 for adult lung cancer and cardiovascular diseases). Tumours
most often found associated with maternal smoking in pregnancy or ETS exposure are childhood brain tumours and leukaemia-lymphoma, with relative risks
of up to 2 or greater in selected studies. In a few studies, risks associated with
paternal smoking are higher than the maternal ones. This evidence from human studies coupled with the demonstration of genotoxic effects on the foetus
of exposure to metabolites of tobacco smoke, and the demonstrable presence
of adducts, should lead to strong recommendations aimed at fully protecting
foetuses, new-borns and infants from tobacco smoke (Sasco and Vainio, 1999).
These epidemiological data are supported by the nding that DNA adduct levels
which are formed in human placenta, umbilical cord vein and artery are higher
in tissues from smokers than from non-smokers. It is concluded that the foetus
can metabolise some of the genotoxic compounds found in tobacco smoke to
DNA-binding metabolites. The presence of DNA adducts in foetal tissues is
indicative of potential genomic damage, which may result in an increased risk
of development of serious diseases, like cancer in childhood or later during the
life span of the individual (Hansen et al., 1992).
Conclusions
The complexity of cancer is a challenge for science and society. Evaluating
human cancer risk is a difcult task. Multiple mechanisms of carcinogenesis
cannot be easily classied and it may take many years to develop current
methods for identifying each cellular disorder leading to cancer (Tomatis et
al., 1997).
The majority of carcinogens genotoxic or non-genotoxic are chemicals which
have been introduced into every day life during the last 50 years. Exposure to
127
chemicals and radiation as well is mostly involuntary and, if voluntary, it is the

result of inadequate awareness.
More and more evidence are supporting the hypothesis that the environment
plays a major role in the causation of cancer by involving involuntary exposure
to carcinogens.
Scientic data showing the implication of the environment in cancer should
be considered carefully.
References
Anderson, L.M., Diwan, B.A., Fear, N.T., and Roman, E. (2000) Critical windows of exposure for
children's health: cancer in human epidemiological studies and neoplasms in experimental animal
models, Environ. Health Perspect. 108 Suppl. 3, 573-594.
Bishop, A.J., and Schiestl, R.H. (2001) Homologous recombination as a mechanism of carcinogenesis, Biochim. Biophys. Acta 1471 (3), M109-121.
Burke, L., Segall-Blank, M., Lorenzo, C., Dynesius-Trentham, R., Trentham, D., and Mortola, J.F.
(2001) Altered immune response in adult women exposed to diethylstilbestrol in utero, Am. J.
Obstet. Gynecol. 185 (1), 78-81.
Carson, R. (2002) Silent Spring 40th edition, Boston, Houghton Mifin Company, pp 219-221.
Christoforou, T. (2001) The role of the precautionary principle and food security in the European
Community, presented at the conference 'Le principe de prcaution: aspects de droit international
et de droit communautaire', Institut des Hautes Etudes Internationals, Paris, France.
Doll, R., and Peto, R. (1981) The causes of cancer: quantitative estimates of avoidable risks of cancer
in the United States today, J. Natl. Cancer Inst. 66(6), 1191-308.
Dorner, G., Gotz, F., Rohde, W., Plagemann, A., Lindner, R., Peters, H., and Ghanaati, Z. (2001)
Genetic and epigenetic effects on sexual brain organization mediated by sex hormones,
Neuroendocrinol. Lett. 22(6), 403-9
Eaton, L. (2003) World cancer rates set to double by 2020. BMJ 326(7392), 728.
Hansen, C., Sorensen, L.D., Asmussen, I., and Autrup, H. (1992) Transplacental exposure to tobacco smoke in human-adduct formation in placenta and umbilical cord blood vessels, Teratog.
Carcinog. Mutagen. 12 (2), 51-60.
Hatch, E.E., Herbst, A.L., Hoover, R.N., Noller, K.L., Adam, E., Kaufman, R.H., Palmer, J.R., TitusErnstoff, L., Hyer, M., Hartge, P., and Robboy, S.J. (2001) Incidence of squamous neoplasia of
the cervix and vagina in women exposed prenatally to diethylstilbestrol (United States), Cancer
Causes Control 12 (9), 837-845.
Huyghe, E., Matsuda, T., and Thonneau, P. (2003) Increasing incidence of testicular cancer worldwide: a review. J Urol. 170(1), 5-11.
Jain, R.K. (2002) Tumor angiogenesis and accessibility: role of vascular endothelial growth factor.
Semin. Oncol. 29(6 Suppl 16), 3-9
Klip, H., Verloop, J., van Gool, J.D., Koster, M.E., Burger, C.W., and van Leeuwen, F.E. (2002)
Hypospadias in sons of women exposed to diethylstilbestrol in utero: a cohort study, Lancet 359
(9312), 1102-1107.
Knudson, A.G. (1997) Hereditary predisposition to cancer. Ann. N. Y. Acad. Sci. 833, 58-67
Logan, W.P.D. (1982) Cancer Mortality by Occupation and Social Class 1851-1971, IARC No. 36
Series, Studies on medical and Population Subjects No. 44, Government Statistical Services and
the International Agency for Research on Cancer (WHO), Lyon, France.
Markey, C.M., Luque, E.H., Munoz De Toro, M., Sonnenschein, C., and Soto, A.M. (2001) In utero
128
exposure to bisphenol A alters the development and tissue organization of the mouse mammary
gland, Biol. Reprod. 65 (4), 1215-1223.
Melnick, R.L., Kohn, M.C., and Portier, C.J. (1996) Implications for risk assessment of suggested
non-genotoxic mechanisms of chemical carcinogenesis, Environ. Health Perspect. 104 Suppl.
1, 123-124.
Montesano, R., and Hall, J. (2001) Environmental causes of human cancer, Eur. J. Cancer 37 Suppl.
8, S67-87.
Moysich, K.B., Menezes, R.J., and Michalek, A.M. (2002) Chernobyl-related ionising radiation
exposure and cancer risk: an epidemiological review, Lancet Oncol. (5), 269-79.
Nicolopoulou-Stamati, P., and Pitsos, M.A. (2001) The impact of endocrine disrupters on the female
reproductive system, Hum. Reprod. Update, 7(3), 323-30.
Nicolopoulou-Stamati, P., Hens, L., Howard, C.V., and Van Larebeke, N. (2004) Cancer as an
Environmental Disease, Environmental Science and Technology Library Vol. 20, Kluwer
Academic Publishers ISBN: 1-4020-2019-8
Olshan, A.F., Anderson, L., Roman, E., Fear, N., Wolff, M., Whyatt, R., Vu, V., Diwan, B.A., and
Potischman, N. (2000) Workshop to identify critical windows of exposure for children's health:
cancer work group summary, Environ. Health Perspect. 108 Suppl. 3, 595-597.
Oppenheimer, G.M. (2001) Paradigm lost: race, ethnicity, and the search for a new population taxonomy, Am. J. Public Health 91 (7), 1049-1055.
stergaard, G., and Knudsen, I. (1998) The applicability of the ADI (Acceptable Daily Intake) for
food additives to infants and children, Food Addit. Contam. 15 Suppl., 63-74.
Palmer, J.R., Hatch, E.E., Rosenberg, C.L., Hartge, P., Kaufman, R.H., Titus-Ernstoff, L., Noller,
K.L., Herbst, A.L., Rao, R.S., Troisi, R., Colton, T., and Hoover, R.N. (2002) Risk of breast cancer in women exposed to diethylstilbestrol in utero: preliminary results (United States), Cancer
Causes Control 13 (8), 753-758.
Perera, F., Hemminki, K., Jedrychowski, W., Whyatt, R., Campbell, U., Hsu, Y., Santella, R.,
Albertini, R., and O'Neill, J.P. (2002) In utero DNA damage from environmental pollution is
associated with somatic gene mutation in newborns, Cancer Epidemiol. Biomarkers Prev. 11
(10), 1134-1137.
Pott, P. (1775) Chirurgical Observations Relative to the Cataract, the Polypus of the Nose, the Cancer
of the Scrotum, the Different Kinds of Ruptures and the Mortication of the Toes and Feet,
Hawkes, Clarke, and Collins, London, UK.
Rakitsky, V.N., Koblyakov, V.A., and Turusov, V.S. (2000) Nongenotoxic (epigenetic) carcinogens:
pesticides as an example. A critical review. Teratog. Carcinog. Mutagen 20(4), 229-40
Rodriguez, J.W., Kohan, M.J., King, L.C., and Kirlin, W.G. (2002) Detection of DNA adducts in developing CD4+ CD8+ thymocytes and splenocytes following in utero exposure to benzo[a]pyrene,
Immunopharmacol. Immunotoxicol. 24 (3), 365-381.
Sasco, A.J., and Vainio, H. (1999) From in utero and childhood exposure to parental smoking to
childhood cancer: a possible link and the need for action, Hum. Exp. Toxicol. 18 (4), 192-201.
Schonfelder, G., Flick, B., Mayr, E., Talsness, C., Paul, M., and Chahoud, I. (2002) In utero exposure
to low doses of bisphenol A lead to long-term deleterious effects in the vagina, Neoplasia 4 (2),
98-102
Sonnenschein, C., and Soto, A.M. (2000) Somatic mutation theory of carcinogenesis: why it should
be dropped and replaced, Mol. Carcinog. 29 (4), 205-211.
Swan, S.H. (2000) Intra uterine exposure to diethylstilbestrol: long-term effects in humans, APMIS
108 (12), 793-804.
Tomatis, L. (1993) Cell proliferation and carcinogenesis: a brief history and current view based on an
IARC workshop report, International Agency for Research on Cancer, Environ. Health Perspect.
101 Suppl. 5, 149-151.
Tomatis, L., Huff, J., Hertz-Picciotto, I., Sandler, D.P., Bucher, J., Boffett Axelson, O., Balir, A., Taylor,
129
J., Stayner, L., and Barrett, J.C. (1997) Avoided and avoidable risks of cancer, Carcinogenesis
18 (1), 97-105.
Yang, J., Shin, D., Park, S., Chang, Y., Kim, D., and Ikonomou, M.G. (2002) PCDDs, PCDFs,
and PCBs concentrations in breast milk from two areas in Korea: body burden of mothers and
implications for feeding infants, Chemosphere 46(3), 419-28.
Weir, H.K., Thun, M.J., Hankey, B.F., Ries, L.A., Howe, H.L., Wingo, P.A., Jemal, A., Ward, E.,
Anderson, R.N., and Edwards, B.K. (2003) Annual report to the nation on the status of cancer,
1975-2000, featuring the uses of surveillance data for cancer prevention and control. J. Natl.
Cancer Inst. 95(17), 1276-99.
WHO (2003) Global cancer rates could increase by 50% to 15 million by 2020 (www.who.int)
WHO Library Cataloguing-in-Publication Data (2002) National Cancer Control Programmes:
Policies and Managerial Guidelines - 2nd ed., World Health Organisation.
130
Other Health Hazards of Hormone

Disrupters and how to ght them.
Frank Comhaire, Willem Dhooge and Ahmed Mahmoud,
Center for and Reproductive Endocrinology, University Hospital Ghent,
De Pintelaan 185, B-9000 Ghent, Belgium
E-mail: Frank.Comhaire@ugent.be
Summary
The progressive increase in the incidence of male genital tract anomalies including testicular maldescent and hypospadias, male infertility and testicular
cancer suggests a deleterious effect of environmental factors. The association
of these pathologies is called the testicular dysgenesis syndrome (TDS). Many
studies suggest TDS to be caused by man-made endocrine disruptors, mostly
chemicals initiating estrogen actions (xeno-estrogens) or inhibiting the effects
of endogenous androgens (anti-androgens). A strategy to counteract the deleterious effects of environmental hormone disrupters is presented.
Introduction
Male sexual differentiation and development as well as male fertility and
sexuality are under tight endocrine regulation by the hypothalamo-pituitarytesticular (HPT) axis, and cross talk takes place between the HPT axis and
other endocrine and non-endocrine organs. Any factor disturbing the HPT axis
may result in male gonadal dysfunction. Many exogenous substances including
natural and man-made hormonally active endocrine or hormone disruptors
are proven or suspected to inuence male gonadal function.
A temporal decline of male fertility in humans and wildlife has been documented in many studies (See Adamopoulos). These changes in male fertility
131
are paralleled by an increased incidence of endocrine dependant pathologies in the male including hypospadias, cryptorchidism and testicular cancer,
collectively termed the testicular dysgenesis syndrome (Skakkebaek et al.
2001; 2003). A recent study suggests that Leydig cell dysfunction may also be
a component of this syndrome (Andersson et al. 2004). The incidence of other
hormone related diseases are also on the rise, for example prostate cancer in
the male and breast cancer in the female.
The estrogen hypothesis has been put forward as a possible explanation
for these trends (Sharpe and Skakkebaek 1993). Increased exposure to natural
or synthetic chemicals, mainly a group of man-made substances with estrogen-like action (xeno-estrogens) are held responsible for the increase in these
pathologies. Recent in-vitro studies suggest that some heavy metals also have
an estrogen like action (Choe et al. 2003; Johnson et al. 2003). Acting on the
estrogen receptor is not the only mechanism by which endocrine disruptors exert their effect. Some endocrine disruptors are (anti)-androgenic such as phthalates (Fisher 2004) others cause oxidative stress such as pesticides (Abdollahi
et al. 2004). Also, some halogenated polyaromatic hydrocarbons increase the
bio-availability of endogenous estrogens in target tissues through the inhibition
of the enzymes involved in estrogen inactivation (Kester et al. 2002).
A large body of animal and in-vitro experiments supports the endocrine
disruption hypothesis. Fewer data are available from human studies. These are
summarized below.
Cryptorchidism and hypospadias

An increased risk of hypospadias has been reported in the sons of women
exposed to DES in utero (prevalence ratio 21.3 [95% CI 6.5-70.1]) (Klip et al.
2002; Roelofs et al. 2004). Both studies indicate that hypospadias was strongly
associated with low birth weight, twin or triplet pregnancy, pre-term delivery
and use of assisted reproductive techniques, but the risk was also doubled
when the mother was exposed to chemical hazards (pesticides) during gestation
(Morera et al. 2004).
A signicantly increased risk of cryptorchidism, but not of hypospadias, was
found in sons of Danish women working in gardening (adjusted odds ratio =
1.67; 95% condence interval, 1.14-2.47), but not in sons of men working in
farming or gardening (Weidner et al. 1998). On the other hand, paternal occupational exposure to pesticides has also been reported to increase the risk of
cryptorchidism (OR = 12.79, 95% CI: 2.90 - 56.43) (Wang and Wang 2002).
Also, signicantly higher levels of heptachloroepoxide (HCE), have been
132
detected in fatty tissue of children with cryptorchidism compared to children

undergoing other surgical procedures (Hosie et al. 2000).
The results of a recent nested case-control study on DDT in relation to
hypospadias/cryptorchidism were inconclusive (Longnecker et al. 2002) since
sons from mothers with maternal serum levels of DDE greater than or equal to
85.6 g/L had adjusted odds ratios of 1.3 (95% CI: 0.7, 2.4) for cryptorchidism,
and 1.2 (95% CI: 0.6, 2.4) for hypospadias, consistent with a modest-to-moderate association. However, another study involving 7928 boys born to mothers
who were vegetarian during pregnancy (and therefore had a high intake phytoestrogens and of pesticides present in vegetables), had an adjusted odds ratio
(OR) of 4.99 (95% CI, 2.10-11.88) of giving birth to a boy with hypospadias,
compared with omnivores (North and Golding 2000).
Sex ratio
Recent data suggest a declining male proportion at birth in Europe (Martuzzi et
al. 2001). Decreased male to female ratio at birth has been reported following
high levels of exposure to hexachlorobenzene (Jarrell et al. 2002). Exposure of
men to 2,3,7,8-tetrachlorodibenzo-para-dioxin (TCDD) in the Seveso incident
in Italy (Pesatori et al. 2003) and occupational exposures (Ryan et al. 2002)
were linked to a lowered male/female sex ratio in their offspring. In contrast, an
analysis of the sex ratio over 250 years in Finland does not support the hypothesis that agricultural or industrial environmental estrogens play any signicant
role in the changes in sex ratio (Vartiainen et al. 1999).
Prostate cancer
Animal studies indicate that peri-natal exposure to estrogenic compounds can
result in alterations in the size of the adult prostate and increase the incidence of
prostatitis (Stoker et al. 1999). Chronic inammation of the prostate is considered a predisposing factor for prostate cancer (De Marzo et al. 2003). A metaanalysis indicated that occupational exposure to pesticides is associated with
an increased risk of prostate cancer among farmers (Keller-Byrne et al. 1997).
Although the pesticide applicators from Florida were consistently healthier than
the general population, prostate cancer mortality (SMR 2.38; 95% CI 1.83 to
3.04) was signicantly increased (Fleming et al. 1999). A pilot study indicated
oxychlordane and PCB 180 to be associated with an increased risk of prostate
cancer (Ritchie et al. 2003), but both prostate and testicular cancer mortality
were found not to be related to the estimated environmental exposure to the
133
p,p'-DDE in the USA (Cocco and Benichou 1998). Hispanic farm workers with
relatively high levels of exposure to organochlorine pesticides (lindane and heptachlor), organophosphate pesticides (dichlorvos), fumigants (methyl bromide),
or triazine herbicides (simazine) experienced elevated risk of prostate cancer
compared to workers with lower levels of exposure (Mills and Yang 2003).
Testis cancer
The relationship between fetal estrogen exposure and testicular cancer has
initially been suggested by Sharpe and Skakkebaek (1993) and conrmed by
others (Toppari et al. 1997). Also, high levels of cis-nonachlordane have been
reported in patients with testicular cancer (Hardell et al. 2003). Mothers of
the same patients showed signicantly increased concentrations of the sum of
PCBs, HCB, trans- and cis-nonachlordane, the sum of chlordanes, and the sum
of PCBs yielded an OR of 3.8 (95% CI 1.4-10). Odds ratios were also increased
for HCB (OR = 4.4; 95% CI, 1.7-12), for trans-nonachlordane (OR = 4.1; 95%
CI, 1.5-11); and for cis-nonachlordane (OR = 3.1; 95% CI, 1.2-7.8) (Hardell
et al. 2003).
Fighting health hazards caused by hormone disrupters

The gure depicts the trajectory taken by environmental toxins from the source
of pollution to human disease. There are several possible sites of interaction
along this trajectory. Clearly and mainly the sources of pollution must be
phased-out. This implies an adaptation of certain manufacturing processes, agriculture and animal husbandry. The synthetic estrogen ethinyl-estradiol should
be banned (e.g. from oral contraceptives), since this steroid is persistent in the
environment and is effectively absorbed orally (Rudder et al. 2004).
Careful monitoring of external exposure is mandatory using a combination of chemical analysis and biological tests on e.g. surface waters, foodstuff,
drinking water, air, exhausts, etc. Currently used biological assays for estrogens commonly use living cells in vitro, such as human breast cancer cells and
genetically modied yeast cells. These assays are, however, highly sensitive
to toxic inuences, and the signal that is generated and measured represents
the difference between the cell activation by the estrogenic substance minus
the cell inhibition by toxic factors. The nal outcome of these tests may
be false-negative particularly when highly polluted environmental samples
are analyzed. The estrogen receptor binding competitive assay measures the
capacity of a estrogenic substances in a particular environmental sample to
134
compete with natural estradiol-17 for binding to the human estrogen receptor in vitro (Dhooge et al. 2001). This assay does not use living cells and
generates highly reliable and reproducible results, also in toxic environmental
samples.
Sources, Human activity:
Industry,
Agriculture/farming
Transport
Houshold
Environmental
Contamination
External
Exposure
Policy
Risk Analysis
Environmental Analysis
Identification
Environmental
Screening
Chemical analysis
Biological analysis
Biomarkers
of Exposure
Disease
Internal
Exposure
Biomarkers
of Effect
Disturbed Physiological
Processes in the Body
Figure: Human activities cause environmental contamination that results in internal exposure through food and water intake and air. This
can disturb normal (human) physiology resulting in disease. Screening
includes analysis of environmental samples and identication of substances, together with assessment of internal exposure using chemical
and biological analysis and markers of effect. Estimated risk analysis is
sustained by epidemiological data to yield recommendations for environmental policy.
Once the estrogenic activity has been detected, identication of the causal
agents must take place using a combination of biological and chemical tests.
Next it is possible to identify the source of the contamination in order to eradicate it. Simultaneously, assessment of the internal exposure should take
place, whereby blood and urine samples of the population are put through
similar biological and chemical analytical tests. Furthermore, blood samples
135
should be analyzed for markers of organ malfunction or failure, as well as

tumor markers.
Close monitoring does, however, not prevent exposure. Therefore, measures
should be taken to decrease the absorption of hormone disrupting agents after
oral ingestion, whereby the regular intake of probiotics may be helpful. These
are consortia of bacteria (commonly different strains of lactococcus) that can
absorb and metabolize xeno-biotics in the intestinal tract, thus reducing their
uptake in the bloodstream.
In a nal step, inhibiting binding of estrogenic substances to the estrogen
receptor(s) can counteract the deleterious peripheral effects of estrogens and
estrogen-like substances. The latter is attained by means of pharmaceutical
(e.g. Tamoxifen) or phyto-therapeutical products.
References
Abdollahi M, Ranjbar A, Shadnia S, Nikfar S, Rezaiee A (2004) Pesticides and oxidative stress: a
review. Med Sci Monit 10:RA141-147
Andersson AM, Jorgensen N, Frydelund-Larsen L, Rajpert-De Meyts E, Skakkebaek NE (2004)
Impaired Leydig Cell Function in Infertile Men: A Study of 357 Idiopathic Infertile Men and 318
Proven Fertile Controls. J Clin Endocrinol Metab 89:3161-3167
Choe SY, Kim SJ, Kim HG, Lee JH, Choi Y, Lee H, Kim Y (2003) Evaluation of estrogenicity of
major heavy metals. Sci Total Environ 312:15-21
Cocco P, Benichou J (1998) Mortality from cancer of the male reproductive tract and environmental exposure to the anti-androgen p,p'-dichlorodiphenyldichloroethylene in the United States.
Oncology 55:334-339
De Marzo AM, Meeker AK, Zha S, Luo J, Nakayama M, Platz EA, Isaacs WB, Nelson WG (2003)
Human prostate cancer precursors and pathobiology. Urology 62:55-62
Dhooge W, Eertmans F, Comhaire F (2001) Estrogen receptor based in vitro assays for the evaluation
of endocrine disrupters. Folia Histochem Cytobiol Sppl. 2: 44-45.
Fisher JS (2004) Environmental anti-androgens and male reproductive health: focus on phthalates
and testicular dysgenesis syndrome. Reproduction 127:305-315
Fleming LE, Bean JA, Rudolph M, Hamilton K (1999) Mortality in a cohort of licensed pesticide
applicators in Florida. Occup Environ Med 56:14-21
Hardell L, van Bavel B, Lindstrom G, Carlberg M, Dreifaldt AC, Wijkstrom H, Starkhammar H,
Eriksson M, Hallquist A, Kolmert T (2003) Increased concentrations of polychlorinated biphenyls, hexachlorobenzene, and chlordanes in mothers of men with testicular cancer. Environ
Health Perspect 111:930-93
Hosie S, Loff S, Witt K, Niessen K, Waag KL (2000) Is there a correlation between organochlorine
compounds and undescended testes? Eur J Pediatr Surg 10:304-309
Jarrell JF, Gocmen A, Akyol D, Brant R (2002) Hexachlorobenzene exposure and the proportion of
male births in Turkey 1935-1990. Reprod Toxicol 16:65-70
Johnson MD, Kenney N, Stoica A, Hilakivi-Clarke L, Singh B, Chepko G, Clarke R, Sholler PF, Lirio
AA, Foss C, Reiter R, Trock B, Paik S, Martin MB (2003) Cadmium mimics the in vivo effects
of estrogen in the uterus and mammary gland. Nat Med 9:1081-1084
Keller-Byrne JE, Khuder SA, Schaub EA (1997) Meta-analyses of prostate cancer and farming. Am
J Ind Med 31:580-586
136
Kester MH, Bulduk S, van Toor H, Tibboel D, Meinl W, Glatt H, Falany CN, Coughtrie MW, Schuur
AG, Brouwer A, Visser TJ (2002) Potent inhibition of estrogen sulfotransferase by hydroxylated metabolites of polyhalogenated aromatic hydrocarbons reveals alternative mechanism for
estrogenic activity of endocrine disrupters. J Clin Endocrinol Metab 87:1142-1150
Klip H, Verloop J, van Gool JD, Koster ME, Burger CW, van Leeuwen FE (2002) Hypospadias in
sons of women exposed to diethylstilbestrol in utero: a cohort study. Lancet 359:1102-1107
Longnecker MP, Klebanoff MA, Brock JW, Zhou H, Gray KA, Needham LL, Wilcox AJ (2002)
Maternal serum level of 1,1-dichloro-2,2-bis(p-chlorophenyl)ethylene and risk of cryptorchidism, hypospadias, and polythelia among male offspring. Am J Epidemiol 155:313-322
Martuzzi M, Di Tanno ND, Bertollini R (2001) Declining trends of male proportion at birth in
Europe. Arch Environ Health 56:358-364
Mills PK, Yang R (2003) Prostate cancer risk in California farm workers. J Occup Environ Med
45:249-258
Morera AM, Asensio M. J., Chossegros L., Chauvin M. A., Valmalle A. F., Mouriquand P. (2004) A
survey of risk factors in hypospadiacs compared with controls. BJU International 93:55-55
North K, Golding J (2000) A maternal vegetarian diet in pregnancy is associated with hypospadias. The ALSPAC Study Team. Avon Longitudinal Study of Pregnancy and Childhood. BJU
International 85:107-113
Pesatori AC, Consonni D, Bachetti S, Zocchetti C, Bonzini M, Baccarelli A, Bertazzi PA (2003)
Short- and long-term morbidity and mortality in the population exposed to dioxin after the
"Seveso accident". Ind Health 41:127-138
Ritchie JM, Vial SL, Fuortes LJ, Guo H, Reedy VE, Smith EM (2003) Organochlorines and risk of
prostate cancer. J Occup Environ Med 45:692-702
Roelofs L, Brouwers M, Gier RDE, Feitz W, Kiemeney B, Roeleveld N (2004) Diethylstilbestrol,
risk factors and hypospadias development. BJU International 93:55-55
RudderJ, Wiele TV, Dhooge W, Comhaire F,Verstraete W (2004) Advanced water treatment with
manganese oxide for the removal of 17 alpha-ethynylestradiol (EE2). Water research 38:184192.
Ryan JJ, Amirova Z, Carrier G (2002) Sex ratios of children of Russian pesticide producers exposed
to dioxin. Environ Health Perspect 110:A699-A701
Sharpe RM, Skakkebaek NE (1993) Are oestrogens involved in falling sperm counts and disorders
of the male reproductive tract? Lancet 341: 1392-1395
Skakkebaek NE, Holm M, Hoei-Hansen C, Jorgensen N, Rajpert-De Meyts E (2003) Association
between testicular dysgenesis syndrome (TDS) and testicular neoplasia: evidence from 20 adult
patients with signs of maldevelopment of the testis. APMIS 111:1-9
Skakkebaek NE, Rajpert-De Meyts E, Main KM (2001) Testicular dysgenesis syndrome: an increasingly common developmental disorder with environmental aspects. Hum Reprod 16:972-978
Stoker TE, Robinette CL, Cooper RL (1999) Perinatal exposure to estrogenic compounds and the
subsequent effects on the prostate of the adult rat: evaluation of inammation in the ventral and
lateral lobes. Reprod Toxicol 13:463-472
Toppari J, Larsen JC, Christiansen P, Giwercman A, Grandjean P, Guillette LJ Jr, Jegou B, Jensen
TK, Jouannet P, Keiding N, Leffers H, McLachlan JA, Meyer O, Muller J, Rajpert-De Meyts E,
Scheike T, Sharpe R, Sumpter J, Skakkebaek NE (1997) Male reprodcutive health and environmental xenoestrogens. Environ Health Perspect 104 suppl. 4: 741-803.
Vartiainen T, Kartovaara L, Tuomisto J (1999) Environmental chemicals and changes in sex ratio:
analysis over 250 years in nland. Environ Health Perspect 107:813-815
Wang J, Wang B (2002) Study on risk factors of cryptorchidism. Zhonghua Liu Xing Bing Xue Za
Zhi 23:190-19w3
Weidner IS, Moller H, Jensen TK, Skakkebaek NE (1998) Cryptorchidism and hypospadias in sons
of gardeners and farmers. Environ Health Perspect 106:793-796
137
Impact of the environment on

reproductive health:
a bitter lesson from Athens
Adamopoulos D.A. & Koukkou E
Department of Endocrinology, Diabetes & Metabolism,
Elena Venizelou Hospital, 2 Venizelou Square, Athens 11521 Greece
e-mail: hel-soc-andro@ath.forthnet.gr
Introduction
Over the last 20-30 years a wealth of information has been accumulated indicating that several parametres of reproductive health have been seriously
compromised in some industrialized societies and this deterioration has been
attributed to a number of factors, the main being the changes observed in the
environmental conditions prevailing in each particular area. Moreover, important economic, social and cultural changes have drastically modied existing
patterns for the expression of reproductive activity in these societies, the net
outcome being a signicant decline of procreation as seen by the gradual dropping of birthrates some times well below the replacement level. In this country,
a number of dramatic changes have occurred during the last few decades affecting enormously all parameters of everyday life and activity. These changes
have been particularly evident in the Attica basin which houses approximately
40% of the countrys total population. Therefore, one would expect that certain
sensitive parameters of reproductive health of men living in the capital city and
its surroundings may have felt the impact of such changes.
138
Clinical studies
In the course of our work in the eld of the Endocrinology of Reproduction
over more than a 30-year long period in the same Institution, certain aspects of
reproductive health have been investigated in a random fashion in large cohorts
of people living in the Greater Athens area.
The main ndings of these studies are as follows:
Firstly, a declining trend of mean seminal volume and a decrease in total
sperm count was observed over the years of observation (P<0.05) while over
the same period a signicantly rising trend has been observed for certain air
pollution indices as NO, NO2 and SO2 (P<0.01 for each index). Obviously, any
causative relationship between the biological and the environmental changes
observed remains a matter of conjecture at present (Adamopoulos et al, 1996).
Secondly, during the years 1969 to 2003, a total of 221.799 live baby deliveries was recorded in the hospitals archives. During that period, the absolute number of male newborns showed a gradual reduction, but of greater
importance was the declining trend in the male to female newborns ratio noted.
This ratio, universally found as greater than one, showed a markedly declining tendency from 1.09 in the initial to 1.04 in the nal year (0.95% drop,
p<0.01). Therefore, it appears that a marked decrease has occurred not only
in the absolute but also in the relative number of newborn males as compared
to female babies born in that 35-year period and in this particular population (
Savoglou et al . 2001)
Moreover, when the sex specic differences in the delivery prole, the
outcome of delivery, the anthropometric characteristics and the parametres
related to perinatal risk factors were assessed (in the total number of newborn
babies for one year (1998)) it was found that although the sex prematurity
ratio was similar to that of absolute numbers ratio (male to female), as were
other parameters such as the mode of delivery, the perinatal mortality, etc., in
the two sexes, perinatal care was necessary for 538 out of the 2554 newborn
males, the corresponding gure being 472 for the 2415 newborn females and
the mortality during intensive care therapy was 4.3% (n=23) for the male and
3.2% (n=15) for the female newborns, indicating that newborn boys are more
fragile than newborn girls (Savoglou et al, 2002).
Regarding women, the mean age at natural menopause appears to be relatively stable in Western Societies, at an average age of 50-51 years. On the
other hand, spontaneous permanent cessation of menstruation with hypergonadotropism before the age of 40 years (WHO, 1996), has been estimated to
approximate 1% with small, although signicant variations related to race or
139
ethnicity. However, this may be an underestimation if the hypothesis that up to

10% of the women of general population who became postmenopausal by the
age of 45 may have experienced an accelerated decline of their fertility before
the age of 32. In this country there is no recent and detailed study on this topic
except an early publication on the mean age at menopause for Athenians, a
quarter of a century ago Since as mentioned above, a number of important
changes in dietary, life-style and health considerations took place in our society
during that period, it was essential that a fresh and more detailed look into the
age of menopause and its different subtypes should be undertaken. From the
results of our study, it appears that for a considerable number of Greek women
a relatively young age at menopause has been recorded, and this is considerably higher than the 1.0% observed in American women . In fact, the total of
spontaneous (7.1%) and induced (3.4%) premature menopause cases has never
being encountered in any other study and its magnitude reaches the limits of an
epidemic for this population (Adamopoulos et al, 2002).
The implications of these ndings are twofold: Firstly, the reproductive
capacity in a large part of this female population was compromised very early
in life with most of those women being unaware and totally unprepared for an
early change in life. Secondly, this state of severe oestrogen depletion dened a
relatively large group of women who not only were deprived of their ability to
procreate but also had the need for hormone replacement therapy at a relatively
young age and for prolonged period of time.
Finally, a gross insufciency of public awareness on reproductive health
issues has been demonstrated in ageing Athenian men and this nding became
more relevant since, a better overall physical, mental, sexual and biochemical
condition was observed in properly informed men (Adamopoulos et al, 1999).
Therefore, the need for a proper education of the general public on reproductive
health issues becomes a social necessity and a task for health professionals
(Nikopoulou & Adamopoulos, 2001).
Conclusions
From these observations it appears that a number of problems related to the reproductive health of contemporary Athenians has gradually emerged in recent
years and while their cause has not been clearly established at present, their
impact is well documented and felt. Whether, multiple and different factors or
the common overall adverse environmental milieu or both were related to any
or all of the relevant aspects of severed reproductive health is a matter of conjecture at present. However, it is clear, that the overall pattern of reproductive
140
health problems in this geographic area is similar to that observed in heavily

compromised environments elsewhere on the planet.
References
Adamopoulos, D.A., Pappa, A., Nicopoulou, S., Andreou, E., Karamertzanis, M., Michopoulos, J.,
Deligianni, V., and Simou, M. (1996) Seminal volume and total sperm number trends in men
attending subfertility clinics in the Greater Athens area during the period 1977-1993, Hum.
Reprod., 11, 1936-1941.
Adamopoulos, D.A., Nicopoulou, S.C., Pangalos, G., and Xenoudakis, N. (1999) Attitudes of aging
Athenians to andropenia and its consequences and to potential hormone substitution therapy,
Aging Male, 2, 44-52.
Adamopoulos, D.A., Karamertzanis, M., Thomopoulos, A., Pappa, A., Koukkou, E., and Nicopoulou,
S. (2002) Age at menopause and prevalence of its different types in contemporary Greek women,
Menopause, 9, 443-448
Nicopoulou, S.C., and Adamopoulos, D.A. (2001) Gonadal decline-related manifestations in aging
hospital doctors, The Aging Male, 4, 8-13.
Savoglou, K., Vasilaki, K., Strouthou, M., Lempidaki, Th., Papantoniou, A., Bantouna, P., Liossis,
G., and Sofatzis, J. (2001) Is sex a risk factor for the newborn? Proc. 11th National Congress of
Perinatal Medicine, 3-4 March, 2001, Athens, abstract no 070A.
Savoglou, K., Vasilaki, K., Liossis, G., Sofatzis, J., and Papageorgiou, A. (2002) Is a male newborn
more susceptible to perinatal risk factors? The Journal of Maternal & Neonatal Medicine, 11,
Suppl. 1, abstract no 133.
WHO (1996) WHO Scientic Group Research on the menopause I the 1990s. A report of the WHO
Scientic Group. Geneva: World Health Organization, 860:1-79
141
Ovarian stimulation
New trends in IVF.
Is there any evidence?
J. Serna1, MD, PhD and A. Pellicer2, MD, PhD
IVI Madrid; 2IVI Valencia, Universitat de Valncia
Is there any evidence that support the trend towards obtaining a great number
of embryos, in one IVF cycle, to achieve an ongoing pregnancy?
Evidence accumulated demonstrates that overall pregnancy rates, per IVF
attempt, increase signicantly when more than one embryo is transferred. The
undesirable side-effect of this so-called is the unbearable high multiple pregnancy rate (1;2). High order pregnancies cause higher mortality and morbidity
to the conceptus, as well as to the mother than singletons(3).
In Sweden, a reduction in the number of embryos routinely transferred was
done, from three to two. The pregnancy and live birth rates remained unchanged
but, whilst multiple pregnancy rates did not change, triplets nearly vanished
(4). Nowadays, due to improvements in clinical and embryo culture techniques
that led to an increment on the implantation rate, there is a trend towards looking for elective couples for single embryo transfer (1;5). Thurin et al., reported
that single embryo transfer plus frozen-thaw single embryo transfer, in selected
patients, yields the same success as transfer of two embryos in a single cycle
(3). Although great majority of couples will need a two-embryo transfer, recent
research focuses on selecting the best embryo to transfer.
As less oocytes are needed, milder ovarian stimulation protocols develop.
There are novel protocols to induce mild ovarian hyperstimulation, with gonadotropins started on the fth day of ovarian cycle instead of day 3. This new
protocol seems to require fewer amounts of gonadotropin per cycle, less days
of stimulation, less oocytes retrieved but more embryo transfer per oocyte
retrieval and higher percentage of good quality embryos per cycle (6). Milder
stimulation may result in selection of good quality oocytes, which may result
142
in better quality embryos. Mild stimulation may select oocytes more likely to
result in pregnancy.
Mild stimulation has the advantage of low drop-out rates in an IVF programme and the aim is to achieve a live birth through a single embryo transfer.
Increasing advances in laboratory procedures and oocyte quality determination tends towards single embryo transfer, but prospective case-control studies,
if feasible, are needed to demonstrate its cost-effectiveness benets.
Is there any evidence to use antagonist/agonist in selected cases?
Several prospective randomize trials using unselected infertile women
shows no signicant differences in the results (7). The antagonist lowers the
LH secretion in the pituitary launching the hypothesis that will not be the
best for oocyte maturation. In clinical practice, a prospective randomize trial
demonstrated, that in patients where a profound LH suppression were done,
better result in ongoing pregnancy were achieved (8;9).
In poor responders agonist does not seem to offer any benet (10). Although,
it seems that the antagonist could be of benet in some group of patients, more
studies are required.
Is there any evidence about the patients to use FSH and/or LH and/or
hMG?
In 2002, the WHO recommended further clinical studies about the use of
LH in ovarian stimulation to establish the criteria for clinical LH uses (11).
Nevertheless, the controversy persists, as there are publication that favour the
use of LH (12;13), others neutral, and others that advice against the use of it
(14).
In unselected patients, the use of LH is not essential (15). Todays trend is
to use it in selected clinical situations as: the population of patients for which
LH could be benecial (all patients, poor responders, and/or normal responders
with low levels of basal LH), the stimulation protocol (type and regimen of
GnRH agonist or GnRH antagonist) and the preparation of LH (recombinant,
hMG or small amount of hCG). Ferrareti el al. states that in hyporesponsive
patients (low response with normal amount of FSH but normal response with
increasing the doses or the length) the addition of recLH improves the outcome,
in terms of implantation and live birth rates per cycle. They use LH as an
emergency drug, in patients that plateaus during ovarian stimulation.
To the best of our knowledge, no studies have compared the effectiveness
of LH contained in hMG preparations with recombinant LH. It has to be noted
that hMG contains hCG that contributes to the overall activity in these preparations (16); however, using low-dose hCG as LH activity does not adversely
143
affect follicular maturation (17). At this stage, we can only speculate that the
difference between the two drugs can produce different biological effects in
specic conditions.
Is there any evidence about using GnRHa for ovulation induction rather
than hCG?
hCG for ovulation induction acts through its LH-like effect but have the
disadvantage of a longer half-life and greater bioactivity. These entail a higher
incidence of major complications such as the ovarian hyperstimulation syndrome (OHSS).
GnRHa can be used for ovulation induction due to its are-up effect on
the pituitary, releasing LH and FSH in a pattern very similar to that seen with
the physiological midcycle surge. GnRHa also generates an intense luteolysis,
probably due to the further blockade of the pituitary LH release. This luteolysis
is so strong that not even pregnancy-associated hCG could support the corpora
lutea.
The absence of a long-acting FSH-like effect and the strong luteolysis
caused by GnRHa induction of ovulation seems to prevent the moderate to
severe OHSS (18).
There is large evidence that support the use of GnRHa for ovulation induction when a risk of OHSS is suspected, but there are no prospective randomized
studies comparing GnRHa vs. hCG regarding OHSS. GnRHa for ovulation
induction has a clinical limitation: when there are low LH left in the pituitary
such as the GnRHa-based ovarian stimulation protocols.
Moreover, clinical studies are to be done focusing on the role of the recLH
in triggering ovulation.
Bibliography
1.
2.
3.
4.
5.
Assisted reproductive technology in the United States: 2000 results generated from the
American Society for Reproductive Medicine/Society for Assisted Reproductive Technology
Registry. Fertil Steril 2004; 81(5):1207-1220.
Nyboe-Andersen A, Gianaroli L, Nygren KG. Assisted reproductive technology in Europe,
2000. Results generated from European registers by ESHRE. Hum Reprod 2004; 19(3):490503.
Thurin A, Hausken J, Hillensjo T, Jablonowska B, Pinborg A, Strandell A et al. Elective singleembryo transfer versus double-embryo transfer in in vitro fertilization. N Engl J Med 2004;
351(23):2392-2402.
The National Board of Health and Welfare. Ofcial statistics of Sweden. 2004.
Strandell A, Bergh C, Lundin K. Selection of patients suitable for one-embryo transfer may
reduce the rate of multiple births by half without impairment of overall birth rates. Hum
Reprod 2000; 15(12):2520-2525.
144
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.

Hohmann FP, Macklon NS, Fauser BC. A randomized comparison of two ovarian stimulation
protocols with gonadotropin-releasing hormone (GnRH) antagonist cotreatment for in vitro
fertilization commencing recombinant follicle-stimulating hormone on cycle day 2 or 5 with
the standard long GnRH agonist protocol. J Clin Endocrinol Metab 2003; 88(1):166-173.
Loutradis D, Stefanidis K, Drakakis P, Milingos S, Antsaklis A, Michalas S. A modied gonadotropin-releasing hormone (GnRH) antagonist protocol failed to increase clinical pregnancy
rates in comparison with the long GnRH protocol. Fertil Steril 2004; 82(5):1446-1448.
Kolibianakis EM, Zikopoulos K, Schiettecatte J, Smitz J, Tournaye H, Camus M et al. Profound
LH suppression after GnRH antagonist administration is associated with a signicantly higher
ongoing pregnancy rate in IVF. Hum Reprod 2004; 19(11):2490-2496.
Cabrera RA, Stadtmauer L, Mayer JF, Gibbons WE, Oehninger S. Follicular phase serum
levels of luteinizing hormone do not inuence delivery rates in in vitro fertilization cycles
down-regulated with a gonadotropin-releasing hormone agonist and stimulated with recombinant follicle-stimulating hormone. Fertil Steril 2005; 83(1):42-48.
Cheung LP, Lam PM, Lok IH, Chiu TT, Yeung SY, Tjer CC et al. GnRH antagonist versus
long GnRH agonist protocol in poor responders undergoing IVF: a randomized controlled trial.
Hum Reprod 2005; 20(3):616-621.
Hugues JN. Ovarian stimulation for assisted reproductive technologies. Vayena E, Rowe PJ,
Grifn PD, editors. 102-123. 2002. Geneva, Switzerland. Current practices and controversies
in assisted reproduction. Report of a WHO meeting. Marketing and dissemination.
Kolibianakis EM, Albano C, Camus M, Tournaye H, Van Steirteghem AC, Devroey P.
Relationship between LH and oestradiol in IVF cycles before GnRH antagonist initiation.
Reprod Biomed Online 2003; 7(2):190-193.
Ferraretti AP, Gianaroli L, Magli MC, D'angelo A, Farfalli V, Montanaro N. Exogenous luteinizing hormone in controlled ovarian hyperstimulation for assisted reproduction techniques.
Fertil Steril 2004; 82(6):1521-1526.
Perin PM, Maluf M, Czeresnia CE, Sousa PD. The effect of recombinant human luteinizing
hormone on oocyte/embryo quality and treatment outcome in down-regulated women undergoing in vitro fertilization. Fertility and Sterility 80, S76-S77. 2003.
Balasch J, Vidal E, Penarrubia J, Casamitjana R, Carmona F, Creus M et al. Suppression of
LH during ovarian stimulation: analysing threshold values and effects on ovarian response and
the outcome of assisted reproduction in down-regulated women stimulated with recombinant
FSH. Hum Reprod 2001; 16(8):1636-1643.
Filicori M, Cognigni GE, Pocognoli P, Tabarelli C, Spettoli D, Taraborrelli S et al. Modulation
of folliculogenesis and steroidogenesis in women by graded menotrophin administration. Hum
Reprod 2002; 17(8):2009-2015.
Filicori M, Cognigni GE, Samara A, Melappioni S, Perri T, Cantelli B et al. The use of LH
activity to drive folliculogenesis: exploring uncharted territories in ovulation induction. Hum
Reprod Update 2002; 8(6):543-557.
Kol S. Luteolysis induced by a gonadotropin-releasing hormone agonist is the key to prevention of ovarian hyperstimulation syndrome. Fertil Steril 2004; 81(1):1-5.
145
Induction of Monoovulatory Cycles for

assisted Reproductive technology (ART)
P. G. Crosignani, E. Somigliana, M. Colombo, A. Riccaboni,
G. Ragni
Iatrogenic twinning
Multiple pregnancies after ovarian stimulation are currently the cause of the
majority of iatrogenic twinning (1,2). So far there seems to be no way to reduce
the rate of multiple births after ovarian stimulation without also reducing the
rate of conception (2,3).
The adverse medical, economic and social consequences of bearing triplets
are widely recognized. Moreover, even twins face greater risks of disability
and death than singletons (4,5). The considerable human and nancial costs of
multiple births thus call for a re-evaluation of the protocols of ovarian stimulation.
Intrauterine insemination (IUI)

For couples with male or unexplained infertility, intrauterine insemination
(IUI) is more effective than timed intercourse and cervical insemination (6). In
women with idiopathic infertility IUI in stimulated cycles further improves the
pregnancy rate compared with natural cycle IUI (Table 1).
The following have a negative impact on IUI outcome:
duration of infertility
age of the female partner
146
history of pelvic inammation

presence of severe male factor(s).
Table 1:
Pregnancies after intrauterine insemination: stimulated versus natural cycles (7).

IUI in COH-cycles
IUI in natural cycles
(pregnancies/cycles)
(pregnancies/cycles)
97/1007
52/1069
2.0 (1.4-2.8)
40/349
28/337
1.4 (0.86-2.4)
O.R. (95% C.I.)
Unexplained infertility
(6 studies 1990-2000)
Male subfertility
(5 studies 1990-2000)
As already mentioned, the most important risk associated with IUI after ovarian
stimulation is the incidence of multiple gestation that can be as high as 29% (8).
This is why in the presence of more than three follicles it has been suggested
the procedure should be stopped or the cycle converted to IVF, but despite this
risk the method is still widely used.
Milder ovarian stimulation methods have been recently introduced in order
to reduce the risk of iatrogenic twin pregnancies. Simply lowering the follicle
stimulating hormone (FSH) dose can give an acceptable rate of pregnancy per
cycle (10%) with a lower rate of twins and triplet (Table 2).
Table 2:
Clinical pregnancies in 510 controlled ovarian hyperstimulation* and intrauterine insemination cycles (9).
Outcome
No. (%)
Clinical pregnancies
46 (9% per cycle)
Births
36 (7% per cycle)
Twins (+ 1 triplet)
5 (14% of deliveries)
*FSH 112 IU (day 2-6), then small increments
A new method of milder ovarian stimulation

A new class of drugs, the GnRH antagonists, are now commercially available
and are being investigated. Considering that a premature LH surge, which may
interfere with the timing of IUI, is reported frequently in stimulated cycles (10),
these drugs may possibly have a useful role in this specic context.
147
A prospective, randomized trial has been organized to identify a regimen

of induced oligo-ovulation associated with intrauterine insemination that may
achieve both a low risk of multiple births and an acceptable pregnancy rate
(11). Sixty-six couples with unexplained infertility or moderate male subfertility were enrolled. Starting on day 3 of the cycle, 32 patients were randomized
to receive 50 IU recombinant FSH per day and 34 received this treatment on
alternate days. All women received a GnRH antagonist starting on the day
when a leading follicle >14 mm was visualized, until human chorionic gonadotropin (hCG) was administered. Insemination was done 34 hours after
hCG injection. The clinical pregnancy rate per initiated cycle was the main
outcome measurement.
The combined daily use of low-dose recombinant FSH and a GnRH antagonist induced the growth of 1-2 follicles in the majority of cycles. Despite
the presence of only one or two follicles IUI produced an unexpectedly high
number of clinical pregnancies (11 in 32 cycles).
As unexplained infertility is the best diagnosis for IUI and was the indication for treatment of the majority of patients in this study, this could be the
reason for the high rate of pregnancies. Nevertheless, taking into account that
in idiopathic infertility after multifollicular ovarian stimulation the expected
rate of pregnancy after IUI is 10%, and considering the small number of mature follicles (1-2), an improvement in the quality of oocytes could be another
reason for the success rate.
A better quality of follicles stimulated by low-dose FSH and controlled
by the antagonist is also suggested by a recent study in previously poorly
responsive ICSI patients (12) observed during a second spontaneous ICSI
cycle. These women were treated when the follicle reached a diameter of 14-15
mm with low-dose FSH and a GnRH antagonist (for a few days) and the new
method of pharmacological treatment normalized the ovarian response, leading
to a good normo-responder success rate.
Similarly, the use of a GnRH antagonist improved the IVF-ICSI results
in patients who had already undergone ovarian hyperstimulation in previous
cycles (13).
If the ongoing IUI multicenter trial conrms the preliminary ndings the
rigid rule more oocytes more pregnancy will be broken and it will be possible to achieve good clinical results without the unacceptable risk of multiple
pregnancies.
148
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Dickey R.P. A year of inaction on high-order multiple pregnancies due to ovulation induction.
Fertil. Steril., 79, 14-16, 2003.
Jones H.W. Multiple births: how are we doing? Fertil. Steril., 79, 17-21, 2003.
Collins J.A. Reproductive technology the price of progress. N. Engl. J. Med., 331, 270-271,
1994.
Bergh T., Ericson A., Hillensjo T., Nygren K.G., Wennerhalm U.B. Deliveries and children
born after in-vitro fertilisation in Sweden 1982-95: a retrospective cohort study. Lancet, 354,
1579-1585, 1999.
Cain J.M. Ethical guidelines in the prevention of iatrogenic multiple pregnancy. Int. J.
Gynaecol. Obstet., 71, 293-294, 2000.
Farquhar C., Prentice A., Barlow D., et al. Menstrual disorders and subfertility group. The
Cochrane Library, Issue 3. Chichester, UK: Wiley, 2004.
Cohlen J.C., Te Velde E.R. Mild ovarian hyperstimulation for intrauterine insemination. In:
Ovulation Induction, Tarlatzis B. ed., Elsevier, pp.55-63, 2002.
Gleicher N., Oleske D.M., Tur-Kaspa I., Vidali A., Karande V. Reducing the risk of high-order
multiple pregnancy after ovarian stimulation with gonadotrophins. N. Engl. J. Med., 343: 2-7,
2000.
Healy D., Rombauts L., Vollenhoven B., Kovaks G., Burmeister L. One triplet pregnancy in
510 controlled ovarian hyperstimulation and intrauterine insemination cycles. Fertil. Steril.,
79: 1449-1451, 2003.
Cohlen, B.J. Intrauterine insemination and controlled ovarian hyperstimulation. In Templeton,
A.A., Cooke, I., OBrien, P.M.S. (eds) Evidence-based Fertility Treatment, RCOG Press,
London, pp. 205-216, 1998.
Ragni G., Alagna F., Brigante C., Riccaboni A., Colombo M., Somigliana E., Crosignani P.G.
GnRH antagonists and mild ovarian stimulation for intrauterine insemination: a randomized
study comparing different gonadotrophin dosages. Hum. Reprod., 19, 54-58, 2004.
Ubaldi F., Rienzi L., Ferrero S., Baroni E., Iacobelli M., Sapienza F., Greco E. Use of GnRH
antagonists with minimal stimulation in natural ICSI cycles in poor-responder patients. RBM
Online, in press.
Somigliana E., Ragni G., Riccaboni A., Engl B., Brigante C., Crosignani P.G. Is a protocol
with GnRH antagonists more suitable than a long protocol in patients at high risk of OHSS? A
preliminary study. 60 ASRM Conference, Philadelphia, Pennsylvania, October 16-20, 2004
149
Neuroendocrine aspects of amenorrhea

related to stress
Alessandro D. Genazzani, Chiara Lanzoni, Claudia Strucchi,
Hilda Mehemeti, Federica Ricchieri, Marlyse Ngo Mbusnum,
Ombretta Gamba
Department of Obstetrics and Gynecology,
University of Modena and Reggio Emilia, Italy
email: algen@unimo.it
Introduction
In clinical practice, hypothalamic amenorrhea is mainly associated with
metabolic, physical or psychological stress. In fact, it occurs after severe dieting, heavy training or intense emotional events, all situations that can induce
amenorrhea with or without body weight loss (2). A specic correlation exists
between loss of weight and amenorrhea (1, 2) and when the loss of weight is
below a critical point and the ratio between fat and muscolar masses is reduced,
the loss of menstrual cyclicity is typical. In fact, after dieting as well as during
intense training of dancers or runners amenorrhea is a frequent symptom (3).
The low ratio may be due both to high energy consumption and to reduced food
intake. Psychological stressors as emotional, familiar or working problems
may have an impact on food intake. Reduced food intake can induce amenorrhea through specic metabolic signals which amplify the stress response to
fasting (4). Associated to a psychological stressor recorded as heavy negative
event, often many patients show affective disorders (neuroticism, somatization,
anxiety) and these mix of situations lead to the disruption of the hypothalamuspituitary activity controlling the ovarian function (5) (Fig. 1).
150
METABOLIC
PHYSIC
PSYCHOLOGIC
Brain
NEUROTRANSMITTERS
NEUROPEPTIDES
NEUROHORMONES
Hypothalamu
GnRH
Pituitar
LH
FSH
Fig. 1 Stressors are typically grouped as for physical, metabolic or

psychological origin. Usually there is a perfect mixture of the three,
it is very uncommon to nd that only one is acting as unique stressor.
These cascades of situation negatively affect GnRH release and the reproductive axis, activating or inhibiting hypothalamic and/or extra-hypothalamic areas
in brain as well as acting in the periphery. In particular, one of the key events
of this modulatory action is played by neurotransmitters and neuropeptides
produced in the central nervous system. These neuronal pathways are sensitive
to external and internal environmental changes (light-dark cycle, temperature)
as well as to cognitive, social, cultural and emotional events. Each of these
signals may become stressor agents when acute changes occur, and through the
integration with the hormonal signals they can stimulate adaptive responses.
In primate females, and in human females in particular, an adaptative mechanism during stress is represented by the reduction of reproductive axis activity,
blocking a function which is not really essential to survive. Some intermediate
151
steps, such as poly- or oligo-menorrhea can anticipate the occurrence of the

amenorrheic condition, which is the last and worst stage of this clinical adaptive response to stress. What it is interesting to observe is that human species
has been going on evolving in these 20 thousands years, especially from the
technological and cultural point of view, permitting an incredible change of life
style and surviving so that the expectancy of life is incredibly longer. Though
such changes, our endocrine and neuroendocrine systems have been demonstrated to work and react as they feel to be still frozen 10-15 thousands years
ago. In fact though evolution permitted to our species to come down from the
trees and to start to move as bipeds, no more as simple primates, our neuroendocrine systems apparently work as a primate, as nothing was changed from
those times. The physiological meaning of this is extremely important since
it means that whatever stressor of the 21st century (dieting, sport, training or
psychological stressors) hits the human being, the adaptive response is similar
and superimposable to the one that might be induced by the sight or the attack
of a wild animal or by lack of food or by strenuous fatigue due to migration.
Neuroendocrine mechanism driving the stress-induced

hypogonadism in experimental animals
Most of the knowledge about stress-induced reproductive failure passes through
many experimental animal models. In monkeys and in rats the common response
to stressors is the increase of adrenocorticotropic hormone (ACTH) and cortisol
plasma levels. It has been demonstrated that the intraventricular injection of corticotropin releasing hormone (CRF) reduces GnRH and LH release (6, 7). Since
corticotropin releasing hormone (CRF) is the specic hypothalamic stimulating
factor for ACTH, elevation of ACTH in response to stress is anticipated by the
elevation of CRF stimulation. The evidence of a central site of action for CRF
in blocking GnRH-induced LH release is demonstrated by the fact that CRF
antagonists reverses the stress-induced LH decrease in rats (6). CRF elevation
as adaptative response to stress is also responsible for the increase of central
-endorphin (EP) release. This last is probably the most important peptide
of the endogenous opioid peptides (EOPs) family and is a potent inhibitor of
GnRH-LH secretion. Because of this evidence a connection has been suggested
between the activation of the hypothalamus-pituitary-adrenal (HPA) axis and
the stress-inhibition of the hypothalamus-pituitary-gonadal (HPG) axis (8).
Since naloxone, a specic opioid receptor antagonist, is able to counteract the
CRF-induced LH secretory blockade (9) opioid peptides have been considered
the key factor of the stress-induced inhibition of the HPG axis.
152
Peripheral hormonal signal, such as glucorticoid hormones or prolactin

(PRL), are also activated by stress and are able to act as stress-induced hormonal
signal. In fact cortisol itself exerts a suppressive effect on GnRH-stimulated
LH release in rats (10) and such an action is mainly played at the pituitary level
but it cannot be excluded that an additional negative effect may be present on
extrapituitary areas, indirectly inhibiting LH secretion (11). Also prolactin is
increased and responds to external stimuli, including emotional and physical
events as well as internal rhythms such as sleep. This mechanism has been
extensively studied in the rat (12) and is mediated by activation of several
stimulating factors like thyrotropin releasing hormone, vasoactive intestinal
peptide, oxytocin, or by the failure of the dopaminergic control. In any case,
the nal result of stress-related hormone responses is a negative effect both on
gonadotropin secretion and on gonadal steroid byosynthesis.
Neuroendocrine mechanisms of hypothalamic

amenorrhea
Hypothalamic amenorrhea (13-15) is a model of hypogonadism characterized
by several neuroendocrine aberrations which occur after a relatively long period of time of exposure to a repetitive and/or chronic stressor(s) so that to
affect the neuroendocrine hypothalamic activity (16, 17) as well as the release
of several hypophyseal hormones (8, 15, 17-20) (Fig. 2). The reproductive
axis is severely altered in these patients and both the opioid and dopaminergic
systems have been proposed as potential mediators of stress-related amenorrhea in humans (21, 22).
As demonstrated in experimental animals, the EOPs exert an inhibitory effect on the episodic release of both GnRH and LH also in humans (23, 24), with
some differences which are of great interest. When the specic opioid receptor
antagonist naloxone is administered, it causes the increase of LH plasma levels
during the late follicular and luteal phases of the menstrual cycle but not during the early follicular phase (9, 25, 26). During postmenopause the naloxone
administration does not induce any LH release, but when patients underwent
to estradiol administration LH plasma levels diminuished and the naloxoneinduced LH response is restored, thus demonstrating that a tight relationship
links opioidergic system with gonadal steroids (27). Also hypothalamic amenorrhea is not responsive to naloxone (28, 29), but after two months of hormonal
replacement therapy LH response to naloxone was recovered in at least 53%
of the patients (30) (Fig. 3).
153
stress
STRESS can be
acute
Just sometime, quite rarely
Minimal changes of the

CNS and hypothalamus
activities
chronic
Often, persistent condition
Important changes of CNS and hypothalamus

activities as soon as the time duration of the
stressant condition(s) last more than what it is
expected to last an acute stressant event (this is
subjective).
Fig. 2: Stress-induced neuroendocrine malfunction occurs only when

such stressor(s) act in a repetitive (chronic) manner.
On these basis several studies have been done on the efcacy of opioid
receptor antagonist on the restoration of a normal gonadotropin release
and of menstrual ciclicity (30-32). Recently it has been demonstrated that
in hypothalamic amenorrhea the naltrexone administration, a long-acting
opioid receptor antagonist, is effective in restoring the hypothalamic GnRH
discharge and ovulatory cycles in hypothalamic amenorrhea associated with
weight loss (31), independently from the response observed to naloxone
infusion before starting treatment (32). This last study reported that the
recovery of the ovarian function occurred in 80% of the patients and resulted
to be independent from the body weight recovery which appeared exactly
three months after the menstrual ciclicity was recovered (32). These data
seem to conrm that in stress-induced amenorrhea opioidergic system can
be antagonized by chronic naltrexone administration independently from
the body weight recovery. This last appears to be inuenced by naltrexone
centrally and/or by the increasing of gonadal steroid plasma levels as soon
as the menstrual ciclicity is restored, thus conrming that opioidergic tone
and/or steroid milieau are deeply involved in the modulation of the many
central nervous system functions/activities such as the hypothalamic centers
ruling food intake.
154
ESTROGENS
DA
A
OPIOIDS
NA
SE
GABA
GnR
Fig. 3: The role of estrogens is essential in maintaining specic neuronal/neuroendocrine functions. When stress iinduces neuroendocrine
dysfunction(s), quite often a hypoestrogenic condition occurs as consequence of the ovarian blockade worsening the abnormal neuroendocrine control of GnRH release from the hypothalamus.
Also the dopaminergic system is involved in the negative modulation of
GnRH release. In fact, the blockade of dopamine receptors by metoclopramide
caused the increase in LH plasma levels in women with hypothalamic amenorrhea, but not in eumenorrheic women (21), thus supporting the evidence of an
impaired dopaminergic activity in stress-induced amenorrhea.
Impaired serotoninergic activity has been reported in hypothalamic amenorrhea. In fact a blunted cortisol response to fenuramine, a serotoninergic
agonist, has been demonstrated and related to an increased serotoninergic tone
(33, 34). Serotonin seems to partecipate to the stress-induced neuroendocrine
events leading to the HPA axis impaired activity, and interacts with EOPs in
the regulation of the spontaneous GnRH-induced LH release. This interaction
between the opioidergic and serotoninergic axes is supported by the fact that
in normal subjects fenluramine administration blocks the naloxone-induced
155
LH secretion, and determines the signicant increase of plasma ACTH and

cortisol plasma levels (33, 34). However, even though the administration of
cyproheptdine cloridrate, a serotonin receptor antagonist, at the dose of 4 mg/
day has been demonstrated to be effective in increasing LH, FSH, GH and fT3
plasma levels, no effect of cyproheptadine was observed on naloxone-induced
LH response (35).
Stress and metabolic signals in hypothalamic amenorrhea

The mechanisms by which undernutrition and/or energy consumption cause
the decrease in central drive to the reproductive axis are complex and probably involves also not yet known pathways. However a clear correlation exists
between the incidence of reproductive dysfunction and the severity of body
weight loss (36). As above mentioned the percentage of body fat lost seems to
be determinant for the induction of the blockade of the reproductive axis. In
fact the suppression of the central drive(s) to the HPG axis in undernutrition
takes place only when the lost of weight includes a signicant loss of body
fat (36, 37). An alternative hypothesis is that in the early stages of dieting
or undernutrition some physiological changes serve as signal to activate the
suppression of the reproductive axis and the more is the undernutrition state
the more profound the block becomes, leading to a greater suppression of the
HPG axis (4).
The efcacy of dieting in inducing a specic central changes is supported
by several data on primates. One day after initiation of fasting monkeys show a
signicant reduction of gonadotropin episodic discharge with the concomitant
reduction of mean plasma concentrations of LH, FSH and gonadal steroids (38).
Fasting-induced suppression of gonadotropin release results from a decrease in
hypothalamic stimulation to the pituitary, rather than from a decrease in pituitary
responsiveness to endogenous GnRH (38). Similar results were observed in humans (39) and it is of interest the observation that in hypothalamic amenorrhea
LH more than FSH seems to be the more sensitive to the hypothalamus functional
impairment, since only LH plasma levels are signicantly reduced (15, 18, 40).
These data have also enforced the possible existence of an additional system(s)
modulating FSH but not LH episodic release from pituitary in humans (41, 42).
The concomitant possible involvment of metabolic and/or cellular abnormal
conditions as causal factors of the defective function of hypothalamic GnRH
discharge has been suggested in patients affected by hypothalamic amenorrhea
associated with weight loss.
156
Clinical considerations of stress-induced abnormal

reproductive function
All the above discussed items are extremely important since give us the clear
idea that hypothalamus in females is a great computer that takes care of all
inputs and denes specic outputs so that to monitor/modulate/regulate a lot
of other biological functions such as sleep, glucose control, heart function,
feeding, obviously reproduction and many others. This happens also in males
but it is incredibly active and sensitive in females. Try to think for a moment
as if a human female is living lets say 20 thounds years ago. For that times
reproduction was probably the less important function since a human being (or
a primate) could perfectly survive without reproduction and the surviving of
the single human being could not be garanteed if reproduction hits its goal (i.e
the occurance of a pregnancy) especially during seasons/periods during which
no food was available, or a strenuous energy consumption was ongoing (migration) as well as psychologic stressors (fear to die). For those times a pregnancy
in the wrong moment might mean an incredible higher risk to die. To avoid this
and to avoid to loose that single human being, hypothalamus developped the
ability to block the reproductive axis in reversible way so that to avoid ovarian
function (i.e. ovulation), with the chance to restart it only when the external
conditions might be improved and more adequate.
Life in these 21st century is not as the one of many thousands years ago but
it has always a lot of stressfull events that can trigger our hypothalamus and
omeostatic system(s) and induce a blockade of reproduction. Though this has
to be considered an incredibly well designed defensive system, unfortunately it
might be activated in peculiar period of times such as during pubertal development, inducing the delayed menarche/puberty (Fig. 4).
Indeed when intensive sport training or recreational activity is started at a
pre-pubertal age, it is not so rare to observe a signicant delay in the occurence
of pubertal maturation (2, 43). More or less there is a delay of 5 months in the
occurrence of menarche for each year of training (2). Such observation resulted
evident in prepubertal/pubertal girls performing sport and in dance training (2,
13, 43) and in young postmenarchal adolescents that reported the occurrence of
amenorrhea. The meaning of this observation is quite obvious since indicates
that if energy consumption and physical stressors are too much, growth and
reproductive axis maturation might not occur in the same time. In fact most
of the girls that suffer for this condition recover a normal development and/or
mestrual ciclicity as soon as training is signicantly reduced or suspended. The
presence of the right amount of fat is fundamental for pubertal development
157
since it is considered as a specic and oblidged reserve of energy that the body
might need to have stored in case a pregnancy occurs within the very rst ovarian cycles (36, 43). Nowadays this reserve of fat is important just for the beginning of the menstrual ciclicity (i.e. menarche) since pregnancy during pubertal
age is not so common in western countries (more frequent in under developped
countries) but it is important to consider this biological aspect every time we
study a girl that wants to start or have just started any kind of physical activity.
Physical activity has not to be strenous or stressant so that to avoid any conict
with the maturation/activation of her reproductive axis. A delay in such event
might induce a reduce bone mass peak, osteopenia and then a reduced bone
mass density during fertile life, exposing the girl to damages of the skeleton
and of the muscle activity (Fig. 5). Hypoestrogenism during adolescence, with
no menarche and/or menstrual ciclicity and with a sub-normal development of
sex-steroid dependent tissues (fat distribution, breast development) might be
responsible also of an abnormal or conicting self-image.
Physical STRESS and menarche
Training
before
pubertal
period
15.10.5 yrs
Delayed menarche
occurrence (2-3 yrs)
Training
after
12.30.2 yrs
Normal menarche
occurrence
Fig. 4: Menarche and pubertal maturation is weak and sensitive

moment in young girls. Whatever metabolic, physical or psychological
(chronic) stressor hit the neuroendocrine system before and/o during
pubertal development might induce a delay in menarche occurrence.
Training and agonistic activity started after menarche do not alter the
completion of pubertal maturation.
158
Hypoestrogenism
OSTEOPENIA
OSTEOPOROSIS
Nutritional defect
Compensatory hormonal
changes
Fig. 5: Among the many aspects related to the amenorrheic condition, osteopenia and the reduced bone mass peak have always to be
considered and monitored. Reduced feeding, excess of training and the
omeostatic compensation might induce osteopenia. Young girls, dancers, athletes should never have such osteopenic condition since this
might expose them to severe damages on bones/muscles during their
training/agonistic activity as well as in the general amount of calcium
stored in their skeleton. This last is important for the whole life long,
especially at the beginning of the far to come perimenopausal/menopausal period.
Conclusions
The importance of stress in the determinism of amenorrhea is clear and it
remains of fundamental importance the fact that whatever is the causal factor
inducing the reduction of food intake the result is always an impairment of
the central neuroendocrine modulation of the hypothalamus-pituitary-gonadal
axis. In some cases, such as for athletes or dancers, excessive training and/or
controlled/reduced feeding may induce amenorrhea later than in non-exercising
women. This might depend on the fact that training enables to be physically
more resistant to stressors and to stressant situations. In any case the amenorrheic condition, expecially the one related to weight loss and reduced hypothalamic function, deserves an attention since it may be the prelude to anorexia or
it may hide psychological or psychiatric diseases. The fact that amenorrhea is
characterized by low estradiol plasma levels exposes all amenorrheic patients
to all the risks of hypoestrogenemia such as reduction of bone density till to osteopenia, increased total cholesterol, altered lipoproteins, abnormally reduced
thyroid hormones. A greater attention has to be given to young girls starting
sport activity, dance or agonistic training.
159
In conclusion, hypothalamic amenorrhea have to be considered a complex

disease occurring after the occurrence of (severe) stressant physical, psychological events which are able to affect through the reduced food intake and/or
energy availability the neuromodulation of the human reproductive axis.
References:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Batrinos ML, Panitsa-Faia C, Courcoutsakis N, Chatzipavlou V. (1990) Incidence, type,

and etiology of menstrual disorders in the age group 12-19 years. Adolesc Pediatr Gynecol 3:
149-153
Frisch RE, McArthur JW. (1974) Menstrual cycles: fatness as a determinant of minimum
weight for height necessary for their maintenance or onset. Science 185: 949-51
Veldhuis JD, Evans WS, Demers LM, Thorner MO, Wakat D, Rogol AD. (1985) Altered neuroendocrine regulation of gonadotropin secretion in women distance runners. J Clin Endocrinol
Metab 61: 557-62
Cameron JL, Helmreich DL, Schreihofer DA. (1993) Modulation of reproductive hormone
secretion by nutritional intake: stress signals versus metabolic signals. Hum Reprod 8: 162-7
Facchinetti F, Fava M, Fioroni L, Genazzani AD, Genazzani AR. (1993) Stressful life
events and affective disorders inhibit pulsatile LH secretion in hypothalamic amenorrhea.
Psychoneuroendocrinology 18: 397-404
Rivier C, Rivier V, Vale W. (1986) Stress-induced inhibition of reproductive functions: role of
endogenous corticotropin- releasing factor. Science 231: 607-9.
Petraglia F, Sutton S, Vale W, Plotsky P. (1987) Corticotropin-releasing factor decreases
plasma luteinizing hormone levels in female rats by inhibiting gonadotropin- releasinghormone release into hypophyseal-portal circulation. Endocrinology 120: 1083-1088
Genazzani AD, Petraglia F, Gastaldi M, Volpogni C, D'Ambrogio G, Facchinetti F, Genazzani
AR. (1993b) FSH secretory pattern and degree of concordance with LH in amenorrheic, fertile
and postmenopausal women. Am J Physiol 264: E776-E781
Petraglia F, Vale W, Rivier C. (1986) Opioids act centrally to modulate stress-induced decrease
in luteinizing hormone in the rat. Endocrinology 119: 2445-50
Ringstrom SJ, Suter D, D'Agostino J, Hoestler JP, Scwartz NB. (1991) Effects of glucocorticoids on the hypothalamic-pituitary- gonadal axis. In "Stress and related Disorders from
Adaptation to Dysfunction". Genazzani AR, Nappi G, Petraglia F and Martignoni E (eds) ,
Parthenon Publ., Carnforth, UK, pp 297-305
Kamel F, Kubajak CL. (1987) Modulation of gonadotropic secetion by cortisosterone interaction with gonadal steroids and mechanism of action. Endocrinology 121: 561-8
Gala RR. (1990) The physiology and mechanisms of the stress- induced changes in prolactin
secretion in rat. Life Sci 46: 1407-10
Cannavo, Curto L., Trimarchi F. (2001). Exercise-related female reproductive dysfunction.
J. Endocrinol Invest 24: 823-832
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th
ed. Waschington, DC: American Psychiatric Association, 1995
Genazzani AD, Petraglia F, Fabbri G, Monzani A, Montanini V, Genazzani AR. (1990)
Evidence of luteinizing hormone secretion in hypothalamic amenorrhea associated with weight
loss. Fertil Sterll 54: 222-6
Vigersky RA, Andersen AE, Thompson RH, Lauriaux DL. (1977) Hypothalamic dysfunction
in secondary amenorrhea associated
with simple weight loss. N Engl J Med 297:1141-46
160
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.

Berga SL, Mortola SF, Girton L, Suh B, Laughlin G, Pham P, Yen SSC. (1989) Neuroendocrine
aberrations in women with functional hypothalamic amenorrhea. J Clin Endocrinol Metab 68:
301- 8
Genazzani AD, Petraglia F, Benatti R, Montanini V, Algeri I, Volpe A, Genazzani AR. (1991)
Luteinizing hormone (LH) secretory burst duration is independent from LH, prolactin, or
gonadal steroid plasma levels in amenorrheic women. J Clin Endocrinol Metab, 72: 1220-5
Genazzani AD, Petraglia F, Gastaldi M, Volpogni C, Surico N, Genazzani AR. (1994b) Episodic
release of prolactin in women with weight loss-related amenorrhea. Gynecol Endocrinol 8:
95-100
Fioroni L, Fava M, Genazzani AD, Facchinetti F, Genazzani AR. (1994) Life events impact in
patients with secondary amenorrhea. J Psychosom Res 6: 617-22
Quigley ME, Sheehan KL, Casper RF, Yen SSC. (1980) Evidence for increased dopaminergic and opioid activity in patients with hypothalamic hypogonadotropic amenorrhea. J Clin
Endocrinol Metab 50: 949-54
Petraglia F, Panerai AE, Rivier C, Cocchi D, Genazzani AR. (1988) Opioid control of gonadotropin secretion. In "Brain and Female Reproductive Function." Genazzani AR, Montemagno
U, Nappi C, Petraglia F (Eds). The Parthenon Publishing Group, Carnforth, UK, pp 65-72.
Khoury SA, Reame NE, Kelch RP, Marschall JC. (1987) Diurnal patterns of pulsatile luteinizing hormone secretion in hypothalamic amenorrhea: reproducibility and responses to opiate
blockade and an a2-adrenergic agonist. J Clin Endocrinol Metab 64: 755-762
Petraglia F, D'Ambrogio G, Comitini G, Facchinetti F, Volpe A, Genazzani AR. (1985)
Impairment of opioid control of luteinizing hormone secretion in menstrual disorders. Fertil
Steril 43: 535- 40
Quigley ME, Yen SSC. (1980) The role of endogenous opiates on LH secretion during the
menstrual cycle. J Clin Endocrinol Metab 51: 179-81
Snowden UE, Khan-Dawood SF, Dawood MY. (1984) The effect of naloxone on endogenous
opioid regulation of pituitary gonadotropins and prolactin during the menstrual cycle. J Clin
Endocr Metab 59: 292-296
Melis GB, Paoletti AM, Gambacciani M, Mais V, Fioretti P. (1984) Evidence that estrogens inhibit LH secretion through opiods in postmenopausal women using naloxone.
Neuroendocrinology 39: 60-64
Lightman SL, Jacobs HS, Magnuire AK, Mc Garrick G, Jeffcoate SL. (1981) Constancy of
opioid control of luteinizing hormone in different pathophysiological states. J Clin Endocrinol
Metab 52: 1260-1263
Veldhuis JD, Kulin HE, Warner BA, Santner SJ. (1982) Responsiveness of gonadotropin
secretion to infusion of opiate- receptor antagonist in hypogonadotropic individuals. J Clin
Endocrinol Metab 55: 649-653
Remorgida V, Venturini PL, Anserini P, Salerno E, De Cecco L. (1990) Naltrexone in functional hypothalamic amenorrhea and in the normal luteal phase. Obstet Gynecol 76: 1115-20
Genazzani AD, Gastaldi M, Petraglia F, Battaglia C, Surico N, Volpe A, Genazzani AR. (1995)
Naltrexone administration modulates the neuroendocrine control of luteinizing hormone secretion in hypothalamic amenorrhea. Hum Reprod 10: 2868-71
Genazzani AD, Petraglia F, Gastaldi M, Volpogni C, Gamba O, Genazzani AR. (1995)
Naltrexone treatment restores menstrual cycles in patients with weight loss-related amenorrhea. Fertile Steril 64: 951-6
Yen SSC. (1984) Opiates and reproduction: studies in women. In "Opioid modulation of endocrine function". Delitala G ed. Raven Press, New York, p. 191-9
Kalra SP, Kalra PS. (1984) Neural regulation of luteinizing hormone secretion in the rat.
Endocr Rev 4: 311-351
Genazzani AD, Strucchi C, Malavasi B, Tortolani F, Vecchi F, Luisi S, Petraglia F. (2001)
161
36.
37.
38.
39.
40.
41.
42.
43.
Effects of cyproheptadine, a serotonin receptor antagonist, on endocrine parameters in weightloss related amenorrhea. Gynecol Endocrinol 15: 279-285
Frisch RE. (1984) Body fat, puberty and fertility. Biol Rev 59: 161-88
Reid RL, Van Vugt DA. (1987) Weight-related changes in reproductive function. Fertil Steril
905-13
Cameron JL, Nosbich C. (1991) Suppression of pulsatile luteinizing hormone and testosterone
secretionduring short term food restriction in the adult male rhesus monkey (Macaca Mulatta).
Endocrinology 128: 1532-40
Cameron JL, Weltzin T, McConaha C, Helmreich DL, Kaye WH. (1991) Suppression of reproductive axis activity in men undergoing a 48 hour fast. J Clin Endocrinol Metab 73: 35-41
Genazzani AD, Petraglia F, Volpogni C, Gastaldi M, Pianazzi F, Montanini V, Genazzani AR.
(1993) Modulatory role of estrogens and progestins on growth hormone episodic release in
women with hypothalamic amenorrhea. Fertil Steril 60: 465-70.
Genazzani AD, Petraglia F, Gastaldi M, Volpogni C, Gamba O, Massolo F, Genazzani AR.
(1994) Evidence suggesting an additional control mechanism regulating episodic secretion
of luteinizing hormone and follicle stimulating hormone in prepubertal children and postmenopausal women. Hum Reprod 9: 1807- 12
Genazzani AD, Massolo F, Ferrari E, Gandol A, Petraglia F, Genazzani AR. (1996) Longterm GnRH-agonist admnistration revealed a GnRH-independent mechanism stimulating FSH
discharge in humans. Eur J Endocrinol 134: 77-83
Frish RE, Wyshak G, Vincent L. (1980) Delayed menarche and amenorrhea in ballet dancers.
N Engl J Med 303: 17-19
162
IVF or surgery rst?

Fibroids and IVF: Which comes rst?
Beth W. Rackow, MD and Aydin Arici, MD
Section of Reproductive Endocrinology and Infertility, Department of Obstetrics,
Gynecology & Reproductive Sciences, Yale University School of Medicine,
New Haven, Connecticut, USA
Abstract
There is no consensus about the impact of uterine broids on fertility. We review
here past and recent studies which investigate the effects of submucosal, intramural, and subserosal broids on IVF outcomes. We discuss the importance of
proper evaluation of the uterus and endometrial cavity, and current options for
optimal broid management in patients desiring fertility. Several studies have
reviewed the data on broids and infertility, further exploring this potential
relationship. Two recent studies investigated reproductive outcomes before
and after myomectomy, and IVF outcomes based on broid size and location.
Both studies concluded that broids can impair reproductive outcomes. Several
papers thoroughly reviewed medical and surgical management options for patients with broids and desired fertility. Although several medical therapies
may reduce broid volume or decrease menorrhagia, myomectomy remains the
standard of care for future fertility. Recent data identied an increased rate of
pregnancy complications after uterine artery embolization compared to laparoscopic myomectomy. A new procedure, MRI-guided focused ultrasound ablation, shows promise for the management of symptomatic broids, and possibly
for the management of broids prior to pregnancy. As with embolization, more
data is needed to evaluate post-procedure fertility and pregnancy outcomes.
Fibroid location, followed by size, is the most important factor determining the
impact of broids on IVF outcomes. Any distortion of the endometrial cavity
seriously affects IVF outcomes, and myomectomy is indicated in this situation.
Myomectomy should also be considered for patients with large broids, and
for patients with unexplained unsuccessful IVF cycles.
163
Introduction
Uterine broids affect 20-50% of women of reproductive age, and the prevalence increases with age, thus they are the most common benign tumor in this
population [1-3]. While broids often cause symptoms such as pelvic pressure
and pain, abnormal bleeding, and distortion of adjacent organs such as the
bladder and bowel, many patients are asymptomatic [1, 4, 5]. Fibroids are
present in approximately 5-10% of infertility cases, and can be the sole factor
identied in 1-2.4% of infertile patients [1, 6, 7]. Fibroids have been implicated
in both recurrent pregnancy loss and infertility, however the latter association
is a subject of debate.
A number of theories explore the anatomical and functional changes that
broids may cause, and thus predispose to infertility. Anatomically, broids
distort the uterus and can enlarge and elongate the cavity, alter the contour and
surface area of the cavity, obstruct tubal ostia or the cervical canal, or displace
the cervix in the vagina. These acquired abnormalities can impede migration of
sperm, ovum, or embryo, and can impair implantation [1, 8, 9]. Uterine function
may be affected: broids may cause dysfunctional and altered uterine contractility, thus hinder gamete transport and embryo implantation [1, 10]. Furthermore
broids may damage the overlying endometrium, causing endometrial vascular
disturbances, inammation, ulceration, thinning and atrophy, and an altered
biochemical environment which may impair implantation [1, 11-13]. These
theories are plausible, although several are generally unproven [1, 2, 14].
Multiple studies have investigated the effect of uterine broids on fertility
by studying fertility after myomectomy. A literature review identied 1,193
subjects who underwent abdominal myomectomy for infertility, and the postoperative pregnancy rate was 40% [1]. The presence of submucosal broids
appears to impair fertility, as fertility improves after hysteroscopic or abdominal myomectomy [15-17]. Intramural and subserosal broids may also impact
fertility since abdominal myomectomy signicantly improved reproductive
outcomes in patients with infertility or pregnancy loss, especially when a single
broid was removed, and myomectomy did not appear to impair fertility [9,
18, 19]. Another study noted that laparoscopic and abdominal myomectomy for
broids at least 5 cm in size equally improved fertility [20]. Postoperative conception rates in these studies ranged from 42-70%. Despite these heterogeneous
studies, it remains unclear when to remove intramural and subserosal broids
in patients with otherwise unexplained infertility. However, it is generally accepted that submucosal broids decrease fertility, and their removal improves
pregnancy rates [2, 6, 8, 14]
164
A number of studies have specically looked at the impact of broids on in

vitro fertilization (IVF) outcomes. Studies of IVF patients are uniquely able to
exclude certain infertility factors such as variables of sperm function, abnormal pelvic anatomy and tubal function, and fertilization [8, 21]. We discuss in
this review the recent, available evidence concerning uterine broids and IVF
outcomes, and aims to identify the best current evaluation of broids, the appropriate evidence-based management of broids in patients undergoing IVF,
and areas for future research.
Do intramural and subserosal broids affect IVF outcomes?
Many studies have investigated the impact of intramural and subserosal broids
on IVF outcomes. A prospective study compared 61 subjects with intramural
broids less than 5 cm to 61 matched controls. All subjects had normal endometrial cavities on hysterosalpingogram, average broid size was 1.5 cm, and
average number of broids was 2.1 [22]. Compared to the controls, the broid
group had lower implantation rates (13.6 vs. 20.2%), lower pregnancy rates
(34.4 vs. 47.5%), lower delivery rates (22.9 vs. 37.7%), and higher miscarriage
rates (33.3 vs. 20.7%) which highlight the potential negative impact of small
intramural broids on IVF outcomes [22].
A similar study involved 112 patients with intramural broids and 322
controls [23]. Ultrasound diagnosed all broids, and a sonohysterogram or
hysterosalpingogram was performed if broids were near the endometrial cavity. For the majority of subjects (n=106) with a mean broid size of 2.3 cm
(90% range 2.1-2.5 cm), signicantly reduced pregnancy, implantation, and
ongoing pregnancy rates (23.3%, 11.9%, 15.1%) were noted compared to the
control group (34.1%, 20.2%, 28.3%). These authors concluded that intramural
broids signicantly hinder conception, effectively halving the chance of ongoing pregnancy after IVF, and propose transferring more embryos in an attempt
to improve outcomes [23].
Stovall et al. conducted a prospective study comparing 91 patients with
intramural and subserosal broids to 91 controls, all undergoing IVF with embryo transfer or zygote intrafallopian transfer [24]. Fibroids were evaluated by
transvaginal ultrasound as well as a hysterosalpingogram, however broid size
was not discussed. Implantation, clinical pregnancy, and delivery rates for the
study group (13.8%, 37%, 33% respectively) were signicantly different from
the control group (19.7%, 53%, 48%). The abortion rates were comparable for
the two groups. Although the broid group had reasonable pregnancy rates, the
authors concluded that intramural and subserosal broids negatively impact
implantation and pregnancy rates in IVF [24].
165
Oliveira et al. performed a retrospective study to compare 245 patients with

intramural and subserosal broids to 245 controls undergoing IVF with intracytoplasmic sperm injection (ICSI) [25]. Transvaginal ultrasound and hysterosalpingogram determined broid location. There was no signicant difference
in pregnancy rate based on the presence, number, or location of broids, and
the miscarriage rates were comparable between the broid and control groups.
However, intramural broids greater than 4 cm were associated with a statistically signicant lower pregnancy rate (29%) compared to broids 0.4-2.0 cm
(53%) and 2.1-4.0 cm (51%). A similar trend was also noted between larger
intramural broids and lower implantation rates. The authors concluded that
subserosal and intramural broids greater than 4 cm may impair IVF-ICSI
outcomes, and should be further investigated. [25].
Two IVF studies included patients with abnormal uterine cavities. EldarGeva et al. retrospectively investigated assisted reproductive technology (ART)
outcomes with intramural, subserosal, and submucosal broids [26]. The study
group comprised 88 patients (106 cycles), and the control group included 249
subjects (318 cycles). Fibroid location was determined by transvaginal ultrasound. Most subjects underwent IVF with embryo transfer, and 20% underwent
gamete intrafallopian transfer. Trends were evident for the pregnancy rate per
transfer and implantation rate among the control group (30.1%, 15.7%) and
subserosal (34.1%, 15.1%), intramural (16.4%, 6.4%), and submucosal (10%,
4.3%) broid groups. Thus intramural and submucosal broids were associated with signicantly lower pregnancy and implantation rates, even if the
endometrial cavity was normal, and subserosal broids did not appear to affect
ART outcomes [26].
A similar study investigated the effect of uterine broids, with or without
normal endometrial cavities, on IVF outcomes [13]. The study group comprised 46 patients undergoing 172 IVF cycles compared to 50 control subjects.
Fibroids were diagnosed by a combination of physical exam, hysterosalpingogram, hysteroscopy, and ultrasound, but broid size and location were not
detailed. There were no signicant differences between study and control group
pregnancy rate per transfer (22.1 vs. 25.1%), implantation rate per embryo (6.5
vs. 9.7%), and abortion rate (36 vs. 25%). However, when the study group was
stratied based on a normal (n=28) or abnormal (n=18) endometrial cavity,
signicant differences in pregnancy rate (30.2 vs. 9.0%) and implantation rate
(8.9 vs. 2.7%) were noted, while abortion rates were similar (36 vs. 40%). The
authors concluded that broids which distort the uterine cavity signicantly
impair implantation and pregnancy rates, however broids with a normal endometrial cavity do not appear to affect IVF outcomes. [13].
166
In contrast, several other studies demonstrated no impact of broids on IVF

outcomes. Surrey et al. studied 399 IVF patients, 73 of whom had broids, all
with normal cavities by hysteroscopy [27]. A decreased implantation rate was
noted in subjects less than 40 years old compared to age-matched controls
(21.4 vs. 33.9%), and a trend toward lower clinical pregnancy and live birth
rates was noted. These ndings were not appreciated in subjects 40 years of
age and older. Neither broid size nor volume correlated with implantation.
The authors considered the pregnancy and delivery rates highly acceptable,
and concluded that IVF live birth rates were not affected by intramural broids
with a hysteroscopically normal cavity. [27].
A similar retrospective study evaluated 39 subjects with uterine broids and
normal cavities compared to 367 controls, all undergoing IVF-ICSI [28]. Fibroid
location was identied by transvaginal ultrasound and hysterosalpingogram, all
broids were less than 7 cm with mean size 3.5 cm, and 92% of subjects had
a single broid. No signicant differences were identied between the clinical
pregnancy (38.5 vs. 33.5%), implantation per embryo (12.5 vs. 13.8%), and
abortion (20 vs. 15.5%) rates for the broid and control groups. The authors
concluded that broids less than 7 cm with a normal endometrial cavity did
not impair IVF outcomes. The authors routinely recommend myomectomy
for patients with broids greater than 7cm, or with a broid impinging on the
endometrial cavity [28].
A third study investigated IVF-ICSI implantation and pregnancy rates in
the setting of intramural and subserosal broids [29]. This retrospective study
compared 108 patients with uterine broids, 73 intramural and 35 subserosal,
to 324 controls, all with a normal endometrial cavity. Fibroids were diagnosed
by transvaginal ultrasound, maximum size 10 cm, and a normal cavity was conrmed by hysterosalpingogram or hysteroscopy. Pregnancy rates per embryo
transfer and implantation rates were comparable for the intramural (30.2%,
9.8%), subserosal (33.3%, 12.7%), and control groups (33.2%, 11.2%), and
the miscarriage rates were also similar. The authors concluded that provided a
normal endometrial cavity, intramural and subserosal broids were not detrimental to IVF-ICSI outcomes [29].
Jun et al. performed a retrospective study to evaluate the effect of broids on
IVF outcomes [30]. They studied 141 subjects with broids, most less than 4 cm
with maximum size 7 cm, compared to 406 controls without broids, some with a
prior myomectomy. All subjects were evaluated by ultrasound, and either a hysterosalpingogram, hysteroscopy, or sonohysterogram. Pregnancy rates were not
signicantly different for the study group (30.5%) compared the control group
(41.6%). Neither broid size nor location (intramural vs. submucosal/subsero-
167
sal) had a signicant effect on pregnancy outcome. This study did not identify
how many patients had each location of broid, and analyzed submucosal and
subserosal broids together, which weakens the results. The authors concluded
that broids do not signicantly affect on IVF outcomes [30].
The effect of broids on IVF outcomes: assessment by other review articles
Three recent articles have reviewed multiple IVF studies to assess the effect
of uterine broids on reproductive outcomes, and reached similar conclusions.
Each manuscript has included some of the previously discussed studies. Pritts
reviewed 11 IVF studies, and identied that patients with submucosal broids
and abnormal uterine cavities had signicantly lower pregnancy rates (relative
risk [RR] 0.32), implantation rates (RR 0.28), and delivery rates (RR 0.75)
compared to infertile controls without broids [14]. In general, infertile women
with broids had signicantly lower implantation rates compared to infertile
controls, however only submucosal broids had a signicant impact on implantation, pregnancy, and delivery rates. After myomectomy for submucosal
broids, pregnancy rates increased. This meta-analysis concluded that submucosal and intracavitary broids hindered reproductive outcomes, and neither
intramural nor subserosal broids adversely impacted fertility [14].
Donnez and Jadoul analyzed six trials comparing IVF outcomes in women
with and without broids, and noted a signicant decrease in pregnancy rates
with a distorted uterine cavity (9%) compared to a non-distorted cavity (33.5%)
and patients without broids (40%) [6]. Although each study had a different
opinion, Donnez and Jadoul concluded that submucosal and intramural broids
which distort the uterine cavity can signicantly impair implantation and pregnancy rates in IVF. Fibroids may have a more subtle effect on IVF outcomes
when the cavity is not distorted [6].
Finally, Surrey reviewed a number of studies to investigate the impact of
intramural broids on IVF outcomes [21]. The author concluded that broids
immediately adjacent to, or impinging upon, the endometrial cavity can negatively impact an IVF cycle, and a myomectomy should be benecial. There
exists no denitive data supporting routine prophylactic myomectomy prior to
IVF for patients with broids and normal endometrial cavities [21].
Evaluating the evidence

Together, these studies explore the relationship between uterine broids and
IVF outcomes. Evidence supports that submucosal broids and intramural -
168
broids which distort the endometrial cavity impair IVF outcomes. However, it
remains unclear whether intramural and subserosal broids, in the setting of a
normal endometrial cavity, have similar effects.
The studies reviewed have a range of limitations. Many studies are retrospective and nonrandomized which leads to some degree of selection bias [6,
21]. Several studies involved small numbers and thus were unable to detect a
signicant difference between study and control groups, some studies utilized
control groups with variable, and often low, pregnancy rates, and others did
not include control groups [6, 21]. A number of studies added confounding
factors by including subjects with a wide range of ages, and subjects undergoing other ART cycles besides IVF [21, 31]. Subjects with large broids were
excluded from many studies, and some studies provided no detail about the size
and location of broids. Most studies evaluated the endometrial cavity with
transvaginal ultrasound or hysterosalpingogram only, and cavity abnormalities
may have been overlooked [21]. These factors limit the quality of the data and
results, and thus the ability to make evidence-based conclusions.
Detailed evaluation of the uterine cavity is essential in the setting of infertility and uterine broids. Congenital and acquired uterine pathology may be
present in up to 10% of infertile women [32]. Transvaginal ultrasound, hysterosalpingogram, sonohysterogram, and hysteroscopy are most commonly used
to evaluate the cavity. Cicinelli et al. evaluated 52 women with submucosal
broids, and noted that sonohysterography most accurately detected size, location, and intracavitary growth; transvaginal ultrasound was less accurate for
intracavitary growth and tumor location but precise for size; hysteroscopy was
least accurate for predicting size, but precisely identied the mass and its location [33]. Furthermore in one IVF population, hysteroscopy found abnormalities
in 43% of patients with a normal hysterosalpingogram [34]. As a diagnostic test,
sonohysterography has been shown to be superior when compared to hysterosalpingography or transvaginal sonography, and is comparable to hysteroscopy
[35, 36]. Accurate examination of the uterine cavity with sonohysterography or
hysteroscopy is a valuable tool in IVF patients with broids.
Options for the conservative management of uterine broids prior to IVF
Several conservative options exist for broid management. Each procedure has
risks and benets depending on the invasiveness, complexity, and length of the
procedure. The risks of abdominal myomectomy include signicant intraoperative blood loss, postoperative discomfort and morbidity, a longer hospital
stay, adhesion formation, and decreased fertility [2, 8]. Adhesions occur with
94% of posterior wall incisions and 55% of anterior uterine incisions, and
169
posterior adhesions are often thicker [37]. Laparoscopic myomectomy involves

less discomfort and a shorter postoperative recovery, however this procedure is
technically more challenging and time-consuming, and not always feasible [2].
There are several reports of uterine rupture after laparoscopic myomectomy,
raising concern about scar integrity [2, 5]. A study of 100 subjects reported a 1%
uterine rupture rate, and no ruptures with the 72 patients undergoing a trial of
labor [38]. There is no recent uterine rupture data for abdominal myomectomy
[2, 6]. Hysteroscopic resection benets include short recovery time, and less
blood loss and discomfort [8]. The risks of hysteroscopy include bleeding and
hyponatremia, both related to the complexity and duration of the procedure,
repeat procedures to completely remove the broid, and intrauterine scarring
[5, 8]. Thus targeted imaging of the myomatous uterus and preoperative mapping will aid in the planning of the most appropriate surgical procedure.
Gonadotropin releasing hormone agonists (GnRHa) are sometimes used in
patients prior to myomectomy. By inducing a reversible hypoestrogenic state,
a rapid 35-65% decrease in uterine and broid size occurs, most pronounced
within three months of treatment, and broid symptoms often improve [3].
However, after discontinuing this therapy, broids tend to grow back to their
original size or larger, thus this treatment is ineffective except in the perimenopause or a preoperative period [2, 3]. Vercellini et al. performed a randomized
controlled trial comparing abdominal myomectomy with and without two
months of GnRHa therapy [39]. Despite a 22% reduction in broid volume for
the GnRHa group, there was no signicant difference between the groups in
blood loss, duration of surgery, postoperative morbidity, and hospital stay. At
six months post-procedure, the GnRHa group had a higher broid recurrence
rate. The author concluded that anemia was the only indication for preoperative
GnRHa. Prior to this study, Lethaby et al. reviewed 26 randomized controlled
trials evaluating GnRHa therapy prior to hysterectomy or myomectomy [40].
They determined that GnRHa effectively increase preoperative hematocrit in
anemic patients, reduce uterine and broid volume, enable the use of a transverse incision instead of a vertical incision, enable the conversion from an
abdominal hysterectomy to a vaginal approach, and reduce intraoperative blood
loss. However, there was inadequate data to assess the effects of GnRHa on
post-myomectomy broid recurrence risk and postoperative fertility [40].
Post-procedure broid growth and recurrence limits the long-term effectiveness of myomectomy. A retrospective study of 622 abdominal myomectomy
patients revealed a 10-year cumulative recurrence rate of 27% [41]. This study
further noted that subjects with a single broid had a lower broid recurrence
rate, and those who conceived and gave birth after myomectomy had an even
170
lower recurrence rate. Buttram and Reiter reviewed 2554 myomectomy patients and identied a 15% broid recurrence rate [1]. Additionally, a review
of abdominal myomectomy studies noted a range of 4% to 47% for broid
recurrence rate [31]. Regardless of the true broid recurrence risk, the potential
for recurrence limits the long-term efcacy of myomectomy [2].
Several new procedures are available to treat broids, however long-term
outcome data is limited including data on post-procedure fertility and pregnancy [6]. Uterine artery embolization (UAE) effectively reduces dominant
broid and uterine volumes, and reduces symptoms by 77-86% at three
months post-procedure [42]. Adverse events associated with UAE include infection necessitating hysterectomy, severe pain, and broid expulsion [2, 5].
Furthermore, a post-procedure amenorrhea rate of 3% has been documented in
subjects under age 40 [42]. Amenorrhea complicates 1% of UAE procedures
and is attributed to ovarian embolization thus ovarian compromise, as well as
endometrial atrophy due to endometrial vascular compromise [2, 3]. Goldberg
et al. investigated pregnancy outcomes after UAE compared to laparoscopic
myomectomy, and identied a signicantly increased risk of preterm delivery
and malpresentation, as well as a trend toward an increased risk of postpartum
hemorrhage and spontaneous abortion with UAE [43]. These ndings may be
due to residual broid burden after UAE, in contrast to complete removal during myomectomy. Although there have been successful pregnancies after UAE
[43-45], the long-term effects of UAE on fertility and pregnancy outcomes are
unknown [3, 43].
Another conservative procedure is myolysis, laparoscopic coagulation and
destruction of uterine broids [46]. This procedure is effective for treating
broids, however may damage or compromise the uterus [8]. Little data is
available about pregnancy outcomes after this procedure, and uterine rupture
has been documented [46]. A third procedure uses MRI-guided focused ultrasound surgery to ablate uterine broids, while preserving adjacent healthy
myometrium. This procedure is safe and effective, achieving an improvement
in broid symptoms, however there is no data on post-procedure fertility and
pregnancy outcomes [47, 48].
Conclusions
The impact of broids on IVF remains controversial. Studies demonstrate that
submucosal broids and intramural broids with endometrial cavity distortion are associated with decreased implantation and pregnancy rates compared
to a normal cavity. However, it remains unclear if small-to-moderate sized
171
intramural broids without cavity distortion or subserosal broids impact IVF

outcomes, and if myomectomy is warranted in these patients.
Most IVF studies included patients with broids 5 cm or less. Furthermore,
the authors of three IVF studies stated that they routinely recommend myomectomy for patients with broids 7 cm [28] and 10 cm [29] or greater, and for
patients with uterine size greater than 12 weeks of gestation [13]. By excluding
subjects with large broids from studies, we may not know the true effect of
broids on fertility. One IVF study determined that intramural broids greater
than 4 cm were associated with a signicantly lower pregnancy rate [25]. Thus
larger broids, even with a normal endometrial cavity, may have a different and
signicant impact on fertility and reproductive outcomes compared to smaller
broids.
Appropriate prospective trials are needed to better decipher the impact of
broids on fertility. To eliminate potential confounding factors, future studies should concentrate on detailing the location, size, and number of broids,
cavity evaluation, attention to age-related subfertility, and careful selection of
control subjects.
When assessing an IVF patient with broids, targeted evaluation of the
uterus and endometrial cavity for broid location is essential. The data suggests that pre-IVF myomectomy is appropriate for submucosal broids, intramural broids which distort the cavity, and likely for large intramural
broids. Furthermore, a patient with broids who has been through several
IVF cycles with good ovarian response, quality embryos, and no pregnancy
should be considered for myomectomy prior to additional IVF cycles as the
presence of broids may be impairing IVF success. Additionally, one might
consider myomectomy in a patient with a signicant broid burden who can
only undergo one cycle of IVF. Without clear, evidence-based guidelines, each
patients situation should be considered individually, the risks and benets of
each intervention weighed, and an appropriate management plan devised.
Please note that this is a copy of an article published in Current Opinion in
Obstetrics and Gynecology, Volume 17, No 3; 2005.
172
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
Buttram VC, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management.
Fertil Steril 1981; 36:433-445.
Manyonda I, Sinthamoney E, Belli A-M. Controversies and challenges in the modern management of uterine broids. Br J Obstet Gynecol 2004;111:95-102.
Olive DL, Lindheim SR, Pritts EA. Non-surgical management of leiomyoma: impact on
fertility. Curr Opin Obstet Gynecol 2004; 16:239-43.
Olufowobi O, Sharif K, Papaionnou S et al. Are the anticipated benets of myomectomy
achieved in women of reproductive age? A 5-year review of the results at a UK tertiary hospital. J Obstet Gynaecol 2004; 24:434-40.
Myomas and reproductive function. American Society for Reproductive Medicine: A Practice
Committee Report. November 2001.
Donnez J, Jadoul P. What are the implications of myomas on fertility? A need for a debate?
Hum Reprod 2002; 17:1424-30.
Verkauf BS. Myomectomy for fertility enhancement and preservation. Fertil Steril 1992; 58:115.
Martin D. Myomata and infertility. Current Womens Health Reports 2003; 3:384-8.
Li TC, Mortimer R, Cooke ID. Myomectomy: a retrospective study to examine reproductive
performance before and after surgery. Hum Reprod 1999; 14:1735-40.
Richards PA, Richards PDG, Tiltman AJ. The ultrastructure of bromyomatous myometrium
and its relationship to infertility. Hum Reprod Update 1998; 4:520-5.
Deglidish J, Loewenthal M. Endometrial changes associated with myomata of the uterus. J
Clin Pathol 1970; 23:676-80.
Farrer-Brown G, Beilby JOW, Tarbit MH. Venous changes in the endometrium of myomatous
uteri. Obstet Gynecol 1971; 38:743-51.
Farhi J, Ashkenazi J, Feldberg D et al. Effect of uterine leiomyomata on the results of in-vitro
fertilization treatment. Hum Reprod 1995; 10:2576-8.
Pritts EA. Fibroids and infertility: a systematic review of the evidence. Obstet Gynecol Surv
2001; 56:483-91.
Fernandez H, Sefrioui O, Virelizier C, Gervaise A, Gomel V, Frydman R. Hysteroscopic resection of submucosal myomas in patients with infertility. Hum Reprod 2001; 16:1489-92.
Garcia CR, Tureck RW. Submucosal leiomyomas and infertility. Fertil Steril 1984; 42:16-9.
Goldenberg M, Bider D, Sivan E et al. Outcome of hysteroscopic resection of submucous
myomas for infertility. Fertil Steril 1995; 64:714-6.
Marchionni M, Fambrini M, Zambelli V et al. Reproductive performance before and after
abdominal myomectomy: a retrospective analysis. Fertil Steril 2004; 82:154-9.
Vercellini P, Maddalena S, de Giorgi O et al. Determinants of reproductive outcome after
abdominal myomectomy for infertility. Fertil Steril 1999; 72:109-14.
Seracchioli R, Rossi S, Govoni R et al. Fertility and obstetric outcome after laparoscopic
myomectomy of large myomata: a randomized comparison with abdominal myomectomy.
Hum Reprod 2000; 15:2663-8.
Surrey ES. Impact of intramural leiomyomata on in-vitro fertilization-embryo transfer cycle
outcome. Curr Opin Obstet Gynecol 2003; 15:239-42.
Check JH, Choe JK, Lee G, Dietterich C. The effect on IVF outcome of small intramural
broids not compressing the uterine cavity as determined by a prospective matched control
study. Hum Reprod 2002; 17:1244-8.
Hart R, Khalaf Y, Yeong C-T et al. A prospective controlled study of the effect of intramural
uterine broids on the outcome of assisted conception. Hum Reprod 2001; 16:2411-7.
173
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
Stovall DW, Parrish SB, Van Voorhis BJ et al. Uterine leiomyomas reduce the efcacy of
assisted reproduction cycles: results of a matched follow-up study. Hum Reprod 1998; 13:1927.
Oliveira FG, Abdelmassih VG, Diamond MP et al. Impact of subserosal and intramural uterine
broids that do not distort the endometrial cavity on the outcome of in vitro fertilization-intracytoplasmic sperm injection. Fertil Steril 2004; 81:2-7.
Eldar-Geva T, Meagher S, Healy DL et al. Effect of intramural, subserosal, and submucosal
uterine broids on the outcome of assisted reproductive technology treatment. Fertil Steril
1998; 70:687-91.
Surrey ES, Lietz AK, Schoolcraft WB. Impact of intramural leiomyomata in patients with a
normal endometrial cavity on in vitro fertilization-embryo transfer cycle outcome. Fertil Steril
2001; 75:405-10.
Ramzy AM, Sattar M, Amin Y et al. Uterine myomata and outcome of assisted reproduction.
Hum Reprod 1998; 13:198-202.
Yarali H, Bukulmez O. The effect of intramural and subserous uterine broids on implantation
and clinical pregnancy rates in patients having intracytoplasmic sperm injection. Arch Gynecol
Obstet 2002; 266:30-3.
Jun, SH, Ginsburg ES, Racowsky C et al. Uterine leiomyomas and their effect on in vitro
fertilization outcome: a retrospective study. J Assist Reprod Genet 2001; 18:139-143.
Vercellini P, Maddalena S, de Giorgi O et al. Abdominal myomectomy for infertility: a comprehensive review. Hum Reprod 1998; 13:873-9.
Lindheim SR, Adsuar N, Kushner DM, Pritts EA, Olive DL. Sonohysterography: a valuable
tool in evaluating the female pelvis. Obstet Gynecol Surv 2003;58:770-84.
Cicinelli E, Romano F, Anastasio PS et al. Transabdominal sonohysterosgraphy, transvaginal
sonography, and hysteroscopy in the evaluation of submucous myomas. Obstet Gynecol 1995;
85:42-7.
Shamma FN, Lee G, Gutmann JN, Lavy G. The role of ofce hysteroscopy in in vitro fertilization. Fertil Steril 1992; 58:1237-9.
Soares SR, dos Reis MMBB, Camargos AF. Diagnostic accuracy of sonohysterography, transvaginal sonography, and hysterosalpingography in patients with uterine cavity diseases. Fertil
Steril 2000; 73:406-411.
Ayida G, Chamberlain P, Barlow D, Kennedy S. Uterine cavity assessment prior to in vitro
fertilization: comparison of transvaginal scanning, saline contrast hysterosonography and
hysteroscopy. Ultrasound Obstet Gynecol 1997; 10:59-62.
Tulandi T, Murray C, Guralnick M. Adhesion formation and reproductive outcome after myomectomy and second-look laparoscopy. Obstet Gynecol 1993; 82:213-5.
Dubuisson J-B, Fauconnier A, Deffarges J-V et al. Pregnancy outcome and deliveries following laparoscopic myomectomy. Hum Reprod 2000; 15:869-73.
Vercellini P, Trespdi L, Zina B et al. Gonadotropin-releasing hormone agonist treatment
before abdominal myomectomy: a controlled trial. Fertil Steril 2003; 79:1390-5.
Lethaby A, Vollenhoven B, Sowter M. Efcacy of pre-operative gonadotropin hormone releasing analogues for women with uterine broids undergoing hysterectomy or myomectomy: a
systematic review. Br J Obstet Gynecol 2002; 109:1097-1108.
Candiani GB, Fedele L, Parazzini F, Villa L. Risk of recurrence after myomectomy. Br J Obstet
Gynaecol 1991; 98:385-9.
Pron G, Bennett J, Common A et al. The Ontario broid embolization trial. Part 2. Uterine
broid reduction and symptom relief after uterine artery embolization for broids. Fertil Steril
2003; 79:120-7.
Goldberg J, Pereira L, Berghella V et al. Pregnancy outcomes after treatment for bromyomata: Uterine artery embolization versus laparoscopic myomectomy. Am J Obstet Gynecol
174
44.
45.
46.
47.
48.

2004; 191:18-21.
Ciraru-Vigneron N, Ravina JH. Reply of the authors. Fertil Steril 2001; 75:1247-8.
Ravina JH, Vigneron NC, Aymard A et al. Pregnancy after embolization of uterine myoma:
report of 12 cases. Fertil Steril 2000; 73:1241-3.
Arcangeli S, Pasquarette MM. Gravid uterine rupture after myolysis. Obstet Gynecol 1997;
89:857.
Stewart EA, Gedroyc WM, Tempany CM et al. Focused ultrasound treatment of uterine broid
tumors: safety and feasibility of a noninvasive thermoablative technique. Am J Obstet Gynecol
2003; 189:48-54.
Hindley J, Gedroyc WM, Regan L et al. MRI guidance of focused ultrasound therapy of uterine
broids: early results. Am J Roentgen 2004; 183:1713-9.
175
Treatment of tubal pathology or IVF?

John Bontis MD, PhD,
1st Dept of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Greece
Introduction
Tubal factor infertility resulting from various forms of tuboperitoneal damage
remains an extremely common cause of female infertility, accounting for more
than 35% of all cases of female infertility. Cornual occlusion, distal occlusion,
peritubal disease with or without ovarian involvement and multifocal disease
are included in the spectrum of tubal pathology, that disrupt not only the anatomic integrity but also the functional capacity of the tubes.
Probably the most severe form of tubal pathology is hydrosalpinx. Patients
with hydrosalpinges have been identied as a subgroup with signicantly lower
implantation and pregnancy rates than patients with other tubal pathology. The
main causes of hydrosalpinx are pelvic inammatory disease, previous ectopic pregnancy, endometriosis, previous abdominal operations, and history of
peritonitis and tuberculosis. Hydrosalpinx may be diagnosed with hysterosalpingography (HSG), transvaginal ultrasound, hydrosonography, laparoscopy,
salpingoscopy, hydrolaparoscopy and MRI. Laparoscopy is the gold standard
method for diagnosing hydrosalpinx but salpingoscopy is also is also essential
part of diagnostic and prognostic evaluation of the tubal mucosa.
Surgical management of hydrosalpinx

Many studies conclude that surgical management of hydrosalpinx improve
pregnancy rates. The rate of pregnancy after salpingoplasty depends on the
degree of destruction of the epithelium of the hydrosalpinx, hence the prognostic factors include the extent of adhesions, the nature of adhesions, the
176
diameter of the hydrosalpinx, the macroscopic condition of the endosalpinx and

tubal wall thickness. According to the previous criteria most authors suggest
four stages for the classication of hydrosalpinx, stages I, II, III and IV. The
success of pregnancy is higher in stages I and II but disappointing in stages
III and IV (Bontis et al 1996). On the contrary ectopic pregnancies are more
often reported in patients with stages III and IV. According to the literature
microsurgical and laparoscopic salpingostomy result in the same conception
rates but minimal access surgery has advantage over laparotomic microsurgery
as shorter hospital stay, less postoperative pain, and less adhesion formation are
reported after laparoscopy (Audebert et al 1998, Bontis and Dinas 2000).
Hydrosalpinx and IVF

In Vitro Fertilization (IVF) was rst developed as fertility treatment to overcome mechanical obstruction for women without functional fallopian tubes. In
patients with hydrosalpinges poor IVF results have been reported compared to
women with other tubal factor related infertility. Strandell et al (1994) reported
that the pregnancy rate in women with hydrosalpinges was 13% compared
with 23% in women with mild tubal damage. Vandromme et al (1995) had in
their series 10% pregnancy rate in women with hydrosalpinges and 23% in the
other group. Other studies demonstrated that hydrosalpinges adversely affect
implantation and pregnancy rates and increase the pre-clinical miscarriages,
spontaneous abortions and ectopic pregnancies (Kassabji et al 1994, Katz et al
1996, Andersen et al 1994, Vejtrop et al 1995, Strandell et al 1999).
Factors affecting implantation in presence of

hydrosalpinx
Retrospective studies have shown an impaired outcome of IVF in the presence
of hydrosalpinx. Meta-analysis of these data clearly demonstrated that the probability of achieving pregnancy in the presence of hydrosalpinx was reduced by
half, but on the contrary the rate of miscarriage was doubled. (Zeyneloglou
et al 1998, Camus et al 1999). Various factors affect the implantation rate
of the fertilized ovum after IVF and the hydrosalpinx uid may act on two
target systems: directly on the transferred embryos or on the endometrium
and its receptivity or both. The proposed mechanisms by which hydrosalpinx
decreases the success of implantation are: 1) reux of the hydrosalpinx uid
into the uterine cavity and mechanical washout of the embryos (Mansour et
al 1991, Andersen et al 1996), 2) irreversible endometrial damage simultane-
177
ously with the acute phase tubal damage (Strandell et al 1994) 3) release of
cytokines, lymphokines, prostaglandins, leukotrienes and other inammatory
compounds directly to the endometrium or via the lymphatic system (Rifo et
al 1989, Ben Rafael and Orvieto 1992, Cross et al 1994), 4) alteration in 3
integrin expression (Lessey et al 1996), 5) delayed hypersensitivity response
secondary to production of a 57-kDa heat-shock protein, leading to miscarriage
and chronic endometritis caused mainly by chlamydia trachomatis (Witkin et
al 1994) 6) increase in endometrial peristalsis (Ijland et al 1999). It is most
likely that low implantation rates in the presence of hydrosalpinx is caused by
a mixture of the above mentioned mechanisms.
Surgical management of hydrosalpinges before IVF

One of the rst studies to prove that surgical management of hydrosalpinx
improves the pregnancy rate was that by Vandromme et al. They compared
three groups of women with hydrosalpinx, salpingectomy and normal tubes.
The pregnancy rate was 10%, 22% and 31% respectively. Other studies showed
that surgical treatment of hydrosalpinx before IVF increases the chances of
pregnancy (Kassabji et al 1994, Shelton et al 1996). The rst prospective
randomized trial examining the effect of surgical intervention before IVF
showed a positive effect of salpingectomy on inplantation rates. (Dechaud et
al 1998). It was the prospective randomized study of Strantell et al (1999)
which proved that in patients with bilateral hydrosalpinges, salpingectomies
signicantly improved the implantation rate. In the same study in patients with
visible hydrosalpinges on ultrasonographic exanimation the pregnancy and
delivery rates also improved after salpingectomy (45,7 vs 22,5% and 40 vs
17% respectively). In a Cohranes review of all randomized controlled studies
the conclusion stated is that laparoscopic salpingectomy should be considered
for all women with hydrosalpinges due to undergo IVF (Johnson et al 2002).
The effect of salpingectomy on ovarian function has been debated and needs
further evaluation.
Other surgical, but not so invasive techniques, that have been also proposed
before IVF include needle aspiration of the hydrosalpinx uid at the time of
oocyte retrieval (Aboulghar et al 1990, Van Voorhis et al 1998), cautery or
mechanical occlusion of the tube proximal to the uterus (Stadmauer et al 2000,
Murray et al 1998) and salpingoplasty. Still randomized trials are needed to
assess the value of these forms of surgical approach.
178
Conclusion
Surgical management of hydrosalpinx prior to IVF increases the pregnancy
rates. Laparoscopic salpingectomy should be offered in women with hydrosalpinx, especially in those that have bilateral disease or in cases where hydrosalpinges are large enough to be visible on ultrasound.
References
Aboulghar MA, Mansour RT, Sesour GI et al. Transvaginal ultrasonic needle guided aspiration of
pelvic inammatory masses before ovulation induction for in vitro fertilisation. Fertil Steril
1990; 53: 311-314.
Andersen A, Yue Z, Meng F et al. Low implantation rate after in vitro fertilisation in patients with
hydrosalpinges diagnosed by ultrasonography. Hum Reprod 1994;9: 1935-1938.
Audebert AJ, Pouly JL, Von Theobald P. Laparoscopic mbrioplasty: an evaluation of 35 cases. Hum
Reprod 1998;13: 1496-1499.
Ben-Rafael Z & Orvieto R. Cytocines-involvement in reproduction. Fertil Steril 1992;58: 10931099.
Bontis J, Tarlatzis BV, Grimbizis G et al. Microsurgical and laparoscopic management of tubal
fertility: report of 763 cases. Middle East Fertil Soc J 1996;1:17-29.
Bontis J, Dinas K. Management of hydrosalpinx: Reconstructive surgery or IVF? Ann NY Acad Sci
2000; 900: 260-271.
Camus E, Poncelet C, Gofnet F et al . Pregnancy rates after in vitro fertilization in cases of tubal
infertility with or without hydrosalpinx: a meta-analysis of published comparative studies. Hum
Reprod 1999;14:1243-1249.
Cross Jc, Werb Z and Fisher SJ. Implantation and the placenta: key pieces of the development puzzle.
Science 1994;166:1508-1518.
Dechaud H, Daures JP, Arnal F et al. Does previous salpingectomy improve implantation and pregnancy rates in patients with severe tubal factor infertility who are undergoing in vitro fertilisation? A pilot prospective randomized study. Fertil Steril 1998;69: 1020-1025.
Johnson NP, Mak W, Sowter MC. Laparoscopic salpingectomy for women with hydrosalpinges
enhances the success of IVF: a Cochrane review. Hum Reprod 2002;17: 543-548.
Ijland MM, Hoogland HJ, Dunselman GA et al. Endometrial wave direction switch and the outcome
of in vitro fertilization. Fertil Steril 1999;71:476-481.
Kassabji m, Sims J, Butler L et al. Reduced pregnancy outcome in patients with unilateral or bilateral
hydrosalpinx after in vitro fertilization. Eut J Obstet Gynaecol Reprod Biol 1994;56:129-132.
Katz E, Akman MA, Damewood MD et al. Deleterious effect of the presense of hydrosalpinx on
implantation and pregnancy rates with in vitro ferilisation. Fertil Steril 1996;66: 122-125.
Lessey BA, Ilesanmi AO, Lessey MA et al. Luminal and glandular endometrial epithelium express
integrins differentially throughout the menstrual cycle: implications for implantation, contraception and infertility. Am J Reprod Immunol 1996;35:195-204.
Mansour RT, Aboulgar MA, Serour GI et al. Fluid accumulation of the uterine cavity before embryo
transfer: a possible hindrance for implantation. J In Vitro Fert Embryo Transf 1991;8:157-159.
Murray DL, Sagoskin AW, Widra EA et al. The adverse effect of hydrosalpinges on in vitro fertilizationpregnancy rates and the benet of surgical correction. Fertil Steril 1998;69:41-45.
Stadmauer LA, Riehl RM, Toma SK et al. Cauterisation of hydrosalpingew before in vitro fertilisation is an effective surgical treatment associated with improoved pregnancy rates. Am J Obstet
179
Gynecol 2000; 183: 367-371.
Shelton KE, Butler L, TonerJP et al. Salpingectomy improoves the pregnancy rate in vitro fertilisation
with hydrosalpinx. Hum Reprod 1996;11: 523-525.
Strandell A, Lindhard A, Waldernstrom U, et al. Hydrosalpinx and IVF outcome: a prospective, randomized multicentre trial in Scandinavia on Salpingectomy prior to IVF. Hum Reprod 1999;14:
2762-2769.
Strandell A, Waldernstrom U, Nilsson L et al. Hydrosalpinx reduces in vitro fertilisation/embryo
transfer pregnancy rates. Hum Reprod 1994; 9: 861-863.
Strandell A, Thorburn J, Hamberger L. Risk factors for ectopic pregnancy in assisted reproduction.
Fertil Steril 1999;71: 282-286.
Vandromme J, Chasse B, Lejeune B et al. Hydrosalpinges in in vitro fertilisation: an unfavorable
prognostic feature. Hum Reprod 1995; 10: 576-579.
Van Voorhis BJ, Sparks AE, Syrop CH et al. Ultrasound guided aspiration of hydrosalpinges is
associated with improoved pregnancy and implantation rates after in vitro fertilisation cycles.
Hum Reprod 1998; 13: 736-739.
Vejtrop M, Petersen K, Andersen AN et al. Fertilisation in vitro in the presense of hydrosalpinx and
in advanced age. Ugeskr. Laeger 1995;157: 4131-4134.
Witkin SS, Sultan KM, Neal GS et al. Unsuspected chlamydia trachomatis infection and in vitro
fertilisation outcome. Am J Obstet Gynecol 1994;171: 1208-1214.
Zeynoglou HB, Arici A, Olive DL. Adverse effects of hydrosalpinx on pregnancy rates after in vitro
fertilization-embryo transfer. Fertil Steril 1998;70:492-499.
180
Uterine septum resection or IVF which comes rst ?

Dr Pirard.Cline, Dr Laurent Pascale, Pr Donnez Jacques
Congenital malformations may be associated with recurrent pregnancy loss,

preterm labor, abnormal fetal presentation, and infertility. The most common
uterine anomaly is the septate uterus. Its incidence in the general population is
estimated to be 1.8% (Ashton et al 1988).
It is not clear why uterine anomalies are associated with reproductive failure.
According to histologic observations, the septum is described as broelastic tissue (Fedele and Bianchi 1995). Using scanning electron microscopy to
compare endometrial biopsy specimens obtained from different areas of the
uterine cavity, Fedele et al (1993) found that septal endometrium showed defective development, indicative of a reduction in sensitivity to steroid hormones.
They subsequently postulated that endometrial septal defects could play a role
in the pathogenesis of primary infertility in case of uterine septa.
Another hypothesis that could explain reproductive failure is that spontaneous miscarriage may be the result of a poor blood supply to the septum, leading
to poor implantation dynamics (Burchell et al 1978).
In a review published in 2000, Homer et al reported the reproductive outcome of women with an untreated septate uterus. Out of 1376 pregnancies,
1085 (79%) ended in miscarriage and 125 (9%) in preterm delivery. But if we
181
calculate the percentage of preterm deliveries out of ongoing pregnancies, a

hefty 42% of patients who escaped the very high risk of miscarriage, delivered
prematurely.
Bearing this in mind, it is logical to try to improve the situation.
Hysteroscopic resection of an intrauterine septum may benet patients
suffering from infertility or recurrent pregnancy loss. Many Mllerian fusion
defects respond well to hysteroscopic treatment. Several different procedures
have been adopted, with more or less similar results.The basic concept involves
the transcervical observation of the uterine septum by means of hysteroscopiy,
followed by its resection ( Chervenak and Neuwirth, 1981; Valle and Sciarra,
1986; Gallinat, 1993). The use of an operative hysteroscope permits the passage of surgical instruments. A partial or complete uterine septum can be easily
resected using an Nd-YAG laser and if present, a vaginal septum may also de
removed during the same procedure
In a review published in 2000, Homer et al reported data from several series that compared the outcomes of pregnancies before and after hysteroscopic
metroplasty in patients with a septate uterus. The miscarriage rate, preterm
delivery rate and term delivery rate were 88%, 9%, and 3% respectively before
surgery, and 14%, 6%, and 80% after hysteroscopic metroplasty. This is in line
with the drops in the miscarriage rate after abdominal metroplasty, reported by
Ayhan et al in 1992 (90% before operation and 17 % after).
More recently, other authors have published their ndings on reproductive
outcome after hysteroscopic metroplasty for a septate uterus. Hickok (2000)
reported his experience with hysteroscopic treatment of uterine septa. The preoperative pregnancy loss rate was 77.4%, while the postoperative miscarriage
rate was 18.2%. Patton et al (2004) reported very similar result. In the specic
case of complete septate uterus, duplicated cervix and vaginal septum, 12 out
of 16 women conceived after surgery. The pregnancy loss rate was 81% before
surgery and 18% after. Litta et al (2004) reported their experience with hysteroscopic metroplasty under laparoscopic guidance for patients with a septate
uterus. Out of 35 patients treated, 26(75%) achieved pregnancy. Only 3 patients
delivered prematurely.
Table 1 summarizes the reproductive outcome after hysteroscopic metroplasty for septate uterus. After surgery, the miscarriage rate is 14.3% (88/617).
Out of 529 ongoing pregnancies, the preterm delivery rate is 7.2% (38/529)
and the term delivery rate 92.8% (491/529)
In terms of fertility, three different situations need to be addressed: patients
experiencing recurrent miscarriage, patients suffering from primary infertility and patients for whom IVF treatment is indicate.
11
16
22
12
15
12
57
24
55
14
71
62
49
115
94
16
40
20
69
20
735
De Cherney and Polan*
Fayez
March and Israel
Perino and al
Daly et al
Choe et Baggish
Fedele et al
Cararach et al
Pabuccu et al
Valle
Mencaglia and Tantini
Patton et al
Hickok
Jourdain et al
Colacurci et al
Litta et al
Total
617
18
46
17
62
103
44
41
65
12
75
15
56
Chervenak and Neuwirth
N of pregancies
N of patients
Author
N of ongoing
529
( 85.7%)
(14.3%)
18
36
10
18
14
58
91
42
29
55
11
60
14
48
14
88
10 (21.8%)
2 (16.6%)
4 (18.2%)
3 (18%)
4 (6%)
12 (12%)
2 (4.5%)
12 (29%)
10 (16%)
1 (8.3%)
15 (20%)
1 (7%)
8 (14%)
2 (13%)
2 (18%)
miscarriages (%) pregnancies (%)
N of
Table 1: Reproductive outcome after hysteroscopic metroplasty for septate uterus
(7.2%)
38
10
(92.8%)
491
15
31
10
17
14
58
84
40
29
45
10
55
14
44
14
deliveries ( %)
preterm deliveries (%)

0
pregnancies with term
N of ongoing
pregnancies with
N of ongoing
182
183
Recurrent miscarriage
The prevalence of septate uterus has been found to be increased in women
experiencing recurrent miscarriage compared to fertile women. ( Raziel et all
1994).De Cherney et al (1986) demonstrated that hysteroscopic removal of the
septum in women with recurrent rst trimester miscarriage improved reproductive outcome. Fedele et al (1993) later showed that, in women with recurrent
miscarriage, the presence of a uterine septum is an indication for metroplasty.
These patients are potentially fertile with no obvious indications for IVF.
Patients with primary infertility

The role of hysteroscopic metroplasty in patients with primary infertility remains controversial. Homer et al reported, in their review in 2000, a gross
pregnancy rate of 48% after septoplasty in 84 infertile patients. According to
some authors, this treatment not only increases the pregnancy rate, but also
reduces the miscarriage rate and the preterm delivery rate when these women
nally become pregnant (Fedele et al 1995 and Marabini et al 1994).
Pabuccu and Gomel recently reported (2004) their results on a group of
patients with uterine septa and otherwise unexplained primary infertility.
Sixty-one patients aged < 35 years underwent hysteroscopic metroplasty.
After a period of 8-14 months, the pregnancy rate was 41% (25/61) and the
live birth rate 29.8% (18/61).
In this particular population of patients with primary infertility, the pregnancy rate and live birth rate were lower than those described in patients with
previous miscarriages.
The authors concluded that this could be due to the fact that women who
have experienced miscarriage have proven fertility, compared to those suffering from primary infertility.
Patients for whom IVF treatment is indicated

Until now, no prospective randomized study has been published to evaluate the
benets of metroplasty for patients with a septate uterus, for whom assisted
reproduction is indicated. However, in 1991, Kirsop et al reported improved results with IVF after hysteroscopic treatment of uterine abnormalities. In 1996,
Dicker et al published their results on 144 women who underwent hysteroscopy
after experiencing a miscarriage. Intrauterine abnormalities, mainly uterine
septa were found in 14 cases (9.7%). They concluded that an incomplete uterine
septum may be an important factor predisposing women to early pregnancy
184
wastage. Other authors also recommended uterine metroplasty for women contemplating assisted reproduction. ( Daly et al 1989; Valle et al 1986).
Complications
Operative hysteroscopy is a safe and effective method of management of uterine septa associated with recurrent pregnancy loss, and makes future vaginal
delivery possible. However, classic perioperative complications such as uid
overload, infection, hemorrhage or perforation may result from the hysteroscopic procedure itself. Because hysteroscopic metroplasty is a relatively short
procedure involving avascular tissue, the risk of signicant uid overload is
minimal. Only one case of pulmonary edema during hysteroscopic metroplasty
has been reported (Cararach et al 1994).
March and Israel (1987) reported signicant bleeding in 3 (3%) out of 91
patients within the rst 10 days of hysteroscopic septal incision. De Cherney et
al (1986) reported one perforation, which did not require surgical intervention,
out of 72 completed septoplasties with the resectoscope. Lobaugh et al (1994)
reported one case of uterine rupture during the second of two pregnancies
after unevenful hysteroscopic metroplasty. Other authors have also reported
uterine rupture after hysteroscopic metroplasty. Most of the time, surgery was
performed without any complications (Mencaglia and Tantini 1996; Kerimis et
al 2002; Angell et al 2002). Conturso et al (2003) reported spontaneous uterine
rupture at 28 weeks of pregnancy in a patient with a history of hysteroscopic
resection of a uterine septum, complicated by fundal perforation.
In one of our series of 17 complete uterine septa treated by hysteroscopy,
10 out of 17 women became pregnant and no signs of cervical incompetence
were observed. (Nisolle and Donnez 1996). Prophylactic cerclage was never
performed after resection of a complete cervical and uterine septum. In another
of our series (Donnez and al 1997), perioperative and postoperative complications were encountered in only 3 cases out of 70 (1.8%). In this series, no uid
overload or hemorrhage was encountered and perforation was noted in only
one case, after a second resection in the same patient.
Two postoperative complications encountered in another hospital were uterine ruptures during delivery. These two cases were twin pregnancies and the
deliveries were very long, taking > 24 h.
We thus concluded that, in normal conditions, the delivery can be performed
vaginally following uterine septum resection, but in case of multiple pregnancy,
Caesarean section should be considered.
185
Conclusion:
Uterine septum resection or IVF: which comes rst?
Operative hysteroscopy is a simple, safe and effective method of management of uterine septa with minimal perioperative and postoperative complications. The pregnancy and delivery outcome after hysteroscopic metroplasty is
signicantly improved in women who have suffered recurrent miscarriages.
Patients embarking on IVF routinely undergo an assessement of the uterine
cavity before starting treatment. At that time, any uterine anomalies, such as
a septate uterus are investigated. Because of the safety and effectiveness of
surgery, and the impact that surgery could have on the pregnancy and delivery
outcome, we recommend it before starting IVF, even if infertility factors other
than the presence of a uterine septum may be involved.
In normal conditions, the delivery can be performed vaginally following
uterine septum resection, but in case of multiple pregnancy (more common after IVF), vigilance is mandatory and Caesarean section should be considered.
References:
Ashton, D., Amin, H.K., Richart, R.M. and Neuwirth, R.S. (1988) The incidence of symptomatic
uterine anomalies in women undergoing transcervical tubal sterilization. Obstet. Gynecol., 72,
28-30
Fedele, L. and Bianchi, S. (1995) Hysteroscopic metroplasty for the septate uterus. Obstet Gynecol
Clin North Am, 22, 473-489
Fedele, L., Arcaini, L., Parazzini, F., Vercellini, P., Nola, G. (1993) Reproductive prognosis after
hysteroscopic metroplasty in 102 women: life-table analysis. Fertil. Steril., 59, 768-72
Burchell, R.C., Creed, F., Rasoulpour, M and Whitcomb, M (1978) Vascular anatomy of the human
uterus and pregnancy wastage. Br. J Obstet. Gynaecol, 85, 698-706.
Homer, H.A., Li, T-C. and Cooke, I.D. ( 2000) The septate uterus: a review of management and
reproductive outcome. Fertil. Steril, 73, 1-14
Chervenak, F.A. and Neuwirth, R.S. (1981) Hysteroscopic resection of the uterine septum. Am J
Obstet. Gynecol. 141, 351
Valle, R.F. and Sciarra, J.J. (1986) Hysteroscopic resection of the septate uterus Obstet. Gynecol.
67, 253
Gallinat, A. (1993) Endometrial ablation using the Nd-YAG laser CO2 hysteroscopy. In Leuken,
R.P. and Gallinat, A. (eds), Endoscopic Surgery in Gynecology. Demeter Verlag GmbH, Berlin,
pp 109-116
Ayhan, A., Yucel, I., Tuncer, Z. and Kisnisci, H. (1992) Reproductive performance after conventional
metroplasty: an evaluation of 102 cases. Fertil. Steril, 57, 1194-1196
Hickok, L. (2000) Hysteroscopic treatment of the uterine septum: a clinicians experience. Am. J.
Obstet. Gynecol., 182, 1414-1420
Patton, Ph., Novy, M., Lee, D., Hickok, L. (2004) The diagnosis and reproductive outcome after
surgical treatment of the complete septate uterus, duplicated cervix and vaginal septum. Am. J.
of Obstetrics and Gynecology, 190, 1669-1678
Litta, P., Pozan, C., Merlin, F., Sacco, G., Saccardi, C., Ambrosini, G., Capobianco, G. and Dessole,
186
S. (2004) Hysteroscopic metroplasty under laparoscopic guidance in infertile women with septate
uteri : follow-up of reproductiv outcome. J. Reprod. Med., 49(4), 274-8
De Cherney, A. and Polan M.L. (1983) Hysteroscopic management of intrauterine lesions and intractable uterine bleeding. Obstet Gynecol, 61, 392-397
Fayez, J.A. (1986) Comparison between abdominal and hysteroscopic metroplasty. Obstet. Gynecol.,
70, 399-406
March, C.M. and Israel, R. (1987) Hysteroscopic management of recurrent abortion caused by the
septate uterus. Am. J. Obstet. Gynecol., 156, 834-842
Perino, A., Mencaglia, L., Hamou, J. and Cittadini, E (1987) Hysteroscopy for metroplasty of uterine
septa: report of 24 cases Fertil Steril, 48, 321-323
Daly, D.C., Maier, D. and Soto-Albors, C. (1989) Hysteroscopic metroplasty: six yearsexperience.
Obstet. Gynecol., 73, 201-205
Choe, J.K. and Baggish, M.S. (1992) Hysteroscopic treatment of septate uterus with neodymiumYAG laser Fertil Steril, 57, 81-84
Cararach, M., Penelle, J., Ubeda, A. and Labastida, R; (1994) Hysteroscopic incision of the septate
uterus: scissors versus resectoscope. Hum Reprod, 9, 87-97
Pabuccu, R., Atay, V., Urman, B., Ergun, A. and Orhon, E (1995) Hysteroscopic treatment of septate
uterus. Gynaecol Endosc, 4, 213-215
Valle, R.F. (1996) Hysteroscopic treatment of partial and complete uterine septum. International
Journal of Fertility and Menopausal studies, 41, 310-315
Mencaglia, L. and Tantini, C. (1996) Hysteroscopic treatment of septate and arcuate uterus. Gynaecol
endosc, 5, 151-154
Jourdain,O., Dabysing, F., Harle, T., Lajus, C., Roux, D., Dallay, D. (1998) Management of septate
uterus by exible hysteroscopy and Nd :YAG laser. Int. J. Gynaecol. Obstet., 63(2), 159-62
Colacurci, N., De Placido, G., Mollo, A., Carravetta, C., De Franciscis P. (1996) Reproductive outcome after hysteroscopic metroplasty. Eur. J. Obstet. Gynecol. Reprod. Biol., 66(2), 147-50
Raziel, A., Arieli, S., Bukovsky, I., Caspi, E. and Golan, A. (1994) Investigation of the uterine cavity
in recurrent aborters. Fertil. Steril, 62, 1080-1082
DeCherney, A. H., Russel, L.J.B., Graebe, R.A. et all, ( 1986) Resectoscopic management of
Mllerian defects. Fertil. Steril., 45, 726
Marabini, A., Gubbini, G., Stagnozzi, R., Stefanetti, M., Filoni, M. and Bovicelli, A. (1994)
Hysteroscopic metroplasty. Ann N Y Acad Sci, 734, 488-492
Pabucu, R. and Gomel, V. (2004) Reproductive outcome after hysteroscopic metroplasty in women
with septate uterus and otherwise unexplained infertility. Fertil. Steril, 81, 1675-1678
Kirsop, R., Poter, R., Torode, H., Smith, D. and Sauders, D. (1991) The role of hysteroscopy in
patients having failed IVF/GIFT transfer cycles. Aust N Z Obstert Gynaecol, 31, 263-264
Dicker, D., Ashkenazi, J., Dekel, A., Orvieto, R., Feldberg, D., Yeshaya, A. and Ben-Rafael, Z. (1996)
The value of hysteroscopic evaluation in patients with preclinical in-vitro fertilisation abortions.
Hum Reprod, 11, 730-731
Lobaugh, M.L., Bammel, B.M., Duke, D. and Webster, B.W. (1994) Uterine rupture during pregnancy in a patient with a history of hysteroscopic metroplasty Obstet. Gynecol. 83, 838-840
Kerimis, P., Zolti, M., Sinwany, G., Mashiach, S. and Carp, H. (2002) Uterine rupture after hysteroscopic resection of uterine septum. Fertil Steril , 77, 618-620
Angell, N.F., Tan Domingo, J. and Siddiqi, N. (2002) Uterine rupture at term after uncomplicated
hysteroscopic metroplasty. Obstet Gynecol, 100, 1098-1099.
Conturso, R., Redaelli, L., Pasini, A. and Tenore, A. (2003) Spontaneous uterine rupture with amniotic sac protrusion at 28 weeks subsequent to previous hysteroscopic metroplasty. Eur J Obstet
Gynecol and Reprod Biol, 107, 98-100
Nisolle, M. and Donnez, J. (1996) Endoscopic treatment of Mllerian anomalies. Gynecol. Endosc.,
5, 155-160
187
Donnez, J. and Nisolle, M. (1997) Endoscopic laser treatment of uterine malformations. Hum Reprod,
12, 1381-1387
188
In vitro maturation
In vitro maturation of human oocytes,
potential benet of in vivo priming
with FSH/hCG before aspiration and
priming of the endometrium.
Anne Lis Mikkelsen MD: Dr.SCI.
Herlev University Hospital, Dk-2730 Herlev Denmark
Background.
The basis of in vitro maturation (IVM) is the maturing in vitro of oocytes from
Germinal Vesicle (GV) stage of development to the metaphase II (MII) stage.
In fully-grown oocytes resumption of meiosis in vivo is triggered by luteinizing
hormone (LH) surge. Removal of the oocyte from the follicle is the corresponding in vitro signal. Oocyte maturation includes nuclear and cytoplasmic events.
The end point whether in vivo or in vitro is a MII oocyte which can be fertilized
and which can support normal embryonic development.
The immature oocytes are retrieved ultrasound guided transvaginally from
antral follicles of 2-10 mm in diameter. A high proportion of these in vitro
matured oocytes are able to resume meiosis and reach the MII stage in vitro.
Their ability to be fertilized after 28 - 36 hours of IVM is also high and a similar
proportion is able to undergo early cleavage stage development comparable to
conventional IVF and ICSI embryos.
The ability of immature oocytes to spontaneously resume meiosis when
removed from the follicle was rst demonstrated by Pincus and Enzman in
1935 (1). This was later conrmed by Edwards (2,3). In 1969 Edwards et al. (4)
were able to demonstrate for the rst time the fertilization of in vitro matured
human oocytes.
189
Oocyte maturation includes nuclear maturation and cytoplasmic maturation.

Nuclear maturation is dened as resumption of meiosis and progression to
MII. Cytoplasmic maturation refers to processes that prepare for egg activation, pronuclear formation and early embryodevelopment. Even though oocytes
may be competent to complete nuclear maturation they may be decient in
cytoplasmic maturation and resumption of meiosis is not itself a sufcient
guide to developmental competence (5). Evaluation of the development of
oocytes following fertilization is generally considered to be a valid criterion
for developmental competence of the oocyte (6). However, the effects of cytoplasmic aberrations are seldom expressed at an early stage of development but
instead more frequently associated with cleavage and peri-implantation stages
(5). Therefore, fertilization and pronuclear development may occur in a wide
spectrum of eggs, which lack the capacity to develop normally to term and the
guide to the full developmental capacity is delivery of healthy infants.
IVM followed by IVF-ET.

Immature oocytes have been obtained from women who were undergoing
routine superovulated In Vitro Ferilization (IVF) (rescue IVM). During controlled ovarin hyperstimulaion the oocyte population may be heterogeneous
and this leads to retrieval of oocytes at different stages of maturation. About
15% of oocytes will remain in prophase I of meiosis. These oocytes can mature
in vitro and develop into viable embryos In 1983 Veeck and co-workers (7)
reported two pregnancies from ET of developed immature oocytes obtained
from stimulated cycles in their IVF programme. Other reports have been made
by several groups after that (8,9). These oocytes, however, may represent an
inferior population as they failed to mature although the follicles were exposed
to supra-physiological concentrations.
In this chapter the experience obtained in handling immature oocytes from
two main groups are summarized: The rst group is women suffering from
polycystic ovarian syndrome (PCOS), as these women are extremely sensitive
to stimulation with Follicle Stimulating Hormone (FSH) in assisted reproduction, and they have a signicant risk of developing ovarian hyperstimulation
syndrome (OHSS). The second group is regular cycling women with normal
ovaries referred for IVF or Intracytoplamic Sperm Injection (ICSI) due to severe
male infertility. In both groups aspiration of immature oocytes has been performed in unstimulated cycles and after priming with FSH and/or after priming
with human Chorionic Gonadotrophin (hCG) before aspiration. Furthermore,
the impact of emdometrial priming will be discussed.
190
Immature oocytes obtained from women with PCOS.

No priming. .
Trounson et al. (10) described the rst pregnancy. The following year another
pregnancy was reported in a patient with PCOS treated with IVM, combined
with ICSI and assisted hatching (11). Barnes et al. (12) compared rates of
maturation, fertilization and cleavage between untreated regularly ovulation
and irregularly or anovulatory polycystic women. In almost all the parameters
analysed oocytes from regularly cycling patients performed better. The reason
for this was not determined. Later Cha et al.,(13) achieved a pregnancy rate of
27.1%. However this high pregnancy rate was obtained after transfer of an average 6.3 embryos per patient, and the implantation rate was still low (6.9%)
To compensate for this, endogenous priming with FSH (14,15) or hCG
(16,17) has been suggested before oocyte pick-up and IVM.
Priming with FSH.
It has been postulated, that FSH stimulation before oocyte retrieval might increase either the number of immature oocytes retrieved or the maturational
potential and developmental competence of the oocytes. Suikkari et al. (14)
proposed low-dose (37.5 IU) recombinant FSH (rFSH) from previous lutheal
phase until leading follicle reached 10 mm. This resulted in maturation and
fertilization rates in women with PCOS comparable with those in regularly
cycling women, however no pregnancies were achieved.
A benecial effect of FSH priming was found in a prospective randomized study (15). Oocytes obtained after priming with rFSH (150 IU per day)
for 3 days were compared with oocytes obtained in unstimulated cycles. FSH
priming resulted in improved pregnancy rate (29% vs. 0%) and implantation
rate (21.6% vs. 0%) compared with the non-primed group. This was partly explained by the increased size of the folllicles in the stimulated group compared
to the non-stimulated group. Previous studies have demonstrated that human
oocytes appear to have a size dependent ability to resume meiosis and complete
maturation (18). Not only FSH priming but also the following FSH deprivation
caused by withholding exogenous FSH should enhance the competence of the
oocytes. It has been hypothesized that oocyte differentiation may be incomplete
during follicular growth, and that oocytes from plateau phase follicles have
increased competence (19).
Priming with hCG.
In 1999 Chian et al reported, that giving 10.000 IU hCG 36 hoours before
191
oocyte retrieval improved maturation rate of immature oocytes from PCOS

women (20). In a prospective randomised study they later demonstrated, that
hCG priming not only improved the maturation rate, but also hastened the
maturation proces (16). The authors showed that 46% of the oocytes were
already maturing in hCG primed patients and the oocytes completed meiosis
12 24 hours ahead of oocytes from unprimed (no hCH stimulation) patients.
The nal outcomes of fertilization, embryo development and pregnancy rates
for hCG primed and unprimed patients were not signicantly different. The
potential mechanism of the action of hCG on these small follicles is unclear.
In a multicenter study including 1000 cycles with hCG priming before immature oocyte retrieval pregnancy rates of 30 35 % has been obtained (21).
The implantation rate is however still low (10 15%). Similar pregnancy rate
of 33.8% and implantation rate of 10.5% has been reported by Lin et al. (22)
using hCG priming. Additional FSH priming (75 IU per day for 6 days initiated
on day 3) did not make any difference.
Immature oocytes from regular cycling women with

normal ovaries.
No priming.
Control of the menstrual cycle is a complex process involving both the hypothalamic-pituritary axis as well as local (paracrine and endocrine) factors.
The follicles destined to ovulate will be selected from a cohort of follicles,
which enter the follicular phase of the menstrual cycles with a diameter of 2-6
mm. The selected follicle will grow to a diameter of 20-25 mm at the time of
ovulation. Circulating levels of FSH and LH regulate the follicular growth and
development. The rise in serum FSH levels during the early follicular phase
causes a cohort of follicles, responsive to FSH stimulation to grow and the
dominant follicle can be distinguished from other cohort follicles by size (>10
mm diameter). Synthesis of oestradiol is closely linked to development of the
preovulatory follicle and the concentrations of oestradiol in the follicle and
serum correlate signicantly with the size of the follicle. The increase in the
concentration of oestradiol is the principal factor for establishment of dominance. It has a negative feed-back on the hypothalamus axis with subsequent
decrease in the level of FSH. The dominant follicle withstands this decline,
while subordinate follicles are susceptible to a decline in gonadotrophins and
follicles undergo atresia. The subordinate follicles, however, can be rescued
and thereby avoid atresia by stimulatory treatments with FSH or by retrieval
of immature oocyte and in vitro maturation.
192
The timing of oocyte aspiration in unstimulated cycles may be critical allowing as many follicles as possible to reach sufcient size for cytoplasmic
competence of the oocytes (23), while avoiding a prolonged negative effect
of the developing dominant follicle. The rst births from IVM of immature
oocytes from unstimulated cycles used oocytes that had been retrieved at different moments in the menstrual cycle (12, 24 - 26).
Up to the point of dominant follicle selection all oocytes in the cohort undergo processes such as RNA transcription, protein synthesis, and organelle
modications and redistributions that prepare them for the potential of resumption of meiosis and eventual fertilization. Mikkelsen et al. (27, 28) aimed at
oocyte collection to coincide with selection of the dominant follicle. Oocytes
were aspirated after a leading follicle of 10 mm and an endometrial thickness
of at least 5 mm were observed at ultrasound. Pregnancy rate of 18% - 24%
per transfer was obtained in cycles with a detected increase in the level of oestradiol on the day of aspiration. Oocytes originating from the ipsilateral ovary
did not show to have an impaired competence to mature and cleave compared
to oocytes originating from the contralateral ovary (29).
FSH priming.
Previous observations have reported that the quantum of recruitable follicles
is xed as early as the proceeding luteal phase and a short early follicular
FSH stimulation may not alter the number of recruitable oocytes. Few studies
have examined the effect of priming with FSH before aspiration of immature
oocytes in regularly menstruating women. (14, 22, 30-32). The series are small,
a variety of stimulation regimens have been used and limited information can
be drawn.
Wynn et al (30), administered 600 IU rFSH to women over 5 days (300 IU
on day 2, 150 IU on day 4 and 150 IU on day 6). A mean of 7.5 oocytes we
received from rFSH compared with 5.2 from umprimed women. Wynn et al.,
(30) did not perform fertilization of the oocytes and no conclusion concerning
developmental capacity can be drawn from that experiment.
Later studies of the treatment of women for 1 or 3 days with rFSH early in
the follicular phase showed no difference in recovery rate of oocytes, or rates
of maturation, fertilization or cleavage in culture (22). This was conrmed in a
prospective randomized study (30). In one group oocytes were aspirated after
priming with rFSH (150 IU per day) for 3 days followed by deprivation for 2-3
days. In the other group oocytes were obtained in unstimulated cycles and the
day of aspiration was xed in the same way (after a follicle of 10 mm could be
demonstrated). FSH priming did not increase the number of oocytes recovered
193
and no benet on FSH priming compared to natural cycle on the maturation

rate, fertilization rate, cleavage rate or pregnancy rate could be demonstrated.
Studies in cattle indicate an advantage of using moderate follicle stimulation
followed by a period of FSH deprivation to obtain optimal embryo production
from bovine oocytes (19). Similar studies in human are lacking. Mikkelsen et
al. (31) compared 2 vs. 3 days priming and were unable to demonstrate any
difference in the implantation rate between the two groups.
hCG priming.
Child et al. (33) described the use of hCG priming with 10.000 IU 36 hours
before aspiration in unstimulated regular cycling women. The authors demonstrated that immature oocytes retrieved from normal ovaries achieved similar
maturation rates compared to oocytes retrieved from PCOS. The yield of immature oocyte, and hence the yield of embryos were signicantly less in women
with normal ovaries than from women with PCOS. In both groups the number
of follicles and measument of basal FSH, and oestradiol are useful in predicting
the number of immature oocytes retrieved and the pregnancy rate (28,32).
Priming of the endometrium.
Puncturing follicles before they have reached maturity may result in an endometrium that is inadequately primed due to lack of adequate endogenous
oestradiol and progesterone for implantation. This may explain the low implantation rate reported in the early study (10). Exogenous priming with oestradiol and progesterone is needed and one must synchronise the window of
implantation with the embryo development. An increased maturation rate and
fertilization rate have been found when midfollicular priming with oestradiol
was initiated compared to early endometrial priming (24). It is well know from
hormone replacement in recipients of donor oocytes that 2-day-old embryos
are best transferred into the endometrial cavity on day 3 or 4 of progesterone
exposure. In our studies we aimed at imitating the normal priming as closely
as possible and initiated oestradiol on the day of aspiration and supplemented
with progesterone 2 days later. The women received 17--oestradiol 2 mg
orally three times a day and progesterone 100 mg 3 times a day. Oestrogen and
progesterone were continued until pregnancy test, and if the pregnancy test was
positive until day 90 of gestation (27-29). This model has been reported in the
main part of the studies.
194
Conclusion.
Recent data taken together suggest that in future immature oocyte retrieval
combined with IVM could possibly replace standard stimulated IVF in selected
patients.
In women with PCOS there is evidence from previous studies that competent oocytes could originate after priming with hCG. Priming with FSH for
3 days followed by deprivation for 2-3 days before harvesting of immature
oocytes from patients with PCOS may improve the maturational potential of
the oocytes and the implantation rate of the cleaved embryos.
In unstimulated cycles of regular cycling women the recovery of oocytes
has to coincide with selection of the dominant follicle. In stimulated cycles a
time interval between FSH administration and aspiration has been found to
improve the developmental capacity of oocytes.
195
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Pincus G and Enzmann EV 1935 The comparative behaviour of mammalian eggs in vivo and
in vitro. Journal of Experimental Medicine 62, 665-75.
Edwards RG 1965a Maturation in vitro of human ovarian oocytes. Lancet II, 926-9.
Edwards RG 1965b Maturation in vitro of mouse, sheep, cow, pig, rheusus monkey and human
ovarian oocytes. Nature 208, 349-51.
Edwards RG, Bavister BD, Steptoe PC 1969 Early stages of fertilization in vitro of human
oocytes matured in vitro. Nature 221, 632-635.
Eppig JJ, Schultz RM, OBrien M 1994 Relationship between the developmental programs
controlling nuclear and cytoplasmic maturation of mouse oocytes. Devopmental Biology
164,1-9.
Eppig JJ, OBrien MJ, Pendola FL et al.1998 Factors affecting the developmental competence of mouse oocytes grown in vitro: Follicle stimulation hormone and insulin. Biology of
Reproduction 59, 1445-53.
Veeck LL, Wortham JW, Witmeyer J et al. 1983. Maturation and fertilization of morphologically immature human oocytes in a program of in vitro fertilization. Fertility and Sterility 1983;
39, 594-602.
Nagy ZP, Cecile J, Liu J et al.1996 Pregnancy and birth after intracytoplasmic sperm injection
of in vitro matured germinal vesicle stage oocytes:case report. Fertility and Sterility 65, 104750.
Liu J, Katz E, Garcia JE et al 1997. Successful in vitro maturation of human oocytes not
exposed to human chorionic gonadotropin during ovulation induction, resulting in pregnancy.
Fertility and Sterility 67, 566-68.
Trounson A, Wood C, Kausche A 1994 In vitro maturation and the fertilization and developmental competence of oocytes recovered from untreated polycystic ovarian patients. Fertility
and Sterility 62, 353-62.
Barnes FL, Crombie A, Gardner DK, Krause A, Lachum-Kaplan O, Suikkari A-M, Tiglias J,
Wood C and Trounson AO. 1995 Blasttocyst development and birth after in vitro maturation
of human primary oocytes, intracytoplasmic sperm injection and assisted hatching Human
Reproduction 10; 3243-3247.
Barnes FL, Kausche A, Tiglias J et al 1996 Production of embryos from in vitro-matured
primary human oocytes. Fertility and Sterility 65,1151-6.
Cha KY, Han SY, Chung HM 2000 Pregnancies and deliveries after in vitro maturation culture
followed by in vitro fertilization and embryo transfer without stimulation in women with
polycystic ovary syndrom. Fertility and Sterility 73, 978-83.
Suikkari A-M, Tulppala M, Tuuri T et al. 2000 Lutheal phase start of low-dose FSH priming
of follicles results in an efcient recovery, maturation and fertilization of immature human
oocytes. Human Reproduction 15, 747-51.
Mikkelsen A.L., Lindenberg S 2001 Benet of FSH priming of women with PCOS to the invitro maturaation procedure and the outcome. A randomized prospective study. Reproduction
122, 587-92.
Chian RC, Buckett WM, Tulandi T et al 2000 Prospective randomized study of human chorionic gonadotrophin priming before immature oocyte retrieval from unstimulated women with
polycystic ovarian syndrome. Human Reproduction 15,165-70.
Child TJ, Guleki B, Abdul-Jalil AK aand Tan SL 2001. In vitro maturation and fertilization
of oocytes from unstimulated normal ovaries, polycystic ovaries, and women with polycystic
ovarian syndrome. Fertil Steril, 76, 936-42.
196
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.

Durenzi KL, Wentz AC, Saniga EM et al 1997. Follicle stimulating hormone effects immature
oocytes: in-vitro maturation and hormone production. Journal of Assisted Reproduction and
Genetics 14,199-204.
Barnes FL and Sirard MA. 2000 Oocyte maturation. Semin Reprod Med ; 18: 123-31
Chian RC, Gulekli B, Buckett WM and Tan TL. 1999. Priming with human chorionic gonadotropin before retrieval of immature oocytesin women with infertility due to polycystic ovary
csyndrome. New.Engl.J. Med. 341, 1624-1626.
Chian R-C 2004. In-vitro maturation of immature oocytes for infertile women with PCOS.
Reproductive BioMedicine Online 8, 547- 552.
Lin Y-H, Hwang J-L, Huang L-W, Mu L-W et al., 2003. Combination of FSH priming and
hCG priming for in-vitro maturation of human oocytes. Hum Reprod 2003; 1632-1636.
Trounson A, Anderiesz C, Jones G 2001 Maturation of human oocytes in vitro and their developmental competence. Reproduction 121, 51-75
Russell JB, Knezevich KM, Fabian K et al. 1997 Unstimulated immature oocyte retrival: early
versus midfollicular endometrial priming. Fertility and Sterility 67, 616-20.
Thornton MH, Francis MM, Paulson RJ 1998 Immature oocyte retrieval: lessons from unstimulated IVF cycles. Fertility and Sterility, 70, 647-50.
Cobo AC, Requena A, Neuspiller F et al 1999 Maturation in vitro of human oocytes from
unstimulated cycles: selection of the optimal day for ovum retrieval based on follicular size.
Human Reproduction 14,1864-68.
Mikkelsen AL, Smith S, Lindenberg S 2000 Impact of oestradiol and inhibin A concentrations
on pregnancy rate in in-vitro oocyte maturaturation. Human Reproduction 15,1685-1690.
Mikkelsen A.L., Andersson A-M, Skakkebk, N.E et al 2001 Basal concentrations of oestradiol may predict the outcome of IVM in regular menstruating women. Human Reproduction
16, 862-7.
Mikkelsen Al, Lindenberg S 2001d Inuence of the dominant follicle on in vitro maturation
of human oocytes. Reproductive Biomedicine Online 3,199-204.
Wynn P, Picton HM, Krapez J et al 1998. Pretreatment with follicle stimulating hormone
promotes the number of human oocytes reaching metaphase II by in-vitro maturation. Human
Reproduction 13, 3132-8.
Mikkelsen Al, Smith SD, Lindenberg S 1999 In vitro maturation of human oocytes from
regular menstruating women may be succesfull without FSH priming. Human Reproduction
14,1847-1851.
Mikkelsen AL, Hst E, Blaabjerg J, Lindenberg S 2003. Time interval between FSH priming
and aspiration of immature oocytes for in-vitro maturation: a prospective randomized study.
RBMOnline 16, 416-20.
Child TJ, Sylvestre C, Pirwany I and Tan S 2002. Basal lerum levels of FSH and estradiol in
ovulatory ad anovulatory women undergoing treatment by in-vitro maturation of immature
oocytes. Human Reproduction 17; 1997-2002.
197
IVM as an alternative
in poor and over responders.
Hananel E.G Holzer MD, William M Buckett MB ChB MD MRCOG,
Seang Lin Tan MBBS, FRCOG, FRCS(C), MMed (O&G), MBA.
Department of Obstetrics and Gynecology McGill University, Royal Victoria Hospital
Women's Pavilion F6.58, 687 Pine Avenue West. Montreal. Canada H3A 1A1
Since the rst live birth following IVF treatment was reported over 25 years
ago (1), over a million children have been born as a result of IVF. Over the
past 25 years, the increasing use of controlled ovarian stimulation protocols
has contributed to the continuing improvements in the success rates of IVF (2).
By increasing the number of mature follicles, the number of mature oocytes
retrieved is increased. This in turn leads to an increased number of embryos
available for transfer and consequently an increase in clinical pregnancy rate.
Nevertheless, the two extremes of response to ovarian stimulation remain
a challenge for the fertility specialists. On the one hand stand the poor responders patients who, even when given high dose gonadotropins for ovarian
stimulation, do not respond adequately and on the other hand stand the over
responders patients who are tremendously sensitive to stimulation with exogenous gonadotropins and are at an increased risk of developing ovarian hyper
stimulation syndrome (OHSS). For both these challenging types of patient
needing IVF treatment, in vitro maturation of oocytes (IVM) may serve as
an effective alternative treatment. IVM avoids the risks and costs of ovarian
stimulation while still generating increased numbers of embryos to choose
from for transfer.
Poor responders
A poor response to ovarian stimulation with gonadotropins can be dened as a
198
plasma estradiol level less than 1000 pg/ml on the day of hCG administration,
and where less than three mature oocytes are retrieved (3). Poor response to
gonadotropin stimulation occurs more often in older women but may also be
present in young women - those with a normal endocrine prole as well as
those with abnormal endocrine parameters known to be associated with a poor
response (4). Some poor responders appear to respond to stimulation but have
a low estrogen level, others have few or slow-growing follicles. Normally these
patients require prolonged stimulation and higher doses of gonadotropins. They
also experience a high cancellation rate because of the smaller number or size
of follicles.
Many different ovarian stimulation protocols have been tried for treatment
of poor responders in IVF. These include increasing the gonadotrophin dose,
although the high dose gonadotropin yield is questionable (5, 6). The GnRH
analog "are up" protocol has had limited success in the treatment of poor
responders even when preceded by combined estrogen and progesterone
treatment or when growth hormone was added (7-10). The introduction of
GnRH antagonists raised hopes for a better ovarian response, but until now it
is still not clear whether these protocols actually lead to a better response and
result in a higher pregnancy rate than the conventional GnRH analog protocols
(12-15). Recently aromatase inhibitors have been combined into the treatment
protocols of poor responders, the results seem promising but are still preliminary (16, 17). Overall, no single protocol seems to benet all poor responders
(11) and the treatment of poor responders continues to challenge those involved
in fertility care.
The small number of follicles and their small size often warrant cycle cancellation. As an alternative to cancellation, immature oocytes could be collected from the stimulated but unresponsive ovaries and than matured in vitro.
Such pregnancies were rst reported after cryopreservation of in vitro matured
oocytes (18). Liu et al (19) reported eight cases of immature oocytes collection in young patients who had a poor response to gonadotropin stimulation.
Three pregnancies were achieved. We recently reported 41 patients who were
identied as resistant to gonadotropin stimulation (20). When the follicles did
not grow despite increasing dose of gonadotropins, hCG was administrated and
oocyte retrieval was performed 36 hours later. We advocated that giving hCG
36h before collection would optimize the successful pregnancy rate in such
poor responders because at least some in-vivo matured could be collected after
hCG administration. 459 oocytes were collected and 80% were matured (17.2%
were mature at retrieval). After ICSI,39 patients had an embryo transfer. The
pregnancy and implantation rates were 46.3% and 16.5% respectively (20).
199
These results demonstrate that immature oocyte retrieval followed by IVM is

a possible alternative to cancellation of the treatment cycle in women with a
poor response following ovarian stimulation.
IVM of oocytes collected from unstimulated ovaries has been performed
for over 10 years mostly for women with polycystic ovaries. The pregnancy
rates have reached 30-35% (21). Poor responders to previous gonadotropin
stimulation, may benet from immature oocyte collection from unstimulated
ovaries. Eight women with a previous poor response to IVF underwent oocyte
collection without ovarian stimulation. hCG was administrated 36 h before
collection. An average 2.3 immature oocytes were collected and an average
1.7 were matured in-vitro. Six (of eight) women underwent embryo transfer of
1-3 embryos (average 1.7) and one patient became pregnant and subsequently
delivered (22). The number of embryos produced and available for embryo
transfer were similar to the previous IVF treatments (22).
We have recently shown that the presence of a dominant follicle does not
hamper the maturation and developmental potential of the small antral follicles
thus both mature and immature oocytes could be collected in a natural cycle
and produce viable embryos and increase the pregnancy rates (21,23).
From these preliminary studies it seems that IVM is a possible option for
patients with a poor ovarian response in an ongoing stimulated IVF cycle or
with a history of a previous low response to gonadotropin stimulation.
Over-responders
To generate multiple follicles before IVF collection the ovaries are stimulated
with gonadotropins. Some women are extremely sensitive to stimulation with
exogenous gonadotropins and are at increased risk of developing ovarian hyperstimulation syndrome (OHSS) (24). The most severe manifestation involves
massive ovarian enlargement and multiple cysts, hemoconcentration and thirdspace accumulation of uid. The syndrome may be complicated by renal failure
and oliguria, hypovolemic shock, thromboembolic episodes, adult respiratory
distress syndrome (ARDS), and death (25). Women with polycystic ovaries
have a signicantly increased risk of developing OHSS due to exogenous
gonadotropins than women with normal ovaries (26). Despite many years of
clinical experience, there are no precise methods to completely prevent severe
OHSS. The risk can be reduced by withholding the ovulation-inducing trigger
of hCG (27). Thus, in conventional ovarian stimulation for IVF where there
has been an over-response and there is a high chance of developing OHSS, the
cycle would be cancelled.
200
Immature oocyte retrieval followed by IVM and IVF may provide an alternative to cancellation of these cycles (21). Initially, one live birth was reported
from immature oocytes that were collected from a patient at substantial risk of
developing OHSS (28). Lim et al (29) reported 17 patients with a high risk of
developing OHSS who then underwent immature oocyte collection followed
by IVM. Eight out of 17 (47.1%) clinical pregnancies were achieved In this
group of patients, hCG was given 36 h before oocyte collection when the leading follicle reached a mean diameter of 1214 mm and indeed 11.6% of the
oocytes had already reached the metaphase II stage at collection. Even though
the safest measure to prevent OHSS is to withhold hCG administration (27),
there were no cases of OHSS reported in these patients, who were at a high risk
of developing the syndrome (29).
So far, there have been more than 30 healthy live births obtained from this
group of patients following oocyte retrieval and IVM treatment. Therefore,
the patients who are at risk of developing OHSS during controlled ovarian
hyperstimulation can resort to immature oocyte retrieval and IVM treatment
rather than canceling the cycle.
Women with a history of over-responding to gonadotropin therapy and
OHSS or patients with an increased risk of over-responding may benet from
collection of immature oocytes from unstimulated ovaries (IVM). Patients with
PCO or PCOS are prone to over-respond to gonadotropin therapy and may be
referred for IVM treatment. In vitro maturation of immature oocytes collected
via transvaginal ultrasound-guided aspiration has been performed since 1994,
over 300 babies have been born and the clinical pregnancy rate is currently
around 35%. It has been recently shown that the presence of a dominant follicle
does not hamper the maturation and developmental potential of the small antral
follicles (21) thus both mature and immature oocytes could be collected in a
natural cycle and produce viable embryos and pregnancies (21, 23).
Priming with hCG 36 hours before collection improves the in vitro maturation rate (30). And ultrasound scan in the follicular stage predicts the number
of immature oocytes that can be collected (31) and can help us in dening the
patients that are at an increased risk for over-responding.
Conclusion
In vitro maturation of oocyte can be offered as a treatment option for the two
extremes of ovarian response. Patients who are respond poorly to ovarian
stimulation with gonadotropins as well as those who over respond can benet
from immature oocyte collection followed by IVM, as an attractive alternative
201
to cycle cancellation. It may also be prudent and worthwhile to refer patients

with a history of over and poor response, for immature oocyte collection without ovarian stimulation followed by IVM.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Steptoe PC, Edwards RG, Birth after re-implantation of a human embryo The Lancet
1978;2:336.
Assisted Reproductive Technology in the United States: 2000 results generated from the
Registry Fertil Steril 2004;81:1207-20.
Nikolettos N, Al-Hasani S, Felberbaum R, Demirel LC, Kupker W, Montzka P et al.
Gonadotropin-releasing hormone antagonist protocol: a novel method of ovarian stimulation
in poor responders. Eur J Obstet Gynecol Reprod Biol 2001; 97:2027.
Lashen H, Ledger W, Lopez-Baernal A, Barlow D. Poor responders to ovulation induction: is
proceeding to in-vitro fertilization worthwhile? Hum Reprod 1999;14:9649.
Land J, Yarmolinskaya M, Dumoulin J, Evers J. Higher dose menopausal gonadotrophin
stimulation in poor responders does not improve in vitro fertilization outcome. Fertil Steril
1996;65:9615.
Lashen H, Ledger W, Bernal A, Evan B, Barlow D. Super ovulation with high gonadotrophin
dose for invitro fertilization, is it effective? J Assisted Reprod Genet 1998;15:43843.
. Padilla S, Dugan K, Maruschak V, Shalika S, Smith R. Use of the are up protocol with high
dose human follicle stimulating hormone and human menopausal gonadotrophin for IVF in
poor responders. Fertil Steril 1996;65:796 9.
Karande V, Morris R, Rinehart J, Miller C, Rao R, Gleicher N. Limited success using the are
protocol in poor responders in cycles with low basal follicle stimulating hormone levels during
in vitro fertilization. Fertil Steril 1997;67:900 3.
Surrey E, Bower J, Hill D, Ramsey J, Surrey M. Clinical and endocrine effects of a microdose
GnRH agonist are regimen administered to poor responders who are undergoing in vitro
fertilization. Fertil Steril 1998;69:419 24.
Schoolcraft W, Schlenker T, Gee M, Stevens J, Wagley L. Improved controlled ovarian hyperstimulation in poor responders in vitro fertilization patients with a microdose follicle stimulating hormone are, growth hormone protocol. Fertil Steril 1997;67:937
Surrey ES, Schoolcraft WB. Evaluating strategies for improving ovarian response of the poor
responder undergoing assisted reproductive techniques. Fertil Steril. 2000;73:667-76
Craft I, Gorgy A, Hill J, Menon D, Podsiadly B. Will GnRH antagonists provide new
hope for patients considered difcult responders to GnRH agonist protocols? Hum Reprod
1999;14:295962.
Akman M, Erden H, Tosun S, Bayazit N, Akosy E, Bahceci M.Addition of GnRH antagonist
in cycles of poor responders undergoing IVF. Hum Reprod 2000;15:21457.
Nikolettos N, Al-Hassani S, Felberbaum R, Damirel L, Kupker W, Montzka P, et al.
Gonadotrophin-releasing hormone antagonist protocol: a novel method of ovarian stimulation
in poor responders. Eur J Obstet Gyn Reprod Biol 2001;97:2027.
Akman M, Erden H, Tosun S, Bayazit N, Akosy E, Behceci M. Comparison of agonistic are
up protocol and antagonistic multiple dose protocol in ovarian stimulation of poor responders:
results of a prospective randomized trial. Hum Reprod 2001;16:868 70
Goswami SK, Das T, Chattopadhyay R, Sawhney J, Kumar J, Chaudhury K, et al. A random-
202
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.

ized single-blind controlled trial of letrozole as a low-cost IVF protocol in women with poor
ovarian response: a preliminary report. Hum Reprod 2004;19:20315.
Schoolcraft W, Surrey E, Minjarez D, Gardner DK. Antagonist/letrozole protocol for patients
failing microdose agonist are stimulation. Fertil Steril 2002;78(suppl 1):S234.
Check ML, Brittingham D, Check JH, Choe JK. Pregnancy following transfer of cryopreserved-thawed embryos that had been a result of fertilization of all in vitro matured metaphase
or germinal stage oocytes. case report. Clin Exp Obstet Gynecol. 2001;2869-70
Liu J, Lu G, Qian Y, Mao Y, Ding W. Pregnancies and births achieved from in vitro matured
oocytes retrieved from poor responders undergoing stimulation in in vitro fertilization cycles.
Fertil Steril. 2003;80:447-9.
Chian RC, Son YW, Yoon SH, Lim JH, Tan SL. Pregnancies achieved from in vitro matured
oocytes retrieved from poor responders in stimulated IVF cycles. ABSTRACT Hum Reprod
2004;19:100i.
Chian RC, Lim JH, Tan SL. State of the art in in-vitro oocyte maturation. Curr Opin Obstet
Gynecol 2004;16:211-19.
Child TJ, Gulekli B, Chian RC, Abdul-Jalil K, Tan SL. In-vitro maturation (IVM) of oocytes from unstimulated normal ovaries of women with a previous poor response to IVF.
ABSTRACT Fertil Steril 2000;74:s45.
Chian RC, Buckett WM, Abdul Jalil AK, Son WY, Sylvestre C, Rao D et al Natural-cycle
in vitro fertilization combined with in vitro maturation of immature oocytes is a potential
approach in infertility treatment. Fertil Steril 2004;82:1675-1678
Beerendonk CCM, van Dop PA, Braat DDM, Merkus JMWM. Ovarian hyperstimulation
syndrome: facts and fallacies. Obstet Gynecol Surv 1998;53:439449.
Elchalal U, Schenker JG The pathophysiology of ovarian hyperstimulation syndrome--views
and ideas. Hum Reprod. 1997;12:1129-37.
MacDougall MJ, Tan SL, Balen A, Jacobs HS. A controlled study comparing patients with and
without polycystic ovaries undergoing in-vitro fertilization. Hum Reprod.1993 ;8:233-7.
Orvieto R. Can we eliminate severe ovarian hyperstimulation syndrome? Hum Reprod
2005;20:320-2.
Jaroudi KA, Hollanders JMG, Sieck UV, Roca GL, El-Nour AM, Coskun S. Pregnancy after
transfer of embryos which were generated from in-vitro matured oocytes. Hum Reprod 1997;
12:857859.
Lim KS, Son WY, Yoon SH, Lim JH. IVM/F-ET in stimulated cycles for the prevention of
OHSS.ABSTRACT Fertil Steril 2002; 78:S10.
Chian RC, Gulekli B, Buckett WM, Tan SL. Priming with human chorionic gonadotropin
before retrieval of immature oocytes in women with infertility due to the polycystic ovary
syndrome. N Engl J Med. 1999;341:1624, 1626.
Tan SL, Child TJ, Gulekli B. In vitro maturation and fertilization of oocytes from unstimulated
ovaries: predicting the number of immature oocytes retrieved by early follicular phase ultrasonography. Am J Obstet Gynecol. 2002;186:684-6.
203
Health status and development of

children who are born after IVM.
Anne Lis Mikkelsen. MD, Dr Med Sci.
The Fertility Clinic, Herlev University Hospital, 2730 Herlev
Introduction.
In vitro maturation (IVM) of human oocytes will have important clinical benets to controlled ovarian hyperstimulation for In Vitro Fertilization (IVF). The
IVM protokol is relative simple with a shorter period of treatment. In addition
the side effects of stimulation in particular ovarian hyperstimulation syndrome
(OHSS) are eliminated (1-7).
About 300 children have been born in the world (5-7). At the Fertility Clinic
Herlev University Hospital, IVM has resulted in the birth of 47 children between July 1998 and August 2004. In the following chapter I will present 1) the
perinatal outcome of the total cohort of pregnancies and 2) information about
health status and development of the rst 18 children by follow-up at 6 months,
1 year and 2 years of age.
Subjects.
The study compromised 47 consecutive new-borns delivered after IVM
between July 1998 and August 2004. The patients were obtained from infertile couples referred for IVF/ICSI at the Fertility Clinic Herlev University
Hospital. Indications for IVF/ICSI were especially impaired quality of the
sperm (n=27). In 25 cases ejaculated sperm were used, in 2 cases testicular
sperm were used for ICSI. In 8 cases infertility were due to tubal factor, in
10 cases due to polycystic ovary syndrome (PCOS) and in one case due to
unknown infertility.
204
In brief, immature oocytes were obtained from follicles of 5 -10 mm. Oocyte
aspiration was performed transvaginally and healthy appearing oocytes were
matured for 28 30 hours in vitro. ICSI was performed on all Metaphase II
oocytes. The oocytes were then cultured to day 2 or 3 after fertilization at
which time suitable embryos (maximum 2) were replaced into the women.
Endometrial priming consisted of 17--oestradiol started the day of oocyte
retrieval, and the women received 2 mg orally three times per day. Two days
after aspiration, treatment with intravaginal progesteron suppositories was initiated and continued until the pregnancy test. Oestrogen and progesterone were
continued if the pregnancy test was positive until 50 days gestation (1,2).
All pregnancies in the present study were obtained after transfer of fresh
embryos.
Pros and cons of prenatal diagnosis were discussed in detail at 6 8 weeks of
gestation. A nuchal translucency (NT) screening at 10 14 weeks of gestation
and a second trimester ultrasound examination at 18 22 weeks of gestation
was offered in all pregnancies.
In view of possible risk factors due to the new technique of in vitro maturation couples were also offered a prenatal test by chorion villous sampling
(CVS) or amniocentesis (AT).
For all pregnancies written data on pregnancy outcome with regard to the
babies were obtained from medical les of the hospitals where the mothers
had been treated.
The follow-up study consisted of the rst 18 IVM children. The parents lled
in a questionnaire concerning development and general health of their children
before examination at the age of 6 and 12 months. The same paediatrician
performed the three examinations of each child. Concerning the developmental
evaluation the revised Denver-II-developmental screening test was used.
Total IVM cohort.

All IVM deliveries obtained from the beginning of our IVM programme to
August 2004 were followed (n=46). The mean age of the mothers was 31 years
(range 26 - 38 years) and 30 were primiparae.
Of the included 47 children 45 were singletons and 2 were twins with 26
boys and 21 girls including one case of stillbirth.
Nuchal translucency measurement was possible in all foetuses. In one case
the measured NT was 3 mm. Chromosomal analysis was performed by CVS
revealing a normal karyotype. The pregnancy was continued, nuchal translucency normalised, and no structural defects including foetal echocardiography
205
were observed at second trimester ultrasound. The mother delivered at term a

girl with a soft cleft palate. Otherwise the girl was healthy.
Second trimester ultrasound was performed in 35 foetuses and they were
all normal.
At postnatal follow up of the children no other malformations except for the
soft cleft palate were recognised, giving a malformation rate of 1/47 (2.1%).
Chromosomal analyses were performed electively by CVS or AT in 12
foetuses on patients request. All except one, who had an inherited structural
aberration, were normal. This aberration was a small pericentric inversion in
chromosome 20 with a karyotype 46, XX, var(20)cenh+, inherited from the
father (46XY, var(20)cenh+). There were no loss of chromosomal material and
correspondingly at examining no clinical affection of neither the father nor the
daughter was found. In further 21 cases karyotyping were performed on umbilical cord blood, obtained at the delivery, and they were all normal. Conclusively
one abnormal karyotype was found giving an overall rate of 1/33 (3%)
Two preterm deliveries were observed. One boy was delivered at gestational
week 32 + 4 by caesarean section due to severe preeclampsia. The birth weight
was 1745 gram. One set of twins (boys) was delivered vaginally at 34 gestational weeks with birth weights of 2240 and 2060 gram respectively.
The remaining babies were born at term (median gestational age 40 weeks
(range 37 - 42 weeks) and median weight 3720 gram (range 2900 - 5290 gram).
A total of 31 were delivered vaginally and 15 by caesarean section.
One pregnancy ended with the birth of a dead girl at gestational age 42 + 2,
giving a mortality rate of 2.1% (1/47). An autopsy showed signs of asphyxia,
but otherwise no pathological ndings. According to the consultant at the delivery ward, the death of the baby was not supposed to have any relation to the
mode of which the patient became pregnant.
Follow-up study.
In the follow-up study 18 consecutive singleton babies participated, nine boys
and nine girls. The rst girl in the study had reached the age of nine months
when the examinations started, and therefore had her rst examination at age
12 months. Another girl born with a cleft palate only participated in the rst
examination, probably because of many contacts to the hospital in relation
to the surgical correction of her cleft palate. Finally, three children moved to
another part/region of the country and did not participate in the examination at
24 months. An interview by phone with the mother of one these children gave
reason to believe in development according to age.
206
All children had an Apgar score of 10 at 5 minutes and only two children
had an Apgar score less than 8 at 1 minute (5 and 6 respectively).
The group in general was found to be rather homogeneous regarding the
motor function (table 1). At the age of six months 3/16 children had a slight
motor delay (5, 4 and 4 months respectively) and all of these had a normal score
at the following two examinations. One child was found to be delayed at age 12
months (scored 9 months) as well as 24 months (scored 21-22 months).
Tables
Table 1:
Motor development
Delayed
As expected for age
Advanced
Age of 6 months (n=17)
13
15
12
Delayed
As expected for age
Advanced
15
10
Table 2:
Language development
The language development was found to be more heterogeneous, primarily

because of advanced language development for one third to one half of the children (table 2). At age 6 months, where language assessment is more difcult,
all but two children were estimated to have a normal language development for
age. At age 12 months one third (ve girls, one boy) and at 24 months one half
(six girls, one boy) of the children had a slightly advanced language development. One child had a minor delay (3 months) at the last examination. Another
child had a delayed language development, but at all examinations and most
marked at the last examination (biological age 25 months, language about 18
months) and was referred to audiologic testing for hearing impairment.
All children but one, who at age 24 months were found to have a degree of
hyperactivity with short concentration span and some aggressiveness, showed
normal behaviour for age. This child were the one with also delay in gross
motor function and language development as mentioned above.
207
Conclusion
The rate of malformations as well as the rate of abnormal karyotypes is comparable with other studies of pregnancies and children born after assisted reproduction. All children born after IVM had normal growth and health and
development of the children were according to age.
The children in this follow-up study are young and consequently the results
are preliminary. Regarding the more soft signs as behavioural development,
learning disabilities, social abilities etc as well as discrete motor disabilities, a
follow-up at 5 years of age would be benecial.
References
1.
2.
3.
4.
5.
6.
7.
Mikkelsen AL, Andersson A-M, Skakkebk NE, Lindenberg S. Basal concentrations of oestradiol may predict the outcome of in-vitro maturation in regularly menstruating women. Human
Reproduction 2001; 16: 862-7.
Mikkelsen AL, Lindenberg S. Benet of FSH priming of women with PCOS to the in vitro
maturation procedure and the outcome: a randomized prospective study. Reproduction 2001;
122: 587-92.
Picton HM. Oocyte maturation in vitro. Reproductive endocrinology 2002: 14: 295-302.
Trounson A, Anderiesz C, Jones G 2001 Maturation of human oocytes in vitro and their developmental competence. Reproduction 121, 51-75
Cha KY, Han Sy Chung HM 2000 Pregnancies and deliveries after In itro maturation culture
followed by in vitro fertilization and embryotransfer without stimulation in women with polycystic ovary syndrome. Fertility and Sterility 73, 978-83.
Child TJ, Guleki B, Abdul-Jalil AK aand Tan SL 2001. In vitro maturation and fertilization
of oocytes from unstimulated normal ovaries, polycystic ovaries, and women with polycystic
ovarian syndrome. Fertil Steril, 76, 936-42.
Chian R-C, Bucket WM, Tan 2004. In-vitro maturation of human oocytes. Reproductive
BioMedicine Online 8, 148 66.
208
Hot controversies in Infertility

Investigation and Treatment of
repeated implantation failure following
IVF and ET
Ehud J. Margalioth, Talia Eldar-Geva,
Michael Gal, Avraham Ben-Chetrit.
IVF unit, Shaare Zedek Medical Center, Ben Gurion University of the Negev,
Jerusalem, Israel
Treatment of infertile couples has progressed immensely during the last years.
Assisted reproductive technologies have bypassed the natural fertility potential
of any couple and today we can see pregnancies of up to 76% in a single
treatment cycle. (1). Of close to 100,000 ART treatment cycles performed in
the USA during the year 2000 nearly 40% resulted with a pregnancy and the
delivery rate was close to 30% (2).
In most IVF units over 50% of the treatment cycles fail. Failure could be
caused by many different factors such as inappropriate ovarian stimulation, suboptimal laboratory culture conditions, and faults in embryo transfer techniques.
These would usually cause a low pregnancy rate to the whole unit. But even in
successful units with a high pregnancy and delivery rates, from time to time, some
couples have repeated implantation failure. The aim of this article is to summarize
the reported etiologies for repeated implantation failure (RIF), highlight the suggested investigations and tests to be performed, in order to attain the reason for the
repeated failures, and review the recommended treatment strategies.
Denition of RIF
Denition of repeated implantation failure has become very difcult. In the past
failure to achieve a pregnancy following 3 to 5 IVF cycles in which many highgrade embryos were transferred easily to the uterus was dened as repeated
209
implantation failure. At that time in most cases 3 or 4 embryos were transferred

each time, and RIF was also dened as failure to achieve a pregnancy following
transfer of at least 10 high-grade embryos.
Today with the tendency of transferring only 1 or 2 embryos it is not clear
what is the denition of RIF .We suggest that RIF should be dened as IVF
cases in which no pregnancy was achieved after transferring a number of good
embryos that would exceed 200% if the number of embryos transferred was
multiplied by the implantation rate of a certain IVF unit.
Assumed Etiologies for RIF.

Embryonic loss, which occurs repeatedly after assisted reproduction, may be
attributed to many factors. These can be grouped into three categories: embryonic genetic abnormalities, lack of endometrial receptivity, and suboptimal
laboratory culture conditions.
Genetic abnormalities may be due to increased chromosomal abnormalities
of the female partner, of the sperm cells, or of the developing embryos.
Table 1:
Assumed Etiologies
Defective embryonic development

Sperm defects
Genetic abnormalities
Zona hardening
Lack of endometrial receptivity
Uterine cavity abnormalities such as synechia, polyps and myomas
Immunological pathology
Altered expression of endometrins
Thrombophilia
Hydrosalpinges
Hostile culture conditions
Chromosomal abnormalities
Increased chromosomal abnormalities at advanced maternal age have been
closely linked to embryonic aneuploidy. Raziel et al (3) have found increased
frequency of female partner chromosomal abnormalities (translocations, mosaicism, inversion and deletion) even in young women with high-order implanta-
210
tion failure after in vitro fertilization. Tarlatzis et al (4) found similar ndings
and add that chromosomal breakages, particularly at the centromere region,
were also observed with signicantly increased frequency in the patients than
in the controls (6.18 vs. 1.42% respectively; P<0.001).
Gianaroli et al. (5) detected aneuploidity in 54% of embryos of patients who
underwent at least 3 unsuccessful IVF cycles despite the transfer of morphologically normal embryos.
Using comparative genomic hybridization Voullaire et al (6) have detected
chromosome abnormality in 76/126 (60%) of single blastomeres biopsied prior
to implantation from embryos from 20 women with repeated implantation failure following IVF. The abnormalities detected included aneuploidy for one
or two chromosomes [32/126 (25%)] and complex chromosomal abnormality
[37/126 (29%)]. They concluded that the disruption of the normal sequence
of chromosome replication and segregation in early human embryos, caused
either by maternal cytoplasmic factors or mutations in cell cycle control genes,
might be a common cause for RIF. Rubio and co-investigators (7) have found
increased incidence of sperm chromosomal abnormalities in patients with normal karyotypes and RIF. Thus it can be assumed that many patients with RIF
develop a high percentage of chromosomally abnormal embryos that fail to
implant despite regular morphology and developmental rate.
Zona Hardening
Prior to fertilization, the zona pellucida surrounding the mammalian oocyte
acts as a species-specic sperm barrier and is involved in sperm binding. After
fertilization, the zona plays a role in blocking polyspermic fertilization, it protects the integrity of the preimplantation embryo during early embryonic development, and also helps its oviductal transport. Zona hardening occurs naturally
after fertilization in order to ensure this threefold function. A combination of
lysins produced by the cleaving embryo or the uterus and physical expansion
reduces the zona thickness in preparation for hatching. Zona hardening, may
also be induced by in vitro culture and by in vivo aging. Recently, failure of the
embryonic zona pellucida to rupture following blastocyst expansion has been
suggested as a possible contributing factor in implantation failure.(8)
Hydrosalpinges
Patients with hydrosalpinges have lower implantation and pregnancy rates.
Zeyneloglu et al. (9) have found a reduction of 50% in implantation rate when
211
1144 women with hydrosalpinges were compared to 5569 women undergoing

IVF without hydrosalpinges. The adverse effects on embryonic implantation
attributed to hydrosalpings were summarized in two meta-analyses (9-10).
Different theories have evolved to explain the adverse effect hydrosalpinges
on implantation and pregnancy rates. Reux of hydrosalpinx uid into the
uterine cavity may simply result in mechanical factors diminishing embryonic
endometrial apposition. Hydrosalpinx uid is commonly slightly alkaline and
may also contain cytokines, prostaglandins or other inammatory compounds.
These inammatory mediators may result in either direct embryo-toxicity or
adverse effects on the endometrium. An association of hydrosalpinges with
altered endometrial histology and a lack of expression of endometrial integrins
such as V alfa beta 3 could be the reason for implantation failure (11).
Immunology
Many have investigated the role of an immunological cause for repeated implantation failure. The association of antiphospholipid antibodies and in vitro
fertilization failure is controversial. Such an association has been shown in
some studies (12-13 ) but large prospective studies failed to reveal an association (14- 15). Part of this confusion relates to differences in antibodies tested.
Stern et al (16) have found that beta 2 glycoprotein I antibodies and antinuclear
antibodies are associated with RIF while Denis et al (14) could not nd any
association between elevated antiphospholipid antibodies and pregnancy rate
in IVF.
Other components of the immunological system have been shown to be defective in RIF patients. Matsubayashi et al (17) studied the role of anti annexin
V antibodies. Annexin V, a potent anticoagulant, was isolated and cloned from
human umbilical cord arteries and placentae in the mid 1980s. It was shown to
act as an inhibitor of phospholipid-dependent blood coagulation and may be
necessary for trophoblast differentiation and maintaining pregnancy
This group demonstrates that women with recurrent IVF-ET failure
showed a greater incidence (8.3%) of anti annexin antibodies than normal
nonpregnant women (1.1%) or pregnant controls (0). This data support the
possibility that anti annexin antibodies may prevent normal implantation and
cause RIF.
Implantation and uterine receptivity are controlled primarily, although not
exclusively by locally acting growth factors and cytokines. Ledee-Bataille et
al (18) have found in the endometrium of patients with repeated implantation
failure elevated natural killer cells (NK) and dysregulation of interleukin (IL)
212
12 and 18. They suggest that some cases of RIF are related to distinct local
dysregulation of the immune network.
Kwak-Kim et al (19) have studied T-helper 1 (Th1) and Th2 intracellular
cytokine expression in peripheral blood lymphocytes of women with RIF. They
have found increased T helper 1 cytokine responses by circulating T cells in
infertile women with multiple implantation failures after IVF.
Others suggest that failure of appearance of a certain integrinalpha V
beta3in the endometrium, at the time of implantation is the cause of implantation failure. (20)
Tei et al (21) have measured the levels of endometrial alpha V beta3 expression in 35 patients with RIF and have found a lower level than in 12 fertile
controls. Nine patients were treated with danazol and all showed a signicant
increase in the alpha v beta 3 staining. The signicantly decreased expression
of endometrial integrin alpha v beta 3 suggested that functional, but not morphological, endometrial defect may be one of the causes for the patients with
unexplained infertility or RIF.
Suggested Methods for Treatment of RIF

1) Procedures preceding a new treatment cycle:
a) Hysteroscopy
b) Salpyngectomy in case of Hydrosalpyngs
c) Endometrial biopsy
2) Change of culture conditions
a) Coculture
b) ZIFT
c) Blastocyst transfer
3) Treatment of embryos
a) Assisted Hatching
b) PGD
c) Cytoplasmatic transfer
4) Change of endometrial receptivity
a) Endometrial biopsy
b) Prolonged GnRh-a treatment
c) Danazol
d) Steroids
e) Aspirin
f) IVIG
g) Heparin-Clexan
213
5) Change in transfer method

a) ZIFT
b) Blastocyte transfer
c) Transfer many embryos
Repeat hysteroscopic evaluation

RIF might be due to undiagnosed uterine pathology. Dicker et al (22) evaluated
the value of repeat hysteroscopic evaluation in patients with RIF. One hundred
and ten women with normal initial hysteroscopy who failed to conceive during three or more IVF-ET cycles underwent repeat hysteroscopic evaluation.
In 20 patients (18.2%), visualization revealed uterine abnormalities, mainly
newly added endometrial lesions, i.e., hyperplasia, polyps, endometritis, and
synechiae. They concluded that repeat hysteroscopic evaluation, in cases of
recurrent IVF-ET failure, revealed signicant uterine pathology. Schiao et al
(24) describe similar ndings.
Demirol and Gurgan (24) conducted a study to evaluate if the diagnosis and
treatment of intrauterine lesions with ofce hysteroscopy is of value in improving the pregnancy outcome in patients with RIF. Four hundred and twenty-one
patients who had undergone two or more failed IVF-embryo transfer cycles
were prospectively randomized into two groups. Group I (n = 211) did not have
ofce hysteroscopic evaluation, Group II (n = 210) had ofce hysteroscopy.
The patients who had normal hysteroscopic ndings were included in Group IIa
(n = 154) and patients who had abnormal hysteroscopic ndings were included
in Group IIb (n = 56). Intrauterine lesions diagnosed were operated during the
ofce procedure. . There was a signicant difference in the clinical pregnancy
rates between patients in Group I and Group IIa (21.6% and 32.5%, P = 0.044,
respectively). Treatment of intrauterine pathologies found by hysteroscopic
evaluation of RIF patients improved the pregnancy outcome.
Salpyngectomy
In 2 large prospective, randomized trials involving prophylactic salpingectomy
in patients with severe tubal factor infertility and hydrosalpinges the clinical
outcomes following prophylactic salpingectomy improved, particularly if they
had either bilateral hydrosalpinges or hydrosalpinges large enough to be visualized by ultrasound (25-26).
214
Endometrial Biopsy
Many assume that decreased endometrial receptivity is the major cause for RIF.
Endometrial injury or endometrial stimulation may cause a pseudo decidual
reaction that enhances implantation. This may be due to histamine release,
secretion of different cytokines and growth factors(27)
We have described a protocol for repeated implantation failure (28) that
included hysteroscopy, D&C, triple antibiotic and estrogen treatment. Of 14
patients who had RIF in 98 transfer cycles, following treatment with this
protocol, 6 patients conceived (implantation rate of 24%, pregnancy rate of
43%).
Barash et al (29) performed repeated endometrial biopsies in 45 cases.
Pregnancy rate in the IVF cycle following the biopsy was doubled. They concluded that local injury to the endometrium increased the incidence of implantation.
Coculture
One of the methods suggested to improve in vitro culture conditions has been
the development of coculture systems in which a variety of different cells have
been used. The suggested benecial effects of the cocultures include the secretion of embryotrophic factors such as nutrients and substrates, growth factors,
and cytokines and the removal of potentially harmful substances such as heavy
metals, ammonium, and free radical formation, detoxifying the culture medium
(30).
The most promising coculture method seems to be coculture of embryos
on homologous endometrial cells. Jayot et al (31) reported a pregnancy rate of
21% in 90 patients with RIF following coculture of embryos on homologous
endometrial cells. Simon et al (30) in 168 cycles in patients with RIF reported
of a pregnancy rate of 20%. They reported that a coculture system with human
endometrial epithelial cells (EEC) is benecial to the human blastocyst because
of the induction of secretion of embryonic paracrine molecules. Moreover, the
cocultured improves uterine receptivity by increasing endometrial adhesion
molecules such as the 3 integrin subunit. Spandorfer et al (32) reported on
1030 cases all with previously failed IVF cycles. Following autologous endometrial coculture a pregnancy rate of 49% was achieved. Coculture with
endometrial cells appears to be a valuable approach for the selection of a good
quality embryo before transfer and was found to be of benet to patients with
repeated failures of implantation.
215
Zygote Intra Fallopian Transfer (ZIFT)

In contrast to standard IVF-ET, ZIFT allows early embryonal growth in the
natural tubal environment and transport of the embryos into the uterine cavity
under natural physiologic regulation. This technique also prevents spillage of
embryos after transcervical ET. Initial retrospective studies reported superior
results of implantation and PRs after ZIFT as compared with standard IVF-ET
(33). This enthusiasm later was curtailed by the results of a series of prospective randomized studies that failed to demonstrate any difference in implantation rates in ZIFT as compared with standard IVF-ET (34-36). These studies,
together with the complexity and cost of ZIFI', led to the discontinuation of this
method in most IVF units. But we (37) and Levran et al (38) have found that the
main value of ZIFT is in cases of repeated failure of implantation in standard
IVF-ET. The success of ZIFT in RIF patients is based on the assumption that
failure to achieve pregnancy after repeated transcervical ET's could result from
either failure of the transfer technique (spillage of embryos from the cervix) or
inappropriate uterine culture conditions.
Assisted Hatching
In order to help embryos escape from their zonae during blastocyst expansion, different types of assisted hatching have been developed. Zona drilling
involves the creation of an opening in the zona with acidied medium, whereas
zona slitting is carried out in the same manner as partial zona dissection. More
recently, laser-assisted hatching has been introduced. In vitro studies with both
mouse and human embryos have indicated that an articial gap in the zona
pellucida signicantly improves the hatching ability of blastocysts grown in
vitro as compared to non-micromanipulated embryos. However, the clinical
relevance of assisted hatching within an assisted reproduction program remains
controversial and elusive (39). While most studies suggest that assisted hatching is of no benet (40-42) 3 prospective randomized studies have shown that
in cases of RIF AH signicantly increases the pregnancy and implantation rate
(43-45).
Blastocyst Culture and Transfer

Since the introduction of IVF, human embryos hae been routinely transferred
into the uterus around the two- to eight-cell stage (on day 2 or 3), at the time when
they would normally be in the fallopian tube. In these conditions, up to 90%
of apparently healthy embryos are destined to vanish. Transfer of embryos at
216
the blastocyst stage is a more physiological approach since the human embryos
enter the endometrial cavity only after day 5 at the morula-blastocyst stage
Activation of the embryonic genome occurs at the 8 10 cell stage (day 3) .
Up to this stage embryonic development depends only on the maternal oocyte
genome. Culturing the embryos to the blastocyte stage examines the propriety
of the spermatozoal and the whole embryonic genome.
Levitas et al (46) studied blastocyst-stage embryo transfer in patients who
failed to conceive in three or more day 2-3 embryo transfer cycles in a prospective, randomized study. They have found that transfer of blastocyst-stage
embryos carries a signicantly higher implantation rate. And thus suggest that
transferring embryos at the blastocyst stage, instead of at the cleavage stage,
will have a benecial effect. Others (47-49) found similar results, and all report
on a signicantly increased pregnancy rate following blastocyst transfer in RIF
cases.
Cytoplasmatic Transfer
Repeated implantation failure might be due to the fact that in some patients
ooplasmic components are compromised. The introduction of a small amount
of ooplasm from a donor oocyte or zygote may alter the function of oocytes,
with probable deciencies (50).
Cytoplasmic transfer from fertile donor oocytes or zygotes into compromised oocytes from patients with RIF has led to the birth of nearly 30 healthy
babies worldwide (51-52). Transfer of small amounts of cytoplasm probably
involves mRNAs, proteins and mitochondria, as well as other factors and organelles. Even though the use of cytoplasmic transfer has been employed in
several IVF clinics, and pregnancies have resulted, it is still considered an
experimental procedure since it is not known whether the physiology of the
early embryo is affected.
Huang et al (53) reported on injection of cytoplasm aspirated from the tripronucleate zygotes of donors into metaphase II oocytes in patients with repeated
implantation failure after assisted fertilization procedures. They reported of 5
healthy infants born after this procedure. They advocate this treatment to RIF
cases.
PGD
Many have shown that patients with RIF develop a high percentage of chromosomally abnormal embryos that fail to implant despite regular morphology
217
and developmental rate. Pehlivan et al (54) studied the value of using preimplantation genetic diagnosis (PGD) to try and improve implantation rates in
RIF patients who failed 3 and more previous IVF cycles. Fluorescence in-situ
hybridization (FISH) on blastomeres from biopsied day 3 embryos was performed for chromosomes 13, 16, 18, 21, 22, X and Y. There was a signicantly
higher rate of chromosomal abnormalities (67.4%) compared with controls
(36.3%). In 57 cycles, a pregnancy rate of 34.0% and an implantation rate of
19.8% was observed in RIF failure patients, with all the pregnancies coming
from the transfer of at least one chromosomally normal blastocyst on day 5.
They concluded that the use of PGD along with blastocyst transfer in RIF cases
improves IVF outcome.
Munne (55) states that selecting chromosomally normal embryos for replacement can signicant increase in implantation in RIF when at least eight
chromosomes are analyzed. Gianaroli et al (56) have found that 57% of
embryos examined by PGD in RIF patients were abnormal. In addition, the
percentage of chromosomally abnormal embryos was directly proportional
to the number of IVF failures. They conclude that the high rate of chromosomally abnormal embryos in these patients may have been the cause of
implantation failure in their previous IVF cycles. Therefore, the possibility
of transferring embryos with a normal FISH complement could improve the
chance of pregnancy.
Wilding et al (57) in a prospective clinical study applied PGD for the treatment of 94 couples with a history of failed IVF-ET ( 2 IVF cycles). Blastomeres
from 6- to 8-cell embryos were analysed using FISH with commercial chromosomal probes, and normoploid embryos were transferred on day 3 after fertilization. Both 3- and 5-probe PGD resulted in a signicantly higher outcome
than controls for failed IVF-ET.
Wilton et al compared the use of comparative genomic hybridization (CGH)
to FISH during PGD of embryos from patients with RIF. CGH was able to identify many chromosomal abnormalities that would have been missed if those
cells had been analyzed by FISH. The clinical pregnancy rate per transfer and
implantation rate was 11% and 7% for embryos analyzed by FISH and 21% and
15% for embryos analyzed by CGH. Comparative genomic hybridization was
found to be more effective than FISH for identifying chromosomally normal
embryos, which may result in a higher clinical pregnancy rate and implantation
rate after embryo transfer.
In contrast to these articles in a prospective randomized controlled clinical
trial (59), comparing the outcome after blastocyst transfer combined with PGD
using FISH, (of a group similar to RIF: women aged > 36 years), with a control
218
group without PGD, no benet was found to the PGD procedure.

The exact benet of performing PGD to RIF cases still has to be evaluated
in a prospective randomized controlled clinical trial.
Immuno Therapy
Since there is evidence to suggest that immunological factors may be involved
in RIF, immunotherapy with intravenous immunoglobulin (IVIG) has been introduced empirically into IVF programs. Coulm et al. (60 ) reported that 9 of 16
women (56%) with RIF became pregnant following IVIG treatment. Sher and
colleagues (61) reported variable success with IVIG while Balasch et al (62)
did not nd IVIG useful in treatment of RIF and Stephenson and Fluker (63)
in a prospective, randomized, double blind, placebo-controlled clinical trial,
found that IVIG did not improve the live-birth rate in couples with repeated
unexplained IVF failure. The effectiveness of IVIG treatment in RIF cases is
still unresolved.
Treatment of RIF by Danazol was reported by Tei et al (64). In a prospective, randomized, controlled study, of 81 patients who experienced RIF, 40
received danazol (400 mg/d orally for 12 weeks) following the unsuccessful
IVF-ET and 41 served as controls.
Conception occurred in 16 of 40 (40%) danazol-treated patients at the subsequent cycle and showed a signicant increase when compared with 8 of 41
(19.5%) control subjects (P < .05). The patients treated with danazol showed a
signicant increase in the alpha V beta 3 endometrial integrin staining. Danazol
was found to increase receptivity of the endometrium in these patients and
upgrade the alpha V beta 3 endometrial integrin (65)
Wurfel et al (66) investigated whether the leucocytic ultraltrate LeukoNorm
Cytochemia, which is approved for the treatment of immunologically-based
recurrent spontaneous abortions (RSA), improves treatment results in patients
with repetitive IVF or ICSI failures. In their study they have found that the
administration of LeukoNorm Cytochemia can signicantly improve treatment
results in patients with repetitive IVF or ICSI failures. The most favorable
results were observed with a dosage of 1 unit/10 kg on 5 consecutive days,
starting with the day of oocyte retrieval. These results imply that, in the IVF
or ICSI programs, there exists a group of patients with disturbances in the embryo-maternal dialogue, and therefore no conceptions. Furthermore, the results
demonstrate that the administration of LeukoNorm Cytochemia can improve
the implantation rate of transferred embryos in these patients. They concluded
that growth factors and cytokines synthesized and secreted by leucocytes have
219
an important inuence on embryonic implantation and growth

Combined treatment of prednisone for immunosuppression and aspirin as
an anti-thrombotic agent, starting before ovulation induction, has been reported
to improve pregnancy rate in autoantibody seropositive patients who have RIF
(67-68).
Personal experience
At the IVF unit in Shaare Zedek Medical Center about 10% of our cycles are
of patients with RIF. Since the regulations in Israel force the medical insurance
companies to nance IVF treatment, if needed, until a couple has two children,
patients have no nancial restrictions on the number of IVF cycles that they
undergo.
We believe that there are many reasons for RIF and that we do not have the
tools to diagnose in each case the exact cause for the repeated failure.
In the older age group we believe that the major cause for RIF is chromosomal abnormalities of the embryos. Since we do not have the ability to do
PGD with FISH at our unit, we transfer in these cases as many embryos as
possible.
In cases with any hint of autoimmune disease we treat with steroids (0.5
mg Dexamethasone or 5 10 mg of Prednisone) and aspirin (100mg) during
the whole cycle. During the past years we have occasionally performed ZIFT
to patients who failed 5 or more ET especially (but not only) if the embryo
transfer was difcult. Of 86 ZIFT cycles 20 pregnancies were achieved (23%
pregnancy rate). Assisted Hatching by mechanical PZD was performed in 71
cases of young (<35) women with more than 3 failures. Twenty three (32%)
pregnancies were achieved. During the last year we are performing endometrial
biopsies on days 12 and 21 of the cycle preceding the IVF treatment. Of 30
women who underwent the biopsies 10 conceived (33%).
220
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Gardner DK, Surrey E, Minjarez D, Leitz A, Stevens J, Schoolcraft WB. Single blastocyst
transfer: a prospective randomized trial. Fertil Steril. 2004 81(3):551-5.
Assisted reproductive technology in the United States: 2000 results generated from the
Registry. Fertil Steril. 2004 81(3):1207 1220
Raziel A, Friedler S, Schachter M, Kasterstein E, Strassburger D, Ron-El R. Increased frequency of female partner chromosomal abnormalities in patients with high-order implantation
failure after in vitro fertilization. Fertil Steril. 2002 Sep;78(3):515-9.
Tarlatzis et al Tarlatzis BC, Toncheva DI, Vatev IT. Signicance of chromosomal aberrations
for the unsuccessful procedures of assisted reproduction. Eur J Obstet Gynecol Reprod Biol.
2000;88(2):181-7.
Gianaroli L, Magli MC, Munne S, Fiorentino A, Montanaro N, Ferraretti AP. Will preimplantation genetic diagnosis assist patients with a poor prognosis to achieve pregnancy? Hum
Reprod. 1997 Aug;12(8):1762-7.
Voullaire L, Wilton L, McBain J, Callaghan T, Williamson R Chromosome abnormalities
identied by comparative genomic hybridization in embryos from women with repeated implantation failure. Mol Hum Reprod. 2002 Nov;8(11):1035-41.
Rubio C, Gil-Salom M, Simon C, Vidal F, Rodrigo L, Minguez Y, Remohi J, Pellicer A.
Incidence of sperm chromosomal abnormalities in a risk population: relationship with sperm
quality and ICSI outcome. Hum Reprod. 2001 Oct;16(10):2084-92.
De Vos A, Van Steirteghem A. Zona hardening, zona drilling and assisted hatching: new
achievements in assisted reproduction. Cells Tissues Organs. 2000;166(2):220-7.
Zeyneloglu HB, Arici A, Olive DL. Adverse effects of hydrosalpinx on pregnancy rates after
in vitro fertilization and embryo transfer. Fertil Steril 1998; 70:492-9.
Camus E, Poncelet C, Gofnet F, et al. Pregnancy rates after in-vitro fertilization in cases
of tubal infertility with and without hydrosalpinx: a meta-analysis of published comparative
studies. Hum Reprod 1999; 14:1243-9.
Meyer WR, Castelbaum AJ, Somkuti S, et al. Hydrosalpinges adversely affect markers of
endometrial receptivity. Hum Reprod 1997; 12:1393-8.
Birkenfeld A, Mukaida T, et al. Incidence of autoimmune antibodies in failed embryo transfer
cycles. Am J Reprod Immunol (1994); 31:65-8.
Coulam CB, Kaider BD, Kaider AS, Janowicz P, Roussev RG. Antiphospholipid antibodies
associated with implantation failure after IVF/ET. J Assist Reprod Genet (1997); 14:603-8.
Denis AL, Guido M, Adler RD, Bergh PA, Brenner C, Scott RT. Anriphospholipid antibodies
and pregnancy rates and outcome in in vitro fertilization patients. Fertil Steril (1997); 67:108490.
Eldar-Geva T, Wood C, Lolatgis N, Rombauts L, Kovacs G, Fuscaldo J, Trounson AO.
Cumulative pregnancy and live birth rates in women with antiphospholipid antibodies undergoing assisted reproduction. Hum Reprod. 1999 Jun;14(6):1461-6.
Stern C, Chamley L, Hale L, Kloss M, Speirs A, Baker HW: Antibodies to beta2 glycoprotein
I are associated with in vitro fertilization implantation failure as well as recurrent miscarriage:
results of a prevalence study. Fertil-Steril. 1998; 70(5): 938-44
Matsubayashi H, Arai T, Izumi S, Sugi T, McIntyre JA, Makino T: Anti-annexin V antibodies
in patients with early pregnancy loss or implantation failures. Fertil-Steril. 2001 Oct; 76(4):
694-9
Ledee-BatailleN, Dubanchet S, Coulomb-L'hermine A, Durand-Gasselin I, Frydman R,
Chaouat G: A new role for natural killer cells, interleukin (IL)-12, and IL-18 in repeated
221
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
implantation failure after in vitro fertilization. Fertil-Steril. 2004 Jan; 81(1): 59-65
Kwak-Kim JY, Chung-Bang HS, Ng SC, Ntrivalas EI, Mangubat CP, BeamanKD, Beer AE,
Gilman-Sachs A: The prevalence of dominant Th1 immune responses in peripheral blood
lymphocytes may reect the systemic contribution of Th1 cytokines to RSA or multiple implantation failures in IVF cycles. Hum-Reprod. 2003 Apr; 18(4): 767-73
Thomas K, Thomson A, Wood S, Kingsland C, Vince G, Lewis-Jones I. Endometrial integrin
expression in women undergoing in vitro fertilization and the association with subsequent
treatment outcome. Fertil Steril. 2003 Sep;80(3):502-7.
Tei C, Maruyama T, Kuji N, Miyazaki T, Mikami M, Yoshimura Y: Reduced expression of
alphavbeta3 integrin in the endometrium of unexplained infertility patients with recurrent
IVF-ET failures: improvement by danazol treatment. J-Assist-Reprod-Genet. 2003 Jan; 20(1):
13-20
Dicker D, Ashkenazi J, Feldberg D, Farhi J, Shalev J, Ben-Rafael Z. The value of repeat hysteroscopic evaluation in patients with failed in vitro fertilization transfer cycles. Fertil Steril.
1992 Oct;58(4):833-5.
Schiano A, Jourdain O, Papaxanthos A, Hocke C, Horovitz J, Dallay D. [The value of hysteroscopy after repeated implantation failures with in vitro fertilization]Contracept Fertil Sex.
1999 Feb;27(2):129-32.
Demirol A, Gurgan T Effect of treatment of intrauterine pathologies with ofce hysteroscopy
in patients with recurrent IVF failure. Reprod Biomed Online. 2004 May;8(5):590-4.
Dechaud H, Daures J, Arnal F, Humeau C, Hedon B. Does previous salpingectomy improve
implantation and pregnancy rates in patients with severe tubal factor infertility who are undergoing IVF? A pilot prospective randomized study. Fertil Steril 1998;69:1020-5.
Strandell A, Lindhard A, Waldenstrom U, Thorburn J, Janson PO, Hamberger L. Hydrosalpinx
and IVF outcome: a prospective, randomized multicentre trial in Scandinavia on salpingectomy prior to IVF. Hum Reprod. 1999 Nov;14(11):2762-9.
Basak S, Dubanchet S, Zourbas S, Chaouat G, Das C. Expression of pro-inammatory cytokines in mouse blastocysts during implantation: modulation by steroid hormones. Am J Reprod
Immunol. 2002 Jan;47(1):2-11.
Friedler S, Margalioth EJ, Kafka I, Yaffe H. Treatable uterine cause for in-vitro fertilisation
failures. Lancet. 1993 May 8;341(8854):1213.
Barash A, Dekel N, Fieldust S, Segal I, Schechtman E, Granot I. Local injury to the endometrium doubles the incidence of successful pregnancies in patients undergoing in vitro fertilization. Fertil Steril. 2003 Jun;79(6):1317-22.
Simon C, Mercader A, Garcia-Velasco J, Nikas G, Moreno C, Remohi J, Pellicer A. Coculture
of human embryos with autologous human endometrial epithelial cells in patients with implantation failure. J Clin Endocrinol Metab. 1999 Aug;84(8):2638-46.
Jayot S, Parneix I, Verdaguer S, Discamps G, Audebert A, Emperaire JC. Coculture of embryos
on homologous endometrial cells in patients with repeated failures of implantation. Fertil
Steril. 1995 Jan;63(1):109-14.
Spandorfer SD, Pascal P, Parks J, Clark R, Veeck L, Davis OK, Rosenwaks Z. Autologous
endometrial coculture in patients with IVF failure: outcome of the rst 1,030 cases.J Reprod
Med Jun;49(6):463-7.
Asch RH. Uterine versus tubal embryo transfer in the human. Comparative analysis of implantation, pregnancy, and live-birth rates. Ann N Y Acad Sci. 1991;626:461-6.
Fluker MR, Zouves CG, Bebbington MW. A prospective randomized comparison of zygote
intrafallopian transfer and in vitro fertilization-embryo transfer for nontubal factor infertility.
Fertil Steril. 1993 Sep;60(3):515-9.
Tournaye H, Devroey P, Camus M, Valkenburg M, Bollen N, Van Steirteghem AC. Zygote
intrafallopian transfer or in vitro fertilization and embryo transfer for the treatment of male-
222
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.

factor infertility: a prospective randomized trial. Fertil Steril. 1992 Aug;58(2):344-50.
Toth TL, Oehninger S, Toner JP, Brzyski RG, Acosta AA, Muasher SJ. Embryo transfer to the
uterus or the fallopian tube after in vitrofertilization yields similar results.Fertil Steril. 1992
May;57(5):1110-3.
Friedler S, Margalioth EJ, Kafka I, Yaffe H: ZIFT as efcient alternative treatment in non-tubal
infertility. The Seventh World Congress on IVF and Assisted Procreation, Paris, June 30,
1991.
Levran D, Mashiach S, Dor J, Levron J, Farhi J. Zygote intrafallopian transfer may improve
pregnancy rate in patients with repeated failure of implantation. Fertil Steril. 1998;69(1):2630.
The role of assisted hatching in in vitro fertilization: A review of the literature
Fertil Steril 2004 ;82,suppl 1 s164-5 Cohen J, Alikani M, Rosenwaks Z. Implantation enhancement by selective assisted hatching using zona drilling of human embryos with poor prognosis.
Hum Reprod. 1992;7:685-691
Hurst BS, Tucker KE, Awoniyi A, Schlaff WD. Assisted hatching does not enhance IVF success in good-prognosis patients. J Assist Reprod Genet. 1998;15:62-64
Hellebaut S, De Sutter P, Dozortsev D, Onghena A, Qian C, Dhont M. Does assisted hatching
improve implantation rates after in vitro fertilization or intracytoplasmic sperm injection in all
patients? A prospective randomized study. J Assist Reprod Genet. 1996;13:19-22
Nakayama T, Fujiwara H, Yamada S, Tastumi K, Honda T, Fujii S. Clinical application of a new
assisted hatching method using a piezo-micromanipulator for morphologically low-quality
embryos in poor-prognosis infertile patients. Fertil Steril. 1999;71:1014-1018
Chao KH, Chen SU, Chen HF, Wu MY, Yang YS, Ho HN. Assisted hatching increases the
implantation and pregnancy rate of in vitro fertilization (IVF)-embryo transfer (ET), but not
that of IVF-tubal ET in patients with repeated IVF failures. Fertil Steril. 1997;67:904-908
Magli MC, Gianaroli L, Ferraretti AP, Fortini D, Aicardi G, Montanaro N. Rescue of implantation potential in embryos with poor prognosis by assisted zona hatching. Hum Reprod.
1998;13:1331-1335
Levitas Levitas E, Lunenfeld E, Har-Vardi I, Albotiano S, Sonin Y, Hackmon-Ram R,
Potashnik G. Blastocyst-stage embryo transfer in patients who failed to conceive in three
or more day 2-3 embryo transfer cycles: a prospective, randomized study. Fertil Steril. 2004
Mar;81(3):567-71.
Barrenetxea G, de Larruzea AL, Ganzabal T, Jimenez R, Carbonero K, Mandiola M. Blastocyst
culture after repeated failure of cleavage-stage embryo transfers: A comparison of day 5 and
day 6 transfers. Fertil Steril. 2005 Jan;83(1):49-53.
Guerif F, Bidault R, Gasnier O, Couet ML, Gervereau O, Lansac J, Royere D. Efcacy of
blastocyst transfer after implantation failure. Reprod Biomed Online. 2004 Dec;9(6):630-6.
Cruz JR, Dubey AK, Patel J, Peak D, Hartog B, Gindoff PR. Is blastocyst transfer useful as
an alternative treatment for patients with multiple in vitro fertilization failures? Fertil Steril.
1999;722:18-20.
Cohen J, Scott R, Alikani M, Schimmel T, Munne S, Levron J, Wu L, Brenner C, Warner C,
Willadsen S. Ooplasmic transfer in mature human oocytes. Mol Hum Reprod. 1998;4(3):26980.
Barritt J, Willadsen S, Brenner C, Cohen J. Cytoplasmic transfer in assisted reproduction. Hum
Reprod Update. 2001 Jul-Aug;7(4):428-35.
Malter HE, Cohen J Ooplasmic transfer: animal models assist human studies. Reprod Biomed
Online. 2002 Jul-Aug;5(1):26-35
Huang CC, Cheng TC, Chang HH, Chang CC, Chen CI, Liu J, Lee MS. Birth after the injection
of sperm and the cytoplasm of tripronucleate zygotes into metaphase II oocytes in patients
with repeated implantation failure after assisted fertilization procedures. Fertil Steril. 1999
223
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
Oct;72(4):702-6.
Pehlivan T, Rubio C, Rodrigo L, Romero J, Remohi J, Simon C, Pellicer A. Impact of preimplantation genetic diagnosis on IVF outcome in implantation failure patients. Reprod Biomed
Online. 2003 Mar;6(2):232-7.
Munne S. Preimplantation genetic diagnosis and human implantationa review. Placenta
2003 Oct;24 Suppl B:S70-6.
Gianaroli L, Magli MC, Munne S, Fiorentino A, Montanaro N, Ferraretti AP. Will preimplantation genetic diagnosis assist patients with a poor prognosis to achieve pregnancy? Hum
Reprod. 1997 Aug;12(8):1762-7.
Wilding M, Forman R, Hogewind G, Di Matteo L, Zullo F, Cappiello F, Dale B. Preimplantation
genetic diagnosis for the treatment of failed in vitro fertilization-embryo transfer and habitual
abortion. Fertil Steril. 2004 May;81(5):1302-7.
Wilton L, Voullaire L, Sargeant P, Williamson R, McBain J. Preimplantation aneuploidy
screening using comparative genomic hybridization or uorescence in situ hybridization of
embryos from patients with recurrent implantation failure. Fertil Steril. 2003;80(4):860-8.
Staessen C, Platteau P, Van Assche E, Michiels A, Tournaye H, Camus M, DevroeyP, Liebaers
I, Van Steirteghem A. Comparison of blastocyst transfer with or without preimplantation genetic diagnosis for aneuploidy screening in couples with advanced maternal age: a prospective
randomized controlled trial. Hum Reprod. 2004 Dec;19(12):2849-58. Epub 2004 Oct 07.
Coulam CB, Krysa LW, Bustillo M. Intravenous immunoglobulin for in-vitro fertilization
failure. Hum Reprod (1994;) 9:2265-9.
Sher G, Zouves C, Feinman M, Maassarani G, Matzner W, Chong P, ChingW: A rational basis
for the use of combined heparin/aspirin and IVIG; immunotherapy in the treatment of recurrent
IVF failure associated with antiphospholipid antibodies. Am-J-Reprod-Immunol. 1998 Jun;
39(6): 391-4
Balasch J, Creus M, Fabregues F, Font J, Martorell J, Vanrell JA: Intravenous immunoglobulin
preceding in vitro fertilization-embryo transfer for patients with repeated failure of embryo
transfer. Fertil-Steril. 1996 Mar; 65(3): 655-8
Stephenson MD, Fluker MR: Treatment of repeated unexplained in vitro fertilization failure
with intravenous immunoglobulin: a randomized, placebo-controlled Canadian trial. FertilSteril. 2000 Dec; 74(6): 1108-13
Tei C, Miyazaki T, Kuji N, Tanaka M, Sueoka K, Yoshimura Y. Effect of danazol on the
pregnancy rate in patients with unsuccessful IVF-ET. J Reprod Med. 1998 Jun;43(6):541-6.
Tei C, Maruyama T, Kuji N, Miyazaki T, Mikami M, Yoshimura Y: Reduced expression of
alphavbeta3 integrin in the endometrium of unexplained infertility patients with recurrent
IVF-ET failures: improvement by danazol treatment. J-Assist-Reprod-Genet. 2003 Jan; 20(1):
13-20
Wurfel W, Fiedler K, Krusmann G, Smolka B, von-Hertwig I: Verbesserung der
Behandlungsergebnisse durch LeukoNorm Cytochemia bei Patientinnen mit mehrfachen,
frustranen IVF- oder ICSI-Behandlungszyklen. [Improving treatment outcome by LeukoNorm
Cytochemia in patients with multiple, failed IVF or ICSI treatment cycles] Zentralbl-Gynakol.
2001 Jun; 123(6): 361-5
Sher G, Feinman M, Zouves C, et al. High fecundity rates following in-vitro fertilization and
embryo transfer in antiphospholipid antibody seropositive women treated with heparin and
aspirin. Hum Reprod (1994); 9:2278-83.
Geva E, Amit A, Lerner-Geva L, Yaron Y, Daniel Y, Schwartz T, Azem F, Yovel I, Lessing
JB: Prednisone and aspirin improve pregnancy rate in patients with reproductive failure and
autoimmune antibodies: a prospective study. Am-J-Reprod-Immunol. 2000;43(1): 36-40
224
Is There a Life for IUI after the Advent

of ICSI?
Matan Yemini MD, Jesse Hade MD, Arie Birkenfeld MD.
Diamond Institute for Infertility & Menopause Millburn NJ, USA.
It is estimated that male factor infertility is partially or solely responsible for

inability to conceive in 40-50% of couples with infertility. Couples affected by
male factor infertility have an estimated conception rate of about 2% per cycle.
The approach to the management of the couple with male factor infertility
should include the assessment and treatment of the female partner. A study of
the couples attending a male infertility clinic indicated ovulatory problems in
17%, tubal disorders in 6% and endometriosis in 8% of female partners ( 1 ).
Treatment of a correctable condition in the woman may lead to achievement
of pregnancy despite the persistence of male factor.
Unfortunately, most cases of male infertility are idiopathic or may be genetically related, and, therefore, there is no surgical procedure or therapeutic
agent with the capacity to improve sperm production for these patients. The
good news is that we can still overcome most causes of male factor infertility.
Techniques such as intra uterine insemination (IUI) or in vitro fertilization
(IVF) with intracytoplasmic sperm injection (ICSI) have been employed with
good success. IVF with ICSI is the ultimate answer for couples with severe
sperm problems. However, it is medically demanding, expensive, and not always available. IUI on the other hand is less medically demanding, relatively
easily available and less costly, but it is signicantly less successful. Medical
data, risk versus benet, emotional and religious aspects, as well as nancial
parameters, should all be part of our concerns as we advise the infertile couple
on the treatment of choice. However, the lack of consistent data from good
quality comparative studies makes counseling of the couple in their choice of
treatment difcult.
225
The introduction of IVF in 1978 had a signicant positive impact on many

infertile couples with the exception of those suffering from signicant male
factor infertility. The introduction of ICSI, in 1993, changes those couples
perspectives for conception. There is no doubt that ICSI is one of the most
dramatic changes in reproductive medicine. It has been widely use to treat male
factor infertility and has become the rst option of care for many couples. The
results have been a decline in the use of other types of reproductive treatments,
sometimes regardless of their potential benets and cost-to-results ratio.
ICSI is a product of the last 10 years. The use of IUI, on the other hand, goes
back to the ancient Middle East. Scholars at that time discussed the possibility
of pregnancy without sexual intercourse. A document in Arabic from the year
1322 states that articial insemination had been practiced in some animals.
In 1677, Louis Van Hammen, a Dutch university student, is thought to be
the rst to observe sperm through a light microscope. Dr. John Hunter, from
England, was the rst to treat male factor infertility successfully by autologous
insemination of the wife of a rich merchant who suffered from hypospadia. Dr.
William Pancoast, from Philadelphia, was the rst to use heterologous semen
for insemination using the most generous looking medical student who was
selected by his class as the donor.
The answer to the question, Is there a life for IUI after the advent of ICSI
? is in a way the advice we have to give a couple with male factor infertility
looking for their best treatment. The answer is as simple as, ICSI is better,
as it gives you a better chance to conceive per attempt, or is as complex as,
There is no simple answer to your question. You have to consider medical,
economic, emotional, and religious aspects before we can reach any conclusion. And even then we are not going to have one simple answer.
The spontaneous pregnancy rate for couples with mild to moderate male
factor infertility is considered to be 2-3%. (2, 3 ) The use of IUI to increase
conception in these couples has been the focus of a substantial number of studies. Considerable amount of evidence indicates that the use of IUI can achieve
pregnancy rates of 10.5-17.9% per cycle. ( 4, 5) Other studies found similar
results, but describe pregnancy rates of 7%. (2) Despite these gures the role of
IUI has remained controversial. The wide variations in patient selection criteria
and cycle regimens between different publications make it difcult to reach a
unied conclusion. A survey of IUI results of male factor infertility described a
6.4% pregnancy rate in 7039 insemination cycles. ( 6 ) We have collected data
of 23 studies of oligospermic male IUI cycles resulting in 125 pregnancies in
2151 cycles, an average of 5.8% pregnancy rate per cycle. These results are
better then the 2% expected pregnancy rate, however, most IUI studies failed
226
to compare the results with a control intercourse-only group. One prospective

randomized study showed a higher success for IUI in oligospermic couples
compared to LH surge timely intercourse. (6) However, an additional study
by the same group indicated an advantage to IUI only during the rst cycle. A
control crossover study comparing IUI with intercourse showed no advantage.
As a result of that, there remains no consensus for the role of IUI in oligospermic couples.
The signicantly better pregnancy rate per cycle achieved by IVF-ICSI is
driving a consensus to advise our patient against IUI when male infertility is
the problem. One of the differences between IUI and IVF is the aggressiveness
with which we use fertility drugs. The concerns of multiple pregnancy and hyperstimulation syndrome, which may or may not be preventable with IVF, make
many of us more conservative with the use of controlled ovarian stimulation in
IUI cycles. This by itself may have a negative effect on IUI results. Looking
at 278 IUI cycles, we have learned that the pregnancy rate was 12.3% for non
control ovarian stimulation cycles, 11.3% for clomid cycles and 30.4% for
HMG/FSH cycles. A literature summary of 13 studies, with 1328 unstimulated
IUI cycles of male factor infertility couples, resulted in 63 pregnancies (4.7%).
Six studies of 601 IUI/ HMG cycles resulted in 49 pregnancies (8.2%).
The relative inuence of various semen characteristics on the likelihood of
a success is controversial. The magic number of 10 million motile sperm for
insemination has been subjected to various studies. ( 7 ) Others suggested the 10
million mark as the minimum threshold value of motile sperm in the ejaculate
needed to advise for IUI. ( 8 ) Aiming for the magic number, attempts were
made to accumulate sperm by freezing multiple ejaculates from oligospermic
men. Unfortunately, this treatment approach was proven ineffective and useless
(6). Improvements in sperm cryopreservation methods may open the doors for
sperm cryo-accumulation for IUI treatment of oligospermic men. A preliminary study by Iizuka et al ( 9 ) was the driving power of our rst pilot study in
1991. Ten severely oligospemic men (count less then 3 million/ml) underwent
24 cycles of IUI with cryo-accumulation of 3-10 samples per cycle, resulting
in 3 deliveries. Similar results have been reported by others in ( 10 ). Since
then, we have use sperm cryo-accumulation in conjunction with IUI. A larger
review of insemination cycles performed at our center was recently conducted.
It included 966 patients who completed 1677 IUI cycles. Of these cycles, 272
inseminations were performed for couples with varying degrees of male factor infertility. Sixty nine of these cycles had severe oligospermia with less
then 5 million sperm found on semen analysis, and the other 209 cycles were
conducted on couples with mild to moderate male factor with 5-19 millions
227
sperm on sperm analysis. For comparison, 1339 IUI cycles were performed on
couples without male factor infertility. Couples with normal semen analysis had
pregnancy rate of 18% per IUI cycle. This pregnancy rate did not differ when
compared to couples undergoing insemination with sperm cryo-accumulation
for the mild to moderate male factor (15.9 %) and the severe male factor group
(16%). A lower pregnancy rate was achieved when no cryo-acumulation was
used, 11.4% and 6.3% respectively. These results are encouraging and indicate
a potential benet for couples with male factor infertility.
A better pregnancy rate is the main justication for the use of IVF-ICSI over
IUI for sever male factor. At the present, there is no real data to contradict this
statement. On the other hand, there are no good randomized studies comparing
these two types of treatment. One may try to speculate from conclusions of
studies comparing IVF to IUI in couple with idiopathic and mild to moderate
male factor infertility. A prospective randomized study reported no signicant
differences in cumulative pregnancy rates between IUI and IVF, while the cost
for IVF was more than twice that of IUI. ( 3 ) Similar results have been reported
in the UK. (11 ) This evidence makes IUI attractive as it is less invasive, requires
less intensive monitoring and is associated with lower risk.
It seems that current evidence supports IUI as the rst-line of treatment
for mild to moderate male factor infertility. Unfortunately this may not be the
case in many instances. There are very few studies which looked at the question: what is that we are offering our patients?. Study done in Australia and
New Zealand had found that one third of IVF units offer IVF as the rst line
of treatment even in the absence of tubal anomalies and male factor problems
(12 ). We have are afraid that the case may be the same in other part of the
western world. There is no real data evaluating the same question in cases of
signicant male factor infertility. We speculate that if studies like these will be
done, IVF-ICSI will be found to be the rst line of treatment in all cases. One
can claim that, in the current climate of evidence based medicine, IUI with
controlled ovarian stimulation should be the rst-line of treatment for mild to
moderate male factor infertility. IVF-ICSI is still the best treatment for severe
male factor, at least, until such a time when improvements in IUI technique or
sperm cryo-accumulation controlled studies comparing IUI to IVF-ICSI will
prove us wrong.
228
Reference:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Wang C, Swerdloff RS. Medical Treatment of Male Infertility in Infertility Evaluation and
Treatment, Saunders Company,1995.
Speroff S, Glass RH, Kase NG, Male Infertility in Clinical Gynecologic Endocrinology and
Infertility, Lippincott Williams & Wilikins, 1999.
Goverde AJ, McDonne J. Vermmeden JP et al. Intrauterine Insemination or in-vitro fertilisation
in idiopathic subfertility and male subfertility : a randomized and cost effectiveness analysis.
Lancet 335,2000.
Stone BA, Vargyas JM, Ringler GE et al. Determinants of outcome of intrauterine insemination: analysis of outcomes of 9963 consecutive cycles, Am J. Obstet. Gynecol. 180, 1999.
Kaplan PF, Austin DJ Freund R. Subcutaneous human menopausal gonadotrophin administration for controlled ovarian hyperstimulation with intra uterine insemination cycles. Am. J.
Obstet. Gynecol. 182, 2000.
Byrd W, Sperm Preparation and Homologous Insemination inInfertility Evaluation and
Treatment, Saunders Company 1995.
Wainer R, Albert M, Dorion A et al. Inuence of the number of motile spermatozoa and of their
morphology on the success of intrauterine insemination. Hum. Reprod., 19,2004.
Van Voorhis BJ, Bamett M, Sparks AE et al. Effect of the total motile sperm count on the
efcacy and cost effectiveness of intrauterine insemination and in vitro fertilization. Fertil.
Steril., 76,2001.
Iizuka R. Articial Insemination Progress and Clinical Application. 1989.
Aboulghar MA, Mansour RT, Serour GI et al. Cryopreservation of occasionally improved
semen samples for intrauterine insemination: a new approach in the treatment of idiopathic
male infertility. Fertil. Steril., 56,1991.
Philips Z, Barraza- Llorens M, Posnett J. Evaluation of the relative cost effectiveness of
treatment for infertility in UK. Hum. Reprod.,15, 2000.
Miskry T, Chapman M. The use of intrauterine insemination in Australia and New Zealand.
Hum. Reprod., 17,2002.
229
Does PGD help in patients with

repeated IVF failure?
George B. Maroulis
Repeated IVF failure in 3 repeated IVF procedures could be due to either a.

recurrent ovarian poor response b. poor endometrium c. failure of fertilization
repeatedly or d. failure in the presence of reasonable number of embryos transfered in the presence of good endometrium. In such cases (i.e. d.) age is a
very important parameter which affects success. Probably the most important
factor for success of IVF is the quality of embryos. Embryos with structural
chromosal aberrations (translocations, deletions, inversions with aneuploidies)
may not successfully implant.
Arrested embryos show up to 71.3% chromosomal abnormalities in 41.1%
in normally developing embryos Gianarolli found that in up to 57% embryos
are abnormal in repeated IVF failures.
The idendication of good embryos is key to success. Age, appearance of
embryos at 8 cell stage, blastocyst formation and lately the chromosome constitution of embryos may be factors that can predict success. Munne found that at
age 25-34, 39% embryos are abnormal but at age 42-44, 61% are abnormal.
PGD can identify the embryos that are normal by chromosomal or PCR
procedures. The identication of embryos that are abnormal reduces the possibilities of failure. Recent studies show that there is an increase in the implantation rate when PGD is used. However age is a very signicant factor difcult
to overcome.
After PGD improvement in IVF was up to 7.1% (Munne 2002) and 7.7% in
our experience (Kapetanakis and Maroulis, ESHRE poster 2004). With PGD
in women 41 years age success rate cannot overcome that observed in younger
women. Our experience shows that implantation rate is increased but cannot
reach that observed in younger women, which implies that other chromosomes
230
than the ones currently studied or other factors may inuence implantation and
need to be identied in patients with recurrent IVF failure.
Bibliography
Gianarolli L., et al Fert. Steril 72:837, 1999
Munne S et al, Fertil,Steril, 78:234, 2002
Kapetanakis E, G. Maroulis (ESHRE 2004 Meeting abstract)
231
Factors affecting Frozen Embryo

Transfer program.
Hashim H., Al Salman F., Felemban A., Al Fozan H., Hassan S.,
Bugnah M.
Section of IVF/Reproductive Endocrinology, Department of Obstetrics and Gynecology,
King Fahad National Guard Hospital, King Abdul Aziz Medical City,
Riyadh, Saudi Arabia.
Objective: The aim of our study was to determine the factors affecting success
in our embryo cryopreservation program.
Materials and Methods: 206 cycles were commenced and analyzed, all patients had HRT (Hormone Replacement Therapy) cycle and none of them had
a natural cycle. Freezing procedure usually is done on day 3 of the fresh cycle
(when the embryos are at 6-8 cell stage) and only the good quality grade (I)
and (II) embryos could be frozen. For all cases slow freezing was used, and
thawing was done on the same day of transfer. Embryo transfer is performed
on day 18 from starting oestradiol valerate regime, and a maximum of three
embryos are to be transferred.
Results: There was a signicant difference when comparing the mean age from
the two groups (P value is <0.00) and the mean BMI (P value is <0.05) but
other factors showed no signicant difference
Conclusion: Although freezing was performed when the embryos are at the 6-8
cells stage assuring that the cleavage is at acceptable range and also being strict
in freezing only the morphologically good quality embryos allows fewer
number of embryos for freezing but gives only a one step selection and less
time in the classical in vitro development. Among our population, and within
232
our initial performance, the most important factors when commencing FET
cycle appears to be the womans age and BMI.
Table 1:
Pregnant
Non-pregnant
P Value
No. Of cycles
64
142
Mean Age
30 4.47
32 5.11
<0.00
Mean BMI
30.12 5.21
28.59 4.82
<0.05
Mean Endometrial
thickness
10.5 2.59
12.8 13.70
N.S.
Mean No. Of
embryos transf.
2.9 0.52
2.8 0.54
N.S.
Mean No. Of Grade I

embryos
1.8 0.86
1.8 0.86
N.S.
Mean No. Of Grade

II embryos
1.7 0.90
1.6 0.83
N.S.
Key Words: Embryo freezing/ Cryopreservation.
Introduction:
With controlled ovarian stimulation, more eggs are produced than needed for
establishing a pregnancy. The ability to cryopreserve, thaw and transfer the
supernumerary embryos has become an important tool in infertility treatment.
In addition to that, It is well known that frozen embryo transfer (FET) cycle is
less invasive and also less expensive procedure in comparison with the fresh
stimulated one (1).
While embryo cryopreservation success has increased over time, there is always room for improvement. In order to do so, you need to know the factors that
may inuence the success of such procedure. This study is aiming to determine
the factors affecting the success in our embryo cryopreservation program.
Materials and methods:

Patients:
A series of 206 cycles were commenced and analyzed. Patients were divided
into two groups, pregnant (group I) and non-pregnant (group II). All patients
233
received oestradiol valerate tablets after down-regulation using GnRH-agonist

is conrmed by ultrasound & oestradiol level and this is counted as day (1).
An ultrasound scan is performed (16) days later to check the endometrial thickness. Embryo transfer is usually done on day (18) of the cycle. After embryo
transfer is done, patients will continue on the oestradiol valerate tablets and
progesterone vaginal pessaries until the result of the pregnancy test is known.
Pregnancy test is usually done (16 days) after embryo transfer.
Embryo freezing:
In the fresh cycle, Embryo development was evaluated daily, and the grading
criteria for day (2) and day (3) were based on the number, evenness of the
balstomeres, and the amount of fragmentation. For all patients, fresh embryo
transfer was done on day (3) post ovum pick up. Cryopreservation is done
on day (3) after the oocyte recovery when the embryos are at 6-8 cells stage.
According to our policy, only good quality (Grade I and II) embryos are to be
cryopreserved. The embryo will be considered (grade I) when embryo showed
even-sized blastomeres, at 6-8 cells stage of cleavage on day (3), in addition to
no fragmentation, and will be considered (grade II) when embryo shows slight
blastomere size difference and/or less than 25% fragmentation. Embryos were
loaded into 250l straws and frozen in a controlled rate freezer (Planer Kryo
10 Series III freezing unit, Planer product Ltd., UK) at 2oC/min to 7oC, at
0.3oC/min to 30oC and then plunged into liquid nitrogen, after dehydration/
equilibration in three steps cryopreservation buffer with 1.5m Propanediol
(Sydney IVF Cryopreservation Kit, K-SICS-5000, Cook, Australia).
Embryo thawing:
Thawing procedure is usually performed about three to four hours before transfer. Cryo-straws containing the embryos will be removed from the liquid nitrogen storage tank quickly, kept at room temperature for 30 seconds and then
immersed in the 30o C water bath for one minute. Embryos then removed and
sequentially incubated for 5 minutes in four steps thawing solutions containing
decreased concentrations of 1,2 Propanediol and sucrose using (Sydney IVF
Thawing Kit, K-SITS-5000, Cook, Australia). Then embryos were cultured in
cleavage medium (Sydney IVF Cleavage medium, SICM, Cook, Australia) until
transfer. A maximum of three embryos are usually transferred on the same day
of thawing. Only the number of embryos intended for transfer will be thawed.
The embryo thawing strategy is to achieve a goal of having three (grade I, II)
embryos. Depending on the availability and if embryo(s) did not survive or if
25% of the balstomeres showed degeneration, more embryos could be thawed.
234
Analysis:
Data are presented as mean SD. Where appropriate, data were analyzed with
unpaired Students t-test or x2-test. P<0.05 is considered to be statistically signicant.
Results:
A comparison was done between pregnant group (n=64) [clinical pregnancy
was conrmed by a detectable intrauterine gestational sac on ultrasound] and
non- pregnant group (n=142) in the Mean age, mean BMI, mean endometrial
thickness at the time of embryo transfer, mean number of embryos transferred
(table 1), also in the mean number of (grade I) and (grade II) embryos transferred (table 2). The mean age was less in the pregnant group than in the nonpregnant group and that was signicant (P value is <0.00). Interestingly, the
BMI was lower signicantly in the non-pregnant group (P=<0.05). There was
no signicant difference between the two groups with regards to the mean
endometrial thickness or number and quality of embryos transferred.
Table 1:
Pregnant
Non-pregnant
P
Value
No. of cycles
64
142
Mean age
30 4.47
32 5.11
<0.00
Mean BMI
30.12 5.21
28.59 4.82
<0.05
Mean endometrial thickness
10.5 2.59
12.8 13.70
N.S.
Mean No. of embryos

transferred
2.9 0.52
2.8 0.54
N.S.
Table 2:
Differences between pregnant and non-pregnant group in the quality of embryos transferred:
Pregnant
Non-pregnant
P Value
Mean No. of grade I

embryos transferred
1.8 0.86
1.8 0.86
N.S.
Mean No. of grade II

embryos transferred
1.7 0.90
1.6 0.83
N.S.
235
Discussion:
The morphologically best quality embryos usually have the priority to be transferred in the stimulated cycle to give the patients the best opportunity of achieving pregnancy and avoiding the possibility of losing good quality embryos in
the freezing thawing process.
Freezing excess embryos before the fresh embryo transfer procedure is
popular in current IVF practice. Predominance of studies has shown that human
embryos survive and implant at higher rates when frozen at pronuclear stage
compared with the cleavage stage (2,3,4).
Freezing at the cleavage stage is also popular because of a better embryo
selection compared with the pronucleate freezing (5,6). However, it should be
noticed that reported survived embryos include those with some blastomeres
lysed after thaw, which is common. The accepted denition of the survived
cleavage embryo is one of which more than 50% of the blastomeres remain
intact after the thawing procedure (7,8).
It is well known that womans age is considered as a prognostic factor when
IVF treatment is proposed to infertile couples as marked decline in success
rates observed at 35-37 years. Interestingly, in egg donation programs in the
United Sates, 33 years has been recommended as a cut-off age for the commercial recruitment of donors (9,10,11).
In the female partner, the obesity is associated with an impaired response
to ovarian stimulation and increase risk of early pregnancy loss occurring before 6 weeks gestation where underweight (BMI< 18.5), was not related to an
impaired outcome of IVF or ICSI. (12). In our study, obesity did not inuence
the pregnancy rate in the FET cycle.
In conclusion, among our population and within our initial performance,
the womans age seems to be considered as a prognostic factor also when
commencing FET cycle.
236
References:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Van Voorhis BJ, Syrop CH, Allen BD, Sparks AET, Stovall DW. The efcacy and cost effectiveness of embryo cryopreservation compared with other assisted reproductive techniques.
Fertil Steril. 1995;64:647-650.
Veeck LL, Amundson CH, Brothman LJ, DeScisciolo C, Maloney MK, Muasher SJ, et al.
Signicantly enhanced pregnancy rates per cycle through cryopreservation and thaw of
pronuclear stage oocytes. Fertil Steril. 1993;59:1202-1207.
Demoulin A, Jouan C, Gerday C, Dubois M. Pregnancy rates after transfer of embryos obtained
from different stimulation protocols and frozen at either pronucleate or multicellular stages.
Hum Reprod. 1991;6:799-804.
Quinn P. Success of oocyte and embryo freezing and its effect on outcome with in vitro
fertilization. Semin Reprod Endocrinol. 1990;8:272-280
Dawson KJ, Conaghan J, Ostera GR, Winston RML, Hardy K. Delaying transfer to the third
day post-insemination, to select non-arrested embryos, increases development to the fetal heart
stage. Hum Reprod. 1995;10:177-182.
Lin YP, Cassidenti DL, Chacon RR, Soubra SS, Rosen GF, Yee B. Successful implantation
of frozen sibling embryos is inuenced by the outcome of the cycle from which they were
derived. Fertil Steril. 1995;63:262-267.
Damario MA, Hammitt DG, Galanits TM, Session DR, Dumesic DA. Pronuclear stage cryopreservation after intracytoplasmic sperm injection (ICSI) and conventional in vitro fertilization (IVF): implications for timing of the freeze. Fertil Steril. 1999;72:1049-1054.
Testart J, Lassalle B, Belaisch-Allart J, Hazout A, Forman R, Rainhorn JD, et al. High pregnancy rate after early human embryo freezing. Fertil Steril. 1986;46:268-272.
Weckstein LN, Jacobsen A, Galen D, Hampton K, Ivani K, Anders J. Improvement of pregnancy rates with oocyte donation in older recipients with the addition of progesterone vaginal
suppositories. Fertil Steril. 1993;60:573-575.
Faber BM, Lindheim SR, Hamacher P, et al. The impact of an egg donors age and her prior
fertility on recipient pregnancy outcome. Fert Steril 1997;68:370-372.
Damario MA, Hammitt DG, Galanits TM, Stevens SA, Session DR, Dumesic DA. Anonymous
oocyte donation performed exclusively with embryos cryopreserved at the pronuclear stage.
Fertil Steril. 1999;71:830-835.
Fedoresak P, Dale PO, Storeng R, Ertzeid G, Bjercke S, Oldereid N, Omland AK, Ayholm
T, Tanbo T. Impact of overweight and underweight on assisted reproduction treatment. Hum
Reprod. 2004;19:2523-8.
Gianaroli L, Magli MC, Munne S, Fiorentino A, Montanaro N, Ferraretti AP. Will preimplantation genetic diagnosis assist patients with a poor prognosis to achieve pregnancy?. Hum
Reprod. 1997;12:1762-1767.
Jones Jr HW, Jones D, Kolm P. Cryopreservation: a simplied method of evaluation. Hum
Reprod. 1997;12:548-553.
Jones GM, Trouson AO, Lolatgis N, Wood C. Factors affecting the success of human blastocyst
development and pregnancy following in vitro fertilization and embryo transfer. Fertil Steril.
1998;70:1022-1029.
237
The Use of Advanced Reproductive

Technologies in Israel: Are the
professional partners seeing eye to eye?
Yael Simon a, Boris Kaplan b,c
Member of the Israeli Bar, Ph.D. student, Universite Pierre Mendes-France
Law school, Grenoble II, France.
b
General Health Services, Dan-Petah-Tikva District, Israel.
c
Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
a
Technological progress is one of the main features of the 20th Century. It has
helped to improve many aspects of our every day life, bringing comfort and
longevity to far more people than ever before. The medical domain is one of
those areas where scientic progress has made, and is still taking enormous
steps forward.
One of the elds in which spectacular changes were achieved is that of
reproduction. The use of advanced technologies in the eld of reproduction is
unique. It is unique in the sense that unlike other medical specialties, reproduction issues are at the center of our civilization. Dilemmas regarding birth
are related to the way we perceive life and human existence. It is the fabric of
which numerous philosophical, religious and ethical creeds are woven. And if
we are to add to the complexity of it all, for many centuries it is a procedure
that was considered to be mystical and mostly beyond the control and the free
will of the person in question.
Advanced Reproductive Technologies (ART) shake our notion of human
reproduction in two ways. First, they set new possibilities for human reproduction: they allows to choose whether and when to bear children, and they solve,
in what seems to lay people childlike simplicity, problems of infertility by deciphering the biological mechanism of reproduction. Yet, by so doing they remove
the blessing of ignorance and leave us to face our own dilemmas. Dilemmas
238
regarding human autonomy (who should have access to treatment?);1 regarding

moral standards (what sort of families will be created by this procedure?);2 and
dilemmas regarding professional responsibility (who are the professionals that
ought to take part in this procedure?).
The present study had examined in two different surveys the positions of
two major professional groups that are involved in ART procedures in Israel.
The rst survey took place during the months of March to June 2003.3 It was
conducted on 155 gynecologists (out of 600 who received a questionnaire)
specializing in this eld. The second survey took place at about the same time
the following year, but was destined to lawyers specializing in the legal aspect
of ART. 208 lawyers received the questionnaire, of which 193 had lled and
returned it.
It should be noted that Israel stands at one of the top places in the list of
countries implementing to the fullest the possibilities offered by ART. It offers
free treatment to women under the age of 51 who are childless or who have only
one child;4 and it allows and regulates Surrogate-Mother Agreements under
strict legal supervision of Ministry of Justice ofcials.5
The questionnaires used in these two surveys were identical. They contained
10 questions that may be divided into 3 main groups:
1. The rst group of questions regards the changes in the past three decades
as to the term Family. It inquires as to the positions of the respondents
of what they perceive as a Family (a traditional family, a single-parent
one, or a same sex family). All these possibilities are, of course, available
through the use of ART.
2. The second group of questions checks the respondents positions as to the
gynecologists role in the process, and, more generally, to the social scope
and consequences of the implementing this procedure.
3. The third group of questions explores the repondents acceptance to the
participation of other professional partners in the process, such as lawyers,
social workers and psychologists.
The study shows differences in the rates gynecologists and lawyers perceive the social scope of the implementation of ART. Most physicians consider
these procedures as inuencial in the social arena in changing preconception
as to parenthood, while only two thirds of lawyers consider it to have such
consequences. The same gap appears in the second question: 80% of the gynecologists considered their role in the process as of being of high importance,
whereas only 56.5% of the lawyers shared this view.
As to questions regarding new family structures the study found that only
54% of gynecologists dismissed the narrow denition of a family (in which
239
only a traditional denition of a family was valid), as opposed to 73.1% of

lawyers who dismissed the same denition.
A little over 50% of both groups (51% of gynecologists, and 59.6% of
lawyers) agreed that the term family may also legitimately include same sex
couples. Also, both groups have accepted nearly at the same rate (67.1% of
the gynecologists, and 75.7% of lawyers) that single parent families are to be
considered within the consensual denition of a family.
As to the prospects of sharing responsibility with other professional in
implementing the ART procedures, the study shows that 81.7% of lawyers felt
the gynecologists should not be the sole decision-maker in the process (only
65.2% of gynecologists shared that view).
As to the participation of social workers and / or psychologists and lawyers
in the decision making process prior to the treatment we found very similar
rates both groups. 49.7% of gynecologists and 51.8% of lawyers agreed that
social workers and/or psychologists ought to take part in the decision making
process prior to the commencement of the treatment. In addition, only 20%
of gynecologists and only 25.3% of lawyers felt jurists ought to approve the
necessity of the treatment prior to its beginning.
Conclusions
The study shows that both lawyers and gynecologists consider the implementation of the treatment to be essentially of medical and social nature (rather
than of legal one). As to the role of the gynecologist in the procedure, we
conclude that although both groups agree that the gynecologist should not be
the sole decision-maker in the process, the lawyers tend to oppose that claim
more widely (81.7%) in comparison to the gynecologist respondents group
(65.2%). Regarding the denition of a family, they both acknowledge the
social changes that lead to acceptance of new family models, and as a whole
they agree at about the same rates as to the acceptance of single parent and
same sex family constructions.
Reference
1
2
3
Sandor J. Reproductive Rights in Hungarian Law: A New Right to Assisted Procreation, Health
Hum Rights 2000; 4(2): 196-218.
Bernat E. Towards a New Legal Regulation of Medically Assisted Reproduction: The Austrian
Approach. Med Law 1992; 11(7): 545-55.
Y. Simon and B. Kaplan, Social Aspect of Implementing New Reproduction Technologies in
Israel and Its Consequences : A Survey of Gynecologists opinions, Clinical and Experimental
Obstetrics and Gynecology (in press).
240
4
5

By virtue of the Israeli National Health Insurance Law of 1994.
Law of Contracts to Carry Embryos, Laws of the State of Israel, 1996.
Table: Jurists Questionnaire on Social Impact of ART (n=193):
Agree
Do not
agree
No opinion
1. The use of new reproduction technologies is of social consequences.
66.9%
15.5%
17.6%
2. The gynecologist plays a role in

reshaping the social reality through
the progress in reproduction technologies.
56.5%
19.7%
23.8%
3. A "real" family consists only of a

traditional heterogeneous couple.
21.3%
73.1%
5.6%
4. A "real" family is also one that

consists of a same-sex couple.
59.6%
33.7%
6.7%
5. A "real" family is also one that

consists of a single parent.
75.7%
21.2%
3.1%
6. The interests of the unborn child

ought to be taken into consideration
by the gynecologist involved in the
procedure.
78.0%
14.7%
7.3%
7. Fertility treatments ought to be

available to everyone.
52.4%
37.3%
10.3%
8. The treating gynecologist ought

to be the sole decision-maker in the
process.
11.5%
81.7%
6.8%
9. Social workers and/or psychologists ought to approve the necessity

of the treatment prior to its beginning.
51.8%
34.2%
14.0%
10. Jurists ought to approve the necessity of the treatment prior to its
beginning.
25.3%
61.7%
13.0%
241
Review of non-surgical and surgical

treatment, and the role of insulinsensitizing agents in the management of
infertile women with polycystic ovary
syndrome
Ahmed M. Saleh 1*, M.D., FRCSC and Hala S. Khalil 2 MSc.
Department of Obstetrics and Gynecology 1. Riyadh Armed Forces Hospital
and Department of Biological and Medical Research 2. King Faisal Specialist
Hospital and Research Center. Riyadh, Saudi Arabia.
E-mail: drsaleh2002@hotmail.com
Objectives: To review the non-surgical and surgical treatment, and the role of
insulin-sensitizing agents in the management of anovulatory infertile women
with polycystic ovary syndrome (PCOS).
Materials and methods: The search term of subfertile women with anovulation and PCOS was used for identication of randomized controlled trials. Non
randomized controlled studies were identied through computer MEDLINE
and EMBASE search for years 1980-2002.
Results: For obese PCOS women weight loss of > 5% of pretreatment weight
restores menstrual regularity in 89% of whom 30% achieved spontaneous
pregnancy. It was estimated that 75-80% of anovulatory PCOS women will
respond to clomiphene citrate (CC) and 35-50% will achieve pregnancy. For
CC-resistant PCOS women (20-25%), CC + metformin (1.5 g/day) for 3 to
6 months have a 70% chance of restoration of regular menses and ovulation,
and a 23% chance of pregnancy. Laparoscopic ovarian drilling (LOD) can be
242
offered to CC-resistant PCOS women. There was no statistically signicant

difference in the ovulation rate following LOD with electrocoagulation and
laser 83% and 77.5% respectively (Odds Ratio (OR) = 1.4, 95% CI: 0.9-2.1),
while there was a signicantly higher cumulative pregnancy rate at 12 months
after surgery 65% and 54.5% respectively (OR = 1.5, 95% CI: 1.1-2.1).
Conclusion: Diet and exercise followed by CC should be used for non-surgical ovulation induction. For CC-resistant PCOS women, metformin may be
included in a stepwise approach before a surgical approach. LOD with electrocautery is superior to laser drilling and gonadotrophin therapy.
Key words: Polycystic ovary syndrome, ovulation and pregnancy, laparoscopic
ovarian drilling, insulin resistance.
Introduction
Polycystic ovary syndrome (PCOS) is a prevalent and heterogenous condition, affecting 6-10% of reproductive aged women and 35-40% of infertile
women (1-3). It is the most common cause of chronic anovulation (4). Patients
may also present with menstrual irregularities (usually oligo- or amenorrhea),
hirsutism, acne or a combination of all. Treatment of this condition has generally been prescribed to alleviate symptoms that bring the women to medical
attention, such as infertility or hirsutism. Recently, the association between
PCOS-related hyperandrogenemia, insulin resistance and hyperinsulinemia has
been recognized as an important factor in the reproductive abnormality (6-7).
Women with PCOS have an increased prevalence of impaired glucose tolerance
(35-40%) and a prevalence of frank type 2 diabetes mellitus (7.5 -10%) (8-9).
Furthermore, long-term risks of metabolic consequences in women with
PCOS who are characterized by the insulin resistance are also increased such
as dyslipidemia, hypertension and coronary artery disease and endometrial
carcinoma (5, 8, 9).
Diagnosis
Many investigators in Europe have used the characteristic ultrasound features
(10), others used biochemical criteria: [1] early follicular phase (days 2 5 of
menstrual cycle) plasma luteinizing hormone (LH): follicle stimulating hormone (FSH) ratio 2 : 1, [2] LH concentration > 10 IU/L, [3] elevated serum
androgen levels [testosterone 2.5 nmol/l, androstenedione 10 nmol/l or free
243
androgen index > 4, with the exclusion of other endocrine disorders including non-classical adrenal hyperplasia, androgen-secreting tumors, Cushing's
syndrome, hyperprolactinemia, and thyroid dysfunction (11).
Pathogenesis:
The fundamental pathophysiology of PCOS remains unclear, however, the
basic triggering factor is the hyperandrogenemia. Most investigators believe
that PCOS is a primary ovarian disorder (12-17). Others believe it results from
hypothalamic disturbance, a primary adrenal disorder or a combination of these
factors (12-17). Insulin resistance and hyperinsulinemia can occur in obese or
non-obese PCOS women (18-19). The denition of insulin resistance in PCOS
is not yet agreed upon; however, hyperinsulinemia is a compensatory increase
in insulin secretion secondary to peripheral insulin resistance. Laboratory criteria that suggest the presence of hyperinsulinemia in PCOS women include an
elevated fasting insulin concentration > 25 U/ml (> 180 pmol/L) (21). Insulin
resistance can be diagnosed by euglycemic clamp technique or when fasting
glucose (mg/dl), to fasting insulin (U/ml), ratio < 4.5 (20). Although insulin
resistance and hyperinsulinemia have two different denitions, the pathogenesis and the effects are the same. Women with PCOS have varying degrees of
insulin resistance depending on their body weight compared to weight-matched
control subjects, hence, obesity acts synergistically with PCOS to increase the
degree of insulin resistance and hyperandrogenemia (19-23). The mechanism
of insulin resistance could be caused by defects at any step of insulin binding
sites (receptors) and actions. Several defects have been described: antireceptor
antibodies, receptors blocked or decient in the number or the afnity of the
binding domain of the insulin receptor, or post-receptors defective in the insulin
signaling transduction pathway (24-25). Therefore, insulin will fail to act as a
glucose-lowering hormone. Thus insulin binds to the insulin growth factor-I
receptors (IGF-I) stimulating the ovarian theca cells with or without LH in a
synergistic manner to increase androgen production from the ovary and reduce
hepatic production of sex hormone-binding globulin (SHBG), this in turn impairs follicular maturation and ovulation or alters gonadotropin secretion, as
shown in Figure 1 (26-27).
Management
The choices of treatment depend on the patients age and the presence of other
infertility factors. Treatment for women with PCOS must be individualized
under two main categories; obese or non-obese PCOS with or without insulin
resistance.
244
occurs due to defects in insulin receptors, the insulin binds to IGF-I receptors, which have exactly the same
Obesity
Insulin
PCOS
IGF-I
Receptor
LH
Theca
cells
Androgens
Fig 1: This is hypothetically, the insulin resistant pathophysiology

in women with obesity and PCOS. Hyperinsulinemia is primarily a
result of compensatory peripheral insulin sensitivity. Insulin sensitivity
occurs due to defects in insulin receptors, the insulin binds to IGF-I
receptors, which have exactly the same structure as insulin receptors.
This with or without synergetic action of LH, will stimulate ovarian
theca cells to increase androgen production.
Non-surgical
Ideally, for obese PCOS women a combination of dietary restriction and exercise remains the best form of treatment. Several investigators have shown
that weight loss of more than 5% of pretreatment weight had a benecial effect
in terms of reducing LH (45% decrease), fasting insulin (40% decrease), testosterone (35% decrease) and reduced progression to type 2 diabetes mellitus
by 58% (32-34). It also improves diabetes control, serum lipid proles and
restores menstrual function regularity in 89% of whom 30% achieved spontaneous pregnancy (35-36).
If weight loss is unsuccessful, or if the patient is lean and pregnancy is
desired, clomiphene citrate (CC) is widely used for ovulation induction in anovulatory PCOS women. It was estimated that 75-80% of patients will respond
to CC and 35-50% will achieve pregnancy (37-38). The reason why CC failed
to induce ovulation in the remaining 20-25% of PCOS patients remains unclear.
The patients who failed to respond to the incremental doses up to 150 mg of CC
are called clomiphene-resistant PCOS. Therefore, different strategies have been
245
advocated for ovulation induction such as; gonadotrophin, pulsatile LH-releasing hormone (LH-RH) or insulin-sensitizing agents (49). Insulin-sensitizing
agents are drugs that can reduce serum insulin or improve the insulin sensitivity
and thus lower the androgen levels. Currently four categories of medication are
known: diazoxide, metformin, thiazolidinediones, and d-chiro-inositol. Among
these medications, metformin is the most comprehensively evaluated drug with
proven effectiveness. Metformin (Glucophage) is an oral biguanide antihyperglycemic agent that has been used for many years in Europe for the treatment
of type 2 diabetes mellitus. In a hyperglycemic patient metformin lowers blood
glucose levels by enhancing insulin sensitivity at postreceptor level, inhibiting
hepatic glucose production and enhancing peripheral glucose uptake. While
in an insulin resistance and/or hyperinsulinemia in PCOS patients metformin
increases the number of insulin receptors leading to a reduction in the insulin
concentration, therefore it does not cause hypoglycemia (22, 83-84). It also
increases SHBG and decreases total and free androgen levels, thus restoring
normal ovulatory cycles (50-51). In 1994 Velazques et al published the rst case
series on the use of metformin in oligo-amenorrheic women with PCOS (50).
Following this publication numerous studies have shown that administration
of metformin 500 mg three times per day or 850 mg twice daily for 4-8 weeks
(1.5 g/day) to insulin resistant and/or hyperinsulinemic obese and lean PCOS
women restores menstrual cycle and ovulation response to CC and ultimately
improves pregnancy rates (52-55).
Metformin for ovulation induction

Four randomized controlled trials have compared metformin with placebo (51,
53, and 78, 79) showing that 56% of PCOS patients ovulated with metformin
compared with 35% on placebo (Relative Risk (RR) = 1.5, 95% CI: 1.2-2.0).
In CC-resistant PCOS women, two randomized controlled trials have compared
ovulation and pregnancy rates of additional metformin to CC versus CC to
placebo (54, 85). Of a total 82 CC-resistant PCOS women, the ovulation rate
was 70% versus 19% (RR = 4.1, 95% CI: 2.2-7.9) and pregnancy rate was 23%
versus 2.3% (RR = 10.0, 95% CI: 1.3-74.8.) respectively (54, 85). The above
data demonstrates that metformin augments the effect of CC on signicantly
higher ovulation and pregnancy rates.
The data on the effect of coadministration of metformin with FSH ovulation
induction or IVF did not signicantly improve ovulation and pregnancy rates
(80-82).
246
Surgical
Ovarian wedge resection was the rst surgical treatment proposed by Stein
and Leventhal for ovulation induction (39). This procedure was largely abandoned because of the greater risk of post-surgical formation of adhesions (40).
Gjonnaes in 1984 was the pioneer in describing laparoscopic ovarian drilling
(LOD) in women with PCOS using a unipolar electrode (57). He reported an
ovulation rate of 92% and a pregnancy rate of 58%. Following this procedure
similar techniques were performed by either electrocoagulation or laser to produce multiple holes on the ovarian surface as described by Tulandi and Daniell
(41, 66). The technique of LOD is performed under general anesthesia by using three-puncture abdominal ports. A 10-mm videolaparoscopy is introduced
through the subumbilical port and two 5-mm punctures at the right and left
lower abdominal side used for grasping forceps and diathermy needle or laser
ber. Ovarian diathermy is performed by using an insulated monopolar needle
and electrocoagulation at a setting of 30 to 40 watts to a standard depth of 8
mm. Pure cutting of 30 to 40 watts is used to pierce the ovarian capsule followed by a coagulation current for 2 to 4 seconds at each point. Its mechanism
of action is still not clear, but it is associated with a decrease in androgen levels
together with changes in gonadotrophin secretion and estrogen levels after
the procedure (42). Several theories explain these changes after laparoscopic
destruction of androgen-producing stroma of the ovaries: [1] it may decrease
the amount of substrate available for peripheral aromatization to estrogen. This
restores the feedback mechanism to the hypothalamic-pituitary ovarian axis,
allowing appropriate gonadotrophin stimulation of follicular maturation and
ovulation; [2] at ovarian level, reduction of intra-ovarian androgen allows follicular maturation and ovulation; [3] it may reduce the levels of inhibin allowing a secondary rise in the FSH level, and in combination with the reduction
of local androgen levels may facilitate follicular growth and ovulation; [4]
in response to thermal injury, the ovary produces a number of growth factors such as IGF-I, which sensitize the ovary to circulating FSH resulting in
stimulation of follicular growth and maturation (42-43). In our study (31), we
postulate that ovarian drilling may reduce ovarian volume, stroma volume,
VEGF and improve insulin sensitivity. In this study, there were no changes in
ovarian volume, stroma volume and serum VEGF levels after ovarian drilling. Furthermore, we found no correlation between insulin and VEGF levels
and no change of insulin responses to the oral glucose tolerance test (OGTT)
(31). In that study, we did not distinguish women with hyperinsulinemia from
those with normoinsulinemia. However, in another recent study, we found that
in women with hyperinsulinemia the glucose and insulin responses to OGTT
247
after ovarian drilling were lower than before surgery; no differences were seen
in women with normoinsulinemia (21). The mechanism of these ndings is
unclear; it is possible that this is related to the amount of androgen reduction
after ovarian drilling. There are however, few criterion favorable responses to
LOD, such as shorter duration of infertility, use of electrocoagulation rather
than laser, and preoperative high LH levels (48). Several investigators have
shown there is no statistically signicant difference in the ovulation rates following LOD with electrocoagulation and laser 83% versus 77.5% respectively
(Odds Ratio (OR) = 1.4, 95% CI: 0.9-2.1), although there is a signicantly
higher cumulative pregnancy rate at 12 months after surgery 65% versus 54.5%
respectively (OR = 1.5, 95% CI: 1.1-2.1), (Table 1and 2), (57-64, 48,42) and
(60, 65-69, 71-74) respectively.
Table 1:
Cumulative ovulation and pregnancy rates at 12 months after electrocoagulation laparoscopic ovarian drilling.
Authors
Year
Technique
Ovulation
rate(%)
Pregnancy rate
(%)
Gjonnaess et al57
1984
Electrocoagulation
57/62 (92)
24/35 (80)
Greenblatt et al
1987
Electrocoagulation
5/6 (83)
4/6 (66)
Armar et al59
1990
Electrocoagulation
17/21 (81)
11/21 (52)
Gurgan et al60
1991
Electrocoagulation
5/7 (71)
4/7 (57)
Naether et al61
1993
Electrocoagulation
90/104 (86)
73/104 (70)
Merchant et al62
1996
Electrocoagulation
65/74 (88)
62/74 (84)
Pelosi et al
1996
Electrocoagulation
25/30 (83.3)
21/30 (70)
Tulandi et al64
1997
Electrocoagulation
30/34 (88.2)
24/34 (70)
48
Li et al
1998
Electrocoagulation
88/111 (97)
62/111 (56)
Felemban et al42
2000
Electrocoagulation
82/112 (73.2)
61/112 (54)
464/561 (82.7)
346/534 (64.8)
58
63
Total
Table 2.
Cumulative ovulation and pregnancy rates at 12 months after laser laparoscopic ovarian
drilling.
Authors
Year
Technique
Ovulation rate
(%)
Pregnancy rate
(%)
Huber et al65
1988
Nd:YAG
5/8 (62)
0/8 (0)
Daniell et al66
1989
CO2 + KTP
60/85 (71)
48/85 (56)
248
Kojima et al67
1989
Nd:YAG
10/12 (83)
7/12 (58)
Yanagibori et al68
1989
Nd:YAG
NA
3/6 (50)
Keckstein et al69
1990
CO2
15/19 (79)
7/19 (44)
Gurgan et al
1991
Nd:YAG
7/10 (70)
4/10 (40)
Rossmanith et al71
1991
Nd:YAG
8/11 (73)
4/11 (36)
Gurgan et al
1992
Nd:YAG
34/39 (87)
20/39 (51)
Ostrzenski et al73
1992
CO2
12/12 (100)
9/12 (75)
Heylen et al74
1994
Argon
35/44 (80)
32/44(73)
186/240 (77.5)
134/246 (54.5)
60
72
Total
The discrepancy between ovulation rate and pregnancy rate might be due to
the laser having supercial thermal penetration to the ovary 2-4 mm, hence it
produces a greater rate of adhesions than with electrocoagulation (60). Among
lasers, CO2 laser produces more adhesion formation than the Nd:YAG laser
(72). In contrast, the depth of penetration by using insulated unipolar diathermy
needle is 8 mm, which minimizes injury to the ovarian surface, produces less
adhesion rates and a higher pregnancy rate than with laser (42). Second-look
surgery for postoperative pelvic adhesions was reviewed by Felemban et al,
they found that LOD by laser produced more adhesions than by electrocautery
41.5% and 31% respectively (60, 70).
The number of ovarian punctures made by LOD is empirically chosen by
the gynecologist depending on the ovarian size. Amer et al (44) has recently
investigated the minimal effective number of ovarian punctures and the amount
of thermal energy needed. They retrospectively investigated the restoration
of regular menstrual cycles, ovulation and conception rates after LOD in 161
women with CC-resistant PCOS who had 2 punctures per ovary versus 3, 4, 5,
6 and 7-10 punctures per ovary, with xed monopolar coagulation current at
30-watt power and duration of 5 seconds to each penetration. They concluded
that thermal energy of 300 Joules produced by 2 punctures per ovary is useless and has signicantly poor results (ovulation rate = 27% and pregnancy
rate = 13%). While thermal energy of 450 to 900 Joules produced by 3
to 6 punctures per ovary gives a statistically signicant higher ovulation rate
58-62% (P < 0.05), and pregnancy rate of 45-60% (P < 0.05), eliminating the
need for 7 punctures per ovary (thermal energy of > 1000 Joules), which
may result in excessive ovarian destruction without additive improvement in
the outcome (44). In long-term follow-up studies Amer et al (45-46) reported
that the benecial improvement in menstrual regularity, reproductive perfor-
249
mance and endocrine effects (signicant decrease in serum concentration of

LH, testosterone, androstenedione and free androgen index) of LOD appear to
be sustained for up to 9 years in most women with PCOS, while Gjonnaess et
al reported the late endocrine effects were sustained for 18-20 years following
ovarian electrocautery (47).
Conclusion
Lack of etiology to PCOS has led to symptom-oriented therapy. Treatment of
anovulatory PCOS should be a stepwise approach starting with diet and exercise, followed by CC. For CC-resistant PCOS women with insulin resistance
and/or hyperinsulinemia 3 to 6 months metformin therapy in combination with
CC improves menstrual cyclicity, ovulation and fertility outcome in 70% and
23% women respectively. Unfortunately, this treatment may not be of help to
all patients, especially if they have normal insulin and glucose dynamics. There
are insufcient data to make any conclusions on the effect of metformin on
FSH ovulation induction or IVF in CC-resistant PCOS women. Surgical ovulation induction in the form of LOD using unipolar cautery or laser is a common
approach used nowadays for CC-resistant PCOS women. Retrospective studies
have shown no statistically signicant difference in the ovulation rates following LOD with electrocoagulation and laser 83% versus 77.5% respectively,
however, there is a signicantly higher cumulative pregnancy rate at 12 months
65% versus 54.5% respectively following the procedure. Deep penetration to
8 mm using insulated unipolar diathermy needle with thermal energy 450 to
900 Joules produced by 3 to 6 punctures per ovary has a signicantly higher
ovulation rate = 58-62% and pregnancy rate = 45-60% than the thermal energy
of 300 Joules produced by 2 punctures per ovary (ovulation rate = 27% and
pregnancy rate = 13%). The application of 7 punctures per ovary (thermal
energy of > 1000 Joules) offered no improvement in the results.
In Cochrane review, Farquhar et al (56) compared LOD versus gonadotrophin ovulation induction, and found no statistically signicant differences
in ovulation and pregnancy rates between the two modalities of treatment.
However, the use of gonadotrophin as a second line of therapy for anovulatory
CC-resistant PCOS is more expensive, and is associated with a much higher
risk of multiple pregnancies, higher rate of spontaneous miscarriage and developing ovarian hyperstimulation syndrome.
250
References:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Knochenhauer ES, Key TJ, Kahsar-Miller M, Waggoner W, Boots LR, Azziz R. Prevalence
of the polycystic ovary syndrome in unselected black and white women of the southeastern
United States: a prospective study. J Clin Endocrinol Metab 1998;83(9):3078-82.
Hull MG. Infertility and ovarian disease. Endocrinological and demographic studies. Gynecol
Endocrinol 1987;1:235-45.
Franks S. Polycystic ovary syndrome. N Engl J Med 1995;333:853-61.
Frank S, Adams J, Mason H. Ovulatory disorders in women with polycystic ovarian syndrome.
Clin Obstet Gynecol 1985;12:605-32
Fagan TO. The cardiovascular dysmetabolic syndrome. Am J Med 1998; 105(Supple 1A)
77S-82S.
Nestler JE. Insulin and ovarian androgen excess. In: Azziz R, Nestler JE, Dewailly D, eds.
Androgen Excess Disorders in women. Philadelphia: Lippincott-Raven Publishers, 1997, pp
473-83.
Dunaif A. Insulin resistance and the polycystic ovary syndrome: Mechanisms and implications
for pathogenesis. Endocr Rev 1997;18:774-800.
Talbott E, Clerici A, Berga SL, Kuller L, Guzick D, Detre K et al. Adverse lipid and coronary
heart disease risk proles in young women with polycystic ovary syndrome: results of a casecontrol study. J Clin Epidemol 1998;51(5):415-22.
Legro RS, Kunselman AR, Dodson WC, Dunaif A. Prevalence and predictors of risk for type 2
diabetes mellitus and impaired glucose tolerance in polycystic ovary syndrome: a prospective,
controlled study in 254 affected women. J Clin Endocrinol Metab 1999;84(1):165-9.
Polson DW, Adams J, Wadsworth J, Franks S. Polycystic ovariesA common nding in normal
women. Lancet 1988;1:870-2.
Zawadesky JK, Dunaif A. Polycystic ovary syndrome. In Dunaif A, Givens JR, Haseltine FP,
Merriam GR, eds. Cambridge, MA: Blackwell Scientic, 1992 pp 377-84.
Yen SSC, Vela P, Rankin J. Inappropriate secretion of follicle-stimulating hormone and luteinizing hormone in polycystic ovarian disease. J Clin Endocrinol Metab 1970;30:435-42.
Barnes R, and Roseneld RL. The polycystic ovary syndrome: pathogenesis and treatment.
Ann Intern Med 1989;101:386-99.
McKenna TJ. Pathogenesis and treatment of polycystic ovary syndrome. N Engl J Med
1988;318:558-62.
Poretsky L, and Piper B. Insulin resistance, hypersecretion of LH and a dual defect hypothesis
for the pathogenesis of polycystic ovary syndrome. Obstet Gynaecol 1994;84:613-21.
Lobo RA. The role of the adrenal in the polycystic ovary syndrome. Semin Reprod
Endocrinol.1984;2:215-62.
Gilling-Smith C, Willis DS, Beard RW, Franks S. Hypersecretion of androstenedione by isolated thecal cells from polycystic ovaries. J Clin Endocrinol Metab 1994;79:1158-65.
Burghen GA, Givens JR, Kitabochi AE. Correlation of hyperandrogenism with hyperinsulinism in polycystic ovarian disease. J Clin Endocrinol Metab 1980;50:113-6.
Change RJ, Nakamura RM, Judd HL, Kaplan SA. Insulin resistance in nonobese patients with
polycystic ovary syndrome. J Clin Endocrinol Metab 1983;57:356-9.
Legro RS, Finegood D, Dunaif A. A fasting glucose to insulin ratio is a useful measure of insulin sensitivity in women with polycystic ovary syndrome. J Clin Endocrinol Metab 1998;83:
2694-8.
Saleh A, Morris D, Tan SL, Tulandi T. Effects of laparoscopic ovarian drilling on adrenal
steroids in polycystic ovary syndrome patients with and without hyperinsulinemia. Fertil Steril
2001;75:501-4.
251
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
Homburg R. Should patients with polycystic ovarian syndrome be treated with metformin? A
note of cautious optimism. Hum Reprod 2002;17:853-56.
Pasquali R, Casimirri F, Balestra V, Flamia R, Melchionda N, Fabbri R et al. The relative
contribution of androgen and insulin in deterring abdominal fat distribution in premenopausal
women. J Endocrinol Invest 1991;14(10):839-46.
Robinson S, Kiddy D, Gelding SV, Willis D, Niththyananthan R, Bush A et al. The relationship
of insulin sensitivity to menstrual pattern in women with hyperandrogenism and polycystic
ovaries. Clin Endocrinol (Oxf) 1993;39:351-5.
Hunter SJ, Garvey WT. Insulin action and insulin resistance: disease involving defects in
insulin receptors, signal transduction, and the glucose transport effector system. Am J Med
1998;105:331-45.
Cara JF, Roseneld RL. Insulin-like growth factor I and insulin potentiate luteinizing-hormone-induced androgen synthesis by rat ovarian thecal-intestitial cells. Endocrinology
1988;123:733-39.
Hernandez ER, Resnick CE, Svoboda ME, Van Wyk JJ, Payne DW, Adashi EY. Somatomedian
C/insulin-like growth factor I as an enhancer of androgen biosynthesis by cultured rat ovarian
cells. Endocrinology 1988;122:1603-12.
Agrawal R, Sladkevicius P, Engmann L, Conway GS, Pyane NN, Bekis J et al. Serum vascular
endothelial growth factor concentration and ovarian stromal blood ow increased in women
with polycystic ovaries. Hum Reprod 1998;13:651-5.
Goalstone ML, Natarayan R, Stanldley PR, Walsh MF, Leitner JW,Scott CK et al. Insulin potentiates platelet-derived growth factor action in vascular smooth muscle cells. Endocrinology
1998;139:4067-72.
Lu M, Amano S, Miyamoto K, Garland R, Keogh K, Qin W et al. Insulin-induced vascular endothelial growth factor expression in retina. Investigative Opthal Visual Science 1999;40:32816.
Tulandi T, Saleh A, Payne N, Jacobs H, Tan SL. Effects of laparoscopic ovarian drilling on
serum vascular endothelial growth factor (VEGF) and on insulin responses to oral glucose
tolerance test. Fertil Steril 2000;74:585-8.
Futterweit W. An endocrine approach to obesity. In: Simopoulos AP, Vanltallie TB, Gullo
SP, Futterweit W, eds. Obesity: New Directions in Assessment and Management. New York:
Charles Press, 1994, pp 96-121.
Kiddy DS, Hamilton-Fairley D, Bush A, Short F Anyaoku V, Reed M et al. Improvement in
endocrine and ovarian function during dietary treatment of obese women with polycystic ovary
syndrome. Clin Endocrinol (Oxf) 1992;36:105-11.
Pasquali R, Antenucci D, Casimirri F, Venturoli S, Paradisi R, Fabbri R et al. Clinical and
hormonal charachtistics of obese and amenorrheic hyperandrogenic women before and after
weight loss. J Clin Endocrinol Metab 1989;68:173-89.
Holte J, Bergh T, Berne C, Wide L, Lithell H. Restored insulin sensitivity but persistently
increased early insulin secretion after weight loss in obese women with polycystic syndrome.
J Clin Endocrinol Metab 1995;80:2586-93.
Anderson P, Seljeot I, Abdelnoor M, Arnesen H, Dale PO, Lovik A et al. Increased insulin
sensitivity and brinolytic capacity after dietary intervention in obese women with polycystic
ovary syndrome. Metabolism 1995;44:611-16.
Lobo RA, Paul L, Granger L. Clomiphene and dexamethasone in women unresponsive to
clomiphene alone. Obstet Gynecol 1982;60:497-501.
Garcia J, Jones GS, Wentz AC. The use of clomiphene citrate. Fertil Steril 1977;28:707-17.
Stein IF, Leventhal ML. Amenorrhea associated with bilateral polycystic ovaries. Am J Obstet
Gynecol 1935;29:181-91.
Kistner RW. Peritubal and periovarian adhesions subsequent to wedge resection of the ovaries.
252
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.

Fertil Steril 1969;20:35-42.
Tulandi T. Laparoscopic treatment of polycystic ovarian syndrome. In: Atlas of Laparoscopic
and Hysteroscopic Techniques for Gynecologists (Ed. T. Tulandi). WB Saunders, London, pp
93-95,1999.
Felemban A, Tan SL, Tulandi T. Laparoscopic treatment of polycystic ovaries with insulated
needle cautery: A reappraisal. Fertil Steril 2000;73:266-9.
Kovacs G, Buckler H, Gangah M, Burger H, Healy D, Baker G, Phillips S. Treatment of
anovulation due to polycystic ovarian syndrome by laparoscopic ovarian cautery. Br J Obstet
Gynaecol 1991;98:30-5.
Amer SAK, Li TC and Cooke ID. Laparoscopic ovarian diathermy in women with polycystic
ovarian syndrome: a retrospective study on the inuence of the amount of energy used on the
outcome. Hum Reprod 2002;17:1046-51.
Amer SAK, Gopalan V, Li TC, Ledger WL and Cooke ID. Long term follow-up of patients
with polycystic ovarian syndrome after laparoscopic ovarian drilling: clinical outcome. Hum
Reprod 2002;17:2035-42.
Amer SAK, Banu Z, Li TC and Cooke ID. Long term follow-up of patients with polycystic
ovarian syndrome after laparoscopic ovarian drilling: endocrine and ultrasonographic outcomes. Hum Reprod 2002;17:2851-7.
Gjonnaess H. Late endocrine effects of ovarian electrocautery in women with polycystic ovary
syndrome. Fertil Steril 1998;69:697-701.
Li TC, Saravelos H, Chow MS, Chisabingo R, Cooke ID. Factors affecting the outcome of
laparoscopic ovarian drilling for polycystic ovarian syndrome in women with anovulatory
infertility. Br J Obstet Gynaecol 1998;105:338-44.
Tan SL, Farhi J, Homburg R, Jacobs HS. Induction of ovulation in clomiphene-resistant polycystic ovary syndrome with pulsatile GnRH. Obstet Gynecol 1996;88:221-6.
Velazquez EM, Mendoza S, Hamer T, Sosa F, Glueck CJ. Metformin therapy in polycystic
ovary syndrome reduces hyperinsulinemia, insulin resistance, hyperandrogenemia, and systolic
blood pressure, while facilitating normal menses and pregnancy. Metabolism 1994;43:64754.
Nestler JE, Jakubowicz DJ. Decreases in ovarian cytochrome P450c17 activity and serum free
testosterone after reduction in insulin secretion in women with polycystic ovary syndrome. N
Engl J Med 1996;335:617-23.
Diamanti-Kandarakis E, Kouli C, Tsianateil T, Bergiele A. Therapeutic effects of metformin
on insulin resistance and hyperandrogenism in polycystic ovary syndrome. Eur J Endocrinol
1998;138:269-74.
Nestler JE, Jakubowicz DJ, Evans WS, Pasquali R. Effects of metformin on spontaneous and
clomiphene-induced ovulation in the polycystic ovary syndrome. N Engl J Med 1998;338:187680.
Vandermolen DT, Patts VS, Evans WS. Metformin increases the ovulatory rate and pregnancy
rate from clomiphene citrate in patients with polycystic ovary syndrome who are resistant to
clomiphene citrate alone. Fertil Steril 2001;75:310-15.
Yu Ng EH, Sun Wat NM, Ho PC. Effects of metformin on ovulation rate, hormonal and
metabolic proles in women with clomiphene-resistant polycystic ovaries: a randomized,
double-blinded placebo-controlled trial. Hum Reprod 2001;16:1625-31.
Farquhar C, Vandekerckhove P, Lilford R. Laparoscopic drilling by diathermy or laser
for ovulation induction in anovulatory polycystic ovary syndrome. The Cochrane Library
2001;Volume (Issue 4).
Gjonnaess H. Polycystic ovarian syndrome treated by ovarian electrocautery through the laparoscope. Fertil Steril 1984;4:20-5
Greenblatt EM, Casper RF. Endocrine changes after laparoscopic ovarian cautery in polycystic
253
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
ovarian syndrome. Am J Obstet Gynecol 1987;156:279-85.

Armar NA, McGarrigle HG, Holownia P, Jacobs HS, Lacheline GCL. Laparoscopic ovarian
diathermy in the management of anovulatory infertility in women with polycystic ovaries:
endocrine changes and clinical outcome. Fertl Steril 1990;53:45-9.
Gurgan T, Kisnisci H, Yarali H, Develioglu O, Zeyneloglu H, Aksu T. Evaluation of adhesion formation after laparoscopic treatment of polycystic ovarian disease. Fertil Steril 1991;56:1176-8.
Naether OGJ, Baukloh V, Fischer R, Kowalczyk T. Long term follow up in 206 infertility
patients with polycystic ovarian syndrome after laparoscopic electrocautery of the ovarian
surface. Hum Reprod 1994;9:2342-9.
Merchant RN. Treatment of polycystic ovary disease with laparoscopic low-watt bipolar electrocoagulation of the ovaries. J Am Assoc Gynecol Lapros 1996;3:503-8.
Pelosi MA, Pelosi MA. Laparoscopic electrosurgical furrowing technique for the treatment of
polycystic ovaries. J Am Assoc Gynecol Lapros 1996;4(1):57-60.
Tulandi T, Watkin K, Tan SL. Reproductive performance and three dimensional ultrasound
volume determination of polycystic ovaries following laparoscopic ovarian drilling. Int J Fertil
1997;42:436-40.
Huber J, Hosmann J, Spona J. Endoscopic laser incision of the polycystic ovary. Geburtshilfe
Frauenheilkd 1989;49:37-40.
Daniel JF, miller W. Polycystic ovaries treated by laparoscopic laser vaporization. Fertil Steril
1989;51:232-6.
Kojima E, Yanagibori A, Otaka K. Ovarian wedge resection with contact Nd:YAG laser irradiation used laparoscopically. J Reprod Med 1989;34:444-6.
Yanagibori A, Kojima E, Ohtaka K, Morita M, HirakawaS. Nd:YAG laser therapy for infertility
with a contact-type probe. J Reprod Med 1989;34:456-60.
Keckstein G, Rossmanith W, Spatzier K, Schneider V, Borchers K, Steiner R. The effect of
laparoscopic treatment of polycystic ovarian disease by CO2 laser or Nd:YAG laser. Surg
Endosc 1990;4:103-7.
Felemban A and Tulandi T. Laparoscopic treatment of polycystic ovarian syndrome-related
infertility. Infertil Reprod Med Clin North Am 2000;(11) 1:49-60.
Rossmanith WG, Keckstein J, Spatzier K, Lauritzen C. The impact of ovarian laser surgery on
the gonadotropin secretion in women with polycystic ovarian disease. Clin Endocrinol (Oxf)
1991;34:223-30.
Gurgan T, Urman B, Aksu T, Yarali H, Develioglu O, Kisnisci HA. The effect of short-interval
laparoscopic lysis of adhesions on pregnancy rate following Nd:YAG laser photocoagulation
of polycystic ovaries. Obstet Gynecol 1992;80:45-7.
Ostrzenski A. Endoscopic carbon dioxide laser ovarian wedge resection in resistant polycystic
ovarian disease. Int J Fertil 1992;37:295-9.
Heylen SM, Puttemans PJ, Brosens IA. Polycystic ovarian disease treated by laparoscopic
argon laser capsule drilling: comparison of vaporization versus perforation technique. Hum
Reprod 1994;9:1038-42.
Morin-Papunen LC, Koivunen RM, Ruokonen A, Martikainen HK. Metformin therapy improves the menstrual pattern with minimal endocrine and metabolic effects in women with
polycystic ovary syndrome. Fertil Steril 1998;69:691-6.
Glueck CJ, Wang P, Fontaine R, Tracy T, Sieve-Smith L. Metformin-induced resumption of
normal menses in 39 of 43 (91%) previously amenorrheic women with polycystic ovary syndrome. Metabolism 1999;48:511-9.
Glueck CJ, Wang P, Fontaine R, Tracy T, Sieve-Smith L. Metformin to restore normal menses
in oligo-amenorrheic teenage girl with polycystic ovary syndrome (PCOS). J Adolesc Health
2001;29:160-9.
Nestler JE, Jakubowicz DJ. Lean women with polycystic ovary syndrome respond to insu-
254
79.
80.
81.
82.
83.
84.
85.

lin reduction with decrease in ovarian P450c17alpha activity and serum androgens. J Clin
Endocrinol Metab 1997;82:4075-9.
la Marca A, Morgante G, Paglia T, Ciotta L, Cianci A, De Leo V. Effects of metformin on
adrenal steroidogenesis in women with polycystic ovary syndrome. Fertil Steril 1999;72:9859.
Yarali H, Yildiz BO, Demirol A, Zeyneloglu HB, Yigit N, Bukulmez O, et al. Co-administration
of metformin during rFSH treatment in patients with clomiphene citrate-resistance polycystic
ovarian syndrome: a prospective randomized trial. Hum Reprod 2002;17:289-94.
De Leo V, la Marca A, Ditto A, Morgante G, Cianci A. Effects of metformin on gonadotropininduced ovulation in women with polycystic ovary syndrome. Fertil Steril 1999;72:282-5.
Stadtmauer LA, Toma SK, Riehl RM, Talbert LM. Metformin treatment of patients with polycystic ovary syndrome undergoing in vitro fertilization improves outcomes and is associated
with modulation of insulin-like growth factors. Fertil Steril 2001;75:505-9.
Bailey CJ and Turner RC. Metformin. N Engl J Med 1996;334:574-9.
Patane G, Piro S, Rabuazzo AM, Anello M, Vigneri R, Purrello F. Metformin restores insulin
secretion altered by chronic exposure to free fatty acids or high glucose; A direct metformin
effect on pancreatic beta cells. Diabetes 2000;49:735-40.
Kocak M, Caliskan E, Simsir C, Haberal A. Metformin therapy improves ovulatory rates,
cervical scores, and pregnancy rates in clomiphene citrate-resistant women with polycystic
ovary syndrome. Fertil Steril 2002;77:101-6.
255
The peritoneal uid. a cause or a

consequence of endometriosis?
Jacek Szamatowicz, 2Piotr Laudaski.
Department of Gynaecology, 2Department of Pathophisiology of Pregnancy,

Medical University in Bialystok, Poland
1
Endometriosis is an invasive but benign gynaecological disease characterized

by the presence of endometrial glands and stroma outside the uterine cavity. It
is a very common abnormality that affects between 5-40% of normal women
and even 60% of women with pelvic pain and/or infertility.
The pathophysiology and natural history of endometriosis remains enigmatic. There are three different conditions of that condition: endometriosis of
the peritoneum, endometriotic cysts of the ovaries and deep inltrating endometriosis.
The retrograde menstruation and implantation of endometriotic tissue on the
surface of the peritoneum has been proposed as possible mechanisms of developing of that disease. Anyway studies have shown that retrograde menstruation
occurs in most of women at reproductive age and that fact made it unclear why
endometriosis develops in such a small number of women. It was proposed that
endometriosis develops when disproportion between the amount of menstrual
blood and ability of the immune system to neutralize it appears [2].
Peritoneal endometriosis is almost always accompanied by the presence of
peritoneal uid. The role of it and different actions that take place in such a
milieu were subject of scientic investigations[5].
The origin of peritoneal uid was investigated since late 70s. In fact it is
very often found in healthy women formed as ovarian exude and increased
vascular permeability due to increased concentration of estrogenes and porogesterone in the lutheal phase [11].
Subsequent investigations have revealed that peritoneal uid of women with
256
endometriosis differs from that of healthy ones. The aim of this presentation is
to point what changes in the uid may cause a development of endometriosis
and what is the consequence of such condition.
Peritoneal uid of women with endometriosis contains a large amount of
macrophages and activated macrophages. That causes abnormal expression
of photolytic enzymes such as: matrix metalloproteinases and their inhibitors,
aberrant expression of aromatase, deciency of 17-hydroxy-steroid dehydrogenase type 2 and resistance to protective action of progesterone. Imbalances
in secretion prole of different cytokins such as: IL-6, IL-8 or growth factors
such as: TGF- or VEGF which in some way inuence the course of disease
were also noted [7]. But the question remains whether those actions are the
consequence of endometriosis in peritoneal cavity or it was activation of the
macrophages leading to secretion of this substances and allowing fragments
of endometrial epithelium to implant. Peritoneal uid of women with endometriosis has a chemotactic activity for cellular components of immunity [6].
Endometrial tissue in the peritoneal cavity activates macrophages which are
supposed to clean that environment from alien tissue. Activation of that macrophages is disturbed in some way and their hyperactivation together with much
lower activity of natural killer cells are believed to profoundly contribute to the
progression of the disease [10]. The question is whether the improper action
of endometriosis in peritoneal uid is a consequence of the presence of endometrial cells in the peritoneal cavity or disturbed macrophage function allows
endometrial debris to implant. The fact is that immunological cells by their
hyperactivation secrete many different substances which are crucial for the
development of that disease. Our study we demonstrated the presence of statistically higher concentration of levels of different metaloproteinases (MMPs)
in peritoneal uid. It is proposed that MMPs may enable endometrial tissue to
digest into the peritoneal extracellular matrix and underlying connective tissue
[12]. The production of this enzymes take place in the endometrial stroma but
as well as in polymorphic mononuclear leukocytes. Another important source
of these substances are macrophages, neutrophils and eosynophils. They are
activated as a consequence of a low grade inammation state present in the
peritoneal cavity of women with endometriosis.
Matrix metaloproteinases are not the only substances produced and secreted
as a consequence of endometriosis. Another group is chemoattractant chemokines. In previous studies we show that chemokine growth-regulated may
play a possible role in the pathogenesis of endometriosis possibly by chemoattraction and activation of neutrophils [9]. This substance intensely stimulates
neutrophil degranulation and enzyme release. As a result, acute inammatory
257
reaction and angiogenesis is induced in endometriotic implants. The interaction of different chemokines with their receptors on leukocytes allows for the
selective activation and chemotaxis of neutrophils, eosinophils, lymphocytes
or monocytes necessary for the sites of evolving inammation [1]. There may
be different sources of high concentrations of chemokines in the peritoneal
uid. The most important seem to be mesothelial cells that constitute most of
the peritoneal uid cells. Peritoneal macrophages and endometrial cells are
also potential sources of these chemoattractant cytokines. It was proposed that
arrangement of these factors is involved in the pathogenesis of endometriosis
but the scheme seems to be unrelated. It is obvious anyway that all substances
mentioned above play a crucial role in the development of endometriosis. They
are a consequence of activated by inammatory process different cellular elements in the peritoneal uid but by allowing endometrial tissue to implant and
grow they play a major role in the development of such a debilitating disease
[13].
It is very interesting to nd out all the pathophisiological processes that take
place in the peritoneal uid of women with endometriosis and to differentiate
the mechanisms that are caused by the presence of endometrial implants or are
a consequence of them. Endometriosis is an estrogen responsive disease and
one can not forget that its progression is dependent on aromatase activity. It
was found that endometriotic implants express aromatase mRNA and in that
way is sex steroid hormone dependent disease. Endometrial implants have
a strong expression of sex steroid receptors. The role of steroid present in
peritoneal uid on the progression of endometriosis still remains unknown. It
is suggested that hormonal milieu is very important in regulating the proteolitic
imbalance associated with peritoneal adhesion formation and endometriosis.
Our study showed that the ability of endometrial implants to survive in the
peritoneal environment is prolonged in women with endometriosis [8]. We
demonstrated the presence of strong immunoreactivity to Bcl-2 the protein
which is responsible to cell survival in the endometrial implants [14]. However
many studies have failed to nd the correlation between the concentration of
estradiol or progesterone and impaired apoptosis in endometrial implants. This
is the only aspect where peritoneal uid content have no any immpact on the
development of this disease [3].
It is very difcult to distinguish what is the rst, endometriosis or peritoneal
uid often present with this disease. In fact peritoneal uid is found frequently
in women where no endometirial implants have been shown. This is why it
is a very elegant subject for the investigations to study. Many investigations
concentrate only on exploring the differences between some substances or ac-
258
tivity of different cells found in the peritoneal uid of women with and without
endometriosis. But to nd the answer what is caused and what is a consequence
of this disease it is a very tricky question. In fact it is very difcult to nd
out whether impaired immunological system is a result of endometriosis or
endometrial tissue was able to develop because improper actions of cellular
elements of peritoneal uid take place. Endometriosis remains a very enigmatic
disease. In fact we have to deal not only with ectopic endometrial implants per
se, but also with pathological changes that take place in the whole body. A part
of this there is a peritoneal uid which take a huge role in the pathogenesis as
a cause and then in the remission of this disease as a consequence.
References:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Busiek D.F., Baragi V., Nehring L.C. Matrilysisn expression by mononuclear phagocytes and
its regulation by cytokines and hormones. J.Immunol.1995,154,6484
Dmowski W.P., Braun D., Gebel H. Endometriosis: Genetic and immunologic aspects. Prog.
Clin.Biol.Res.!990,323,99
Harada M., Suganuma N., Furuhashi M., et al. Detection of apoptosis in human endometriotic
tissues. Mol.Hum.Reprod. 1996,2,307
Hill J.A. Immunology of endometriosis. Fertil. Steril. 1992,58,262
Konincx P.R., Kennedy S.H., Barlow D.H. Pathogenesis of endometriosis: the role of peritoneal uid.Gynecol. Obstst.Invest. 1999,47,23
Lebovic D.I., Mueller M.D., Taylor N. Immunobiology of endometriosis. Fertil. Steril.
2001,75,1
McLaren J., Prentice A., Charnock-Jones D.S. et al. Vascular endothelial growth factoris produced by peritoneal uid macrophages in endometriosis and is regulated by ovarian steroids.
J.Clin.Invest. 1996,98,482
McLaren J., Prentice A., Charnock-Jones D.S. Immunolocalization of the apoptosis regulating
proteins Bcl-2 and Bax in human endometrium and isolated peritoneal uid macrophages in
endometriosis. Hum. Reprod. 1997,12,146
Oral E., Seli E., Bahtiyar M.O. et al. Growth-regulated alpha expression in the peritoneal
environment with endometriosis. Obstet. Gynecol. 1996,88,1050
Osterlunck D.J., Meuleman C., Waer M. et al.The natural killer activity of peritoneal lymphocytes isdecreased in woman with endometriosis. Fertil. Steril. 1992,58,290
Szamatowicz J., Laudanski P. The role of adhesive molecules in the pathogenesis of endometriosis.Ginekol.Pol. 1999,11,845
Szamatowicz J., Laudaski P., Tomaszewska I. Matrix metalloproteinase-9 and tissue inhibitor
of matrix metalloproteinase-1: a posible role in the pathogenesis of endometriosis. Human.
Reprod. 2002,2,284
Szamatowicz J., Laudaski P., Tomaszewska I., Szamatowicz M. Chemokine growth-regulated-: a possible role in the pathogenesis of enometriosis. Gynecol. Endocrinol. 2002, 4,176
Szamatowicz J., Laudaski P., Tomaszewska I., Chyczewski L. Apoptosis and Bcl-2 expression in human endometrial implants. Pol. J. Gynaecol. Invest. 2001,4,79
259
Should treatment with clomiphene

citrate continue? What should we offer
to failures?
Ariel Weissman, M.D. IVF Unit
Department of Obstetrics and Gynecology, Wolfson Medical Center,
Holon, Sackler Faculty of Medicine, Tel Aviv University Israel
Email: a_w@zahav.net.il
Clomiphene citrate (CC) was rst synthesized in 1956 and became available for
clinical use in 1961. For more than 40 years it has been the most extensively
used fertility drug worldwide. Clomiphene is considered by many the treatment of choice for WHO Group II ovulatory dysfunction. It can be also used
for controlled ovarian stimulation (COH) in the treatment of unexplained or
mild to moderate male factor infertility prior to intrauterine insemination (IUI)
or prior to IVF. The CC challenge test is commonly used for the functional
assessment of ovarian reserve.
The rst clinical trial of CC therapy demonstrated successful ovulation
induction in 80% of anovulatory women, half of whom conceived following
treatment 1. Neither treatment regimens nor treatment results of CC therapy
have changed appreciably during the years. The causes for the popularity
of CC are obvious: its low cost, easy (oral) administration, easy and simple
monitoring, scarce adverse reactions and acceptable pregnancy rates. Simply
because of the nancial burden, CC is the only fertility drug accessible to
patients in many parts of the world. On the other hand, CC has several
disadvantages which limit its use and give rise to the ongoing present debate regarding its future use 2-5. Disadvantages of CC usage include: (1)
CC resistance and failures (2) anti-estrogenic effects on cervical mucus and
endometrium (3) current racemic mixture of the En/Zu-isomer in the tablet (4)
relative lower efcacy as compared to the combination of gonadotropins and
260
GnRH agonists in IVF (5) putative future risk of ovarian and breast cancer
with the use of CC.
Recent advances in reproductive endocrinology shed light on the pathophysiology of both CC resistance and failure. The introduction of GnRH antagonists
into clinical practice along with advances in the IVF laboratory have led to (1)
the development of softer stimulation protocols, (2) establishment of strict
limits on the number of embryos being replaced, and (3) revolutionized the
current denition of ART success by setting the birth of a singleton healthy
baby as a primary measure of success. Old CC seems to be well adjusted to
survive the current changes, and will therefore continue to play a role in the
management of infertility at the beginning of the 21st century.
Clomiphene resistance = insulin resistance?

Approximately 70% of patients who respond to CC do so at a dose of 50 or 100
mg of CC 6. The maximum daily dose is usually 200-250 mg. Patients who do
not ovulate while receiving the 150-250 mg dose of CC are considered CC-resistant. Relatively inexpensive treatment alternatives for CC-resistant patients
include prolonged duration of CC treatment or higher doses 7 and adjunctive
use of dexamethasone 8, 9, but the improvement in response is limited. An effective alternative treatment for CC-resistant patients is gonadotropin induction
of ovulation; however, this therapy incurs substantial increases in costs and
risks of multiple pregnancy and ovarian hyperstimulation syndrome (OHSS)
compared with ovulation induction with CC.
Many women with PCOS are insulin-resistant and have compensatory hyperinsulinemia 10-12. Hyperinsulinemia plays a pathogenic role in PCOS and
appears to contribute to both chronic anovulation 13-15 and hyperandrogenism
13, 16, 17
. Of note, obese women with PCOS are particularly resistant to ovulation
induction with CC, and there is a positive correlation between obesity and dose
of CC required to induce ovulation 18. Moreover, anovulatory women with
PCOS who remain anovulatory with CC show greater insulin resistance than
women with PCOS who ovulated successfully in response to CC treatment 19.
Since increasing obesity is associated with increasing hyperinsulinemia 10, the
high degree of hyperinsulinemia in obese women with PCOS may account for
their poor responsiveness to CC. In theory, hyperinsulinemia could adversely
affect folliculogenesis and ovulation by increasing intra-ovarian androgen
production 20, altering gonadotropin secretion 21, or directly affecting follicular
development.
Several studies of women with PCOS have shown that when insulin secre-
261
tion is decreased with insulin sensitizing drugs, such as metformin13-15, 17, 22,
troglitazone 16 or d-chiro-inositol 23, the rates of spontaneous ovulation and
ovulation in response to CC both increase 17.
The most extensively studied insulin-sensitizing drug in the treatment of
PCOS is metformin 17, 24. Metformin (dimethylbiguanide) is an orally administered drug used to lower blood glucose concentrations in patients with non-insulin-dependent diabetes mellitus (NIDDM)25. It is antihyperglycemic in action
and does not cause hypoglycemia. Metformin enhances insulin sensitivity in
both the liver, where it inhibits hepatic glucose production, and the peripheral
tissue, where it increases glucose uptake and utilization in muscle tissue. By
increasing insulin sensitivity, metformin reduces insulin resistance, insulin
secretion, and hyperinsulinemia26.
Metformin has been administered to women with PCOS to reduce insulin
resistance and the sequelae of hyperinsulinemia including hyperandrogenism
27
. However, not all studies on metformin have demonstrated a benecial effect
on insulin resistance and the various endocrine parameters 28-30.
Two randomized controlled trials comparing metformin in combination
with CC vs. CC alone, have demonstrated that the addition of metformin to
CC enhances the ovarian response in obese patients (BMI > 28 kg/m2) with
PCOS 17, 31. In the famous trial conducted by Nestler et al. 17, 61 women were
randomized to 34 days of pretreatment with metformin or placebo, with one
cycle of CC added to each group if anovulatory by day 34. They examined the
patient ovulation rate as an end point and found metformin to be superior to
placebo (34% vs. 4%), metformin plus CC to be superior to placebo plus CC
(90% vs. 8%), and metformin with or without CC to be superior to placebo
with or without CC (89% vs. 12%). All these differences were statistically
signicant. Their conclusion was that the frequency of both spontaneous and
CC-induced ovulation can be increased in obese PCOS patients via metformin
treatment.
In the second trial, metformin in combination with CC was compared to CC
alone in 90 women, with both ovulation and pregnancy as an end point 31. The
patients of both groups received CC at 50 to 100 to 150 mg daily for 5 days for
up to six cycles, depending on ovulatory response, with the lowest effective
dose continued for the next cycles. The patients of the CC plus metformin group
also received co-treatment of metformin 500 mg t.i.d. for 6 months. Patients in
the CC plus metformin group had a higher number of mature preovulatory follicles, higher ovulation rate (80% vs. 65%), higher pregnancy rate per patient
(29% vs. 8%), higher pregnancy rate per cycle (5% vs. 1.5%), and a lower rate
of mild to moderate ovarian hyperstimulation syndrome (9% vs. 69%). Again,
262
all these differences between the two groups were statistically signicant. In
addition, patients in the CC plus metformin group had a statistically signicant
reduction in their serum fasting insulin levels, whereas there was no change in
the CC-alone group. The investigators concluded that the addition of metformin to CC enhances the ovarian response in obese patients with PCOS.
Studies on the use of troglitazone alone or troglitazone combined with CC in
CC-resistant women, resulted in ovulation in 74-83% of patients16, 32, of whom
39% achieved pregnancy 32.
In summary, it appears that for many cases with CC-resistance there is associated hyperinsulinemia and insulin resistance. The problem of CC-resistance
can be solved in the majority of such cases with the addition of insulin-lowering
agents. Data are currently limited on combined use of oral insulin sensitizing
agents and CC with respect to ovulation rates, number of ovulatory cycles produced per woman, and pregnancy rates in CC-resistant women. Nevertheless,
this novel therapeutic approach is promising with regard to the role of CC in
the management of anovulatory infertility in the 21st century.
Clomiphene Citrate and endometrial development

(thickness)
One of the well known and described problems associated with CC use is
its anti-estrogenic effect on the endometrium. Endometrial thickness and ultra-structure seems to be impaired in a fraction of patients treated with CC
compared with spontaneous cycles 33-43. This could interfere with endometrial
receptivity and conception.
Dickey and Holtkamp 44 reported that in patients stimulated with CC for IUI,
no pregnancy was observed when the endometrial thickness was <6 mm on
the day of hCG administration, while all preclinical abortions occurred when
endometrial thickness was 6-8 mm. A fresh new look at the same old problem,
recently reported by Kolibianakis et al. 45 has yielded surprising results. In a
prospective study, 168 couples were stimulated with CC from day 3 to day
7 of the cycle and endometrial thickness was assessed by ultrasound three
times on the day of ovulation triggering. Ovulation was triggered with HCG
as soon as 1 follicle of 17 mm was present by ultrasound independently
of endometrial thickness. IUI was performed 36 h after HCG administration.
The main outcome measure was ongoing pregnancy. No difference was observed in endometrial thickness between patients who did or did not achieve
an ongoing pregnancy (7.6 +/- 0.3 versus 7.6 +/- 0.2 respectively; P = 0.7). No
discriminative ability of endometrial thickness on the achievement of ongoing
263
pregnancy could be shown by receiver operating characteristic (ROC) curve

analysis (area under the ROC curve 0.51, 95% CI: 0.44-0.59). It was concluded
that endometrial thickness cannot predict ongoing pregnancy achievement in
IUI cycles stimulated with CC.
Several methods have been proposed to overcome the problem of thin endometrial lining associated with CC use. Starting CC early on day 1, 2 or 3 of the
cycle 44, 46, 47, adding estradiol in the follicular phase48-51, delaying administration
of hCG 52, or administrating gonadotropins for some days following CC have
all been proposed as alternatives. In a recent study it has been shown that the
addition of vaginal E2 and progesterone to CC ovulation induction regimens
normalizes the alterations in endometrial morphology. It was suggested that
hormonal treatment combining vaginal E2 and progesterone may improve
endometrial receptivity in CC cycles and ultimately yield higher pregnancy
rates.53. The relative effectiveness of the above mentioned strategies has not
been thoroughly studied and needs further examination.
Stereoisomeric composition of Clomiphene Citrate

Clomiphene citrate is available as a racemic mixture of two stereo-chemical isomers referred to as (cis) Zu-clomiphene or the (trans) En-clomiphene conguration, the former being signicantly more potent. Zu-clomiphene is much more
effective in inducing ovulation than En-clomiphene and accounts for most of the
therapeutic efcacy of the drug formulation54, 55. In the commercially available
preparation, the isomers are in the ratio of 38% Zu- and 62% En-clomiphene.
In some parts of the world, the drug is available in its Zu form as a 10 mg tablet,
which is reportedly equipotent with the 50 mg tablet sold in the United States and
Europe. Limited experience suggests that the clinical utility of CC may indeed
be due to its cis isomer 56, 57 but it remains uncertain whether cis-CC is more
effective than CC proper in terms of ovulation and conception rates 58-61.
Following the development of a reverse phase high pressure liquid chromatography (HPLC) assay that could distinguish the CC isomers, a comparison of
the pharmacokinetic disposition of the Zu and En isomers of CC was performed
62
. It was apparent that each isomer exhibited its own characteristic pharmacokinetic prole, the En isomer being absorbed faster and eliminated more
completely than the Zu isomer. Although CC tablets contain 62% En isomer
and 38% Zu isomer, the observed plasma concentrations of the Zu isomer were
much higher than those of the En isomer. Because the Zu isomer is considered
more estrogenic than the En isomer, response of the target tissues should vary
according to both the relative afnity and the concentrations of each isomer
264
interacting with the relevant estrogen receptor.

Chemically, CC (like tamoxifen) is a nonsteroidal triphenylethylene derivative that exhibits both estrogen agonist and antagonist properties 55. In general,
estrogen agonist properties are manifest only when endogenous estrogen levels
are extremely low. Otherwise, CC acts solely as a competitive estrogen antagonist. CC is cleared through the liver and excreted in stool. About 85% of an
administered dose is eliminated after approximately 6 days, although traces may
remain in the circulation for much longer 62. The half life of CC is estimated to be
5-7 days and, therefore, accumulation of CC takes place every 28-40 days when
a trial of CC is given 55. Levels of the Zu- isomer remain detectable in the circulation for more than a month after treatment and may accumulate over consecutive
cycles of treatment 63. Young et al. 63 have recently shown that CC induction of
ovulation results in an isomer-specic systemic accumulation of Zu-clomiphene
across consecutive cycles of treatment. However, because the combined maximum concentrations of En-clomiphene and Zu-clomiphene achieved in women
are generally well below those demonstrated to have adverse effects in vitro,
these early observations appear to have little if any clinical relevance.
Variability in metabolism may explain variability in response that could be
amplied by the geometric isomerism of CC. Recently, it has been suggested
that monitoring of plasma drug concentration of Zu-clomiphene might allow
the prediction of response to CC in individual patients at an early stage of their
treatment, thereby increasing the efcacy of treatment64. If variation in CC
concentration due to different rates of metabolism contributes to the success
or failure of treatment at a given dose, then the plasma concentration of Zuclomiphene, the active isomer, would be expected to reach a critical value in
all patients who eventually respond. In other words, patients who respond at
higher doses would be expected to show lower concentrations compared with
those who respond to a 50 mg dose, when exposed to similar doses. Prospective
studies should be performed to conrm this attractive hypothesis. Furthermore,
Although the current racemic of CC seems to be safe and effective, monoisomeric preparation of CC containing only the active Zu-isomer could be another
option worth investigating. Nevertheless, since CC has been off-patent for a
long time there is scarcely any support from the pharmaceutical industry to
carry out up-to-date studies on this old drug. However, such studies are needed,
because it seems that new information on the capacity of individual patients to
metabolize CC might accelerate dose individualization and improve the therapeutic outcome with this orphan drug64.
265
Clomiphene Citrate in combination with GnRH

antagonists in controlled ovarian hyperstimulation for IVF
Clomiphene citrate was one of rst drugs used in early protocols for COH prior
to IVF, either alone or in combination with gonadotropins65-68. As a result of
the widespread use of gonadotropin-releasing hormone (GnRH) agonists for
COH, CC administration has declined rapidly over the last 20 years. Although
GnRH agonists offer an effective solution for the problem of premature LH
surges, they could not be combined with CC. Administration of GnRH agonists
early in the cycle suppresses pituitary function, which is a prerequisite for CC
action. Recently, GnRH antagonists have been introduced into clinical practice.
The administration of GnRH antagonists is associated with an immediate suppression of LH endogenous secretion. Due to the different modes of action of
GnRH antagonists and GnRH agonists, CC may be used in GnRH antagonist
cycles 69.Since the major problem of the old CC-gonadotropins protocols was
the high incidence of premature LH surges, the addition of GnRH antagonists
to the treatment protocol could potentially solve this problem.
Experience with the use of CC in combination with gonadotropins and
GnRH antagonists is rapidly accumulating and has been generally favorable
70-78
. This protocol is consistent with the modern trends of prescribing softer,
more cost-effective and safer stimulation protocols. More studies are awaited
with interest before rm conclusions regarding the future use of CC for COH/
ART can be made.
The use of Clomiphene Citrate and future risk for

ovarian and breast cancer
Two epidemiologic studies published early in the last decade suggested that the
risk of ovarian cancer might be signicantly increased in women exposed to
ovulation inducing drugs79, 80. Long-term (>12 months) CC therapy was found
to be associated with a slight increase in future risk of ovarian cancer (relative
risk, 1.5 to 2.5). Subsequent studies, however, have failed to corroborate those
ndings 81-89. Due to these initial reports, the Committee on Safety of Medicines
(CSM) in the UK advised doctors to adhere to the manufacturers recommendations of limiting treatment to a maximum of 6 months. A recent pooled analysis
of eight case-control studies concluded that neither fertility drug use nor use for
more than 12 months was associated with invasive ovarian cancer90. Another
recent meta-analysis91 has shown that ovarian cancer does not appear to be
increased in treated infertile patients versus untreated infertile patients. Treated
266
infertile patients may have a lower incidence of ovarian cancer than untreated
infertile patients. The data regarding the use of fertility drugs including CC
and future risk for breast cancer are also reassuring81, 92, 93. Rossing et al.93 have
found that the risk among women who had taken CC was reduced relative to
infertile women who had not used this drug (adjusted relative risk, 0.5; 95%
CI, 0.2-1.2), but the reduction in risk did not increase with duration of use. The
possibility that use of CC as treatment for infertility lowers the risk of breast
cancer should be further explored in larger studies93.
In summary, patients with concerns should be counseled that no causal
relationship between ovulation inducing drugs and ovarian cancer has been
established and no change in prescribing practices is warranted94. In any
case, prolonged treatment with CC is generally futile and should therefore be
avoided94.
Summary
Clomiphene citrate is here to stay. It complies well with the goals of infertility
therapy at the 21st century: (1) decreased treatment costs (2) increased treatment safety (less multiple pregnancies and OHSS), without adversely affecting
treatment efcacy. Many cases of CC resistance may be solved with combined
therapy including CC and insulin lowering drugs. COH protocols including CC,
gonadotropins and GnRH antagonists are promising and should be thoroughly
examined. Many of the issues regarding the safety of CC therapy (cancer risk)
have also been resolved in favor of CC.
References
1.
2.
3.
4.
5.
6.
7.
Greenblatt RB. Chemical induction of ovulation. Fertil Steril 1961; 12:402-4.

Out HJ, Coelingh Bennink HJ. Clomiphene citrate or gonadotrophins for induction of ovulation? Hum Reprod 1998; 13:2358-61.
Tarlatzis BC, Grimbizis G. Future use of clomiphene in ovarian stimulation. Will clomiphene
persist in the 21st century? Hum Reprod 1998; 13:2356-8.
Dickey RP, Taylor SN, Rye PH, Lu PY. Future use of clomiphene in ovarian stimulation. A
role for clomiphene in the 21st century? Hum Reprod 1998; 13:2361-2.
Messinis IE, Milingos SD. Future use of clomiphene in ovarian stimulation. Clomiphene in
the 21st century. Hum Reprod 1998; 13:2362-5.
Gysler M, March CM, Mishell DR, Jr., Bailey EJ. A decade's experience with an individualized
clomiphene treatment regimen including its effect on the postcoital test. Fertil Steril 1982;
37:161-7.
Lobo RA, Granger LR, Davajan V, Mishell DR, Jr. An extended regimen of clomiphene citrate
in women unresponsive to standard therapy. Fertil Steril 1982; 37:762-6.
267
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
Parsanezhad ME, Alborzi S, Motazedian S, Omrani G. Use of dexamethasone and clomiphene

citrate in the treatment of clomiphene citrate-resistant patients with polycystic ovary syndrome
and normal dehydroepiandrosterone sulfate levels: a prospective, double-blind, placebo-controlled trial. Fertil Steril 2002; 78:1001-4.
Hoffman D, Lobo RA. Serum dehydroepiandrosterone sulfate and the use of clomiphene citrate in anovulatory women. Fertil Steril 1985; 43:196-9.
Dunaif A, Segal KR, Futterweit W, Dobrjansky A. Profound peripheral insulin resistance,
independent of obesity, in polycystic ovary syndrome. Diabetes 1989; 38:1165-74.
Dunaif A, Segal KR, Shelley DR, Green G, Dobrjansky A, Licholai T. Evidence for distinctive
and intrinsic defects in insulin action in polycystic ovary syndrome. Diabetes 1992; 41:125766.
Ehrmann DA, Sturis J, Byrne MM, Karrison T, Roseneld RL, Polonsky KS. Insulin secretory
defects in polycystic ovary syndrome. Relationship to insulin sensitivity and family history of
non-insulin-dependent diabetes mellitus. J Clin Invest 1995; 96:520-7.
Moghetti P, Castello R, Negri C, et al. Metformin effects on clinical features, endocrine and
metabolic proles, and insulin sensitivity in polycystic ovary syndrome: a randomized, doubleblind, placebo-controlled 6-month trial, followed by open, long-term clinical evaluation. J Clin
Endocrinol Metab 2000; 85:139-46.
De Leo V, la Marca A, Ditto A, Morgante G, Cianci A. Effects of metformin on gonadotropininduced ovulation in women with polycystic ovary syndrome. Fertil Steril 1999; 72:282-5.
Glueck CJ, Wang P, Fontaine R, Tracy T, Sieve-Smith L. Metformin-induced resumption of
normal menses in 39 of 43 (91%) previously amenorrheic women with the polycystic ovary
syndrome. Metabolism 1999; 48:511-9.
Hasegawa I, Murakawa H, Suzuki M, Yamamoto Y, Kurabayashi T, Tanaka K. Effect of troglitazone on endocrine and ovulatory performance in women with insulin resistance-related
polycystic ovary syndrome. Fertil Steril 1999; 71:323-7.
Nestler JE, Jakubowicz DJ, Evans WS, Pasquali R. Effects of metformin on spontaneous
and clomiphene-induced ovulation in the polycystic ovary syndrome. N Engl J Med 1998;
338:1876-80.
Lobo RA, Gysler M, March CM, Goebelsmann U, Mishell DR, Jr. Clinical and laboratory
predictors of clomiphene response. Fertil Steril 1982; 37:168-74.
Murakawa H, Hasegawa I, Kurabayashi T, Tanaka K. Polycystic ovary syndrome. Insulin
resistance and ovulatory responses to clomiphene citrate. J Reprod Med 1999; 44:23-7.
Barbieri RL, Makris A, Randall RW, Daniels G, Kistner RW, Ryan KJ. Insulin stimulates
androgen accumulation in incubations of ovarian stroma obtained from women with hyperandrogenism. J Clin Endocrinol Metab 1986; 62:904-10.
Olson BR, Scott DC, Wetsel WC, et al. Effects of insulin-like growth factors I and II and insulin on the immortalized hypothalamic GTI-7 cell line. Neuroendocrinology 1995; 62:155-65.
Morin-Papunen LC, Koivunen RM, Ruokonen A, Martikainen HK. Metformin therapy improves the menstrual pattern with minimal endocrine and metabolic effects in women with
polycystic ovary syndrome. Fertil Steril 1998; 69:691-6.
Nestler JE, Jakubowicz DJ, Reamer P, Gunn RD, Allan G. Ovulatory and metabolic effects of
D-chiro-inositol in the polycystic ovary syndrome. N Engl J Med 1999; 340:1314-20.
Seli E, Duleba AJ. Optimizing ovulation induction in women with polycystic ovary syndrome.
Curr Opin Obstet Gynecol 2002; 14:245-54.
Bailey CJ, Turner RC. Metformin. N Engl J Med 1996; 334:574-9.
Dunn CJ, Peters DH. Metformin. A review of its pharmacological properties and therapeutic
use in non-insulin-dependent diabetes mellitus. Drugs 1995; 49:721-49.
Futterweit W. Polycystic ovary syndrome: clinical perspectives and management. Obstet
Gynecol Surv 1999; 54:403-13.
268
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.

Acbay O, Gundogdu S. Can metformin reduce insulin resistance in polycystic ovary syndrome? Fertil Steril 1996; 65:946-9.
Crave JC, Fimbel S, Lejeune H, Cugnardey N, Dechaud H, Pugeat M. Effects of diet and
metformin administration on sex hormone-binding globulin, androgens, and insulin in hirsute
and obese women. J Clin Endocrinol Metab 1995; 80:2057-62.
Ehrmann DA, Cavaghan MK, Imperial J, Sturis J, Roseneld RL, Polonsky KS. Effects of
metformin on insulin secretion, insulin action, and ovarian steroidogenesis in women with
polycystic ovary syndrome. J Clin Endocrinol Metab 1997; 82:524-30.
El-Biely MM, Habba M. The use of metformin to augment the induction of ovulation in obese
infertile patients with polycystic ovary syndrome. Middle East Fertil Soc J 2001; 6:43-49.
Mitwally MF, Kuscu NK, Yalcinkaya TM. High ovulatory rates with use of troglitazone in
clomiphene-resistant women with polycystic ovary syndrome. Hum Reprod 1999; 14:27003.
Eden JA, Place J, Carter GD, Jones J, Alaghband-Zadeh J, Pawson ME. The effect of clomiphene citrate on follicular phase increase in endometrial thickness and uterine volume. Obstet
Gynecol 1989; 73:187-90.
Randall JM, Templeton A. Transvaginal sonographic assessment of follicular and endometrial
growth in spontaneous and clomiphene citrate cycles. Fertil Steril 1991; 56:208-12.
Fleischer AC, Pittaway DE, Beard LA, et al. Sonographic depiction of endometrial changes
occurring with ovulation induction. J Ultrasound Med 1984; 3:341-6.
Imoedemhe DA, Shaw RW, Kirkland A, Chan R. Ultrasound measurement of endometrial
thickness on different ovarian stimulation regimens during in-vitro fertilization. Hum Reprod
1987; 2:545-7.
Rogers PA, Polson D, Murphy CR, Hosie M, Susil B, Leoni M. Correlation of endometrial
histology, morphometry, and ultrasound appearance after different stimulation protocols for
in vitro fertilization. Fertil Steril 1991; 55:583-7.
Yeko TR, Nicosia SM, Maroulis GB, Bardawil WA, Dawood MY. Histology of midluteal
corpus luteum and endometrium from clomiphene citrate-induced cycles. Fertil Steril 1992;
57:28-32.
Bonhoff AJ, Naether OG, Johannisson E. Effects of clomiphene citrate stimulation on endometrial structure in infertile women. Hum Reprod 1996; 11:844-9.
Massai MR, de Ziegler D, Lesobre V, Bergeron C, Frydman R, Bouchard P. Clomiphene citrate
affects cervical mucus and endometrial morphology independently of the changes in plasma
hormonal levels induced by multiple follicular recruitment. Fertil Steril 1993; 59:1179-86.
Wolman I, Sagi J, Pauzner D, Yovel I, Seidman DS, David MP. Transabdominal ultrasonographic evaluation of endometrial thickness in clomiphene citrate-stimulated cycles in relation
to conception. J Clin Ultrasound 1994; 22:109-12.
Hosie MJ, Murphy CR. A scanning and light microscope study comparing the effects of clomiphene citrate, estradiol 17-beta and progesterone on the structure of uterine luminal epithelial
cells. Eur J Morphol 1995; 33:39-50.
Dehbashi S, Parsanezhad ME, Alborzi S, Zarei A. Effect of clomiphene citrate on endometrium
thickness and echogenic patterns. Int J Gynaecol Obstet 2003; 80:49-53.
Dickey RP, Holtkamp DE. Development, pharmacology and clinical experience with clomiphene citrate. Hum Reprod Update 1996; 2:483-506.
Kolibianakis EM, Zikopoulos KA, Fatemi HM, et al. Endometrial thickness cannot predict
ongoing pregnancy achievement in cycles stimulated with clomiphene citrate for intrauterine
insemination. Reprod Biomed Online 2004; 8:115-8.
Kelekci S, Saygili-Yilmaz E, Inan I, Eminsoy G. A trial of a new regimen with clomiphene
citrate administration to reduce the antiestrogenic effects on reproductive end organs. Eur J
Obstet Gynecol Reprod Biol 2004; 116:54-7.
269
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
Biljan MM, Mahutte NG, Tulandi T, Tan SL. Prospective randomized double-blind trial of the
correlation between time of administration and antiestrogenic effects of clomiphene citrate on
reproductive end organs. Fertil Steril 1999; 71:633-8.
Yagel S, Ben-Chetrit A, Anteby E, Zacut D, Hochner-Celnikier D, Ron M. The effect of ethinyl
estradiol on endometrial thickness and uterine volume during ovulation induction by clomiphene citrate. Fertil Steril 1992; 57:33-6.
Unfer V, Costabile L, Gerli S, Papaleo E, Marelli G, Di Renzo GC. Low dose of ethinyl
estradiol can reverse the antiestrogenic effects of clomiphene citrate on endometrium. Gynecol
Obstet Invest 2001; 51:120-3.
Gerli S, Gholami H, Manna C, et al. Use of ethinyl estradiol to reverse the antiestrogenic
effects of clomiphene citrate in patients undergoing intrauterine insemination: a comparative,
randomized study. Fertil Steril 2000; 73:85-9.
Shimoya K, Tomiyama T, Hashimoto K, et al. Endometrial development was improved by
transdermal estradiol in patients treated with clomiphene citrate. Gynecol Obstet Invest 1999;
47:251-4.
Dickey RP, Olar TT, Taylor SN, Curole DN, Matulich EM. Relationship of endometrial thickness and pattern to fecundity in ovulation induction cycles: effect of clomiphene citrate alone
and with human menopausal gonadotropin. Fertil Steril 1993; 59:756-60.
Elkind-Hirsch KE, Phillips K, Bello SM, McNicho M, de Ziegler D. Sequential hormonal
supplementation with vaginal estradiol and progesterone gel corrects the effect of clomiphene
on the endometrium in oligo-ovulatory women. Hum Reprod 2002; 17:295-8.
Adashi EY. Clomiphene citrate: the case for a monoisomeric preparation. Baillieres Clin Obstet
Gynaecol 1993; 7:331-47.
Clark JH, Markaverich BM. The agonistic-antagonistic properties of clomiphene: a review.
Pharmacol Ther 1981; 15:467-519.
Charles D, Klein T, Lunn SF, Loraine JA. Clinical and endocrinological studies with the
isomeric components of clomiphene citrate. J Obstet Gynaecol Br Commonw 1969; 76:110010.
Pandya G, Cohen MR. The effect of cis-isomer of clomiphene citrate (cis-clomiphene) on
cervical mucus and vaginal cytology. J Reprod Med 1972; 8:133-8.
Connaughton JF, Jr., Garcia CR, Wallach EE. Induction of ovulation with cisclomiphene and
a placebo. Obstet Gynecol 1974; 43:697-701.
MacLeod SC, Mitton DM, Parker AS, Tupper WR. Experience with induction of ovulation.
Am J Obstet Gynecol 1970; 108:814-24.
Murthy YS, Parakh MC, Arronet GH. Experience with clomiphene and cisclomiphene. Int J
Fertil 1971; 16:66-74.
Van Campenhout J, Borreman E, Wyman H, Antaki A. Induction of ovulation with cisclomiphene. Am J Obstet Gynecol 1973; 115:321-7.
Mikkelson TJ, Kroboth PD, Cameron WJ, Dittert LW, Chungi V, Manberg PJ. Single-dose
pharmacokinetics of clomiphene citrate in normal volunteers. Fertil Steril 1986; 46:392-6.
Young SL, Opsahl MS, Fritz MA. Serum concentrations of enclomiphene and zuclomiphene
across consecutive cycles of clomiphene citrate therapy in anovulatory infertile women. Fertil
Steril 1999; 71:639-44.
Rostami-Hodjegan A, Lennard MS, Tucker GT, Ledger WL. Monitoring plasma concentrations
to individualize treatment with clomiphene citrate. Fertil Steril 2004; 81:1187-93.
Quigley MM, Schmidt CL, Beauchamp PJ, Pace-Owens S, Berkowitz AS, Wolf DP. Enhanced
follicular recruitment in an in vitro fertilization program: clomiphene alone versus a clomiphene/human menopausal gonadotropin combination. Fertil Steril 1984; 42:25-33.
Quigley MM, Schmidt CL, Beauchamp PJ, Maklad NF, Berkowitz AS, Wolf DP. Preliminary
experience with a combination of clomiphene and variable dosages of menopausal gonadotro-
270
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.

pins for enhanced follicular recruitment. J In Vitro Fert Embryo Transf 1985; 2:11-6.
Quigley MM, Maklad NF, Wolf DP. Comparison of two clomiphene citrate dosage regimens
for follicular recruitment in an in vitro fertilization program. Fertil Steril 1983; 40:178-82.
Quigley MM, Berkowitz AS, Gilbert SA, Wolf DP. Clomiphene citrate in an in vitro fertilization program: hormonal comparisons between 50- and 150-mg daily dosages. Fertil Steril
1984; 41:809-15.
Cassidenti DL, Paulson RJ, Lobo RA, Sauer MV. The synergistic effects of clomiphene citrate
and human menopausal gonadotrophin in the folliculogenesis of stimulated cycles as assessed
by the gonadotrophin-releasing hormone antagonist Nal-Glu. Hum Reprod 1992; 7:344-8.
D'Amato G, Caroppo E, Pasquadibisceglie A, Carone D, Vitti A, Vizziello GM. A novel protocol of ovulation induction with delayed gonadotropin-releasing hormone antagonist administration combined with high-dose recombinant follicle-stimulating hormone and clomiphene
citrate for poor responders and women over 35 years. Fertil Steril 2004; 81:1572-7.
Mansour R, Aboulghar M, Serour GI, Al-Inany HG, Fahmy I, Amin Y. The use of clomiphene
citrate/human menopausal gonadotrophins in conjunction with GnRH antagonist in an IVF/
ICSI program is not a cost effective protocol. Acta Obstet Gynecol Scand 2003; 82:48-52.
Hwang JL, Huang LW, Hsieh BC, et al. Ovarian stimulation by clomiphene citrate and hMG
in combination with cetrorelix acetate for ICSI cycles. Hum Reprod 2003; 18:45-9.
Fiedler K, Ludwig M. Use of clomiphene citrate in in vitro fertilization (IVF) and IVF/intracytoplasmic sperm injection cycles. Fertil Steril 2003; 80:1521-3.
Engel JB, Olivennes F, Fanchin R, et al. Single dose application of cetrorelix in combination
with clomiphene for friendly IVF: results of a feasibility study. Reprod Biomed Online 2003;
6:444-7.
Williams SC, Gibbons WE, Muasher SJ, Oehninger S. Minimal ovarian hyperstimulation for
in vitro fertilization using sequential clomiphene citrate and gonadotropin with or without the
addition of a gonadotropin-releasing hormone antagonist. Fertil Steril 2002; 78:1068-72.
Weigert M, Krischker U, Pohl M, Poschalko G, Kindermann C, Feichtinger W. Comparison
of stimulation with clomiphene citrate in combination with recombinant follicle-stimulating
hormone and recombinant luteinizing hormone to stimulation with a gonadotropin-releasing
hormone agonist protocol: a prospective, randomized study. Fertil Steril 2002; 78:34-9.
Engel JB, Ludwig M, Felberbaum R, Albano C, Devroey P, Diedrich K. Use of cetrorelix in
combination with clomiphene citrate and gonadotrophins: a suitable approach to 'friendly
IVF'? Hum Reprod 2002; 17:2022-6.
Tavaniotou A, Albano C, Smitz J, Devroey P. Effect of clomiphene citrate on follicular and
luteal phase luteinizing hormone concentrations in in vitro fertilization cycles stimulated with
gonadotropins and gonadotropin-releasing hormone antagonist. Fertil Steril 2002; 77:733-7.
Rossing MA, Daling JR, Weiss NS, Moore DE, Self SG. Ovarian tumors in a cohort of infertile
women. N Engl J Med 1994; 331:771-6.
Whittemore AS. The risk of ovarian cancer after treatment for infertility. N Engl J Med 1994;
331:805-6.
Potashnik G, Lerner-Geva L, Genkin L, Chetrit A, Lunenfeld E, Porath A. Fertility drugs and
the risk of breast and ovarian cancers: results of a long-term follow-up study. Fertil Steril 1999;
71:853-9.
Modan B, Ron E, Lerner-Geva L, et al. Cancer incidence in a cohort of infertile women. Am
J Epidemiol 1998; 147:1038-42.
Brinton LA, Lamb EJ, Moghissi KS, et al. Ovarian cancer risk after the use of ovulationstimulating drugs. Obstet Gynecol 2004; 103:1194-203.
Brinton LA, Lamb EJ, Moghissi KS, et al. Cancer Risk After the Use of Ovulation-Stimulating
Drugs. Obstet Gynecol Surv 2004; 59:657-659.
Gocze P, Krommer K, Csermely T, et al. [Ovulation induction therapy and malignant ovarian
271
86.
87.
88.
89.
90.
91.
92.
93.
94.
cancer]. Orv Hetil 2000; 141:71-5.

Venn A, Watson L, Bruinsma F, Giles G, Healy D. Risk of cancer after use of fertility drugs
with in-vitro fertilisation. Lancet 1999; 354:1586-90.
Venn A, Watson L, Lumley J, Giles G, King C, Healy D. Breast and ovarian cancer incidence
after infertility and in vitro fertilisation. Lancet 1995; 346:995-1000.
Mosgaard BJ, Lidegaard O, Kjaer SK, Schou G, Andersen AN. Ovarian stimulation and borderline ovarian tumors: a case-control study. Fertil Steril 1998; 70:1049-55.
Mosgaard BJ, Lidegaard O, Kjaer SK, Schou G, Andersen AN. Infertility, fertility drugs, and
invasive ovarian cancer: a case-control study. Fertil Steril 1997; 67:1005-12.
Ness RB, Cramer DW, Goodman MT, et al. Infertility, fertility drugs, and ovarian cancer: a
pooled analysis of case-control studies. Am J Epidemiol 2002; 155:217-24.
Kashyap S, Moher D, Fung MF, Rosenwaks Z. Assisted reproductive technology and the
incidence of ovarian cancer: a meta-analysis. Obstet Gynecol 2004; 103:785-94.
Brinton LA, Scoccia B, Moghissi KS, et al. Breast cancer risk associated with ovulationstimulating drugs. Hum Reprod 2004; 19:2005-13.
Rossing MA, Daling JR, Weiss NS, Moore DE, Self SG. Risk of breast cancer in a cohort in
infertile women. Gynecol Oncol 1996; 60:3-7.
Use of clomiphene citrate in women. Fertil Steril 2004; 82:90-96.
272
Prevention of pregnancy failure in IVF

Aspirin and other adjuvants in assisted
reproduction
Dr Salim Daya
Dept of Obstetrics and Gynaecologym, McMaster University Hamilton, Ontario, Canada
Email: dayas@mcmaster.ca
Treatment of infertility has been improved signicantly since the introduction

of assisted reproductive technology (ART) with which pregnancy rates have
increased steadily. Much of the increase in success rates can be attributed to
improvements in ovarian stimulation regimens and laboratory techniques for
gamete and embryo culture. However, in spite of these advances, the pregnancy rate remains relatively low, implying that implantation of the embryo is
a critical factor in establishing success with ART. Implantation is a complicated
process involving interaction between the embryo and the endometrium. By
identifying factors involved with the implantation process, it may be possible
to improve the success rates with assisted reproduction.
Among the many factors postulated to be involved in the implantation process, improving blood ow to the endometrium, promoting an immunosuppressive environment, and reducing uterine contractility are three factors that will
be the focus of review in this paper.
Improving blood ow to the uterus and ovary

Blood ow can be measured by the use of Doppler ultrasound directed against
the uterine and ovarian arteries to generate blood ow velocity waveforms.
The pulsatility index (PI) measures the resistance to ow and has been used as
an indicator of blood ow velocity; a decreased PI reects low resistance and
indicates increased blood velocity. The likelihood of implantation of embryos
transferred into a uterus with impaired perfusion was reduced (1,2), suggesting
a causal link between perfusion and implantation. The awareness that a good
273
blood ow to the uterus may be important for the establishment of pregnancy

has led to several different attempts to improve the probability of pregnancy
by using therapies that can increase blood ow. Similarly, studies on improving blood ow to the ovaries are also being conducted to identify therapeutic
options to improve success rates with assisted reproduction.
1. Aspirin
An important factor controlling tissue perfusion is the equilibrium between
thromboxane (which has vasoconstricting and platelet aggregating properties)
and prostacyclin (which has vasodilating properties) (3). The daily administration of aspirin in low doses induces a shift in the balance towards prostacyclin
leading to vasodilatation and enhanced blood ow. In one study, impaired uterine perfusion was observed in 37% of women being prepared for embryo transfer with thawed embryos (4). The use of aspirin was associated with improved
uterine blood ow in 57% of these women. Consequently, its potential role in
assisted reproduction to boost pregnancy rates (believed to be low because of
impaired uterine perfusion) is of much interest.
The evidence in the literature is not consistent in demonstrating the efcacy of aspirin. In one randomized trial the use of aspirin, when compared
with placebo, was associated with improved ovarian and uterine blood ow
and signicantly a higher pregnancy rate (5). In contrast, in another randomized trial of similar size no difference in pregnancy rates was observed with
low dose aspirin administration (6). Although there were clinical differences
between these studies in terms of dosage 100 mg versus 80 mg), onset of
administration of aspirin (mid-luteal phase versus follicular phase), method
of assisted reproduction employed (IVF versus ICSI), and the choice of the
control intervention (placebo versus no treatment), the profound difference in
the outcomes of these trials indicates that more studies are required to test the
hypothesis of the purported benecial effect of aspirin.
Searching the literature until 2004, using electronic and hand searching of
papers that have been published or presented at scientic meetings enabled a
systematic review on aspirin use in assisted reproduction to be undertaken.
Only randomized or quasi-randomized studies were selected. In total, ten trials (comprising 2520 subjects) were identied, of which seven were in patients undergoing IVF or ICSI, two were in recipients in an oocyte donation
programme, and one was in poor responders. The pooled sample of subjects
provided a power of over 80% of detecting an absolute improvement in clinical
pregnancy rate per patient of 5.3% with aspirin over a control rate of 30%, at
274
a 5% detection threshold using a two-tailed hypothesis test. Because there was

signicant heterogeneity in the effect of treatment, the random effects model
was used to pool the data.
The results are summarized in the odds ratio tree shown in gure 1. Overall,
there was no statistically signicant benet with aspirin use in infertile women
undergoing treatment with assisted reproduction (odds ratio for clinical pregnancy per patient was 1.18 (95% condence interval (CI) 0.86-1.61), p = 0.30).
In subgroup analyses, a non-signicant effect was observed in the one trial
in poor responders (with a sample size of only 61 subjects) (OR 0.47, 95%
CI 0.02-7.16), and in the seven trials comprising 2386 women undergoing
treatment with IVF or ICSI (OR 1.09, 95% CI 0.80-1.49, p = 0.58). The only
signicant benet from aspirin use was observed in the two trials comprising
73 recipients of donated oocytes (OR 3.57, 95% CI 1.32-9.66, p = 0.012). The
result of this combined analysis in the donor oocyte programme should be
interpreted with caution because of the small aggregated sample size and the
consistent null effect observed in the other subgroup analyses. Further study in
the donor oocyte programme is necessary to determine whether the observation
of a benecial effect is real or merely represents a type I error of hypothesis
testing.
Figure 1: Common odds ratios for clinical pregnancy per patient in

different subgroups comparing aspirin to placebo or no treatment.
Uterine perfusion has not been studied consistently among these trials to
enable any conclusions to be drawn about the benecial effects of aspirin
275
administration on this outcome event. The available data from the trials that
did measure uterine blood ow are contradictory, with one trial demonstrating
improved perfusion, whereas no effect on uterine perfusion was observed in
another trial. Similarly, in the non-randomized study of two doses of aspirin
(150 or 300 mg), improved blood ow was observed only in about half of the
women with poor uterine perfusion (4).
The supporters of aspirin use argue that because aspirin is relatively innocuous, its administration in assisted reproduction and its continued use during
pregnancy is not harmful. A review of the potential risk of aspirin use provides
a contrary viewpoint (7). First, the risk of miscarriage is increased with aspirin
commenced at conception. Not all trials in the systematic review provided data
on the numbers of miscarriage to allow any meaningful comparison of this
outcome event. However, among the few trials reporting on miscarriage rates,
a tendency towards a higher rate of miscarriage with aspirin use was observed.
Second, the use of aspirin is associated with an increased risk of damage to the
gastrointestinal mucosa and gastrointestinal haemorrhage. Third, the likelihood
of antenatal, intrapartum and postpartum bleeding is higher in women taking
low-dose aspirin. Finally, animal data and limited human data suggest that
prenatal use of aspirin may be associated with congenital malformations and
cognitive and behavioural defects in the offspring. Given the lack of efcacy
and the potential for harm to the female and her offspring, low-dose aspirin
should not be recommended for use in assisted reproduction; in the donor
oocyte programme, the potential benet of aspirin requires further study with
randomized trials.
2. Sildenal citrate (Viagra)

It is now well established that the endometrial assessment is an indicator of
likelihood of success with assisted reproduction. The goal is to have a trilaminar endometrial pattern with a thickness of at least 8 mm on the day of
HCG administration. Although hormonal stimulation can achieve the desired
response, it has been postulated that adequate uterine perfusion is necessary to
promote appropriate endometrial development. Vascular smooth muscle can
be relaxed by nitric oxide (NO) produced via a pathway mediated by cyclic
guanosine monophosphate (cGMP) (8). Sidenal citrate is a type 5-specic
phosphodiesterase (PDE) inhibitor that prevents the degradation of cGMP
thereby potentiating the effect of NO on vascular smooth muscle. In humans,
NO synthetase isoforms have been identied in the vascular endothelium of the
myometrium and endometrium (9). The clinical availability of sildenal citrate
276
has led to its increased use as a method that may improve uterine perfusion
thereby enhancing the development of the endometrium in women undergoing
treatment with assisted reproduction.
The rst report of the use of sildenal citrate was a case series of four
patients with prior failed cycles owing to poor endometrial response (10). In
response to sildenal citrate at a dose of 25 mg intravaginally four times a
day for seven days, the PI was reduced signicantly compared to placebo in a
cross-over comparison. The endometrial thickness was better than that in their
previous cycles and three women conceived. This encouraging report led to
another case series involving ten women who had had poor uterine artery blood
ow and poor endometrial development (<8 mm thickness) in previous failed
cycles with assisted reproduction (11). Sildenal citrate administration at the
same dose was commenced from the third day of the stimulation protocol to
the evening before oocyte retrieval. Although the endometrial thickness was
much better than in previous cycles, the PI of the uterine and ovarian arteries
showed no change with treatment. Three of the ten women conceived. Thus,
these two small studies provide contrasting data on the effect of sidenal citrate
on uterine blood ow and call for the need for more studies.
A larger study was undertaken in a cohort of 105 women <40 years, with
normal ovarian reserve and at least two consecutive prior IVF failures attributed
to inadequate endometrial development (12). All women received sildenal
citrate. In 70% of the women the endometrial thickness was 9 mm and the
pregnancy rate was 45% compared to the rest of the women who had thinner
endometrial development in whom no pregnancies were observed. The authors
concluded that the therapeutic effect of sildenal was mediated via improved
endometrial thickness. It is clear that the major problem with this study is
its observational design. The only way to adequately evaluate the efcacy of
sildenal citrate is with a randomized controlled trial.
To date, there is no published evidence from randomized trials on the efcacy of sildenal citrate in assisted reproduction. However, in 2002 the results
of a randomized, third part blinded, placebo controlled, cross-over trial was
undertaken in ten women with poor prognosis undergoing embryo transfer with
thawed embryos (ve women in an IVF treatment programme and the other
ve in a donor oocyte programme) (13). There was no signicant difference
in the endometrial thickness between placebo and sildenal citrate in either of
the two assisted treatment groups. These data call into question the inferences
made from the observational studies previously described and suggest that any
benecial effect observed is likely to be related to factors other than the use of
sidenal citrate.
277
Although the side effects such as headaches and hypotension are relatively
low with sidenal citrate, data from the post-marketing adverse events reports of
the Food and Drug Administration in the USA show that there are a high number
of deaths and serious cardiovascular events associated with this treatment (14).
Thus, in the absence of data on safety and efcacy, there is concern about recommending the use of sidenal citrate to women undergoing assisted reproduction.
There is an urgent need to perform better quality studies on this issue.
3. Nitroglycerin
Based on the benecial effect of nitric oxide in improving blood ow to
the heart, it has been postulated that improved uterine perfusion can also be
achieved by vasodilatation caused by NO donors such as nitroglycerin (NTG).
Two randomized trials on the efcacy of NTG have been published (15,16).
Although the rst trial was conducted to evaluate the possible benecial effect on embryo transfer by causing smooth muscle relaxation, its effect on the
pregnancy rate is relevant to the present discussion of uterine perfusion (15). In
this trial (comprising 120 subjects) NTG was administered by sublingual spray
at a dose of 800 ug three minutes before embryo transfer and the control group
received placebo. No difference in pregnancy rates was observed.
The second trial involved 138 subjects who were randomized on the day
before embryo transfer to receive NTG patch (5 mg) or placebo in the morning,
followed by a repeated dose the next morning after an overnight rest period
with no treatment (16). The subjects continued using the patches until either
the results of the pregnancy test were available or menstruation occurred. No
differences were observed in clinical pregnancy rates or PI of the uterine artery
on the day before and day of embryo transfer.
When the data were pooled using a xed effects model (because there was
no signicant heterogeneity of treatment effect), the common OR for pregnancy per patient was 0.87 (95% CI 0.50 1.51, p = 0.63). Thus, the evidence
from these small studies does not support the use of NTG for assisted reproduction.
4. L-arginine
Increased vascularization of the ovarian follicles is observed during folliculogenesis. Gonadotropins, steroids, prostaglandins and vasoactive molecules
inuence ovarian blood ow. In this regard, NO has been recognized as an
intracellular and intercellular modulator. In vivo, NO is formed from L-argi-
278
nine (17) and is believed to be involved in follicular maturation and ovulation

(18,19). This effect of NO and the observation of enhanced vascularization of
the follicles during folliculogenesis led to the hypothesis that L-arginine may
have a therapeutic role in assisted reproduction (20,21).
This hypothesis was tested in two randomized trials to evaluate the efcacy
in assisted reproduction of L-arginine administered orally at a daily dose of 16
g throughout the ovarian stimulation cycle. The rst trial, in poor responders,
demonstrated a lower cancellation rate, increased numbers of oocytes collected
and embryos transferred with L-arginine (20). Doppler ow measurements of
uterine and perifollicular arteries demonstrated improved blood ow with L-arginine; this effect was inversely correlated with the concentration of nitrite/nitrate in the plasma. In this small trial of 34 subjects, there were no pregnancies
in the control group, and all three pregnancies in the experimental group ended
in miscarriage. Thus, although there appeared to be improvement in ovarian
response and endometrial receptivity, the relatively high rate of miscarriage is
a concern.
The second trial was equally small (37 subjects), but was based on a sample
size calculation that would provide 90% power of detecting a difference of 1.7
follicles >17 mm between the experimental and control groups (21). It was conducted with narrow inclusion criteria in women with tubal infertility and normal ovarian response. Although more follicles were obtained with L-arginine
there were fewer mature follicles and more immature follicles compared with
placebo. Despite decreased blood ow resistance in the perifollicular arteries
with L-arginine, there were fewer good quality embryos and the pregnancy rate
was signicantly lower compared with placebo. The authors speculate that the
elevated intrafollicular levels of nitrite/nitrate resulting from administration of
L-arginine may have a detrimental effect on both embryos and the likelihood
of pregnancy.
When the data from the two trials were pooled using a random effects model
(because of heterogeneity in the effect of treatment, likely due to the different
patient populations), the common OR for clinical pregnancy per patient was
1.05 (95% CI 0.30-3.64, p = 0.94). For this reason of apparent inefcacy, and
because of the observed detrimental effect on embryos, L-arginine administration does not appear to have a role in assisted reproduction.
Promoting an immunosuppressive environment

Research in the immunology of recurrent miscarriage has suggested that an
immunosuppressive environment is necessary for the successful outcome of the
279
pregnancy. This concept has been extended to the area of assisted reproduction
in which implantation failure is a common event. The use of methylprednisolone to create an immunosuppressed environment (by reducing the numbers
of uterine lymphocytes) was found to improve the likelihood of implantation
of zona-dissected human embryos (22). Further clinical studies were then undertaken to evaluate the efcacy of corticosteroids in assisted reproduction. In
a cohort study of two groups of patients (previous IVF failure or pregnancy
loss, and rst IVF cycle), the short term administration of methylprednisolone
(60 mg orally daily for four days starting on the day of oocyte retrieval) resulted in clinical pregnancy rates per patient of 47.8% and 42.4% respectively
(with some patients having more than on cycle with embryo transfer) (23).
The authors postulated that the benecial effect of the glucocorticoids is by
stimulating the release of immunosuppressive factors by the endometrium either through direct action or indirectly via progesterone production by human
granulosa cells.
In a larger prospective, controlled study comparing two different doses of
methyprednisolone (16 mg and 60 mg) to no treatment in women undergoing
their rst cycle of IVF or in those who had previously failed to achieve pregnancy with IVF, no differences were observed in the clinical pregnancy rate per
patient with treatment (24). Although it is not clear how assignment to the different groups was undertaken, these results question the role of corticosteroids
in assisted reproduction and require randomized trials to be undertaken so that
their efcacy can be evaluated properly.
In a comprehensive search of the literature, ve trials were found comparing corticosteroids with either placebo or no treatment. In one trial detailed
data were not available to allow it to be included in the meta-analysis. The
remaining four trials provided six comparisons comprising 1144 cycles of treatment. Unfortunately, one of the trials permitted multiple cycles per patient, and
because data were not available for the rst cycle of treatment in this trial, the
overall results from the cycles of treatment are included in the meta-analysis.
It is recognised that such inclusion will introduce bias in the estimation of the
effect of treatment. Consequently, a subgroup analysis was also performed after
excluding this trial. The common OR for clinical pregnancy per cycle with all
included trials was 1.20 (95% CI 0.93-1.55, p = 0.16), and with the excluded
trial, the common OR for clinical pregnancy per patient (with 1069 subjects)
was 1.18 (95% CI (0.91-1.53, p = 0.22).
These results indicate that to date, there is no clear evidence to support
the use of corticosteroids for a short course around the time of embryo transfer. Although the absolute treatment effect from this meta-analysis was 3.4%,
280
indicating the possibility of a small benecial effect, the total sample size is
not sufcient to exclude this estimate being a chance nding. Furthermore,
the dose and type of corticosteroids used was not consistent across the trials.
Consequently, if corticosteroids are to be used in assisted reproduction, they
should be administered within the context of an appropriately powered, randomized, placebo controlled trial so that their efcacy can be evaluated condently.
Also, the optimal dose and duration of treatment needs to be established.
Reducing uterine contractility

The uterus has contractile activity that is undergoes periodic changes during
a menstrual cycle (25). The frequency of contractions increases during the
follicular phase and reaches a peak of four to ve contractions per minute
in the late follicular phase. In contrast, in the luteal phase uterine contractile
frequency decreases signicantly and reaches a nearly quiescent state. These
effects are inuenced by estradiol and progesterone, respectively. The observation that increased uterine contractility at the time of embryo transfer is associated with a lower chance of pregnancy (25), has led investigators to search for
methods to reduce the frequency of contractions so that implantation can be
facilitated. Luteal phase support with vaginal progesterone has been shown to
be associated with a signicantly decreased frequency of uterine contractions
(25). Given that the luteal phase is routinely supported with progesterone in
the vast majority of treatment cycles with assisted reproduction employing a
gonadotropin releasing hormone agonist, it will not be discussed further in this
paper. Also, a recently published systematic review has demonstrated improved
pregnancy rates with luteal phase support (26).
The evidence in the literature on therapies to reduce uterine contractions in
women undergoing treatment with assisted reproduction is limited and will be
discussed briey.
1. Piroxicam
Prostaglandin, synthesized from arachidonic acid by cyclooxygenase, stimulates uterine contraction. Nonsteroidal anti-inammatory drugs (NSAID) block
the action of cyclooxygenase and inhibit the production of prostaglandin.
NSAIDs have been used effectively to reduce uterine contractions that cause
dysmenorrhoea. Until recently, their use in assisted reproduction had not been
undertaken because of safety concerns (27) and increased risk of spontaneous
abortion (28). Piroxicam is an NSAID that is very effective in the treatment
281
of dysmenorrhoea and is of low risk when used in pregnancy. Its use in assisted reproduction was the subject of a recent randomized, placebo-controlled,
double-blind trial (29).
The trial was performed on 188 cycles involving fresh embryo transfer and
78 cycles involving thawed embryo transfer. Piroxicam was administered orally
at a dose of 10 mg 1-2 hours before the embryo transfer procedure. In fresh
embryo transfer cycles, the clinical pregnancy rate with piroxicam (46.8%)
was signicantly higher than with placebo (27.6%). The absolute treatment
effect was 19.2%, indicating that for every ve women receiving piroxicam in
this manner, one additional clinical pregnancy could be achieved compared to
placebo. The result in the thawed embryo transfer cycles was equally impressive in favour of piroxicam (25.6% versus 7.7%). This large treatment effect is
very encouraging, but needs to be substantiated by other studies to ensure it is
not the result of a type I error of hypothesis testing.
2. Ritodrine
Premature labour is a relatively frequent condition for which treatment with a
variety of tocolytic agents is possible. Ritodrine has been used effectively for
this purpose because of its smooth muscle relaxing properties. In a randomized
trial comparing ritodrine to no treatment in assisted reproduction, a signicantly
higher pregnancy rate was observed with treatment (46.7% versus 16.7%) (30).
This paper was presented at a scientic meeting in 2000, but further details of
the trial are not available in the literature. Consequently, no further comment
can be made about the use of ritodrine in assisted reproduction, except to say
that if the results are substantiated by additional trials, then a potentially very
effective treatment will become available to increase the pregnancy rates. The
side effects from using ritodrine may limit its widespread applicability.
282
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Battaglia C, Larocca E, Lanzani A, Valentini M, Genazzani AR. Doppler ultrasound studies

of the uterine arteries in spontaneous and IVF stimulated ovarian cycles. Gynecol Endocrinol
1990; 4: 245-250.
Steer CV, Mills C, Campbell C, Mason BA, Tan Sl, Collins WP, Crayford T. The use of transvaginal color ow imaging after in vitro fertilization to identify optimum uterine conditions
before embryo transfer. Fertil Steril 1992; 57: 372-376.
Bussolino F, Bendetto C, Massobrio M, Camussi G. Maternal vascular prostacyclin activity in
pre-eclampsia. Lancet 1980; ii: 702.
Wada I, Hsu CC, Williams G, Macnamee MC, Brinsden PR. The bents of low-dose aspirin therapy in women with impaired uterine perfusion during assisted conception. Hum
Reprod 1994; 9: 1954-1957.
Rubinstein M, Marazzi A, Polak de Fried E. Low dose aspirin treatment improves ovarian
responsiveness, uterine and ovarian blood ow velocity, implantation, and pregnancy rates in
patients undergoing in vitro fertilization: a prospective, randomized, double-blind placebocontrolled assay. Fertil Steril 1999; 71: 825-829.
Urman B, Mercan R, Alatas C, Balaban B, Isiklar A, Nuhoglu A. Low-dose aspirin does not
increase implantation rates in patients undergoing intracytoplasmic injection: a prospective
randomized study. J Assisted Reprod Genet 2000; 17: 586-590.
Daya S. Recurrent spontaneous early pregnancy loss and low dose aspirin. Minerva Gynecol
2003; 55: 441-449.
Ballard SA, Gingell CJ, Tang K, et al. Effects of Sildenal on the relaxation of human corpus
cavernosum tissue in vitro and on the activities of cyclic nucleotide phosphodiesterase isoenzymes. J Urol 1998; 159: 2164-2171.
Telfer JF, Irvine GA, Kohnen G, et al. Expression of endothelial and inducible nitric oxide
synthase in non-pregnant and decidualized human endometrium. Mol Hum Reprod 1997; 3:
69-75.
Sher G, Fisch JD. Vaginal sildenal (Viagra): a preliminary report of a novel method to
improve uterine artery blood ow and endometrial development in patients undergoing IVF.
Hum Reprod 2000; 15: 806-809.
Paulus WE, Strehler E, Zhang M, Jelinkova L, El-Danasouri I, Sterzik K. Benet of vaginal
sidenal citrate in assisted reproduction therapy. Fertil Steril 2002; 77: 846-847.
Sher G, Fisch JD. Effect of vaginal sildenal on the outcome on in vitro fertilization (IVF)
after multiple IVF failures attributed to poor endometrial development. Fertil Steril 2002; 78:
1073-1076.
Black SH, Bergman LL, Lincoln SR, Blauer KL, Opsahl MS. Viagra did not normalize
controlled endometrial development (CED) in poor prognosis patients in a randomized placebo-controlled cross-over trial. Fertil Steril 2002; 78 (Suppl 1): (Abstract P-365).
Federal Drug Administration (Internet). Bethesda (MD): The FDA; New Safety Information
Summaries 1998. (Updated 1998 November 24; cited 2002 July 23). Available from: www.
fda-gov/medwatch/safety/I 998/safety98.htm.
Shaker AG, Fleming R, Jamieson ME, Yates RWS, Coutts JRT. Assessments of embryo transfer after in-vitro fertilization: effects of glyceryl trinitrate. Hum Reprod 1993; 8; 1426-1428.
Ohl J, Lefebvre-Maunoury C, Wittemer C, Nisand G, Laurent M-C, Hoffman P. Nitric oxide
donors for patients undergoing IVF. A prospective, double-blind, randomized, placebo-controlled trial. Hm Reprod 2002; 17: 2615-2620.
Moncada S, Palmer RMJ, Higgs EA. Nitric oxide: physiology, pathophysiology, and pharmacology. Pharmacol Rev 1991; 43: 109-142.
283
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
Anteby EY, Hurwitz A, Korach O, et al. Human follicular nitric oxide pathway: relationship
to follicular size, estradiol concentrations and ovarian blood ow. Hum Reprod 1996; 11:
1947-1951.
Tao M, Kodama H, Kagabu S, et al.Possible contribution of follicular interleukin-1 to nitric
oxide generation in human pre-ovulatory follicles. Hum Reprod 1997; 12: 2220-2225.
Battaglia C, Salvatori M, Maxia N, Petraglia F, Facchinetti F, Volpe A. Adjuvant L-arginine
treatment for in-vitro fertilization in poor responders. Hum Reprod 1999; 14: 1690-1697.
Battaglia C, Regnani G, Marsella T, Facchinetti F, Volpe A, Venturoli S, Flamigni C. Adjuvant
L-arginine treatment in controlled ovarian hyperstimulation; a double-blind, randomized study.
Hum Reprod 2002; 17: 659-665.
Cohen J, Malter H, Elsner C, Kort H, Massey J, Mayer MP. Immunosuppression supports
implantation of zona pellucida dissected human embryos. Fertil Steril 1990; 53: 662-665.
Polak de Fried E, Blanco L, Lancuba S, Asch RH. Improvement of clinical pregnancy rate and
implantation rate of in-vitro fertilization-embryo transfer patients by using methyprednisone.
Hum reprod 1993; 8: 393-395.
Lee K-A, Koo JJ, Yoon T-K, Do BR, Ko J-J, Cha K-Y. Immunosuppression by corticosteroid
has no effect on the pregnancy rate in routine in-vitro fertilization/embryo transfer patients.
Hum Reprod 1994; 9: 1832-1835.
Fanchin R. Assessing uterine receptivity in 2001. Ultrasonographic glances at the new millennium. Ann N Y Acad Sci 2001; 943: 185-202.
Daya S, Gunby J. Luteal phase support in assisted reproduction cycles. The Cochrane
Database of Systematic Reviews 2004, Issue 3. Art. No.: CD004830. DOI: 10.1002/14651858.
CD004830.
Matt DW, Bozelleca JF. Toxic effects on female reproductive system during pregnancy, parturition, and lactation. In: Witorsch RJ (ed) Reproductive toxicology. 2nd edition. New York: Raven
Press, 1995: 175-193.
Neisen GL, Sorensen HT, Larsen H, Pedersen L. Risk of adverse birth outcome and miscarriage
in pregnant users of nonsteroidal anti-inammatory drugs: population based observational
study and case-control study. Br Med J 2001; 322: 266-270.
Moon HS, Park SH, Lee JO, Kim KS, Joo BS. Treatment with piroxicam before embryo
transfer increases the pregnancy rate after in vitro fertilization and embryo transfer. Fertil Steril
2004; 82: 816-820.
Tsirigotis M, Pelekanos M, Gilhespie S, Gregorakis S, Pistodis G. Ritodrine use during the
peri-implantation period reduces uterine contractility and improves implantation and pregnancy rates post-implantation. Presented at the 16th Annual Meeting of the European Society
of Human Reproduction and Embryology, Bologna, Italy 2000 (Abstract O-024).
284
Prevention of multiple pregnancies

attributable to IVF/ICSI
Loutradis D, Drakakis P, Makrigiannakis A, Antsaklis A
1st Dept OB/GYN, Athens University Medical School. Athens, Greece
Introduction
The incidence of twin and higher order (triplet or greater) multiple pregnancies
has increased over the past 15 years primarily due to the increased use of drugs
for ovulation induction (OI), superovulation (SO) and assisted reproductive
technologies (ART), including in vitro fertilization (IVF), intracytoplasmic
sperm injection (ICSI), gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT) .
Large, multicenter studies of IVF programmes have shown that three factors
play signicant role in the success of an IVF procedure, and, consequently, in
the risk for multiple births (1). These are the patients age, the number of embryos transferred and the ability to select good quality embryos for transfer. It is
evident from the literature that there is a discrepancy among scientists concerning the policy of multiple pregnancies due to in different culture and as well as
how each society approach the problem. For example, two papers concerning
the serious problem of multiple pregnancies in USA and in Europe have been
published recently in Fertility and Sterility and in Human Reproduction having a different philosophy towards the severity of this problem, as well as the
methods to avoid this iatrogenetic complication.
The paper by Adamson et al from USA shows that the overall pregnancy
rate in Europe is approximately 29% per fresh transfer and the average female
patient age is 33 years old while in the United States pregnancy rate is 38%
with an average female patient age of 35 years (2). He also stressed that in
some European countries signicant restrictions are imposed on reproductive
285
techniqiues resulting in the so-called reproductive tourism. In Scandinavia

among other countries, the use of elective single embryo transfer is increasing,
especially among younger patients, in order to reduce the number of twins as
well as triplets. Across Europe, the trend is to replace fewer embryos, although
there is still a wide variation from country to country. Europeans generally
tend to accept, support, and promote a much stronger regulatory environment
with mandatory clinical limitations than their U.S. counterparts. It is clear that
multiple births are more complicated and costly for the babies, mothers, families, and society and that the desired outcome of any ART cycle is a healthy
singleton baby. The multiple birth rate in the United States is viewed as a
serious problem, just as it is in other countries, and solutions to the problem
have been and are being developed in a systematic, evidence-based manner. It
is impossible to eliminate multiple births completely even with single embryo
transfer. If ART is to be performed, some twins and possibly triplets will
result. Of note is that the monozygotic twinning rate has increased 6 to 12
times after ART and Adamson remarked that it is not reasonable to argue that
ART should be abandoned to prevent multiple births. Therefore, the harms
of multiple births must be balanced against the benets of any birth at all, as
well as the multiple pregnancies that result in healthy babies. We shouldnt
forget that the great majority of fertile and subfertile women who have twin
or triplet pregnancies will have healthy babies and a satisfactory outcome.
Many of them perceive the multiple births as an advantage (3).
On the other hand, Ombel et al from Europe presented another point of view
in Human Reproduction (4). They believe that infertility treatment should not
aim to achieve a successful conception, but to offer the parents a healthy and
normal child, a twin pregnancy being regarded as an adverse outcome. There
is no doubt that the major complication of assisted reproductive technologies
is the high incidence of multiple pregnancies, a condition responsible for a
substantial part of the cost and of the suffering of the procedure. Transferring
multiple embryos into the uterus maximizes pregnancy rates, but it yields an
unacceptably high multiple pregnancy rate. Unfortunately, a high multiple
pregnancy rate is not only associated with IVF or ICSI, but also with non-IVF
procedures such as ovulation induction therapies whether or not associated
with intrauterine insemination (IUI).
The current situation

From 1980 up until 1997, the rate of annual live born babies from twin gestations increased by 52% (from 68,399 to 104,137 babies) while the number
286
of higher-order multiple gestations increased by 404% (from 1,377 to 6,727

babies) (2). Ovulation induction is responsible for a greater percentage of
higher order multiple gestations compared to ART. In a recent review, ovulation
induction accounted for 10-69% of triplet gestations compared to 24% to 30%
associated with ART and 7% to 18% arising spontaneously (1). Quadruplet
and higher order multiple gestations were associated with ovulation induction in 5% to 72%, with ART in 42%, and with cases of spontaneous conceptions in 6% to 7% (1). In an analysis of the Society for Assisted Reproductive
Technology (SART) databases and of the Center for Disease Controls (CDC)
of the National Center for Health Statistics Data, the CDC has estimated that
for triplets and higher-order multiple births approximately 20% were attributable to spontaneous events (related to the age of the female partner), 40%
were attributable to ovulation inducing drugs without ART, and 40% were
attributable to ART (5). Further analysis of the same data indicated that 10% of
all multiple births, the overwhelming preponderance of which are spontaneous
twins, are associated with IVF and related procedures.
Even though there is a discrepancy among the scientic society concerning
this eld, we will analyze in this chapter the risks associated with multiple
gestations and will present approaches to reduce the risk of multiple gestation
after infertility therapy in order to provide physicians with appropriate information to counsel couples contemplating treatment for their infertility.
Prevention of multiple pregnancies

Natural Cycle
Natural cycle IVF has been almost completely replaced by the more effective
technique of stimulated IVF/ICSI. Natural cycle IVF is, however, a low risk,
low cost and patient-friendly procedure that may be suitable for some patients.
The advantages of this technique include almost no multiple pregnancies, a
zero risk of ovarian hyperstimulation syndrome (OHSS), fewer interventions
per cycle, and less physical and emotional stress for patients when compared
to stimulated ovulation protocols.
Pelinck et al. (2002) have published a thorough literature review that addresses the issue of effectiveness of natural cycle or mildly stimulated protocols
in IVF (6). It reviews 20 studies of natural cycle IVF: 12 case series and eight
in which a comparison has made between natural cycle IVF and IVF with ovarian stimulation. While good-quality, randomized, controlled trials and formal
cost-effectiveness analyses are lacking, the 20 selected studies comprised a
total of 1800 cycles of natural cycle IVF resulting in 819 embryo transfers
287
(45.5% per cycle) and 129 ongoing pregnancies (7.2% per cycle and 15.8% per
embryo transfer). However, at least for the moment, we need more data from
randomized, controlled trials in order to clarify the role of natural cycle IVF in
the treatment of infertility.
Individualization of the number of embryos transferred
The most successful indicator of multiple births is, however, the quality and,
consequently, the implantation potential of the embryos transferred. Great efforts have been made to identify the key features of high-quality embryos (7).
The benets of these approaches have recently been shown from the experience
of several countries in which the introduction of elective single embryo transfer
(eSET) has dramatically reduced the twins rate and has completely eliminated
the incidence of higher-order multiple pregnancies, without causing a decrease
in the overall pregnancy rate (8). From these data, it has been estimated that,
if you have the ability to select two embryos by morphological criteria as the
cleavage rate, the equal size of the blastomeres and the percentages of extracellurar fragmentation of the embryo, then you maximize the pregnancy rate of the
transfer of 2 embryos (41.7%) and make it comparable to that of the transfer
of 3 (41.7%). However, for 2 transferred embryos the higher order pregnancy
rate is 1.1% and for 3 it is 12.6%. (9) This observation was conrmed by Magli
et al (2001) who showed that chromosomal analysis of the day 3 embryos is
strictly related to cleavage rate while it appears than an abnormal cleavage rate
is associated with chromosomal abnormalities and the lowest incidence of such
abnormalities is observed in embryos without framgmatation (10).
Preimplantation genetic diagnosis
Assessment of the chromosomal constitution can be used to assess the implantation potential of the embryo. It has been suggested that the use of preimplantation genetic diagnosis (PGD) for aneuploidy might help to reduce the
incidence of early abortions (11).
Multifetal pregnancy reduction (MPR)
Selective reduction is still only a palliative procedure that presents as a last
minute solution to patients that already have established a multiple pregnancy.
All patients have clearly expressed that they would have preferred not to have
faced this difcult choice, even though they had been duly informed of the risk
of multifetal pregnancy. Even though the MPR is an invasive procedure, the
benets from this method are: 1.The reduction of triplet pregnancies to twins
increases gestation by 2-3 weeks. 2.The reduction to twins from higher order
288
pregnancies prolongs the pregnancy even more (12). Due to the ethical and
emotional problems raised by MPR it is clear that this procedure should not
be viewed as the optimal solution to the problem of conceiving three or more
fetuses.
Blastocyst transfer
The success of embryo transfer may be improved by prolonging the in vitro culture period from the pronuclear to the blastocyst stage, thereby allowing better
assessment of the embryos viability. Thus, whereas there have been no reports
of implantation rates above 28% when pronucleate embryos are transferred, or
no reports of implantation rates greater than 50% with the transfer of cleavagestage embryos, implantation rates of up to 70% are possible following transfer of
day 5 embryos. Prior to blastocyst formation, the maternal-embryonic genome
transition is not complete. The cleavage-stage embryo is essentially cleaving
under the control of proteins and messenger ribonucleic acid synthesized during
oocyte maturation. Therefore, cytoplasmic deciencies and chromatin damage
in either the oocytes or sperm may not be apparent prior to compaction.
In a prospective, randomized trial comparing the transfer of one or two
blastocysts in a group of good prognosis patients, it was determined that an
ongoing pregnancy rate of 60.9% could be established with the transfer of
a single blastocysts with no twin pregnancies (13). However the hypothesis
that the success of embryo transfer may be improved by prolonging the in
vitro period from the pronuclear to the blastocyst stage needs a prospective
randomized trial comparing the transfer of one blastocyst with day 1 or day 3
embryo transfer.
The role of cryopreservation
Irrespective of the implantation rate achieved with fresh blastocyst transfer,
the SET and DET procedures would not be valid if it were not possible to successfully cryopreserve the remaining blastocysts to maximize the possibility
of pregnancy from a single IVF procedure. With effective cryopreservation,
a higher pregnancy rate and a lower multiple gestation rate can be achieved.
Outcomes are signicantly enhanced when the cumulative effect of adding
pregnancies resulting from the use of thawed pre-embryos (only from cycles
failing to become pregnant after fresh transfer) to cycles using fresh pre-embryos is examined. At least in some programmes, the probability of pregnancy
following transfer of a thawed pre-embryo is nearly equal to that resulting
from transfer of fresh pre-embryos. With effective cryopreservation, a higher
pregnancy rate and a lower multiple gestation rate can be achieved.
289
Discussion
One of the strongest predictive factors for pregnancy rate and multiple births
is the age of the mother, with pregnancy rates decreasing with age, particularly
after 38 years. The type of infertility problem also plays a role, since couples
affected by male factor infertility have a higher pregnancy rate compared to
those with a female factor. Other possible correlating factors, such as the FSH
dose and tubal infertility have odds ratios which are generally close to one,
suggesting a low impact of these variables on pregnancy rates.
Although no consensus has been reached about how to address the problem
of multiple pregnancies associated with ART, it was agreed that reducing multiple pregnancies constitutes a major challenge for infertility treatment.
The key issue is whether it is ever acceptable to risk the prospect of multiple
births by transferring more than one embryo and, if so, what should inuence
the decision to transfer one, two or three embryos. Although the suggestion that
SET should apply to all patients undergoing IVF was vigorously discussed, this
approach was not widely accepted. Instead, an initial strategy was proposed that
might potentially halve the number of multiple births without unduly harming
the overall pregnancy rate. Thus, it was suggested that SET should be applied to
all patients with good prognosis or, alternatively, to the rst and second cycles
of IVF in patients <35 years of age. Only after such a strategy has been widely
adopted and the outcomes analyzed scientically should it be recommended
as a useful guideline. Perhaps then the more difcult question of lowering the
number of embryos transferred to poor prognosis patients will be considered.
Furthermore, it was suggested that a prospective, randomized trial comparing
outcomes following transfer of thawed single embryos on day 3 or day 5 could
help to evaluate the usefulness of SET after cryopreservation and thawing.
It was agreed that triple embryo transfer should be avoided in most patients. Because of the overall consensus that transfer of any more than two
embryos poses a true risk for higher order multiple pregnancies, it is important
to maintain non-transferred embryo viability through effective cryopreservation programmes, thus allowing further implantation attempts without the need
of ovulation induction regimens.
Embryo reduction has been used as a method for reducing multiple pregnancies, but this is considered an unsuitable intervention in couples undergoing IVF/ICSI. Nevertheless, it may be acceptable as an emergency or salvage
procedure, as long as patients are well informed before treatment about the
associated risks and have agreed to undergo this technique, if required or desired. It is recognized that such programmes are not universally available or
universally permissible.
290
Finally, the role of natural cycle IVF in the treatment of infertility shoul not
be forgotten. It will become clearer if more data are available from randomized,
controlled trials and it may help signicantly to reduce multiple gestation.
The European situation

Within Europe, there is little consensus between countries on the prevention
of multiple pregnancies. Some European countries have passed laws aiming
at reducing the number of multiple pregnancies, for example by restricting the
number of embryos transferred, while others have ofcial regulations set by
national scientic societies. Nevertheless, a large number of countries have no
national restrictions, although individual clinics may set their own guidelines.
Accordingly, there are substantial national differences in the number of embryos
transferred and the percentages of multiple pregnancies. As might be expected,
countries with few or no regulations have a high proportion of multiple births,
generally as a result of transferring a higher number of embryos.
The USA situation

Although there is no national legislation concerning the practice of ART in
the USA, guidelines are provided by the American Society of Reproductive
Medicine (ASRM) and its predecessor, the American Fertility Society, in the
form of reports by Ethics and Practice Committees. The most recent guidelines,
which date from November 1999 (14), provide the recommendations for preembryo transfer according to the womans prognosis. Despite the availability of
such guidelines, however, the total number of multiple births has been increasing each year from 1980 to 2001 (15). Although the percentage increase in
multiple births varied on a year-by-year basis, the rate of triplet births remained
similar from 1999 to 2001.
In conclusion, the occurrence of multiple births as a result of ART treatment
is a serious problem faced by all patients, professionals, and society. It is the
responsibility of all ART practioners to participate in solving this problem.
291
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Norwitz. ER. Multiple pregnancy: trends, past, present, and future. Infertil Reprod Med Clinics
North Am 9:351-69, 1998.
Adamson D, Baker V. Mulptiple births from assisted reproductive technologies: a challenge
that must be met. Fertil Steril 81:517-522, 2004
Pinborg A, Loft A, Schmid L et al. Attitudes of IVF/ICSI twin mothers towards twins and
single embryo transfer. Hum Reprod 18:621-7, 2003.
Ombelet W, De Sutter P, Van der Elstand J et al. Hum Reprod Update 11(1):314, 2005
National Center for Health Statistics, CDC. Contribution of assisted reproductive technology
and ovulation-inducing drugs to triplet and higher-order multiple births-United States, 19801997. MMWR Morb Mortal Wkly Rep 49:535-8, 2000.
Pelinck MJ, Hoek A, Simons AH. Efcacy of natural cycle in IVF: a review of literature. Hum
Reprod Update 8:129-139, 2002
Loutradis D, Drakakis P, Kallianidis K et al Oocyte morphology correlates with embryo quality
and pregnancy rate after intracytoplasmic sperm injection Fertil Steril 72(2):240-244, 1999.
De Sutter P, Van der Elstand J. Single embryo transfer and multiple pregnancy role relution in
IVF/ICS: a 5 year appraisal. Reprod Biomed Online 6:464-465, 2003.
Bertarelli Group. Infertility therapy-associated multiple pregnancies (births): an ongoing
epidemic. Proceedings of an Expert Meeting, Reprod Biomed Online Vol 7 supp 2, p.12-13,
2003
Magli MC, Gianaroli L, Ferratetti AP. Chromosomal abnormalities in embryos. Mol Cell
Endocrinol 183(supp.1) S29-34, 2001
Giannaroli L, Magli MC, Ferrquett AP et al. Preimplantation diagnosis for aneuploidies in
patients undergoing in vitro fertilization with a poor prognosis. Identication of the categories
for which it should be proposed. Fertil Steril 72: 837-844, 1999.
Loutradis D, Drakakis P. Multiple pregnancies of Assisted Reproductive Technologies (ART)
3rd ESHRE Campus Symposium Syllabus pp64-74, 1995.
Gardner DK, Lane M. Towards a single embryo transfer. Reprod Biomed Online 6:470-481,
2003.
The Practice Committee of the American Society of Reproductive Medicine. Multiple pregnancy associated with infertility therapy. Fertil Steril 82, suppl.1, S153-157, 2004
Martin. JA, Hamilton BE, Ventura SJ et al. Births: Final Data for 2001. National vital statistics
reports Vol. 51, No 2, p104. National Center for Health Statistics, Hyattsville, MO, USA.
292
Embryo transfer
Luteal phase support in assisted
reproductive technologies
Dr Salim Daya
Dept of Obstetrics and Gynaecology, McMaster University Hamilton, Ontario, Canada
Email: dayas@mcmaster.ca
Fertilization of at least one oocyte occurs in most cycles of treatment with

assisted reproduction technologies (ART). However, in only 28-41% of cycles
do the embryo transfer procedure result in pregnancy (1,2), suggesting that
implantation of the embryo is a critical factor in limiting the success with ART.
The current practice of transferring several embryos simultaneously is likely to
overcome aneuploidy in the embryo as a cause of implantation failure, because
the likelihood that at least one of the transferred embryos will be euploid is
quite high.
Implantation is a complicated process involving interaction between the
embryo and the endometrium. Development of the endometrium to provide
optimal conditions for the embryo begins in the proliferative phase and extends
throughout the luteal phase. The corpus luteum produces progesterone, which
promotes secretory transformation of the endometrium, so that implantation
can occur, and provides the necessary hormonal support for the early stages of
pregnancy (3).
After ovulation has occurred, the granulosa cells remaining in the collapsed
follicle rapidly undergo luteinization under the inuence of luteinizing hormone (LH). The corpus luteum requires ongoing stimulation by LH to maintain
adequate production of progesterone (4). Both LH and human chorionic gonadotropin (hCG), can activate the LH receptor in the corpus luteum to initiate
the synthesis of progesterone (5).
Granulosa cells are aspirated from the follicles during the oocyte retrieval
procedure for assisted reproduction. Aspiration of granulosa cells in this manner
293
is associated with a disruption of the luteal phase (6-8), the extent of the disruption varying according to the vigour of the aspiration (6). Thus, the hormonal
environment necessary for implantation may be altered, although this effect has
not been observed consistently (9). Additionally, the current practice of using
a gonadotropin releasing hormone agonist (GnRHa), to prevent a premature
surge of LH by inducing suppression of the pituitary gland, is associated with
persistent blockage of LH output for at least 10 days after the administration
of GnRHa has been discontinued (10,11). Consequently, the ability of the corpus luteum to produce progesterone is impaired (11,12) and the pulsatility of
progesterone secretion is suppressed (13).
The prolonged administration of GnRHa can affect ovarian steroidogenesis
directly. Granulosa cells from women treated with GnRHa have been shown
to produce less progesterone in vitro than when GnRHa was not used (14).
In addition, in almost half of the cycles in which GnRHa was used without
luteal phase support, a delay in endometrial development of more than 2 days
was noted, and ultrastructural analysis was abnormal in all women (15). This
iatrogenic luteal phase defect resulting from the use of GnRHa has been conrmed recently by reviewing the effect of ovarian stimulation on the luteal
phase (16).
The corpus luteum is also important for supporting the pregnancy during
the early stages before the placenta can take over this role. This luteoplacental
shift is believed to occur 36 days after the LH surge (17). Removal of the
corpus luteum in early pregnancy is associated with miscarriage, which can be
prevented by progesterone support (18).
The state of progesterone deciency observed in assisted reproduction is
commonly treated with either progesterone or human chorionic gonadotropin
(HCG) administration in the luteal phase, an approach that is now accepted as
a standard of care.
Luteal phase support in assisted reproduction

There have been many randomized trials performed to evaluate the efcacy of
luteal phase support in assisted reproduction, but most of the trials have had
insufcient power to permit reliable inferences to be made about the benet
of such therapy. Therefore, it is necessary to conduct a systematic review of
the evidence and critically appraise the trials so that the estimate of the effect
of treatment can be ascertained by pooling the results from valid studies using
meta-analysis.
A Cochrane review was undertaken to address the issue of luteal phase treat-
294
ment efcacy (19). In a comprehensive search of the literature up to the end

of 2003, 82 trials were identied, of which 59 met the criteria for inclusion in
the meta-analysis. Ovarian stimulation protocols included, clomiphene citrate
alone, clomiphene citrate + human menopausal gonadotropin, gonadotropins
without GnRHa, and gonadotropins with GnRHa. In most trials, oocytes were
retrieved transvaginally using ultrasound guidance; in some of the older studies
oocytes were retrieved via laparoscopy. In the majority of trials, the method of
assisted reproduction was in vitro fertilization (IVF) or intracytoplasmic sperm
injection (ICSI), but gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT) were used in some cycles. The trials were assessed for
validity and were ranked methodologically as fair, with an average score of 10
out of a maximum of 21 (19).
The luteal phase support regimens were highly varied. HCG was administered intramuscularly or subcutaneously, two to four times over the luteal
phase in doses ranging from 1,000 IU to 5,000 IU. Progesterone was usually
administered daily via intramuscular, vaginal (in cream, micronized form, pessaries, gel or ring formats), or oral routes. In addition, in some studies both
progesterone and HCG were administered concurrently.
The 59 included trials involved 80 comparisons in which clinical pregnancy
per transfer was the outcome. The result for the different treatment comparisons
are shown in gure 1 for trials in which GnRHa was not used, and in gure 2
for trials in which GnRHa was used.
Altogether, there were 15 trials (1931 cases) in which either progesterone
or HCG use was compared with placebo or no treatment. Pooling these results
gave an overall OR of 1.34 (95% CI 1.06 to 1.69), with an absolute increase in
pregnancy rate with luteal phase support of 5% (95% CI 1% to 8%). In eight
trials without GnRHa (860 cases), the OR for clinical pregnancy was 1.34
(95% CI 0.95 to 1.88), with an increase in pregnancy rate with luteal phase
support of 5% (95% CI -1 to 10). In seven trials with GnRHa (1071 cases), the
OR for clinical pregnancy was 1.35 (95% CI 0.98 to 1.85), with an increase
in pregnancy rate with luteal phase support of 5% (95% CI 0 to 9); however,
there was signicant statistical heterogeneity in treatment effect within this
subgroup. Thus, the pooled evidence evaluated in this manner demonstrates a
benecial effect for luteal phase support.
The trials evaluating the use of hCG (when compared with placebo or no
treatment) show a statistically signicantly higher clinical pregnancy rate per
cycle reaching embryo/gamete transfer only when GnRHa is used. When ongoing pregnancies were assessed, the effect of HCG support was also statistically
signicant (OR 1.94, 95% CI 1.32 to 4.29) (19). However, this effect was ob-
295
served only in the two trials in which GnRHa was used. Unfortunately, the risk
of developing OHSS with this approach is signicantly higher in cycles using
GnRHa, with a twenty-fold increase in odds of OHSS compared to no treatment
or placebo. The data from non-GnRHa cycles are insufciently persuasive to
allow any denitive conclusions to be drawn on the risk of OHSS.
Progesterone administration in the luteal phase resulted in an increase in the
odds of clinical pregnancy compared to placebo/no treatment in non-GnRHa
cycles; the effect in GnRHa cycles was in the same direction but was not
statistically signicant unless the data from these two groups were combined
(OR 1.34, 95% CI 1.01 to 1.79) (19).
Figure 1: Common odds ratios for clinical pregnancy per transfer

for subgroup analyses based on type of luteal phase support used in
cycles with no GnRHa down-regulation. In the Treatments Compared
column, the comparisons are shown in experimental versus control
pairings.
There is no evidence of any signicant difference between progesterone and
hCG or between progesterone and progesterone plus hCG with respect to rates
of pregnancy, but the odds of OHSS with progesterone alone are less than half
that with treatments involving hCG (19). This effect was most noticeable when
GnRHa was used. Further, there is no evidence that the addition of estrogen to
progesterone for luteal phase support improves outcomes with assisted reproduction. Finally, there is not yet sufcient evidence to conclude that the oral
route of progesterone administration is not as efcacious as the intramuscular
or vaginal routes, or that the vaginal route is inferior to the intramuscular route.
296
There is no evidence of a difference in efcacy between vaginal progesterone

gel and other types of progesterone administered vaginally.
Although luteal phase support in assisted reproduction is benecial, there
have been few efcacy studies of progesterone use for this purpose when
GnRHa was used for down-regulation of the pituitary gland. Future research
in luteal phase support should be directed to address the issues of the ideal dose,
route of administration, and duration of use of progesterone, and to determine
when in pregnancy luteal phase support can safely be discontinued.
Luteal phase support with GnRH antagonist use

The recent introduction of the GnRH antagonist has provided an alternative
method of preventing the premature LH surge that is potentially more efcient than the GnRH agonist. Its use in assisted reproduction for a signicantly
shorter duration in the treatment cycle and the rapid reversal of its effect when
discontinued are clinically useful features of its action.
Figure 2: Common odds ratios for clinical pregnancy per transfer for
subgroup analyses based on type of luteal phase support used in cycles
with GnRHa down-regulation. In the Treatments Compared column,
the comparisons are shown in experimental versus control pairings.
However, its effect on the corpus luteum needs to be better studied to determine whether luteal phase support is necessary when it is used. One study
297
showed that, in the absence of luteal phase support in a treatment cycle using
a GnRH antagonist, the area under the curve for progesterone was suboptimal
and luteolysis began prematurely (20). Thus the issue of luteal phase support in
assisted reproduction when a GnRH antagonist is used needs further investigation.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Centres for Disease Control. Assisted Reproductive Technology Success Rates 2001. http://
www.cdc.gov/reproductivehealth/ART01/section2a.htm. Accessed on Feb. 18, 2004.
The European IVF-Monitoring Programme (EIM) for the European Society of Human
Reproduction and Embryology. Report prepared by A. Nyboe Andersen, L.Gianaroli and
K.G.Nygren. Assisted reproductive technology in Europe, 2000. Results generated from
European registers by ESHRE. Human Reproduction. 2004;19: Advance Access Online, accessed Feb. 18, 2004.
Daya S. Ovulation induction for corpus luteum deciency. Seminars in Reproductive
Endocrinology 1990; 8: 156-165.
Van der Wiele RL, Bogumil J, Dyrenfurth I, Ferin M, Jewelewicz R, Warren M et al. Mechanisms regulating the menstrual cycle in women. Recent Progress in Hormone Research 1970;
26: 63-103.
Hanson FW, Powell JE, Stevens VC. Effects of hCG and human pituitary LH on steroid secretion and functional life of the human corpus luteum. Journal of Clinical Endocrinology and
Metabolism 1971; 24: 606-615.
Garcia J, Jones C, Acosta A, Wright G. Corpus luteum function after follicle aspiration for
oocyte retrieval. Fertility and Sterility 1981; 36: 565-572.
Frydman R, Testart J, Giacomini P, Imbert MC, Martin E, Nahoul K. Hormonal and histological
study of the luteal phase in women following aspiration of the preovulatory follicle. Fertility
and Sterility 1982; 38: 312-317.
Kreitmann O, Nixon WE, Hodgen GD. Induced corpus luteum dysfunction after aspiration of
preovulatory follicles in monkeys. Fertility and Sterility 1981; 35: 671-675.
Vargyas JM, Kletzly OA, Marrs RP. The effect of laparoscopic follicular aspiration on ovarian
steroidogenesis during the early preimplantation period. Fertility and Sterility 1986; 45: 221225.
Broekmans F, Bernardus R, Berhout G, Schoenmaker J. Pituitary and ovarian suppression
after early follicular and mid-luteal administration of LHRH agonist in a depot formulation:
decapeptyl CR. Gynecological Endocrinology 1992; 6: 153-161.
Smitz J, Devroey P, Camus M, Deschacht J, Khan I, Staessen C et al. The luteal phase and
early pregnancy after combined GnRH-agonist/HMG treatment for superovulation in IVF or
GIFT. Human Reproduction 1988; 5: 585-590.
Calogero AE, Macchi M, Montanini V, Mongioi A, Maugeri G, Vicar E et al. Dynamics of
plasma gonadotrophin and sex steroid release in polycystic ovarian disease after pituitaryovarian inhibition with an analog of gonadotrophin-releasing hormone. Journal of Clinical
Endocrinology and Metabolism 1987; 64: 980-985.
Kubik CJ. Luteal phase dysfunction following ovulation induction. Seminars in Reproductive
Endocrinology 1986; 4: 293-299.
Pellicer A, Miro F. Steroidogenesis in vitro of human granulosa luteal cells pretreated in vivo
with gonadotropin-releasing hormone analogs. Fertility and Sterility 1990; 54: 590-596.
298
15.
16.
17.
18.
19.
20.

Smitz J, Bourgain C, Devroey P, Camus M, Wisanto A, Van Steirteghem AC. The luteal
phase after GnRH analogues-HMG or clomiphene-HMG superovulation: endocrinology
and endometrial morphology. In: Calaf Alsina J, editor(s). GnRH y Analogos en Medicina
Reproductiva. Barcelona: Espaxs SA, Hoechst Iberica SA, 1990:163-168.
Macklon NS, Fauser BCJM. Impact of ovarian hyperstimulation on the luteal phase. Journal
of Reproduction and Fertility 2000; 55 (Suppl): 101-8.
Lenton EA. Pituitary and ovarian hormones in implantation and early pregnancy. In: Chapman
N, Grudzinskas G, Chard T (eds): Implantation: Biological and Clinical Aspects. London:
Springer-Verlag, 1988: 17.
Csapo AI, Pulkkinen MO, Wiest WG. Effects of lutectomy and progesterone replacement
therapy in early pregnant patients. Am J Obstet Gynecol 1973; 115: 759-765.
Daya S, Gunby J. Luteal phase support in assisted reproduction cycles. The Cochrane
Database of Systematic Reviews 2004, Issue 3. Art. No.: CD004830. DOI: 10.1002/14651858.
CD004830.
Beckers NG, Macklon NS, Eijkemans MJ, Ludwig M, Felberbaum RE, Diedrich K, et al.
Non-supplemented luteal phase characteristics after the administration of recombinant human
chorionic gonadotropin, recombinant luteinizing hormone, or gonadotropin-releasing hormone
(GnRH) agonist to induce nal oocyte maturation in in vitro fertilization patients after ovarian
stimulation with recombinant follicle stimulating hormone and GnRH antagonist cotreatment.
J Clin Endocrinol Metab 2003; 88: 4186-4192.
299
New technology and techniques

Virtual Hysteroscopy
to Submucosal Myomas
Keiichi Isaka
M.D. Department of Obstetrics and Gynecology,
Tokyo Medical University Hospital, Japan
E-mail: eda@pc4.so-net.ne.jp
Introduction
Advances in computer processing in recent years have been associated with
remarkable improvements in image processing technology, and it is now possible to use computed tomography (CT) and magnetic resonance imaging
(MRI) data to obtain 3-dimensional images of hollow tubular organs. Virtual
endoscopy (VE) is a type of viewer system that makes it possible to display
3-dimensional reconstructions of bodily structures by real-time imaging, and
by placing the vantage point inside of the object that has the 3-dimensional
structure and displaying it at visual angles close to those of actual endoscopy,
it enables diagnosis that takes advantage of the clinical experience gained from
endoscopic examinations.
There have been numerous reports of its usefulness in relation to clinical
applications in various elds 1~4. Among other things its imaging ability has
been dramatically improved by the advent of the revolutionary multidetectorrow CT (MDCT) in the direction of the long axis of body, and VE is expected
to take its place as a screening method in a variety of elds.
In the gynecological eld, although the uterus has a hollow tubular structure,
there have been no reports of virtual hysteroscopy (VH), and detailed examinations of the uterine cavity are for the most part being performed by optical
endoscopy. Nevertheless, naturally VH imaging can be achieved by expanding
the uterine cavity, and there is strong expectation that it will be applied clini-
300
cally in the eld of gynecology in the future. In the present study we succeeded
in obtaining virtual hysteroscopic images in patients with submucosal myomas
by expanding the uterine cavity and imaging it by the CO2-MDCT we devised,
and we compared them with the actual optical endoscopic ndings and assessed
the usefulness of VH and its clinical applications in the eld of gynecology.
Subjects and Methods

The subjects of the study were 39 patients (mean age: 28.2 years) who had
been diagnosed with submucosal myomas by transvaginal ultrasonography in
the Department of Obstetrics and Gynecology of Tokyo Medical University
Hospital between February 2003 and September 2004 and later treated by hysteroscopic surgery. After obtaining informed consent from all of the patients,
imaging by CO2-MDCT was performed preoperatively, and a hysteroscopic examination was performed at the same time. The examinations were performed
immediately after the end of the patients menses.
A LightSpeed MDCT machine equipped with 8 rows of detectors was used,
and the image acquisition conditions were: tube voltage, 120 Kv; tube current,
286 mA; eld of view (FOV), 30 cm; detector width, 2.5 mm; helical pitch,
0.875:1; acquisition time, 7 sec; exposure dose, 333 mGy. Non-ionic contrast
medium iopamidor 100ml was rapidly infused into a vein on the dorsum of
the hand at a rate of 2.5 ml/sec, and images were acquired in two phases: an
arterial dominant phase (40 sec), and a late phase (90 sec). In the CO2-MDCT
we devised CO2 gas was manually introduced with a balloon catheter inserted
into the uterine cavity before imaging, and the images were acquired with the
uterine cavity in the expanded state. The volume of CO2 introduced ranged
from 6 ml to 35 ml (mean: 15.4 ml). The 2-dimensional transverse images were
transmitted to an Advantage Workstation Ver. 4, and the VE images were created by the surface rendering method. Multiplanar reconstruction (MPR) was
also performed from the images obtained at the same time, and interpretation
in any plane desired was also performed. For external evaluation of the uterine
cavity we used MPR obtained in the arterial dominant phase when the contrast
between the myoma and the myometrium was clear, and we used the late phase
images, in which the myoma enhancement effect was strong, to produce the
VH images. The site of origin, size, and degree of protrusion of the myomas
protruding into the uterine cavity and the thickness of the normal myometrium
thinned by the myomas were interpreted by VH and MPR and assessed in
comparison with the intrauterine ndings observed by actual hysteroscopy.
301
Results
The normal myometrium is rapidly enhanced in the images obtained by CO2MDCT immediately after enhancement, whereas the enhancement effect of the
myoma is weak and homogeneous, and the images show good contrast of both.
Expansion of the uterine cavity by intrauterine introduction of the CO2 gas was
extremely favorable, and the size, site of origin, and degree of protrusion of the
submucosal myomas were all clearly visualized. However, they included cases
in which it was difcult to identify the site of origin by the observations during
hysteroscopy because the expandability of the uterine cavity was poor.
Figure 1: A submucosal myoma with 70% protrusion in the uterine

fundus and the left and right fallopian tubes are clearly visualized
by VH (1-a,b). These ndings are consistent with those observed by
hysteroscopy (1-c). A submucosal myoma is seen in the fundus in the
late-phase sagittal MPR image (1-d).
302
With VH (Figure 1-a,b) in the case shown in Figure 1, expandability of

the uterine cavity was good, a submucosal myoma originating in the uterine
fundus that protruded 70% and the fallopian tubes on both sides were clearly
visualized and matched the imaging by hysteroscopy (Figure 1-c).
Because VH enables multidirectional display and access to areas that are
impossible to observe by actual hysteroscopy, it allows the uterine cavity to
be observed from any angle of view even under conditions in which the endoscope insertion path is narrowed and cannot be advanced any further. Several
submucosal myomas are present in the cavity in the case shown in Figure 2,
and while the area of observation with the exible endoscope is limited, VH
allowed observation of the uterine cavity from the fundus, and more detailed
information could be obtained (Figure 2-a,b).
Figure 2: Multiple primary submucosal myomas are visualized by VH,

and it is possible to observe the uterine cavity from a vantage point inside the uterus (2-a,b). The expandability of the uterine cavity is good
in the MPR sagittal (3-c) and coronal (3-d) late-phase images.
303
Discussion
The advent of MDCT has brought about dramatic changes in CT, and diagnostic imaging itself is about to undergo major changes. MDCT machines
have multiple detectors in the direction of the long axis of body, which allows
marked improvement in spatial and temporal resolution, and images on any
plane desired with a degree of spatial resolution equivalent to transverse images
and 3-dimensional images capable of being used for diagnostic purposes can be
obtained. In recent years there have been numerous reports on the usefulness
of VE, which displays the lining of hollow tubular organs from a vantage point
inside the cavity of organs with a hollow tubular structure, but there had been
no reports of VH, and intrauterine lesions are currently being evaluated by
hysteroscopy. The CO2-MDCT we devised uses a method in which imaging is
performed after expanding the uterus by introducing CO2 gas into the uterine
cavity when performing the MRI diagnosis reported by Akaeda et al 5. Lesions
in the uterine cavity were clearly visualized by this method, and it made virtual
hysteroscopic imaging possible. Determining conditions in the uterine cavity
preoperatively is also important from a safety standpoint, that is, in terms of
deciding on the indications for hysteroscopic surgery and performing operations suited to the technical skill of the surgeon. Since the difculty of surgery
on submucosal myomas, in particular, varies greatly depending on their site
of origin and degree of protrusion, conditions in the uterine cavity must accurately be determined before operating. The degree of protrusion of submucosal
myomas has conventionally been evaluated by MRI, transvaginal ultrasound
tomography, sonohysterography, and hysteroscopy, but adequately reproducible imaging cannot be said to have been obtained by these techniques alone.
Since interpreters have been making diagnoses by reconstructing 2-dimensional images into 3-dimensional images in their heads, if 3-dimensional image
information could be obtained, the diagnostic process would become simpler,
the inter-interpreter differences would become smaller, and reproducible image
information would be obtained. Since the expandability of the uterine cavity is
better with VH imaging obtained by CO2-MDCT than with hysteroscopy, and it
is easier to identify the site of origin of submucosal myomas with a high degree
of protrusion that lls the inside of the uterus and external evaluation of the
uterine cavity by MPR is also possible, CO2-MDCT appeared to be extremely
useful as a preoperative method of evaluation for submucosal myomas.
304
References
1.
2.
3.
4.
5.
Bhandari S, Sup Shim C, Hoon Kim J, Seop Jung I, Young Cho J, Seong Lee J, Sung Lee M,
Sung Kim B: Usefulness of three-dimensional, multidetector row CT (virtual gastroscopy and
multiplanar reconstruction) in the evaluation of gastric cancer: A comparison with conventional endoscopy, EUS, and histopathology. Gastrointest Endosc 2004, 59(6):619-26.
Rollins G: Virtual colonoscopy is as effective as conventional colonoscopy for screening average-risk patients. Rep Med Guidel Outcomes Res 2004, 15(1):1-2, 6-7.
Moorjani N, Conn G, Rahamim JS, Ring NJ: Virtual bronchoscopy and 3D spiral CT reconstructions in the management of kyphosis induced tracheal compression. Thorax 2004,
59(3):272.
Wang D, Zhang WS, Xiong MH, Yu M, Xu JX: Bladder tumors: dynamic contrast-enhanced
axial imaging, multiplanar reformation, three-dimensional reconstruction and virtual cystoscopy using helical CT. Chin Med J (Engl) 2004, 117(1):62-6.
Akaeda T, Isaka K, Kakizaki D, Abe K, Takayama M: Evaluation of endometrial cancer with
3D-VIBE (volume interpolated breath-hold examination) using intrauterine CO 2 gas. Magn
Reson Imaging. 2002, 20(7):551-56.
305
Immune testing in fertility practice:

truth or deception?
Caleb Kallen, MD, PhD and Aydin Arici, MD
Section of Reproductive Endocrinology and Infertility, Department of Obstetrics,
Gynecology & Reproductive Sciences, Yale University School of Medicine,
New Haven, Connecticut, USA
Abstract
A great deal of recent attention has been paid to the role that immunology
may play in reproductive success or failure. Every step in the establishment of
normal pregnancy has been implicated as a possible site of immune-mediated
reproductive failure. To this end, widespread testing of antiphospholipid, antinuclear, antithyroid, and antisperm antibodies, as well as generalized immune
testing (i.e. immunophenotyping and natural killer cell proling) have been employed to diagnose patients with otherwise unexplained infertility or recurrent
pregnancy loss. We review the controversial data surrounding the widespread
and highly variable use of immune testing in current fertility practice with a
view to delineating which, if any, testing is warranted based on sound scientic
evidence. Because it is postulated that early miscarriage, when occult, could
represent a failure of embryo implantation that may be indistinguishable from
unexplained infertility, our analysis of immune testing in clinical practice will
include some discussion pertaining to patients with recurrent early pregnancy
loss. While there is increased prevalence of abnormal immune testing associated with early reproductive failure, the most rigorous studies to date have been
unable to prove a cause and effect between these phenomena. Further, there
is wide variation, and great inconsistency, regarding this association, depending upon which test(s) are employed, the study methodology, and the patient
population being studied. Little certainty has been established regarding the
306
signicance of selected immunological test abnormalities and early reproductive failure. In summary, great variability exists in identifying patients who
are candidates for immune testing, in determining which immunological tests
to perform, what criteria to utilize in distinguishing normal from abnormal
test values, and which treatments to offer based upon the acquired results.
This review argues that the strongest data in the eld of immune-mediated
reproductive failure do not support the use of widespread immune testing in
clinical practice. Therapies provoked by abnormal immunologic test results are
similarly of unproven benet and may cause harm.
Introduction
Approximately 10-15% of couples suffer from infertility, dened as unprotected
intercourse for 12 months without conception. In addition, recurrent pregnancy
loss (RPL), generally dened as three or more consecutive pregnancy losses
prior to 20 weeks gestation, may occur in as many as 2% of child-bearing
women[1,2]. A thorough evaluation of the infertile couple will demonstrate no
explanation for infertility in approximately 10% of cases, whereas the evaluation of RPL will demonstrate no cause in as many as 60% of cases. For these
couples, and the practitioners who care for them, there is strong motivation to
perform additional testing which might lead to an explanation for the unexplained infertility and guide treatment to improve the chances of successful
pregnancy.
Recent attention has focused on a myriad of immunologic tests for the
infertile couple stemming from the hypothesis that a portion of unexplained
infertility and RPL results from immune-mediated reproductive failure. The
immunologic tests purport to identify autoimmune abnormalities (i.e. antiphospholipid, antithyroid, and antisperm antibodies) or more generalized immune
defects (i.e. natural killer [NK] cell dysregulation) that are postulated to cause
reproductive failure. A substantial industry is comprised of laboratories that offer panels of immunologic tests at no small cost or inconvenience to the couple.
Meanwhile, there remains no proven role for autoimmunity, or alloimmunity,
in early reproductive failure. Precise mechanisms by which these disorders
contribute to infertility remain to be established. Further, there is considerable
variability in the methodologies utilized, the validity, and the standardization
for many of the above-mentioned tests. Similarly, the interpretation of test
results (normal, borderline, or abnormal) is inconsistent. The rationale for good
testing in clinical practice should include the ability to secure a diagnosis and
to guide clinical decision-making and treatment plan.
307
Abnormal immune testing has generated the pursuit of numerous therapies,

also of considerable cost and associated with potential risks and adverse side
effects, touted to be effective treatments for these putative immunologic causes
of reproductive failure. These therapies are designed to modulate the immune
system (i.e. glucocorticoid treatment, intravenous immunoglogulin (IVIg), and
peripheral leukocyte immunization) or to compensate for the suspected effects
of the immune defect (i.e. aspirin or heparin to reduce thrombophilia from
thrombogenic autoantibodies). Signicant concern is warranted regarding the
level of evidence supporting the use of these treatments for reproductive failure. Given the lack of strong scientic proof of meaningful association between
abnormal immune testing and adverse reproductive outcome, it is not surprising that the efcacy of commonly offered treatments is similarly uncertain.
The anticardiolipin antibody, lupus anticoagulant,

and infertility
The association of antiphospholipid antibodies (APA) with recurrent pregnancy loss[3-8], particularly anticardiolipin abtibodies (ACA) and the lupus
anticoagulant (LAC), led investigators to explore a role for such antibodies in
unexplained infertility. The thrombogenic nature of these antibodies has been
postulated to interfere with implantation, placentation, and normal vascular
perfusion of the developing embryo, this, despite evidence that women with
the full-blown antiphospholipid antibody syndrome do not demonstrate impairment in conception and generally experience pregnancy loss after 10 weeks of
gestation [9,10].
Determining the true prevalence of APA, both in control populations and
in patients who have experienced RPL or infertility, has been daunting. Data
from heterogeneous sources must be interpreted based on the numbers of autoantibodies tested, availability of assay controls, use of non-standardized test
modalities, patient inclusion criteria, and range selected to distinguish normal
from abnormal test values. To this end, great disparity has been reported on
what constitutes normal versus abnormal testing and what represents the true
prevalence of excess autoantibody in the fertile population when compared to
patients with reproductive failure. The prevalence of serum antiphospholipid
antibody in the general population has been reported to be 1-3% [11,12].
Taylor et al. compared 41 infertile patients with 80 normal pregnant women
and reported a signicant increase in ACA in the infertile patients (17%) versus
the control group (6%) [13]. Roussev et al. reported an incidence of phospholipid antibodies of 42% in 45 patients with unexplained infertility, as compared
308
to 7% in 15 healthy, nonpregnant controls [14]. When restricting analysis to

fertility patients being treated with in vitro fertilization (IVF), the prevalence
of phospholipid antibodies was consistently higher (6-38%) than in control
populations (when available) comprised of normal parous women (highest
prevalence 3.5%) [15-18]. In an uncontrolled analysis of 105 IVF patients,
Gleicher et al. tested 15 separate autoantibodies for three isotypes (IgG, IgM
and IgA) and reported a 25% and 30% incidence of positive autoantibody, in
high and low responders to IVF, respectively [19]. The specic identities of the
abnormal antibodies were not included in the presented data.
The consistent observation has been an increased prevalence of phospholipid
antibodies in the infertile population, especially demonstrated in IVF patients.
The essential question has been whether these autoantibodies cause infertility
(or IVF failure), or simply represent serum markers associated with infertility.
The question has been met with great controversy in the literature[20-22]. There
do not exist large, well-powered, randomized, controlled, prospective studies to
establish that the presence of phospholipid antibodies causes infertility.
As to the question of whether phospholipid antibodies affect IFV success
rates, there appears to be greater consensus. While the initial data by Sher. et
al. suggested that anticoagulation improved IVF outcomes in APA positive
patients, the study was not randomized and was poorly controlled [23]. Two
studies with small sample sizes conrmed the association between positive
APA and IVF failure [24,25]. By contrast, Gleicher et al. studied 105 IVF
patients in a blinded study and found that 27.6% tested positive for at least
one of several autoantibodies, none of which affected pregnancy rates or rate
of miscarriage [19]. Similar ndings were subsequently reported by several
groups [16-18,26-30]. Taken together, the data suggest that the presence of
phospholipid antibodies does not adversely affect IFV cycle outcome, consistent with the committee opinion of the American Society for Reproductive
Medicine in 1999 [31].
Apart from patients with recurrent pregnancy loss, which is clearly associated with elevated ACA and LAC, and where treatment may demonstrate
benet [32-34], the use of antiphospholipid antibody testing in fertility practice
can not be supported by current data and there is insufcient data to support
treatment of positive antibody status in assisted reproductive technologies.
Other antiphospholipid antibodies and infertility

A search for antibodies against other phospholipids that might be implicated in
reproductive failure has also been pursued. These studies have been difcult to
309
interpret given the lack of standardization in the assays employed. It remains

clear that the more testing that one performs on a given population, the more
one is likely to discover an abnormal test value.
In a recent prevalence study, Stern et al. found increased levels of anti2-glycoprotein I IgM (anti-2-GPI, also known as apolipoprotein H), an
anticardiolipin cofactor, in 105 patients with a history of failed IVF when
compared to 106 fertile control patients [35]. Levels of antibody to phosphatidyl inositol, phosphatidyl serine, and phosphatidyl ethanolamine were the
same in fertile controls and patients with failed cycles of IVF. Interestingly,
this same group did not nd a difference in prevalence for any antibody
when comparing fertile controls to new IVF patients, nor did they conrm
increased elevated levels of LAC or ACA in their population of patients
with history of RPL.
By contrast, Balasch et al. found no increased prevalence of anti-2-GPI
antibody in patients with a history neither of failed IVF, nor for RPL patients
with a history of negative testing for ACA and LAC by conventional laboratory
methods. The group did nd elevated levels of anti-2-GPI in RPL patients
with positive tests for LAC and ACA [36]. They concluded that testing for anti2-GPI antibody has no predictive value for patients with RPL or failed IVF if
the patients test negative in standard ACA and LAC testing. Denis et al. tested
IVF patients prospectively for ACA, LAC, and antibodies for phosphatidyl
inositol, phosphatidyl serine, phosphatidyl ethanolamine, phosphatidic acid,
and phosphatidyl choline [27]. They found no association between elevated
antiphospholipid antibody levels and pregnancy rates through IVF. Similar
results were noted by Chilcott et al. who tested IVF patients for LAC, ACA,
anti-phosphatidyl serine and anti-2-GPI antibodies [29], by Eldar-Geva et
al. who tested for three antibody isotypes against each of six phospholipids
[18], and by Kowalik et al. who tested for ACA and anti-phosphatidyl serine
antibodies in IVF patients [28].
To date, there is insufcient prospective, randomized, data to document
causation between various antiphospholipid antibodies and infertility or failed
IVF and insufcient data to support treatment of fertility patients who test
positive for these antibodies.
Antithyroid antibodies and infertility

Several groups have shown that increased levels of anti-thyroid antibodies
(anti-thyroid peroxidase (anti-TPO) and/or anti-thyroglobulin (anti-TG) antibodies) are associated with recurrent pregnancy loss in clinically euthyroid
310
patients [37-40], while other investigators have not[41,42]. Hollowell et al.

recently demonstrated that the prevalence of these antibodies increases with
age, and reaches approximately 7-18% for anti-TPO and 7-16% for anti-TG in
reproductive aged women [43]. The relationship between these autoantibodies
and infertility is disputed.
Sher et al. performed a small (n=82) comparison study without a placebo
group and concluded that the addition of IVIg to heparin and aspirin improved
IVF success rates in women with positive anti-TPO or anti-TG antibodies
[44]. Geva et al. demonstrated increased antithyroid antibodies in infertile
patients with both unexplained infertility (20% positive) and tubal obstruction
(17.5% positive) when compared to healthy nulligravid controls (5%), although, again, the numbers were small (n=120) [45]. In a larger trial (n=700),
Kutteh et al. demonstrated a statistical difference in antithyroid antibody
levels between control patients (14.5%) and patients with RPL (22.5%), but
not patients undergoing fertility treatments (19.2%) [38]. Pregnancy outcomes
were subsequently followed in 873 women undergoing IVF, 16.4% of whom
tested positive for antithyroid antibodies[46]. No difference was found in
pregnancy outcome between patients with and without the antithyroid antibodies, regardless of antibody titer. There is currently no compelling data to
support the use of antithyroid antibody testing in women undergoing assisted
reproduction.
Other autoantibodies and infertility

Associations have been sought between additional autoantibodies and infertility based on theories postulating that any impairment in maternal immune function might ultimately preclude implantation or produce rejection of the partly
allogeneic embryo transplant. Several studies have looked at antinuclear and
anti-smooth muscle antibodies and reported increased levels associated with
infertile patients [13,47] (although not always of statistical signicance) and
poor IVF outcomes in antibody positive patients [24,25,35,48,49]. Successful
treatment (aspirin and/or prednisone) of patients with positive antibody status
have been reported in small and generally poorly controlled studies [50,51].
The small numbers studied, and the great variability in values obtained, preclude any strong conclusions to be rendered from these observations. There is
no compelling evidence that testing for antinuclear and anti-smooth muscle
antibodies in routine clinical practice is relevant to the diagnosis or treatment
of otherwise unexplained infertility.
311
Antisperm antibodies and infertility

The question of whether antibodies bound to spermatozoa can cause infertility is still debated. Such antibodies can be found in both partners and may be
present systemically, in the blood, and locally, in the seminal uid and cervical
mucus. In men, the autoantibodies are felt to be generated after some disruption
of the blood-testis barrier (i.e. testicular torsion, trauma, infection, or surgery
such as vasectomy). In some women, exposure to sperm antigens is similarly
felt to produce an isoimmune response. The presence of antibody on sperm tails
has been reported to interfere with sperm motility and penetration of cervical
mucus [52,53], whereas antibody on sperm heads has been implicated in impaired sperm fertilizing potential [54-58], and embryo development [59].
Kutteh, in a recent review on the role of antisperm antibodies (ASA) in infertility, delineated several questions that remain to be answered: which method
of ASA testing is best, which isotypes (IgM, IgA, or IgG) are most relevant
to infertility, what levels of ASA are signicant, which locations of ASA on
spermatozoa are important, and what is the best method to treat ASA-related
sub-fertility [60]. The World Health Organization guidelines of 1992 maintain
that binding of IgG or IgA to >50% sperm is of probable clinical signicance
[61].
There is general agreement that the mere presence of ASA, even when in
high titer, in the absence of additional causes of infertility, does not generally
cause complete infertility. More likely, high antibody titers may produce impaired fertility. Thus, while the strongest data support a role for IgA in inhibiting
sperm migration to the oocyte, and for both IgA and IgG isotypes in impairing
sperm-ovum interaction, neither mechanism of action appears to produce sterility. While many studies have looked at the effect of ASA on fertilization rates
in IVF[62-65], the majority were not prospective studies, with small numbers
of patients, and many were controlled sub-optimally using prior cycle history
as control group. There remains controversy as to whether, and to what extent,
positive antibody status reduces IVF fertilization rates.
Proposed treatments have included washing sperm, with or without enzymatic treatment, to remove sperm antibodies [66-69], corticosteroids to suppress
antibody production [70-73], intrauterine insemination (IUI), IVF [65,74,75],
and IVF with ICSI [76-78].
There remains no immunologic test that is capable of precluding sperm
fertilizing potential and no consensus on the clinical consequences of antisperm
antibodies. The efcacy of corticosteroids to reduce antisperm antibodies has
not been clearly proven to improve pregnancy rates with, or without, assisted
312
reproduction. Moreover, there are legitimate concerns about the safety of corticosteroid use for this indication, and some data to support that indiscriminate
use of corticosteroids in the infertile patient population may reduce fertility
for some patients [70]. The utility of antisperm testing in fertility practice appears to be of little value in light of the most recent data that demonstrate good
success rates and general safety with a stepwise and empiric approach to male
factor infertility: IUI, followed by IVF, followed by ICSI [79].
Leukocyte testing (immunophenotyping) and infertility

Initiated from research in the eld of recurrent pregnancy loss, an interest
developed regarding a role for NK cells in infertility. NK cells mediate nonmajor histocompatibility complex (MHC) -restricted cytotoxicity of target
cells and, when present in the uterine decidua, have been proposed to play an
important role in implantation and development of the allogeneic embryo. The
controversial theory begins with the proposition that women with RPL have
elevated levels of peripheral CD56 positive NK-cell activity [80], contrary to
what is observed in normal pregnant women [81]. The theory further postulates
that suppression of excess NK cell activity, using peripheral leukocyte infusion
therapy (paternal or third party), glucocorticoid therapy, or IVIg, serves to
promote normal embryonic development. Meanwhile, little is known about the
role of decidual NK cells in placentation or embryo development and how this
may relate to circulating levels of NK cells or their biological activity (which
varies with infection, smoking, and other dynamic factors).
A similar rationale then lead investigators to seek a role for NK cell dysregulation in infertility and failed IVF cycles. Use of ow cytometric analysis
(immunophenotyping) to assay peripheral leukocyte number and cytotoxicity
assay to determine NK cell activity were proposed as useful tests to predict
reproductive failure and guide immunotherapy treatment and response.
Great controversy has surrounded the question of whether or not leukocyte immunotherapy is effective treatment for RPL. Early data, excluding the
majority of studies that were neither randomized nor controlled, suggested
benet from this treatment [82-84]. Further data has demonstrated no benet
of leukocyte immunotherapy for the prevention of RPL [85,86]. Treatment
protocols among the many studies have been quite variable. Most recently, in
the largest study performed to date with appropriate controls and randomization, Ober et al. showed no benet of leukocyte immunotherapy in improving
pregnancy outcome [87].
Immunophenotyping for the diagnosis of unexplained infertility or failed
313
IVF is without strong scientic support in the literature, nor is its application
in cases of RPL. The myriad of treatments to correct any presumed leukocyte
dysfunction are neither well-dened nor proven to be effective: not in the treatment of RPL, much less for the treatment of infertility. The clinical use of
leukocyte testing in fertility practice is not supported by current data.
Conclusions
Strong arguments have been made for biologically plausible mechanisms
whereby autoimmune or alloimmune abnormalities lead to recurrent pregnancy
loss. Much effort has extended the application of these theories to infertility, speculating that unexplained infertility may result from immune-mediated
failure of fertilization, embryo development, or implantation, or by causing
early, occult, pregnancy losses. Research efforts to substantiate theories of immune-mediated early reproductive failure have been hindered by a literature
rich in studies that are underpowered, poorly controlled, not randomized, not
prospective, not blinded, not standardized, and generally not designed to denitively answer the fundamental questions being raised. Thus, many associations
between immune dysregulation and early reproductive failure are unsubstantiated, and others are of unclear signicance to the clinician.
While there exists strong motivation, both for patients and practitioners, to
nd answers to what is otherwise unexplained, this impulse should be resisted
if it leads to the practice of medicine that is not evidence-based. Until strong
evidence for associations between immunologic abnormalities and early reproductive failure can be conrmed, and can be proven to be relevant to the pathophysiology of infertility, widespread immune testing in fertility practice can not
be recommended. In light of currently available evidence, the implementation
of therapies to correct presumed immunologic defects that are proposed to lead
to reproductive failure can not be recommended and may cause harm.
Please note that this is a copy of an article published in Current Opinion in
Obstetrics and Gynecology, Volume 15, No 3; 2003.
314
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Coulam CB. Epidemiology of recurrent spontaneous abortion. Am J Reprod Immunol. 1991;

26: 23-7.
Mills JL, Simpson JL, Driscoll SG, et al. Incidence of spontaneous abortion among normal
women and insulin-dependent diabetic women whose pregnancies were identied within 21
days of conception. N Engl J Med. 1988; 319: 1617-23.
Branch DW, Silver R, Pierangeli S, et al. Antiphospholipid antibodies other than lupus anticoagulant and anticardiolipin antibodies in women with recurrent pregnancy loss, fertile controls,
and antiphospholipid syndrome. Obstet Gynecol. 1997; 89: 549-55.
Yetman DL and Kutteh WH. Antiphospholipid antibody panels and recurrent pregnancy loss:
Prevalence of anticardiolipin antibodies compared with other antiphospholipid antibodies.
Fertil Steril. 1996; 66: 540-6.
Parke AL, Wilson D and Maier D. The prevalence of antiphospholipid antibodies in women
with recurrent spontaneous abortion, women with successful pregnancies, and women who
have never been pregnant. Arthritis Rheum. 1991; 34: 1231-5.
Gleicher N, el-Roeiy A, Conno E and Friberg J. Reproductive failure because of autoantibodies: Unexplained infertility and pregnancy wastage. Am J Obstet Gynecol. 1989; 160: 1376-80;
discussion 1380-5.
Petri M, Golbus M, Anderson R, et al. Antinuclear antibody, lupus anticoagulant, and anticardiolipin antibody in women with idiopathic habitual abortion. A controlled, prospective study
of forty-four women. Arthritis Rheum. 1987; 30: 601-6.
Cowchock S, Smith JB and Gocial B. Antibodies to phospholipids and nuclear antigens in
patients with repeated abortions. Am J Obstet Gynecol. 1986; 155: 1002-10.
Rai RS, Clifford K, Cohen H and Regan L. High prospective fetal loss rate in untreated pregnancies of women with recurrent miscarriage and antiphospholipid antibodies. Hum Reprod.
1995; 10: 3301-4.
Oshiro BT, Silver RM, Scott JR, et al. Antiphospholipid antibodies and fetal death. Obstet
Gynecol. 1996; 87: 489-93.
Lockwood CJ, Romero R, Feinberg RF, et al. The prevalence and biologic signicance of
lupus anticoagulant and anticardiolipin antibodies in a general obstetric population. Am J
Obstet Gynecol. 1989; 161: 369-73.
el-Roeiy A and Gleicher N. Denition of normal autoantibody levels in an apparently healthy
population. Obstet Gynecol. 1988; 72: 596-602.
Taylor PV, Campbell JM and Scott JS. Presence of autoantibodies in women with unexplained
infertility. Am J Obstet Gynecol. 1989; 161: 377-9.
Roussev RG, Kaider BD, Price DE and Coulam CB. Laboratory evaluation of women experiencing reproductive failure. Am J Reprod Immunol. 1996; 35: 415-20.
el-Roeiy A, Gleicher N, Friberg J, et al. Correlation between peripheral blood and follicular
uid autoantibodies and impact on in vitro fertilization. Obstet Gynecol. 1987; 70: 163-70.
Birdsall MA, Lockwood GM, Ledger WL, et al. Antiphospholipid antibodies in women having
in-vitro fertilization. Hum Reprod. 1996; 11: 1185-9.
Kutteh WH, Yetman DL, Chantilis SJ and Crain J. Effect of antiphospholipid antibodies in
women undergoing in-vitro fertilization: Role of heparin and aspirin. Hum Reprod. 1997; 12:
1171-5.
Eldar-Geva T, Wood C, Lolatgis N, et al. Cumulative pregnancy and live birth rates in women
with antiphospholipid antibodies undergoing assisted reproduction. Hum Reprod. 1999; 14:
1461-6.
Gleicher N, Liu HC, Dudkiewicz A, et al. Autoantibody proles and immunoglobulin levels
315
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
as predictors of in vitro fertilization success. Am J Obstet Gynecol. 1994; 170: 1145-9.

Hornstein MD. Antiphospholipid antibodies in patients undergoing ivf: The data do not support
testing. Fertil Steril. 2000; 74: 635-6.
A rational basis for antiphospholipid antibody testing and selective immunotherapy in assisted
reproduction: A rebuttal to the american society for reproductive medicine practice opinion.
American society for reproductive immunology antiphospholipid antibody committee. Fertil
Steril. 2000; 74: 631-4.
Hill JA and Scott RT. Immunologic tests and ivf: "please, enough already". Fertil Steril. 2000;
74: 439-42.
Sher G, Feinman M, Zouves C, et al. High fecundity rates following in-vitro fertilization and
embryo transfer in antiphospholipid antibody seropositive women treated with heparin and
aspirin. Hum Reprod. 1994; 9: 2278-83.
Birkenfeld A, Mukaida T, Minichiello L, et al. Incidence of autoimmune antibodies in failed
embryo transfer cycles. Am J Reprod Immunol. 1994; 31: 65-8.
Geva E, Yaron Y, Lessing JB, et al. Circulating autoimmune antibodies may be responsible for
implantation failure in in vitro fertilization. Fertil Steril. 1994; 62: 802-6.
Balasch J, Creus M, Fabregues F, et al. Antiphospholipid antibodies and human reproductive
failure. Hum Reprod. 1996; 11: 2310-5.
Denis AL, Guido M, Adler RD, et al. Antiphospholipid antibodies and pregnancy rates and
outcome in in vitro fertilization patients. Fertil Steril. 1997; 67: 1084-90.
Kowalik A, Vichnin M, Liu HC, et al. Midfollicular anticardiolipin and antiphosphatidylserine
antibody titers do not correlate with in vitro fertilization outcome. Fertil Steril. 1997; 68: 298304.
Chilcott IT, Margara R, Cohen H, et al. Pregnancy outcome is not affected by antiphospholipid
antibody status in women referred for in vitro fertilization. Fertil Steril. 2000; 73: 526-30.
Hornstein MD, Davis OK, Massey JB, et al. Antiphospholipid antibodies and in vitro fertilization success: A meta-analysis. Fertil Steril. 2000; 73: 330-3.
American Society for Reproductive Medicine Practice Committee Report. Antiphospholipid
antibodies do not affect IVF success. ASRM. 1999.
Cowchock FS, Reece EA, Balaban D, et al. Repeated fetal losses associated with antiphospholipid antibodies: A collaborative randomized trial comparing prednisone with low-dose heparin
treatment. Am J Obstet Gynecol. 1992; 166: 1318-23.
Kutteh WH. Antiphospholipid antibody-associated recurrent pregnancy loss: Treatment with
heparin and low-dose aspirin is superior to low-dose aspirin alone. Am J Obstet Gynecol. 1996;
174: 1584-9.
Kutteh WH and Ermel LD. A clinical trial for the treatment of antiphospholipid antibody-associated recurrent pregnancy loss with lower dose heparin and aspirin. Am J Reprod Immunol.
1996; 35: 402-7.
Stern C, Chamley L, Hale L, et al. Antibodies to beta2 glycoprotein i are associated with in
vitro fertilization implantation failure as well as recurrent miscarriage: Results of a prevalence
study. Fertil Steril. 1998; 70: 938-44.
Balasch J, Reverter JC, Creus M, et al. Human reproductive failure is not a clinical feature
associated with beta(2) glycoprotein-i antibodies in anticardiolipin and lupus anticoagulant
seronegative patients (the antiphospholipid/cofactor syndrome). Hum Reprod. 1999; 14: 19569.
Stagnaro-Green A, Roman SH, Cobin RH, et al. Detection of at-risk pregnancy by means of
highly sensitive assays for thyroid autoantibodies. Jama. 1990; 264: 1422-5.
Kutteh WH, Yetman DL, Carr AC, et al. Increased prevalence of antithyroid antibodies identied in women with recurrent pregnancy loss but not in women undergoing assisted reproduction. Fertil Steril. 1999; 71: 843-8.
316
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.

Bussen SS and Steck T. Thyroid antibodies and their relation to antithrombin antibodies, anticardiolipin antibodies and lupus anticoagulant in women with recurrent spontaneous abortions (antithyroid, anticardiolipin and antithrombin autoantibodies and lupus anticoagulant in
habitual aborters). Eur J Obstet Gynecol Reprod Biol. 1997; 74: 139-43.
Dendrinos S, Papasteriades C, Tarassi K, et al. Thyroid autoimmunity in patients with recurrent
spontaneous miscarriages. Gynecol Endocrinol. 2000; 14: 270-4.
Esplin MS, Branch DW, Silver R and Stagnaro-Green A. Thyroid autoantibodies are not associated with recurrent pregnancy loss. Am J Obstet Gynecol. 1998; 179: 1583-6.
Rushworth FH, Backos M, Rai R, et al. Prospective pregnancy outcome in untreated recurrent
miscarriers with thyroid autoantibodies. Hum Reprod. 2000; 15: 1637-9.
Hollowell JG, Staehling NW, Flanders WD, et al. Serum TSH, T(4), and thyroid antibodies in
the united states population (1988 to 1994): National health and nutrition examination survey
(NHANES iii). J Clin Endocrinol Metab. 2002; 87: 489-99.
Sher G, Maassarani G, Zouves C, et al. The use of combined heparin/aspirin and immunoglobulin g therapy in the treatment of in vitro fertilization patients with antithyroid antibodies.
Am J Reprod Immunol. 1998; 39: 223-5.
Geva E, Lessing JB, Lerner-Geva L, et al. The presence of antithyroid antibodies in euthyroid
patients with unexplained infertility and tubal obstruction. Am J Reprod Immunol. 1997; 37:
184-6.
Kutteh WH, Schoolcraft WB and Scott RT, Jr. Antithyroid antibodies do not affect pregnancy
outcome in women undergoing assisted reproduction. Hum Reprod. 1999; 14: 2886-90.
Wilson C, Elstein M, Eade OE, et al. Smooth-muscle antibodies in infertility. Lancet. 1975;
2:1238-9.
Geva E, Amit A, Lerner-Geva L, et al. Autoimmune disorders: Another possible cause for
in-vitro fertilization and embryo transfer failure. Hum Reprod. 1995; 10: 2560-3.
Cubillos J, Lucena A, Lucena C, et al. Incidence of autoantibodies in the infertile population.
Early Pregnancy. 1997; 3: 119-24.
Geva E, Amit A, Lerner-Geva L, et al. Prednisone and aspirin improve pregnancy rate in patients with reproductive failure and autoimmune antibodies: A prospective study. Am J Reprod
Immunol. 2000; 43: 36-40.
Kim CH, Cho YK and Mok JE. The efcacy of immunotherapy in patients who underwent
superovulation with intrauterine insemination. Fertil Steril. 1996; 65: 133-8.
Kremer J and Jager S. The sperm-cervical mucus contact test: A preliminary report. Fertil
Steril. 1976; 27: 335-40.
Jager S, Kremer J, Kuiken J and van Slochteren-Draaisma T. Immunoglobulin class of antispermatozoal antibodies from infertile men and inhibition of in vitro sperm penetration into
cervical mucus. Int J Androl. 1980; 3: 1-14.
Bronson RA, Cooper GW and Rosenfeld DL. Sperm-specic isoantibodies and autoantibodies
inhibit the binding of human sperm to the human zona pellucida. Fertil Steril. 1982; 38: 7249.
Zouari R and De Almeida M. Effect of sperm-associated antibodies on human sperm ability to
bind to zona pellucida and to penetrate zona-free hamster oocytes. J Reprod Immunol. 1993;
24: 175-86.
Haas GG, Jr., Sokoloski JE and Wolf DP. The interfering effect of human igg antisperm antibodies on human sperm penetration of zona-free hamster eggs. Am J Reprod Immunol. 1980;
1: 40-3.
Clarke GN, Lopata A, McBain JC, et al. Effect of sperm antibodies in males on human in vitro
fertilization (ivf). Am J Reprod Immunol Microbiol. 1985; 8: 62-6.
Rajah SV, Parslow JM, Howell RJ and Hendry WF. The effects on in-vitro fertilization of
autoantibodies to spermatozoa in subfertile men. Hum Reprod. 1993; 8: 1079-82.
317
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
Naz RK. Effects of antisperm antibodies on early cleavage of fertilized ova. Biol Reprod. 1992;
46: 130-9.
Kutteh WH. Antisperm antibodies. Do antisperm antibodies bound to spermatozoa alter normal
reproductive function? Hum Reprod. 1999; 14: 2426-9.
World Health Organization laboratory manual for the examination of human semen and spermcervical mucus interaction. New york: Cambridge university press. 1992; 3-27.
Culligan PJ, Crane MM, Boone WR, et al. Validity and cost-effectiveness of antisperm antibody testing before in vitro fertilization. Fertil Steril. 1998; 69: 894-8.
Vazquez-Levin MH, Notrica JA and Polak de Fried E. Male immunologic infertility: Sperm
performance on in vitro fertilization. Fertil Steril. 1997; 68: 675-81.
Sukcharoen N and Keith J. The effect of the antisperm auto-antibody-bound sperm on in vitro
fertilization outcome. Andrologia. 1995; 27: 281-9.
Ford WC, Williams KM, McLaughlin EA, et al. The indirect immunobead test for seminal
antisperm antibodies and fertilization rates at in-vitro fertilization. Hum Reprod. 1996; 11:
1418-22.
Haas GG, Jr., D'Cruz OJ and Denum BM. Effect of repeated washing on sperm-bound imunoglobulin g. J Androl. 1988; 9: 190-6.
Byrd W, Kutteh WH and Carr BR. Treatment of antibody-associated sperm with media containing high serum content: A prospective trial of fertility involving men with high antisperm
antibodies following intrauterine insemination. Am J Reprod Immunol. 1994; 31: 84-90.
Kutteh WH, Kilian M, Ermel LD, et al. Antisperm antibodies (asas) in infertile males: Subclass
distribution of iga antibodies and the effect of an iga1 protease on sperm-bound antibodies.
Katsoff D, Check JH, Bollendorf A and Benfer K. Chymotrypsin-galactose treatment of sperm
with antisperm antibodies results in improved pregnancy rates following in vitro fertilization.
Shin D, Palermo GD, Goldstein M, et al. Indications for corticosteroids prior to epididymal
sperm retrieval. Int J Fertil Womens Med. 1998; 43: 165-70.
Sharma KK, Barratt CL, Pearson MJ and Cooke ID. Oral steroid therapy for subfertile males
with antisperm antibodies in the semen: Prediction of the responders. Hum Reprod. 1995; 10:
103-9.
Haas GG, Jr. and Manganiello P. A double-blind, placebo-controlled study of the use of methylprednisolone in infertile men with sperm-associated immunoglobulins. Fertil Steril. 1987;
47: 295-301.
Dondero F, Isidori A, Lenzi A, et al. Treatment and follow-up of patients with infertility due
to spermagglutinins. Fertil Steril. 1979; 31: 48-51.
Janssen HJ, Bastiaans BA, Goverde HJ, et al. Antisperm antibodies and in vitro fertilization.
J Assist Reprod Genet. 1992; 9: 345-9.
Lahteenmaki A, Rasanen M, Hovatta O. Low-dose prednisolone does not improve the outcome
of in-vitro fertilization in male immunological infertility. Hum Reprod. 1995; 10:3124-9.
Mercan R, Oehninger S, Muasher SJ, et al. Impact of fertilization history and semen parameters on icsi outcome. J Assist Reprod Genet. 1998; 15: 39-45.
Clarke GN, Bourne H and Baker HW. Intracytoplasmic sperm injection for treating infertility
associated with sperm autoimmunity. Fertil Steril. 1997; 68: 112-7.
Lahteenmaki A, Reima I and Hovatta O. Treatment of severe male immunological infertility
by intracytoplasmic sperm injection. Hum Reprod. 1995; 10: 2824-8.
Krapez JA, Hayden CJ, Rutherford AJ and Balen AH. Survey of the diagnosis and management
of antisperm antibodies. Hum Reprod. 1998; 13: 3363-7.
Aoki K, Kajiura S, Matsumoto Y, et al. Preconceptional natural-killer-cell activity as a predictor of miscarriage. Lancet. 1995; 345: 1340-2.
318
81.
82.
83.
84.
85.
86.
87.

Kwak JY, Beaman KD, Gilman-Sachs A, et al. Up-regulated expression of cd56+, cd56+/
cd16+, and cd19+ cells in peripheral blood lymphocytes in pregnant women with recurrent
pregnancy losses. Am J Reprod Immunol. 1995; 34: 93-9.
Mowbray JF, Gibbings C, Liddell H, et al. Controlled trial of treatment of recurrent spontaneous abortion by immunisation with paternal cells. Lancet. 1985; 1: 941-3.
Gatenby PA, Cameron K, Simes RJ, et al. Treatment of recurrent spontaneous abortion by
immunization with paternal lymphocytes: Results of a controlled trial. Am J Reprod Immunol.
1993; 29: 88-94.
Worldwide collaborative observational study and meta-analysis on allogenic leukocyte immunotherapy for recurrent spontaneous abortion. Recurrent miscarriage immunotherapy trialists
group. Am J Reprod Immunol. 1994; 32: 55-72.
Cauchi MN, Lim D, Young DE, et al. Treatment of recurrent aborters by immunization with
paternal cellscontrolled trial. Am J Reprod Immunol. 1991; 25: 16-7.
Ho HN, Gill TJ, 3rd, Hsieh HJ, et al. Immunotherapy for recurrent spontaneous abortions in
a chinese population. Am J Reprod Immunol. 1991; 25: 10-5.
Ober C, Karrison T, Odem RR, et al. Mononuclear-cell immunisation in prevention of recurrent miscarriages: A randomised trial. Lancet. 1999; 354: 365-9.
319
Sexual dysfunction
Vestibulitis-Conservative Treatment
or Surgery?
Jorma Paavonen, MD
Department of Obstetrics and Gynecology, University of Helsinki Haartmaninkatu 2,
00290 Helsinki, Finland
E-mail: jorma.paavonen@hus.
Summary
Vulvodynia is a distressing and debilitating disorder not fully understood.
Management remains insufcient. Major problems include the task of differentiating the subsets of vulvodynia. The lack of consistent and uniform
terminology remains a source of confusion. The management of classic dysesthetic vulvodynia is fairly straightforward with drugs effective against chronic
neuropathic pain. However, vulvar vestibulitis syndrome (VVS) remains a
challenge. A pragmatic approach is recommended for patients with VVS since
many cases of VVS improve with time. In refractory cases vestibulectomy is
an intervention with the highest reported success rate although the evidence is
based mostly on descriptive studies. Comparative studies of conservative vs.
surgical management of VVS are needed.
Introduction
Recently there has been an increasing interest on vulvar pain syndrome, or vulvodynia. For instance, the National Institute of Health (NIH) has organized three
workshops on vulvodynia since 1997. Last NIH workshop took place in April,
2003 (1). Recommendations and research priorities on vulvodynia have been
outlined in these workshops. Funding for vulvodynia research has also increased
in recent years. Vulva clinics have been established in many countries.
320
Vulvodynia has also become a popular topic in media, and many vulvar
pain oriented associations or foundations have emerged. Such organisations
have become an important source of information to health care professionals
and patients alike. Vulvodynia has now been recognized as a highly prevalent
pain disorder affecting the quality of life of many women. Clearly only the tip
of the iceberg has been recognized so far.
Denition
Vulvodynia is a chronic vulvar pain syndrome consisting of two major subtypes:
dysesthetic vulvodynia and vulvar vestibulitis syndrome (VVS) (2). Patients
with VVS suffer of vulvar hypersensitivity to touching, or allodynia which
causes dyspareunia. Patients with dysesthetic vulvodynia suffer of constant
poorly localised vulvar pain.
History
History of vulvodynia and vulvar vestibulitis syndrome has recently been reviewed (3, 4).
Excessive sensitivity or hyperesthesia of the vulva has been described already in 1889 by Skene, and again by Thomas and Munde in 1891. In 1928,
Kelly described exquisitely sensitive deep-red spots in the mucosa of the hymenal ring as a source of dyspareunia. International Society for the Study of
Vulvar Diseaase (ISSVD) Task Force in 1980 dened vulvodynia as a chronic
burning discomfort in the vulva with multiple causes. In 1987, three criteria
for the diagnosis of VVS were proposed including the presence of supercial
or entry dyspareunia, the presence of focal or diffuse vestibular erythema, and
a positive swab test where light pressure with a cotton tipped swab induces
severe pain sensation.
The terminology for vulvodynia used in the literature has been confusing.
Vulvodynia was introduced by McKay in 1983. Other terms such as nonpathogenic vulvovaginitis, psychosomatic vulvovaginitis, burning vulva syndrome,
and vaginismus have also been used. Term VVS was introduced by Friedrich
in 1987. VVS has also been known by other names, such as adenitis, vestibular
adenitis, focal vulvitis, or more recently, vestibulodynia (5, 6).
Dysesthetic vulvodynia has also been termed as essential vulvodynia, referred nerve root pain, or pudendal neuralgia suggesting that it is a neuropathic
pain syndrome (4).
321
Prevalence
The epidemiology of vulvodynia has not been well studied. Similarly, systematic prevalence or incidence studies in different populations do not exist.
Limited prevalence studies suggest that up to 15% of women have suffered of
vulvodynia at some point (7). A recent, as yet unpublished, survey in a community setting in the UK showed a prevalence of 2.8-9.3% (5).
According to another recent prevalence survey in the US, 16% of women
had experienced chronic vulvar burning which had lasted three months or
longer (1). Approximately 40% of women surveyed had chosen not to seek
treatment even though the symptoms limited sexual activity. More than 60% of
respondents who sought treatment had seen three or more different physicians
for the problem. Vulvodynia is responsible for approximately 4% of a total of
36 million physicians visits for chronic pain by women in the United States.
Age range of vulvodynia patients is highly variable ranging from adolescents
to women in their eighties (8). In general, patients with VVS are younger than
patients with dysesthetic vulvodynia. Descriptive studies suggest that VVS is
rare or nonexistent among black women. Less than 10% of women with vulvar
pain disorders report history of sexual abuse (8).
Symptoms and clinical ndings

Patients describe the pain as burning, stinging, rawness, or stabbing which
is difcult to localize (9, 10). Vulvar burning and pain precludes a scratch
response. Symptoms may have lasted several years.
Patients with VVS typically complain of entry dyspareunia, not deep dyspareunia. Women with VVS do not have chronic constant pain which would
limit their daily activities. Women with primary VVS have never been able to
tolerate introital touch without pain (11). Women with secondary VVS have
had normal sexual activity without pain until VVS developed (11). Patients
with dysesthetic vulvodynia complain of constant neuropathic pain. Typical
symptoms include burning, sharp pain, shooting pain, and constant aching
which usually gets worse towards the evening.
Meticulous vulvar examination is required. The simple denitive test for
VVS requires only a cotton-tipped swab. Vestibular point tenderness at the crypt
next to the hymenal ring can be demonstrated in the posterior vestibulum, anterior vestibulum, or both. Sensitivity and tenderness on touching may be intolerable making gynecologic examination difcult or impossible. Hyperesthesia or
pain perceived on light touch is striking and totally out of proportions. This is
called allodynia which means that sensation perceived, i.e. pain, differs from
322
that applied, i.e. touch. Small reddened areas as markers of inammation can be
present at the sites of maximum point tenderness localized to vestibular glands.
On speculum examination, vaginal mucosa appears normal, and the wet mount
examination usually shows normal lactobacilli predominating, normal estrogen
effect, and few white cells.
Patients with vulvodynia often suffer of overlapping pain syndromes, such
as low back pain, overactive bladder, interstitial cystitis, irritable bowel syndrome, or bromyalgia (8, 12). Many patients also suffer of depression which
can be primary or secondary.
Pelvic oor muscle (PFM) instability is another important nding among
patients with VVS (13-15). Women with VVS have elevated rest tension and
contractile weakness of PFM. This is known as vaginismus. The longer VVS
has persisted the more severe vaginismus.
Diagnosis
Vulvodynia is always a diagnostic challenge (9, 10). Diagnosis of vulvodynia
is clinical and is based on history (introital dyspareunia), clinical ndings on
examination (point tenderness, often vestibular erythema), and exclusion of
other vulvovaginal disorders such as dermatoses. Introital dyspareunia can be
classied into mild (dyspareunia present most of the time, does not prevent
sexual intercourse), moderate (dyspareunia always present, intercourse sometimes possible), or severe (dyspareunia totally prohibits intercourse). Variable
degrees of vaginismus may be present. Patients complaining vulvar pruritus are
not likely to have vulvodynia, and usually present with skin changes. Patients
with dysesthetic vulvodynia usually show normal ndings on gynecologic
examination.
Histopathology
Vestibular biopsy in VVS shows mild to severe non-specic chronic inammation composed primarily of T lymphocytes (3). However, routine biopsy is
of little value in the diagnosis of VVS, but is sometimes necessary to exclude
other vulvar pathologies such as dermatoses or genital ulcer disease.
Immunohistochemical studies of the peripheral nerve supply of the vestibular mucosa have shown an increased density of intraepithelial nerve endings,
epithelial nerve ber proliferatio,n or sprouting. A correlation between degreee
of mucosal inammation and nerve ber proliferation has been demonstrated in
small case-control studies (16, 17). Vulvar sensation is thought to be mediated
323
by unmyelinated C bers and myelinated A delta bers. Afferent bres may

be sensitized, or an increased density of nerve bers may lower mechanical
and thermal thresholds leading to the heightened perception seen in patients
with VVS. The specic cause of the increased density of sensory nerve bers
in patients with VVS is unknown, but could be attributed to increased local
presence of inammatory mediators or neural growth factors.
Etiology
Etiology of vulvodynia is unknown. This largely reects the lack of systematic
high quality clinical studies of the etiology. Most studies of the risk factors or
risk markers of vulvodynia have been relatively small descriptive case-control
studies, and therefore subject to signicant selection bias, ascertainment bias,
and confounding. The level of evidence based on such studies is low, i.e. level
III (comparative studies, correlation studies, case-control studies) or level IV
(expert opinion only).
Selected suspected risk factors or risk markers are shown in Table 1. The
use of oral contraceptives from an early age and for a period of several years
seems to increase the risk for vulvodynia (18). However, this link has not been
well explained. The role of allergic reactions in the etiology of vulvodynia is
not known. A subset of women with VVS may be sensitised to seminal uid
and an allergic reaction to seminal uid may sometimes be associated with the
initiation and persistence of symptoms (19).
Table. 1: Suspected risk factors or risk markers for vulvodynia
Recurrent or persistent vulvovaginal candidiais

Human papillomavirus infection
Contact allergy
Oral contraceptive use
Vulvar trauma or injury
Childhood sexual abuse
High urinary oxalate concentration
Psychosexual anxiety
Herpes simplex virus infection
Autoimmune reaction
Literature reviews do not support the etiologic role of specic viral or bacterial
infections, such as human papillomavirus (HPV), herpes simplex virus (HSV),
324
cytomegalovirus (CMV), or Chlamydia trachomatis. At least 12 small studies

have looked at the prevalence of HPV DNA in VVS with the prevalence ranging
from 0 to 100% suggesting no role for HPV (3, 20). Similarly, response to prolonged treatment with antimycotics (azoles) has been unsatisfactory suggesting
that acute, recurrent, or persistent yeast infection does not cause vulvodynia (21).
However, in many cases of vulvodynia symptoms appear after a severe infection,
such as yeast infection, urinary tract infection, other bacterial infection, or operative intervention or injury. This suggests that there may be a pathogen connection
(22). Indirect evidence supports the idea that VVS is an autoimmune disease. The
currently fashionable concept of molecular mimicry suggests that pathogens express a stretch of protein that is related in sequence and structure to a particular
self-component. This pathogen-encoded epitope can be presented by the major
histocompatibility complex (MHC) and activate self-reactive T cells. Primed
and amplied T cells can then attack self-antigens. The alternative concept of
bystander activation proposes that pathogens disturb self-tolerance through the
inammation associated with infection. Bystander autoimmunity falls within
the broader idea of micro-organism associated immunopathology. However, to
prove these issues for a complex and probably multifactorial disease like VVS is
a very difcult task. Mediators released by inammation on injury can activate
unmyelinated C bers. Prolonged ring of these nerves sensitizes delta bers in
the dorsal horn. Such sensitised neurons can respond abnormally to input from
myelinated delta bers or mechanoreceptors activated by light touch switching
the transmission to central nervous system from normal tactile signal to signal
perceived as pain. This allodynia is a characteristic phenomen among women
with VVS. It is also possible that prolonged chronic stimulation and allodynia
may eventually establish a sympathetically maintained continuous pain of dysesthetic vulvodynia although this is unproven.
Natural history
By denition, vulvodynia is a chronic disorder. In general, the longer the history the less likely it is that spontaneous recovery takes place. In many cases,
symptoms have persisted several years, sometimes even more than 10 years.
This has an enormous negative impact on the health related quality of life. It
is not known whether VVS and dysesthetic vulvodynia constitute a continuum
of the same pain condition. Clearly more research and natural history studies
on vulvodynia are needed.
325
Psychological aspects
Psychological and psychosexual dimensions of vulvar pain are enormous. The
lack of clear-cut physical ndings on examination often leads to physicians
to state that there is nothing wrong, and easily attribute the symptoms to a
psychosomatic disorder. Vulvar vestibulitis is poorly recognized by general
practitioners and even by gynecologists which often leads to doctor shopping.
Vulvodynia patients like patients with other chronic pain syndromes are psychologically distressed and depressed (2). Chronic pain is often a mystery,
causes low self-image, anxiety and isolation, difculty in sleeping, negative
thinking, and even suicidal thoughts. Sexual relationships suffer because of
sexual dysfunction. Only few small case-control studies have attempted to
look into psychological characteristics of vulvodynia patients. Based on such
limited studies, there is no convincing evidence that women with vulvodynia
differ from control women regarding specic psychosocial characteristics.
Women with VVS have more somatic complaints than control women suggesting psychosomatic factors play a role (8). However, this can be primary
or secondary.
Treatment of dysesthetic vulvodynia

Treatment of neuropathic pain syndromes including dysesthetic vulvodynia is
straightforward (2). Tricyclic antidepressants block reuptake of serotonin and
noradrenalin and presumably relieve pain by inhibition of the sodium channel.
Most patients with continuous pain respond to tricyclic agents. Most patients
achieve at least 50 percent reduction in neuropathic pain. However, response
to tricyclics can be insufcient, and benets are sometimes outweighed by
adverse effects. The next drug of choice is an anticonvulsant, gabapentin (2) or
pregabalin. In some cases a combination of two drugs, for instance amitriptyline and gabapentin is more effective and causes less adverse effects than either
drug alone. Selective serotonin reuptake inhibitors (SSRI) differ from tricyclic
antidepressants in that they selectively block serotonin reuptake, but are not as
effective as tricyclic agents against neuropathic pain.
Treatment of vulvar vestibulitis syndrome

Conservative management. Table 2 presents a list of drugs or therapeutic procedures that have been used in the conservative management of VVS. The
level of evidence is generally low. Only few randomized controlled trials of
the treatment of VVS have ever been reported (23).
326
Initial evaluation should include reassurance and exclusion of other causes

of dyspareunia or vulvar pain. If vaginismus is present, biofeedback pelvic
musculature training program should be recommended. This is often successful, and more than half of women with VVS benet, and may be able to resume
intercourse after a few months. Figure 1 shows a simple and pragmatic algorithm used in our Vulva Clinic for the management of patients with VVS. This
algorithm has proven useful in clinical practice. Most severe and refractory
cases end up having vestibulectomy.
Table 2:
Conservative therapies used in the management of vulvar vestibulitis syndrome
Topical estrogen cream

Topical lidocain gel
Topical corticosteroid cream
Topical cromolyn cream
Naproxen cream
Topical podofyllotoxin application
Topical capsaisin cream
Local injections of interferon alpha
Local injection of bethamethasone with bupivacain
Prolonged use of antifungals
Behavioral therapy
Physical therapy with biofeedback
Acupuncture
Surgical management. Vestibulectomy in the treatment of refractory VVS was

rst described by Woodruff in 1981 (24). Literature review of outcomes of surgical treatment of VVS showed a signicant decrease in symptoms (complete
response, partial response, or both) in 89% of a total of 646 cases (25). We
have systematically used vestibulectomy in refractory VVS cases. Overall, 50
patients have had the operation since 1995. As shown in Table 3, 80% of the
patients had satisfactory outcome. All except one of the patients had chosen the
operation again if they had to choose. Thus, a high rate of success in the most
refractory cases can be achieved with proper surgical technique. Compared
to other treatment modalities available surgery seems to provide best results.
However, surgery has been considered the last resort for patients with severe
VVS who fail to respond to conservative management.
327
Vestibulitis
(moderate to severe)
Review Rx options
Discontinue OCs
Phisical therapy
Hx of rec candidiasis
Prolonged Rx with antifungals
No response
Consider other concervative
Rx modalities
No response
Evaluate for vestibulectomy
Figure 1: An algorithm of the management of patients with vulvar
vestibulitis syndrome.
Table 3:
A case series of vestibulectomy in the treatment of vulvar vestibulitis syndrome (Paavonen

J: Unpublished)
Total no.
Age (yr)
Ever pregnant
History of OC use
Duration of sxs
VAS preoper
VAS postoper
Complete or partial response
No response
50
28.1 (18-48)
10/50 (20%)
30/43
4.5 yrs (1-15 yrs)
9.2
2.9*
45 (90%)
5 (10%)
VAS=visual analogic scale; OC= oral contraceptives; *Mean follow-up 21 months (range 2 months 9 years)
328
Comparative studies of surgical vs. non-surgical

management.
One randomized comparison of cognitive-behavioral therapy, electromyographic biofeedback therapy, and vestibulectomy among 78 women with VVS
showed that response to vestibulectomy was signicantly better than the other
two (19). However, all three treatment groups improved signicantly from
pretreatment to 6-month follow-up, as measured by pain reduction or sexual
function.
Research priorities
A research agenda of vulvodynia has been proposed by the National Institute of
Health, United States (1). It is clear that better understanding of the pathogenesis of vulvodynia is necessary for development of new treatment modalities.
Research priorities include:
1. Rene the denition of vulvodynia.
2. Start large multicenter randomized controlled trials of surgical vs. conservative treatment of VVS with adequate follow-up.
3. Develop, standardize and validate methods for evaluating pelvic oor
functions.
4. Conduct epidemiologic studies to identify risk factors or risk markers for
vulvodynia
5. Dene the role of specic microbial pathogens as triggers in the etiology
of vulvodynia.
References
1.
2.
3.
4.
5.
6.
Vulvodynia: Towards understanding a pain syndrome. Proceedings from a workshop April

14-15, 2003. Leppert P and Turner M (eds.)
Lotery HE, McClure N, Galask RP. Vulvodynia. Lancet 2004;363, 1058-1060.
Bohm-Starke N. Vulvar vestibulitis syndrome: Pathophysiology of the vestibular mucosa.
Thesis, Stockholm 2001.
Baggish MS, Miklos R. Vulvar pain syndrome: A review. Obstet Gynecol Surv 1995;50:618627.
Munday P, Buchan A. Vulvar vestibulitis is a common and poorly recognized cause of dyspareunia. BMJ 2004;328:1214-1215.
Bornstein J, Zarfati D, Goldshmid N, Stolar Z, Lahat N, Abramovici H. Vestibulodynia A
subset of vulvar vestibulitis or a novel syndrome? Am J Obstet Gynecol 1997;177:14391443.
329
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Goetsch MF. Vulvar vestibulitis: Prevalence and historic features in a general gynecologic
practice population. Am J Obstet Gynecol 1991;164:1609-1616.
Gordon AS, Panahian-Jand M, McComb F, Melegari C, Sharo S. Characteristics of women
with vulvar pain disorders: Responses to a web-based survey. J Sex Marital Ther 2003;29:4558.
Paavonen J. Diagnosis and treatment of vulvodynia. Ann Med 1995;27:175-181.
Paavonen J. Vulvodynia a complex syndrome of vulvar pain. Acta Obstet Gynecol Scand
1995;74:243-247.
Goetsch MF. Vulvar vestibulitis. Contemporary Obstet Gynecol 1999;10:56-65.
Edwards L. New concepts in vulvodynia. Am J Obstet Gynecol 2003;189 (suppl.):S24-30.
Glazeer HI, Rodge G, Swencionis C, Herz R, Yvonne AW. Treatment of vulvar vestibulitis
syndrome with electromyographic biofeedback of pelvic oor musculature. J Reprod Med
1995;40:283-290.
McKay E, Kaufman RH, Doctor U, Berkova Z, Glazer H, Redko V. Treating vulvar vestibulitis
with electromyographic biofeedback of pelvic oor musculature. J Reprod Med 2001;46:337342.
Bergeron S, Brown C, Lord M-J, Oala M, Binik YM, Khalif S. Physical therapy for vulvar
vestibulitis syndrome: a retrospective study. J Sex Marital Ther 2002;28:183-192.
Bohm-Starke N, Hilliges M, Falconer C, Rylander E. Increased intraepithelial innervation in
women with vulvar vestibulitis syndrome. Gynecol Obstet Invest 1998;46:256-260.
Westrm LV. Willn R. Vestibular nerve ber proliferation in vulvar vestibulitis syndrome.
Obstet Gynecol 1998;91:572-576.
Bouchard C, Brisson J, Fortier M, Morin C, Blanchette C. Use of oral contraceptive pills and
vulvar vestibulitis: a case-control study. Am J Epidemiol 2002;156:254-261.
Babula O, Bongiovanni AM, Ledger WJ, Witkin SS. Immunoglobulin E antibodies to seminal
uid in women with vulvar vestibulitis syndrome: relation to onset and timing of symptoms.
Am J Obstet Gynecol 2004;190:663-667.
Morin C, Bouchard C, Brisson J, Fortier M, Blanchette C, Meisels A. Human papillomaviruses
and vulvar vestibulitis. Obstet Gyneocol 2000;95:683-687.
Bornstein J, Livnat G, Stolar Z, Abramovici H. Pure versus complicated vulvar vestibulitis: a
randomized trial of uconazole treatment. Gynecol Obstet Invest 2000;50:194-197.
Benoist C, Mathis D. The pathogen connection. Nature 1998;394:227-228.
Bergeron S, Binik YM, Khalif S, Pagidas K, Glazer HI, Meana M, Amsel R. A randomized
comparison of group cognitive-behavioral therapy, surface electromyographic biofeedback,
and vestibulectomy in the treatment of dyspareunia resulting from vulvar vestibulitis. Pain
2001;91:297-306.
Woodruff JD, Genadry R, Poliakoff S. Tretment of dyspareunia and vaginal outlet distortions
by perineoplasty. Obstet Gynecol 1981;57:750-754.
Bornstein J, Zarfati D, Goldik Z, Abramovici H. Vulvar vestibulitis: physical or psychosexual
problem? Obstet Gynecol 1999;93:876-880.
330
Androgen insufciency in women:

Does it exist?
George Mastorakos, MD, DSc. Marios C. Markopoulos, MD
Second Department of Obstetrics and Gynecology, Aretaieion Hospital,
Athens University Medical School, Athens, Greece.
E-mail: mastorak@mail.kapatel.gr
1. Introduction
Until recently androgens have been considered as the male hormone as opposed to the female hormone estrogens. This distinction has undoubtedly
contributed to the lack of recognition of androgens effects in women. During
the last decade, numerous studies have claried androgen production and metabolism and have better dened the important physiological effects of androgen
in women. Androgens represent the immediate precursors for the biosynthesis
of estrogens, but also act directly via androgen receptors throughout the body
affecting many organs and systems of the female. The decline of androgen
production is well documented not only in association with pathological entities and causes but also as a consequence of the effects of advancing age on
the ovaries and the adrenals. With most women now expected to live almost
one third of their life after menopause, the interest and consideration of androgen replacement therapy has augmented. Although it is not clear why some
women exhibit symptoms and others do not, it is clear that some symptomatic
women respond to treatment with androgens. Difculties in androgen assays
in women along with lack of sufcient studies result in absence of consensus
on the denition of low androgen levels, which makes androgen insufciency
difcult to diagnose.
331
2. Androgens in women
A variety of androgenic steroids are present in adult women. Androgens are
produced in greater quantities than estrogens in women, as they circulate in
the concentration rate of nanomolar to micromolar in contrast to estrogens
the circulating concentrations of which are in the picomolar range. The major
androgens in women listed in discending order of serum concentration include
dehydroepiandrosterone sulfate (DHEAS), dehydroepiandrosterone (DHEA),
androstenedione (A), testosterone (T), dihydrotestosterone (DHT), with the
latter two having the greatest potency, while the rst three require conversion
to T to express their androgenic effects and are considered as proandrogens
(2-3). The major sources of peripheral androgen production in women are
DHEAS, DHEA and A. Circulating T functions as a prohormone with conversion in target tissues to DHT or E2, by 5a-reductase and aromatase enzymes,
respectively.(Fig.1) Thus, androgens may exert biological effects by acting
directly via
or after conversion
to estrogens (4-5).
Testosterone
as aandrogens
precursorreceptors
for 17-estradiol
and dihydrotestosterone.
TESTOSTERONE
aromatase
5a reductase 1 & 2
17-ESTRADIOL
DHT
Breast, brain, bone, skin,

vascular endothelium,
vascular smooth muscle,
ovaries, testes, placenta
Androgen responsive tissues

( i.e. pilosebaceous unit )
Fig.1: Testosterone as a precursor for 17-estradiol and dihydrotestosterone.

Androgens in women originate from the ovaries, the adrenals and from conversion at peripheral tissue sites. Approximately 25% of T biosynthesis takes
332
place in the ovaries, 25% is produced by the adrenal zona reticularis, and the
rest 50% is derived from the peripheral conversion in adipose tissue, skin, liver
and other peripheral tissues, of which adipose tissue is of greatest importance
(3,6-8). These percentages change after menopause ( Tables 1-3 ).
Tables 1-3: Relative contribution of ovarian, adrenal and peripheral tissues in androgen production
in premenopausal and postmenopausal women.
Table 1
Ovarian production
T
A
DHEA
DHEAS
DHT
Premenopause
Postmenopause
25%
40%
10%
0%
Very small
50%
20%
10%
0%
None
Table 2.
Adrenal production
Premenopause
T
A
DHEA
DHEAS
DHT
25%
50%
50%
90%
Small
Postmenopause
10%
70%
50%
90%
Small
Table 3.
Peripheral production
Premenopause
Postmenopause
50% from A
10% from DHEA
40% from DHEAS
10% from DHEA
Almost entirely from T
40% from A
10% from DHEA
40% from DHEAS
10% from DHEA
Almost entirely from T
333
Biosynthesis of the androgens, both in the adrenals and the ovaries, is modulated by two cytochrome P450 enzymes, P450Scc and P450C17, required for
DHEA and A production from pregenolone and progesterone, respectively.
DHEA is converted to A by 3 hydroxysteroid dehydrogenase (3 HSD), and
A to T by 17 hydroxysteroid dehydrogenase (17 HSD) (29), (g 2).
DHEAS
Cholesterol
STS
P450 SCC
P450 C17
P450 C17
17OH Pregnenolone
Pregnenolone
DHEAS ST
3 HSD
DHEA
3 HSD
P450 C17
Progesterone
P450 C17
17OH Progesterone
aromatase
Estrone
Androstenedione
17 HSD
17 HSD
aromatase
Testosterone
17-Estradiol
5a reductase
DHT
Fig.2: Androgens biosynthesis and conversion to estrogen.

Abbreviations: STS, steroid sulfatase; DHEAS ST, dehydroepiandrosterone sulfotransferase.
The regulation of androgens secretion involves stimulation by LH (ovaries)

and ACTH (adrenals), together with intraglandular paracrine and autocrine
mechanisms. There is no direct evidence for an existing endocrine regulatory
feedback loop and whether a decline in serum androgen levels would result in
elevated circulating gonadotropins (9).
Androgenic action is determined by 1) the biological potency and androgen receptor binding afnity of the androgen, 2) the quantitative level of the
androgen in the circulation, 3) the degree of binding to serum proteins sex _
hormone binding globulin (SHBG) and albumin which determines the androgen bioavailability to the target issues and to some extent its metabolic clearance, and 4) the degree of interconversion to other androgens and estrogens.
Approximately 2/3 of T is bound to SHBG and 20-33% to albumin, leaving
just 1% as non-bound bioavailable or free T (11-13). Serum DHEAS and A
concentrations correspond practically to their bioavailable concentrations, as
334
only a very small proportion binds to serum proteins . According to these factors, serum T levels best reect the clinical androgen status of women. The
serum levels of DHEAS provide an index of adrenal androgen production,
while serum levels of A and DHT generally correlate with T concentrations
and therefore do not provide useful additional information for the womans
androgen status evaluation.
Ovarian and adrenal androgens show a signicant reduction along the reproductive female age. The mean circulating levels of T decline continuously
as the age increases from early reproductive years, and as a result T levels of a
woman in her 40s are approximately half of those in women in their 20s (1,14).
In the late reproductive years, the midcycle rise in free T which characterizes
young ovulating women, disappears despite preservation of normal free T levels during the rest of the cycle (15). After the decline in total and free T with
age in premenopausal years, its levels remain stable or continue to decline.
Thus, a decade after menopause serum levels of T and A in women aged 60
years are about half those in women aged 40 years, whose levels are in turn
signicantly below those of women in mid-20s. The postmenopausal ovary
remains an androgen secreting gland, in response to elevated postmenopausal
LH concentrations. After menopause peripheral conversion of androstenedione
remains a major source of circulating T.
The high circulating levels of DHEAS at birth decrease to almost undetectable levels during the rst year of life. Levels remain low until they gradually
increase between 6 and 10 years of age, as adrenarche occurs. Peak concentrations are reached around 20s, followed by steady decline throughout adult life
(27). Women maintain DHEAS levels within the normal range until the age
of 40 and thereafter there is a linear decline at a rate of 5% per year, so that at
the age of 70s-80s peak concentrations are only 10%-20% of those of young
adults (1,16,17). Adrenopause shows high individual variability and is accompanied by a reduction in the size of the zona reticularis (17).
3. Denition
Considering the lack of sufcient epidemiological data and the limitations of
current laboratory assays, as current assays have limited sensitivities in the
lower ranges found normally in women, the denition of androgen insufciency in women is based on three essential criteria (18):
1) Clinical symptoms of androgen insufciency must be clearly present (table
4) .Such frequently described symptoms are decreased or absent sexual
motivation and desire, persistent and unexplained fatigue, overall decreased
335
sense of well-being. Signs of androgen deciency are thinning or loss of

pubic hair, decreased muscle mass and reduction of bone mineral density
on bone densitometry testing. Due to the fact that the symptoms and signs
consisting androgen insufciency are nonspecic, they alone are not sufcient to establish such a diagnosis.
2) Women should have adequate estrogen status. This criterion could include
normally cycling premenopausal women or pre- and postmenopausal hypogonadal women receiving estrogen replacement therapy, and is based on
the fact that estrogens affect symptoms concerning sexual function, mood
and psychological well being.
3) Free T values should be at or below the lowest quartile of the normal range for
the reproductive age, in conjunction with the presence of clinical symptoms
and adequate estrogen status. Selection of the lowest quartile was based on
the lack of sensitivity of current androgen assays at the lower ranges present
in women and especially at the levels observed in women with androgen
insufciency, in addition to the potential risks of androgen replacement in
women with normal or elevated androgens before treatment.
Table 4:
Symptoms and signs of androgen insufciency in women.
Impaired sexual function with reduced

Sexual motivation
Sexual fantasy
Sexual arousal
Vaginal vasocongestion
Sexual enjoyment
Thinning of pubic hair
Reduced bone density
Reduced muscle mass
Persistent unexplained fatigue and low energy
Dysphoric mood and diminished psychological well being
Vasomotor symptoms
Loss of memory and changes in cognition
Depression
Headaches
To evaluate correctly a woman in suspicion of androgen insufciency, other
causes of symptoms should be excluded. Thyroid disease (hypo- or hyperthyroidism), metabolic and nutritional disorders (iron or vitamin D deciency)
and other causes of chronic fatigue (chronic fatigue syndrome, Lymes disease),
psychiatric disorders (major depression), major life stress events, and medica-
336
tions such as glucocorticoids and selective serotonin reuptake inhibitors should

be ruled out of consideration. Estrogen replacement therapy can precipitate
symptoms of androgen insufciency by increasing SHBG and thereby decreasing free T, which is most commonly found with oral estrogen preparations (19).
Onset of the symptoms following an event associated with decreased androgen
production could lead to the diagnosis of the syndrome.
4. CAUSES
Androgen insufciency in women is caused by multiple pathological processes
and iatrogenic interventions. It is best documented in pituitary, ovarian and
adrenal failure. It may also occur following age-related decrease of circulating
androgens (1). All conditions associated with androgen insufciency are summarized in table 5. Given the negative effects of pituitary, ovarian and adrenal
dysfunction on circulating androgens, stress induced hormonal disturbances
might result in decreased androgen levels.
The symptoms associated with androgen depletion are variable in different eras of womans life. In puberty androgen insufciency is expressed
with lack of adrenarche, the onset of DHEAS and DHEA production, not an
obliquate precursor of gonadarche. During the reproductive years androgen
insufciency may result in decreased sexual functioning and vaginal vasocongestion to erotic stimulation with decreased sexual motivation and enjoyment,
fatigue, increased prevalence of headaches and depression, changes in hair and
skin and in a feeling of energy depletion and diminished quality of life. In the
menopausal woman alterations associated with androgen insufciency include
increased vasomotor ushing, loss of bone and muscle mass and increased loss
of memory.
The use of oral contraceptives during the reproductive age or estrogen replacement therapy by estrogen depleted women, elevate levels of SHBG resulting in decreased free T levels and thus, may unmask an underlying androgen
insufciency.
Table 5:
Causes of androgen insufciency in women.
1. Normal aging
Symptomatic premenopausal or postmenopausal women
with low bioavailable T.
1. Ovarian Deciency
Unilateral or Bilateral oophoerctomy
337
Hysterectomy
Chemotherapy, radiotherapy
Premature Ovarian Failure ( POF )
Ovarian dysgenesis ( i.e. Turners Syndrome )
2. Adrenal Deciency
Lack of adrenarche
Primary adrenal failure ( Addison disease, enzyme
deciencies )
Adrenalectomy
3. Hypothalamus Pituitary Deciency
Structural or functional hypothalamic pituitary
abnormalities
4. Iatrogenic
Exogenous oral estrogen replacement
Chronic glucocorticosteroids administration
Antiandrogens
GnRH antagonists ( chemical ovariectomy )
5. Other
Stress
Anorexia nervosa
Autoimmune disorders ( Systematic lupus rythematosis,
rheumatoid arthritis )
HIV
5. Evaluation and management guidelines

A patient with suspected androgen insufciency should be involved in a comprehensive clinical assessment before initiating a trial of androgen replacement
therapy. Clinical manifestations of androgen insufciency are highly variable,
often nonspecic, and may be associated with many potential etiological factors. The evaluation should include detailed medical and psychosocial history,
physical examination and laboratory assays.
In order to assist clinicians, an algorithmic approach to the diagnosis and
treatment of androgen insufciency is proposed ( 18), as outlined in gure 3.
When the patient ts the clinical denition, then it is important to assess
whether the patient is adequately estrogenized. If not, then estrogen replacement
therapy should be administrated. If the symptoms persist despite patients optimum estrogen state then an alternative explanation or cause for these symptoms
(e.g. major depression, hypothyroidism, chronic fatigue syndrome) should be
338
eliminated from consideration. If the symptoms still cant be explained, then

laboratory tests should be undertaken. This includes assessment of free T, Free
Testosterone Index ( FTI ) and DHEAS.
The total T level is markedly inuenced by SHBG concentration (20), which
is affected by a variety of drugs and clinical conditions, as seen in table 6.
Is the womans clinical picture consistent

with female androgen insufficiency?
Yes
Initiate
estrogen
replacement
No
Is the woman in an optimum

estrogen state?
Yes
Is there an alternative cause of
these symptoms?
Yes
Treat cause
No
Measure free T or
Free Testosterone Index
( 100 X total T / SHBG )
and
DHEAS
Normal
Low
Symptoms
probably not due to
androgen deficiency
Trial of
Testosterone or DHEA
replacement
Fig.3: Algorithm for the diagnosis and initiation of therapy in androgen decient women.
339
Table 6: Clinical conditions that inuence SHBG concentration.
Increased SHBG
Decreased SHBG
Estrogen therapy
Androgen therapy
Contraceptive pills
Hyperandrogenic states
Hormone replacement therapy
Hyperinsulinemia
Pregnacy
Hyperthyroidism
Cirrhosis
Hypogonadism
Antiepileptic medications
Increased prolactin
Hypothyroidism
GH excess
As SHBG rises, the total T levels are increased, possibly giving false information about the bioavailable level of T as free T levels actually may be normal
or low. Therefore the free or bioavailable T level evaluates more accurately
the androgen status in women, and evaluation by equilibrium dialysis is the
optimal assay in this regard (21). The FTI correlates well with free T and can
be used as a substitute measure (22).
The normal ranges of free T or FTI at different ages carried out with highly
sensitive assays have not been established. Thus, values should be at or below
the lowest quartile of the normal range for women at reproductive age to support the diagnosis of androgen insufciency. If that is the case, then the clinician
should consider a trial of androgen replacement therapy. Replacement therapy
with DHEA should be considered when serum concentration of DHEAS is
low, before proceeding to T replacement. The normative ranges for DHEAS
as age declines have been well dened, and DHEAS concentration should be
interpreted against the aged-matched normal range.
6. Treatment
Epidemiological and clinical data demonstrate the positive effects of androgen replacement therapy on some endpoints in a subset of women. Androgens
improve sexual desire and fantasy, frequency of sexual activity and orgasm,
satisfaction and pleasure from sexual activity (18). Androgens improve overall
energy and sense of well being, decrease somatisation and depression (18),
ameliorate vasomotor ushing (23), while correlate positively with bone mineral density and signicantly increase bone formation markers (24).
The symptomatic androgen decient women due to pituitary, ovarian and
340
adrenal failure are the clearest indications for androgen replacement therapy (
ART ). Pre- and postmenopausal women exhibiting symptoms compatible with
androgen insufciency syndrome and featuring low free T or FTI levels ( at
or below the lower quartile for reproductive age ) are also indicated for ART.
Other potential indications that require more data before treatment is recommended include premenstrual syndrome, osteoporosis, HIV wasting syndrome,
systematic lupus erythematosis and rheumatoid arthritis.
Considerations related to androgen replacement therapy in women include
preparations, risks and contraindications. In terms of preparations, T replacement therapy can be administrated orally, buccally, intramuscularly, by subcutaneous implants and transdermally via patches, creams or gels (25). The
ideal androgen preparation for women would reliably achieve into the upper
normal range serum androgen levels without peaks and valleys, combining the
most favorable safety prole. Thus, transdermal administration is preferred
and such preparations for women are currently in development (26). The use of
oral DHEA causes variable increase in T levels and therefore needs monitoring
(27).
Adverse effects in women under androgen replacement therapy are generally mild and occur mainly among those abusing androgens. Acne and hirsutism are the primary androgenic side effects, are not often seen with low dose
ART and resolve with discontinuation of the therapy. Frank virilization, (i.e.
clitorimegaly, deepening of the voice, male pattern balding), is rare with physiologic doses (28).
Table 7:
Contraindications to androgen replacement therapy in women.
Absolute
Relative
Pregnacy
Lactation
Polycythemia
Breast cancer
Endometrial cancer
Acne ( moderate to severe )

Hirsutism (moderate to severe )
Androgenic alopecia
Severe insulin resistance
Anger management disorders
The side effects of androgen administration also include uid retention, polycythemia, hepatic injury, lowering of HDL, sleep apnea, emotional lability and
aggressive behavior. As androgens are aromatized to estrogens, estrogenic side
effects are also potential consequences of androgen therapy, including breast
and endometrial hyperplasia and neoplasia. To date no report has described
endometrial or breast cancer in women under physiological dose ART, although
341
the long term risk for cancer is unknown (12,28). Potential virilization of a female fetus is a serious risk in reproductive age woman. Thus, the administration
of supraphysiological doses of androgens can not be recommended and even
women receiving ART at physiological doses should be monitored clinically
for signs of hyperandrogenism, biochemically evaluated with measurements
of lipids, hematocrit and liver enzymes before and 1-2 months after therapy
initiation, and tested yearly with mammography and endometrial ultrasound
for women with intact uterus.
The contraindications to androgen replacement therapy are listed in table 7.
7. Conclusions
Androgens have important physiological effects in women, although their role
in women hasnt been adequately recognized or understood yet. Androgens
are generally acknowledged to be associated with increased libido, muscle
strength, bone mass and amelioration of mood and vitality. Physiological and
pathological processes as well as iatrogenic interventions that affect androgen
production and bioavailability clearly result in androgen deciency states relative to the levels of healthy reproductive women. Many women experience
a variety of physical symptoms secondary to androgen depletion, as well as
physiological changes that affect their quality of life. Numerous studies demonstrate efcacy of androgen replacement therapy with doses that elevate serum
free T to the upper limits of normal ranges, resulting in increased libido, mood
bone mineral density and improvement of quality of life. Estrogen replacement therapy alone does not relieve all symptoms associated with gonadal
hormones decline, and many women benet from the addition of androgen in
an environment of adequate estrogen levels. Normative data that address the
use of total T or free T to dene androgen deciency are not currently available.
Androgen insufciency in the past has been underdiagnosed due to inability
to measure low circulating measures with commonly used techniques and to
nonspecicity of androgen insufciency symptoms. The clinical utility of such
a diagnosis needs approved efcient androgen preparations. To date androgen
preparations that result in physiological serum androgen levels and avoid liver
metabolism are in development. Thus, androgen replacement therapy should
only be administrated to symptomatic androgen decient women with adequate
estrogen status. Patients should be adequately monitored and informed of the
long term unproved safety of ART. Long term studies are needed to determine
the potential effects of androgen replacement therapy on cardiovascular morbidity and mortality, breast, ovarian and endometrium tissues.
342
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
Braunstein GD. Androgen insufciency in women: a summary of critical issues. Fertil Steril
2002;77(Suppl 4):S94-99.
Demers LM. Biochemistry and laboratory measurement of androgens in women. In: Redmond
GP, ed. Androgenic disorders. New York Raven Press. 1005:21-34.
Vermeulen A. Plasma androgens in women. J Reprod Med 1998;43:725-33.
Simpson ER. Aromatization of androgen in women. Fertil Steril 2002;77(Suppl 4):S6-10.
Simpson E, Rubin G, Clyne C, Robertson K, ODonnell L,Davis S, Jones M. Local estrogen
biosynthesis in males and females. Endocr Relat Cancer 1999;6:131-137.
Longcope C, Hunter R, Franz C. Steroid secretion by the postmenopausal ovary. Am J Obstet
Gynecol 1980;13:564-8.
Adashi EY. The climacteric ovary as a functional gonadotropin driven androgen producing
gland. Fertil Steril 1994;62:20-7.
Judd HL, Fournet N. Changes of ovarian hormonal function with aging. Experiment Gerontol
1994;29:285-98.
Burger HG. Androgen production in women. Fertil Steril 2002;77(suppl 4):S3-5.
Longcope C. Androgen metabolism and the menopause. Semin Reprod Endocrinol 1998;16:1115.
Lobo RA. Androgens in postmenopausal women: production, possible role, and replacement
options. Obstet Gynecol Surv 2001;56:361-76.
Sombooporn W, Davis SR. Testosterone effects on the breast: implications for testosterone
therapy for women. Endocr Rev 2004;25(3):374-388.
Burger HG, Dudley EC, Cui J, Dennerstein L, Hopper JL. A prospective longitudinal study
of serum testosterone dehydroepiandrosterone sulfate and sex hormone binding globulin levls
through the menopausal transition. J Clin Endocrinol Metab 2000;85:2832-2938.
Davis S, Schneider H, Donarti-Sarti C, Rees M, Van Lunsen H, Bouchard C, Derogatis L.
Androgen levels in normal and oophorectomised women. Proc 10th International Congress on
the menopause. Berlin, 2002, p 73. (Abstract F-12-01)
Mushayandebvu T, Castracane DV, Gimpel T, Adel T, Santoro N. Evidence for diminished
midcycle ovarian androgen production in older reproductive aged women. Feril Steril
1996;65:721-23.
Orentreich N. Age changes and sex differences in serum dehydroepiandrosterone sulfate concentrations throughout adulthood. J Clin Endocrinol Metab 1984;59:551-555.
Allolio B, Arlt W. DHEA treatment: myth or reality? Trends in Endocrinol and Metab.
2002;13(7):288-294.
Cameron DR, Braunstein GD. Androgen replacement therapy in women. Fertil Steril
2004;82(2):273-289.
Casson PR, Elkind-Hirsch KE, Buster JE, Hornsby PJ, Carson SA, Snabes MC. Effect of
postmenopausal estrogen replacement on circulating androgens. Obstet Gynecol. 1997;90:995998.
Pugeat M, Crave J, Tourniaire J, Forest m. Clinical utility of sex hormone binding globulin
measurement. Horm Res 1996;45:148-155.
Miller KK, Rosner W, Lee H, Hier J, Sesmilo G, Schoenfeld D, Neubauer G, Klibanski A.
Measurement of free testosterone in normal women and women with androgen deciency:
comparison of methods. J Clin Endocrinol Metab 2004;89(2):525-533.
Vermeulen A, Verdonck L, Kaufman JM. A critical evaluation of simple methods for the estimation of free testosterone in serum. . J Clin Endocrinol Metab 1999;84:3666-72.
Notelovitz M. Hot ashes and androgens: a biological rationale for clinical practice. Mayo
Clin Proc. 2004;79(Suppl 4):S8-13.
343
24.
25.
26.
27.
28.
29.
Kearns AE, Khosla S. Potential Anabolic effects of androgens on bone. Mayo Clin Proc.
2004;79(Suppl 4):S14-18.
Chu MC, Lobo RA. Formulations and use of androgens in women. . Mayo Clin Proc.
2004;79(Suppl 4):S3-7.
Shifren JL, Braunstein GD, Simon JA, Casson PR, Buster J, Redmond GP. Transdermal testosterone treatment in women with impaired sexual function afer oophorectomy. N Eng J Med
2000;343:682-8.
Miller KK. Androgen deciency in women. J Clin Endocrinol Metab 2001;86:2395-2401.
Basaria S, Dobs AS. Safety and adverse effects of androgens: how to counsel patients. Mayo
Clin Proc. 2004;79(Suppl 4):S25-29.
Mastorakos G, Chrousos GP. Adrenal hyperandrogenism. 1996 Reproductive Endocrinology,
Surgery and Technology. Adashi, Rock, Rosenwaks. Raven Press New York, 1539-1553.
344
Surgical practice
The ten steps vaginalhysterectomy
Michael Stark MD
Chairman, division of Obstetrics and Gynaecology,
Helios Hospitals Group President, the New European Surgical Academy (NESA).
Introduction:
Each surgical procedure is composed of hundreds of movements, of which
each should have a purpose. Surgical steps are often traditional and do not base
necessarily on comparative studies.
Surgical procedures should be evaluated for their details. Single, combinations, or sequences of steps should be critically assessed for their necessity and
ways of performance, compared to alternatives.
Vaginal hysterectomies were already performed in the 19th century (1). Most
nowadays practiced ways, the Porges (2), Falk(3), von Theobald (4), Heaney
(5), Joel-Cohen (6), or the Chicago (7) methods are carried out with pre-programmed sequences.
Vaginal route should always be considered when hysterectomy is indicated,
due to the quick recovery, lack of abdominal scar and short hospital stay (5,8). In
order to nd out, if vaginal hysterectomy can still be optimized and simplied,
a re-evaluation of this operation was initiated, where only the common steps in
the used methods were dened and analyzed. These steps were reassessed for
their necessity, and if found so, were critically compared to alternative versions.
As a result, only re-evaluated non-replaceable steps remained.
The result is a simple Ten Steps Vaginal Hysterectomy, easy to learn,
perform, and teach.
345
Method description:
The operation steps, their alternatives and rational:
1.) Separating vaginal wall :
In a patient with a prolapsed uterus, the traditional incision around the cervix
with a perpendicular extension and separating the vaginal wall laterally was
compared to a drop- like incision starting under the urethra, continuing laterally
and down, encircling the cervix from behind, and then back, up to the starting
point from the other side. The vaginal wall is separated laterally and down
using a surgical forceps, so that it is ready for the later anterior colporrhaphy.
The tip of the drop is pulled down, separating vaginal wall from bladder.
This procedure is logical, easy and saves movements (three main movements
compared to six in other methods). In a patient without a prolapse the rst step
will be a circular incision around the cervix about 5mm above the external os,
and then similarly separating the vaginal wall.
(Instruments: Speculum, two uterine forceps, scalpel, surgical forceps)
2.) Detaching bladder from the uterus:
By pushing the bladder up it is separated from the uterus exposing the anterior
peritoneum, but leaving it closed. Opening the anterior peritoneum at that stage
is not necessary, disturbs the dynamic and continuation of movements, and
might cause damage to the bladder when the inter-anatomical relations are not
clear.
(Swab, allis clamp, scalpel)
3.) Opening posterior peritoneum:
The posterior peritoneum is opened, exposing the insertions of the sacro-uterine-ligaments.
(Surgical forceps, scissors)
4.) Dissection of the lower side of the uterus:
In contradiction to the pure anatomical approach which deals with every
structure separately, the sacro-uterine ligaments are clamped together with the
paracervical tissues. It is done by placing one blade of the clamp under the
insertion of the sacro-uterine ligament and then rotate it toward the uterus,
while contra-rotating the uterus. Both anatomical structures are included now
between the blades and the instrument is closed. Both structures are cut and
ligated, leaving the suture material in its full length. This step is safe, bloodless,
dynamically correct and saves time (in most traditional surgical procedures
these elements will be sutured anyhow to each other at the end of the operation). It will produce descence to an unprolapsed uterus.
(Wertheim or Heaney clamp, needle holder, surgical forceps, scissors, two
sutures)
346
5.) Cutting and ligating the uterine arteries:

Both uterine arteries are clamped, cut and ligated.
(Wertheim or Heaney clamp, needle holder, scissors, two sutures)
6.) Opening anterior peritoneum:
The uterus is pulled down rotating while the peritoneum is lifted from behind
and cut open.
(Scissors, surgical forceps)
7.) Dissection of the upper part of the uterus (and appendages):
The round ligaments and blood-vessels are clamped and sutured. The ligature
is placed lateral from the clamp, leaving the ovarian ligaments as long as possible to prevent median position of the ovaries at the end of the operation. The
tissue is cut with scissors medial to the instrument. This will prevent bleeding,
should the later transction suture slip away by traction. The transction suture
is placed between the ligature and the clamp, keeping the full length of the
suture material.
(Wertheim or Heaney clamp, scissors, needle holder, surgical forceps, four
sutures)
8.) A non stage:
It has been shown that like in abdominal hysterectomy peritoneum can be left
open in vaginal hysterectomies (9,10). Besides, the peritoneum is attached to
the ligaments, and closing peritoneum will create an extra peritoneal sac after
tying the ligaments to each other (Step 9) with all consequences involved. If
an enterocele has to be prevented or repaired (11), it should be done at this
stage.
9.) Reconstruction of the pelvic oor:
The left and right sacro-uterine ligaments with the paracervical tissues and
the ovarian ligaments are ligated to each other respectively. An extra stitch to
suture both sacro-uterine ligaments is optional.
(Scissors, eventual one suture)
10.) Closing vaginal wall:
The vaginal wall is sutured continuously.
(Allis clamp, needle holder, surgical forceps, scissors, one suture)
In a prospective pilot study at the Misgav Ladach hospital in Jerusalem
(1998 2000) 79 women underwent vaginal hysterectomy, 43 with a traditional
method (Heaney) and 36 women with the Ten Steps Vaginal Hysterectomy.
There was no difference in both groups for age and parity. The women undergoing the Ten Steps Vaginal Hysterectomy had a signicant shorter operation time
and shorter requirement for analgetics (table 1).
347
Table 1:
Comparison of two vaginal hysterectomy methods:
Heaney
TSVH
n = 43
n = 36
Age
60.9 + 11.3
60.2 + 11.8
N.S.
Parity
3.18 + 2.02
2.54 + 1.7
N.S.
Duration of operation
(minutes)
51.3 + 22.5
32.3 + 11.8
< 0.0001
Duration of hospitalisation 6.2 + 2.3

(days)
6.3 + 1.9
N.S.
Requirement of analgetics 2.58 + 1.0

(days)
2.05 + 1.1
0.0325
Discussion:
Clinical studies concerning surgical procedures should take into account the
early (febrile morbidity, pain-killers needed, mobility) and late outcome (adhesions, organs dysfunction, chronic pains and life quality), next to the costs.
As much as tradition is of a benet in cultural life, it might prevent new
thinking and surgical developments, if procedures will not be subjected to
constant re-evaluation.
Traditional hysterectomies are often replaced nowadays by laparoscopic
assisted vaginal hysterectomies. It was shown, that the convalescence and hospitalisation time is shorter using this method in comparison to abdominal and
vaginal hysterectomies (12). Vaginal hysterectomy proved also to be quick,
but without the need for the high-tech equipment (13). Another advantage of
the vaginal route is the possibility to operate under regional anaesthesia, which
is safer for the high-risk patients and available for countries with limited resources.
The classical contraindications for vaginal hysterectomies: big uteri, previous Caesareans and nulliparity, do not have a signicant higher complications
rate than abdominal or laparoscopic assisted hysterectomies and should therefore not be considered as contraindications (14).
348
Most of the traditional vaginal hysterectomy methods have their rituals,

based on traditional anatomical understanding (2, 3). There are other detailed
technical descriptions, which relate to certain details as mass closure of the
vaginal vault (15), morcellation (16) or operating leaving the cardinal ligaments un-sutured (17).
The Ten Steps Vaginal Hysterectomy is based, next to anatomical considerations, on updated physiological principles. The result is a rational and simple
operation, which avoids unnecessary movements, and is using principles of
aesthetics and functional minimalism. Only 10 instruments and 10 sutures are
needed for this operation. It was indicated that this operation reduces operation
time and the use of pain-killers. More randomised prospective studies will be
needed to evaluate the early and late outcome of this method.
349
References
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
16)
17)
Leodolter S. The transvaginal surgical school in austria. Retrospect- present-future. Gynaekol

Geburtshiliche Rundsch 1995;35(3):142-8
Paldi E, Filmar S, Naiger R, Weisseman A, Feldman E. J . Vaginal hysterectomy using the
Porges method. Report on 100 cases. Gynecol Obstet Biol Reprod (Paris) 1988;17(2):233-6
Falk HC, Soichet S. The technique of vaginal hysterectomy. Clin Obstet Gynecol 1972;
15(3)703-54
Von Theobald P. Simplied vaginal hysterectomy. J Chir (Paris) 2001 Apr;138(2).93-8.
Kalogirou D, Antoniou G, Zioris C, Fotopoulos S, Karakitsos P. Vaginal hysterectomy: technique and results in the last twenty years. J Gynecol Surg 1995 11(4):201-7
Joel-Cohen, SJ: Abdominal and Vaginal Hysterectomy. New Techniques Based on Time and
Motion Studies. William Heinemann Medical Books, London, 1972, pp.170
Lash AF, Stepto RC. Chicago technique for vaginal hysterectomy at the Cook County Hospital.
Clin Obstet Gynecol 1972 Sep;15
Cravello L, Bretelle, F, Cohen D, Roger V, Giuly J, Blank B. Vaginal hysterectomy: apropos
of a series of 1008 interventions. Gynecol Obstet Fertil 2001;29(4):288-94.
Lipscomb GH, Ling FW, Stovall TG, Summitt RL jr. Peritoneal closure at vaginal hysterectomy : a reassessment. Obstet Gynecol. 1996 87(1):40-3
Janschek EC, Hohlagschwandtner M, Nather A, Schindl M, Joura EA. A study of non-closure
of the peritoneum at vaginal hysterectomy. Arch Gynecol Obstet. 2003;267(4):213-6
Cruikshank SH, Kovac SR. Randomized comparison of three surgical methods used at the time
of vaginal hysterectomy to prevent posterior enterocele. Am J Obstet Gynecol 1999;180(4):85965.
Garry R. Comparison of hysterectomy techniques and cost-benet analysis. Baillieres Clin
Obstet Gynecol 1997;11(1):137-48.
Knudsen HJ, Rosgaard A, Rasmussen KL. Vaginal hysterectomy in non-prolapsed uterus.
Ugeskr Laeger 2001;163(15):2133-5
Douchette RC, Sharp HT, Alder SC. Challenging generally accepted contraindications to vaginal hysterectomy. Am J Obstet Gynecol 2001;184(7):1386-9
Mirsky T, Magos A. Mass closure: a new technique for closure of the vaginal vault at vaginal
hysterectomy. BJOG 2001 Dec;(12):1295-7
Switala I, Cosson M, Lanvin D, Querleu D, Crepin G. J. Is vaginal hysterectomy important for
large uterus of more than 500g? Comparison with laparotomy. Gynecol Obstet Biol Reprod
(Paris) 1998; 27(6):585-92
Kudo R, Yamauchi O, Okazaki T, Sagae S, Ito E, Hashimoto M. Vaginal hysterectomy without
ligation of the ligaments of the cervix uteri. Surg Gynecol Obstet 1990 170(4):299-305)
Acknowledgement: I would like to thank Dr. Alexander Pinelis, Dr. Sulma

Gazit, and Mr. Timo Parente for their assistance writing this article.
350
Laparoscopic hysterectomy:
Should we remove the cervix?
Jacques Donnez, Jean Squifet
The development of new accessories and improved technology has enabled gynecologists to perform laparoscopic hysterectomy. Reich et al (1) described the
technique of laparoscopic hysterectomy for the rst time in 1989. Laparoscopyassisted vaginal hysterectomy and bilateral salpingo-oophorectomy have been
routinely performed since 1990 (5) in cases of endometrial cancer and benign
gynecological disease in our department as well as in others (2,3,4).
Several series (5,6,7,8) have documented shorter hospital stay and recovery
times in women having undergone laparoscopic hysterectomy.
In 1990, we performed the rst laparoscopic subtotal (supracervical) hysterectomy (LASH) in our department and the rst series of 32 cases was published
in 1993 (7). Subsequently, a series of 500 cases was described (9).
From July 1990 to December 2002, 1,300 laparoscopic supracervical hysterectomies were performed in our department (Table I). The incidence of LASH
in our series of hysterectomies was 31 %. It increased from an incidence of
2 % (1990) to 22 % (1993) to 46% (1995) to 44 % (1996) and then remained
stable until 1999 (44%). These last ve years, the incidence has remained stable
(44). One of our publications in the New England Journal of Medicine has
demonstrated that the laparoscopic approach is not expensive if non-disposable
material is used (10).
A four-puncture technique was used for LASH.
Three 5-mm second-puncture trocars were inserted: one 3 cm above the
symphysis pubis and the others 4-5 cm laterally, in each lower quadrant within
the safety triangles (between the midline and the epigastric artery area).
351
A 10-mm laparoscope connected to a video camera was placed intraumbilically. After careful inspection of the entire peritoneal cavity, the patient was
moved into the Trendelenburg position.
Only one surgical method was used to transect pelvic ligaments and achieve
hemostasis : bipolar coagulation and transection. Because endoscopic staplers
are very expensive, bipolar coagulation (bipolar grasping forceps, Storz 3mm
wide) and transection were systematically used. Bipolar coagulation was used
to desiccate the utero-ovarian ligaments and vessels and the isthmic portion of
both Fallopian tubes. Scissors were then used to transect the structures within
the coagulated areas. Meticulous hemostasis was achieved by repeated bipolar
coagulation of transected vessels. If a bilateral (or unilateral) salpingo-oophorectomy was required, the infundibulopelvic ligaments were similarly coagulated and transected. The round ligaments were treated in the same way.
The anterior leaf and the posterior leaf of the broad ligament were then
opened with scissors. Hydrodissection made the procedure easier and allowed
the surgeon to expose the uterine vessels.
The vesico-uterine peritoneum was then opened with scissors. The vesicocervical space was dissected no more than 2 cm below the limit between the
cervix and the corpus uteri.
After careful identication of the uterine vessels and ureters, the uterine
vessels were electrocoagulated with the bipolar coagulation forceps and transected.
The unipolar knife or unipolar scissors were then used to cut the cervix
below the level of the internal os and separate the cervix from the corpus.
Hemostasis was achieved by meticulous coagulation. Until November 1993,
longitudinal (vertical or horizontal) posterior colpotomy was performed either
by laparoscopy or through the vagina. Since then, however, the uterus has been
removed through a 12-mm trocar after morcellation using Steiners morcellator
(11).
Now, a new morcellator (Storz)(20mm in size) allows to reduce the duration
of morcellation.
Results
All of our LASH procedures were successful. The patientsages ranged from 34
years to 57 years. The mean duration of surgery was 62 min (morcellation not
included). In the majority of cases, in experienced hands, the average duration
is about 60 min, although, in university teaching hospitals, the learning process
of registrars leads to an increase in the surgery duration (Table I).
352
The estimated blood loss was systematically less than 100 ml. There were
four cases of bladder injuries. There were no other intraoperative complications
such as bowel or ureteral injuries. All patients were theoretically able to leave
the hospital the rst day following surgery. Many, nevertheless, prefer to stay
2 or 3 days, knowing that the Belgian insurance system offers reimbursement
for up to 10 days hospitalisation.
In some cases, a second-look laparoscopy performed in cases of ovarian
cysts allowed us to explore the pelvic cavity and to demonstrate the absence of
severe adhesions on the cervical stump. Patients were requested to undergo a
PAP-smear and a colposcopy every two years.
In 11 patients (Table II), laparoscopy must be performed because of a tumor located in the pouch of Douglas causing deep dyspareunia. Symptoms
were due to a small piece (3cm) of the morcellated uterus which had not been
removed during the rst laparoscopy (LASH). Laparoscopy allowed us to dissect the forgotten specimen which was covered by peritoneum.
In 1990, the LASH technique was not frequently used in our department.
Indeed, in a series of 204 hysterectomies carried out in the department in 1990,
only 4 LASH (2 %) were performed. At the time, the disadvantage of the
technique, which is the remaining cervix, was considered as a potential risk
factor for cervical cancer. It is obvious that the risk is low in some groups of
the population. Moreover, this question is never asked when an endometrial
ablation is performed. Subsequently, the incidence of LASH increased from
just 2 % to 44 % of all hysterectomies. Since the uterus can be removed laparoscopically with the help of Steiners morcellator, LASH must be considered
as a STRICTLY LAPAROSCOPIC APPROACH to hysterectomy. No patients
required major analgesics the day after surgery.
Numerous advantages were noted :
1. Rapid recovery similar to that observed after laparoscopic surgery for
infertility.
2. Reduced postoperative discomfort and shorter hospital stay.
3. Lower rate of complications when compared to laparoscopic hysterectomy (LH) and LAVH.
4. Decreased risk of vaginal vault prolapse.
5. Decreased risk of post-hysterectomy urine incontinence.
6. Absence of decreased libido.
Patients who underwent LASH reported much less discomfort than patients
who underwent other types of hysterectomy. No patients required major analgesic drugs. Only 8 % of patients required analgesic drugs a few hours after
353
surgery, but no patients required drugs the day after surgery. Patients were
able to ambulate very soon after LASH (the same day) just as patients who underwent laparoscopic adhesiolysis, ovarian cystectomy or salpingoneostomy.
Sexual intercourse was permitted 2 weeks after surgery. There was only one
case of cervical prolapse and no signs of enterocele in patients reviewed in a
ve-year follow-up (n=570). There were no signs of enterocele.
A serious complication rate of 3 % was reported after LAVH (laparoscopyassisted vaginal hysterectomy) and LH (laparoscopic hysterectomy) in a multicentric study in the UK (16) as well as in Belgium (17). Ureteral and/or bladder
damage occurred at a rate of 2 % after LH. In our series, as in the series of Lyons
(18), ureteral complications were rarely noted (only one case in our series). The
LASH technique reduces the risk of ureteral injury, but does not eliminate it.
Indeed, thermal damage due to the coagulation could provoke ureteral stula.
Nevertheless, four cases of bladder injury (laparoscopically repaired) occurred
in patients with a medical history of 2 or 3 Caesarean sections.
Sutton (19) reported a high rate of complications after SLH (subtotal laparoscopic hysterectomy) in Paris, but this high rate can only be explained either
by an inappropriate surgical technique or by the learning curve of some of
the surgeons involved in the study. Indeed, the high rate of cyclical bleeding
after SLH can only be accounted for by an inappropriate section of the upper
part of the cervix, leaving in place the isthmic portion of the uterus with endometrium. In our technique, in the rst series of 32 cases (7), we encountered
this problem and we frequently recommended cutting the cervix accordingly
and coagulating the upper part of the cervical canal.
One other advantage of LASH is the preservation of the cardinal ligaments
and the utero-sacral ligaments which probably play a role in pelvic organ suspension and in bladder continence control (20).
According to Kilkku et al (21) and Virtanen et al (22), the libido and orgasmic frequency are not affected by subtotal hysterectomy but are signicantly
reduced by total hysterectomy.
Preliminary results of a prospective study carried out in our department
conrm that sexual satisfaction is not affected by LASH.
Because of the feasibility of the technique, the very low morbidity rate and
the quick recovery, LASH could be suggested as a strictly laparoscopic approach in some indications and especially in cases of a uterus with multiple
submucosal myomas. Indeed, we know that in such cases, the recurrence rate of
bleeding after hysteroscopic myoma resection and endometrial ablation is more
than 25 % after a 2-year follow-up (14) and LASH can be proposed instead of
hysteroscopic surgery to women with this type of pathology.
354
Failures of endometrial laser ablation and partial endometrial laser ablation

for dysfunctional bleeding in a normal-sized uterus occur in about 3-5 % of
cases (12). Failed endometrial ablation must also be considered as an indication
for LASH. Because of the good results and the absence of complications, the
technique of LASH is proposed in our department in cases of :
1. enlarged uterus with multiple broids (up to a 13-week gestational volume)
and normal cervix (even in nulligravida);
2. failures of endometrial ablation and/or myomectomy (failure demonstrated
by the recurrence of meno-metrorrhagia);
3. myomatous uterus in women who have a medical history of Caesarean section;
4. multiple submucosal myomas even if the uterine volume is < 7 gestational
weeks
5. as a step of laparoscopic sacroxation in cases of uterine prolapse.
Table I: Preoperative and early postoperative complications in a series of 900 LASH
1,300
Duration of surgical procedure

including morcellation
62 (30145)
111 (40-168)
Uterine weight
182 g (60g -250g)
Complications
1. Peroperative
- Fever > 38(after the second day)
- Bladder incision (< 1 cm)
4* (0.3 %)
- Ureter
2**
- Hemorrhage
2 (0.2%)
2. Postoperative
-Urinary tract lesion**
2 (0.2%)
- Colon or rectal perforation
- Peritonitis*** (>10 days post-op)
1
0
*sutured laparoscopically (in three patients with a previous history of 2 or 3 Caesarean sections).
**stula caused by thermal damage treated by JJ stent
*** treated by laparoscopy and medical therapy (unknown origin).
355
Table II.
Late follow-up (> 5 years) (n = 570)
- Fistula
- Cyclical bleeding
12 (2%)*
- Cervical prolapse
- Pelvic pain or dyspareunia
- Abnormal smear
- Second-look laparoscopy
Burch
- Serous mucinous or dermoid ovarian cyst
6 (1.1%)
- Forgotten morcellated specimen
11 (2%)
* Since 1992, care has been taken to cut the cervix below the internal os so that no remaining
endometrium persists. Laparoscopic coagulation of the upper part of the cervical canal is carried
out.
The risk induced by the preservation of the cervix has long been considered to
be the development of a cervical stump carcinoma but this risk is only 0.10.4
% (21,23). However, historically, subtotal hysterectomy was condemned well
before cervical smears became accepted.
Today, systematic cervical smears, colposcopy and biopsy, if required, are
determining factors in the selection of the case and the post-operative follow-up
of the patient. How many cases of invasive cervical carcinomas are observed
in consultations every year ? Because the incidence of this disease is very low
in the group of women followed up every year by PAP smear, and because
we now have accurate means to keep a close check on the cervix, the risk of
encountering invasive cervical cancer is virtually nil.
We consider that patients suffering from uterosacral ligament endometriosis
or deep endometriosis with dyspareunia and dysmenorrhea must be excluded.
Indeed, total hysterectomy with resection of the uterosacral ligaments is more
appropriate in these cases.
So far, more than 1,300 cases have been performed with an excellent followup to date because of the low rate of complications and good acceptance by the
patient. This suggests this strictly laparoscopic approach as the hysterectomy
procedure of choice in selected cases.
356
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Reich, H., De Caprio, J., Mac Glynn, F. (1989). Laparoscopic hysterectomy. J. Gynecol. Coll.
Surg., 5, 213.
Nezhat, C., Nezhat, F., Silfen, S.L. (1990). Laparoscopic hysterectomy and bilateral salpingooophorectomy using multire GIA surgical stapler. J. Gynecol. Coll. Surg., 6, 287.
Mage, G., Canis, M., Wattiez, A., Pouly, J.L., Bruhat, M.A. (1990). Hystrectomie et coelioscopie. J. Gynecol. Obstet. Biol. Reprod., 19, 573-576.
Padial, J.G., Sotolongo, J., Caseay, M.J., Johnson, C., Osbord, N.G. (1992). Laparoscopy-assisted vaginal hysterectomy : report of seventy-ve consecutive cases. J. Gynecol. Surg., 8;
81.
Liu, C.V.Y. (1992). Laparoscopic hysterectomy. Report of 215 cases. Gynecol. Endoscopy, 1,
73-77.
Reich, H., Mac Glynn, F., Sekel, L. (1990). Total laparoscopic hysterectomy. Gynecol.
Endoscopy, 2, 59-63.
Donnez, J., Nisolle, M. (1993). LASH : laparoscopic supracervical (subtotal) hysterectomy. J.
Gynecol. Surg., 9, 91-94.
Phipps, J.H., John, M., Hassanaien, M., Saeed, M. (1993). Laparoscopic and laparoscopically
assisted vaginal hysterectomy : a series of 114 cases. Gynecol. Endoscopy, 2, 7-12.
Donnez, J., Nisolle, M., Smets, M., Polet, R., Bassil, S. (1997). LASH: Laparoscopic supracervical (subtotal) hysterectomy. A rst series of 500 cases. Gynecol. Endoscopy, 6, 73-76.
Nisolle, M., Donnez, J. (1997). Alternative technique of hysterectomy. New. Engl. J. of
Medicine, 336, 291-292.
Nisolle, M., Grandjean, P., Gillerot, S., Donnez, J. (1991). Endometrial ablation with the NdYAG laser in dysfunctional bleeding. Minimally Invasive Therapy, 1, 35.
Garry, R. Laparoscopic hysterectomy in the UK in 1992 (personal communication).
Cusumano, P.G., Deprest, J., Hardy, A., Van Herendael, B., Verly, M. Multicentric registration on laparoscopic hysterectomy; a one-year experience. Proceedings of the First European
Congress of Gynecologic Endoscopy. Clermont-Ferrand, France, September 1992, 46.
Lyons, T.L. (1993). Laparoscopic supracervical hysterectomy using the contact Nd-YAG laser.
Gynecol.. Endoscopy, 2, 79-81.
Sutton, C. SLH compared with TAH (personal communication).
Parys, B.T., Haylen, B.T., Hutton, J.L., Parsons, K.F. (1989). The effects of simple hysterectomy on vesicourethral function. Brit. J. Urol., 64, 594-599.
Kilkku, P., Gronroos, M., Rauramon, L. (1985). Supravaginal uterine amputation with peroperative electrocoagulation of endocervical mucosa. Description of the method. Acta Obst.
Gynecol. Scand., 64, 175-177.
Virtanen, H., Makinen, J., Tenho, T., Kiilholma, P., Pitkanen, Y., Hirvonen, T. (1993). Effects
of abdominal hysterectomy on urinary and sexual symptoms. Brit. J. Urol., 72:868-72.
Steiner, R.A., Wight, A., Tadir, Y., Haller, U. (1993). Electrical cutting device for laparoscopic
removal of tissue from the abdominal cavity. Obstet. Gynecol., 81, 471-474.
Storm, H.H., Clemmenson, I.H., Manders, T., Brinton, L.A. (1992) Supravaginal uterine amputation in Denmark 1978-1988 and risk of cancer. Gynecol. Oncol., 45, 198-201.
357
Laparoscopic myomectomy / myolysis :

to whom should it be proposed ?
Pascale Jadoul, MD, Jacques Donnez, MD, PhD
Department of Gynecology, Cliniques Universitaires St. Luc,
Universit Catholique de Louvain, Avenue Hippocrate, 10, B-1200 Brussels Belgium
E-mail:donnez@gyne.ucl.ac.be
Introduction
Leiomyomas of the uterus are the most common solid pelvic tumours, estimated to occur in 20 to 50 % of women [1]
Two issues that need to be addressed when dealing with uterine myomas are
which myomas should be removed and which procedure should be performed
to remove them. To answer these questions, the classic risk-benet ratio analysis must be applied. The best treatment is that which improves symptoms with
the fewest side effects and complications, and the lowest risk of recurrence.
When treatment is indicated, the art is choosing the right one. Medical
treatment, abdominal myomectomy, laparoscopic myomectomy or myolysis,
hysteroscopic myomectomy, myoma embolization and hysterectomy all have
a place in the treatment of myomas. While hysterectomy is the best option in
older women, for women wishing to preserve their fertility, the indications and
choice of treatment are more problematic.
This article sets out to determine the right indications for myomectomy
and to dene the place of laparoscopic myomectomy and myolysis in women
wishing to maintain their fertility.
358
Indications for myomectomy

At least 50% of leiomyomas remain asymptomatic. While there is no disputing
that myomas may cause menorrhagia, dysmenorrhea, pelvic discomfort, and
bladder and bowel compression symptoms, the relationship between leiomyomas and infertility and also between leiomyomas and obstetrical complications
remain subjects of debate.
Myomas causing menorrhagia, pain or signs of bladder or bowel compression should be treated. In women who have completed their families, hysterectomy might be considered the most effective treatment and is often very
successful. In symptomatic women who still wish to conceive, conservative
treatment should be proposed.
The question is, are there indications for myomectomy in asymptomatic
patients ?
Myomectomy for infertility?

Ideally, to prove a relationship between broids and infertility, prospective randomized studies should be performed, comparing women desiring pregnancy
with and without myomas, in order to compare pregnancy rates and possibly
the time needed to achieve pregnancy. Such studies have not been performed.
Another possibility would be to compare pregnancy rates of infertile women
with and without myomas, in whom other infertility factors have been excluded.
There is only one publication comparing spontaneous conception in infertile
women with and without myomas, in whom andrologic and tubal infertility factors had been excluded [2]. Bulleti found a signicant difference in pregnancy
rates between infertile women with and without myomas (11% fertility rate in
women with myomas versus 25% in those without). However, the methodology of this article is questionable as the follow-up was short and the different
groups too small to allow conclusions to be drawn as to the inuence of myoma
location, number and size.
Our knowledge of the relationship between myomas and fertility results
from indirect proof.
In vitro fertilization provides a good model to assess the role of myomas in
infertility, since other factors, such as tubal or andrologic factors, are excluded
allowing us to investigate the inuence of myomas on embryo implantation for
embryos of the same quality.
It is generally accepted that the anatomical location of a broid is an impor-
359
tant factor, with submucosal myomas most likely to cause infertility, followed
by intramural and nally subserosal myomas. Myomas may also be associated
with implantation failure or gestation discontinuation due to focal endometrial vascular disturbance, endometrial inammation, secretion of vasoactive
substances or an enhanced endometrial androgen environment [3,4]. On the
other hand, myomas may cause dysfunctional uterine contractility, which may
interfere with sperm migration, ovum transport or nidation [4-6]. This possible
interference of myomas with sperm migration and ovum transport cannot be
assessed by the IVF model.
Another indirect way of assessing the inuence of myomas on fertility is to
analyse the effect of myomectomy on fertility outcome in infertile women.
Myomas and assisted reproduction

Several authors have compared the results of IVF in women with untreated
myomas and without myomas.
Submucosal leiomyomas signicantly decrease IVF pregnancy rates [7-10]
while hysteroscopic resection of submucosal myomas results in a signicantly
higher pregnancy rate compared to controls with a normal uterine cavity [11].
For intramural and subserosal broids, there seems to be no consensus.
In patients with a distorted uterine cavity, a signicant decrease in pregnancy rates has been described [8].
The impact on fertility of broids that do not deform the uterine cavity is
uncertain. For Fahri [8] Ramzy [12], Jun [13] and Yarali [14], the presence of
myomas that do not distort the cavity, even those measuring up to 10cm [14],
does not impact negatively on pregnancy rates.
On the contrary, for Eldar-Geva [9], Stovall [15], Hart [16], Check [17] and
Oliveira [18], intramural myomas that deform the cavity do indeed decrease
pregnancy rates. Hart [16] and Check [17] claim that even myomas of less
than 5 cm can inuence pregnancy rates while Oliveira [18] believes that only
myomas of 4 cm or more have a negative effect on pregnancy rates.
Effects of myomectomy on fertility outcome

in infertile patients
Numerous studies on fertility outcome after myomectomy in infertile patients
have been published and were reviewed by us in 2002 (table 1) [19]. Most of
them were retrospective analyses. Some focused on myoma location, but others
did not distinguish myoma type.
360
The global pregnancy rate after myomectomy in infertile women, regardless

of the kind of surgery undertaken, varies between 9.6 and 76.9 %.
How can we explain this discrepancy?
Considerable differences in results persist even when different kinds of surgery are considered separately. After hysteroscopic myomectomy, pregnancy
rates are between 16.7 and 76.9% and, after laparoscopic or laparotomic myomectomy, between 9.6 and 75%.
The differences encountered with the same surgical approach demonstrate
the inuence of different factors on pregnancy rates. Factors implicated are age,
number of myomas, myoma size, myoma location and technical factors.
Age over 35 years and an association with other infertility factors decrease
pregnancy rates [12, 20-23].
In Fauconniers study [22], fertility rates were found to be lower in women
who had associated tubal pathology, male or ovulatory factors. Vercellini [21]
showed decreased pregnancy rates after myomectomy in women over 35 years
of age, and when the duration of infertility before myomectomy exceeded 2
years. With regard to the number of myomas, some authors observed a lower
pregnancy rate when more broids were removed [24,25], while others noted
no difference [21,22,26].
For Sudik [24], pregnancy rates were higher after removal of myomas with a
volume of > 100 ml ( +/- 8 cm diameter). Others, however, found no difference
according to myoma size [21,22,26].
Ancien [27] and Sudik [24] demonstrated no inuence of myoma location.
Fauconnier [22] found a lower pregnancy rate with posterior myomas. Dessolle
[25] detected better results when there was distortion of the uterine cavity
before myomectomy.
Technical factors, like the surgeons skill and experience, and probably the
material and techniques used, surely also play a role.
All in all, the conclusions on the impact on pregnancy rates of the number, size and location of myomas, and their capacity to distort the cavity, are
somewhat contradictory. These contradictions, and the inuence of a patients
age and associated fertility factors, coupled with the probable role of technical
factors, lead us to question the real impact of myomas on fertility.
Myomectomy is therefore indicated only after a complete evaluation of
other potential infertility factors [28].
Myomectomy to improve pregnancy outcome?

Although our objective is to analyse the impact of myomas on fertility, the goal
361
for the infertile couple is not the pregnancy itself, but the birth of a healthy
child. We should therefore also concentrate on the impact of myomas and myomectomy on pregnancy outcome.
Benson [29] showed a signicant increase in miscarriage rates in women
with myomas, particularly women with multiple myomas.
In a retrospective study by Sheiner [30] women with uterine myomas during pregnancy had a 3.5-fold increase in the incidence of intrauterine growth
retardation, a 4-fold increase in placental abruption, a 5-fold increase in the
incidence of transverse lie or breech presentation, a 5-fold increase in the cesarean section rate and a 70% increase in premature rupture of membranes.
According to Li [20], Vercellini [21] and Marchionni [31] miscarriage rates
are signicantly reduced after myomectomy.
Laparoscopic myomectomy and myolysis

Myomas can be treated conservatively by medical treatments or uterine artery
embolization, or surgically by myomectomy (abdominal, laparoscopic or hysteroscopic) or myolysis.
When comparing techniques for conservative treatment of myomas in
women of reproductive age, important issues are :
safety
short- and long-term efciency
Submucosal myomas should be removed by hysteroscopy. For intramural
and subserosal myomas, our aim is to compare laparoscopic myomectomy and
myolysis with abdominal myomectomy and uterine artery embolization.
Safety
Three prospective randomized studies have compared abdominal and laparoscopic myomectomy [32-34].
Mais and Serrachioli showed that laparoscopic surgery is associated with
shorter hospitalization, faster recovery, less expense, less blood loss, less fever
and fewer surgical complications than abdominal myomectomy. Case-control
studies by Stringer [35] and Silva [36] conrmed the benets of laparoscopic
myomectomy over abdominal myomectomy. In these two studies, however,
surgery time was longer in the laparoscopy group.
Several case-series have conrmed the feasibility and safety of laparoscopic
myomectomy [19, 37-43].
Overall, these studies reveal a low complication rate. Surgery may take
362
longer than with open procedures, but the recovery time is shorter.
In these studies, the conversion rate to laparotomy was less than 2% of
cases, even when large, deep myomas were resected.
Some authors have reported the laparoscopic removal of very large myomas, up to 21 cm [42, 44-45].
The main drawback of laparoscopic myomectomy is the risk of hemorrhage.
In the three randomized studies, laparoscopy was not accompanied by increased blood loss, but in Stringers study [35], blood loss was greater with
laparoscopic myomectomy.
Are there objective factors predicting possible blood loss during laparoscopic myomectomy ?
Blood loss seems to be correlated to myoma size.
In Sinhas study of 91 women with myomas of at least 9 cm in size [45], 20
required transfusion during or after myomectomy. A woman in whom a 21cm
myoma was resected laparoscopically lost 2000 ml of blood and eventually
underwent abdominal hysterectomy for dilutional coagulopathy.
In Takeuchis series [44], blood loss was signicantly greater when myomas
were over 10 cm in size. There was no association between blood loss and
number of myomas.
From these studies, it is reasonable to conclude that blood loss is related to
myoma size. It is also reasonable to assume that blood loss is inuenced by the
surgeons technical skill and experience.
How can blood loss be reduced during laparoscopic myomectomy ?
Some surgeons inject vasopressin into myomas to reduce bleeding [43-46].
Others remove large myomas without the use of vasopressin [37].
To our knowledge, no studies to date have proved the efcacy of vasopressin.
Another possibility is to perform ligation or coagulation of the uterine artery
[47]. The safety of this technique in women desiring pregnancy has not been
proven, however.
In theory, preoperative GnRH agonist therapy might shrink myomas, thereby
simplifying myomectomy and diminishing blood loss.
Three prospective randomized studies have evaluated the effect of preoperative treatment with GnRH agonists for laparoscopic myomectomy [48-50].
The principal advantage of GnRH agonists appears to be correction of
anemia before surgery, and a slight reduction in blood loss. However, GnRH
agonists make the procedure more difcult by occulting the plane of cleavage
and increasing operating time and the risk of conversion [51]. Moreover, they
may be associated with a higher recurrence rate [52].
363
Preoperative GnRH therapy should not therefore be routinely used.

It is difcult to compare laparoscopic myomectomy with uterine artery embolization (UAE) as they involve two completely different techniques.
In a review of published data from trials involving between 60 and 305
patients who underwent UAE, the symptom improvement rate was between 80
and 92 % and the hysterectomy rate was between 0 and 2 % [53].
Procedural complications secondary to arterial puncture, contrast injection, arterial catherization and non-target-organ embolization are intrinsic to
all embolization procedures, but are fortunately rare and minimized by the
radiologists experience.
Chronic discharge is relatively benign, affecting 7 % of patients [54].
Serious sequelae of UAE are infectious complications in 1 2 % of cases [53].
Infection can occur even months after the procedure and is more common in
case of large myomas.
At least one case of death due to septicaemia as a result of pyometrium has
been reported [55].
Laparoscopic myolysis is not associated with safety problems other than the
classic complications of laparoscopy.
Efciency
As the purpose of myomectomy is to preserve fertility, the main short- and
long-term issues are fertility outcome and pregnancy outcome.
Pregnancy after laparoscopic myomectomy and myolysis
The only prospective randomized study comparing laparoscopic and abdominal
myomectomy [33] shows no difference in pregnancy rates between the two
groups (54% versus 56%).
In Campos retrospective study, comparing 22 women who underwent laparoscopic myomectomy with 19 women who underwent abdominal myomectomy, the pregnancy rates were found to be similar [56].
Overall, one can expect pregnancy rates to be similar after laparoscopic and
abdominal myomectomy.
It is logical to assume that pregnancy rates are inuenced by the presence
of adhesions. There are no prospective randomized studies comparing adhesion formation between laparoscopic and abdominal myomectomy. However,
prospective studies and surgical case series seem to point to an advantage with
laparoscopy. Dubuissons analysis of the literature shows that the rate of postoperative adhesions after laparoscopic myomectomy is, on average, 41.3% and
364
after abdominal myomectomy, 98 % [39]. However, the incidence of adhesions

is very variable, ranging from less than 2% in Di Gregorios report [41] to 66%
in Hassons series [57].
These gures should be viewed with caution, however, as they are often
derived from retrospective data and there are a great many other confounding
variables such as methodology, number of sites checked and types of adhesions.
Interestingly, when prospective studies are conducted to analyse the efcacy
of adhesion barriers during laparoscopic myomectomy, the overall incidence of
adhesions seems to be higher than in the retrospective case series.
Three prospective randomized controlled studies have evaluated the efcacy
of these adhesion barriers.
Mais [32] concluded that oxidized regenerated cellulose (Interceed,
Gynecare) signicantly reduced, but did not prevent, adhesions after laparoscopic myomectomy. Pellicano [58] showed that, during second-look laparoscopy, 72 % of patients were adhesion-free with the use of hyaluronic acid gel,
compared to an adhesion-free rate of only 22% in the control group. Mettler
[59] reported a decrease in adhesion formation with the use of SprayGel, a
synthetic absorbable adhesion barrier. Whether any of these interventions enhance pregnancy rates or reduce clinical symptoms of pelvic adhesive disease
remains to be proved.
No data are available on pregnancy rates after laparoscopic myolysis.
However, very dense adhesions have been demonstrated in 10 to 50% of
cases[60,61], which might impair fertility.
There are no randomized studies comparing pregnancy rates after laparoscopic myomectomy and uterine artery embolization. Although successful
pregnancies have been achieved after UAE [62-64] serious complications of
UAE can impair fertility. Amenorrhea complicates 1 % of procedures [53].
One to 2 % of subjects experience ovarian failure [65] and postprocedural
hysterectomy is necessary in 1 % to 2% of patients, mostly for infectious complications [66] Olive [67] described a signicant rate of premature ovarian
failure and occasional damage to endometrial vasculature with atrophy and
adhesion formation.
Laparoscopic myomectomy must therefore be considered a far better option
for women wishing to preserve their fertility.
Pregnancy outcome after laparoscopic myomectomy and myolysis
In the only randomized trial to compare pregnancy outcome after laparoscopic
and abdominal myomectomy [33], no signicant differences were found in
365
postoperative miscarriage rates or preterm deliveries. The cesarean section rate

was 78% in the abdominal myomectomy group and 65% in the laparoscopic
myomectomy group.
In other, non-controlled studies [38,42,43,56] cesarean section rates were
between 45 and 80%.
Overall, cesarean section rates vary widely and seem similar after laparoscopic and abdominal myomectomy.
The only study to compare obstetrical outcome after laparoscopic myomectomy and uterine artery embolization is a retrospective study by Goldberg [68],
which compared 53 pregnancies after uterine artery embolization with 139
pregnancies after laparoscopic myomectomy. This study showed a signicant
increase in preterm delivery and malpresentation after UAE.
A major concern after laparoscopic myomectomy is the risk of uterine rupture during pregnancy or labor due to insufcient closure or healing of the
uterine incision.
A few case reports in the literature report uterine rupture after laparoscopic
myomectomy [69-75]. Dubuisson describes 3 uterine ruptures, all occurring
before labor [76].
Extensive thermal damage due to overaggressive use of electrosurgery has
been blamed for poor vascularization and tissue necrosis with adverse effects
on scar strength [76].
This risk does not appear to be related to the depth of the myoma, as in
Liengs case, the myoma removed was subserosal with a pedicle of 2 to 3 cm
[75]. His patient achieved pregnancy by IVF 6 weeks after myomectomy. Lieng
therefore recommends waiting 3 months after myomectomy before attempting
pregnancy.
However, these case reports do not allow us to draw any conclusions as to
the relative risk, compared to abdominal hysterectomy. Moreover, there are no
recent reports on the risk of uterine rupture after abdominal myomectomy.
Cases of uterine rupture during pregnancy after laparoscopic myolysis have
also been published [77-79].
Overall, the prognosis for pregnancy in women who have undergone laparoscopic myomectomy appears to be comparable to published reports on abdominal myomectomy. Data are insufcient, however, to determine whether cesarean
section should be routinely advocated for delivery after myomectomy.
Recurrence
In Rossettis randomized trial, recurrence rates after laparoscopic and abdominal myomectomy were similar (23 and 27%) [26]. Serrachioli also showed
366
no signicant difference in a randomized trial [33]. Marret retrospectively

analysed 126 laparoscopic and 176 abdominal myomectomies and found a
2.5 and 3.6% recurrence rate respectively at two years of follow-up [80]. In
Doridots retrospective analysis of 196 women who underwent laparoscopic
myomectomy, recurrence was 12.7 % at 2 years of follow-up and 16.7% at 5
years [40]. The risk of recurrence in this study was related to the number of
myomas and was higher in nulliparous women.
Figures on recurrence rates must be interpreted with caution, as imaging
modality and duration of follow-up are likely to greatly inuence ndings.
Recurrence risk seems to be comparable after laparoscopic and abdominal
myomectomy.
Conclusion
The two main issues that need to be addressed when uterine myomas are encountered are which myomas should be removed and which procedure should
be used for this purpose.
Myomas causing menorrhagia, pain or signs of bladder or bowel compression should generally be treated. In older women who have completed their
families, hysterectomy might be considered the best option and is indeed very
successful in most cases. In symptomatic women with a desire for pregnancy,
conservative treatment should be proposed.
In asymptomatic women who present with infertility or who wish to conceive, there is no consensus on the indications for myomectomy.
Submucosal myomas should be removed. As far as intramural myomas are
concerned, those distorting the uterine cavity should be removed. There is no
general consensus on myomas not distorting the uterine cavity. We feel it is
acceptable to propose myomectomy for myomas of 4 to 5 cm in size.
Laparoscopic myomectomy is feasible, safe and comparable to abdominal
myomectomy with respect to fertility and pregnancy outcomes. Its main advantage over abdominal myomectomy is the faster recovery time and shorter
hospital stay. Its drawback is the risk of hemorrhage. This risk seems to be
related to myoma size and inuenced by the surgeons experience.
In women of reproductive age, laparoscopic myomectomy must be favored
over uterine artery embolization. Indeed, the latter technique is associated with
complications impairing fertility and further prospective trials should be conducted before proposing it to women wishing to preserve their fertility.
Laparoscopic myolysis is a feasible technique, but associated with a risk of
adhesions and therefore not appropiate for young women.
367
Table 1:
(from Donnez J and Jadoul P, Human Reprod 2002; 17:1424-30)
AUTHOR
STUDY
MYOMA
TREAT PR(%) Lps/

MENT lpt Hsc
(Starks, 1998)
Prospective
32
SS,IM,SM
Lpt
62.5
(Brooks et al, 1989)
Retrospective
15
SM
Hsc
33.3
(Gatti et al., 1989)
Retrospective
30
Lpt
43.3
(Egwuatu, 1989)
Retrospective
52
SS,IM,SM
Lpt
9.6
(Prien-Larsen and
Kjer,1989)
Retrospective
33
Lpt
31
(Loffer, 1990)
Retrospective
12
SM
Hsc
58.3
(Vollen-Hoven et al.,
1990)
Prospective
13
Lpt
46
(Donnez et al., 1990)
Retrospective
24
SM
Hsc
67
(Valle, 1990)
Retrospective
16
SM
Hsc
62
(Corson and Brooks,

1991)
Retrospective
13
SM
Hsc
76.9
(Hucke et al, 1992)
Retrospective
14
SM
Hsc
28.6
(Verkauf, 1992)
Retrospective
24
SS,IM,SM
Lpt
58.3
(Liu et al., 1993)
Prospective
IM, SM
Lpt
75
(Gehlbach et al., 1993)
Retrospective
37
SS,IM,SM
Lpt
57
(Tulandi et al., 1993)
Prospective
26
SS,IM
Lpt
61.5
(Fayez and empsy,1993)
Retrospective
38
SS,IM,SM
Lpt
63
(Abramovici et al., 1994) Prospective
10
Lpt
50
(Nezhat et al., 1994)
Retrospective
14
SS,IM,SM
LAM
28.3
(Sirjusingh et al., 1994)
Retrospective
38
SS,IM,SM
Lpt
37
(Goldenberg et al., 1995) Retrospective
15
SM
Hsc
46.6
(Hallez, 1995)
Retrospective
32
SM
Hsc
56
(Cravello et al., 1995)
Retrospective
16
SM
Hsc
25
(Darai et al., 1996)
Retrospective
52
SS,IM
Lpt, lps 30.8
(Dubuisson et al., 1996)
Prospective
21
>50 mm
Lps
33.3
(Ancien and Querada,

1996)
Retrospective
20
SS,IM,SM
Lpt
15
368
AUTHOR
STUDY
MYOMA
TREAT PR(%) Lps/

MENT lpt Hsc
(Hasson et al., 1996)
Retrospective
17
SS,IM,SM
Lps
71
(Miller et al., 1996)
Prospective
41
Lps
73.1
(Sudik et al., 1996)
Retrospective
67
Lpt, lps 58.2
(Darai et al., 1997)
Retrospective
29
SS,IM,SM
Lps
(Kuhlman et al., 1997)
Retrospective
41
Lpt, lps 61
(Seineira et al., 1997)
Retrospective
30
SS,IM,SM
Lps
16.7
(Preutthipan and
Theppisai, 1998)
Retrospective
12
SM
Hsc
16.7
(Campo and Garcea,

1999)
Prospective
24
SS,IM
Lps
54.1
(Vercellini et al., 1999)
Retrospective
138
SS,IM
Lpt
55
(Vercellini et al., 1999)
Retrospective
40
SM
Hsc
37.5
(Giatras et al., 1999)
Retrospective
41
SM
Hsc
60.9
(Varasteh et al., 1999)
Retrospective
36
SM
Hsc
53
(Li et al., 1999)
Retrospective
30
SS,IM
Lpt
43
(Ribiero et al., 1999)
Retrospective
28
>50mm
Lps
64.3
(Serrachioli et al., 2000)
Prospective
115
>50mm
Lpt, lps 54.8
(Dubuisson et al., 2000)
Retrospective
81
SS,IM
Lps
53
(Bernard et al., 2000)
Retrospective
31
SM
Hsc
35.5
(Fernandez et al., 2001)
Retrospective
59
SM
Hsc
27.1
(Dessolle et al., 2001)
Retrospective
88
SS,IM
Lps
47.7
(Zollner et al., 2001)
Retrospective
49
SS, IM, SM
Lpt, lps,
41
hsc
(Rossetti et al., 2001)
Retrospective
29
SS, IM
Lps
TOTAL
1631
48.2
65.5
49 (615/1255)
45 (168/376)
48 (783/1631)
SS = subserosal, IM = intramural, SM = submucosal, Lpt = laparotomy, Lps = laparoscopy, Hsc =

hysteroscopy, LAM = laparoscopy-assisted myomectomy,= not mentioned.
369
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Verkauf,B.S. (1992) Myomectomy for fertility enhancement and preservation. Fertil. Steril.,
58, 1-15.
Bulleti,C., De Ziegler,D., Polli,V. et al. (1999) The Role of Leiomyomas in Infertility. J. Am.
Assoc. Gynecol. Laparosc., 6, 441-445
Deligdish,L. and Lowenthal,M. (1970) Endometrial changes associated with myomata of the
uterus. J. Clin. Pathol., 23, 676-680.
Buttram,V.C. and Reiter,R.C. (1981) Uterine leiomyomata : etiology, symptomatology, and
management. Fertil. Steril., 36, 433-445.
Hunt,J.E. and Wallach,E.E.(1974) Uterine factor in infertility: an overview. Clin. Gynecol., 17,
44-64.
Vollen-Hoven,B.J., Lawrence,A.S. and Healy,D.L. (1990) Uterine broids: a clinical review.
Br. J. Obstet. Gynecol., 97, 285-288.
Seoud,M.A., Patterson,R., Muasher,S.J. et al. (1992) Effects of myomas or prior myomectomy
on in vitro fertilization performance. J. Assist. Reprod. Genet., 9, 217-221.
Fahri,J., Ashkenazi,J., Feldberg,D. et al. (1995) Effect of uterine leiomyomata on the results
of in vitro fertilization treatment. Hum. Reprod., 10, 2576-2578.
Eldgar-Geva,T., Meagher,S., Healy,D.L. et al. (1998) Effect of intramural, subserosal and
submucosal uterine broids on the outcome of assisted reproductive technology treatment.
Fertil. Steril., 70, 687-691.
Healy,D.L. (2000) Impact of uterine broids on ART outcome. Environmental HealthPerspectives. 108, 845-847
Narayan,R., Rajat and Goswamy,K. (1994) Treatment of submucous broids, and outcome of
assisted conception. J. Am. Assoc. Gynecol. Laparosc., 1, 307-311.
Ramzy,A.M., Satta,M., Amin,Y. et al. (1998) Uterine myomata and outcome of assisted reproduction. Hum. Reprod., 13, 198-202.
Jun,S.H., Ginsburg,E.S., Racowsky,C. et al. (2001) Uterine leiomyomas and their effect on in
vitro fertilization outcome: a retrospective study. J. Assist. Reprod. Genet., 18, 139-143.
Yarali,H, Bukulmez,O. (2002) The effect of intramural and subserous uterine broids on implantation and clinical pregnancy rates in patients having intracytoplasmic sperm injection.
Arch. Gynecol. Obstet., 266, 30-33.
Stovall,D.W., Parrish,S.B., Van Voorhis,B.J. et al. (1998) Uterine leiomyomas reduce the efcacy of assisted reproduction cycles : results of a matched follow-up study. Hum. Reprod.,
13, 192-197.
Hart,R., Khala,Y., Yeong,C.T., Seed,P., Taylor,A., Braude,P. (2001) A prospective controlled
study of the effect of intramural uterine broids on the outcome of assisted conception. Hum.
Reprod., 16, 2411-2417.
Check, J.H., Choe,J.K., Lee,G., Dietterich,C. (2002) The effect on IVF outcome of small
intramural broids not compressing the uterine cavity as determined by a prospective matched
control study. Hum. Reprod., 17(5), 1244-1248.
Oliveira,F.G., Abdelmassih,V.G., Diamond, M.P., Dozortsev,D., Melo,N.R., Abdelmassih,R.
(2004) Impact of subserosal and intramural uterine broids that do not distort the endometrial
cavity on the outcome of in vitro fertilization-intracytoplasmic sperm injection. Fertil.Steril.,
81, 582-587.
Donnez,J., Jadoul,P. (2002) What are the implications of myomas on fertility ? A need for a
debate ? Hum. Reprod., 17(6), 1424-30.
Li,T;C;, Mortimer,R. and Cooke,I.D. (1999) Myomectomy: a retrospective study to examine
reproductive performance before and after surgery. Hum. Reprod., 14, 1735-1740.
370
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.

Vercellini,P., Maddalena,S., De Giorgio,O. et al. (1999) Determinants of reproductive outcome
after abdominal myomectomy for infertility. Fertil. Steril., 72, 109-114.
Fauconnier,A., Chapron,C., Babaki-Fard, K. et al. (2000) Recurrence of leiomyomata after
myomectomy. Hum. Reprod. Update, 6, 595-602.
Zollner,U., Classen,V., Steck,T. et al. (2001) Fertility and pregnancy outcome after myomectomy. Geburtsh. Frauenheilk., 61, 213-219.
Sudik,R., Husch,K., Steller,J. et al. (1996) Fertility and pregnancy outcome after myomectomy
in sterility patients. Eur. J. Obstet. Gynecol. Reprod. Biol., 65, 209-214.
Desolle,L., Soriano,D., Poncelet,C. et al. (2001) Determinants of pregnancy rate and obstetric
outcome after laparoscopic myomectomy for infertility. Fertil. Steril., 76, 370-374.
Rossetti,A., Sizzio,O., Soranna,L., Mancuso,S., Lanzone,A.(2001) Fertility outcome: longterm results after laparoscopic myomectomy. Gynecol Endocrinol., 15, 129-134.
Ancien,P. and Querada,F.(1996) Abdominal myomectomy: results of a simple operative technique. Fertil. Steril., 65, 41-51.
American Society for Reproductive Medicine Practice Committee. Myomas and reproductive
function. American Society for Reproductive Medicine Practice Committee Report, nov 2001.
Available on-line at http://www.asrm.org/membersonly/practice/myomas.pdf
Benson,C.B., Chow,J.S., Chang-Lee,W., Hill,J.A., Doubilet,P.M. (2001) Outcome of pregnancies in women with uterine leiomyomas identied by sonography in the rst trimester. J. Clin.
Ultrasound, 29(5), 261-264.
Sheiner,E., Bashiri,A., Levy,A.,Hershkovitz,R., Katz,M., Mazor,M. (2004) Obstetric characteristics and perinatal outcome of pregnancies with uterine leiomyomas. J. Reprod. Med., 49,
182-186.
Marchionni,M., Fambrini,M., Zambelli,V., Scarselli,G., Susini,T. (2004) Reproductive performance before and after abdominal myomectomy : a retrospective analysis. Fertil. Steril., 82,
154-159.
Mais,V., Ajossa,S., Guerriero,S., Mascia,M., Solla,E., Melis,G.B.(1996) Laparoscopic versus
abdominal myomectomy : a prospective, randomized trial to evaluate benets in early outcome. Am. J. Obstet. Gynecol., 175, 654-658.
Seracchioli,R., Rossi,S., Govoni,F. et al. (2000) Fertility and obstetric outcome after laparoscopic myomectomy of large myomata : a randomized comparison with abdominal myomectomy. Hum. Reprod., 15, 2663-2668.
Rossetti,A., Sizzi,O., Soranna,L., Cuccineli,F., Mancuso,S., Lanzone,A.(2001) Long term
results of laparoscopic myomectomy : recurrence rate in comparison with abdominal myomectomy. Hum. Reprod., 16, 770-774.
Stringer, N.H., Walker,J.C., Meyer,P.M. (1997) Comparison of 49 laparoscopic myomectomies
with 49 open myomectomies. J. Am. Assoc. Gynecol. Laparosc., 4, 457-464.
Silva,B.A., Falcone,T., Bradley,L., et al. (2000) Case-controlled study of laproscopic versus
abdominal myomectomy. J. Laparoendoscopic Adv. Surg. Techniques, 10, 191-197.
Adamian,L.V., Kulakov,V.I., Kiselev,S.I., Murashkov,A.V. (1996) Laparoscopic myomectomy
in treatment of large myomas. J. Am. Assoc. Gynecol. Laparosc., 3 suppl: S1.
Seineira, P., Arisio,R., Decko,A. et al. (1997) Laparoscopic myomectomy: indications, surgical
technique and complications. Hum. Reprod., 12, 1927-1930.
Dubuisson,J.B., Fauconnier,A., Deffarges,J.V., Norgaard,C., Kreiker,G., Chapron,C. (2000)
Pregnancy outcome and deliveries following laparoscopic myomectomy. Hum. Reprod., 15,
869-873.
Doridot,V., Dubuisson,J.B., Chapron,C., Fauconnier,A., Babaki-Fard,K. (2001) Recurrence
of leiomyomata after laparoscopic myomectomy. J. Am. Assoc. Gynecol. Laparosc., 8, 495500.
Di Gregorio,A., Maccario,S., Raspollini,M. (2002) The role of laparoscopic myomectomy in
371
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
women of reproductive age. Reprod Biomed Online, 4, 55-58.

Malzoni,M., Rotond,M., Perone,C., Labriola,D., Ammaturo,F., Izzo,A., Panariello, S., Reich,H.
(2003) Fertility after laparoscopic momectomy of large uterine myomas: operative technique
and preliminary results. Eur. J. Gynaecol. Oncol., 24, 79-82
Landi,S., Fiaccavento,A. Zaccoletti,R., Barbieri,F., Syed,R., Minelli,L. (2003) Pregnancy outcomes and deliveries after laparoscopic myomecotmy. J. Am. Assoc. Gynecol. Laparosc.,10,177181..
Takeuchi, H., Kinoshita,K. (2002) Evaluation of adhesion formation after laparoscopic myomectomy by systematic second-look microlaparoscopy. J. Am. Assoc. Gynecol. Laparosc., 9,
442-446.
Sinha,R., Hegde,A., Warty,N., Patil,N. (2003). Laparoscopic excision of very large myomas.
J. Am. Assoc. Gynecol. Laparosc., 10, 461-468.
Hurst,B.S., Stachhouse,D.J., Matthews,M.L., Marshburn,P.B. (2000) Uterine artery embolization for symptomatic uterine myomas. Fertil.Steril., 74, 355-369.
Sinha,R.Y., Hegde,A., Warty,N, Jain,R. (2004) Laparoscopic devascularization of uterine myomata followed by enucleation of the myomas by direct morcellation. J. Am. Assoc. Gynecol.
Laparosc., 11, 99-102.
Zullo,F., Pelicano,M., DeStefano,R., Zupi,E., Mastrantonio,P. (1998) A prospective randomised
study to evaluate leuprolide acetate treatment before laparoscopic myomectomy; efcacy and
ultrasonographic predictors. J. Am. Assoc. Gynecol. Laparosc.,178, 108-112.
Campo,S., Garcea,N. (1999) Laparoscopic myomectomy in premenopausal women with and
without preoperative treatment using gonadotrophin-releasing hormone analogues. Hum.
Reprod.,14, 44-48.
Palomba,S., Morelli,M., Noia,R., et al. (2002) Short-term administration of tibolone plus
GnRH analog before laparoscopic myomectomy. J. Am. Assoc. Gynecol. Laparosc.,9, 170174.
Dubuisson,J.B., Fauconnier,A., Fourchotte,V., Babaki-Fard,K., Coste, J., Chapron,C. (2001)
Laparoscopic myomectomy : predicting the risk of conversion to an open procedure. Hum.
Reprod., 16, 1726-1731.
Vercellini,P., De Giorgi,O., Aimi,G., Panazza,S., Uglietti, A., Crosignani, PG. (1998) Abdominal
myomectomy for infertility : a comprehensive review. Hum Reprod, 13, 973-879.
Belli,A.M. (2002) Uterine artery embolization for the treatment of broids. CME Radiol, 3(1),
20-25.
Reidy,J.F., Bradley,E.A., Forman,R.G., et al. (1999) Uterine artery embolisation. Results in
234 patients (abstract). Minim. Invasive Ther. Allied Techno.l, 8 suppl, 26.
- Vashisht,A., Studd,J., Carey,A., Burn,P. (1999) Fatal septicaemia after broid embolisation.
Lancet, 354, 307-308.
Campo,S., Campo,V., Gambadauro,P. (2003) Reproductive outcomes before and after laparoscopic or abdominal myomectomy for subserous or intramural myomas. Eur. J. Obstet.
Gynecol. Reprod. Biol., 110, 215-219.
Hasson,H.M., Rotman,C., Rana,N., Sistos,F., Dmowski,W.P. (1992) Laparoscopic myomectomy. Obstet. Gynecol., 80, 884-888.
Pellicano,M., Bramante,S., Cirillo,D., et al. (2003) Effectiveness of autocrosslinked hyaluronic
acid gel after laparoscopic myomectomy in infertile patients : a prospective, randomized, controlled study. Fertil. Steril., 80, 441-444.
Mettler,L., Audebert,A., Lehmann-Willenbrock, E., Schive-Peterhansl,K., Jacobs,V.R. (2004)
A randomised, prospective, controlled, multicenter clinical trial of a sprayable, site-specic
adhesion barrier system in patients undergoing myomectomy. Fertil. Steril., 82, 398-404.
Zreik,T., Rutherford,T. and Palter,S. (1998) Cryomyolysis: a new procedure for the conservative treatment of uterine broids. J. Am. Assoc. Gynecol. Laparosc., 1, 33-38.
372
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.

Donnez,J. Squifet,J.L., Polet,R. (2000) Laparoscopic myolysis. Hum. Reprod. Update, 6,
609-613.
Forman,R.G., Reidy,J., Nott,V. et al. (1999) Fibroids and Fertility. SMIT/CIMIT 11th annual
scientic meeting. Boston Sept 1999.
Ravina,J.H., Vigneron,N.C., Aymard,A. et al. (2000) Pregnancy after embolization of uterine
myoma: report of 12 cases. Fertil. Steril., 73, 1241-3.
Mc Lucas,B., Goodwin,S., Adler,L. et al. (2001) Pregnancy following uterine broid embolization. Int. J. Gynecol. Obstet., 74, 1-7.
Hurst,B.S., Matthews,M.L., Marshburn,P.B. (2005) Laparoscopic myomectomy for symptomatic uterine myomas. Fertil. Steril., 83, 1-23.
Godfrey,C.D., Zbella,E.A. (2001) Uterine necrosis after uterine artery embolisation for leiomyoma. Obstet. Gynaecol., 98, 950-952.
Olive,D.L., Lindheim,S.R., Pritts,E.A. (2004) Non-surgical management of leiomyoma : impact on fertility. Curr. Opin. Obstet. Gynecol., 16, 239-243.
Goldberg,J., Pereira,L., Berghella,V., Diamond,J., Darai,E., Seinera,P., Seracchioli,R. (2004)
Pregnancy outcomes after treatment for bromyomata : uterine artery embolization versus
laparoscopic myomectomy. Am. J. Obstet. Gynecol, 191, 18-21.
Harris,W.W.J. (1992) Uterine dehiscence following laparoscopic myomectomy. Obstet.
Gynecol., 80, 545-546.
Mecke,H., Wallas,F. and Brocher,A. (1995) Pelviskopische Myomenukleation: Technik,
Grenzen, Komplicationen. Geburtsh Frauenheilk., 55, 374-379.
Friedman,W., Maier,R.F. and Luttkus,A. (1996) Uterine rupture after laparoscopic myomectomy. Acta Obstet. Gynecol. Scand., 75, 683-684.
Pelosi,M. and Pelosi,M.A. (1997) Spontaneous uterine rupture at thirty-three weeks subsequent
to previous supercial laparoscopic myomectomy. Am. Obstet. Gynecol., 177, 1547-1549.
Hockstein,S. (2000) Spontaneous uterine rupture in the early third trimester after laparoscopically assisted myomectomy. J. Reprod. Med., 45, 139-141.
Malberti, S., Ferrari,L, Milani,R. (2004) Spontaneous uterine rupture in the third trimester of
gestation after laparoscopic myomectomy. A case report. Minerva Ginecol., 56(5), 479-480.
Lieng,M., Istre,O., Langebrekke,A. (2004) Uterine rupture after laparoscopic myomectomy.
J. Am. Assoc. Gynecol. Laparosc., 11, 92-93.
Dubuisson,J.B., Chavet,X., Chapron,C., Grgorakis,S.S., Morice,P. (1995) Uterine rupture after
laparoscopic myomectomy. Hum. Reprod., 10, 1475-1477.
Arcangeli,S. and Pasquarette,M. (1997) Gravid uterine rupture after myolysis. Obstet. Gynecol.,
49, 857.
Vilos,G., Daly,L. and Tse,B. (1998) Pregnancy outcome after laparoscopic electromyolysis. J.
Am. Assoc. Gynecol. Laparosc., 5, 289-292.
Nkemayim,D.C., Hammadeh,M.E., Hippach,M. et al. (2000) Uterine rupture in pregnancy
subsequent to previous laparoscopic electromyolysis. Case report and review of literature.
Arch. Gynecol. Obstet., 264, 154-156.
Marret,H., Chevillot,M., Giraudeau,B., Study Group of the French Society of Gynaecology
and Obstetrics. (2004) A retrospective multicentre study comparing myomectomy by laparoscopy and laparotomy in current surgical practice. What are the best patient selection criteria ?
Eur. J. Obstet. Gynecol. Reprod. Biol., 117(1): 82-86.
373

A new safer bipolar intelligent
coagulation system
Wallwiener C., Neunhoeffer E., Wallwiener M., Klein R.,
Menger M., Zubke M.
Department of Obstetrics and Gynaecology, University of Tuebingen (Germany)
Development Division and Product Management, ERBE Elektromedizin GmbH
Department of Experimental Surgery, University of Homburg (Germany)
Introduction
Electrosurgical methods have become a domain in all of the surgical disciplines
and have replaced a great part of conventional surgical techniques. Especially
advanced laparoscopic procedures have necessitated the development of new
technology for vascular control.
For all the importance of energy-based vessel ligation and the great variety
of electrosurgical application-instruments, only a suboptimal haemostasis and
strength of the vessel seal can be realised, which might stem from the little
knowledge of the mechanism of agency that we possess as of today.
How then, can adverse coagulation effects in electro-surgery be minimized,
whilst favoured results are optimized?
The objective was to gauge the innovative bipolar coagulation system by
adjusting the modulation of the current as well as the intelligent self-control,
thus attaining an ideal permanent seal with minimal complication-rate, abdication of ligature and smallest lateral thermal damage.
Background: Mechanism of bipolar electrosurgical action

Basic principle of the coagulation is the thermal effect, which is used to selectively alter tissue by transforming electrical energy into heat as dictated by
374
Joule's Law (J=IRt/a). Through high frequency AC current (about 300 kHz)
both electrolytic and faradic effect can be averted in human tissue.
When heating tissue above temperatures of 100C, intra and extra cellular
uids evaporate and cells shrink. Thermal Fusion of proteins and other biological materials leads to haemostasis. In order to achieve thermal fusion, the tissue
temperature must be risen slowly; otherwise, the vapour pressure tears the cell
membrane explosively apart, resulting in a cut without haemostasis.
Thermal fusion is inuenced by the dynamic energy intake as well as the
dosage of applied energy. In bipolar coagulation, the interaction between impedance and current allows the high temperatures necessary for vessel ligation.
Common bipolar thermal fusions are characterised through a pulse frequency, i.e. an energy intake, which is not dependant on impedance. This "pseudointelligence" denes a predetermined relation between pulse and pause duration, which can be halted by changes in the tissue but other than that, can not
be affected.
Methods
132 skeletonized porcine vessels with different diameters (ranging from 2-8
mm), primarily renal arteries, were sealed ex-vivo through application of precisely controlled electro-thermal energy and physical pressure, using BiClamp
(with new subtler application forceps) and Vio (ERBE Elektromedizin GmbH),
a self-controlling system.
At this, all relevant parameters concerning current and ow of energy were
recorded digitally and evaluated. Subsequently, the burst-pressure (bp) was
determined to serve as characteristic of the seal quality.
Hereunto, the vessels were drawn on a titan adapter, secured with pursestring sutures and connected to the pressure application device. After the sealing, saline was infused under constant pressure-monitoring, until either the seal
or the vessel burst, which dened the burst pressure in mmHg.
Histology allowed the evaluation of morphological changes in the tissue.
As for statistical analysis, the Pearson-Chi-Square-Test was applied and
statistical signicance assumed, when p < .05.
In this study, 3 modulations of electro-thermal energy were tested for their
efcacy in vascular control. In Mode 1 and 2, only the lengths of pauses between the impulses were varied (Mode 1: 300ms, Mode 2: 30ms), whereas in
Mode 3 a completely new modulation of current was suggested.
375
Results
Statistical analysis
When comparing Mode 1-3, the vessels within each group were assigned
grades according to the realised burst pressure (bp 100mmHg = Grade 1; bp >
100mmHg and < 300mmHg = Grade 2; bp 300mmHg = Grade 3).
With the Pearson Chi-Square-Test, the results were proven to be signicant
with p=.042 (Mode 3 vs. Mode 2 p=.035, Mode 3 vs. Mode 1 p=.07, Mode 2
vs. Mode 1 p=.673 (not signicant)).
Seal failures (Tab 1):
Vessels whose seals could not resist a pressure of 100 mmHg were considered
"seal-failures".
Within the test groups, the numbers of failures were distributed as follows:
out of 43 vessels coagulated with Mode 1, 15 (equalling 35%), respectively 14
out of 50 vessels (equalling 28%) coagulated with Mode 2 could not match the
minimal requirements, whereas only 1 vessel out of 20 (equalling 5%) in the
group coagulated with Mode 3 failed to resist a bp of 100 mmHg.
Diameter:
Mode1 = 4,4 mm
Mode2 = 4,5 mm
Mode3 = 4,3 mm
60
seal failures
50
n vessels
40
50
43
30
20
28 %
35 %
15
5%
20
14
10
Mode1
Mode2
Mode3
376
Seal quality (Tab 2):

The comparison of the mean burst pressures between the groups coagulated
with different modulations served as parameter of the seal quality.
When taking all results, including failures, into account determining the
mean bp, the following differences between the seal quality could be accounted for: bp Mode1 = 329 mmHg, bp Mode2 = 371 mmHg, bp Mode3 = 528
mmHg.
Changes in the application of the electro thermal energy led to improvements in the seal quality of 12.8% from Mode 1 to Mode 2 and of 60.5% from
Mode 1 to Mode 3.
When not including the failures in the analysis, the seal quality still differed
(bp Mode 1 = 485 mmHg; bp Mode 2 = 504 mmHg; bp Mode 3 = 556 mmHg)
and led to improvements of 3.9% respectively 14.6%.
The mean vessel diameters within the test groups were the following: diameter () Mode 1 = 4.4 mm; Mode 2 = 4.5 mm; Mode 3 = 4.3 mm.
600
mmHg
550
bp with failures
500
bp without
f il
556
528
504
485
450
400
+3.9%
350
300
+14.6%
371
329
+12.8%
250
+60.5%
200
Mode 1
Mode 2
Mode 3
Dependence of the seal quality on vessel diameter (Tab 5):

Employing Mode 3, 2 groups of vessels were coagulated, at which the mean
diameters in the groups C1 and C2 were 5.0 mm (ranging from 4.0 to 5.5 mm)
respectively 2.6 mm (ranging from 2.0 to 3.5 mm).
In C1, the realised median bp was 471 mmHg, in C2 681 mmHg. The seal
quality was the better, the smaller the vessel was.
377
The results suggest that seal quality correlates reciprocal with the increase
in vessel calibre.
750
mmHg
650
(mm)
681
550
450
471
2,6
350
250
C1
C2
Multiple Coagulation (Tab 6):

Analogous to prevalent clinical practice, multiple coagulations (4x) were performed, using Modes 1 and 2 and compared with single coagulations, employing Mode 3.
700
mmHg
650
600
550
643
597
556
500
450
400
multiple coagulations
350
300
250
200
Mode1 E2 Mode2 E2 Mode3 E3
378
With Modes 1 and 2, bp of 597 mmHg, respectively 643 mmHg could be

realised via multiple coagulations.
The seal quality did only marginally differ from the seal quality achieved
with Mode 3, thereby indicating that multiple coagulations are not superior to
single coagulations with Mode 3, but in fact cause more thermal lateral damage
and carry a higher risk to cause a rupture.
Conclusion
Due to the reproducibility and validity of the results, an in vitro model is now
at disposal to examine more specications, particularly since knowledge of
thermal fusion is fragmentary.
Through modication of parameters, the modulation of current ow in the
bipolar coagulation system could be optimised and a safer thermal fusion, particularly in single coagulations was made possible.
"Pseudo Intelligence": Prevalent bipolar Coagulation (Mode 1 & 2):
Prevalent Coagulations are characterised by a stiff, tissue-independent pulse
frequency (Tab 3).
This pulse frequency resulted in a long coagulation time (approximately
10-12 seconds) and a high number of unsatisfying seals.
"Intelligent" bipolar thermal fusion (Mode 3):

Reasons for that can primarily be attributed to the constantly decreasing current
and the fact that the relation between pulse and pause duration remains steady
whilst current ow is too little to ensure the high temperatures needed to assure
379
thermal fusion. In this approach the pulse duration was set on 800 ms with a
pause interval, which lasted 300 ms (Mode 1), respectively 30 ms (Mode 2).
Due to a dynamic time sequence, Mode 3 is characterised by an impedancedependant energy intake. The dosage of energy is adjusted to tissue impedance; the current ow is regulated by the tissue itself, resulting in both shorter
coagulation time and greater seal quality.
The pulse frequency was altered in Mode 3. As soon as current ow decreases to a minimal level, the pause interval and the next pulse are initiated
(Tab 4).
Figure 1: Coagulation
Figure 2: Determination burst pressure (bp)
Figure 3: Setting
380
Due to a higher energy density per time unit, a faster rise in temperature
is realized and the high heat level can remain constant, which accounts for an
ideal thermal fusion.
Contrary to prevalent "pseudo intelligence", which can only independently
stop the coagulation process, now a safer intelligent bipolar coagulation system
is at disposal, which, based on defaults from the tissue, regulates current ow
during the whole of the process autonomously.
Vessels can now be closed effectively and maintain closure at a pressure
level sufcient for clinical use.
381
Uterine artery embolization in the

treatment of hemorrhage in Obstetrics
and Gynaecology
Kowalski Jan, Tarkowski Rafa, Nowakowski Andrzej.
First Department of Gynecology, Medical University of Lublin,
ul. Staszica 16, 20-081 Lublin, Poland
Embolization of arteries, an interventional procedure is an important method

performed in the treatment of haemorrhages. This method has been applied for
the past three decades in obstetrics and gynaecological practice [1-6]. These
percutaneous therapeutic options play a signicant role in the treatment of
haemorrhages in advanced non-operative neoplastic either uterine or bladder
tumours. The next important application are haemorrhages after pelvic injuries
or surgical complications [3]. Haemorrhages due to ectopic cervical pregnancy
or spontaneous and articial miscarriages can also be treated by uterine artery
embolization [4, 6]. There are some literature data on efcacy of embolization
in the managment of severe postpartum hemorrhages caused by uterine atony,
uterine rupture, DIC and placenta accreta [4, 5].
The technique of the procedure

Embolization of uterine arteries is performed by interventional radiologists.
The procedure is performed in sedation and local anesthesia. After insertion
of the catheter into the internal illiac arteries through either axillary or femoral
artery, bilateral arteriography of pelvic organs is carried out. Catheter size 3 to
5 French is inserted percutaneously either through axillary or femoral artery
into the internal illiac or uterine arteries. Mostly used embolic material are
polyvinyl alcohol (PVA) particles with diameter between 150 and 700 m,
stainless steel coils or pelets, silicone spheres, gel foam or gelatine sponges.
382
Gel foam or gelatine sponges are absorbed within two months after the procedure and there is a possibility of artery recanalisation. The amount of embolic
microspheres depends on tumour size. Polyvinyl alcohol spheres mechanically
close the arteries from 0,3 to 1 mm wide in diameter. Ischaemic changes cause
hyalinic degeneration with many acellular areas. After the procedure is completed control arteriogram is performed to estimate the efcacy of embolization
(Fig. 1).
Fig. 1: Bilateral embolization of uterine arteries for treatment of

broid. A- arteriography of pelvic organs. B- selective arteriography of
the myoma. C- control arteriogram after completed embolization.
After the procedure, pressure dressing should be applied on the wound for
about 3 hours and the patient should stay horizontally for 30 to 120 minutes.
The procedure lasts from 70 to 140 minutes, and its length depends on anatomical conditions and the experience of the radiologist.
Treatment of gynaecological neoplasms with

embolization.
Obliteration of arteries is very helpful if performed preoperatively to reduce
tumour burden or blood lost during the surgery. The other indication for interventional radiology is pain palliation in patients who cannot be treated surgically. In the treatment of neoplasms embolic materials that allow small vessels
embolization are preferred to reduce the possibility of collateral circulation
formation [7].
383
Embolization of internal illiac arteries in caeses of

carcinoma of the uterine cervix.
Embolization can be carried out in the treatment of hemorrhage in advanced
cases of uterine cervix carcinoma. If patients are qualied for this procedure
further chemotherapy cannot be applied due to lower tumour perfusion. Artery
embolization can also be used in the treatment of haemorrhages in advanced
endometrial and bladder carcinoma [8, 9]. In most patients embolization is
successful to stop bleeding followed by long bleeding-free time (Fig. 2). In
some patients the procedure may increase the quality of life due to reduction
in bleeding, however in other cases complications such as stulas may occur
with subsequent decrease in patients life quality.
decrease in patients life quality.
Fig 2: Embolisation of internal illiac arteries in patients with carcinoma of the cervix. A- Angiography before and B- after the embolization
is completed.
384
Embolization in the treatment of symptomatic

leiomyomas
Nowadays selective bilateral uterine arteries embolization is an alternative
procedure to surgical treatment of uterine leiomyomas. The main advantages
of embolization are high technical and clinical successful rate, shortening of
hospital stay, shortening absence at work and minimal inuence on hormonal
axis [10, 11]. Psychological reasons must also be noticed. Patients avoid surgery and have the whole genital tract preserved. As other treatment methods,
embolization possesses disadvantages, the main is the lack of histological
examination of the tumour. Opinions concerning the use of MRI for differentiation between malignant and benign uterine tumours are not concordant
[12, 13]. That is why some centres recommend laparoscopy and hysteroscopy
before qualication for this procedure. The next disadvantage is that there is no
randomised data concerning the inuence of embolization on future fertility.
Indications and contraindications for uterine arteries embolization in the treatment of myomas are presented in the table 1. UAE is not recommended for the
management of large myomas. McLucas et al. noticed that the risk of failure of
UAE in treatment of myomas grows 10% for every centimetre over 8,7 cm of
tumour diameter [14]. Embolization is also not recommended in patients with
coexisting adenomyosis [11]. Results of treatment of symptomatic broids in
regard to literature data and our own results are presented in table 2.
Table 1:
Indications and contraindications for UAE for treatment of symptomatic broids.
Indications
Contraindications
Symptomatic myomas
Pregnancy
High risk of general anaesthesia or surgical Allergy for contrast medium

treatment.
Severe anaemia
Acute renal failure
Patients who refuse blood transfusion (eg.

Jehowahs witnesses)
Irradiations of pelvic organs
Patients after multiple myomectomies
Infections (PID)
Desire of uterus preservation and/or avoiding surgery- Patients choice
Coexistence of other pelvic

tumors.
385
Table 2:
Results of UAE in the management of symptomatic broids concerning normalisation

of menses and improvement of life quality- based on literature data.
Menorrhagia [%] Quality of life [%]
Ravina [29]
16
64
Goodwin [30]
11
86
87
Hutchins [31]
305
87
84
Siskin [32]
49
95
Treatment of leyomyomas with UAE and surgical myomectomy has very similar results as to normalisation of menorrhagia and pain relief [15]. Comparison
of complications after surgery and UAE requires randomised trials.
Embolization of arteries in the managment of severe

postpartum hemorrhages
Arteries embolization can be successfully applied in the management of severe
postpartum haemorrhages (PPH) mostly due to damage of vagina or uterine
cervix and placenta accreta. In most cases described in the literature this method
is highly effective in the management of postpartum haemorrhages and allows
to preserve the uterus and normal regular menses [16, 17] (Fig. 3). As suggested
by Bloom et al. embolization performed before hysterectomy decrease blood
lose, duration of the procedure (embolization), stay at intensive care unit and
possibility of other complications [18]. The biggest literature report concerns
36 cases of embolization in the treatment of postpartum haemorrhages [19].
The authors performed bilateral occlusion of anterior trunk of hypogastric arteries using gelatine sponges. Immediate success was achieved in all case and
35 patients avoided hysterectomy. In 3 patients secondary embolization was
needed. Complications such as puncture site false aneurysm, regressive lower
limb paraesthesia, femoral vein thrombosis and puncture site hematoma were
noticed in 5 cases. Boulleret et al. concluded that immediate efcacy, low
morbidity and preservation of fertility make embolization the technique of
choice for severe postpartum haemorrhage management. In the case of placenta
accreta which can be diagnosed by ultrasound examination before delivery,
embolization can be planned and performed before haemorrhage occurs [20].
In these cases placenta is excreted (delivered) secondary after 12 to 28 days.
Patients who undergo arterial embolization for obstetrics haemorrhage should
expect to have normal menses with preservation of fertility [19, 21].
386
Fig. 3: Selective embolization in patient with postpartum haemorrhage. Three attempts of haemorrhage management by traditional
methods were uneffective, and patient was qualied for embolisation.
A- Angiography before and B- after the embolization is completed.
ijured vessel.
Embolization in the treatment of ectopic pregnancy

Cervical pregnancies have generally been treated with hysterectomy because
of the potential for massive haemorrhage. Obliteration of uterine artery can be
successfully performed in the treatment of ectopic pregnancy situated in uterine
cervix or in the scar after caesarean section [20, 22]. In most cases of ectopic
pregnancy unilateral procedure is sufcient [23]. Case reports suggest that
highly selective occlusion of blood vessels can also be effective in the treatment of ectopic pregnancy. This alternative method allows to preserve proper
function of genital organs. After an initial angiography and before embolization
chemotherapeutic agent may be administered through the catheter.
Embolization and preservation of fertility

Inuence of embolization on fertility and possibility of successful uneventful
pregnancy is still uncertain. Observations collected until now concern patients
treated because of uterine bromas and postpartum hemorrhages (PPH). In
group of patients treated with embolization because of PPH the authors emphasize the possibility of normal menses, preservation of fertility and uneventful
pregnancies but study groups are small: up to 30 patients [18- 21] . On the other
hand, the latest data on pregnancy outcomes in patients with leyomyomata
387
treated with artery embolization are not so promising [24- 27]. Pregnancies
in this group of women were characterised by higher risk of preterm delivery
and malpresentation compared with laparoscopic myomectomy. Higher risk
of abortion and postpartum haemorrhages was also observed but the difference was not signicant. Leaving broid in the uterine wall may decrease the
implantation ability and possibility of term delivery. The rst reason of conception difculties could be preterm ovarian failure noticed in 1-2 % women
treated with embolization caused by embolic material occluded ovarian vessels.
Payne et al. found obliterating particles in the ovary of patient who underwent
hysterectomy after embolization [28]. The other reason of decreased ovarian
reserve and preterm ovarian failure could be the radiation absorbed during the
procedure. Mean dose absorbed during the embolization is about 22 cGy and
the next 2 cGY at control tomography.
Acknowledgements
We thank Professor Magorzata SzczerboTrojanowska for providing gures.
References
Gilbert WM, Moore TR, Resnik R, Doemeny J, Chin H, Bookstein JJ. . Angiographic emolization
in the management of hemorrhagic complications of pregnancy. Am J Obstet Gynecol 1992;
166: 493-497.
Hansch E, Chitakara U, McAlpine J, El-Sayed Y, Dake MD, Razavi MK. Pelvic arterial embolization for control of obstetric hemorrhage: a ve-year experience. Am J Obstet Gynecol 1999;
180:1454-60.
Schwartz PE, Goldstein HM, Wallace S, Rutledge FN. Control of arterial hemorrhage using percutaneous arterial catheter technigggues in patients with gynecologic malignanciens. Gynecol
Oncol 1975; 3: 276- 88.
Mitty HA, Sterling KM, Alvarez M, Gendler R. Obstetric hemorrhage: prophylactic and emergency
arterial catheterization and embolotherapy. Radiology 1993;188:183-87.
Greenwood LH, Glickman MG, Schwartz PE, Morse SS, Denny DF. Obstetric and non-malignat
gynecologic bleeding treatment with agiographic embolization. Radiology 1987; 164:155-59.
Frates MC, Benson CB, Doubilet PM, Di Salvo DN, Brown DL, Laing FC, Rein MS, Osathanondh
R. Cervical ectopic pregnancy:results of conservative treatment.Radiology 1994;191:773-75.
Quinn SF, Frau DM, Saff GN, Kavanagh J, Roberts W, Cavanagh D, Clark RA.Neurologic complications of pelvic intraarterial chemoembolization performed with collagen material and cisplatin.
Radiology 1988; 167: 55-7.
Lelle RJ, Majewski A.Experiences with selective catheter embolization of the internal iliac artery in
life-threatening hemorrhage from uterine cancers. Geburtshilfe Frauenheilkd 1987; 47: 574-7.
Yalvac S, Kayikcioglu F, Boran N, Tulunay G, Kose MF, Bilgic S, Haberal A. Embolization of uterine
artery in terminal stage cervical cancers. Cancer Invest 2002; 20:754-8.
Bednarek W, Kotarski J. Embolizacja ttnic macicy jako alternatywna metoda leczenia miniakw
388
macicy (Uterine artery embolization as an alternative method for treatment of uterine broids).
Przegld Menopauzalny (Menopausal review). 2002;1:17-21.
Kotarski J. Commentary to Schwartz ML, Klein A, McLucas B. Embolizacja ttnic macicznych
w leczeniu miniakw macicy. Ginekologia po Dyplomie (Postgraduate gynecology, Polish
edition) 2002;4:71-72.
Schwartz LB, Zawin M, Carcangiu ML, Lange R, McCarthy S. Does pelvic magnetic resonance imaging differentiate among the histologic subtypes of uterine leiomyomata? Fertil Steril 1998;70:
580-7.
Pietura R, Janczarek M, Bednarek W, Kotarski J, Szczerbo-Trojanowska M. The use of magnetic
resonance imaging for the evaluation of treatment outcome in uterine artery embolisation for
broids. Ginekol Pol. 2003;74:1549-56.
McLucas B, Goodwin SC, Adler L, Reed R. Fatal septicaemia after broid embolisation. Lancet
1999; 354: 1730.
Razavi MK, Hwang G, Jahed A, Modanloo S, Chen B. Abdominal myomectomy versus uterine
broid embolization in the treatment of symptomatic uterine leiomyomas. Am J Roentgenol
2003;180:1571-5.
Ornan D, White R, Pollak J, Tal M. Pelvic embolization for intractable postpartum hemorrhage:
long-term follow-up and implications for fertility. Obstet Gynecol. 2003;102: 904-10.
Salomon LJ, deTayrac R, Castaigne-Meary V, Audibert F, Musset D, Ciorascu R, Frydman R,
Fernandez H. Fertility and pregnancy outcome following pelvic arterial embolization for severe
post-partum haemorrhage. A cohort study. Hum Reprod 2003;18: 849-52.
Bloom AI, Verstandig A, Gielchinsky Y, Nadiari M, Elchalal U. Arterial embolization for persistent
primary postpartum haemorrhage: before or after hysterectomy? Br J Obstet Gynaecol 2004;111:
880-4.
Boulleret C, Chahid T, Gallot D, Mod R, Tran Hai D, Ravel A, Garcier JM, Lemery D, Boyer L.
Hypogastric arterial selective and superselective embolization for severe postpartum hemorrhage: a retrospective review of 36 cases. Cardiovasc Intervent Radiol 2004; 27: 344-8.
Descargues G, Douvrin F, Degre S, Lemoine JP, Marpeau L, Clavier E. Abnormal placentation
and selective embolization of the uterine arteries. Eur J Obstet Gynecol Reprod Biol 2001; 99:
47-52.
Descargues G, Mauger Tinlot F, Douvrin F, Clavier E, Lemoine JP, Marpeau L. Menses, fertility and
pregnancy after arterial embolization for the control of postpartum haemorrhage. Hum Reprod
2004;19: 339-43.
Yitzhak M, Orvieto R, Nitke S, Neuman-Levin M, Ben-Rafael Z, Schoenfeld A. Case Report: Cervical
pregnancy a conservative stepwise approach. Human Reproduction, 1999; 14: 847-9.
Su YN, Shih JC, Chiu WH, Lee CN, Cheng WF, Hsieh FJ.Cervical pregnancy: assessment with
three-dimensional power Doppler imaging and successful management with selective uterine
artery embolization. Ultrasound Obstet Gynecol 1999;14: 284-7.
Chen YJ, Wang PH, Yuan CC, Yen YK, Yang MJ, Ng HT, Chang SP, Liu WM. Pregnancy following
treatment of symptomatic myomas with laparoscopic bipolar coagulation of uterine vessels. Hum
Reprod. 2003;18:1077-81.
McLucas B, Goodwin S, Adler L, Rappaport A, Reed R, Perella R. Pregnancy following uterine
broid embolization. Int J Gynecol Obstet, 2001;74: 1-7.
Goldberg J, Pereira L, Berghella V, Diamond J, Darai E, Seinera P, Seracchioli R. Pregnancy outcomes
after treatment for bromyomata: uterine artery embolization versus laparoscopic myomectomy.
Am J Obstet Gynecol 2004;191: 18-21.
Ravina JH, Vigneron NC, Aymard A, Le Dref O, Merland JJ. Pregnancy after embolization of uterine
myoma: report of 12 cases. Fertil Steril, 2000;73:1241-1243.
Payne JF, Robboy SJ, Haney AF. Embolic microspheres within ovarian arterial vasculature after
uterine artery embolization. Obstet Gynecol. 2002;100:883-6.
389
Ravina JH, Herbreteau D, Ciraru-Vigneron N, Bouret JM, Houdart E, Aymard A, Merland JJ. Arterial
embolization to treat uterine myomata. Lancet 1995; 346: 671-72.
Goodwin SC, Vedantham S, McLucas B, Forno AE, Perrella R Preliminary experience with uterine
artery embolization for uterine broids. J Vasc Interv Radiol 1997; 8: 517-26.
Hutchins FL Jr, Worthington-Kirsch R, Berkowitz RP.Selective uterine artery embolization as primary treatment for symptomatic leiomyomata uteri. J Am Assoc Gynecol Laparosc 1999; 6:
279-84.
Siskin GP, Stainken BF, Dowling K, Meo P, Ahn J, Dolen EG.Outpatient uterine artery embolization for symptomatic uterine broids: experience in 49 patients. J Vasc Interv Radiol 2000; 11:
305-11.
390
In vivo proton magnetic resonance

spectroscopy:
A novel non-invasive discriminatory
test for ovarian tumors ?
EA Boss1, RD Kok1, DWJ Klomp2, UFH Engelke2, H Boonstra1,
RA Wevers2, JO Barentsz3, A Heerschap3, LFAG Massuger1
1) Department of Obstetrics and Gynaecology, 2) Laboratory of Pediatrics and
Neurology, 3) Department of Radiology, University Medical Center Nijmegen,
Nijmegen, The Netherlands
Abstract
The aim of this study was to evaluate the feasibility of in vivo proton magnetic resonance spectroscopy (1H-MRS) in the determination of ovarian cyst
uid components. Data were compared with in vitro proton nuclear magnetic
resonance spectroscopy (1H-NMRS). This study was our rst step to develop
a model that may ultimately lead to a novel test for an accurate non-invasive
differentiation of ovarian tumors.
Patients and methods

A 53 year old patient with an adnexal mass was included in this pilot study
after informed consent was obtained. First, in vivo MR examinations were
performed on a clinical MR system. After one week explorative laparotomy
was performed and the tumor was removed. Subsequently, aseptic ne needle
aspiration was performed for cyst uid collection. After cooled transport to the
laboratory, cyst uid was centrifuged at 3000 g for 5 min for cell separation
and stored at 70 oC for two weeks, until in vitro 1H-NMRS analysis was per-
391
formed. Histopathologic diagnosis was performed by a gynecologic pathologist

and revealed cystadenocarcinoma.
MRS measurements
In vivo 1H-MRS
The patient was positioned inside the magnet bore of a clinical 1.5 Tesla MR
system (Magnetom Vision, Siemens, Erlangen, Germany). The body coil was
used for radio frequency excitation. A linear polarized surface coil ( 19cm) for
receiving was positioned as close as possible to the adnexal mass. MR images
were made to select a voxel of interest of 20 cc of exclusively ovarian cyst uid
for 1H-MRS (gure 1).
Figure 1: Sagittal MR image (1.5 Tesla) of a 55-year old patient with

an ovarian tumor. The voxel of interest (20 cc) that was used for 1HNMR spectroscopic analysis of ovarian cyst uid is indicated
MR spectra using a stimulated echo acquisition mode (STEAM) sequence [1]
at an echo time (TE) of 20 ms with outer volume suppression was acquired.
Subsequently, two MR spectra at a point-resolved spectroscopy (PRESS) sequence [2] at TEs 135 and 270 ms, were aquired, to diminish possible contamination of lipid signals. The repetition time was 2500 ms. The number of
averages was 256. The total examination time amounted 60 minutes.
392
In vitro 1H-NMRS
Single pulse 1H-NMR spectra (500 MHz) were obtained on a Bruker DMX500. Measurements were performed essentially as described before [3-5]. We
performed two separate analyses, the rst after deproteinization over a lter
(3000g for 2h, mass cut-off 10 kDa), without pH standardization. A second
experiment involved adjustment to pH 2.5 + 0.10, in order to correlate chemical shift of the non pH standardized sample with our ovarian cyst uid model
compound data base [5]. Chemical shifts were calibrated with respect to the
chemical shift position of the trimethylsilyl 2,2,3,3-tetradeuteropropionic acid
(TSP) resonance. Phase and baseline were corrected manually.
Results
Figure 2a presents the in vitro 1H-NMR spectrum of the cyst uid sample without pH standardization. High intensities were visible for leucine, isoleucine, valine, lactic acid, alanine, acetic acid, glutamine, methionine. These assignments
were conrmed by comparing them with the spectrum of the pH standardized
sample (spectrum not shown).
Figure 2b shows the in vivo 1H-MR spectrum obtained with a STEAM
sequence at TE 20 ms. Distinct signals of lactic acid (1.33 ppm) were obtained, which was inverted in the MR spectrum obtained at TE 135 ms. Also
a resonance of acetic acid (2.03 ppm) was clearly visible, but could not be
completely resolved from glutamine and methionine contributions. A third
resonance complex at 0.9 ppm was obtained, most likely to be contributions
of the valine, isoleucine, and leucine resonances. PRESS spectra obtained at
TE 135 and 270ms showed the same resonances except for the glutamine and
methionine signals.
Discussion
This pilot study shows that in vivo 1H-MRS of ovarian cyst uid is feasible.
The obtained resonances correspond with results from in vitro 1H-NMRS on
ovarian cyst uid from the same patient. With in vivo 1H-MRS resonances
for lactic acid and acetic acid were clearly visible. Okada et al. [6] performed
single voxel 1H-MRS on benign and malignant tumors of the female pelvis. In
line with our results they found lactic acid as the characteristically obtained signal. In our previous in vitro studies we detected signicantly higher lactic acid
concentrations in cyst uid from malignant tumors, than those found in benign
tumors. The in vivo 1H-MRS cyst uid lactic acid signal might be used as an
393
Lactic acid
TSP
Acetic acid
Alanine
Valine,
Leucine,
Isoleucine
Glutamine, Methionine
4.0
3.0
2.0
ppm
1.0
0.0
Lactic acid
Acetic acid
Valine, Leucine,Isoleucine
Glutamine, Methionine
4.0
3.0
2.0
1.0
ppm
Figure 2: In vitro 1H-NMR spectrum of malignant ovarian cyst uid

sample (upper part) and in vivo 1H-NMR spectrum (s20) of the same
394
index of differentiation among benign and malignant ovarian tumors. However,

overlap in the cyst uid concentration ranges was seen. Further research is
needed to examine the possibilities of using non invasive in vivo 1H-MRS in
the discrimination between benign and malignant ovarian tumors based on differences in the contents of cyst uid. Other components that showed signicant
differences between malignant and benign tumors with in vitro 1H-NMRS have
to be evaluated in further detail with in vivo MRS. Quantication of metabolites
with in vivo spectra may be difcult since an internal standard is lacking. Since
we found a large level of overlap in cyst uid concentrations between benign
and malignant tumors with our in vitro studies the highest in vivo accuracy
probably will be achieved by using a combination of analytes.
References
1.
2.
3.
4.
5.
6.
Frahm J, Merboldt KD, Hanicke W. Localized proton spectroscopy using stimulated echoes.
J. Magn Reson 1987;72:502-8
Ordidge RJ, Bendall MR, Gordon RE, Connelly A. Volume selection for in-vivo biological
spectroscopy. In: Govil G, Khetrapal CL, Saran A, eds. Magnetic resonance in biology and
medicine. New Delhi, India: Tata McGraw-Hill 1985:387-97
Wevers RA, Engelke U, Wendel U, de Jong JGN, Gabrels FJM, Heerschap A. Standardized
method for high-resolution 1H-NMR of cerebrospinal uid. Clin Chem 1995;41:744-51
Massuger LFAG, van Vierzen PBJ, Engelke U, Heerschap A, Wevers R. 1H-Magnetic
Resonance Spectroscopy: A new technique to discriminate benign from malignant ovarian
tumors. Cancer 1998;82(9):1726-30
Boss EA, Moolenaar S, Massuger LFAG, Boonstra H, Engelke UFH, de Jong JGN, Wevers
RA. High Resolution proton Magnetic Resonance Spectroscopy of cyst uid from benign and
malignant ovarian cysts. NMR in Biomed 2000;13:1-8.
Okada T, Harada M, Matsuzuki K, Nishitani H, Aono T. Evaluation of female intrapelvic
tumors by clinical proton MR spectroscopy. JMRI 2001;13:912-917.
395
Choriocarcinoma-ultrasonographic
models
Branka Nikolic MD, PhD1, Ana Mitrovic MD PhD1 Vesna Lackovic2
Branka Nikolic spec Obs/Gyn Obst. Gyneacol. Clinic "Narodni front" Medical Faculty.
Vesna Lackovic Institure for Hystology Medical Faculty, University of Belgrade;
1
2
Narodnog fronta 62, 11000 Beograd, Serbia and Montenegro
e-mail: n_branka@eunet.yu
Abstract
Choriocarcinoma is malignant Gestational Trophoblastic Neoplasm (GTN). It
is not easy to diagnose it in early stage and all diagnostic parameters can be of
a great value in early detection of this serious disease.
Transvaginal Color Doppler ultrasonography (TVUS) could be helpful in
early detection of GTN even in malignant types of GTN.
TVUS examination in GTN detection and during Follow up programme
may reduce or prevent the development of potential malignant GTN. Early
detection of malignant GTN is the rst step in successful treatment and reproductive health prevention.
GTN usually has a specic ultrasonographic picture, which is recognized, as
multiple cystic spaces in uterine cavity with or without fetal tissue. Theca luteal
cysts on one or both ovaries can also be seen during ultrasound examination
and more often in malignant forms of GTN.
Ultrasonography is of a limited value in cases with partial mole and
malignant GTNs. Malignant GTN does not have a specic ultrasonographic
picture. It can vary from changes in homogenicity of uterine wall structure
to picture of malignant foci, protrusion of malignant tissue in uterine wall
and even destruction of uterine tissue. TVUS could be of a great value in
early detection of trophoblastic malignancy development in uterine wall,
396
neovascularisation and low Resistance index following malignant forms of

GTN.
Introduction
It is well known that the ultrasonography has a limited value in GTN detection especially in cases of partial mole and all types of malignant GTN (2).
Therefore ultrasonographic examination should be repeated in post evacuation
period and during the Follow up programme. Blood beta choriogonadotropine
(hCG) value may indicate that more ultrasonograc examinations than usual
are necessary. That means that very slow dynamic of beta hCG decreasing in
post evacuation period, or no signicant changes in sequential repeated blood
beta hCG level and especially blood beta hCG increasing needs repeated ultrasonographic examinations (2,3 ).
Although the histological ndings conrmed mole or partial mole which
are benign types of GTN, increasing blood beta hCG values after the vacuum
aspiration and ultrasonographic picture could be of a great help in detecting of
developing malignant GTN (1.3).
Sometimes the histological conrmation of choriocarcinoma performing
explorative curettage is not possible because of a deep protrusion of malignant
trophoblastic tissue in uterine wall. Choriocarcinoma is determined with blood
beta hCG increasing and specic Doppler ultrasonographic ndings: changes
in echogenicity of uterine tissue, hypervascularisation (hot spots), Resistance
Index values lower than 0.5(1). Histological assessment after the repeated explorative curettage or hysterectomy can conrm the type of malignant GTN
(4, 5).
Ultrasonographic models of early detection of choriocarcinoma could be
seen and presented throughout case reports of very different ultrasonographic
pictures and usually reect the results of clinical and ultrasonography experience and skillfulness.
Ultrasonographic ndings were analysed with hystological ndings and
changes in values of blood beta hCG (1,6).
Material and methods

During last four years GTN was conrmed in 65 women hospitalised on our
department and in 17 women malignant GTN was histologicaly conrmed. All
65 women were ultrasonographicaly examined before treatment. Transvaginal
Doppler ultrasonography was performed in all cases. In one case (16 years old
397
patient) Computed Tomography was done to conrm ultrasonographic nding suspected of trophoblastic tissue protrusion in uterine wall. This imaging
method has proved useful in this setting and could be used to diagnose changes
in uterine structures.
Histological examination conrmed GTN in 61 cases after vacuum aspiration. In other 4 perimenopausal and menopausal women operative treatment
was performed because of rapid enlargement of uterus and uterine bleeding
where GTN was conrmed according to ultrasonograpic ndings and high
blood beta hCG levels. GTN was conrmed after histological assesment.
Transvaginal ultrasonography was done twice a week after the vacuum aspiration . Blood beta hCG was also measured on ten days in all cases except
in malignant GTNs where chemotherapy was administrated and beta hCG was
measured twice a week during the treatment. During Followe up programme
beta hCG was controled twice monthly until decreases to normal level. During
the follow up programme ultrasonography was done once a month until three
sequential blood beta hCG were normal. After that period ultrasonography was
done in malignant GTNs once a year.
Results
The last four years results of investigation showed that transvaginal Doppler
ultrasonography could be helpful in early detection of malignant GTN as well
as in following up the changes in uterine structure before and during the chemotherapy. Photo-documentation is also of a great value because most of patients
are in reproductive age and those changes in uterine structure could have an
impact on fertility.
In 17 women with conrmed malignant GTN ultrasonographic model was
varying from almost normal ultrasonographic picture to signicant destruction
of uterine tissue. GTN can appear throughout very different ultrasonographic
models.
In all 65 women GTN were clinically, ultrasonographicaly, laboratory and
histologicaly conrmed. Changes in uterine wall structures in 48 patients with
benign GTNs and in 13 patients with malignant GTNs were not detected during
transvaginal Doppler examinations.In 4 patients ultrasonographis picture was
signicantly different from normal nndings.
The most frequent medical reason for repeating ultrasonography out of
standard procedure was increasing blood beta HCG, nausea, vomiting, painful
breasts or uterine bleeding.
Transvaginal Doppler was done and in some cases of malignant GTN
398
changes in uterine wall structure were discovered. Transvaginal Doppler ultrasonography shows a normal appearing endometrium, whereas the myometrium
contains hypo or hiperechoic or even anechoic spaces.
Figure 1: Choriocarcinoma in 18 year old woman
Figure 2: Choriocarcinoma in the same patient ve months after GTN

Resistance Index was measured on the level of vessels suspected on neovascular vessels in malignant lesions. Spectral analysis of the vessels surrounding
malignant lesions shows high blood ow velocity with a low resistance index
(RI) (Figure 2: RI 0,319).
399
Figure 3a, 3b and 3c: Choriocarcinoma in 19 years old patient
400
Serial ultrasonography is not an accurate method of assessing malignant

GTN but it can be of a great value in early detection of uterine tissue damages, destructions, and sometimes even a neovascularisation throughout low
Resistance index in suspected malignant foci.
The following pictures are results of transvaginal Doppler ultrasonographic
estimation of malignant GTN representing different ultrasonographic models
of choriocarcinoma:
Transvaginal Doppler ultrasonography image shows changes in homogenicity of uterine wall structure caused by protrusion of malignant trophoblastic
tissue in posterior uterine wall.
This ultrasonography picture was seen three weeks after the vacuum aspiration in patient with diagnosed GTN-complete mole. Blood beta hCG has decreasing rate during rst three weeks after vacuum aspiration when started increasing. Curettage performed and Choriocarcinoma histologicaly conrmed.
Choriocarcinoma in the same patient ve months after GTNcomplete
mole diagnosed and chemotherapy administrated because of Choriocarcinoma.
Protrusion of malignant trophoblastic tissue in posterior uterine wall with destruction was shown at the Figure 2. At rst the protrusion of trophoblastic
tissue was ultrasonographicaly suspected and low Resistance Index (RI 0,319)
was measured in the eld of malignant tissue protrusion. In next two months
destruction of uterine wall appeared as a clear ultrasonographic nding.
During the treatment by mean of chemotherapy and after the treatment ultrasonographic picture was pointing at the trophoblastic tissue protrusion. After
two months of choriocarcinoma histologicaly conrmed the eld of destruction
was clearly seen. Dimensions of the eld of destruction were the same in next
two years.
Ultrasonographic picture shows a normal appearing endometrium, whereas
the myometrium contains two anaechoic spaces that look like two separated
gestational sacs (Figure 3a).
Theca luteal cysts were seen on both ovaries at 7 weeks gestation when
GTN-complete mole was ultrasonographicaly conrmed (Figure 3b).
Spectral analysis of the vessels surrounding malignant lesions shows high
blood ow velocity with a low Resistance Index (lower than 0,4) (Figure 3c).
Most trophoblastic tissue invasions are small to be diagnosed and smaller than
this one close to right uterine horn (Figure 4a).
This suspicious lesion with hypervascularisation surrounding the invasion
of malignant tissue and with RI lower than 0.4 was proved with other imagine
technique-CT (Figure 4b)
401
Figure 4a and 4b: Choriocarcinoma in 16 years old patient
Figure 5. Choriocarcinoma in 47 year old perimenopausal patient

Choriocarcinoma histologicaly conrmed post GTN-partial mole. Partial mole
was ultrasonographicaly diagnosed and histologicaly conrmed post vacuum
aspiration.
Figure 6: Choriocarcinoma three months after legal abortion in 43

year old patient
402
In the most number of malignant GTN ultrasonographic picture is nonspecic

and almost normal (Figure 5). Tissue changes and development of trophoblastic
tissue malignancies are usually very small to be diagnosed during transvaginal
Doppler ultrasonography and can be diagnosed through histological assessment
and measuring blood beta hCG level.
Multiple anaechogenic foci of malignant trophoblastic tissue destruction in
uterine wall (cheese like uterus) with increasing blood beta hCG . Hysterectomy
done and polychemiotherapy administrated (EMA). Hystological assesment
conrmed choriocarcinoma protrudion close to perimetrium.
Conclussion
Choriocarcinoma is uncommon cause of uterine bleeding, pelvic pain, nausea or
painful breasts after vacuum aspiration in patients where GTN is diagnosed.
Each GTN patient has to be carefully examined.
Changes in uterine structures must be checked by mean of serial transvaginal Doppler ultrasonography.
Transvaginal Doppler ultrasonography is useful in making early diagnose
of uterine structure changes, detection of hot spots, neovascularisation (low
Resistance Index values), ovarian theca luteal cysts.
Other imagine techniques (CT, MRI) could also be used in proving diagnose
of malignant GTN (7).
Existing data of those malignant GTN cases could be useful in checking up
of changes during Follow up period.
Acknowledgement
This work is a part of project No 1-333 Supported by Ministry of Health and
Welfare, Serbia and Montenegro
403
References:
1.
2.
3.
4.
5.
6.
7.
Nikolic B Lukic R Choriocarcinoma-postdisease ultrasonographic ndings.Int J Gynecol

Cancer 2004,14,677-679
Berkowitz S, Tuncer S, Bernstein R, Goldstein P. Management of gestational trophoblastic
diseases: subsequent pregnancy experience. Semin Oncol 2000; 27 (6):678-685.
Ozalp S, Yalcin T, Tanir M. A hospital-based multicentric study results on gestational trophoblastic disease management status in a developing country: Eur J Gynecol Oncol 2001; 22
(3):221-222.
Yalcin T, Ozalp S, Tanir M. Assessment of gestational trophoblastic disease by Doppler ultrasonography. Eur J Obstet Gynecol Reprod Biol 2002; 103 (1):83-7.
Polat P, Suma S, Kantarey M, Alper F, Levent A. Collor Doppler US in the evaluation of uterine
vascular abnormalities. Radiographics 2002; 22 (1):47-53.
Tapper R, Shulman A, Altaras M, Goldberg S, Maynon R. The role of color Doppler ow in the
management of nonmetastatic gestational trophoblastic disease. Gynecol Obstet Invest 1994;
38 (8):14-17.
Kohorn EI, McCarthy SM, Taylor KJ. Nonmetastatic gestational trophoblastic neoplasia: Role
of ultrasonography and magnetic resonance imaging. J Reprod Med 1998; 43 (1):14-20.
404
Screening and treatment of ovarian cancer
Prophylactic oophorectomy,
salpingectomy and omentectomy
in BRCA carriers with or without
hysterectomy
P. E. Schwartz, MD
Yale University School of Medicine, New Haven, CT, USA
Summary
Introduction: The purpose of this study is to determine whether the addition
of a hysterectomy is benecial for BRCA carriers undergoing prophylactic
oophorectomy(PO).
Materials and Methods: An English language MEDLINE review of BRCA,
prophylactic oophorectomy and prophylactic hysterectomy was performed.
Results: PO is recommended for BRCA1/2 germline mutation carriers to
prevent ovarian cancer. However, several studies have now recognized that
primary peritoneal cancers, fallopian tube cancers and uterine serous cancers
are also associated with BRCA1/2 mutations.
Conclusion: Complete removal of not only the ovaries, but the fallopian tubes
and uterus and possibly the omentum provides substantial cancer prophylaxis
benets for women with BRCA1/2 germline mutations.
Introduction
Inactivating mutations of the BRCA1 and BRCA2 genes are associated with
inherited breast and ovarian cancers.1 These cancers account for up to 10% of
405
all breast and epithelial ovarian cancers. Unique founder mutations have now
been identied in Ashkenazi Jewish, Asian as well as in Western European
populations.2 Carriers of BRCA1 mutations have been reported to have a
lifetime risk for developing breast cancer of 60-85% and their lifetime risk
for developing epithelial ovarian cancer has been reported to be 15-65%.2,3
Carriers of BRCA2 mutations may have a similar risk of breast cancer but a
10-20% risk of ovarian risk.1 The high risk for ovarian cancer in women with
BRCA1/2 mutations and the lack of effective techniques for the early detection
of ovarian cancer has led many centers to recommend prophylactic oophorectomy to avoid the development of ovarian cancer.4,5 However, there are many
questions regarding the role of prophylactic oophorectomy in the reduction of
ovarian cancer risk as well as it decreasing the possibilities of breast cancer.6
Additionally, BRCA1/2 germline mutations have now been associated with
fallopian tube, primary peritoneal and uterine serous cancers.7-14 This article
will concentrate on prophylactic oophorectomy in BRCA carriers and whether
there is a benet to performing a hysterectomy or omentectomy at the same
surgery. A MEDLINE review of BRCA, prophylactic oophorectomy and
prophylactic hysterectomy was performed to address this issue.
Timing of prophylactic oophorectomy

Prophylactic oophorectomy has been recommended in women known to have
BRCA1 or BRCA2 mutations once they have completed childbearing.4,5 The
ideal age to perform this surgery has not been identied. Some authorities have
recommended that the best opportunity for achieving a reduction in ovarian cancer risk and prolonging life is to perform the surgery as close to 30 years of age as
possible.15 One recent study reported that the mean age of women with BRCA1
or BRCA2 mutations who underwent surveillance only and subsequently developed ovarian cancer was 50.3 years, suggesting that at least half of the patients
would still have beneted from a prophylactic oophorectomy had they waited
until their age was well into the late forties before they underwent the procedure.1
However, another study reported that 70 percent of the women with a BRCA
mutation had developed breast cancer when prophylactic oophorectomy was
deferred until 47.5 years of age.4 If prophylactic oophorectomy is benecial in
reducing breast cancer risk, an earlier age for this surgery is necessary.
The reason for delaying prophylactic oophorectomies in premenopausal
women is related to the well-documented increased risk for cardiovascular
events and osteoporosis associated with an early menopause and hot ashes,
406
sexual dysfunction and cognitive changes associated with the menopause.4,5

Some centers have routinely recommended administering hormone replacement therapy (HRT) following prophylactic oophorectomy until the patient
reaches age 50.4,5 By combining progestins with estrogen one can decrease the
risk of endometrial cancer in the retained uterus. HRT in some series has not
had an impact on the benecial effect of prophylactic oophorectomy in patients
with BRCA1 or BRCA2 mutations.4,5
The recently reported Womens Health Initiative (WHI) study revealed that
women who take estrogen and progestin in combination have a statistically
increased risk for the development of breast cancer.16 Although the breast cancer risk for any one individual in that study was small (<1/1000), it was a
statistically measurable risk that has frightened many women into not taking
HRT. Nevertheless, in the second of the two groups of patients participating
in the WHI study, i.e. women who previously had a hysterectomy and were
randomized to either estrogen or placebo, there has been no reported increased
risk for breast cancer in the group taking estrogen only. Removing the uterus at
the time of prophylactic oophorectomy would allow the patient to take estrogen
only postoperatively and avoid any deleterious effects due to the progestin.
Fallopian tube cancer in brca1/2 carriers

Recent studies have suggested that there is an increased risk for fallopian tube
carcinoma associated with BRCA1/2 mutations.7-10 In a genetic, epidemiological study of 44 women with fallopian tube cancer, 5 cancers were associated with BRCA1 germline mutations and 2 were associated with BRCA2
mutations.8 The sites of these occult fallopian tube cancers have been reported
to be in the distal end of the fallopian tube. When one performs a prophylactic
oophorectomy only, the interstitial part of the fallopian tube is left in vivo.
Performing a total hysterectomy at the time of the prophylactic oophorectomy
will remove the entire fallopian tube.
Uterine serous cancer in brca1/2 carriers

The association of uterine cancers in women with germline mutations of the
BRCA1/2 genes has been anecdotal. Recently a series of 20 Ashkenazi Jewish
women with uterine serous cancer have been reported, four of whom had
BRCA1 mutations.14 Nine of the 20 had breast cancer diagnosed prior to the
uterine serous cancer diagnosis. Serous cancers of the uterus tend to occur
in older age women and tend to be hormonally insensitive tumors.17 Their
407
management is palliative when found in an advanced stage, but can be curative

when identied in an early stage.
Tamoxifen is routinely recommended in women with breast cancer to prevent the development of cancer in the contralateral breast and to prolong the
progression-free interval.18 Tamoxifen has been shown to reduce the incidence
of contralateral breast cancer in women with BRCA1/2 germline mutations.19
Tamoxifen has been associated with both low grade and highly curable endometrioid adenocarcinomas of the uterus as well as with serous cancers of the
uterus.18,20 Nevertheless, some authors advocate prophylactic oophorectomy
only and tamoxifen in BRCA1/2 positive breast cancer patients who do not
elect to have prophylactic mastectomies.21 Performing a hysterectomy at the
time of prophylactic oophorectomy in breast cancer patients receiving tamoxifen who have a germline BRCA1/2 mutation would seem extremely prudent!
Should a hysterectomy be routinely performed in women

who undergo prophylactic oophorectomy?
The identication of fallopian tube cancers in association with women who
carry these BRCA1/2 germline mutations would strongly argue for the routine
removal of the entire fallopian tube including the interstitial part of the tube
when a patient undergoes prophylactic oophorectomy. This can be best accomplished by performing a hysterectomy. The removal of uterus would also
remove the potential for developing a serous cancer of the uterus, particularly
in women who already have been diagnosed to have breast cancer.
The majority of studies of women who have undergone prophylactic oophorectomy appear to include women at extremely high risk for developing ovarian
cancer. In one study, 69 of 98 (70%) of the participants who underwent prophylactic oophorectomy had already experienced breast cancer as did similar
numbers (45 of 72, 62%)of patients in the surveillance group.4 In another study,
200 of 551 (36.3%) patients known to have BRCA1 or BRCA2 mutations had
previously been diagnosed to have breast cancer.5 Most physicians encounter
patients who do not have family cancer histories comparable to those included
in the latter studies. Alternative strategies to prophylactic oophorectomy, including the use of oral contraceptives and tubal ligations, can be employed for
lower risk women who do have BRCA1 or BRCA2 mutations.22 However, for
those women who have experienced breast cancer at a young age, prophylactic
oophorectomy in combination with a hysterectomy gives the best protection
against experiencing additional gynecologic cancers and will allow patients to
take estrogen replacement therapy.4,5
408
Should a prophylactic omentectomy be performed at the

time of prophylactic oophorectomy?
Serous cancers of the peritoneum, i.e. primary peritoneal carcinomas, do occur
in women who have BRCA1 and BRCA2 germline mutations. Indeed, one
early ovarian cancer detection program study reported that 7 of the 10 so-called
ovarian cancers detected were primary peritoneal cancers.13 Three of four primary peritoneal cancers tested were associated with BRCA1 mutations. These
cancers cannot be recognized early using detection techniques such as serum
tumor markers and endovaginal ultrasounds and have been reported to occur
after prophylactic oophorectomy was performed.12 The incidence of BRCA1/2
germline mutations in 68 Ashkenazi Jewish women with primary peritoneal
cancers in a population based epidemiologic study was 28% compared to a
30% mutation rate among Stage III and IV ovarian cancer patients.12
Serous cancers of the peritoneum may be recognized in an advanced stage
by a CT scan revealing the presence of ascites, in association with the dominant mass being in the omentum. The ovaries not being obviously involved by
cancer. Since the dominant mass is routinely the omentum in this disease, one
might support performing a prophylactic omentectomy at the time of a prophylactic bilateral salpingo-oophorectomy and hysterectomy. This may provide
additional prophylaxis of another site at risk for malignant change in women
with BRCA1/2 mutations. The benets of such a surgical approach are theoretical only. The incidence of serous cancers of the peritoneum in patients with
BRCA1/2 germ line mutations remains unknown. Short follow-up in many
studies limits our opportunity to know how great a risk a patient truly is for a
primary peritoneal cancer and who among the BRCA1 and BRCA2 germline
mutation carriers is at high risk for this disease. Of course, one should routinely perform peritoneal washings at the time of prophylactic oophorectomy to
identify malignant cells that might establish the presence of an occult primary
peritoneal cancer.
References
1.
2.
3.
4.
Haber DH. Prophylactic oophorectomy to reduce the risk of ovarian and breast cancers in
carriers of BRCA mutations. N Engl J Med 346:1660-1662, 2002.
Struewing JP,. Hartge P, Wacholder S, et al. The risk of cancer associated with specic mutations of BRCA1 and BRCA2 among Ashkenazi Jews. N Engl J Med 336:1401-1408, 1997.
Liede A, Narod SA. Hereditary breast and ovarian cancer in Asia: Genetic epidemiology of
BRCA1 and BRCA2. Hum Mutation 20:413-424, 2002.
Kauff ND, Satagopan JM, Robson ME, et al. Risk-reducing salpingo-oophorectomy in women
409
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
with BRCA1 or BRCA2 mutation. N Engl J Med 346:1609-1615, 2002.

Rebbeck TR, Lynch HT, Neuhausen SL, et al. Prophylactic oophorectomy in carriers of
BRCA1 or BRCA2 mutations. N Engl J Med 346:2616-1622, 2002.
Moller P, Borg A, Evans DF, et al. Survival in prospectively ascertained familial breast cancer:
Analysis of a series stratied by tumour characteristics, BRCA mutations and oophorectomy.
Int J Cancer 101:555-559, 2002.
Aziz S, Kuperstein G, Rosen B, et al. A genetic epidemiological study of carcinoma of the
fallopian tube. Gynecol Oncol 80:341-345, 2001.
Zweemer RP, van Diest PJ, Veriheijen RH, et al. Molecular evidence linking primary cancer
of the fallopian tube to BRCA1 germline mutations. Gynecol Oncol 76:45-50, 2000.
Paley PJ, Swischer E, Garcia RL, et al. Occult cancer of the fallopian tube in BRCA1 germline
mutation carriers at prophylactic oophorectomy: a case for recommending hysterectomy at
surgical prophylaxis. Gynecol Oncol 80:176-180, 2001.
Rose PG, Shrigley R, Wiesner GL. Germline BRCA2 mutation in a patient with fallopian tube
or carcinoma a case report. Gynecol Oncol 77:319-320, 2000.
Bandera C, Muto M, Schorge JO, Berkowitz RS, Rubin SC, Mok S. BRCA1 gene mutations
in women with papillary serous carcinoma of the peritoneum. Obstet Gynecol 92:596-600,
1998.
Menczer J, Chetrit A, Barda G, et al. Frequency of BRCA mutations in primary peritoneal
carcinoma in Israeli Jewish women. Gynecol Oncol 88:58-61, 2003.
Karlan BY, Baldwin RL, Lopez-Luevanos E, et al. Peritoneal serous papillary carcinoma, a
phenotypic variant of familial ovarian cancer: implications for ovarian cancer screening. Am
J Obstet Gynecol 180:917-928, 1999.
Lavie O, Hornreich G, Ben-Arie A, et al. BRCA1/2 germline mutations in women with uterine
serous papillary carcinoma. Gynecol Oncol 92:521-524, 2004.
Grann VR, Jacobson JS, Thomason D, Hershman D, Heitjan DF, Neugut AI. Effect of prevention strategies on survival and quality-adjusted survival of women with BRCA1/2 mutations:
An updated decision analysis. J Clin Oncol 20:2520-2529, 2002.
Writing Group for the Womens Health Initiative Investigators. Risks and benets of estrogen
plus progestin in healthy postmenopausal women. Principle results from the Womens Health
Initiative randomized controlled trial. JAMA 288:321-333, 2002.
Carcangiu ML, Chambers JT. Uterine papillary serous carcinoma: a study of 108 cases with
emphasis on the prognostic signicance of associated endometrioid carcinoma, absence or
invasion and concomitant ovarian cancer. Gynecol Oncol 47:298-305, 1992.
Fisher B, Costatino JP, Redman CK, Fisher ER, Wickerham DL, Cronin WM. Endometrial
cancer in tamoxifen-treated patients: Findings from the National Surgical Adjuvant Breast and
Bowel Project (NSABP) B-14. J Natl Cancer Inst 86:527-537, 1994.
Narod SA, Brunet JS, Ghardirian P, et al. Tamoxifen and risk of contralateral breast cancer in
BRCA1 and BRCA2 mutation carriers: a case-control study. Lancet 356:1876-1881, 2000.
Magriples U, Naftolin F, Schwartz PE, Carcangiu ML. High grade endometrial carcinoma in
tamoxifen-treated breast cancer patients. J Clin Oncol 11:485-490, 1993.
Eisen A, Weber BL. Prophylactic mastectomy for women with BRCA1 and BRCA2 mutations
facts and controversy. N Engl J Med 345:207-208, 2001.
Narod SA, Sun P, Ghardirian P, et al. Tubal ligation and risk of ovarian cancer in carriers of
BRCA1 or BRCA2 mutations: a case-control study. Lancet 357:1467-1470, 2001.
410
Lymphadenectomy in Ovarian Cancer:

A waste of time?
S. Fotiou, MD, PhD
2nd Dept. Of Obstetrics & Gynecology, Athens University Aretaieio Hospital
Around 90% of ovarian malignancies are of epithelial origin. Epithelial ovarian

cancer (EOC) is the most deadly gynecologic cancer with more women dying
each year from it than from cervical and endometrial cancer combined. The
low overall survival is mainly attributed to the advanced stage of the disease
at initial presentation.
Ovarian cancer spreads mainly via transperitonial and lymphatic routes.
The lymphatic spread follows three main directions. From the subovarian lymphatic plexus 6 to 8 collecting trunks follow the ovarian blood vessels to the
paraaortic region between the bifurcation of the aorta and the renal vessels.
Secondly, lymphatic channels lead from the mesovarium to the pelvic wall and
lymph nodes (external, internal, common iliac and obturator). The third route
of efferent lymphatics runs along the round ligament to the external iliac and
inguinal lymph nodes.
Despite awareness of the potential for retroperitoneal spread of EOC, the
role of pelvic and paraaortic lymphadenectomy is still debated. Many authors
believe that lymphadenectomy is an important step in the surgical management of the disease and has diagnostic, prognostic and possibly, therapeutic
value. However, it is commonly stated that lymphadenectomy is hazardous
and lengthy with no proven survival benet for the patients. The controversy is
mainly due to the lack of prospective randomized studies. Consequently, some
important questions concerning this procedure are worthy to be addressed.
In early EOC: Is lymphadenectomy mandatory in the surgical staging of
patients with localized disease? Should it be performed in all stages and in all
411
histologic subtypes? Should it be bilateral or unilateral? Should it be partial or

complete?
In advanced EOC: What is the role and the possible indications of lymphadenectomy?
Early Ovarian Cancer

The incidence of pelvic and paraaortic lymph node involvement has been consistently reported to lie at approximately 40 to 60% (1-3). The rate of nodal
metastasis increases with the stage of the disease. An incidence of 12-20% has
been reported in stage I, 24-40% in stage II and 48-74% in stage III disease
(1-4). Another important factor inuencing the rate of nodal involvement is the
tumor grade. Baiocchi reported an incidence of nodal metastasis of 3,9%, 7,7%
and 38,5% in stage I, grade 1,2 and 3 tumors, respectively (5). In a recent study
by Morice et al (3) 85 patients with stage I disease who underwent complete
pelvic and paraaortic lymphadenectomy were included. The frequency of nodal
involvement was 20% for all stage I and 13%, 33%, and 38% for stage IA, IB
and IC, respectively. In these series, none of the 15 patients with stage IA grade
1 disease had nodal involvement.
Apart from the stage and the tumor grade, the histologic subtype has been
reported to inuence the rate of nodal involvement. This rate is particularly
high in serous papillary (2) and clear-cell tumors (6) and the lowest in mucinous tumors (5). In the study of Morice et al (3) none of the 20 patients with
stage I mucinous tumors had nodal involvement.
The anatomic location of nodal metastasis varies in the different reports.
In 8-40% of the cases the positive nodes are located in the pelvis and 15-40%
in the paraaortic area (3,7,8). About 35-40% of the patients have no nodal
involvement (1,9). Most authors agree that paraaortic nodes, particularly those
located between the inferior mesenteric artery and left renal vein, are most
frequently involved (3, 5). In the series of Morice et al this nodal group had
metastasis in 38% of the patients with unilateral ovarian tumors (3). In the work
of Benedetti-Panici et al, all 35 patients with stage I disease had ipsilateral
nodal involvement and the authors suggested the performance of unilateral
paraaortic lymphadenectomy for these cases (2). However, more recent studies
have reported on contralateral nodal involvement (5,8). Cass et al observed
three cases with contralateral pelvic and/or paraaortic nodal metastasis (10) and
in the study by Morice et al 11,1% of patients with unilateral stage I disease
had contralateral paraaortic nodal metastasis (3).
412
In conclusion, the above data underlines the importance of lymphadenectomy during surgical staging even in cases of apparent stage I EOC. In these
patients the two procedures most likely to upstage the disease are cytology and
node dissection. Young et al showed that 1/3 of the patients initially assessed as
having only pelvic disease were upstaged after a careful staging relaparotomy
(11). Lymphadenectomy in apparent early EOC can identify patients with occult nodal metastasis which may very well affect decisions of post-surgical
management. In young patients with stage IA disease, fertility preservation
may be an issue. Conservative surgery in the form of unilateral oophorectomy
only can be performed provided that the patient has been fully staged and occult
extraovarian spread of the disease has been excluded. When the intraoperative
diagnosis of malignancy is in doubt or the pathologists reports a borderline
tumor, not performing a lymphadenectomy seems appropriate.
The existing evidence supports the view that lymphadenectomy in early
ovarian cancer should include both the pelvic and paraaortic nodes up to the
level of the left renal vein. Due to the possibility of contralateral node involvement, nodal dissection should be carried out bilaterally even in cases with
unilateral stage I disease. Nevertheless, lymphadenectomy may be omitted in
patients with stage IA, grade 1 disease and possibly in those with unilateral
mucinous tumors without extraovarian spread.
Advanced EOC
The most important prognostic factor for patients with advanced EOC is the
size of the residual tumor at the end of the operation. Cytoreductive surgery
should be directed towards removing the maximum tumor burden and therefore
extirpation of enlarged positive nodes seems to be of mandatory importance.
This opinion is supported by the observation that chemotherapy was shown to
have limited effect on retroperitoneal metastasis (12). It has been suggested
that at the end of systematic therapy lymph nodes may harbour occult disease
and act as sanctuary sites increasing the rate of early relapse (13). Burghardt
et al retrospectively analyzed the 5-year survival for stage III ovarian cancer
with optimal debulking. They found a superior (53%) survival rate in patients
who underwent lymphadenectomy as compared to those without lymph node
dissection (13%) (1). Similar results were reported by Di Re et al (9). Spirtos
et al observed that patients with negative nodes had similar survival to that of
patients with resected positive paraaortic nodes (13). However Parazzini et al
in a large multicentric clinical trial found no survival benet of selective pelvic
and paraaortic lymphadenectomy in patients with advanced disease. In particu-
413
lar nodal status was not proved to be of prognostic signicance in patients with
optimal cytoreduction (14).
Table 1:
Operative data of aortic lymhadenectomy
Years
1986-1992
1993 -1998
Number of patients
309
302
Operating time (min- 75 (45-135)

utes) (range)
45 (25-90)
Estimated Blood loss 350 (100-2000)

(ml) (range)
200 (50-1500)
Postoperative
(days) (range)
6 (4-105)
stay 10 (7-55)
From Benedetti-Panici et al (15)

Table 2:
Perioperative complications of aortic lympadenectomy
Years
Number of patients
Introperative complications
Vessel lesion*
Severe hemorrhage (>1000 ml)
Postoperative complications
Deep venous thrombosis
Pulmonary embolism
Infectious morbidity
Lymphocyst
Lymphatic ascites
1986-1992
309
1993 1999
302
30 (10%)
5 (2%)
14 (5%)
3 (1%)
15 (15%)
3 (1%)
60 (19%)
1 (0,3%)
9(3%)
2 (1%)
44(15%)
1(0.3%)
10 (3%)
* requiring repair
From Benedetti-Panici et al (15)

In patients with advanced disease and normal-appearing retroperitoneal
nodes, the role of systematic pelvic and paraaortic lymphadenectomy remains
unclear.
Since no randomized study has demonstrated the benet of lymphadenectomy on survival in advanced stage disease, retroperitoneal dissection for staging
purposes in disseminated EOC does not seem to be justied. Lymphadenectomy
414
is not a simple innocuous procedure especially in patients undergoing extensive

cytoreductive surgery. The operative data and parioperative complications of
paraaortic lymphadenectomy have been presented by Benedetti-Panici et al
(Table 1 and 2). The authors had no deaths related to nodal dissection. Intraoperative complications consisted mainly of vessel lesions and severe hemorrhage which were promptly managed (15).
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Burghardt E, Girardi F, Lahousen M, et al. Patterns of pelvic and paraaortic lymph node
involvement in ovarian cancer. Gynecol Oncol 1991; 40:103-106
Benedetti-Panici P, Greggi S, Maneschi F, et al. Anatomical and pathological study of retroperitoneal nodes in epithelial cancer. Gynecol Oncol 1993; 51: 150-154
Morice P, Joulie F, Camatte S, et al. Lymph node involvement in epithelial ovarian cancer:
analysis of 276 pelvic and paraaortic lymphadenectomies and surgical implications. J Am Col
Surg 2003; 197: 198-205
Pickel H, Lahousen M, Stettner H, Winter R. The prognostic importance of pelvic and paraaortic lymph node involvement in ovarian cancer. CME J Gynecol Oncol 1999 ; 4:47-50
Baiocchi F, Raspagliesi F, Grosso G, et al. Early ovarian cancer : is there a role for systematic
pelvic and paraaortic lymphadenectomy? Int J Gynecol Cancer 1998; 8: 103-108
Sakuragi N, Yamada H, Oikawa M, et al. Prognostic signicance of lymph node metastasis and
clear cell histology in ovarian carcinoma limited to the pelvis (pT1MO and pT2MO). Gynecol
Oncol 2000; 79: 251-255
Wu PC, Qu JY, Lang JH, et al. Lymph node metastasis of ovarian cancer: a prelimanary survey
of 74 cases of lymphadenectomy. Am J Obstet Gynecol 1986; 155: 1103-1108.
Onda T, Yoshikawa H, Yokota H, et al. Assessment of metastasis to aortic and pelvic lymph
nodes in epithelial ovarian carcinoma. A proposal for essential sites for lymph node biopsy.
Cancer 1996; 78: 803-808.
Di Re F, Baiocchi G, Fontanelli R, et al. Systematic pelvic and paraaortic lymphade-nectomy
for advanced ovarian cancer: Prognostic signicance of node metastasis. Gynecol Oncol 1996;
62: 360-365.
Cass I, Li AJ, Runowicz CD, et al. Pattern of lymph node metastasis in clinically unilateral
stage I invasive epithelial ovarian carcinomas. Gynecol Oncol 2001; 80: 56-61.
Young R, Decker D, Wharton JT. Staging laparotomy in early ovarian cancer. JAMA 1983;
250: 3072-3076.
Burghardt E, Winter R. The effect of chemotherapy on lymph node metastasis in ovarian
cancer. Bailliere Clin Obst Gynaecol 1989; 3: 167.
Spirtos N, Gross G, Freddo J, Ballon S. Cytroreductive surgery in advanced epithelial cancer
of the ovary: The impact of aortic and pelvic lymhadenectomy. Gynecol Oncol 1995; 56:
345-352.
Parazzini F, Valsechhi G, Bolis G, et al . Pelvic and paraortic lymph nodal status in advanced
ovarian cancer and survival. Gynecol Oncol 1999; 74: 7-11.
Benedetti Panici P, Maneschi F, Cuttilo G, et al. Aortic lymphadenectomy for gyneco-logical
malignancies : surgical technique and perioperative complications. CME J Gynecol Oncol
2000; 5: 107-110.
415
WHI Whats next?

HT and heart disease:
is it still an unsettled issue?
George E Christodoulakos
Menopause Clinic, 2nd Department of Obstetrics and Gynecology, University of Athens
Aretaieio Hospital
Estrogen deciency (ED) is a principal factor among risk factors for cardiovascular disease (CVD). Menopause related ED has been associated with an
increased risk for CVD. ED has both metabolic and vascular consequences and
affects a number of CVD risk factors, which contribute to an increase in CVD
risk. As a result, coronary artery disease (CAD) along with stroke are the two
main contributors of mortality among postmenopausal women.
Hormone therapy (HT) has a benecial effect on the metabolic and vascular consequences. Observational studies have suggested that long term HT
expresses an anti-atherogenic prole via mechanisms which include favorable
modulations of lipids lipoproteins, coagulation brinolysis and glucose metabolism, the decrease in homocysteine levels, enhancement of vasodilation, a
decrease in the expression of vascular cell adhesion molecules as well as maintenance of endothelial integrity and function and vascular extracellular matrix
homeostasis. In accordance to the above, observational studies have reported a
CAD risk reduction ranging from 31-44%. However, the results of two randomized clinical trials (RCTs) evaluating the effect of HT on primary (WHI) and
secondary (HERS) CAD prevention have questioned the efcacy of HT, despite
conrming estrogens lipid lowering effect. The discrepant results between
the observational and RCT studies may be explained by differences in the populations investigated and the regimens administered. Observational studies addressed younger, healthy, recently menopaused women initiating HT soon after
menopause. In the WHI the women investigated were of a rather advanced age
(mean age 63 years) and initiated treatment long after becoming menopausal.
416
RCTs investigating intermediate CAD outcomes (Table 1) following administration of different ET / EPT regimens have reported neither harm nor
benet. In all these studies the mean age was >= 63.5 years and treatment was
initiated long after menopause onset. In contrast the EPAT study reported a
decrease in intima media thickness in the carotid artery of women receiving
17b-estradiol. RCTs evaluating CAD outcomes (HERS I II, ESPRIT, WHISP,
WHI, 2) also addressed women of rather advanced age (mean age
62.6-66.7 years). Despite advanced age and late therapy initiation these studies
reported no increase in CAD risk and in fact a trend for later benet. However,
both HERS I and WHI reported a signicant increase in early CAD events and
this is admittedly alarming.
Table 1:
RCTs evaluating intermediate CAD outcomes
Study
age
ERA
65.8
PHOREA
regimen
effect
CEE / CEE+MPA
17b-E2+gestodene
HERS sub-study
67
CEE+MPA
WAVE
65
CEE / CEE+MPA
WELL-HART
63.5
17b-E2 / 17b-E2+MPA
PAPWORTH
<70
17bE2+NETA (tsd)
EPAT
62.2
17b-E2
CASHMERE
OPAL
59
17bE2+Dydrogesterone
tibolone / CEE+MPA
?
?
A number of reasons may be responsible for the discrepant results between

observational and RCTs studies and explain why the WHI study did not associate HT with cardioprotection. The mean age in the WHI is much higher than
the mean age of symptomatic women attending a Menopause Clinic. Because
of advanced age the WHI population included women with a high prevalence
of increased BMI and hypertension. This is a sample already at high risk for
CAD. Women at this age may lack symptoms of atherosclerosis but this does
not exclude the presence of a lesion. Carotid ultrasonography has shown that
increased intima media thickness in individuals > 50 years associated with a
417
5-fold increase in the CAD risk. Furthermore, cases of myocardial infarction

have been reported, even in the absence of risk factors for atherosclerosis. In
women of advanced age under a high estrogen dose, as is the case in WHI,
alterations in homeostasis may disrupt the cycle of damage : repair in the arterial endothelium.
Treatment initiation in the onset of menopause may also account for the
absence of a cardioprotective effect in the WHI. Menopause related estrogen
loss enhances dyslipidemia. Although dyslipidemia is responsible for CAD
risk substantially less compared to vascular endothelial factors, late (10 years)
initiation of HT allows dyslipidemia to contribute to atherosclerosis. Estrogen
receptor expression differs in normal and atherosclerotic arteries. Estrogen
receptor levels in postmenopausal women with diseased coronary vessels are
decreased and this may compromise endothelial response to HT and explain
the lack of cardioprotective effect in the WHI. We may hypothesize that HT,
initiated soon after menopause onset, could be benecial and could prevent the
progress of an existing lesion.
Table 2:
RCTs evaluating CAD outcomes
Study
age
HERS I
66.7
ESPRIT
62.6
WHISP
regimen
effect
early events
CEE+MPA
E2
17b-E2+NETA
WHI
63.3
CEE+MPA
WHI updated*
63.3
CEE+MPA
WHI
63.6
CEE
Manson JE, N Engl J Med 2003

The WHI as an RCT study had a tremendous impact on both the public and the
clinicians. Although it has contributed to our understanding on the benet: risk
relation associated with HT. it has not answered questions regarding the effect
of such a therapy on CAD risk. As an example of evidence-based medicine its
418
results deserve consideration. However, if we are to adhere to the principles of

evidence based medicine, these results can not be extrapolated to a different
population from the one studied in the trial, not to a different HT regimen. A
cluster of factors are responsible for the genesis and progression of CAD and
until we understand the specic action and how this different factors interact
the issue of HT: CAD risk will remain unsettled.
419
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Kannel W et al. Menopause risk of cardiovascular disease: The Framingham Study. Ann Intern
Med 1976,85:447-52.
Nasr A, Breckwoldt M. Estrogen replacement therapy and cardiovascular protection: lipid
mechanisms are the tip of an iceberg. Gynecol Endocrinol. 1998;12:43-59.
Lip GY, Blann AD, Jones AF, Beevers DG. Effects of hormone-replacement therapy on hemostatic factors, lipid factors, and endothelial function in women undergoing surgical menopause:
implications for prevention of atherosclerosis. Am Heart J 1997;134:764-71.
Stevenson JC, Oladipo A, Manassiev N, Whitehead MI, Guilford S, Proudler AJ. Randomized
trial of effect of transdermal continuous combined hormone replacement therapy on cardiovascular risk markers. Br J Haematol 2004;124:802-8.
Ylikorkala O, Cacciatore B, Paakkari I, Tikkanen MJ, Viinikka L, Toivonen J. The long-term
effects of oral and transdermal postmenopausal hormone replacement therapy on nitric oxide,
endothelin-1, prostacyclin, and thromboxane. Fertil Steril. 1998;69:883-8.
Christodoulakos G, Lambrinoudaki I, Panoulis C, Papadias C, Economou E, Creatsas G. Effect
of hormone therapy and raloxifene on serum VE-cadherin in postmenopausal women. Fertil
Steril 2004;82:634-8.
Zanger D, Yang BK, Ardans J, Waclawiw MA, Csako G, Wahl LM et al. Divergent effects of
hormone therapy on serum markers of inammation in postmenopausal women with coronary
artery disease. J Am Coll Cardiol. 2000; 36: 1797-802.
Stevenson JC. Cardiovascular effects of estrogens. J Steroid Biochem Mol Biol. 2000;74:38793.
Cushman M. Effects of hormone replacement therapy and estrogen receptor modulators on
markers of inammation and coagulation. Am J Cardiol 2002;90:7F-10F.
Zanger D, Yang BK, Ardans J, Waclawiw MA, Csako G, Wahl LM et al. Divergent effects of
hormone therapy on serum markers of inammation in postmenopausal women with coronary
artery disease on appropriate medical management. J Am Coll Cardiol. 2000;36:1797-802.
Hulley S, Grady D, Bush T, Furberg C, Herrington D, Riggs et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal
women: Heart and Estrogen/ Progestin Replacement Study (HERS) Research Group. JAMA
1998;280:605-613
Walsh BW, Paul S, Wild RA, Dean RA, Tracy RP, Cox DA et al. The effects of hormone
replacement therapy and raloxifene on C-reactive protein and homocysteine in healthy postmenopausal women: a randomized controlled trial. J Clin Endocrinol Metab 2000; 85: 214218.
Grodstein F, Stampfer MJ, Colditz GA, Willett WC, Manson JE, Joffe M, Rosner B, Fuchs C,
Hankinson SE, Hunter DJ, Hennekens CH, Speizer FE. Postmenopausal hormone therapy and
mortality. N Engl J Med. 1997;336:1769-75.
Godsland IF. Biology:risk factor modication by OCs and HRT lipids and lipoproteins.
Maturitas 2004;47:299-303.
Losordo DW, Kearney M, Kim EA, Jekanowski J, Isner JM. Variable expression of the estrogen receptor in normal and atherosclerotic coronary arteries of premenopausal women.
Circulation. 1994;89:1501-10.
420
The million women study A critique

Richard Farmer MB PhD FFPH FFPM
Postgraduate Medical School University of Surrey, Guildford UK
Background
The March 1997 Edition of the British National Formulary (BNF) (1) advised
that after some years of use (of HRT, there is) possibly a slightly increased
risk of breast cancer and that any effect of the progestogen (favourable or
otherwise) on breast cancer is not yet known.
By the end of 1998 the wording of the relevant section in the BNF had been
changed to read as follows: Following publication of an analysis of pooled
original data, the CSM has advised that the increased risk of breast cancer is
related to the duration of HRT use and that this excess risk disappears within
about 5 years of stopping. Women who use HRT for a short time around the
menopause have a very low excess risk. Breast cancers in HRT users were
less likely to have spread beyond the breast than those in non-users. About 45
in every 1000 women aged 50 years not using HRT will have breast cancer
diagnosed over the next 20 years: in those using HRT for 5 years this rises by
2 extra cases in 1000, in those using HRT for 10 years 6 extra cases in 1000
and in those using HRT for 15 years 12 extra cases in 1000. The CSMs view
is that these results do not provide a reason for women to stop their treatment
but the results do emphasise the importance of breast awareness and regular
mammograms (2). In 2003 further changes were introduced. The CSM has
estimated that using all types of HRT, including tibolone, increases the risk
of breast cancer within 1-2 years of initiating treatment. The increased risk is
related to the duration of HRT use (but not to the age at which HRT is started)
and this excess risk disappears within about 5 years of stopping. About 32 in
every 1000 women aged 50-65 years not using HRT have breast cancer diagnosed over 15 to 20 years. In those using oestrogen only HRT for 5 years, breast
421
cancer is diagnosed in about 1.5 extra cases in 1000 and about 5 extra cases in
1000 after 10 years use. In those using oestrogen and progestogen combined
HRT for 5 years, breast cancer is diagnosed in about 6 extra cases in 1000 and
about 19 extra cases in 1000 after 10 years use. Tibolone increases the risk of
breast cancer but to a lesser extent than with combined HRT (3). The changes
in the wording of the BNF reect changes in the licenses of HRT throughout
the European Union.
In 2001 the late Dr Trudy Bush and her colleagues published a review of
studies on the association between HRT and breast cancer (4). Amongst the 45
studies of oestrogen only therapy that they identied, ve showed a statistically signicant increase in risk of breast cancer, one showed a statistically
signicant decrease in risk and the remainder did not show a signicant effect.
For 18 of the studies that showed no association the point estimate was less
than 1, it was greater than 1 in 19 studies and in the remainder it was 1. Fewer
studies of the effect of oestrogen plus progestogen were identied. Of the 20
included in the review, two showed a signicant increase in risk, two showed
a decrease in risk and the remainder showed no signicant effect. Some of the
studies were weak in their design, many involved small numbers and they were
heterogeneous in respect of the populations from which the study subjects were
drawn. They do not provide convincing and consistent material to support a
causal association between hormone replacement therapy and breast cancer.
In the light of the equivocal evidence accumulated over a period of 25 years
it is remarkable that the advice given to physicians by licensing authorities
changed so rapidly between 1998 and 2003. On careful consideration it is clear
that the current view was determined by the publication of three studies the
Collaborative Reanalysis of Observational Studies (5), the Womens Health
Initiative (WHI) randomised trials (6,7) and the Million Women Study (8). It
is instructive to consider briey some aspects of the rst two before examining
the methodology and ndings of the Million Women Study.
The Collaborative Re-analysis of Observational Studies.

The Collaborative Re-analysis (5) combined the data from 51 observational
studies that had recruited cases between 1974 and 1993. The majority of the
studies from which the data accrued were of oestrogen only therapy (ERT) and
80% of the study subjects had used only ERT. For most of the analyses ERT
and HRT were combined. The overall relative risk estimated from the pooled
data was 1.14 (95% CI 1.08 1.20) and there was a small but statistically
signicant increase in risk amongst women who were using HRT at the time of
422
the diagnosis of breast cancer. There was no signicant elevation in risk with
increasing duration of use up to 14 years (Table 1).
Table 1:
Breast cancer risk and duration of use (data extracted from the published paper on the
collaborative re-analysis (4)
Duration of use
Cases
Controls
RR (95% CI) *
Never users
12467
23568
1.00 (0.96, 1.04)
<1 year
1154
2546
1.09 (0.99, 1.19)
1-4 years
1660
3999
1.05 (0.97, 1.13)
5-9 years
813
1912
1.19 (1.07, 1.31)
10-14 years
386
867
1.09 (0.92, 1.26)
15 years and more
337
584
1.58 (1.34, 1.82)
* Calculated from oating standard errors

Table 2:
Breast cancer risk by type of study and exposure status of the controls (data extracted
from the published paper on the collaborative re-analysis (4)
Group
HRT ever users
HRT never users
RR
(95%
CI)
% controls
ever
users
cases
controls
cases
controls
Prospective
studies
1976
7798
2051
8147
1.09
1.00
1.18
48.9
Case-control
with population controls
2813
3362
5562
6880
1.15
1.06
1.24
32.8
Case-control
with hospital
controls
693
1188
4854
8541
1.27
1.09,
1.45
12.2
All Studies
5482
12348
12467
23568
1.14
1.08,
1.20
33.4
Women who had ever used HRT were signicantly less likely to have had tumours that spread to the axillary lymph nodes or beyond the breast. In presenting their main results the authors set out the pooled RRs from the prospective
423
studies, case-control studies with population controls and case-control studies

with hospital controls separately. Table 2 summarises the key ndings. The
highest relative risk is amongst the case-control studies with hospital controls
but the percentage of controls who had ever used HRT was the lowest in that
group. By contrast the lowest RR was derived from the prospective studies,
which also had the highest percentage of ever users amongst the controls.
The UK Committee on Safety of Medicines (CSM) interpreted these data
as demonstrating that HRT increased the risk of breast cancer and that the risk
increased with duration of use. The difference in RR between studies of different basic design serves to demonstrate the fragility of observational studies,
particularly when very small differential risks are involved. The increased risk
with duration of use is entirely driven by the exposure category of 15 years
or more and this category must comprise data from a minority of the studies
because many of them did not have 15 years of data availablecertainly most
of the prospective studies did not. An alternative interpretation of the data
is that the very small apparent increase in risk is because women who have
used or use HRT are diagnosed earlier than women who never used HRT.
The evidence to support this hypothesis includes the observation (from the
collaborative analysis) that breast tumours diagnosed in past and present users
of HRT were signicantly less likely to have spread beyond the breast than
tumours diagnosed amongst never users.
The WHI Trial

The WHI study was a randomised placebo controlled trial amongst post-menopausal women, 21% of whom were over 70 years old at recruitment. There
were two relevant arms to the study. The rst was of combined conjugated
equine oestrogen (CEE) and MPA, conducted amongst women with a uterus
and the second was of CEE conducted amongst women who had had a hysterectomy. 19% of the study subjects in the CEE/MPA arm and 35% in the CEE
arm had used HRT prior to recruitment. The main analyses were carried out
on the intention to treat principle despite the fact that around 40% of women
had stopped taking the study drug at some time with about 10% dropping out
within the rst year. Moreover, during the course of the study about 10% of
women had other HRT initiated by their own physician. In the primary analyses
no adjustment was made for prior therapy with HRT. The hazard ratios (HRs)
from the primary analyses are set out in table 3. In neither of study arms is the
adjusted HR statistically signicant. The unadjusted HR for CEE combined
with MPA of 1.26 is signicant. These results are consistent with earlier nd-
424
ings reviewed by Bush et al (4). The data from the MPA/EE arm were analysed
by follow-up years. The HRs for each year of follow-up were published and are
shown here in table 4. The authors report a signicant z score for trend across
all years. This is an interesting observation but it is clear that it is due mainly
to the HRs of less than 1 in years 1 and 2. Thus, if it is concluded that risk
increases with time then it must also be concluded that risk is reduced during
the rst two years of use.
Table 3:
Hazard ratios for invasive breast cancer from the WHI study
Hazard Ratio Nominal 95% Adjusted 95%

CI
CI
CEE+MAP vs Placebo
1.26
1.00, 1.59
0.83, 2.32
CEE alone vs Placebo
0.77
0.75, 1.55
0.63, 1.15
Table 4:
Hazard ratios for invasive breast cancer by follow-up year CEE+MPA vs placebo
Annualised percentage incidence
Hazard Ratio
Placebo
CEE+MPA
Year 1
0.21
0.13
0.62
Year 2
0.38
0.31
0.83
Year 3
0.29
0.34
1.16
Year 4
0.29
0.50
1.73
Year 5
0.22
0.57
2.64
Year 6+
0.47
0.53
1.12
The Million Women Study.

The study subjects included in the Million Women Study (MWS) were recruited
at the time they attended one of the participating breast cancer screening clinics
in the UK between May 1996 and March 2001. About 53% of the women who
were eligible for screening during the study period took part in the study. Those
who participated were more likely to be users of HRT than those who did not
and were less likely to be socially deprived. Data on use of HRT was collected
through a self-administered questionnaire at the time of recruitment. Some
additional data were collected from a small group of women part way through
the study. Follow-up was through the national cancer registry and the national
death register. The cancer registries in one third of the regions involved were
425
not updated beyond 31 December 2000, thus for the women recruited between
January and March 2001 from centres in these regions there was no morbidity
follow-up. The cancer registries covering the rest of the centres were up-dated
to 31 December 2001.
In the analyses women were classied according to HRT status at the time of
recruitment rather than their HRT utilisation up to the time of the diagnosis of
breast cancer, or end of follow-up for women who did not. The interval between
recruitment and the end of follow-up would have been between 0 months and
ve and a half years. During that period the exposure status of all of the women
would have changed. Those who remained users throughout the study period
would all have had a longer period of exposure than had been recorded on the
recruitment questionnaire, some of the users would have ceased treatment and
some of those who were classied as never users would have become users.
This is made explicit in the published paper. The authors report on a survey of
a random sample of 12,221 (1.4% of those in the study) women done on average 2.8 years after recording of baseline information, the sampling methods
and survey design were not published separately. They found that 22% of the
women who were current users at baseline were no longer using HRT, 19%
of past users at baseline had re-started treatment and the 11% of never users
had started to use HRT. It follows that the classication of the women according to their use of HRT cannot be relied upon. This is important because the
key analyses were comparisons of various categories of users against never
users. The never users included women who could have been past users or
current users at the time the breast cancer was diagnosed, or in the case of those
who did not develop breast cancer, at the end of the survey. It follows that the
reference group was not of never users as stated in the paper, but women who
were never users at an arbitrary point in time, namely when they were invited
to attend for breast screening. It is impossible to predict the effect on the risk
estimates of using this heterogeneous reference group.
The results of the MWS are bewildering. The paper compares the incidence
of invasive breast cancer in various exposure categories with that amongst
never users. Strictly speaking the comparisons are of diagnosed invasive
breast cancer. No account is taken of the possibility that breast cancer may
be diagnosed earlier amongst women who are being treated with HRT due to
more intensive surveillance. Table 5 sets out the risk estimates according to
recency of use and duration of use (these data were abstracted from the gures
in the published paper). Current users have a 66% increase in risk but past
users have no increase in risk. It follows that the risk disappears shortly after
cessation of use of HRT (irrespective of the duration of prior use). In view of
426
the nature of breast tumours where the interval between tumour initiation and
diagnosis is thought to be a matter of years rather than months this nding is
difcult to interpret. Next the investigators nd that there is a 45% increase in
risk after less than one year of treatment with combined HRT. This nding is
not consistent with our current knowledge of the biology of breast tumours it
is certainly not consistent with the HRT initiating the tumour and it is difcult
to believe that growth acceleration could result in such an increase in detected
tumours. Finally, amongst past uses the risk is unaffected by the prior duration
of usein fact past users have no increase in risk compared with never users.
Table 5:
Risk estimates for breast cancer extracted from the published paper on the Million
Women Study (8)
HRT use at baseline
Adjusted
Relative Risk
95% oating
condence
interval
Never users
1.00
0.97, 1.04
Current users
1.66
1.60, 1.72
Last use < 5 years prior to recruitment
1.04
0.95, 1.12
Last use 5-9 years prior to recruitment
1.01
0.88, 1.16
Last use over 10 years prior
0.90
0.72, 1.12
All women
Current users of oestrogen progestogen HRT

Use less than 1 year
1.45
1.19, 1.78
Use 1-4 years
1.74
1.60, 1.89
Use 5-9 years
2.17
2.03, 2.33
Use 10 years or more
2.31
2.08, 2.56
Lifetime use less than 1 year
0.94
0.84, 1.05
Use 1-4 years
1.01
0.92, 1.12
Use 5-9 years
1.14
1.00, 1.30
Use 10 years or more
1.05
0.84, 1.30
Past users of HRT
427
The problem is that the use categories are neither dened in relation to the
diagnosis of the tumour or the supposed date on which the tumour arose. They
are solely dened in relation to what therapy the woman was taking at the time
she was invited for routine mammography.
The fact that just under one million women were included in this study
does not compensate for its eccentric design, it simply narrows the condence
intervals and thereby exaggerates its importance.
Summary
These four investigations, and particularly the Million Women Study, resulted
in substantial changes in the licensing of all HRT between the late 1990s and
the early 2000s. There is no indication that earlier work, and work that was published at about the same time as WHI and MWS, was taken into account. Had
it been taken into account it would have been obvious that the ndings of the
MWS differed from most other studies and that HERS and WHI were broadly
in line with other work, albeit with WHI giving a slightly higher HR for CEE/
MPA. It is possible that combined HRT may increase the risk of breast cancer
but, it is my opinion that the design of the MWS is so awed that it cannot be
taken as providing evidence of an association, let alone a causal association.
The other studies show a possible weak association. It would be interesting to
know how these studies came to be over-interpreted by the authorities and by
a number of supposedly independent commentators.
428
References
1.
2.
3.
4.
5.
6.
7.
8.
British National Formulary Number 33 (March 199. Pub British Medical Association and
Royal Pharmaceutical Society of Great Britain
British National Formulary Number 36 (September 1998) Pub British Medical Association
and Royal Pharmaceutical Society of Great Britain
British National Formulary Number 46 (September 2003) Pub British Medical Association
and Royal Pharmaceutical Society of Great Britain
Bush TL, Whiteman M and Flaws JA. Hormone Replacement Therapy and Breast Cancer: A
Qualitative Review. Obstetrics and Gynaecology (2001) 98:3: 498-508
Collaborative Group on Hormonal Factors in Breast Cancer: Breast Cancer and hormone replacement therapy: collaborative reanalysis of data from 51 epidemiological studies of 52,705
women with breast cancer and 108,411 women without breast cancer. The Lancet (1997) 350:
1047-1058.
Writing Group for the Womens Health Initiative Investigators: Risks and Benets of Estrogen
Plus Progestin in Healthy Postmenopausal Women Principal Results from the Womens
Health Initiative randomized controlled trial. JAMA (2002) 288:3: 321-333.
The Womens Health Initiative Steering Committee: Effects of conjugated equine estrogen in
postmenopausal women with hysterectomy. JAMA (2004) 291: 14:1701-1712
Million Women Study Collaborators: Breast Cancer and Hormone Replacement Therapy in
the Million Women Study. The Lancet (2003) 362: 419-426.
429
Family planning
Newer progestogens. Progesteroneonly pill (POP). Do they offer any
advantage?
S. Rozenberg, R. Gevers
Department of Obstetrics and Gynaecology. CHU St Pierre,
Universit Libre de Bruxelles, Rue Haute 290, 1000 Bruxelles, Belgium
email : serge.rozenberg@skynet.be
Oral contraceptives which contain only progestageso-called minipills,

have been in use in Europe since the seventies. The avoidance of an estrogen
component has probable advantages for some women (higher risk for venous
thrombosis, breast-feeding, side effects of estrogens). The rst generation of
POP did not block pituitary activity to the same extent as conventional combined pills. They were thought to act on the cervical mucus, on the reaction
of the endometrium to implantation, and possibly on sperm capacitation. The
failure rate of the POP (0.71.8/100 womanyears) is higher than that of the
combined contraceptive pill (0.170.41/100 womanyears). The need for timing
of tablet ingestion, and hence patient compliance, contributed to the failure rate
The rst POP contained levonorgestrel, norethisterone or ethynodiol diacetate.
Previous studies have shown that desogestrel administered at a dose of 6075
g/day, inhibited ovulation completely and that it was superior at a dose of 75
g compared to 30 g levonorgestrel, suggesting that absolute compliance is
less a problem with newer POP than with rst generations of POP. Poor cycle
control remains the most troublesome side-effect of POP and is by far the most
common reason for discontinuation of these methods. Gemzell-Danielsson
et al (2002) found that the addition of an anti-progestogen Org 31710 once a
month improved cycle control in initial cycles in women using daily treatment
with 75 g desogestrel and but to a lesser rate during later cycles.
430
Prolonged use of OCs for Symptomatic

Women
P.G. Crosignani
Awareness of the possibility that oral contraceptives (OC) may provide additional health benets for special groups of women is increasing.
Hirsute women
By far the commonest ovarian cause of hyperandrogenisation is polycystic
ovary syndrome (PCOS). For several years the OC of choice for women with
hirsutism has been the preparation containing 35 micrograms of ethinyl estradiol (EE) and 2 mg of cyproterone acetate (CPA), a progestogen with specic
antiandrogen properties. The suppression of ovarian activity by the OC reduces
androgen secretion and therefore improves acne and hirsutism.
There has been evidence in the past that treatment with the combination
of CPA and estrogen, in the form of Diane (1) or the higher- dose reversed
sequential regimen (2,3), might impair insulin sensitivity, which is already low
in 40-60% of PCOS patients. Recent studies, however, found that treatment
of hirsute patients for as long as ve years was associated with no increase of
fasting plasma insulin concentration (4) and no changes in the index of insulin
(5).
Similarly, Cibula et al. (6), using a contraceptive pill containing EE and
norgestimate for the treatment of hirsute patients, reported effective control of
the hyperandrogenic skin with no change in insulin sensitivity. There is also
interest in co-treatment with the OC and GnRH analogs (7), new antiandrogens
(8,9) and insulin sensitizing drugs such as metformin (10).
431
Interestingly, a reduction of excess fat was observed in young hyperandrogenic patients using OC associated with utamide and metformin (9).
Women with symptomatic endometriosis

The effect of OC on regulation of in vitro endometrial cell growth has been
studied by Meresman et al. (11). The programmed cell death of the endometrium is regulated by steroid hormones and by several genes. The proto-oncogene
B cell lymphoma/leukemia-2 (Bcl-2) for instance blocks apoptosis, while the
Bax protein antagonizes its survival activity. The relation between Bcl-2 and
Bax predetermines the cells susceptibility to apoptotic inducers.
Epithelial and stromal endometrial cells from patients with endometriosis
show an increased survival capability probably caused by an abnormally high
effect of Bcl-2. Treatment with a monophasic OC signicantly increases apoptosis, lowering the abnormal Bcl-2 expression and increasing the expression
of Bax (11).
Dysmenorrhea is the most frequent and severe complaint in women with
this disease. Women suffering from dysmenorrhea during cyclic use of an
OC may benet from a shift to continuous administration. A monophasic OC
(desogestrel 0.15 mg and ethinylestradiol 0.02 mg) was prescribed continuously in 50 patients with dysmenorrhea relapsing after conservative surgery
for endometriosis, and not responding to the cyclic use of the same OC (12).
During the two-year study, 38% of women reported amenorrhea, 36% spotting
and 26% breakthrough bleeding. The mean score of menstrual pain showed a
reduction from 75 13 to 31 17.
OC are effective in the control of pain in approximately 75% of women with
endometriosis. Their effect does not seem to be inferior to that of other drugs
used for the disease (13-15).
In symptomatic patients medical treatment plays a role in the therapeutic
strategy when it can be administered for a long time. Given their good tolerability, minor metabolic effects and low cost, contraceptive steroidal preparations
must therefore be considered drugs of choice and are currently the only safe
and economic alternative to surgery (16,17).
Perimenopausal women
Dysfunctional uterine bleeding (DUB) is frequent in women near the menopause, and is still the indication for a substantial proportion of hysterectomies.
Blood loss is generally less in women using hormonal contraception since inhi-
432
bition of estrogen receptor synthesis by progestogen reduces endometrial activity and down-regulates the bleeding. Contraceptive pills can reduce menstrual
blood loss by approximately 50% (18), and the intrauterine progestogen system
is also highly effective in the treatment of dysfunctional uterine bleeding.
Several of the modern hormonal forms of contraception (e.g. progestogenonly preparations, injectables, implants, medicated IUDs) induce amenorrhea
in a large proportion of women and OCs can be taken in long cycles, reducing
the number of annual menstruations. Eliminating menstruation or reducing its
frequency has a profound impact on the occurrence of menorrhagia (19).
OCs for protection against ovarian endometrial and

colorectal cancer.
The inverse relationship between OC use and ovarian cancers is a constant
epidemiological nding. The protection was also found in the years of the
3rd-generation low-dose pills. The overall estimates of protection against the
risk of ovarian cancer for ever use is approximately 40%; OC use reduces the
risk of endometrial cancer by approximately 50% and colorectal cancer risk
by 20% (20).
Risks of oral contraceptives after age 40.

Recent reports of risks with the use of hormonal contraception are quite reassuring. Therefore, today, age by itself is no longer a contraindication for use of
the birth-control pill in non smokers.
References
1.
2.
3.
4.
5.
Jandrain, B.J., Humblet, D.M., Jaminet, C.B., Scheen, A.J., Gaspard, U.J., Lefebvre, P.J. (1990)
Effects of ethinyl estradiol combined with desogestrel and cyproterone acetate on glucose
tolerance and insulin response to an oral glucose load: a one-year randomized, prospective,
comparative trial. Am. J. Obstet. Gynecol., 163(1 Pt 2), 378-381
Seed, M., Godsland, I.F., Wynn, V., Jacobs, H. S. (1984) The effects of cyproterone acetate and
ethinyl oestradiol on carbohydrate metabolism. Clinical Endocrinology (Oxf), 21, 689-99
Dahlgren, E., Landin, K., Krotklewski, M., Holm, G., Janson, P.O. (1998) Effects of two
antiandrogen treatments on hirsutism and insulin sensitivity in women with polycystic ovary
syndrome. Hum. Reprod., 13, 2706-2711.
Falsetti, L., Gambera, A., Tisi, G. (2001) Efcacy of the combination ethinyl oestradiol and
cyproterone acetate on endocrine, clinical and ultrasonographic prole in polycystic ovary
syndrome. Hum. Reprod., 16, 36-42.
The Decode Insulin Study Group (2004) Plasma insulin and cardiovascular mortality in non-
433
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
diabetic European men and women: a meta-analysis of data from eleven prospective studies.
Diabetologia, 47, 1245-1256.
Cibula D., Fanta M., Hill, M., Sindelka G., Skra, J., Zivny J. (2002) Insulin sensitivity in
non-obese women with polycystic ovary syndrome during treatment with oral contraceptives
containing low-androgenic progestin. Hum. Reprod., 17, 76-82.
Vegetti W., Testa G., Maggioni P., Motta T., Falsetti L., Crosignani P.G. (1996) An open randomized comparative study of an oral contraceptive containing ethinylestradiol and cyproterone acetate with and without the GnRH analogue goserelin in the long-term treatment of
hirsutism. Gynecol. Obstet. Invest., 41, 260-268.
Sahin, Y.I., Dilber S., Kelestimur, F. (2001) Comparison of Diane 35 and Diane 35 plus nasteride in the treatment of hirsutism. Fertil. Steril., 75, 496-500.
Ibanez, L., Valls, C., Cabr S., de Zegher, F. (2004) Flutamide-metformin plus ethinylestradioldrospirenone for lipolysis and antiatherogenesis in young women with ovarian hyperandrogenism : the key role of early, low-dose utamide. J. Clin. Endocrinol. Metab., 89, 4716-4720.
Elter K., Imir G., Durmusoglu F. (2002) Clinical, endocrine and metabolic effects of metformin
added to ethinylestradiol-cyproterone acetate in non-obese women with polycystic ovarian
syndrome: a randomized controlled study. Hum. Reprod., 17, 1729-1737.
Meresman, G.F., Aug, L., Baraao, R.I., Lombardi, E., Tesone, M., Sueldo, C. (2002) Oral
contraceptives suppress cell proliferation and enhance apoptosis of eutopic endometrial tissue
from patients with endometriosis. Fertil. Steril., 77, 1141-1147.
Vercellini, P., Frontino, G., De Giorgi, O., Pietropaolo, G., Pasin, R., Crosignani, P.G. (2003a)
Continuous use of an oral contraceptive for endometriosis-associated recurrent dysmenorrhea
that does not respond to a cyclic pill regimen. Fertil. Steril., 80, 560-563.
Moore, J., Kennedy, S., Prentice, A. (2003) Modern combined oral contraceptives for pain
associated with endometriosis (Cochrane Review). In The Cochran Library, Issue 1. Oxford:
Update Software.
Prentice, A., Deary, A.J., Bland, E. (2003) Progestagens and anti-progestagens for pain associated with endometriosis (Cochrane Review). In The Cochran Library, Issue 1. Oxford: Update
Software.
Vercellini, P., Trespidi, L., Colombo, A., Ventola, N., Marchini, M., Crosignani, P.G. (1993) A
gonadotropin-releasing hormone agonist versus a low-dose oral contraceptive for pelvic pain
associated with endometriosis. Fertil. Steril., 60, 75-79.
The Royal College of Obstetricians and Gynaecologists (2000) The investigation and management of endometriosis. Guideline No. 24, July 2000.
Vercellini, P., Fedele, L., Pietropaolo, G., Frontino, G., Somigliana, E., Crosignani, P.G.
(2003b) Progestogens for endometriosis: forward to the past. Hum. Reprod. Update, 9, 387396.
Larsson, G., Milsom, I., Lindstedt, G., Rybo, G. (1992) The inuence of a low-dose combined
oral contraceptive on menstrual blood loss and iron status. Contraception, 46, 327-334.
Thomas, S.L., Ellertson, C. (2000) Nuisance or natural and healthy: Should monthly menstruation be optional for women? Lancet, 355, 922-924.
La Vecchia, C., Altieri, A., Franceschi, S., Tavani, A. (2001). Oral contraceptives and cancer.
An update. Drug Saf., 24, 741-754.
434
Adolescent contraception.
Is there one solution?
George Creatsas, MD, FACS, Aikaterini Deliveliotou, MD
2nd department of obstetrics and gynecology, aretaieion hospital,
University of Athens medical school, Greece
e-mail: geocre@aretaieio.uoa.gr, e-mail: kdeliveliotou@hotmail.com
Introduction
Adolescence is a critical period of the womans life as many gynecological
problems arising from this crucial stage may affect her reproductive health.
Neither children nor adults, adolescent girls represent an age group by themselves with specic health and behavioral problems. Important parameters of
adolescent sexuality such as unintended pregnancies, induced abortions, contraception and sexually transmitted diseases (STDs) should be of main concern,
as all of them are strongly related to a good reproductive health.
Contraception represents one of the revolutions of 21st century. It gives the
woman the capability to satisfy her sexual needs, controlling at the same time
her reproductive ability. Nowadays, it is well known that the onset of puberty
and sexual activity start much earlier than several years before. Recent data
from the National Survey of Family Growth (NSFG), regarding sexual activity,
contraceptive use and births in USA, supports that about 47% of female teenagers (4.6 million) and 46% of male teenagers (4.7 million) had had sexual intercourse at least once.1 Older studies reported that in USA 20% of the girls and
33% of the boys have been sexually active before the age of fteen, whereas
the mean age for the rst sexual experience is about 17 years for girls and 16
years for boys.2
As a consequence of the earlier beginning of sexual life, the rate of teen
pregnancy remains high, making adolescent pregnancy a signicant public
health concern. Nearly one million adolescents become pregnant each year in
435
USA and more than 480000 carry their pregnancy to term.3 It is well recognized
that the teen pregnancy is considered to be a high-risk pregnancy as it is usually
complicated with gestational hypertension, anemia, preterm delivery, and low
birth weight.4
Induced abortions are another aspect of unprotected sexual life of adolescents. Although there are illegal in several countries, numerous unsafe abortions are carried out worldwide every year, especially in adolescent girls. It is
estimated that 260,000 unsafe abortions are performed in Europe each year
(150,000 in southern and 110,0000 in eastern Europe).5 Abortion rates among
adolescents-expressed as a percentage of the total number of abortions performed in each country-increased in most European countries during the 1980s.
By 1989, Hungary and Finland had the highest abortion rates, 11% and 9.5%,
respectively. Belgium had the lowest rate; only 1% of abortions performed,
were in women aged 18 years and younger.6
From all these data we can conclude that effective contraception in adolescence is a matter of major magnitude. Contraceptive choices affect the longterm sexual health and fertility of adolescents, particularly when contraception is not used correctly or consistently. The objectives of this chapter are to
highlight recent trends in contraceptive use among adolescents, to examine
their familiarity with various methods, including emergency contraception, and
make recommendations focusing on two of the most popular contraceptive
methods, which are oral contraceptives and condoms.
Contraceptive methods
The recommended contraceptive methods for adolescents can be divided in
hormonal and nonhormonal and are listed in the table 1.
Table 1:
Contraceptive choices in adolescence
HORMONAL METHODS
NON-HORMONAL METHODS
Combined oral contraceptives
Condoms
Emergency contraception
Contraceptive Sponge
Injectable contraception
Cervical caps
Implants
Periodic abstinencewithdrawal
Hormonal contraceptive methods
436
Combined oral contraceptives

Combined oral contraceptives (COCs), rstly introduced in the 1960s, are
considered to be the most effective method of contraception in adolescents
today. The third generation COCs, especially the ultra low dose containing 15
g of ethinylestradiol, have all the advantages of OCs and at the same time are
lacking in the side effects that the previous generation COCs had. The list of
its multiple benecial effects is long, including the suppression of functional
ovarian cysts, the prevention of endometriosis and pelvic inammatory disease
(PID), the normalization of menstrual cycle, the improvement of acne and
hirsutism and the control of dysmenorrhea. In contrast, potential disadvantages
of COCs are considered to be the long-term use needed even in girls with
infrequent intercourses, the low compliance rate due to lack in education and
the insufcient protection against sexually transmitted diseases.
Creatsas et al 7 have shown that the use of a third generation COC by 50 adolescents, for a 6-month period, was 100% effective in pregnancy prevention,
did not change their metabolic prole, while the rate of breakthrough bleeding was only 0.7%.8 In another large population study with 12000 randomly
selected women, aged 15-49 years, the oral contraceptive was conrmed to be
the most widely used method of contraception, followed by very high levels
of satisfaction (>90%).
On the other hand, there is some data supporting that the use of COCs
predisposes to lower genital tract infections due to Chlamydia Trachomatis,
Mycoplasma spp and Neisseria gonorrhoea.9 Although there are a few reports
indicating a relative risk of up to 5.0 in women using COCs as compared to
non-users, it is yet not clear whether are the COCs which are responsible for
viral infections, including HIV, or the greater freedom of unprotected multiple
sexual intercourses these girls used to have.10
Injectablesimplants
The injectable contraceptive methods include the long-acting injectable progestin Depo-Medroxyprogesterone Acetate (DMPA: Depo-Provera) and the
implants Norplant and Inplanon.
DMPA, very popular in the USA, is given in a standard dose of 150 mg
intramuscularly every 3 months and yields a pregnancy rate of 0-5.2 per 1000
women-years. This agent should be recommended to teenagers under great
consideration of the potential impact on bone density, as women gain a major
proportion of their ultimate bone density during adolescence. Rome et al in a
study including 370 adolescent girls concluded that over a 12-month period,
437
there was evidence of decreased bone formation and resorption in the DMPA
and OC groups when compared to that in the control group, indicating a suppressive effect of DMPA on bone metabolism in girls.11 Another injectable, not
very much used by adolescents, is norethisterone enanthate, which is administered two-monthly in a dose of 200mg.
Norplant (levonorgestrel) implant used in a small number of adolescents
in our institution, was 100% effective in pregnancy prevention and did not
seem to affect the adolescents metabolic prole.12 As concerning Implanon
(etonorgestrel) implant there is so far no signicant data regarding its application during adolescence. Both of these implants are recommended for use in
mentally retarded adolescent girls.
Emergency contraception
Emergency contraception (EC), often referred to as the "morning after" pill,
has been available for more than two decades in North America and Europe,
offering an alternative effective contraceptive choice for adolescents, after unprotected sex or contraception failure, or for use in cases of sexual assault. EC
is highly effective in preventing pregnancy if taken within 72 hours of unprotected sexual intercourse. It works by either preventing ovulation or changing
the lining of the uterus so that implantation cannot occur. Yuzpe13 has proposed
a method using two tablets of a COC containing 50g ethinyl-estradiol and
250-g levonorgestrel (LNG) given twice at a 12-hour interval. Unfortunately
this method has an inadequate failure rate as high as 3.2%. The administration
of two doses of 750 g LNG at a 12-hour interval, having a failure rate of
only 1.2%, should be preferred and recommended to adolescents. Regarding
mifepristone (RU 486), there is no data concerning young girls, as it has not
been used extensively in adolescents.
A survey conducted by Langille and Delany 14of 14- to 19-year-olds at a
high school in Nova Scotia showed that 80% of the girls had heard of EC, but
only 10% were aware of the time limits within which EC is effective. Overall,
they had a poor understanding of the risks, benets or effectiveness of EC.
These young women had learned about EC for the most part through their
sexual health education classes in grades 7 to 9. Only 2% had heard about it
through their physician.
All Family Planning Centers (FPC) and the gynecological units should
be capable of providing EC and the healthcare professionals who deal with
adolescents should be familiar with this method as well. It is emphasized that
teenagers should have a free access to the FPC and that all adolescents seen
438
for emergency contraception should also be offered a screening for STDs at

the same time.
Free Pharmacy access remains controversial, as showed in a randomized
control trial of 2117 women, aged 15 to 24 years, where women in the Pharmacy
access group were no more likely to use emergency contraception than the
Clinic access group. This study is concluding that there is clear evidence that
neither pharmacy access nor advance provision of EC pills compromises contraceptive or sexual behavior, so that it seems unreasonable to restrict access
to emergency contraception to Clinics only. 15
Non-hormonal contraceptive methods

Condoms
Among the Non-hormonal contraceptive methods the male condom is the
most popular because it is easily available, cheep and has no side effects. The
estimated effectiveness of the male condom used correctly and consistently,
is 88%. However, the major advantage, related to the use of the condom during adolescence, is the protection against STDs. In many countries the FPC,
schools or other services offer it. Meade et al in a review study report that
across seven studies examining condom use during pregnancy, 78-88% of teens
engaged in at least some sex without condoms, and over one-third never used
condoms, whereas participants mentioned a mean of 5.7-6.5 unprotected sex
episodes per month.16 In an other study, among 253 students from two high
schools, girls appeared to have more difculty in asking how condoms should
be used.17 Family Planning Centers are responsible to inform young people on
the safety and efcacy of the condom as well as on its correct and consistent
use, paying attention in its failure rate which is unfortunately 10 times higher
in adolescents than in adults.
As opposed to male condom, the female condom, or vaginal pouch, is a
relatively new method, which gives girls the control of a barrier method and
provides some STDs protection. Although available in several countries, is
not popular in sexually active adolescent girls. The Canadian Contraception
Study revealed that although 41% of young unmarried women 15 to 17
years of age were aware of it, no one reported using it as a method of
contraception, and only 3% had a favorable attitude towards the female
condom.18
Cost is a major factor, as the female condom is considerably more expensive
than the male condom.
439
The contraceptive sponge

Contraceptive sponge is an alternative barrier method suggested for contraception during adolescence. Psychoyos et al 19 have proposed a vaginal sponge
impregnated in Nonoxynol 9, benzalkonium and sodium cholate (Protectaid)
which has both spermicidal, antibacterial and antiviral properties, including
protection against Human Immunodeciency Virus (HIV). The authors reported a 100% efcacy, with only two positive cervical cultures among 20
women using the sponge, during a 12-month period. Diaz et al 20 reported the
use of a sponge in only 2 out of 208 adolescents, who completed a 54-item
questionnaire. Furthermore small size Fem Cap was developed a few years
ago but there is still no data on its extensive use by adolescents.21
Intrauterine devices
Although Intrauterine devices (IUDs) are very much in use among adult
women, their use in nulliparous women is restricted. Despite the lack of
data in literature concerning the use of levonorgestrel releasing intrauterine
systems or Gynex during adolescence, there is a study with 120 adolescents where the reported satisfaction by the Cu-7 Intrauterine device was so
far 72% and the pregnancy rate was 2.0 per 100 women years.22 According
to our experience, copper-bearing IUDs should be used under specic circumstances.
Other ineffective methods- Abortions
Regardless of the above-mentioned effective and safe contraceptive methods
adolescents, unfortunately in their majority, still prefer ineffective methods, such as periodic abstinence, interrupted coitus and withdrawal prior to
ejaculation.5 This is the reason why abortions rate remains high during adolescence. Worldwide, 10% of the 50 million abortions performed annually concern
adolescents 15-19 years old. In the USA, among the one million teenagers who
become pregnant every year, 50% carry their pregnancies to term; 35 % opt for
an abortion and 15% miscarry or experience in utero fetal deaths.23
Kaminski et al 24 published data showing that 71% of the adolescents requesting for an abortion had not used any kind of contraception during the
previous 3 months, 5% of the conceptions occurred after forgetting to take
a contraceptive pill and 24% after highly random contraception, condom or
withdrawal, practiced very irregularly.
According to all these studies, it becomes clear that a high proportion of
sexually active teenagers continue to use abortion as a means of contraception.
440
Dual protection
The Dual protection or double Dutch method is dened as any method of birth
control combined with a condom. Dual protection prevents pregnancy and
transmission of STDs at the same time and should be particularly important
contraceptive choice for adolescents. It is therefore imperative to note that some
STDs, such as human papilloma virus (HPV), can exist outside the vagina, so
that the protection afforded by a condom is not absolute.
Studies on dual method use are limited, but several reasons can be hypothesized as to why concurrent use with a condom appears to be low. First,
contraceptive methods, such as OC or condoms, are compliance-dependent,
and it is well understood that compliance rate is extremely low during adolescence. Second, for those adolescents who seem to perceive pregnancy as the
greatest imminent threat, once this aim has been reached with one method, their
motivation to take further measures is very low.
Making the choice
It is very important to create a friendly environment prior to the initiation of
the consultation to adolescents, in order to understand that whatever said is
condential and aims to their benet. The discussion should provide the basic
information about the potential contraceptive choices and should underline
their safety and efcacy. Both boys and girls should be advised to further discuss the methods with their parents, if they like it, and to contact their physician
before they stop or change their contraceptive method.
Consideration of contraceptive methods should be balanced between the
objectives of reducing unintended pregnancies and the need for STI protection.
Counselling concerning the choice of contraception method must take into
account the individual needs while methods that require co-operation from a
partner may not be appropriate for all girls. The condom is recommended in all
cases, especially in adolescents with no permanent sexual partner or with unstable periodic, relationships. The low dose COCs should be suggested in girls
with frequent sexual intercourses while preventive and educational programs
need to concentrate on relationships with a main partner in order to improve
the use of dual protection.
Aboriginal youth, street youth, sex trade workers and other marginalized
youth, although they represent a small proportion of adolescents, may be at
higher risk of both unintended pregnancy and STDs. More targeted research
is needed to guide programs development and to ensure that, once developed,
programs meet the needs of all adolescents in an appropriate, accessible and
culturally sensitive way.
441
Overall assessment- conclusions

Sexual education programs have started in many countries during the past
decade, allowing to do the rst assessment of their success and effectiveness,
regarding the improvement of contraceptive counseling and prevention of adolescent pregnancies. Recent data from the National Survey of Family Growth
(NSFG) 1, regarding sexual activity, contraceptive use and births in USA, reports that about 3 out of 4 teens used a method of contraception at their rst
intercourse, showing a remarkable increase in the use of contraceptives by
teenagers. Simultaneously, the pregnancy rate for teenagers fell 27% overall
during 19902000, reaching an historic low of 84.5 pregnancies per 1,000
women aged 1519 years. This rate was the lowest reported since 1976. The
overall decline is reected in signicant reductions in birth and abortion rates,
while pregnancy rates fell more for 1517-year-old teenagers (33%) than for
1819 year olds (20 %).25
Although the pregnancy rate in adolescents seems to decrease in some
countries it remains a major public health problem with long-term effects on
their sexual health and fertility and on the society as a whole. The challenge
facing policy makers and program administrators will be to increase awareness and knowledge among adolescents, in order to help them make the best
contraceptive choices throughout their lives. The media and the press should
play an important role, as adolescents rely on information obtained from these
sources. Teenagers have the right to choose, but they also must act responsibly,
especially in terms of the preservation of their reproductive health care.
Due to the multi-faceted nature of this issue, comprehensive sexual health
promotion and education would go a long way towards reducing unintended
pregnancies in teenagers. Increasing resources to fund research and trials associated with new, reversible contraceptive methods, providing simultaneously
protection against STDs, is expected to help signicantly. Successful strategies
aiming in the triad of improving technology, community services and adolescents knowledge should be one of the primary goals towards implementation
of a better reproductive health in the new millennium.
References
1.
2.
3.
4.
Abma JC, Martinez GM, Mosher WD, Dawson BS. Teenagers in the United States: sexual
activity, contraceptive use, and childbearing, 2002. Vital Health Stat 23 2004(24):1-48.
Pierre N, Cox J. Teenage pregnancy prevention programs. Curr Opin Pediatr 1997; 9(4):3106.
Henshaw SK, Finer LB. The accessibility of abortion services in the United States, 2001.
Perspect Sex Reprod Health 2003; 35(1):16-24.
Chandra PC, Schiavello HJ, Ravi B, et al. Pregnancy outcomes in urban teenagers. Int J
442
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.

Gynaecol Obstet 2002; 79(2):117-22.
Creatsas G, Vekemans M, Horejki J, al e. Adolescent sexuality in Europe: a multicentric study.
Adolesc Pediatr Gynecol 1995; 8:59-63.
Creatsas GC. Adolescent pregnancy in Europe. Int J Fertil Menopausal Stud 1995; 40 Suppl
2:80-4.
Skouby SO. Contraceptive use and behavior in the 21st century: a comprehensive study across
ve European countries. Eur J Contracept Reprod Health Care 2004; 9(2):57-68.
Creatsas G, Adamopoulos P, Elefteriou N, al e. Clinical and metabolic effects of the monophasic gestodene/ethinylestradiol pillfor contraception durin adolescence. Adolesc Pediatr
Gynecol 1991; 4:76-79.
Creatsas G, Hassan E. Education and adolescent sexual behavior. In: Contraceptive choices
and realities (Edited by: van Lunsen RHW, Unzeitig V, Creatsas G). Carnforth: parthenon
Publishing 2000:44-50.
Hicks D. Sexually transmitted diseases and contraceptives methods. Fert Contr Rev 1994;
3(3):3-7.
Rome E, Ziegler J, Secic M, et al. Bone biochemical markers in adolescent girls using either
depot medroxyprogesterone acetate or an oral contraceptive. J Pediatr Adolesc Gynecol 2004;
17(6):373-7.
Cardamakis E, Creatsas G, Deligeoroglou E, Tzingounis V. Norplant subdermal implant system as long term contraception during adolescence. Unpupl data.
Speroff L, Darney P. A clinical guide for Contraception. Philadelphia, Williams & Wilkins
1996:5.
Langille DB, Delaney ME. Knowledge and use of emergency postcoital contraception by
female students at a high school in Nova Scotia. Can J Public Health 2000; 91(1):29-32.
Raine TR, Harper CC, Rocca CH, et al. Direct access to emergency contraception through
pharmacies and effect on unintended pregnancy and STIs: a randomized controlled trial.
J 2005; 293(1):54-62.
Meade CS, Ickovics JR. Systematic review of sexual risk among pregnant and mothering
teens in the USA: pregnancy as an opportunity for integrated prevention of STD and repeat
pregnancy. Soc Sci Med 2005; 60(4):661-78.
Weisberg E, North P, Buxton M. Sexual activity and condom use in high school students. Med
J Aust 1992; 156(9):612-3.
Fisher WA, Boroditsky RBM. The 1998 contraception study. Can J Human Sexuality 1999;
8:161-227.
Psychoyos A, Creatsas G, Hassan E, et al. Spermicidal and antiviral properties of cholic acid:
contraceptive efcacy of a new vaginal sponge (Protectaid) containing sodium cholate. Hum
Reprod 1993; 8(6):866-9.
Diaz A, Jaffe LR, Leadbeater BJ, Levin L. Frequency of use, knowledge, and attitudes toward
the contraceptive sponge among inner-city black and Hispanic adolescent females. J Adolesc
Health Care 1990; 11(2):125-7.
Shihata AA. The FemCap: a new contraceptive choice. Eur J Contracept Reprod Health Care
1998; 3(3):160-6.
Kulig JW. Adolescent contraception: nonhormonal methods. Pediatr Clin North Am 1989;
36(3):717-30.
Ventura SJ, al e. Recent declines in teenage birth rates in the United States; Variations by state,
1990-1994. Mon Vital Stat Rep 1996; 45:1-6.
Kaminski M, Crost M, Garel M. Les IVG repetees en France; analyse des bulletins statistiques
d' IVG. Contracept Fertil Steril 1997; 25.
Ventura SJ, Abma JC, Mosher WD, Henshaw S. Estimated pregnancy rates for the United
States. 1990-2000: an update. Nat Vital Stat Rep 2004; 15(52(23)):1-9.
443
Hormonal treatment for males and females
Hormone Therapy in 2005 for Men and

Women: Where Are We?
Marianne J. Legato, M.D
Professor of Clinical Medicine,
Columbia University College of Physicians & Surgeons, New York
Introduction
Probably few subjects have left the public (and the professional community)
as confused as the conundrum of whether or not there is a place for hormone
therapy (HT) in our therapeutic armentarium. The initial near-panic and consternation that followed the ndings of the Womens Health Initiative1 is subsiding, however, and some therapeutic principles have begun to emerge.
All HT is not the same. HT is a broad term that refers to the administration
of estrogen and progesterone, embracing any form of either as well as the
use of both in combination or singly. It also covers both oral and transdermal
administration of the compounds. The preparation most frequently used in the
studies we will be discussing (and that of most interest) is conjugated equine
estrogen (Premarin) and medroxprogesterone acetate given orally. It must be
emphasized, then, that other preparations and other routes of administration
have not been studied and we cannot presume that they have the same consequences as these particular compounds.
This presentation will contrast the history of HT before and after the
pivotally important prospective randomized studies that have caused us to
revise our view of this therapy. In particular, I will review the role of estrogen in the regulation of cardiovascular physiology, discuss some important
misconceptions that governed older treatment guidelines and reconcile apparently conicting conclusions from observational and prospective, randomized studies. In particular, we will consider the old view of menopause as
444
an endocrinopathy, the treatment for which was exogenous estrogen and

consider whether menopause in itself is a signicant risk factor for coronary
artery disease.
Before the rst important randomized prospective trial of the impact of
HT on established coronary artery disease, the HERS study2, the largest trials
concerning the benets of HT were observational and/or retrospective. All of
them showed a 40-50% lower incidence of coronary artery disease (CAD) in
users compared with non users of HT. Physicians concluded that HT lowered
the incidence and ameliorated the course of established CAD, lowered risk
for Alzheimers disease and improved cognition/memory, stabilized mood,
prevented the postmenopausal period of rapid bone loss and had important
miscellaneous effects (improved genito-urinary function, ablated vasomotor
instability, and promised longer and more vigorous life and a more youthful
appearance to users). Four important randomized prospective studies beginning
with HERS (1998)i challenged those ideas: Hers II, which extended the period
of observation an additional. 2.7 years beyond HERS I (2002); ERA3 and the
WHI (2002)ii fundamentally challenged those convictions. We will describe
these studies in detail and review the conclusions investigators drew from the
data that resulted.
Reconciling Observational and Prospective Randomized

Studies
There are limitations to both an observational and a randomized prospective
clinical study. The observational study presents the following issues:
The effect of initial exposure to the drug being assessed is difcult to determine; we miss the woman who started the therapy, had an unpleasant
experience and then quit. Essentially, we are looking at long-term users.
The study relies on self-reporting and by its nature, incorporates a heterogeneous array of usage patterns.
The users may be a different population by virtue of basic good health,
economic status and education than non users.
There is inevitably surveillance bias and uncontrolled confounding in the
study population.
The prospective, randomized trial has its own limitations:
Often, analysis is based on intention to treat rather than adherence.
The results may not be generalizable to the general population.
There is volunteer bias
445
There is an effect from participating in a trial; care is standardized and

meticulous and patients carefully monitored
The effect of a placebo cannot be really assessed; a placebo is actually a
powerful drug and has consequences to the user which are impossible to
quantify.
Finally, there are almost always differences in the centers included in a
multicenter trial which, although one tries to minimize them, cannot be
entirely eliminated.
What Is The Present Status of HT?
Some important practical conclusions can be drawn from our consideration of
both past and more contemporary clinical studies . I will review these in detail
during my presentation, but they include the following:
Estrogen therapy should not be initiated in the older patient (>60 years of
age) or in the patient with established coronary artery disease.
Screening of the vulnerable patient for evidence of hypercoaguability should
be undertaken prior to administering therapy.
In the patient with documented CAD taking HT for a year or more without
complications, it should be continued. If she has never been on HT, consider
the possibility that she may have an untoward cardiovascular event early in
therapy and follow closely.
There are alternative therapies for the postmenopausal women including
niacin/statin for dyslipidemia, bisphosphonates for the treatment of rapid
bone loss in the early menopause or for women at high risk for osteoporosis,
the local use of estrogen intravaginally for dysparunia and recurrent UTIs,
and paroxitine for vasomotor instability and disturbed sleep patterns.
Guidelines for use:
o start early: HT is most benecial if begun at the time of menopause
o use the lowest dose needed to alleviate vasomotor instability
o consider limiting use to 5-7 years; risk of breast cancer rises with the
duration of use
o use simultaneous rather than sequential CEE/MP regimens; the incidence
of breast cancer is higher in sequential therapy.
o Give Premarin in the morning and MPA at night; the latter acts as a sedative
o Patients with a history of thrombo-emoblic phenomena are not candidates for the therapy
CEE/MPA has no demonstrated efcacy in the secondary prevention of
CAD.
446
There has been no randomized, prospective trial to test the efcacy of HT

in the primary prevention of CAD in the younger patient.
In conclusion, the best treatment of the patient with CAD concentrates not on
HT, but on managing the risk factors that predispose to its development and/or
its deterioration in established illness. These include careful management of
diabetes, weight reduction, smoking cessation, correction of dyslipidemia and
hypertension and stress reduction. An appropriate exercise regimen and the use
of standard medications in the patient who has established CAD (antiplatelet
agents, beta blockers, ACE inhibitors) complete the armamentarium for the
standard of care.
We will also discuss the use of testosterone in women for the treatment of
female sexual disorder and in the aging male, reviewing the available data and
making recommendations for evidenced-based therapy.
(Endnotes)
Writing Group for the Womens Health Initiative Investigators. JAMA. 288(3).321-333.2002
Hulley S et al. JAMA..280:605-613. 1998
3
Herrington DM et al. E Engl J Med.343:522.2000
1
2
447
Hormone replacement therapy in

the aging male and nutriceutical
alternatives
Frank Comhaire and Ahmed Mahmoud
Center for Medical & Urological Andrology, and Reproductive Endocrinology
University Hospital Ghent 6 K 12 IE, De Pintelaan 185, B-9000 Ghent, Belgium
E-mail: Frank.Comhaire@Ugent.be
Androgens in young and ageing men

It is now well established that androgen levels decline in ageing men. This
becomes evident from the age of 45-50 years on as far as the concentration of
total testosterone is concerned. There is an earlier and stronger decline of the
free testosterone fraction than of the total testosterone (T) concentration, as a
result of the increased binding capacity for T in serum. In general, the decrease
of the serum concentration of estradiol (E2) is rather moderate with age, or E2
may even increase as a result of the aromatase activity of increasing amounts
of fat tissue.
Furthermore, T concentrations in young men are higher in the early morning
than in the afternoon, reecting a circadian rhythm that results from variability
of the hypothalamo-pituitary pulsatile secretion of luteinising hormone releasing hormone (LHRH) and luteinising hormone (LH). During ageing, this circadian variation progressively fades away. The decline of androgen secretion with
ageing is partially attributable to impaired hypothalamic secretion of LHRH
and decreased stimulation by LH, partially to primary testicular deterioration.
448
Androgens and Andropause

The major questions are whether the age-related decline of T causes andropause,
also called male climacteric, and which are the symptoms of this condition.
Furthermore, one can wonder whether restoration of the hormonal situation
by means of hormone replacement therapy (HRT) can successfully be applied
in the male.
The term andropause is not adequate for the physiological decline of androgen secretion, which does not stop but occurs rather gradually with time.
Several authors prefer to use the letter-word PADAM (Partial or Progressive
Androgen Deciency of the Ageing Male). At least one third of all men older
than 50 years present a signicant decline of early morning T concentration to
values lower than 375 ng/dl in blood, the cut-off value corresponding to the
5th percentile of the T concentration of young men between 20 and 40 years
of age. The suggested cut-off concentration may, however, not be considered
as an absolute value.
In order to decide if a man suffers from the PADAM syndrome, one should
rely on an entity of signs and symptoms. These are somewhat articially categorised into 3 groups: psychological symptoms, somato-vegetative symptoms,
and sexual complaints.
The psychological symptoms include discouragement, depressive mood, irritability, anxiousness and nervous tension. Patients experience lack of vitality,
and fatigue that is related to psychological factors (burn-out) as well as to the
decrease of lean body mass and muscular strength.
Somato-vegetative symptoms include joint and muscle complaints, sweating that may occur in burst, possibly together with hot ushes, increased need
for sleep, sleep disturbances, weakness and impaired well-being. Memory and
the capacity to concentrate decrease, and physical exhaustion occurs after minor efforts.
Sexual symptoms include decreased potency with erectile dysfunction due
to weak and short lasting erections, decreased orgasmic sensation and lower
volume of the ejaculate, and decreased libido. Also, nocturnal and early morning erections are less common and less rigid.
Body and visceral fat increases, which induces a higher risk of cardiovascular disease and insulin resistance. The relative hypoandrogenism is associated
to progressive loss of bone mass leading to osteoporosis increasing the risk of
vertebral or hip fractures.
449
The Diagnosis of Andropause

The diagnosis of andropause is based on history taking, that may conveniently
make use of an ageing males symptoms rating scale. Systemic diseases that
commonly occur in the aged population should be eliminated, such as diabetes
mellitus, vascular sclerosis, or malignancy. During physical examination, small
testicular volume and weak testicular consistence are common ndings, and
scanty pubic hair may reect hypoandrogenism.
The diagnosis requires measurement of testosterone, free testosterone and,
perhaps, 5alfa-3alfa-androstanediol to conrm the hypo-androgenic state.
Examination of the prostate is mandatory including assessment of PSA in
serum, and digital rectal examination and/or ultrasonography of the prostate.
Optimal hormone replacement therapy

The ideal HRT should full the following main criteria:
it should create physiological T concentrations in blood (probably between
400 and 700 ng/dl in blood taken between 8 and 12 a.m.),
it should restore circadian variation,
it should produce normal ratios of DHT/T and of E2/T.
Acceptable price, absence of rst passage through the liver, no local irritation at the site of application, not causing environmental pollution, and
respecting the personal privacy of the user are additional requirements. Also, it
is mandatory that treatment can be interrupted immediately if any side effects
would occur.
Several pharmaceutical products are available today.
Intramuscular injections of testosterone esters such as Testoviron (Schering,
Berlin, Germany) and Sustanon (Organon, Oss, The Netherlands) have the advantage of a guaranteed delivery. However, blood T concentrations are supraphysiological during the rst 3 to 5 days after injection. From day 8 to 10 after
the injection there is a rapid decline to levels lower than physiological, with
resulting deterioration of mood and loss of energy. Furthermore, the circadian
rhythm is not respected. In general, HLD cholesterol decreases (creating an
unfavourable lipid prole), and haematocrite as well as PSA increase.
Testosterone pellets for subcutaneous implantation and the long-acting injectable ester testosterone undecanoate (Nebido, Schering, Berlin, Germany)
also do not full the requirements for optimal physiological substitution. While
maintaining T concentrations within physiological limits over a longer period
of time, they do not restore circadian variations, and metabolic effects are
450
similar to those seen with the esters cited above. In addition, it is impossible to
interrupt hormone effects in case this would be required because of intercurrent
disease or side effects (e.g. activation of a silent carcinoma of the prostate).
1. Oral preparations such as Mesterolon (Proviron, Schering, Berlin,Germany)
or testosterone undecanoate (Andriol, Organon, Oss, The Netherlands)
must be given in a high dose of 240 up to 400 mg daily to exert biological effects. Intestinal uptake and serum T levels are highly variable and
difcult to monitor, there is no diurnal variation, and the ratio of DHT/T
in blood is excessive (commonly >50% as compared to approximately
15% normally). In addition, Mesterolon presents rst passage through the
liver.
2. Transdermal delivery of T with a patch tend to approach the requirements
mentioned above, since the circadian rhythm is more closely respected.
There are scrotal (Testoderm, Alza, USA) and non-scrotal (Androderm,
Smithkline Beecham, UK) patches available on the market. Both systems
produce rather unpredictable T concentrations in blood, and the DHT:T ratio
may be supra-physiological.
Gels have become popular (Androgel, Besin, Brussels, Belgium) because of
their good local tolerance and ease of application. However, transcutaneous
uptake is highly variable, and no more than 9-14% of the testosterone is
absorbed. Also, the diurnal variations are not restored since a steady state
testosterone level is attained.
3. Buccal application of testosterone tablets results in rapid transmucosal
uptake. A novel delivery system is based on the sustained release of testosterone from a bio-adhesive buccal tablet, with high bio-availability and
perfectly mimicking the diurnal variability (not available on the market so
far).
Effects of HRT with testosterone

Prospective cohort studies suggest a favourable benet/risk ratio of HRT with
testosterone on body composition, bone density, and mental well-being of
PADAM patients. So far, trials have been performed using systems for androgen delivery that are sub-optimal. Data on the risk of prostate cancer have been
reassuring, but trials of longer duration and using an appropriate double blind
design are required.
A detailed discussion regarding the prevention of prostate diseases in the
elderly can be found in The aging Male, 2004;7:155-169.
451
Nutraceutical alternatives
In addition to a healthy lifestyle, aging men can promote their good physical
and mental condition by using particular food supplements. Nutraceuticals aim
at preventing or delaying the occurrence of common diseases, maintaining
optimal organ function, and counteracting wear and tear caused by reactive
oxygen species. The judicious combination of vitamins, minerals and plant
extracts helps to maintain adequate brain function and bone strength, and may
protect against common vascular and prostate diseases.
Since a large proportion of the aging population lives in a environment
that is highly polluted by agents that accelerate the aging processes, it may be
useful to start nutraceutical intake rather early in life (between 40 and 50 years
of age).
Wear and tear, a kind of cellular wearing out as a result of oxidative
damage is, among other things, related to the continuous production of oxygen
radicals and that can damage the cell membrane, the mitochondria, and the
DNA. Changed composition of the phospholipids of the cell membrane render
the membrane less uid and impair enzyme functions and receptor activity,
which are linked to the cell membrane. The production of ATP in the mitochondria becomes less efcient, whereby the energy available for the cells reduces.
Redox imbalance is also involved in impairment of the immune system seen
in the elderly. Oxidative damage to the DNA causes genetic changes that can
be mutagenic and, in some circumstances, can promote the occurrence of cancer.
Components of neutraceuticals
By way of example, the composition is given of a nutriceutical that is currently
available on the Belgian market as an OTC (over the counter) product.
Plant extracts
Vinca minor (common periwinkle)
The extract of the Vinca minor, from which the toxic alkaloids have been removed, has long been used because of its favorable effect on the blood circulation of the brain. The vinca extract also stimulates the glucose metabolism of the
brain cells. A benecial effect on memory has been documented in humans.
Serenoa repens (saw palmetto)
The lipido-sterolic extract van Serenoa repens is used because of its favorable
452
effect on the prostate gland. The extract changes the phospholipid composition of the nuclear membrane whereby the reductase activity is inhibited so
that the conversion of testosterone into 5-alpha dihydrotestosterone (which
is 10 times more androgen active than testosterone itself) is decreased. This
effect is lower than that of the pharmaceutical 5-alpha-reductase inhibitors
(Finasteride and Dutasteride). Nonetheless, the therapeutic result of treatment
with serenoa extract on LUTS (lower urinary tract symptoms) or prostatic
complaints is comparable with that of both Finasteride and of the alpha-1
blocker Tamsulosin.
Serenoa extract reduces the prostate volume (albeit to a lesser degree than
the reductase inhibitors), it induces apoptosis, reduces the proliferation of the
stroma cells, and neutralizes the inammatory leukotriene B4. Serenoa extract
is used in the treatment of benign prostate hyperplasia (BPH) and, in contrast
to the pharmaceutical 5-alpha-reductase inhibitors, does not reduce libido. It
seems logical to use Serenoa extract to prevent prostate hyperplasia, but there
have been no controlled studies in this regard.
An extract of the pumpkin pit (Curcubita pepo) is sometimes added to the
Serenoa extract with the intention of enhancing the effect on prostatic complaints by additional inhibition of the 5-alpha-reductase and the aromatase.
Linum
Linum is extracted from linseed oil. It contains lignans, which are converted
by the intestinal ora into enterodiol and enterolactone. Both substances have
a discrete phytoestrogenic effect. Enterolactone is primarily an inhibitor of
aromatase. Administration of linum results in a lower total estrogen load because the production of the very active estrogens (estrone and estradiol) is
inhibited.
Since the testosterone concentration declines more than the estradiol concentration relative hyperestrogenism occurs in older man, and this is associated
with an higher risk of coronary problems and prostate pathology. Inhibition of
the aromatase activity with linum can restore the estrogen-androgen balance.
In epidemiological studies, it has been established that men with a high enterolactone level in the blood do, indeed, run less risk of a heart attack.
Soya isoavones
The primary soya isoavones, daidzein and genistein, are often recommended
for the prevention of prostate cancer. These isoavones are weak estrogens.
They bond more strongly on the beta than on the alpha estrogen receptor.
Less prostate cancer is observed in people who have taken in many soya
453
isoavones in their diet during their entire lives. However, the administering
the soya isoavones to older man does not appear to be appropriate in view
of the relative hyperestrogenism that is present in many of them. Indeed, the
amount of circulating estrogen will increase resulting in an increase of the
concentration of sex hormone binding globulin (SHBG) and stronger reduction of the free testosterone concentration in blood. The estrogen-androgen
equilibrium would be even more disturbed, which could increase the risk of
cardiovascular disease. Also, a higher concentrations of daidzein and genestein
were measured in blood of patients with prostrate cancer than in a control group
of men without this disease.
A similar argument applies for the Ginseng extracts, which also display
signicant estrogenic activity.
Minerals
Zinc (chelate)
Zinc, together with Vitamin B6, plays an important role in the conversion of
the essential omega-3 short-chain fatty acids, such as the 18:3 3 (alpha linolenic acid) into the long-chain polyunsaturated fatty acids eicosa pentaenoic
acid (EPA) and the docohexaenoic acid or cervonic acid (DHA; 22:3 3). The
anti-inammatory properties of the latter have been repeatedly demonstrated
in patients with rheumatoid arthritis and other conditions. Zinc and Vitamin
B6 are necessary for the elongase and desaturase processes that are active in
this conversion.
Selenium (methionine)
Selenium is a strong antioxidant that protects against oxidative DNA damage. Several studies point to the connection between a low selenium content
in the blood and a higher risk of dying as a result of cancer. Prospective
research has also demonstrated a protective effect of selenium against prostate
cancer.
Vitamins and liponic acid
Antioxidant vitamins
Vitamin C, Vitamin E, and liponic acid restore the equilibrium between oxidative overload and the anti-oxidative capacity of the body. The oxidative overload can be the result of the use of tobacco, of intercurrent inammatory or
infectious conditions, of exposure to toxic environmental factors (including
pesticides) and heavy metals, and of hypertension or diabetes. The oxidative
overload causes an accelerated conversion of LDL cholesterol to oxidated LDL
454
cholesterol, which is phagocyted by macrophages in the vascular wall that are

them selves converted to foam cells, promoting the development of arteriosclerosis. A correctly dosed composition of antioxidants retards the conversion of
the LDL cholesterol to its oxidated form, which could inhibit the occurrence of
arteriosclerosis. Vitamin C also reduces the stress-induced constriction of the
coronary arteries, and improves endothelial function.
The results of various prospective studies concerning an anti-arteriosclerosis effect of Vitamin C and Vitamin E are contradictory, and meta-analysis
could not show a positive effect. This conclusion must be interpreted with
caution since highly divergent doses of Vitamin E and C were used in the
various studies. Often synthetic Vitamin E was administered, the biological
activity of which differs signicantly from that of the natural tocopherols.
Natural vegetable Vitamin E consists of various isomers whereby the ratio
between the alpha and gamma forms is important for optimal anti-oxidative
effect. The natural tocopherols are up to 8 times more active than the synthetic
alpha-d-tocopherol. In addition, a high concentration of the latter reduces the
concentration of gamma tocopherol. Administration of nutritional supplements
with a high dose of synthetic alpha-d-tocopherol can exert a paradoxically
unfavorable effect, for example in preventing certain forms of cancer. On the
contrary, the administration of natural Vitamin E, with a correct proportion of
alpha and gamma tocopherols, manifested a protective effect, particularly in the
prevention of prostate cancer. It has also been demonstrated that administration
of Vitamin E reduces the concentration of the mutagenic oxidated DNA (8-OH2-deoxyguanosine) in the cells.
Particularly important is the dose of Vitamin C: more is not always better! Indeed, high doses of Vitamin C can cause a pro-oxidative effect by the
increase of the content of free Fe++, which generates free oxygen radicals via
the Haber-Weiss and Fenton reactions. It has recently been shown that cyclooxygenase-2 (COX2) is involved in the induction of DNA damage and that
Vitamin C promotes this process. On the other hand, the administration of a
balanced combination of antioxidants increases the serum concentration of
ferritin whereby the free Fe++ is more strongly bonded and so can exert less a
pro-oxidative effects.
Vitamin E is fat-soluble and is regenerated by the water-soluble Vitamin
C.
Liponic acid is both fat and water-soluble and has a high buffering capacity, i.e., it can take up many oxygen radicals.
Recent prospective cohort and intervention studies have shown that the
administration of the combination of Vitamins E and C signicantly reduces
455
the risk of Alzheimers disease. Vitamin E also increases the immunological

resistance of the elderly and of patients with HIV infection.
Vitamin A and retinol are not used in the formulation presented here.
Indeed, these substances are applied in large quantities in cattle breeding and
for food preservation. Through these routes, they are sufciently present in
our diet. Large quantities have a hepatotoxic effect and the addition of Vitamin
A turned out to nullify the protection provided by Vitamins E and C in AIDS
patients.
Vitamins B 6, B 9 (folic acid), and B12
Vitamin B6 plays an important role in the elongation and desaturation of the
unsaturated short-chain fatty acids. The combination of the three B vitamins
reduces the concentration of homocysteine in the blood. A high homocysteine
level is an independent risk factor for arteriosclerosis and cardiovascular disease and for osteoporotic bone fractures. The prevalence of bone fractures is
four times higher in men in the highest homocysteine quartile than in those in
the lowest quartile.
Interventions that reduce the homocysteine level in persons with a high
basal blood value, particularly administrating of the combination of Vitamins
B6, 9, and 12, may reduce the risk of fractures and also have a protective effect
against coronary illness.
Ubiquinone Q10 oxidoreductase
The oxido-reductase ubiquinone Q10 plays an important role in the production of adenosine-triphosphate (ATP). Q10 promotes muscle function and is
necessary for the proper operation of the heart muscle. A deciency of Q10
or inhibition of its enzymatic functioning can cause heart failure. The a-polar
polychlorinated biphenyls (PCBs) inhibit the oxido-reductive activity of Q10.
PCBs have been present in our diet for decades and accumulate in the body, and
may be involved in the increasing prevalence of heart failure in the population.
The supplementary administration of Q10 can compensate for the decient
muscle contractility (inotropic activity) and thus combat the occurrence of heart
failure due to environmental pollution.
The cholesterol lowering statins develop their effect by the inhibition of
hydroxy-3-methyl-3-glutaryl-co-enzymA-reductase (HMG-Co-A-reductase).
However, this enzyme is necessary for the synthesis of Q10, and the administration of primarily fat-soluble statins (atorvastatin, uvastatin, and simvastatin) signicantly reduces the content of Q10 in the cells. This decreases the
production of ATP, which explains the muscle complaints and the feeling of
456
fatigue that are commonly mentioned by patients during treatment with statins.
In addition, a higher degree of myocardial stunning has been observed after
induced short coronary ischemia in dogs that were pre-treated with fat-soluble
statins. Although there is no formal proof that such phenomenon also occurs in
humans, the administration of a nutritional supplement with Q10 can prevent
the ATP deciency in the heart-muscle cells and thus protect or improve the
pumping function.
Vitamin D
In elderly people admitted to care institutions, the risk of fall incidents could
be reduced signicantly by the administration of a Vitamin D supplement.
This is ascribed to improved muscular strength rather than to an effect on the
bones.
Complementary substances
Several complementary food supplements display favorable effects
Glucosamine sulfate and chondroitine sulfate are administered to inhibit the
evolution of arthrosis. Their benecial effect is statistically proven, but their
inuence on arthrosis complaints varies. Whether the early administration of
these compounds can prevent, retard, or inhibit the development of arthrosis
has not been univocally demonstrated.
Carnitines support the transport of long-chain fatty acids from the cytoplasm
into the mitochondria, which can enhance energy production in the cells and
will combat fatigue.
With the extracts of Crataegus (hawthorn) and Scilla maritima (sea onion)
a positive inotropic effect has been demonstrated.
The extracts from the bark of the Salix (willow) and of the Pinus maritima
(French maritime pine) display an anti-inammatory activity.
The extract from the Peumus boldus (boldo) protects the liver cells against
toxic damage.
The extract from the Lespedeza bicolor supports the kidney function and has
actually been used in the treatment of patients with renal failure.
A favorable effect of Cordiceps sinensis extract has been demonstrated on the
efciency of insulin, as has been an increase of physical performance capacity.
It is important to point out that the substances cited above have no demonstrable toxic side effects, at least not when correctly extracted products are
used that have not been contaminated by pesticides or other environmental
contaminants and when undesirable alkaloids have been removed during their
preparation.
457
Summary
Whereas the maximum lifespan seems to be genetically determined for each
individual person, the quality of life of elderly people can most probably be
favorably inuenced. The prevention and correction of obesity, the regular
engagement in moderate physical activities, and the early identication and
treatment of diseases of the elderly, such as hypertension, diabetes, and certain forms of cancer, are of essential importance.
Substitution of specic hormonal deciencies may be indicated. Living in
a strongly polluted environment, people are protractedly exposed to numerous
agents, many of which are carcinogenic and/or disturb the hormones and can
upset the proper function of cells and organs. This takes its toll on health at
advanced ages.
There is strong, albeit mostly indirect, evidence that the use of certain nutritional supplements can counteract the deleterious inuences of this exposure, at
least to some degree. In addition, scientic research has reliably revealed that
complementing the diet with a balanced supplement, though not preventing
certain phenomena and diseases of the aging, can delay their occurrence or
slow down their development.
References on request.
458

Oophorectomy using hysterectomy
at what age?
The special case of endometriosis
Adolf E. Schindler MD, PhD
Institute of Medical Research and Education, Essen, Germany
Email: schindler@uni-essen
Endometriosis belongs to the group of benign, proliverative diseases of women

like myoma, endometrial hyperplasia and brocystic breast disease in which
proliferation is dependent upon the action of estrogens at the tissue level (1).
Therefore, one basic principle regarding control or regression of endometriotic
lesions is the reduction or elimination of estrogen production and secretion
from the ovaries or the formation of estrogens of the endometriotic tissue itself
(conversion of androgens to estrogens by tissue aromatase) (2).
To consider oophorectomy at the time of a medically indicated hysterectomy three main reasons for prophylactic oophorectomy have to be taken into
account:
1. Risk reduction of ovarian cancer
2. Risk reduction of breast cancer
3. Therapeutic effects on endometriosis
The decision for prophylactic oophorectomy (PO) at the time of hysterectomy
is from an operative point of view nowadays not relevant, since the operative risk
is not signicant increased by the additional oophorectomy (3). However, removal
of the ovaries in premenopausal women leads consequently to the development
of postmenopausal estrogens withdrawal symptoms and thereby to a loss of life
quality, which is more prominent caused by the abrupt hormone withdrawal by
oophorectomy. In addition, such abrupt ovarian hormone withdrawal, which includes besides estrogen and progesterone also androgen decrease is followed by
negative organic changes such as genital atrophy, osteoporosis, cardiovascular
459
damage, collagen loss (wrinkles, arthrotic changes, urogenital dysfunction), dry

eyes, mental changes and other pathological developments (4). Mainly due to the
acute withdrawal symptoms hormone replacement therapy might than be necessary. Therefore, the decision to carry out prophylactic oophorectomy has to take
into account strong divergent aspects. Therefore, a clinical guidance programme
for the decision about prophylactic oophorectomy in women undergoing hysterectomy has been developed. This was directed mainly towards the reduction of
the risk of subsequent ovarian cancer (5,6). For the association of prophylactic
oophorectomy at the time of hysterectomy in cases with endometriosis to our
knowledge such a guidance programme is not available. Analysis of a questionnaire presented to Australian gynecologists suggested that the current opinion
supports a conservative approach to operative removal of the ovaries, since only
27.5 % of the questioned gynecologists elected to perform bilateral salpingooophorectomy in conjunction with hysterectomy (7). However, there are some
data, which in patients with endometriosis are in favour for oophorectomy at the
time of hysterectomy:
1. The ovaries are preferred structures for endometriosis (2,3)
2. Where endometriosis is the main reason for hysterectomy, 68.3 % reported
that persistence of symptoms in patients after medical treatment was the key
factor (8).
3. Women, who underwent hysterectomy with ovarian conservation had a 6.1
times greater risk of developing recurrent pain and 8.1 greater risk of reoperation (9).
4. When childbearing has been completed.
5. The extent of endometriosis and the severity of symptoms needs to be taken
into account (9).
The American College of Obstetrician Gynecologists developed a set of
criteria for carrying out hysterectomy with or without adnexectomy for endometriosis (10).
The women considered for operation should have a history of the following:
1. Prior detailed operative description or histological diagnosis of endometriosis.
2. Failure of conservative measures to control signicant symptoms.
3. Presence of persistent, signicant adnexal mass.
4. Signicant involvement of other organ systems (eg, uretral or intestinal
obstruction)
5. Presence of pain for more than 6 months with negative effect on patients
quality of life.
460
Specically the combination of 1, 2 and 5; 1,3 and 5 or 1,4 and 5 are pointed
out (10):
The following should be documented in the medical record prior to operation:
1. Attempted medical or conservative surgical therapeutic trial or evidence of
involvement of other organ systems.
2. Normal cervical cytology.
3. Results of endometrial sample or indication D & C was performed (when
abnormal uterine bleeding is present).
4. Discussion of implications regarding ovarian function, ovarian involvement
in the disease, castration and probability of recurrence.
The goal is denitive and permanent relief of symptoms and regression or
eradication of the disease with minimal long-term side effects.
Retrospective studies comparing hysterectomy with bilateral oophorectomy
to hysterectomy with conservation of ovarian tissue in premenopausal women
have revealed discordant results. The incidence of symptom recurrence after
hysterectomy with ovarian conservation has been reported to be as low as 1 %
and as high as 85% in other studies (11,12).
There have been several reports that even after hysterectomy and bilateral
oophorectomy symptomatic endometriosis persists. Ovarian remnants may exist (13, 14), but also high levels of aromatase in these cases may be a reason
since aromatase inhibitors have been effective in such cases after hysterectomy
and oophorectomy (15, 16).
Generally, women with a history of endometriosis, in whom total hysterectomy and bilateral salpingo oophorectomy have been preformed, have a low
risk of recurrence, when hormone replacement therapy (HRT) is administered.
However, in cases with peritoneal endometriosis involvement of > 3 cm makes
HRT a controversial option (18). If there is extraabdominal endometriosis such
as thorax endometriosis HRT should probably be delayed for several months to
allow complete regression of the ectopic endometrial tissues after hysterectomy
and bilateral salpingo-oophorectomy (18).
Prior to hysterectomy and bilateral oophorectomy patients with endometriosis should be tested according to the following suggestion:
Test trial with GnRH-agonist with ovarian suppression and add-back therapy. If in the individual woman a symptom free status with adequate quality
of life can be reached and the patient has no further childbearing desire and is
premenopausal, the medically indicated hysterectomy combined with prophylactic oophorectomy could be recommended.
461
Conclusion
Oophorectomy at the time of medically indicated hysterectomy in women with
endometriosis should be considered:
1. In premenopausal women in whom childbearing has been completed or the
desire to become pregnant has been abandoned.
2. In premenopausal women, whose ovaries are affected by endometrisosis.
3. In premenopausal women with persistence of symptoms after repeated
medical and/ or surgical treatment.
4. In premenopausal women with a favourable test trial with GnRH-agonist
suppression and add-back .
462
References:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Schindler AE. Gutartige proliferative Erkrankungen der Frau. Bcherei des Frauenarztes Vol.
40, Enke Stuttgart, 1991
Schindler AE. Pathophysiology, diagnosis and treatment of endometriosis. Minerva
Ginecologica 36, 419-435, 2004
Schweppe KW, Beller FK. Zur Frage der prophylaktischen Ovarektomie. Geburtsh. Frauenheilk.
39, 1024-1032, 1979
Schindler AE. Behandlung klimakterischer Beschwerden. Klinik der Gegenwart Chapter 15,
Vol. 16, Urban und Schwarzenberg, Mnchen, 1996, 3-44.
Pell I, Dowie J, Clarke A, Kennedy A, Bhavnani V. Development and preliminary evaluation
of a clinical guidance programme for the decision about prophylactic oophorectomy in women
undergoing a hysterectomy. Qual. Saf. Healthcare 11, 32-39, 2002
Bhavnani V, Clarke A, Dowie J, Kennedy A, Pell I. Womens views of two interventions
designed to assist in the prophylactic oophorectomy decision: a qualitative pilot evaluation.
Health Aspectations 5, 156-171, 2002
Dover RW, Chen J, Torode H. Oophorectomy at the time of surgery for moderate endometriosis: a survey of Australian Gynecologists. Aust. N.Z. J. Obstet. Gynecol. 40, 455-458, 2000
Treloar SA, Do KA, OConnor VM, OConnor DT, Yeo MA, Martin NG. Predictors of hysterectomy: An Australian Study. Am. J. Obstet. Gynecol. 180, 945-954, 1999
Namnoun AB, Hickmann TN, Goodman SB, Gehlbach DL, Rock JA. Incidence of symptom
recurrence after hysterectomy for endometriosis. Fert. Steril. 64, 898-902, 1995
American College of Obstetrician Gynecologists. Quality evaluation and improvement in
practice: Abdominal hysterectomy with or without adnexectomy for endometriosis. Int. J.
Gynecol. Obstet. 60, 92-93, 1997
Sheets JL, Symmonds RE, Banner EA. Conservative surgical management of endometriosis.
Obstet. Gynecol. 23, 625-628, 1963
Hammond CB, Rock JA, Parker RT. Conservative treatment of endometriosis: the effect of
limited surgery and hormonal pseudopregnancy. Fert. Steril. 27, 756-766, 1976
Kim KS, Moon WS, Song HW, Kim JH, Cho SN. A case of persistent endometriosis after
total hysterectomy with both salpingo- oophorectomy managed by radiation therapy. Arch.
Gynecol. Obstet. 265, 223-227, 2001
Rana N, Rotman C, Hasson HM, Redwine DB, Dmowski WP. Ovarian remnant syndrome after
laparoscopic hysterectomy and bilateral salpingo oophorectomy for severe pelvic endometriosis. J.Am. Assoc. Gynecol. Laparosc. 3, 423-426, 1996
Bulun SF, Zeituon K, Talyama K, Noble I, Michael D, Simpson I et al. Estrogen production in
endometriosis and use of aromatase inhibitors to treat endometriosis. Endocrine Relat. Cancer
6, 293-301, 1999
Razzi S, Fava A, Sartini A, DeSimone S, Cobellis I, Petraglia F. Treatment of severe recurrent
endometriosis with aromatase inhibitors in a young ovarectomized woman. Brit. J. Obstet.
Gynecol. 111, 182-184, 2004
Matorras R, Elorriga MA, PijoanJI, Ramon O, Rodriguez-Escudero FJ. Recurrence of endometriosis in women with bilateral adnexectomy (with or without total hysterectomy) who received
hormone replacement therapy. Fert. Steril. 77, 303-308, 2002
Joseph J, Reed CE, Sahn SA. Thoracic endometriosis. Recurrence following hysterectomy
with bilateral salpingo- oophorectomy and successful treatment with talc pleurodesis. Chest.
106, 1894- 1896, 1994
463
Endometrial biopsy vs transvaginal

ultrasound as a rst line test in patients
with pathologically proven endometrial
polyps
Jodi P. Lerner, MD, Dorothy Smok, MD
Department of Obstetrics and Gynecology, NY Presbyterian Hospital,
Columbia-Presbyterian Medical Center, New York, NY USA
Endometrial polyps are commonly encountered epithelial tumors arising from

the endometrial cavity. Although many patients are clinically asymptomatic,
there is a subset of perimenopausal and postmenopausal patients that do present
to the clinician with abnormal vaginal bleeding and need a workup to identify
the etiology of this bleeding. Often patients have an ofce endometrial sample
(usually via Pipelle) to search for the cause of the bleeding. If the sample comes
back negative, the patient may be falsely reassured that there is no pathology
within the cavity; the Pipelle does not sample the entire endometrium. These
patients may then be referred for transvaginal sonography (TVS) where the
correct diagnosis of endometrial polyp is suggested. Irregular and thickened
endometrium is often seen sonographically; occasionally a typical hyperechoic
almond shaped endometrial nodule is noted, suspicious for a polyp.
As these polyps are focal and not global endometrial processes, the efcacy
of Pipelle endometrial sampling in this setting has been questioned. Pipelle
endometrial sampling has been determined to be quite accurate in obtaining
endometrial tissue and a correct diagnosis in global endometrial processes
such as endometrial cancer and diffuse proliferation of the endometrial lining.
However, the Pipelle does not perform as well when the pathology is conned
to a small surface area of the endometrial cavity. Stovalls study in 1991 found
that the accuracy of Pipelle sampling directly correlated to the amount of sur-
464
face area of the endometrial lining involved [1]. In a well designed study by
Guido et al. [2], the smaller the surface area of the endometrial cavity in which
the carcinoma was present, the less accurate the Pipelle sample was in correctly
identifying it. In this study 65 patients with known endometrial carcinoma had
endometrial biopsy sampling prior to surgery: the correct diagnosis was made
in only 63% overall (54 patients). Of the 11 false negatives encountered, 8
of the 11 had carcinoma conned to a polyp (5 cases) or less than 5% of the
surface area (3 cases) of the endometrium.
We then wanted to determine if baseline and saline infused sonohysterography performed better than Pipelle endometrial sampling in patients with pathology proven endometrial polyps. We hypothesized that TVS and SIS would
perform better than an endomterial biopsy in identifying endometrial polyps
since polyps are focal processes in the endometrium and at times on a thin stalk
not easily targeted by a blind biopsy. If so, then perhaps a better algorithm for
perimenopausal patients with abnormal uterine bleeding would be to start with
the TVS and SIS rst and to reserve Pipelle sampling if the TVS is negative.
A total of 123 pre-, peri-, and post-menopausal patients who underwent operative hysteroscopy and dilatation and curettage for endometrial polyps over a
single calendar year period (2002) were included in this study cohort. Inclusion
criteria consisted of patients who had had either an endometrial biopsy or TVS
or both, as part of their workup for abnormal vaginal bleeding. These included
pre-menopausal women with menorrhagia or menometrorrhagia and women
with peri- or post-menopausal bleeding. All patients had at least one TVS
evaluation and/or endometrial biopsy performed for possible polyps and all
had pathologic conrmation of endometrial polyps at pathology.
Sixty six patients who were pre- or peri-menopausal and 57 who were postmenopausal met criteria in that they all had endometrial polyps removed hysteroscopically during the study period and had had either an endometrial biopsy
and/or TVS within 6 months prior to the polyp removal. Thirty-four of these
patients had both biopsy and TVS performed: the endometrial biopsy was performed in the ofce prior to TVS as part of their workup for abnormal uterine
bleeding: 10 in the pre/peri-menopausal group and 24 in the post-menopausal
group. Endometrial biopsy sampling alone performed poorly in both of these
groups: 0 of 10 biopsies were suspicious for polyp in the pre/peri-menopausal
group, and 4 of 24 endometrial biopsy samples (16%) in the post-menopausal
group conrmed the presence of a polyp or portion of polyp. An additional 45
patients had endometrial polyps identied on endometrial biopsy performed
rst and went directly to hysteroscopy (no TVS performed): 14 patients in the
pre-/perimenopausal group and 31 postmenopausal patients. Overall (cumula-
465
tive) sensitivity for the endometrial biopsy correctly suggesting the presence
of an endometrial polyp was 58% in the pre- and perimenopausal group and
51% in the postmenopausal group. TVS correctly identied the presence of
endometrial polyps in this cohort with few false positives (all in the pre-/perimenopausal group). There is no ability to elucidate the false negatives in this
cohort because if no polyp was suspected on endometrial biopsy or TVS, the
patient was not taken to hysteroscopy.
In a study by Elpek et al, the sensitivity and specicity of the Pipelle device
in the detection of endometrial polyps were 25% and 88% respectively [3].
Fothergill observed that the Pipelle device did not diagnose any of the 12 cases
of polyps detected at D and C [4]. Of the 5 cases of polyps identied by D
and C in the study of Goldschmidt et al, Pipelle sampling identied only 2 of
the 5 correctly [5]. Preoperative endometrial biopsy sampling appears not be
very accurate in identifying the presence of endometrial polyps in this cohort
of women, especially in the pre-and perimenopausal patients. Endometrial
biopsy sampling is generally considered a more invasive and painful procedure than TVS. TVS provides more information regarding the source of the
abnormal uterine bleeding and can identify other etiologies such as submucous
myomata.
Other sonographic modalities as saline infusion sonohysterography may be
used to further increase the sensitivity of TVS in the detection and localization
of endometrial lesions. Preoperative use of sonohysterography may assist in
choosing the best conservative surgical treatment for the patient, as it is not
always possible to differentiate endometrial from myometrial abnormalities
on TVS as small structural abnormalities may be missed [6]. Randolph et al
described the rst use of intrauterine saline infusion during preoperative transabdominal ultrasound evaluation in 1986 [7]. Parsons and Lense described
the transvaginal technique in 39 patients suspected of having a variety of
endometrial abnormalities, and were able to discern between intracavitary, intramural, and diffuse processes [8]. Many endometrial pathologic conditions,
particularly hyperplasia and carcinoma, are focal in appearance at transvaginal
sonohysterography. Dubinsky et al found that the sensitivity of transvaginal
sonohysterography for carcinoma was 89%, specicity was 46%, positive
predictive value was 16%, and negative predictive value was 97%. Given that
many differing pathologic conditions had a suspicious appearance, the positive
predictive value of transvaginal sonohysterography for carcinoma was low in
their study. On the basis of these preliminary data, the authors suggested that
women with multifocal or sessile lesions undergo endometrial biopsy, and that
benign appearing polyps be removed. Hence, the role of transvaginal sono-
466
hysterography should be to designate patients for more invasive therapy if an

endometrial lesion is detected or for medical therapy if none is present [9].
Based on our ndings and those of other authors, we propose that patients
with pre and peri-menopausal bleeding should begin their workup for abnormal
bleeding with an appropriately timed (post-menstrual) TVS that may better
identify the presence of clinically relevant endometrial polyps. Consideration
for sonohysterography may be given to further increase the sensitivity of
TVS.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
Stovall TG, Photopulos GJ, Poston WM, Ling FW, Sandles LS. Pipelle endometrial sampling
in patients with known endometrial carcinoma. Obstet Gynecol 1991; 77:954-6.
Guido RS, Kanbour-Shakir A, Rulin MC, Christopherson WA. Pipelle endometrial sampling.
Sensitivity in the detection of endometrial cancer. J Reprod Med 1995; 40(8): 553-5.3.
Elpek G, Uner M, Elpek GO, Sedele M, Karaveli S. J Obstet Gynecol 1998;18 (3):274-276.
Fothergill D, Brown V, Hill A: Histological sampling of the endometrium: a comparison between formal curettage and the Pipelle sampler. Br J Obstet Gynecol 1992; 99:779-80.
Goldchmit R. Katz Z. Blickstein I. Caspi B. Dgani R. The accuracy of endometrial Pipelle sampling with and without sonographic measurement of endometrial thickness. Obstet Gynecol
1993; 82(5):727-30.
Goldstein SR. Saline infusion sonohysterography. Clinical Obstet Gynecol 1996; 39(1):24858.
Randolph J, Ying Y, Maier D et al. Comparison of real-time ultrasonography, hysterosalpingography, and laparoscopy/hysteroscopy in the evaluation of uterine abnormalities and tubal
patency. Fertil Steril 1986; 46:828-832.
Parsons A, Lense J. Sonohysterography for endometrial abnormalities: Preliminary results. J
Clin Ultrasound 1993;21:87-95
Dubinsky TJ. Stroehlein K. Abu-Ghazzeh Y. Parvey HR. Maklad N. Prediction of benign and
malignant endometrial disease: hysterosonographic-pathologic correlation. Radiology 1999;
210(2):393-7.
467
HIV infections in women

how to deal with them?
T. Niemiec, MD, PhD
Research Institute of Mother and Child, Department of Obstetrics and Gynecology,
Warsaw, Poland
e-mail: tniemiec@zigzag.pl
Introduction
The rst case of AIDS in women was published in USA in 1981 (1). Since 1985,
when the rst case of HIV infection was noted in Poland, 9.147 of new cases
of HIV infections were registered and 722 people died because of AIDS (2).
According to ofcial data published by National Institute of Hygiene (Warsaw,
Poland) 24,9% of all HIV infected adult patients were women at reproductive
age.
In Poland, 96% of HIV infections and 53% of AIDS cases are diagnosed
in Intravenous Drug Users (IDU) (2). As is the case for other sexually transmitted diseases, women are biologically and socially at greater risk for HIV
infection. So it is not surprising that HIV is spreading at a faster rate among
women than among men. All over the world, we observe increasing rates of
HIV infections among women (3). The majority of these women are in the
reproductive age. Fortunately, with access to appropriate therapies, clinicians
can now offer infected women a much improved prognosis as well as a very
high likelihood of birthing children who will be uninfected. Currently, it is well
known that mother-to-child transmission can occur during pregnancy, delivery
and/or postnatally through breastfeeding. Early in utero transmission appears to
be rare. Approximately 70% of vertical transmissions around time of delivery.
Antenatal transmission generally occurs in the third trimester. The challange
for Polish obstetricians is to increase the knowledge about HIV infection and
468
to recommend all patients in the reproductive age HIV testing to be aware of

their HIV-serological status.
Transmission of HIV in women

HIV infection, AIDS and the risk of contracting or transmitting the virus affect
relationships and areas of womens lives which are gender-dening and lie
at the core of what being a woman means, both to women themselves, and
to wider society. The following aspects of HIV transmission are particular to
women:
Heterosexual intercourse
There is a large pool of infected men
Women retain infected secretions while men do not
Sexual partners of bisexual men
Sexual partners of haemophiliac men
Prostitution
Rape
Contraception
Menstruation
Female to female transmission
Female drug injectors
Female non- drug injectors
Vertical transmission: mother to child (4)
Worldwide, the major route of transmission for women remains unprotected
heterosexual intercourse (4). Male-to-female transmission is still presumed to
be more frequent than female-to-male. There are 3 reasons for this:
there is greater HIV viral load to transmit in semen than in vaginal secretions,
the virus can more easily penetrate the vaginal mucous membrane surface
the semen remains longer at body temperature in the vagina than vaginal
secretions on the penis which means more time for exposure to occur
(5)
However, in developed countries, IDUs form an equal number of new cases
observed, with disproportionate representation from minority populations
Blood transfusion and occupational exposure to HIV have not exclusively
been examined in women and so are poorly documented as specic sources of
469
HIV transmission in women (6). Since 1995 in Poland there has been no HIV
infection as a result of blood transfusion (7).
The rst case of HIV in Poland resulted from heterosexual transmission of
HIV to a farmer who had emigrated from the United States. The second case
came from homosexual transmission and the third from heterosexual transmission (8). Ten years ago, almost 90% of people newly diagnosed with HIV in
Poland were infected through intravenous drug use. Today, only 50% of new
infections are among drug injectors. The other 50% are half heterosexual and
half homosexual route (8).
Pre-conception counselling
In Poland, women are not often offered by their gynaecologists to be HIV
tested. Whats more, in Poland HIV counselling and testing for all pregnant
women has not yet been introduced as a routine practice. Many women are
unaware of risky behaviours practiced by their partners. Social taboo concerning homosexuality, bisexuality and commercial sex together with their
negative moral judgement do not allow open and rational discussion on threats
stemming from them. All these phenomena are conducive to increase in number of infected women in the country, which can be easily observed in Polish
epidemiological statistics (9). Many of these women are less than 30 years old
and plan to be pregnant. Fortunatelly, there is an increasing number of women
who know they are HIV infected before becoming pregnant. So the proper preconception counselling becomes more and more important, and may inuence
pregnancy outcome and improve pregnancy care.
Every gynaecologist/obstetrician should:
offer all women of reproductive age to be HIV tested
inform about consequences of being tested
decrease the level of patients fear associated with the decision to be
tested
educate on HIV/AIDS, safe/safer sexual behaviours and adequate contraception
every gynaecologist should suggest HIV infected women to avoid unintended pregnancies; before possible pregnancy maternal health status
should be optimised, eg. low maternal viral load, good clinical disease
stage should be achieved. Every HIV infected woman who plans pregnancy should receive folic acid, vit C and iron supplementation.
It is a good clinical practice when the woman have the opportunity to meet
the paediatric team prior to pregnancy and delivery. She may then get informa-
470
tions about efcacy of Prevention of Mother to Child Transmission (PMTCT),

possibilities and proper care of children born to HIV infected women.
Psycho-social support for HIV infected pregnant women

Pregnant women are usually advised to avoid taking medication if possible,
when women with HIV are encouraged to take therapy to help prevent MTCT
and some women may nd it difcult to struggle with this conict. Avoiding
breastfeeding and having an elective caesarean section are as well in contradiction with adopted norms . Family and friends questions may be then difcult
to answer. Women may require help with practicalities of formula feeding as
well as nancial support. Living with an HIV diagnosis can lead to fear about
a breach of condentiality, especially if the woman has been diagnosed during
pregnancy or not yet told anyone about her status. There should be a clear local
referral pathway for HIV positive pregnant women. This should include: an
HIV physician; obstetrician; paediatrician and may include a social worker,
health advocate and voluntary workers. (10).
Obstetric management of HIV infected pregnant women

Management of pregnancy in HIV infected women is generally similar to that
in uninfected women.
The rst visit during pregnancy should include:
HIV counselling and informing about risks of vertical transmission.
detection of CD 4 cell counts and plasma RNA viral load
review of womens HIV, hepatitis B virus and hepatitis C virus status
Tuberculosis screening
taking history of sexual partners HIV status
cervical smear collecting; referral for colposcopy and biopsy should be
recommended in case of abnormal cytology
Sexually transmitted diseases (STD) screening and prophylaxis of opportunistic infections
nutritional supplementation eg. Folic acid, iron, vitamins
routine gynaecological examination with special attention regarding
gynecologic manifestations of HIV infection
physical examination
routine lab tests
The standard care in HIV infected pregnant women includes:
to examine these patients every 3-4 weeks;
471
to carry out CD 4 cell counts and plasma viral load determination at least
once every trimester, with the frequency related to the use of antiretroviral therapy.
to repeat the STD screening in third trimester
to repeat cytology 2 times during pregnancy
to carry out ultrasound evaluation of the foetus development every 8
weeks
More invasive monitoring is required in cases of advanced immune deciency and/or presence of clinical symptoms (11).
The only obstetric factors that consistently show an association with risk of
transmission are: mode of delivery and duration of membrane rupture. Invasive
procedures in labour are generally avoided as they pose a theoretical risk of
iatrogenic transmission.
Procedures that may lead to maternal or foetal bleeding, such as external
version or invasive obstetrics procedures routinely carried out as a part of antenatal care like amniocentesis and cordocentesis, should be avoided.
Delivery before 34 weeks of gestation has been shown to be associated with
an increased risk of vertical transmission (12).
Mode of delivery
Over the last decade, the use of three main preventive measures has helped to
reduce MTCT from approximately 25% to less than 2%. These are: actively
discouraging breastfeeding (13); the use of antiretroviral therapy (ART) in
pregnancy and the practice of recommending caesarean section rather than
vaginal delivery (14,15,16).
Elective caesarean section with combination of ART reduces the risk of
vertical transmission of HIV to 1.8% while vaginal delivery is associated with
a 10.5% risk of HIV transmission (1720). Elective caesarean section should
be offered at 37- 38th week of gestation to women with HIV viral load greater
than 1000 copies/ml. So far, there is no evidence in support of benets of
performing caesarean section after the onset of labor, rupture of membranes or
if the maternal HIV-viral load does not exceed 1000 copies/ml (17).
If labour starts prior to the planned delivery date, intravenous zidovudine
should be commenced if this is part of the ART regime. If there is premature
rupture of membrane, with or without labour, the risk of HIV transmission must
be balanced with the risk of premature delivery. There are no known contraindications to the use of short term steroids to promote foetal lung maturity in
HIV infected women (10).
472
Antiretroviral therapy in pregnancy

All HIV infected pregnant women should be offered prophylactic ART during
pregnancy. The choice of therapy and timing of initiation will depend on the
clinical status of the woman and has to balance delaying disease progression
and prevention of vertical transmission with regard to antiretroviral drugs
safety for the developing foetus. The decision should be based on womans
treatment history, her clinical status and the available prognostic markers, CD4
lymphocyte count and plasma HIVRNA levels. These markers are related
to the likelihood of disease progression in the mother and also to the risk of
vertical HIV transmission.
During pregnancy, all antiretrovirals (HAART) with ZDV included should
be initiated after the rst trimester . If there is a risk of pre-term delivery,
HAART should be started soon after the rst trimester, and before mid-second
trimester.
If not requiring antiretroviral therapy for their own health, women should
start the three-part ZDV therapy in the beginning of the third trimester, at 28-32
weeks and have an elective cesarean section at 38 weeks.
Women who received previous prophylactic ZDV may or may not have an
indication for prophylactic ZDV therapy during pregnancy- data are controversial. In these cases testing for ZDV resistant virus should be carried out.
If ZDV drug resistant virus is present, a decreased antiretroviral efcacy is
to be expected. HAART or a combined NRT regimen without ZDV may be
then advisible. Anti retroviral regimens should include Zidovudine (ZDV). If
a woman is not already on therapy, Highly Active Anti-Retroviral Treatment
(HAART) or a combined NRT, regimen without ZDV may be advisible.
Intra partum and neonatal prophylaxis:
When started, antiretroviral therapy should be continued until the time of delivery, including the morning dose of the day of the scheduled cesarean section
delivery. In every case, intravenous ZDV is recommended, during the intrapartum period, and orally for the newborn for 4-6 weeks after birth
Postnatal care for women:
The medical care of HIV infected women after labour is similar to that of
uninfected women. HIV infected women are at higher risk of urinary tract and
wound infections after cesarean section compared with uninfected ones. HIV
infected women should be advised to contact the obstetrician if any signs
of infection, which may be related to delivery, occur shortly after leaving the
hospital. In cases, where antiretroviral therapy was given only to reduce the risk
473
of vertical transmission, the treatment can be stopped if there are no maternal

indications to further treatment.
The follow up of these women once or twice per year is recommended for
screening of cervical lesions and for detection and treatment of other sexually
transmitted infections.
Examination of the vulvar region, associated with colposcopy and biopsy
when indicated, should be considered as a routine procedure in the gynecological care of HIV positive women (12).
VIII. Child born to HIV infected mother

It is still not known what long-term effects of therapy on both the mother and
the child will be. It has been suggested that exposure to antiretroviral therapy,
especially to combination therapy, could have an impact on the developing
foetus and newborn in the short and longer term (21,22). Exposure to ZDV
has been associated with transient anaemia in young infants (23,24). Antenatal
combination of Anti Retroviral Therapy (ART) has been shown to increase
risk of premature delivery (21,25). There have been also anecdotal reports of
congenital abnormalities in newborns exposed to ART in utero (25,26). In utero
and/or neonatal exposure to ZDV or ZDV plus lamivudine (3TC) has been associated with persistent mitochondrial dysfunction and exposure to antiretroviral treatment has been associated with febrile seizures in children younger than
18 months of age (22,25). Data from the Department of Childrens Infectious
Diseases of the Warsaw Medical University, showed high vertical transmission
rates among Polish mothers-infants pairs. From 1989 to 1994 the transmission rate was 31,5%. Since 1995, when recommendations based on ACTG
076 were issued, a decline in the transmission rate to 19,6% was reported (in
children with prophylaxis, even to 1,8%)(27-31). Untill the end of June 2003
in Poland, HIV positive status was recognized in app 100 children aged up to
15. Most of them were vertically infected (30). All of the procedures reducing
the risk of mother to child transmission rely on the womans knowledge of her
HIV-status.
IX. Conclusions
The importance of the awareness of women's risks should be addressed in
both medical specialities and in the general public arena. All women should
be encouraged to come forward for testing by increased media compaings and
prominence of HIV-related literature in all women-related elds. Once diag-
474
nosed, optimum care should meet all their needs through a multidisciplinary
approach with access to midwives, paediatricians, family planning services and
clinics for women.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Centers for Disease Control and Prevention. Current trends update on acquired immunodeciency syndrome (AIDS) Unites States. MMWR 1982;31:507-8,513-4
National AIDS Center, 2005 http://www.aids.gov.pl/temat_en/epidemiologia.
Hamers FF, Downs AM. HIV in Central and Eastern Europe. Lancet 2003; 361: 1035-44.
Fowler MG., Melnick SL, Mathieson BJ. Women and HIV epidemiology and global review.
Obstet Gynecol Clin N Am 1997;24:705-29
Forest BD. Women, HIV and mucosal immunity. Lancet 1991;337:835-6
Low-Beer N, Taylor GP. Women and HIV infection in the UK: a microcosm of a problem. J
HIV Therapy 1998;3:5-8
Rogowska Szadkowska D. Historia naturalna zakaenia HIV. Kliniczne i psychospoeczne
aspekty zakaenia HIV u kobiet, ed. T. Niemiec, Warszawa,2001 (in Polish)
Mascolini M. Interview with A.Horban, IATEC UPDATE,vol.3, n 1, July 2003,10-14
Selwyn P,Carter R, Schoenbaum E et al. Knowledge of HIV antibody status and decisions to
continue or terminate pregnancy among intravenous drug users. JAMA 1989;261;3567-3571
Guidelines for the Management of HIV Infection in Pregnant Women and the Prevention
of Mother-to-Child Transmission.British HIV Association. HIV Medicine These guidelines
appear in the October 2001 issue of HIV Medicine
Niemiec KT. Zakaenie HIV u kobiet. Poradnik dla lekarza praktyka 1997.35-37, National
AIDS Center (in Polish)
Newell ML, Rogers M. Pregnancy and HIV infection: A European Consensus on management.
AIDS 2002, 16 supl.2; S5-S6
Dunn DT,Newell M, Ades AE, Pecham CS. Risk of HIV-1 transmission through breastfeeds.
Lancet 1992; 340: 585-8
Sperling RS, Shapiro DE, Coobs RW,et al. Maternal viral load zidovudine treatment and the
risk of transsmision of HIV-1 from mother to infant. N Engl J Med 1996;335:1621-9
Administration of zidovudine during late pregnancy and delivery to prevent perinatal transmission- Thailand 1996-1998. MMWR 1998;47:151-4
Mandelbrot L. Obstetric factors and MTC of HIV- French perinatal Cohorts. Am J Obstet
Gynecol 1996;175;661-75
European Collaborative Study and the Swiss Mother+Child HIV Cohort Study. Combination
antiretroviral therapy and duration of pregnancy. AIDS 2000; 14:2913-2920.
Barlett J. G.: 2003 Medical Menagment of HIV Infection. John Hopkins University School of
Medicine, Baltimore, 2003
Niemiec KT, Opieka nad kobiet ciarn zakaon HIV; Wybrane aspekty zakaenia HIV I
AIDS u kobiet i dzieci; ed. Niemiec T, Majewski S; Instytut Matki I Dziecka, Warszawa, 2002;
pp: 79-86 (in Polish)
Niemiec KT, Cia i Pord, Kliniczne i Psychospoeczne Aspekty Zakaenia HIV u Kobiet,
ed. Niemiec T, National AIDS Center, Warsaw, 2001, pp. 197-225.(in Polish)
European Collaborative Study and Swiss Mother + Child HIV Cohort Study. Combination
antiretroviral therapy and duration of pregnancy. AIDS 2000; 14:2913-20
Blanche S, Tardieu M, Rustin P, et al. Persistent mitochondrial dysfunction and perinatal
exposure to antiretroviral nucleoside analogues. Lancet 1999; 354: 1084-9
475
23.
24.
25.
26.
27.
28.
29.
30.
31.
Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human
immunodeciency virus type 1 with zidovudine tratment. N Engl J Med 1994; 331:1173-80
Sperling RS,Shapiro DE, McSherry GD, et al. Safety of the maternal-infant zidovudine regimen used in the Pediatric AIDS Clinical Trial Group 076 study. AIDS 1998;12:1805-13
Lorenzi P, Spicher VM, Laubereau B,et al. Antiretroviral therapies in pregnancy: maternal,
fetal and neonatal effects. AIDS 1998;12(Suppl):F241-7
Fundaro C, Genovese O, Rendeli C, et al. Myelomeningocele in a child with intrauterine
exposure to efavirenz. AIDS 2002; 16:299-300
Marczyska M., Szczepaska-Putz M. Vertical Transmission of HIV-1 in Poland. Scand J
Infect Dis 32: 165-167, 2000
Marczyska M, Szczepaska-Putz M. Dziecko zakaone HIV. Dlaczego ryzyko odmatczynego
zakaenia HIV jest wysokie?. Pediatria po Dyplomie., vol.r/4, Sierpie 2000,5-7 (in Polish)
Marczyska M., Szczepaska-Putz M., Odakowska A., Dobosz S. Odmatczyne zakaenia
HIV w Polsce w latach 1989-2000. Przegl Epidemiol. 2001; 55:517-21
Szata W. Epidemiologia zakazen HIV u dzieci i mlodziezy. Dermatologia Kliniczna, nr 2, vol
5, 2003,p.73 (in Polish)
Selwyn P,Carter R, Schoenbaum E et al. Knowledge of HIV antibody status and decisions to
continue or terminate pregnancy among intravenous drug users. JAMA 1989;261;3567-3571
476
Rationale for a safe alternative to

conventional hormone replacement
therapy
Dirk Wildemeersch*, Dirk Janssens**,
Etienne Schacht**, Kris Pylyser***, Nathalie De Wever***
*Contrel Research, Technology Park Zwijnaarde, Ghent, Belgium
**Gynecologische Dienst, Turnhout, Belgium
**Polymer Research Group, University of Ghent, Department of Chemistry,
Ghent, Belgium
***Dienst Anatomo-Pathologie, St. Augustinus Hospital, Veurne, Belgium
Email: dirk.wildemeersch@contrel.be
Abstract
Objective: To evaluate the acceptability and endometrial safety of a novel,
small T-shaped intrauterine levonorgestrel (LNG)-releasing intrauterine system
(IUS), (Femilis Slim), combined with estrogen therapy (ET) in postmenopausal women.
Design: A prospective, non-comparative study. Treatment with the LNG-IUS,
combined with ET, was initiated to suppress the endometrium to prevent endometrial proliferation and bleeding. A 3.0-cm long and 2 mm wide coaxial
brous delivery system, provided with a horizontal arm, 24 mm long, delivering approximately 20 g/day of LNG was used. The calculated duration of
release of the system is at least three years. The majority of women received
percutaneous 17 estradiol, 1.5 mg daily on a continuous basis.
Primary outcome measures: ease of insertion, retention and side effects of
the Femilis Slim IUS. Secondary outcome measures: endometrial safety as-
477
sessed by transvaginal ultrasound examination and by endometrial biopsy in

a subset of women.
Results: One-hundred and seventy insertions were performed in postmenopausal women with median age of age 56.6 (range 43.5-80.3). Insertion was
easy in 161 (94.2 %) and difcult in nine (5.3 %) women. Pain at insertion
was rated as none in 57 women (33.5 %), mild in 105 (61.7 %), moderate in
seven (4.1 %) and severe in one (0.5 %) woman. The system was well retained
in the uterus as no expulsions occurred. The study was well followed-up with
lost-to-follow-up rate (dened as no follow-up during 12 months) of zero at
the time of study analysis. The number of women continuing the method was
160 (94.1%). The histological examinations conducted in 150 women showed
predominantly inactive endometrium characterized by a pseudo-decidual reaction of the endometrial stroma with endometrial atrophy. The mean thickness
(double-layer) of the endometrium was 3.0 mm (range 2-5 mm) which correlated well with the histology results.
Conclusions: The results suggest that the small LNG-IUS is easy to insert in
most postmenopausal women without anaesthesia and dilatation of the cervix.
It is well tolerated, well retained and effective in suppressing the endometrium
during ERT. The small LNG-IUS, combined with parenteral ET could, therefore, be a method of choice for endometrial suppression in women using ERT
with fundamental advantages to systemically applied progestogens which have
been the subject of considerable debate as reported in the recent literature.
Introduction
The addition of progestogen to estrogen replacement therapy (ERT) is necessary to prevent the endometrium from becoming hyperplastic during ERT alone.
However, progestogen, added to estrogen therapy (ET) has been shown to
blunt the rise in HDL-cholesterol. Recent epidemiological evidence suggests an
increase in breast cancer, cardiovascular disease, and venous thromboembolic
events among postmenopausal hormone replacement therapy (HRT) users, attributed to the progestogen component although the underlying mechanism
has not been fully elucidated. The Womens Health Initiative (WHI) study1,
the Million Women Study (MWS)2 and other studies such as the recently published Swedish cohort study3 indicate the need for the development of safer
progestogens and alternative routes of administration to avoid adverse effects.
It has been known for some time that progestogens can compromise the cardio-
478
protective effect of estrogens.4 Therefore, intrauterine systems which deliver a

progestogen direct to the uterus have been developed.
The recently found association between the use of combined systemic estrogen/progestogen and combined sequential estrogen-progestogen regimens
and an increased risk of breast cancer, which has not been shown with estrogen-only therapy, even when administered for longer periods, also prompted
researchers to suggest a low-dose progestogen-releasing IUS to minimize the
impact of the hormone on breast tissue.5
Intrauterine-administered progestogen, such as levonorgestrel (LNG), delivered to the target cells of the endometrium has a profound suppressive effect on
endometrial growth rendering the endometrium inactive and, simultaneously
eliminating uterine bleeding.6-8 The advantage of this route of administration
could therefore be substantial and allow postmenopausal women to fully enjoy
the conrmed health benets of ERT.
The present paper reports on the interim results, as regards ease of insertion,
insertion-related problems, and acceptability of a continuous-combined percutaneous or transdermal estrogen regimen with a small T-shaped LNG-releasing
intrauterine system in postmenopausal women and provides additional data on
endometrial safety. The small Femilis Slim IUS was developed specically to
allow easy insertion and to adapt to the small uterine cavity of postmenopausal
women.
Methods
Description of the T-LNG (Femilis) Slim IUS
The Femilis Slim IUS (Contrel Research, Belgium) has a 3-cm long and 2.0mm wide brous delivery system, consisting of a LNG-ethylene vinyl acetate
(EVA) core and an EVA rate-controlling membrane, that releases approximately
20 g of LNG daily. The drug compartment is provided with crossarms xed to
the upper part of the drug delivery rod. The total length of the cross arms is 24
mm. The polyethylene crossarms contain 22% barium sulfate to render them
radiopaque. The single tail is made of a 00 guage polypropylene.
The in vitro LNG-release is constant over several years (zero-order), except
for the rst 42-90 days of use, and is similar to the in vitro release rate of the
Mirena LNG-IUS (Schering AG, Germany). The duration of release, calculated by extrapolation, is at least three years.
The Femilis Slim IUS is inserted using the 'push-in' technique. Notably,
upon entering the uterine cavity the arms unfold immediately, thus minimizing
perforation. The insertion tube of the Femilis Slim IUS is 3 mm wide. Ease
479
of insertion was recorded as easy, difcult or failed. Pain at insertion

was rated as none, mild, moderate and severe. Following insertion the
proper location of the Femilis Slim IUS was checked by ultrasound.
Figure 1:. The Femilis Slim LNG-IUS
Figure 2:. Photomicrograph showing endometrial atrophy and decidualization of the stroma in a woman using combined ET with a low-dose
intrauterine LNG-releasing system (hematoxylin and eosin, x 20).
Admission
Postmenopausal women with climacteric symptoms were enrolled in the study.
To minimize the drop-out rate, great attention was given to explaining the ad-
480
vantages and possible disadvantages of the replacement therapy. The use of the
LNG-releasing IUS was approved by the Ethics Committee of the University of
Ghent, Belgium and written informed consent was obtained. Prior to the insertion procedure, a medical history was taken and pelvic examination was carried
out and the patient was checked for any clinical signs of sexually transmitted
diseases. Since women included in the study were at low risk for sexual transmitted infections (STIs), no routine chlamydia tests were done. No PAP smear
was taken if cytological abnormalities were absent within six months prior to
entering the study. Following insertion, a transvaginal ultrasound (TVU) was
performed in order to locate the device in the uterus.
Estrogen was administered either by a percutaneous estrogen-containing gel
(Oestrogel, Besins International, Belgium) in a dosage of 0.75 to 1.5 mg/day
or a transdermal matrix system (Systen, Janssen-Cilag, Belgium), in a dosage
of 50 g/day.
Follow-up
Women were followed-up at one, six, and twelve months following insertion
of the IUS and six-monthly thereafter. They were asked about their bleeding patterns and about any side effects or adverse reactions. A gynecological
examination was performed as well as a transvaginal ultrasound to locate the
device and to evaluate the thickness of the endometrium according to Fleischer
et al.9
In order to assess the hormonal effects on the endometrium, an endometrium sample was taken with a suction curette (i.e., Probet, Gyntics, Belgium)
between one and three years after start of the treatment in 150 consecutive
women reporting for follow-up examination. The samples were drawn from all
parts of the uterus to get a representative sample. The biopsies were placed in
phosphate buffered formaldehyde 4% immediately upon collection and stained
with haematoxylin and eosin for examination. They were examined by two
pathologists according to the diagnostic categories of Hendrickson et al.10
Data collection, monitoring and analysis

Data were recorded on standard forms at admission, at each scheduled and
unscheduled follow-up visit, and upon discontinuation from the study. All
data were sent to the data-coordinating centre at the Department of Medical
Informatics and Statistics, University Hospital, Ghent, Belgium, for statistical
data analysis. The rates of discontinuation for individual reasons and groups of
481
reasons were analyzed using the S-PLUS statistical software package (Mathsoft
Corporation)11 and the cumulative discontinuation rates were computed using
survival analysis methods.12,13
Results
Between 3 June 2002 and 27 March 2004, 170 insertions of Femilis Slim
were performed in postmenopausal women with median age of age 56.6 (range
43.5-80.3) (Table 1). Insertion was easy in 161 (94.2 %) and difcult in 9 (5.8
%) women. No failed insertions occurred. Pain at insertion was rated as none
in 57 women (33.5 %), mild in 105 (61.7 %), moderate in 7 (4.1 %) and severe
in one (0.5 %) woman.
Table 1:
Characteristics of the 170 Femilis Slim IUS users: Age distribution.
Age
n
170
mean
57.4
SD
6.7
median
56.6
range
43.5-80.3
The events and cumulative gross discontinuation rates are presented in Table
2. The initial results were published previously.14 There were six (3.5%) removals for medical reasons (three for abnormal bleeding, one of them for cervix
carcinoma grade IA which was diagnosed during follow-up, one for complaints
of pain, two for other medical reasons of which one was for undetected cervical
carcinoma and one in which the patient was being treated for breast carcinoma).
Four women were released for follow-up due to non-compliance with the study
requirements.
The system was well retained in the uterus as no expulsions occurred. The
study with total number of women-months of use of 1,797.5 was well followed-up. The median number of months in situ is 12.6 (range 0.0-21.1). Three
women included in the study did not have a follow-up examination yet.
The histological examinations conducted in 150 postmenopausal women
showed predominantly inactive endometrium characterized by pseudodecidual
reaction of the endometrial stroma with endometrial atrophy.
482
Table 2: Events and cumulative gross discontinuation rates per 100 women in 170 Femilis Slim
IUS users.
No.
Rate SE
Total number of women

recruited
170
Expulsion of the IUS
Removal for medical reasons
Removal for non-medical

reasons
Loss to follow-up
Released from follow-up
2.35 (0.168)
Use-related continuation rate
160
94.11
Median duration of use

(months)
12.6 (0.0-21.1)*
Women-months of use
1,797.5
3.52 (0.960)
*Three women did not have their rst follow-up examination yet
A thin endometrium (mean 3.0 mm, range 2-5), as assessed by transvaginal

ultrasound, was found in all postmemopausal women in this study at followup.
No progestogenic side effects were reported. As all women were postmenopausal at the start of the study, absence of bleeding or amenorrhoea was
quickly established following slight scanty blood-containing discharge which
was usually reported during the initial days, rarely weeks, following insertion
of the LNG-IUS. No serious adverse effects e.g., pelvic inammatory disease
or perforation were observed.
Discussion
Following the publication of the WHI and HERS1,15 studies, reporting signicant risks with estrogen-progestogen therapy (EPT), it was recommended not
to initiate any ET or EPT for primary or secondary prevention of coronary
heart disease (CHD). The conclusions from the WHI and HERS studies are
in contradiction with earlier conducted observational studies and experiments
conducted in humans and animals, as reported by Sarrel and others.4
483
Progestogens adversely modify the metabolic effects of the estrogen. The

negative effects of systemically administered progestogens on the observed
increase in cardiovascular and breast events among WHI study subjects led
us to believe that these effects could be minimized by low-dose progestogen
delivery in the uterus. Frameless and framed levonorgestrel-releasing intrauterine systems have been in development for several years.6-8 The Femilis
Slim intrauterine system was developed specically to facilitate insertion of a
hormone-releasing intrauterine system in the small uterus of a postmenopausal
women to circumvent reported difculties at insertion and during use with
large intrauterine hormone-releasing systems.16-17 A comprehensive review by
Riphagen on the intrauterine application of progestogens in hormone replacement therapy, the 20 g/day releasing Mirena LNG-IUS, in postmenopausal
women showed that the IUS was easy to insert in only 46-90% and cervical
canal dilatation and/or local anaesthesia was necessary in 25% of insertions
in postmenopausal women.18 Moderate pain at insertion was reported by 1025% of women and severe pain in 5-10% of women. The occurrence of these
complaints was to be expected as the Mirena LNG-IUS was not designed for
use in postmenopausal women. Transvaginal ultrasound measurement of the
uterus in postmenopausal women have shown a signicant reduction in size of
the uterus which becomes smaller with time due to the decrease in production
of endogenous estrogens.19 There is, therefore, a need to develop small intrauterine hormone-releasing systems which are compatible with the small uterine
cavity of postmenopausal women. The present study shows that insertion of
the Femilis Slim IUS is easy, even in a small atrophic uterus, causing little
discomfort, and is well tolerated. This translates into a low or zero expulsion
rate which may be explained by its optimal design characteristics. It is likely
that absence of bleeding and reduced or absent uterine contractility contributes
substantially to the good retention and tolerance of the IUS.
The primary role of progestogen postmenopausal hormone therapy is endometrial protection to prevent estrogen-induced hyperplasia. As the risk of
developing hyperplasia, due to unopposed estrogen stimulation, is substantial,
progestogens should be added to ERT in all postmenopausal women with an
intact uterus. Previous research with a frameless 14 g/d releasing LNG-IUS
indicate that locally applied levonorgestrel has a strong anti-proliferative effect
on the endometrium.20 In over one hundred postmenopausal women, using this
LNG-IUS for a period of three years, no hyperplasia was found. A similar low
incidence (0%) of hyperplasia in postmenopausal women receiving ERT and
a low-dose LNG-IUS has been observed in other studies.18 The present study
conrms these results. The study also found a good correlation between the
484
histological and ultrasound ndings. The mean endometrial thickness of 3.0

mm (range 2-5 mm) is in agreement with precision measurements and normal
range of endometrial thickness in postmenopausal women, evaluated by others
using transvaginal ultrasound.21
Conclusions
The results suggest that the small LNG-IUS is easy to insert in most postmenopausal women without anaesthesia and dilatation of the cervix. The simplicity
and safety of the procedure allows acquisition of skill in a minimum of time.
The IUS is well tolerated, well retained and effective in suppressing the endometrium during ERT. The small LNG-IUS, combined with parenteral ET
could, therefore, be a method of choice for endometrial suppression in women
using ERT with fundamental advantages to systemically applied progestogens
which have been the subject of considerable debate as reported in the recent
literature.
Acknowledgment
The authors are grateful to Prof. Dr. G. Van Maele, Dr. Sc. of the Department
of Medical Informatics and Statistics, University Hospital Gent, Belgium for
providing statistical data analysis for the study, Prof. Dr. E. Schacht, Dr. Sc.,
Polymer Research Group, Department of Chemistry, University of Ghent,
Belgium for conducting the in vitro release studies and Dr. Patrick Rowe, MD,
FRCOG, Reproductive Health Consultant, Vesancy, France, for reviewing this
paper.
485
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Writing Group for the Women's Health Initiative Investigators. Risks and Benets of Estrogen
Plus Progestin in Healthy Postmenopausal Women. JAMA 2002;288:321-33.
Million Women Study Collaborator. Breast cancer and hormone-replacement therapy in the
Million Women Study. The Lancet 2003;362:419-27.
Olsson HL, Ingvar C, Bladstrom A. Hormone replacement therapy containing progestins and
given continuously increases breast carcinoma risk in Sweden. Cancer 2003;97:1387-92.
Sarrel. PM. How Progestins Compromise the Cardioprotective Effects of Estrogens (Editorial)
Menopause 1995;2:187-90.
Hully SB, Grady D. The WHI Estrogen-Alone Trial Do Thing Look Any Better. JAMA
2004;291:1769-71.
Wildemeersch D, Schacht E. Endometrial suppression with a new frameless levonorgestrel
releasing intrauterine system in perimenopausal and postmenopausal women: a pilot study.
Maturitas 2000;36:63-68.
Mirena. Product Monograph 2002. Schering AG and Leiras Oy, Finland.
Wildemeersch D, Schacht E, Wildemeersch P. Performance and acceptability of intrauterine
release of levonorgestrel with a miniature delivery system for hormonal substitution therapy,
contraception and treatment in peri- and postmenopausal women. Maturitas 2002;44:237245.
Fleischer AC, Kalemeris GC, Machin JE, Entman SS, James AE. Sonographic depiction
of normal and abnormal endometrium with histopathologic correlation. J Ultrasound Med
1986;5:445-452.
Hendrickson MR and Kempson RL. Surgical pathology of the uterine corpus. In: Major problems in Pathology. Vol 12 Saunders WB. 1980 ISBN 0-7216-4644-1. Page 99-158.
SAS Institute Inc. SAS Users Guide: Basics, Version 5 Edition. Cary, NC: SAS Institute Inc.
1985.
Tietze C, Lewit S. Recommended procedures for the statistical evaluation of intrauterine contraception. Stud Fam Plann 1972;4:35-42.
Farley TMM. Life-table methods for contraceptive research. Statistics in Medicine 1986;
5:475-489.
Wildemeersch D, Janssens D, Weyers S. Continuous combined parenteral estrogen substitution and intrauterine progestogen delivery: the ideal HST combination? Maturitas 2005 (in
press).
Hulley S, Grady D, Bush T, Furberg C, Herrington D, Riggs B, Vittinghoff E for the Heart
and Estrogen/progestin Replacement Study (HERS) Research Group. Randomized Trial of
Estrogen Plus Progestin for Secondary Prevention of Coronary Heart Disease in Postmenopausal
Women. JAMA 1998;280:605-613.
Boon J. The LNG intrauterine system as part of continuous combined HRT in perimenopausal
women. Dissertation, University Utrecht, Faculty of Medicine, The Netherlands, 1998.
Birkhaser MH. New routes of HRT administration. Int J Fert 1998;43:206-7.
Riphagen FE. Intrauterine application of progestins in hormone replacement therapy: a review.
Climacteric 2000;3:199-211.
Merz E, Miric-Tesanic D, Bahlmann F, Weber G, Wellek S. Sonographic size of uterus and
ovaries in pre-and postmenopausal women. Ultrasound Obstet Gynecol 1996;7:38-42.
Wildemeersch D, Schacht E, Wildemeersch P, Callewaert K, Pylyser K, De Wever N.
Endometrial safety with a low-dose intrauterine levonorgestrel-releasing system after 3 yeras
of estrogen substitution therapy. Maturitas 2004;48:65-70.
Warming L, Ravn P, Skouby S, Christiansen C. Ultrasound Obstet Gynecol 2002;20:492-5.
486
Gender-based Medicine
How Sex Impacts Normal Human
Function And the Experience of Disease
Professor of Clinical Medicine,
Columbia University College of Physicians & Surgeons, New York
Background
Three important principles were operative at the turn of the last century which
impacted on our view and our practice of medicine. They were as follows:
The average life expectancy of human beings was 48 years of age. Women
did not usually live to experience menopause much less any of the plagues
of older life like osteoporosis, arthritis, coronary artery disease and dementia.
With the exception of women born into wealth families, the socio-economic
condition of women was such that they had very little direct control over
the world around them; they had to depend on alliances by marriage or by
sexual liaison with powerful men. As a result of their lack of political or
economic power, they were considered less valuable than men. Thus, their
concerns and the attention paid to them were of less interest than those of
men.
The physician had little power to prevent illness and, once it was established, to intervene directly to ameliorate or cure the disease. On the other
hand, he was an expert in diagnosing and in predicting the natural course
of illness; his ability to prepare the sick patient and the family for what was
to come surrounded him with an aura of magical powers and contributed to
the larger-than-life image of the physician in the publics eyes.
World War II changed all that: men were away in great enough numbers and
for a long enough time to allow women to have access for the rst time to
487
educational and professional opportunities to which they had never been admitted before. The feminist movement was an inevitable consequence of their
experience during the war; women would never again relinquish the power
to make their own decisions and to make their own money. The second great
societal change was in the power of the physician himself; during this great
conict the rst antibiotics, sulfa and penicillin, were discovered and used
against infection. We learned that a virus caused hepatitis in the course of treating wounded soldiers with human serum. We perfected our techniques of anesthetizing patients so that more complicated surgery could be performed. The
nascent discipline of plastic surgery and the repair of traumatic injuries, born
on the battleelds of the rst World War, was further perfected in the second.
Americans exited from World War II with the conviction that science, although
it admittedly could not guarantee immortality, had the potential to dramatically
improve - and prolong - human life. The National Institutes of Health was the
second inevitable phenomenon to result from the war, and over the ensuing
decades, rapidly developed in one of the most important accomplishments of
American culture and civilization.
The years between 1950 and 1992 saw, then, the emergence of womens
awareness of and determination to increase their political and personal power.
They prevailed on the United States Public Health Service to survey what physicians knew about the unique aspects of their normal physiology and health;
the report of the Task Force devoted answering that question was issued in 1988
and established the fact that apart from reproductive physiology and illness, we
knew virtually knew nothing about women. Indeed, virtually all of our information about human function and its vulnerability to disease had been generated
from studies on men. Stung into action by the report, the National Institutes
of Health mandated the inclusion of women in federally funded clinical studies wherever appropriate. Congress passed the Womens Health Equity Acts
which in 1992 gave legislative authority to the recently established Ofce of
Womens Health Research at the National Institutes of Health. Five years later,
the Federal Drug Administration (FDA) mandated the inclusion of women in
clinical trials of new drugs and interventions wherever appropriate, reversing
its policy of the exclusion of women from such studies which it had adopted in
response to the thalidomide disaster in the 1970s.
The inuence of women grew and continued to impact the way physicians
viewed the female patient and how clinical investigation should be conducted.
In 1994, the Institute of Medicine released its landmark monograph, Women
and Health Research1 and pointed out that fully 2/3 of all clinical research had
been done exclusively on male subjects. The most important example of this
488
was in the eld of cardiovascular medicine, given the fact that cardiovascular
disease is by far the most likely cause of death in women and kills more annually than all cancers combined. The 1990s saw a burgeoning interest in and
increase in studies of the female subject, most prominently and most effectively
deployed in the discipline of cardiovascular medicine. The science of the differences between men and women has expanded to the point where the rst
textbook on the subject has just been published.2 We are now refashioning our
essentially male models of normal human function and rening, correcting and
expanding our understanding of the pathophysiology of disease. Over the past
decade, the discipline of womens health has morphed into the new discipline
of gender-specic medicine, which is the science of the differences in men and
womens normal function and in their experience of disease.
Gender or Sex : What Are We Talking About?

Biological sex is the fact of being male or female. The process of imprinting
and hormonal factors determine the developmental sequence and characteristics of the biological systems of the individual. Gender is a more complex and
amorphous term. People are assigned value and roles depending on their sex by
the societies in which they live. As a consequence, their risk factors for illness,
their control over available resources, their ability to make informed decisions
and achieve adequate education and their dened responsibilities and reward
systems are all affected. These are important determinants of health which
impact the quality and function of biological systems. We cannot always know
what about an individual is the consequence of sex or gender; it is not always
possible to separate one from the other.
What Systems Are Different Between Men and Women?

The following facts will be discussed and elaborated upon during the course
of this lecture:
The brain: the brain is sexed in utero and as a result there are hard-wired
differences in the anatomy and neurotransmitters in the brain between the
sexes. There are also differences in the relative intellectual skills of men
and women, in spite of the protests about the studies that have dened these
differences. Differences in pain discrimination, depression, and addiction
are also dened by sex/gender.
Drug metabolism: the physiology of drug absorption, metabolism by the
P450 system, the impact of hormones on drug metabolism all inuence men
489
and womens gender-specic response to medications.

Intestinal tract: differences in the ow rate and composition of saliva, the
action of the enteric nervous system, composition of bile and the impact
of its breakdown products on the colon, the impact of leptin and in the
pathophysiology of eating disorders all exist as a function of biological
sex/gender.
Cardiovascular system: the composition and function of the normal heart
is signicantly different between men and women. Hypertension, the impact on cardiovascular system and its treatment all have different features,
depending on the sex of the patient.
Immune system: women have a more vigorous immune system than men
and are more likely to mount a defense against invaders that uses inammation as a defense. The reasons for the relatively greater incidence of autoimmune disease in females is not due to hormones; there are important
alternate theories that are more credible.
Skeleton: the anatomy and metabolism of the skeleton is sex-specic in
several respects. Osteoporosis and the pathophysiology of bone metastases
are both impacted by gender.
Pain: men and women experience pain differently, partially as a result of
social conditioning but also by virtue of anatomic and functional differences
in the nervous system. Analgesia and the physiological manifestations of the
experience of pain also are gender-specic.
Sexual dysfunction: important new differences in the process of sexual
arousal, libido, and sexual dysfunction are being iterated in the current literature and will have an important impact on patient care.
The lung: there are differences in the pathophysiology of addiction to
nicotine chronic obstructive lung disease and lung cancer between men and
women. Asthma has important characteristics in females that make it a more
lethal illness for them.
What Does the Future Hold

Studying women and comparing the ndings to those in men is not simply a
feminist or political issue; it is an intellectual imperative. The science is not
only tremendously exciting and revelatory of completely unexpected differences between the sexes; it promises more focused and effective prevention
and treatment of disease.
490
(Endnotes)
Mastroianni AC, Faden R and Federman D, editors. Women and Health Research. National
Academy Press. Washington, D.C. 1994. (Two volumes).
2
Legato MJ, editor. The Principles of Gender-Specic Medicine. Academic Press. New York.
2004. (Two volumes).
1
491
Sleep disturbanceswhy women are

different from men?
Y. Dagan
Adults spend one third of the day sleeping. Surprisingly, physicians pay very
limited attention to this part of their patient's life. This chapter will shed some
light on normal sleep, sleep disorders and especially women's sleep disorders.
At the thirties of the 20th century a German physician came out with the
discovery of electroencephalography (EEG). This new ability to monitor brain
activity opened the gate for sleep research and sleep medicine. Until the discovery of EEG, sleep was considered in many cultures a temporary death.
In the last 70 years since this gate was opened a vast knowledge about sleep
physiology and pathology was developed.
Sleep is dened mainly by three measurements: EEG, EOG [electrooculography] and EMG [electromyography ]1. Normal sleep consists of ve cycles
of 90 minutes and each cycle has ve stages. Stage I is a very supercial and
brief sleep period at the transition from wake to sleep. From Stage II to IV sleep
becomes deeper, which is signied by slower EEG waves and eye movements
and relaxation of body muscles.
The fth stage is quite peculiar and distinct from previous stages. In this
period of sleep, many physiological functions (such as heart rate, breathing,
brain activity and eye movements) become aroused, whereas skeleton muscle
tonus is largely lost. Penile erections in males occur during this stage. It is also
characterized by intensive dreaming. Due to these surprising features, the fth
sleep stage received several names, among which are REM sleep (for rapid eye
movements present in this stage), dream sleep and paradoxical sleep. There is
no gender difference in sleep architecture.2
Sleep is also a part of a chronobiological daily cycle called the circadian
492
rhythm3. Human beings sleep at night and are awake during the day. Thus,
adults spend 6-8 hours in sleep and the rest of the day they are awake.
Sleep disorders
Insomnia
Insomnia is dened as difculties in initiating and/ or maintaining sleep.
Insomnia is a highly prevalent disorder that can lead to substantial impairments in quality of life and functional capacity. It is twice more frequent
among women than in men4. The reason for it is unclear. Insomnia is actually
a hyperarousal disorder throughout the 24 hours interfering with the natural
chronobiological process of relaxation towards sleep. Thus, people suffering of
insomnia are tired during the day, but do not fall asleep due to their permanent
arousal. The causes of the ongoing alertness can be primarily psychological as
part of anxiety or depressive mood or even daily mental exhaustion and bother.
Physical conditions like hyperthyroidism and several drugs that promote hyper
alertness can also provoke insomnia. Alternatively, environmental factors such
as external noise, baby cry or uncomfortable sleeping conditions can give rise
to this sleep disorder. In these cases people will exhibit sleepiness during the
day.
Three phenomena of endocrine changes that are unique for women are
associated with insomnia: PMS (pre-menstrual syndrome), pregnancy and
menopause.
PMS: In PMS, mood changes, especially depression, are frequently accompanied by insomnia5,6. Women who benet for their PMS symptoms by contraceptives and sometimes anti depressive drugs [SSRI ] usually suffer less
from insomnia7. The long-term efcacy and safety of the newer benzodiazepine
receptor agonists (BZRAs) for insomnia, taken nightly or episodically, can treat
successfully PMS-related insomnia.
Pregnancy: During pregnancy and after childbirth, profound uctuations in
steroid and hypothalamic-pituitary-adrenal axis hormones can produce signicant sleep disruption8. Sleeping pills during pregnancy and lactation period are
not recommended.
Menopause: It is believed that night sweats, which result from hormonal
changes characteristic of menopause, lead to increase in arousals during
sleep. However, a recent well-designed study, in which hot ashes were
493
measured by the sternal skin conductance technique, failed to nd any

relationship between hot ashes and insomnia10. Besides hormonal changes,
psychological distress can also appear in peri-menopausal state and promote
insomnia11. The rst line treatment for menopausal insomnia is HRT. Women
who cannot use HRT and suffer from insomnia and/ or hot ashes might
benet from SSRI drugs, which are efcient in treating the emotional tension and hot ashes as well as insomnia12. Further, a single study reports
signicantly lower melatonin levels in postmenopausal obese females with
insomnia compared to controls. Since previous studies described lower melatonin levels in postmenopausal than in premenopausal women, the indication
of melatonin therapy for sleep disorders in menopause, can be handled more
generously13
Snoring and sleep breathing disorders
Snoring is considered a masculine trait. In reality, 50% of men older than 35
years snore, but 25% of women at the same age snore as loud as men do. Fifteen
percent of the snoring women have Obstructive Sleep Apnea Syndrome [ OSAS
]2,14. OSAS patients cease breathing for at least ten seconds ve times in an hour
or more. Most apneas are followed by arousal and oxygen desaturation. The
pathophysiology of OSAS is a combination of narrow larynx pharynx and a
reduction in tissue tension at this area. Most of OSAS patients are obese. The
main complaint of patients with OSAS is a feeling of non restorative sleep
and tiredness during the day. It is accompanied many times by depressive-like
symptoms: concentration and memory deterioration, bad mood, unhedonia and
lack of sexual desire. OSAS is a risk factor for hypertension, coronary heart
disease and CVA15. The best treatment for snoring and OSAS is weight reduction. Surgical E.N.T procedures have only 50% of success for snoring and mild
sleep apnea. The treatment of choice for OSAS patients is Nasal Continuous
Positive Air Pressure [ nCPAP ] device. It has 100% success in solving the
problem, but it is difcult to convince patients, especially women, to use it.
CPAP treatment improves fatigue and other symptoms of OSAS and reduces
the risk for cardio-vascular diseases16.
Pregnancy. Pregnancy, especially its third trimester, is associated with onset
of snoring in some women. A well-designed study of 502 pregnant women
in Sweden found that, whereas 4% of the women snored at the beginning
of pregnancy, during the third trimester the proportion of snoring women
increased to 23%. When compared to non-snorers, snorers in the third trimester showed signicantly higher prevalence of hypertension, preeclampsia
494
and fetus growth retardation17. These results are different from the data of a
previous study of 350 pregnant women that were compared to non pregnant.
Pregnant women reported higher frequency of snoring, but no fetal growth
retardation was observed18. In conclusion, any condition that causes maternal
hypoxemia will be worsened during sleep, particularly in the supine position. Although high circulating levels of progesterone increase respiratory
drive during sleep, in at least some women this protective mechanism is
insufcient to prevent sleep-disordered breathing and hypoxemia. The true
incidence of sleep-disordered breathing during pregnancy remains unknown.
Although many women report sleep disturbance during pregnancy, those
with severe snoring, observed irregular breathing with sleep, or excessive
daytime somnolence should be referred for clinical polysomnography. With
few data thus far available, nasal CPAP would appear to be the treatment
of choice19. Given the possible consequences of sleep apnea for fetal outcome, any signicant sleep-disordered breathing is probably an indication
for treatment20.
A study of 131 women in their ninth month of pregnancy monitored their
sleep duration by actigraphic monitoring found that, controlling for infant birth
weight, women who slept less than 6 hours at night had longer labors and were
4.5 times more likely to have cesarean deliveries. Women with severely disrupted sleep had longer labors and were 5.2 times more likely to have cesarean
deliveries21.
Menopause: The frequency of snoring and OSAS in menopausal women
succeeds that of men unless they have HRT2. This nding suggests that female hormones can prevent snoring and OSAS in pre-menopausal women.
The mechanism by which this effect is achieved remains to be elucidated.
Menopausal women without HRT should be asked about snoring and fatigue and further diagnosed with OSAS, to prevent the negative outcomes of
OSAS.
Conclusions
Good sleep is essential for health. Sleep disorders can occur in women as a
consequence of endocrinological phenomena unique to them. These disorders
are associated with psychological and physical distress of the female patient.
Sleep disorders are frequently overlooked by physicians, thus it is very important to raise the awareness of gynecologists to women sleep disorders.
495
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Lee-Chiong TL, Jr. Sleep and sleep disorders: an overview. Med Clin North Am 2004;88(3):
xi-xiv.
Collop NA, Adkins D, Phillips BA. Gender differences in sleep and sleep-disordered breathing.
Clin Chest Med 2004;25(2):257-68.
Dagan Y. Circadian rhythm sleep disorders (CRSD). Sleep Med Rev 2002;6(1):45-54.
Krystal AD. Insomnia in women. Clin Cornerstone 2003;5(3):41-50.
Moline ML, Broch L, Zak R, Gross V. Sleep in women across the life cycle from adulthood
through menopause. Sleep Med Rev 2003;7(2):155-77.
Chuong CJ, Kim SR, Taskin O, Karacan I. Sleep pattern changes in menstrual cycles of women
with premenstrual syndrome: a preliminary study. Am J Obstet Gynecol 1997;177(3):554-8.
Miller EH. Women and insomnia. Clin Cornerstone 2004;6 Suppl 1B:S8-18.
Sahota PK, Jain SS, Dhand R. Sleep disorders in pregnancy. Curr Opin Pulm Med
2003;9(6):477-83.
Landis CA, Moe KE. Sleep and menopause. Nurs Clin North Am 2004;39(1):97-115.
Moe KE. Hot ashes and sleep in women. Sleep Med Rev 2004;8(6):487-97.
Kloss JD, Tweedy K, Gilrain K. Psychological factors associated with sleep disturbance among
perimenopausal women. Behav Sleep Med 2004;2(4):177-90.
Gambacciani M, Ciaponi M, Cappagli B, et al. Effects of low-dose, continuous combined
hormone replacement therapy on sleep in symptomatic postmenopausal women. Maturitas
2005;50(2):91-7.
Blaicher W, Speck E, Imhof MH, et al. Melatonin in postmenopausal females. Arch Gynecol
Obstet 2000;263(3):116-8.
Jordan AS, McEvoy RD. Gender differences in sleep apnea: epidemiology, clinical presentation and pathogenic mechanisms. Sleep Med Rev 2003;7(5):377-89.
Kiely JL, McNicholas WT. Cardiovascular risk factors in patients with obstructive sleep apnoea syndrome. Eur Respir J 2000;16(1):128-33.
McNicholas WT. Follow-up and outcomes of nasal CPAP therapy in patients with sleep apnea
syndrome. Monaldi Arch Chest Dis 2001;56(6):535-9.
Franklin KA, Holmgren PA, Jonsson F, Poromaa N, Stenlund H, Svanborg E. Snoring, pregnancy-induced hypertension, and growth retardation of the fetus. Chest 2000;117(1):137-41.
Loube DI, Poceta JS, Morales MC, Peacock MD, Mitler MM. Self-reported snoring in pregnancy. Association with fetal outcome. Chest 1996;109(4):885-9.
Guilleminault C, Kreutzer M, Chang JL. Pregnancy, sleep disordered breathing and treatment
with nasal continuous positive airway pressure. Sleep Med 2004;5(1):43-51.
Edwards N, Middleton PG, Blyton DM, Sullivan CE. Sleep disordered breathing and pregnancy. Thorax 2002;57(6):555-8.
Lee KA, Gay CL. Sleep in late pregnancy predicts length of labor and type of delivery. Am J
Obstet Gynecol 2004;191(6):2041-6.
496
The Impact of Gender On the

Experience of Coronary Artery Disease
Columbia University College of Physicians & Surgeons Founder/Director
Partnership for Gender-Specic Medicine at Columbia
Introduction
Coronary artery disease (CAD) is an important entity for both sexes, but what
is unappreciated is the lethal nature of the illness for women. Most women
fear breast cancer as the disease most likely to kill them. In fact, CAD kills
233,000 American women annually while all cancers combined claim 246,000.
Between ages 45 and 60, 1 in 9 women have the disease; after 60 years of age,
1 in 3 women have the disease. Twenty-four percent of all deaths in American
women is due to coronary artery disease. Not only is the disease important for
women, it is more dangerous for them than for men: women younger than 75
have twice the mortality as same aged men with the disease.1
The clinical presentation of CAD is signicantly different in men and
women: womens symptoms appear a decade later than those of men, in whom
the disease becomes clinically apparent at about age 35. Women present more
commonly with unstable angina, while their male counterparts are diagnosed
rst because of an acute myocardial infarction (AMI). By the time there is an
episode, however, including AMI, women has less extensive coronary arteriosclerosis and develop smaller infarcts than men.
A careful study of the available data currently available about women and
coronary artery disease revealed that much of the research on this entity has
excluded women or included them only in limited numbers. Of those that included women, only 20% of articles reviewed provided separate ndings on
women, even when women were included in the study. 2
497
Risk Factors
Three risk factors for CAD cannot be changed: age, family history and menopausal state.
1. Age
Women are 10 years older than men at the time of the initial manifestation of
the disease and 20 years older at the time of their rst myocardial infarction.
There is a 40 fold increase in CAD in women between the ages of 75 and 84
and by age 80, the incidence is equal in the two sexes. The increase in incidence
is gradual, with no abrupt acceleration at the time of menopause.
2. Family History
Having a parent with a myocardial infarction before the age of 60 increases
womens RR of an MI to 2.8 and the RR of fatal CAD to 5.0.3 The death of a
rst degree relative of coronary artery disease before the age of 55 signicantly
increases the risk for women, particularly if the decedent is a female.
3. Menopause
Menopause has been considered an endocrinopathy for which estrogen is
the cure. In a separate lecture, I will discuss the status of HT with particular
reference to the primary and secondary prevention of CAD in 2005. Since
the advent of the important observational trials, 4,5,6 the role of HT in women
to prevent CAD and to ameliorate established illness has undergone signicant rethinking. We are still sorting through data to decide when and how
to use HT in the menopausal patient at risk. It is unlikely that we can safely
offer HT to the patient with established coronary artery disease, however,
particularly if she is over 60. In general, if HT is to be used, ve guidelines
seem appropriate. They are as follows:
Start HT as soon after menopause as is feasible.
Communicate to the patient that after 5 years of use, the risk for breast
cancer increases slightly.
Assess the vulnerable patient for a hypercoaguable state
Do not use HT in the patient with established CAD except for a compelling
reason, particularly if she is over 60 years of age.
Follow the patient closely in the rst year of use, which is the time period
in which most untoward events will cluster.
Four risk factors for CAD can be treated. They are hypertension, diabetes,
dyslipidemia and obesity.
498
4. Hypertension
The optimal value for blood pressure has been lowered to 130/80 mm Hg. High
normal blood pressure (130-139/85-89 increases the RR for CVD to 2.5 for
women and 1.6 for men. 7 Isolated systolic hypertension (loss of elasticity in
the large arteries) affects 37% of women aged 55 and older. Treatment of these
patients reduces the incidence of stroke by 30% and the incidence of CAD by
32%.8 Treatment of severe hypertension benets both sexes alike.9
5. Diabetes
Diabetes is a particularly important risk factor for women; it increases risk
5-7 fold in women compared with 2-4 fold increase in men for CAD. 10The
risk for a fatal MI increases sharply for women as the duration of diabetes
increases: the RR is 16-25 for diabetes of over 25 years duration. Fifty percent
of the increased risk is due to dyslipidemia, particularly a low HDL in diabetic
women.11 Diabetes may impair estrogen binding and raise testosterone levels,
negating the advantage of the premenopausal state in women. Diabetic women
who smoke have an additional 3 fold increase in risk. 12 Unfortunately, there is
no evidence that tight glycemic control is effective in risk reduction; the best
treatment for the diabetic patient is to modify other risk factors such as obesity,
smoking, hypertension and the dyslipidemia that all act synergistically with
diabetes to increase CAD risk.13
6. Dyslipidemia
Total cholesterol increases with age and plateaus in men at age 45-50. In
women, the increase continues until the age of 60-65.14 For women under 65,
a total cholesterol greater than 240 mg/dL is associated with a RR for CAD
of 2.44; an LDL mg/dL greater than 160 is associated with a RR of 3.27.
For women over 60, high levels of TC and LDL had a much lower RR: 1.12
and 1.13 respectively.15 HDL is a particularly important entity for women:
for a value less than 50 mg/dL, risk doubles After age 65, the risk is higher
after age 65 (RR 1.75) compared with that for men (RR 1.09). An important
paper by Gong et al in 2003 showed that female HDL-associated estradiol
stimulates NO release by the endothelial cell in both the premenopausal and
postmenopausal woman on HT. 16 This work provides the rst evidence for
why HDL in the premenopausal female protects against ischemic heart disease.
Male-derived HDL had no such effect unless it was enriched with estrogen.
Only estrogen-associated HDL stimulated eNOS. The mechanism of action of
this HDL bound estrogen is not transcriptional; isolated membrane caveolae
and isolated plasma membranes shoed the effect of HDL-estrogen on eNOS
499
stimulation. Hypertriglyceridemia produces a RR of 4.7 for women and 2.1

in men for CAD.
7. Obesity and the WHR
Being 30% over ideal body weight increases the RR for CAD to 3.3. for women. An increased waist-hip ratio (WHR) (over 0.9 for men and 0.8 for women)
predicts elevated triglyceride and low HDL levels. Central obesity correlates
with hypertension and in men with insulin resistance. WHR is a more accurate
predictor of risk than body mass index (BMI) or total weight and explains the
gender difference in the incidence of MI. Low BMI (<21) is protective against
the development of CAD. Obesity increases risk because of its association
with hypertension, dyslipidemia, glucose intolerance and insulin resistance. 17
Obesity is also associated with an elevation in thrombotic markers like brinogen and plasminogen activator inhibitor-1.18 as well as inammatory markers
(interleukin 6 and C-reactive protein).19 Liposuction does not reduce the risk
for CAD; it removes subcutaneous abdominal fat without altering visceral fat
mass, the size of remaining fat cells, intramyocellular fat or intrahepatic fat.20
8. Lifestyle and Risk for CAD
Four lifestyle factors: exercise, smoking, stress and alcohol all bear on the risk
for CAD.
Manson et al in a study of over 73,000 women that walking and vigorous
exercise were associated with similar risk reductions for CAD and presented
the rst quantication of risk of a sedentary life style.21Women who spent
12-15 hours a day lying down or sleeping and women who spent 16 hours/day
sitting had a RR of 1.38 for CAD.
Smoking is the leading preventable cause of death in both sexes; it is one
of strongest predictors of premature CAD and premature death from CAD in
women. 40% of all deaths from CAD are directly attributable to smoking. The
Nurses study showed that the effect is dose dependent, and even 1-4 cigarettes
a day double vulnerability to CAD. There is a gender-difference in the success
of the nicotine patch: women who benet most are those with a variant gene
that makes addiction to nicotine stronger. There was no difference in response
to the patch in men with the variant gene. 22
Men have more pronounced cardiovascular reactivity to stress than women.
Oxytocin, the release of which is enhanced by estrogen, promotes the tend and
befriend reex in women which decreases blood pressure and increases their
pain threshold. Women are more likely to repress hostility, however, than men
and to be angry longer.23 Finally, the prevalence of depression is three times
500
higher in patients with CAD than that of other persons. 24

The Nurses Health Study showed that 10-15 gm alcohol/day reduces risk
by 40% over a four year follow-up period.25Fifty percent of risk reduction is
due to changes in HDL levels.26Other benecial effects include an increase
In tissue-type plasminogen activator and reduced platelet aggregation. With
higher levels of consumption, women are more susceptible to alcoholic liver
disease and alcoholic cardiomypathy compared with men.
Symptoms
Chest pain in women is a problem; the clinical dilemma is whether it is true
angina or non-coronary pain. Myocardial infarction is the initial manifestation
in 39% of men and 31% of women with CAD. MI is unrecognized in 35% of
women and 27% of men. In 15-20% of women, acute myocardial infarction
presents as epigastric or back pain, dyspnea, nausea and diaphoresis.
Testing
Exercise radionuclide angiography is limited by its insensitivity for estimating peak ejection fraction in women. The stress test has a 54% positive rate
in women and there is signicantly less specicity (36%) in the presence of
an abnormal resting EKG in women compared with men (54%). The Stressechocardiogram, therefore, has particular value for women. There is no gender
difference in the specicity and sensitivity of thallium-210 scintigraphy after
correction for breast artifact in women.
The Myocardial Infarction

Women have a higher overall mortality from their rst myocardial infarction.
They are twice as likely as men to die in the rst few weeks after their MI: 39%
of women c/w 31% of men die in year one following the MI. Twenty percent
of women c/w 15% of men will have a second attack in 4 years.
Gender and Treatment:

Is There Gender Prejudice in the Care of the Female Patient With CAD?
Women are still less likely to be offered therapeutic cardiac procedures than
men.27 The reasons are unknown. They are less likely than men to have a
revascularization process in the year after cardiac catheterization; this is related
501
to a difference in the extent of the disease. Women are less likely to receive
beta blockers, cholesterol lowering drugs and aspirin after having sustained an
acute MI compared with men.
Women benet from early invasive management with acute coronary syndromes: the TACTIS-TIMI randomized trial looked at an early invasive strategy
of cardiac catheterization 4-48 hours after the acute MI with revascularization
when appropriate.28 This was compared with conservative management. Men
and women had a similar benet from early invasive strategy. There was a
28% odds reduction in the primary end point in spite of important differences
in the baseline characteristics and presentations of men and women. (Women
were older, had more hypertension but had less previous MIs, CABG, elevated
cardiac markers and in general had less severe disease (17% of women had
critical lesions compared with 9% of men).
The National Heart Lung and Blood experience with women and percutaneous transluminal coronary angioplasty (PTCA) showed that even though
women were older by 4.5 years and sicker than the men studied, 95.7% of them
survived the procedure.29 Womens mortality was 2.6% compared with 0.3%
for men, however. Women were less likely than men to restenose. A later study
in Northern New England of over 33,000 patients, about 1/3 of whom were
women showed that over a 5 year period from1994 to 1999, stent use increased
from 4 to 85%.30 The clinical success rates of stenting increased and that of
emergency coronary artery bypass grafting (CABG) decreased signicantly.
The rates for any bypass surgery declined by 72% and the mortality was similar
in the two sexes, although on the whole women were 5-6 years older than the
men in the study.
Eysmann et al did a meta-analysis of CABG and showed that womens RR
of death was 2.19 higher than that of men. The difference was due to greater
severity of disease and smaller vessel size. The authors pointed out that women
had less relief of symptoms but a similar 5-10 year survival rates compared
with men. These data are important to know, since in three separate studies,
men were referred more frequently than men for CABG.31,32,33
502
(Endnotes)
1
Vaccarino V et al. Arch Intern Med.158:2054. 1998.

Grady D et al. Report of the UCSF/Stanford Evidence-based Practice Center, July, 2003. AHRQ
Publication No 03-0035.
3
Colditz GA et al. Am J Epidemiol.123:48.1986.
4
Hulley S. et al. JAMA 280:605.1998
5
Manson et al, N Engl J Med.349:523.2003
6
Herrington DM N Engl J Med.343:522.2000
7
Vasan RS et al. N Engl J Med.345:1291.2001
8
Stasson JA et al. Lancet.350:757.1997.
9
Gueyfer F et a. Ann Intern Med.126:761.1997.
10
Perthman JA et al. Am J Obstet Gynecol.158.1568.1988.
11
Manson JE. Arch Intern Med.1511.1568.1991.
12
Vital Statistics. Alexandria VA. ADA.1991.
13
Manson JE et al. Arch Intern Med.151:1141.1991.
14
Jousilahi P et al. Ann Intern Med.124:713.1996.
15
Monolio TA et al. Ann Epidemiol.2:161.1992.
16
Gong M et al. J Clin Invest.111:1579.2003.
17
Rexrode KM et al. Curr Opin Cardiol.290:495.1996.
18
Duncan BB et al. Obes Res.8:279.2000
19
Visser M et al. JAMA 272:2131.1999.
20
Klein S et al. N Eng J Med.350:2549.2003.
21
Manson JE et al. N Eng J Med.347:716.2002.
22
Yudkin P. BMJ. March 20, 2004.
23
Rozanski et al. Circulation. 99:2192.1999.
24
Thomas SP. Women and Anger. NY Springer. 1993.
25
Fuchs et al. N Engl J Med. 332:1245.1995.
26
Sess HD et al. Curr Opi Nephrol. Hypertens.8:353.1999.
27
Ghali WA Ann Intern Med.136:723.2002.
28
Glaser R et al. JAMA. 288:3124.2002.
29
Kelsey Sf et al. Circulation.87:720.1993.
30
Malenka DJ et al. J Am Coll Cardiol.40:2092.2002.
31
Ayanian JA. New Engl J Med.124:221.1991
32
Davis KBJ Am J Cardiol.25.1000.1995.
33
Bickel NA Ann Intern Med.116.791.1992.
2
503
Urogynecology
Can SUI be treated medically?
How to treat
A. Liapis
Associate Professor of Obstetric & Gynecology . Specialist in Urogynecology.
Aretaieion Hospital, Athens, Greece
There are 3 types of treatment options available for women with SUI: conservative, pharmacological and surgical treatment.
Conservative treatment options include:
Lifestyle interventions
Pelvic oor muscle training (PFMT)
Other treatments
Conservative therapy is considered the rst-line treatment for SUI, unless
the patients condition is very severe. There are only limited data available
which adequately studied the outcomes of conservative treatments in a larger
number of women. Data comparison is difcult due to lack of consistency in
the selection and reporting of outcome measures.
Lifestyle interventions
In this category belong: weight-loss, stop smoking and uid management which
are recommended as supportive measures in order to prevent deterioration of
SUI.
According to the most studies that assessed the effect of these lifestyle changes
on SUI did not actually studied the effect of applying or removing the behaviour in question, but did only report association (1).
504
Pelvic oor muscle training

Pelvic oor muscle training remains the mainstay of therapy, especially for
women with stress urinary incontinence. The purpose of pelvic oor muscle
exercises is to increase the womans awareness of pelvic muscle function and to
strengthen the voluntary muscles to withstand increases in abdominal pressure.
Women without prolapse who follow an intensive exercise regimen led by a
physiotherapist or a nurse, report signicant benet from pelvic oor muscle
exercises.
Moreover at least 70% of women who have an initial successful outcome
from PFMT will report a durable benet four or more years after cessation of
formal exercise training (2). Pelvic oor muscle exercises have been compared
to vaginal cones, biofeedback bladder training and electrical stimulation (2).
The combination therapy of PFMT with the above methods seems to have
no additional benet than the PFMT alone but might be useful for some women
to learn how to perform a correct PFM contraction.
Treatment such as electromagnetic stimulation and weighted vaginal cones
can also be used individually to improve the function of the PFM (1).
Compliance seems to be low and adverse effects such as bleeding and discomfort have been reported (2).
Pharmacological treatment
The pharmacological treatment of stress incontinence aims at increasing intraurethral pressure by increasing tone in the urethral smooth muscle or by affecting tone of the striated muscles in the urethra and pelvic oor. Although several
drugs may contribute to such an increase in intraurethral pressure, including
-AR antagonists and imipramine, only a-AR agonists and estrogens alone or
together, have been more widely used (3, 4). At present, there is no globally
developed or widely approved pharmacological treatment available to treat SUI
in women. There is, however, limited or no evidence on the efcacy of these
drugs and some are associated with signicant side-effects.
a1-Adrenoceptor agonists
The a1A-subtype is involved in urethral smooth muscle contraction.
It is hypothesized that a1-AR agonists stimulate a1A-ARs located in the bladder neck and in the urethral smooth muscle, which induces contraction of the
smooth muscle both during bladder lling and voiding. This action increases
505
urethral closure pressure and prevents urine loss (3). No drug with appropriate
sub-type selectivity is currently available, and the role of a-AR agonists in
the treatment of stress incontinence has yet to be established. Outcomes of a
recent Cochrane review suggest there is only weak evidence that the use of
a1-AR agonists is better than placebo in the treatment of SUI (4) and they may
cause some side effects such as: headache, cold extremities, increase blood
pressure arrhythmias and thats why some drug have been removed from the
market (5).
a-AR agonists has been used in combination with estrogens and with other
nonsurgical treatments of stress incontinence such as pelvic oor exercises and
electrical stimulation and can be used in women with mild stress incontinence
or in those not suitable for surgery.
In carefully selected cases, selective a-AR agonists may be used on an on
demand basis in certain situations known to provoke leakage (5).
Tricyclic antidepressants
Tricyclic antidepressants (e.g. imipramine) are sometimes used for the treatment of SUI.
Imipramine, among several other pharmacological effects, inhibits the reuptake of noradrenaline and serotonin in adrenergic nerve ending. In the urethrea, this can be expected to enhance the contractile effects of noradrenaline
on urethral smooth muscle. Theoretically, such an action may also inuence
the striated muscles in the urethra and pelvic oor by effects at the spinal cord
level (3,6) (Onufs nucleus).
Gilia et al (7) reported in an open study on 30 women with stress incontinence
that imipramine 75mg daily, produced subjective continence in 21 patients and
increased mean maximal urethral closure pressure from 38 to 48 cmH2O.
Lin et al (8) assessed the efcacy of impipramine (25mg imipramine three
times a day for 3 months) as a treatment for SUI. A urodynamic study and after
treatment had shown control of SUI at 60% of the patients. No RCTs on the
effects of imipramine seem to be available.
Oestrogens
The role of oestrogens in the treatment of stress incontinence has been controversial even though there are a number of reported studies (9). Some have
given promising results but this may be because they were observational, mot
randomized, blinded or controlled.
506
The situation is further complicated by the fact that a number of difference

types of oestrogens have been used with varying doses, routes of administration
and duration of treatment.
During the menstrual cycle and in pregnancy the circulating level of oestrogens and progesterone uctuate, which can inuence the prevalence of urinary
symptoms. Furthermore, the menopause and subsequent estrogen deciency
might be an aetiological factor in the development of SUI (9).
Jackson et al (10) treated 57 postmenopausal women with SUI with estradiol
valerate 2mg or placebo daily for 6 months. There are no signicant change
in objective outcome measures although both the active and placebo group
reported subjective benet.
There have been two meta-analyses performed which have helped to clarify
the situation.
In the rst, a report of 166 articles identies which were published in English
between 1969 and 1992, only 6 were controlled trials and 17 uncontrolled
series. The results showed that there was a signicant subjective improvement
for all patients and those with SUI (11).
In the second meta-analysis, Sultana and Walter (12) reviewed 8 controlled
and 14 uncontrolled prospective trials and included all types of estrogen treatment. They also found that estrogen therapy was not an efcacious treatment
of SUI but may be useful for the often associated symptoms of urgency and
frequency.
Estrogens when given alone, therefore, does not appear to be an effective
treatment for stress incontinence. However, several studies have shown that
it may have a role in combination with other therapies (for combination with
a-AR agonists).
In a randomized trial, Ishiko et al (13) compared the effects of the combination of pelvic oor exercise and estriol (1mg/day) in 66 patients with postmenopausal stress incontinence.
They found a signicant stress incontinence score in mild and moderate
stress incontinence patients in both groups 3 months after the start of therapy
and concluded that combination therapy with estriol plus pelvic oor exercise
was effective and capable of serving as rst-line treatment for mild stress incontinence.
Clunbuterol
Since -AR antagonists have been used as a treatment for SUI, it seems paradoxical that the selective 2-AR agonists, Clenbuterol, was found to cause
507
signicant clinical improvement and increase in the MUCR.

Yasuda et al (14), reported in a study of 77 patients with SUI that 56 patients
presented improvement in the clenbuterol group and 48 (out of 88) in the placebo group and the changes in MUCP was +3.3cmH2O in Clenbuterol and -1.5
cmH2O in the placebo group.
Ishiko et al (15) investigated the effects of Clenbuterol on 61 female patients
with SUI in a 12-week randomized study, comparing drug therapy to pelvic
oor exercises and a combination of drug therapy and pelvic oor exercises.
The improvement of incontinence was 76.9%, 52.6% and 89.5%, in the respective groups.
Further well designed RCTs are needed in order to evaluate the its potential
as a treatment for SUI.
New agents used for treatment of Stress Incontinence

Duloxetine
Duloxetine, a combined uorepinephrine and S-HT reuptake inhibitor, has been
shown in animal experiments, to increase the neural activity to the external
urethral sphincter and increase bladder capacity through effects on the central
nervous system (16).
Mechanism of action
Neurotransmitters
Role of serotonin and noradrenaline
Animal studies and early human studies have attributed a key to the serotonin
and noradrenaline in the central control of the UI. Most studies have indicated that central serotonergic activation inhibits bladder sensory mechanisms,
inhibits bladder parasympathetic excitatory efferent pathways, augments the
sympathetic activity to the bladder and urethra and enhances the somatic motor
input to the rhabdosphincter (16,17,18).
Noradrenalibe variably affects the LUT, depending on the receptor subtype
with which it interacts (19,20).
At Onufs nucleus in the sacral spinal cord, terminals of nerve tracts from
higher centers in the CNS synapse with the pudental motor neurons. Animal
studies have shown that the neurotransmitters serotonin and NA, are involved
at this level of interaction (18) and facilitate from Onufs nucleus the impulses
that travel along the pudendal motor bres to release ACh at the rhabdosphincter neuroeffector juction inducing its contraction.
508
Role of glutamate
Glutamate plays an important role as neurotransmitter in both supraspinal efferent tracts and in the afferent limb of the micturition reex ().
Though the exact junction of glutamate has not been denitely established
it is believed that glutamate functions as the obligatory on switch to initiate
rhabdosphincter contraction and that removal of glutamatergic synaptic input
is the signal for sphincter relaxation during voiding. Based on pharmacological
studies of fascial motor neuron it would be predicted that serotonin and NA
only amplify the excitatory effect of glutamate on the rhabdosphincter motor
neuron (21). Therefore, it is likely that prolonging the effect of endogenous
serotonin and NA results in contraction of the rhabdosphincter during bladder
lling but not during voiding.
Frequency of side effects of duloxetine used in patients with Stress Urinary
Incontinence
Table 1:
TEAEs occurring in 5% of duloxetine-treated patients and to a statistically signicant

greater extent than with placebo in all phase 3 studies
TEAE
% of patients
(range in 3 studies)
% of patients discontinuing
(range in 3 studies)
Nausea
23-28
3-6
Fatigue
10-15
*< 1-3*
Insomnia
13-14
1-2
Dry mouth
12-19
0< 1
Constipation
10-14
0< 1
Dizziness
8-12
2-4
Headache
7-15
<1
* In at least 1% of duloxetine-treated patients and to a statistically greater extent than with

placebo in at least 1 of the 3 trials.
Moore K. Int. J. Obst Gynecol 2004;86 (suppl 1):853-862.
Results of duloxetine used in patients with SUI

Cardozo L et al (23) evaluated the effect of duloxetine in double-blind randomized, placebo controlled study (80mg twice a day for 4 weeks) as a treatment
for SUI in 55 women and 54 women with placebo.
They found signicant improvements with duloxetine compared with
509
placebo in incontinence episode frequency (-60% versus 27%, p<0.001). IQOL score (+10.6 versus +2.4, p=0.003) and pad use (-34.5% versus 4.8%,
p=0.008).
Schuessler et al (24) reported in a double-blind, placebo controlled study
in women with SUI a signicant dose-dependent decrease in the incontinence
episodes (IEF) frequency reduction of IEF. The median was 41% for placebo
compared with 54% for 20mg/day of duloxetine (p=0.06), 59% for 40mg/day
(p=0.002) and 64% for 80mg/day (p<0.001). These ndings were essentially
the same in subjects with severe SUI. In the group receiving 80mg/day, the
mean change in I-QOL was statistically signicant compared to the placebo
group.
PGI-I ratings were also signicantly different with 44% of the 80mg/day
group reporting much better compared with 27% of the placebo group.
Discontinuation rates for Duloxetine use in patients with SUI in relation to
specic site effects is shown in Table 1.
Discontinuation rates for Duloxetine use in patients with SUI in relation to
dose were 5% for placebo and 9%, 12% and 15% for Duloxetine 20, 40 and
80mg/day, respectively (p=0.04 for over all treatment effect). No event was
considered clinically severe, nausea occurred most often.
Current management of SUI in women

The results obtained thus far suggest that duloxetine will be useful as rstline therapy in women with mild or moderate SUI. Among the factors to be
considered in choosing between PFMT and duloxetine is the patients willingness and ability to comply with the prescribed regimen. For women with
more bothersome SUI, the choice is usually between PFMT and surgery. In
most cases, Urology and Urogynecology unless PFMT has been ruled out or
has not provided the desired level of relief. The availability of an additional
noninvasive option opens the way for more effective treatment of patients for
whom neither PFMT nor surgery is acceptable or appropriate.
510
SUI
Bothersome ?
No
No treatment
Yes
Willing to do lifelong
exercises ?
Yes
PFMT
No
Willing to risk anesthesia &

surgical complications ?
No
Yes
Duloxetine
Surgery
Schuessler et al, 2003.
Figure: An algorithmic guide to physician-patient discussion

of treatment options
511
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Wilson PD, Bo K, May-Smith J et al. Conservative treatment in women. In: Abrams P, Cardozo
L, Ikhoury S, Wein A, editors. Incontinence, 2nd ed. Plymouth : Plymbridge Distributors Ltd,
2002, p. 571-624.
Bo K, Talseth T, Holme I, Single blind, randomized trial of pelvic oor exercises, electrical
stimulation, vaginal cones and no treatment in Management of genuine stress incontinence in
women BMS 1993; 318:487-93.
Andersson K-E, Appel R, Award S, et al. Pharmacological treatment of urinary incontinence in:
Abrams p. Cardozo L. Khoury S. Wein A. editors incontinence 2nd ed Plymouth: Plymbridge
Distributors Ltd 2002 p. 479-611.
Alhasso A, Glazener GMA, Pickard R, NDow J. Adrenergic drugs for urinary incontinence in
adults (Cochrane review) in: The Cochrane Library, issue 2, 2003 Oxford Update Software.
Fleming GA. The FDA, regulation and the risk stroke N. Engl J Medicine 2000, 43. 188687.
Viktrup L, Bump RC. Pharmacological agents used for the treatment of stress urinary incontinence. Current Med Res Opin 2003;19:485-90.
Gilia I, Radej M, Kovacic M, Parazajdes J. Comparative treatment of female stress incontinence with imipramine. J Urol 1984;132:909-11.
Lin HH, Sheu BC, Lo MC, Huang SC. Comparison of treatment outcomes for imipramine for
female genuine stress incontinence. Br J Obstet Gynecol 1999;106:1089-92.
Hextall A. Oestrogens and lower urinary tract function. Maturitas 2000;36:83-92.
Jackson S, Shepherd A, Abrams P. The effect of oestradiol on objective urinary leakage in postmenopausal stress incontinence: a double blind placebo controlled trial. Neurolorol Urology
1996;15:322-325.
Funtl JA, Cardozo L, McClish DK. Estrogen therapy in the management of urinary incontinence in postmenopausal women: a meta-analysis. First report of the hormones and Urogenital
Terapy Committee. Obstet Gynecol 1994;83:12-18.
Sultana CJ, Walters MD. Oestrogen and urinary incontinence in women. Maturitas 1990;20:12938.
Ishiko O, Ushiroyama T, Jaji E, Mitsuhashi Y, Tamura T, Yamamoto K, Kawamura Y, Ogita
S. Beta(2)-Adrenergic agonists and pelvic oor exercises for female stress incontinence. Int J
Gynecol Obstet 2000;71:39-44.
Yasuda K, Kawabe K, Takimoto Y, Kondo A, Takaki R, Imabayashi K, Toyoshima A, Sato A,
Shimaraki I, and the Clenbuterol Clinical Research Group. A double blind clinical trial of a
b2-adrenergic agonist in stress incontinence. Int Urogynecology J 1993;4:146-51.
Ishiko O, Hirai K, Sumi T, Tatsuta I, Ogita S. Hormone replacement therapy plus pelvic
oor muscle exercise for postmenopausal stress incontinence. A randomized controlled trial.
J Reprod Med 2001;46:213-26.
Thor , Katoasc , Danuser , et al. The role of 5-HT 1A-receptors in control of lower
urinary tract function in cats. Brain Res 2002;946:290- 7.
Kakizaki , Yoshiyama , Koyanagi , et al. Effects of W100635, a selective 5- 1Areceptor antagonist on the micturition- reex pathway in the rat. Am J Physiol Regul Inter
Comp Physiol 2001; 280:R1407-13.
Dauser , Thor . Spinal 5-2 receptor-mediated facilitation of pudendal nerve reexes
in the anaesthetized cat. J Pharmaco1 1996;118:150-4.
Krier J, Thor , de Groat WC. Effects of clonidine on the lumbar sympathetic pathways to
the large intestine and urinary bladder of the cat. Eur J Pharmaco1 1979;59:47-53.
Espey MJ, Downie JW, Fine . Effect of 5-HT receptor and adrenoreceptor antagonists on
512
21.
22.
23.
24.

micturitin in conscious cats. Eur J Pharmacol 1992;221:167-70.
McCall RB, Aghajanian GK. Serotonergic facilitation of facial motoneuron excitation. Brain
Res 1979;169:11-27.
Moore K. Duloxetine: a new approach for treating stress urinary incontinence. Int J Obst
Gynecol 2004;86:853-862 (suppl. 1).
Cardozo L, Drutz H, Baygani S, Bump R. Pharmacological treatment of women awaiting
surgery for stress urinary incontinence. Obst Gyn 2004;104:511-519.
Schuessler B, Baessler K. Pharmacological treatment of stress urinary incontinence: expectations for outcome. Urology 2003;62 (suppl. 4A):31-38.
513
Endoscopy
Robotics in Gynecology Surgery
Tommaso Falcone, M.D
Department of Obstetrics and Gynecology Cleveland Clinic Foundation,
Cleveland, Ohio
Email:falcont@ccf.org
Introduction
Laparoscopy surgery has been used routinely in gynecology for more than 25
years. Early reports of gynecologic procedures performed by laparoscopy were
not met with general enthusiasm. However in the last decade most gynecologic
procedures have been performed by laparoscopy. The patient benets of reduced postoperative discomfort and morbidity and more rapid return to activity
with surgery performed by laparoscopy are well established. However many
procedures are performed by few gynecologists in limited centers. Typically
most gynecologists will manage simple procedures such as tubal ligation, ovarian cystectomies, lysis of tubo-ovarian adhesions, and cautery of endometriosis laparoscopically. However hysterectomy, myomectomy, incontinence and
prolapse procedures, tubal microsurgery as well as advanced endometriosis
are typically still managed by laparotomy. Access to Robotic technology was
developed to allow the gynecologist to perform complex surgery by laparoscopy. .
Surgical robots
The rst commercial application of robotics was the AESOP (Automated
Endoscopic System for Optimal Positioning) device by Computer Motion
(Goleta, CA) to hold and position the laparoscope. It is a voice-activated
system that uses simple verbal commands to move the laparoscope position.
The purpose of this robotic arm is to allow the surgeon to directly control the
514
laparoscope. In this way both the surgeon and the assistant are able to use both
hands to perform the surgery. The use of AESOP as a laparoscope holder was
assessed in gynecologic surgery (1) and was found to be useful.
There are two Food and Drug Administration (FDA) approved robotic systems that have been used for gynecologic procedures, Zeus (Computer Motion
Inc., Goleta, CA) and da Vinci (Intuitive Surgical, Mountain View, California).
These robotic systems consist of three or four remotely controlled robotic arms
that are placed at the surgical site and a workstation called a robotic console.
The surgeon sits at this console that has a monitor, a control panel and two
handles that control the surgical instruments. This robotic console is attached
to the robotic arms by cables. The FDA regulations require that the console
be placed in the same room as the operative table. Two different groups have
reported tele-surgery. A single surgeon seated at the console can manipulate the
laparoscope and the aparoscopic surgical instruments simultaneously. There is
no observed delay between the movement of the handles and the movement of
the instruments.
Clinical experience
The rst laparoscopic gynecologic procedure using a robot was reported in
1998. Using an early prototype of the Zeus robot, a tubal anastomosis was
successfully performed (2). A subsequent prospective trial was then performed
to evaluate pregnancy rates (3). Ten patients with previous tubal ligations underwent laparoscopic tubal anastomosis using the ZEUS robotic system using the identical technique employed at laparotomy. However it is unclear if
this approach is superior to laparoscopic tubal reversal without the robot. The
Cleveland Clinic group compared results with and without robotic assistance
for laparoscopic tubal anastomoses(4) The operative times were longer with
the use of the robot. In this study, the patients realized no short -term benet
from the robot. This is probably due to the fact that the increased precision of a
robotic tubal surgery may not be critical for the outcomes such as postoperative
recoveryc or even pregnancy rate. The recent trend in laparoscopic tubal surgery is to perform a tubal anastomoses with fewer sutures than the traditional
technique without compromise in success. Precision of surgical technique may
be more important with other surgical procedures.
These devices would potentially be more useful if they could be applied to a
greater variety of complex gynecologic procedures. Two common gynecologic
surgical procedures, adnexectomy and hysterectomy, were performed with the
Zeus device in an animal model (5).
515
Advincula et al reported their preliminary experience with the use of the

robot for laparoscopic myomectomies (6). In this report of 35 patients, the
mean weight of the leiomyoma was 223 +244 g (95% CI 135-310), the mean
number of leiomyomas was 1.6 (range 1-5) and the mean diameter was 7.9
+3.5cm ( 95% CI 6.6-9.1). The mean blood loss was 169 + 198 mL. The mean
operative time was 230 + 83 minutes (95% CI 201-260). Five cases required
between 350 and 400 minutes to complete the procedure. There was a trend
towards decreased operative times with experience. There were three conversions to laparotomy.
Currently one published report of robot-assisted laparoscopic hysterectomy
exists. It is a series of eleven benign and malignant cases from Diaz-Arrastia
et al (7). All patients underwent a bilateral salpingo-oophorectomy. In patients
where there was a pre-operative diagnosis of malignancy, a cancer staging was
also performed with the da Vinci Surgical System. Most hysterectomies had a
vaginal component to the surgical procedure. Operative times ranged from 4.5
to 10 hours and estimated blood loss ranged from 50 to 1500 ml.
Sacrocolpopexy is a technique for management of posthysterectomy vaginal vault prolapse that has a high success rate. It is requires dissection of the
retroperitoneal space with suturing of a mesh from the vagina to the sacral
promontory. It is usually performed by laparotomy and is associated with
prolonged hospital stay and convalescence. A minimally invasive approach
would be a major benet. However this requires an expert laparoscopist with
advanced skills in suturing. A case series from Mayo clinic reported their initial
experience with roboticassisted laparoscopic sacrocolpopexy for vagianl vault
prolapse (8). The vagina was mobilized and the presacral space exposed with
conventional laparoscopic techniques. The robot was used exclusively to suture
the mesh into place. Multiple interrupted 1.0 Gore-Tex sutures were used to
secure the mesh to the vagina and sacral promontory. The average operative
time was 3 hours 42 minutes. No complications occurred. Patients only stayed
in the hospital one night.
Conclusion
Despite evidence of the feasibility of conducting gynecologic surgery with a
computer-enhanced system, the scope of clinical utility is yet to be determined.
Robotic systems will evolve and will become a necessary part of the future
minimally invasive surgeon.
516
References
1.
2.
3.
4.
5.
6.
7.
8.
Mettler L, Ibrahim M, Jonat W. One year of experience working with the aid of a robotic
assistant (the voice-controlled optic holder AESOP) in gynecologic endoscopic surgery. Hum
Reprod 1998;13:2748-50.
Falcone T, Goldberg J, Garcia-Ruiz A, Margossian H, Stevens L. Full robotic assistance for
laparoscopic tubal anastomosis: a case report. J Laparoendosc Adv Surg Tech. 1999;9:10713.
Falcone T, Goldberg JM, Margossian H, Stevens L. Robotically assisted laparoscopic microsurgical anastomosis: A human pilot study. Fertil Steril 2000;73:1040-2
Goldberg JM, Falcone T. Laparoscopic microsurgical tubal anastomosis with and without
robotic assistance. Hum Reprod 2003;18:145-7.
Margossian H, Falcone T, Robotically assisted laparoscopic hysterectomy and adnexal surgery.
J Laparoendosc Adv Surg Tech 2001;11:161-165.
Advincula AP, Song A, Burke W, Reynolds RK. Preliminary eperience with robot-assisted
laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 2004; 11:511-518.
Diaz-Arrastia C, Jurnalov C, Gomez G, Townsend C Jr. Laparoscopic hysterectomy using a
computer-enhanced surgical robot. Surg Endosc 2002;16(9):1271-1273.
DiMarco DS, Chow GK, Gettman MT, Elliott DS. Robotic-Assisted Laparoscopic sacrocolpopexy for Treatment of Vaginal Vault Prolapse. Urology 2004;63:373-76.
517
Laparoscopic Hysterectomy
why is it not more popular.
George Pantos
Aristotle University, Thessaloniki 54623, Greece
E-mail: Padosgyn@hol.gr
Hysterectomy is one of the most frequently performed gynaecologic operations,

while it has been reported that in the USA more than 600,000 hysterectomies
are performed annually (1). Of these, 75% are done abdominally and the rest
25% vaginally (2), while more striking is the evidence that in Europe and
especially in some countries just like Germany there is a signicant preference
for the vaginal approach in comparison to USA, where exactly the opposite
exists. The rst hysterectomies attemped were vaginal and F.Osiander reported
in 1808 vaginal hysterectomies in seven patients, all of whom died (3). It was
not until 50 years later that the rst successful abdominal hysterectomy was
performed by W. Freund (4) and since then it became the preferred operation
following a series of surgical anaesthetic advances. Despite the fact that a
small decrease in the frequency of hysterectomy has been noticed from 1980
(7.1%0) until 1986 (6.6%0) and nally in 1993 (5,5 %0), the existence of signicant disantvantages correlated with abdominal hysterectomy consisted the
necessary prerequisite for further investigation and application of other more
effective surgical approaches. It was not until 1989, when Harry Reich reported
in themedical literature the rst cases of total laparoscopic hysterectomy (5)
and since then LH has been used all over the world, representing an important
milestone in endoscopic surgery.
518
Critical analysis of Laparoscopic Hysterectomy or Why is

it not more popular
The procedure
The goal of laparoscopic hysterectomy (LH) is the removal of the uterus or the
corpus in the case of subtotal hysterectomy either under endoscopic direction
or by facilitating to perform vaginal hysterectomy. In fact, LH is actually a
spectrum of procedures with varying amount of laparoscopic involvement in
comparison with the initial report of H. Reich (1989) (5). Such variation in the
technical aspects of LH has a certain impact on the required technical skill of
the surgeon, operation time, complications and cost of the intervention.
Since LH includes a wide spectrum of procedures, several attempts have
been made in order to classify the procedure (6,7,8). A universal classication system would allow for a procedure-specic aspects evaluation, cost and
morbidity associated determination and educational as well as credentialing
programme ellaboration. Such a universal classication system does not exist, so making difcult the direct evaluation of clinical outcomes and critical
judgement of each procedure.
Garry and Reich (1993) have proposed the following classication of laparoscopic hysterectomy:
1. Diagnostic laaroscopy with vaginal hysterectomy (VH).
2. Laparoscopic vault suspension after vaginal hysterectomy.
3. Laparoscopic assisted vaginal hysterectomy (LAVH).
4. Laparoscopic hysterectomy (LH)
5. Total laparoscopic hysterectomy (TLH).
6. Laparoscopic supracervical hysterectomy (LSH or CASH).
7. Laparoscopic hysterectomy with lymphadenectomy (LHL).
8. Radical laparoscopic hysterectomy (RLH), which is usually the combination of a laparoscopic lymphadenectomy combined with a radical
Shautas vaginal hysterectomy.
In each classication system, the amount of laparoscopic involvement consists the critical issue, while all include occlusion of the uterine vessels as
a reference point. Even so, there are foundamental differences between the
various classication systems, so making difcult a thourough and objective
evaluation of all aspects of these variations and even more difcult ellaboration
of educational and credentialing programmes.
Indications
The real indications of LH should be difcult vaginal accessand therefore
it must be performed when vaginal route is contraindicated, avoiding a major
519
abdominal surgery. Trully, all hysterectomies should be performed vaginally.

Unfortunately, the percentage of vaginal hysterectomies (VH) varies widely
among the various hospitals due to substantial differences in regional or national training programmes. On the other hand, the long learning curve of LH,
which varies between 10 and 80 procedures results in endoscopists with varying
degrees of capabilities, so making the indications for LH poorly dened and the
percentage of transformation to TAH higher. Finally, the proper implementation of surgical guidelines may have a certain impact on the percentage of VH,
as it was shown by Kovac et al (9), who reported a reduction of the ratio of
TAH to VH from 3:1 to 1:1 after application of the guidelines of the Society
of Reconstructive Surgeons for dening the route for hysterectomy in resident
clinic population.
Results-Cost
Since the rst report of laparoscopic hysterectomy by Reich et al (5), until nowadays there is an increasing number of Centers that have incorporated LH in their
clinical practice, although it has to be mentioned that this approach presupposes
considerable endoscopic experience and essential training and therefore only few
Endoscopic Centers have reported large series. On the contrary, most of the reports
of LH in the literature include only small numbers of patients with signicant variations of the endoscopic involvement, so making really difcult a critical evaluation
of their scientic value. The results of LH are analyzed in Table I.
Table I: Results of laparoscopic hysterectomy
Authors
Patients
Duration of
intervention
(min)
Hospital stay
(days)
Johns, 1994
199
79
2.45
Liu, 1992
215
114
1.2
Bruhat et al,1992
36
126
Reich, 1993
123
ttonen et al, 40
2000
180
102
1.9
1.5
Total
114 (mean)
1.7 (mean)
688
The role of LH seems to be clear in that it should be an alternative to abdominal hysterectomy and not to vaginal surgery. Therefore, it must be performed
when vaginal route is contraindicated, avoiding a major abdominal surgery. On
520
the other hand, the percentage of VH varies widely among the various hospitals
due to the substantial differences in regional or national training programmes
and therefore incorporation of LH may vary widely. As a bottom line, a welltrained vaginal surgeon may nd fewer indications for LH.
Another advantage of LH over TAH is the reduction in the overall cost of
the endoscopic approach. Devotees of laparoscopic hysterectomy suggested
that the overall savings should result from both shorter hospital stay and early
return to professional activities. On the contrary, prolonged operation times
and the use of disposable laparoscopic instruments have a certain impact on the
overall cost and may eliminate the savings resulted from the shorter hospital
stay. In fact, costs associated with LH may be either direct or indirect. The
former include the economic burdening of the patients themselves or health
care providers for the performance of the intervention. Directly related to this
issue is the duration of the intervention, which is proportional to the skill of the
surgeon, the degree of the specic case and in some instances the availability of
the concrete instrumentation such as stapling devices e.t.c. On the other hand,
most of the reports on the cost-effectiveness in the literature are based on the
initial experience of the surgeon or insitution and the concept of the learning
curve and its impact on the operation time has its true base (10, 11).
The indirect cost-effectiveness of LH is dened as the nancial impact
resulted from the early return to the professional activities and the rapid postoperative recuperation. Indeed, observational studies have reported return to
productive employment in 2.1- 3 weeks in comparison to TAH, which is 5-6
weeks (12).
In conclusion, LH seems to result in higher cost due to the prolonged operation time and increase in use of disposable instruments, which in turn is
outweighed by the shorter hospital stay, faster recovery and earlier return to
professional activities.
Complications.
In 1984, Dicker et al (13), reported a complication rate from total abdominal hysterectomy of 42.8% and from total vaginal hysterectomy of 24.5%.
Although complications after LH are inevitable, in orded this approach to be
considered appropriate and safe should have similar or less in comparison to
TAH. Furthermore, it is imperative to recognize early these complications,
while its repair at the time of the initial intervention improves the overall efcacy of the endoscopic approach. Complications after laparoscopic hysterectomy are shown in Table II, while the differences between LH, TAH and VH
521
are analyzed in Table III. Comparative studies show similar complication rates
between all three approaches. On the contrary, more major complications were
observed in the group of LH and included bladder injuries, bowel laceration,
ureter injuries and reoperation for hemorrhage. Of these, with the acquisition
of surgical skills most of the bladder injuries can be repaired laparoscopically.
Prevention of ureteric trauma may be achieved by elimination of abudant dissection and avoidance of use of stapling devices below the level of the uterine
vessels.
Table II: Complications after laparoscopic hysterectomy
Complications
Authors
Patients
Minor
(N)
Major
(N)
Liu, 1992
215
1.4
3.3
Lee, 1992
24
8.3
4.2
Reich, 1993
123
7.3
5.7
Canis,1993
24
4.2
8.3
Daniel, 1993
62
6.5
Philipps, 1993
114
4.4
Kadar, 1994
24
8.3
Chapron,1994
31
9.7
Deprest
(Belcohyst), 1995
413
81
19.6
1.9
Daniell,1999
500
0.8
Minelli, 1991
Table III: Complication rates in Laparoscopic, Abdominal and Vaginal hysterectomy.
Laparoscopic hysterectomy Abdominal hysterectomy Vaginal hysterectomy

Author
Cases Compli- Cases Complications Cases Complications

cations
Summitt, 1992
28
2 (7.1%)
Nezhat, 1992
10
1 (10%)
10
1 (10%)
28
2 (2.7)
522
Author
Cases Compli- Cases Complications Cases Complications

cations
Philipps, 1993
24
29
Carter, 1994
19
3 (15.8%)
19
3 (15.8%)
East, 1994
50
4 (8%)
10
10
Total
131
10 (7.5%)
68
4 (5.8%)
38
2 (5.2)
The rate of complications is highly variable and is dependent on the surgeons skill level, patient selection and underlying pathology. Nevertheless,
it is reasonable to conclude that laparoscopic hysterectomy is a safe endoscopic approach with a complication rate comparable with that of abdominal
hysterectomy.It is evident that the slight increase in complications indicates
that an advanced degree of endoscopic skill and adequate training together
with precise judgement of the indications and suitable instrument supply are
prerequisites for an optimal surgical outcome. In conclusion, LH done by the
right endoscopist on the right patients and with the right equipment supply will
become more popular and more widely accepted.
References
1.
Levine L, Hillis S, Marchbanks P, et al. Hysterectomy surveillance United States, 1980

1993: NMWR CDC Surveil Summ, 46:1-15,1997
2.
3.
4.
5.
Carter J. Alternatives to total abdominal hysterectomy. N. Engl J Med, 1:259 262, 1997.
Ostander F. Gottinger Gelechte Anhce, 130-134,1808.
Freund W. Zur einer method der totaler uterus exstirpation. . Zbl Gyn, 12:265-269, 1875.
Reich H, De Caprio J, McGlynne F. Laparoscopic hysterectomy. J. Gynecol Surg, 5: 213-217,
1989.
Munro M Parker W. A classication system for laparoscopic hysterectomy. Obstet Gynecol,
82: 624-629, 1993.
Garry R, Reich H, Liu C. Laparoscopic hysterectomy- denitions and indications. Gynaecol
Endosc, 3:1-3, 1994.
Garry R, Reich H. Basic techniques for advanced laparoscopic surgery. In: Laparoscopic hysterectomy (Eds) R. Garry and H. Reich. Blacwell Scientic Oxford, pp 46- 78, 1993.
Kovac S, Barhan S, Lister M, et al. Am J Obstet Gynecol, 187 (6):1521-1527, 2002.
Deprest J, Cusumano P, Donnez J, et al. Belgian national register of laparoscopic hysterectomy : Yearly update. Int J Gynecol Obstet, 46:59-66, 1994.
Economic impact of laparoscopic surgery. Boston: Deloitte and Touch, 13,1993.
Carter J, Ryoo J, Katz a. Laparoscopic-assisted vaginal hysterectomy: A case control comparative study with total abdominal hysterectomy. J Am Gynecol Laparosc, 1:116-121,1994.
Dicker R, Greenspan J, Strauss L, et al. Complications of abdominal and vaginal hysterectomy
among women of reproductive age in the United States. Am J Obstet Gynecol, 144:841-850, 1984.
6.
7.
8.
9.
10.
11.
12.
13.
523
Complications of Laparoscopic
surgery-can they ever be eliminated?
Tommaso Falcone, M.D
Department of Obstetrics and Gynecology, Cleveland Clinic Foundation,
Cleveland, Ohio
Email: falcont@ccf.org
The general perception in the medical literature and the medical community in
general is that laparoscopic surgery is associated with increased incidence of
complications. A meta-analysis of randomized clinical trials comparing laparoscopic surgery to laparotomy demonstrated that there was no increased probability of complications between the two approaches (1). Nonetheless there are
some unique features of laparoscopic surgery that may increase the frequency
of certain injuries.
Injuries related to access to the peritoneal cavity

These injuries are more frequently reported in relation to laparoscopy but are
not unique to it. For example, injuries to nerves in the anterior abdominal wall,
such as the ilioinguinal or iliohypogastric nerves, can be injured by a trocar
or closure of the port site. The location of these nerves is below the anterior
superior iliac spine (ASIS) (2). Injury to these nerves can be avoided at laparoscopy if a trocar is placed above this anatomical area. However these can
also be injured with a low transverse incision that may be unavoidable. Clearly
knowledge of the anatomy can decrease the incidence of this complication.
Insertion of the primary trocar can result in injury to the bowel if there are
subumbilical adhesions from previous laparotomies. Experience with multiple
access sites for insertion of the primary trocar may diminish this complication.
For example, recent work has shown that a left upper quadrant trocar insertion
524
is safe in patients with previous abdominal scars (3). Major vascular injuries
can occur with insertion of the primary trocar. Knowledge of the anatomy of the
major vessels as well as proper technique should avoid most injuries. However
in particularly thin patients injury can occur. Open laparoscopy should be considered in these patients.
Energy related Injuries

Most laparoscopic surgery requires the use of some energy form. Typically
electrocautery or lasers are used. Knowledge of some of the basic physics will
diminish this injury. The most common energy related injury relate to insulation failure or activation of the instrument without the organ in clear view.
All accessories must be thoroughly inspected for deterioration and tested by a
qualied biomedical technician regularly.
Procedure related injuries

How many laparoscopic procedures should be performed until a surgeon is procient? A recent study of the learning curve associated with laparoscopically
assisted vaginal hysterectomies (LAVH) suggests that it takes an experience of
30 cases to signicantly reduce morbidity rates (4). The learning curve of many
laparoscopic procedures appears to be longer than the equivalent procedure by
laparotomy. The concept of learning laparoscopic surgery by a mini-course
caused many complications in the 1990s. The requirement of a formal education became necessary. The issue of training of the new generation of surgeons
is at the forefront of medicine in the USA.
Residents are learning more diseases, more sophisticated pathophysiology
and more procedures or techniques in fewer working hours (less than 80 hours
by law). The operating room is also considered an extremely stressful place, a
condition that is not conducive to learning. This developed the concepts of a
structured education with inanimate models, cadaver models, and most recently
computer simulations. Most recently robotics has been introduced is another
virtual reality tool for training surgeons.
In summary, complications of laparoscopic surgery can be decreased but
with formal training of laparoscopic techniques within the context of a model
that will allow the appropriate number of cases to be performed before proceeding to surgical independence.
525
References:
1.
2.
3.
4.
Falcone T. Laparoscopic surgery is not inherently dangerous for patients presenting with benign gynecologic pathology. Results of a meta-analysis. (comment) Evidence-based Obstetrics
& Gynecology 2002;4:185-6.
Whiteside JL*, Barber MD, Walters MD, Falcone T. Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions. American Journal
of Obstetrics & Gynecology 2003;189:1574-8.
Tulikangas PK*, Robinson DS, Falcone T. Left upper quadrant cannula insertion. Fertil Steril
2003;79:411-12.
Altgassen C, Michels W, Schneider A. Learning laparoscopic-assisted hysterectomy. Obstet
Gynecol 2004;104:308-13.
526
High and low-risk pregnancies

Should all twins be delivered by
cesarean section?
I. Blickstein, MD
Dept. of Obstetrics and Gynecology, Kaplan Medical Center, Rehovot, and the
Hadassah-Hebrew University School of Medicine, Jerusalem, Israel.
Summary
Many that follow the cliche no high risk pregnancy should end with a high
risk delivery would prefer to deliver twins by cesarean section for reasons
that are not evidence-based. The decision for abdominal delivery of twins,
intentionally or not, is based on qualitative variables that were not quantied
and on quantitative variables that suggest no advantage for a cesarean in the
majority of cases.
Introduction
Based on the well-known bad luck mathematical paradox (B. Russell), a
decision to perform a cesarean section (CS) in a given case is likely to be wrong
if based on the probability of a successful vaginal delivery in that case. This
implies a no win situation, where any decision might prove wrong.
The question regarding the mode of delivery becomes pertinent in view of
the fact that the rate of twins is reaching epidemic dimensions in most developed countries. In this setting, the crucial variable is the probability of a safe
vaginal birth in twins. This presentation questions the option to deliver all twins
by cesarean section.
527
The contribution of twins to the overall cesarean rate

The contribution of twins to the overall CS rate can be estimated by noting
that the higher the CS rate (including half of the twins delivered anyway
by CS) the lower the contribution of twins to the overall CS rates. The
best-t correlation (Pearsons R2 = 0.99) is an inversely exponential curve,
suggesting that with increasing CS rates, the contribution of twin to that
rate becomes negligible. Thus, performing CS for all twins is expected
to increase the overall CS rate by 10% in a service with an overall 10%
CS rate but will add only 3.3% to a service with an overall 30% CS rate.
[1]
The CS rate at the Kaplan Medical Center for 1996-2000 is shown in Table
1. During this period, we had (averages) 15.3% cesareans and 2.3% twins, of
which 60.7% were delivered by CS. Abdominal birth for all twins would have
increased our overall CS rate by 5.8%, while delivering all twins vaginally
would have reduced our CS rate by 9.1%, thus changing the overall rate of 15.3
% by no more than +1%.
It is therefore concluded that changing the CS rates for twins will not signicantly change the overall CS rates, and therefore, the issue is not reduction
of CS rate but avoiding unnecessary cesareans.
Arguments in favor of cesarean birth

It seems that one may nd an indication for CS in almost every twin pregnancy.
Considering the negligible contribution of CS for all twins to the overall CS
rate, one may cynically question the wisdom of vaginal delivery (VD) in any
pair of twins. Some confounding variables in deciding about the route of birth
are listed below.
Fertility history. The change in the proportion of induced and spontaneous
twins over the last two decades has been reported by Loos et al [2]. In 1976,
the proportion was one induced twin maternity for every 32 spontaneous twins
while in 1996, this ratio was 1:1.02. These population-based results might be
even more accentuated in many centers with active infertility clinics. Eventually,
the increasing frequencies of iatrogenic pregnancies will increase the proportion of previously infertile women delivering twins, leading to higher rates of
so-called premium pregnancies for which, any mode of delivery except CS
may be declined.[3]
Obviously, once the infertility treatment is successful, the patient is not
528
infertile anymore. In addition, any attribution to past infertility is not directly

associated with the mode of delivery.
Obstetrical history. With current CS rates, there is at least a 1:5 to 1:10 probability that multiparas carrying twins had a previous CS. This fact alone might
exclude the patient from vaginal birth after CS (VBAC) even though VBAC in
twins is currently not contraindicated in 50% of the cases. [4]
Obstetrical skills. Concerns about singleton breech delivery [5] are currently
extrapolated to twin birth, with a presentation combination other than vertexvertex. Twin pairs include at least one breech or transverse lying twin in 50 to
60% of the cases, for which exercising manual dexterity and experience are essential. Higher rates of CSs for twins will undoubtedly decrease the experience
in VDs, creating a vicious circle in favor of CS. The less experienced clinicians
are likely to report on adverse outcome following VD more often, or opt for a
combined delivery when encountered with subtle difculties in delivering the
non-vertex twin. A direct relationship exists between CS rate in twins and the
combined delivery rate, suggesting that those who perform more CSs in twins
and are apparently less experienced in VD of twins, are more likely to decide
on a CS for the second twin.[6]
Because current training does not expose the trainee to operative deliveries
as before, the obstetrician may feel uncomfortable in VD of twins. For him/
her, CS is a solid option. This is one of the cases when inexperience-based
medicine is superior to evidence-based medicine.
Age and size. There are no effective prophylactic measures to increase fetal
growth and reduce prematurity in multiple gestations.[7] Thus, two-thirds of
twins are delivered before 36 weeks gestation (including 14% at <33 weeks)
and half are LBW (including 10% VLBW). In a recent population-based study
we found [8] that the overall frequency of having at least one very low birth
weight (VLBW) twin was 10.8% with a signicantly higher frequency among
nulliparas than among multiparas (OR 2.3, 95%CI 2.1, 2.6). This trend was also
found when both twins were VLBW (5.9%) and when one twin was VLBW and
the other LBW (4.5%). Thus, VLBW twins are encountered in 1:10 gestations
and primarily among nulliparas.
Fetal age and size are frequent arguments against VD for the delivery of
VLBW twins and at less than 32 weeks. While data support VD of vertex
singletons, there are few studies on outcome of small vertex-presenting twins.
Logic, however, suggests no difference between singleton and twins.
529
Maternal complications. The argument in favor of an elective day-time CS

because of a concomitant maternal complication is frequently used. Yet, none
of the true twin-related complications are an absolute indication for CS in
singletons. Pre-eclamptic toxemia is an example for which VD is considered
by many as the preferable option, however, the literature cites gures of over
70% CS in these cases.
One should never forget that several of the some maternal complications
also constitute an a priori risk for maternal operative morbidity and mortality.
[9]
Evidence-based decisions
The attributed risk of most of the above mentioned confounding variables
was not quantied by research, which has taken the easy way to deal with the
optimal way to deliver twins and, indeed, focused on rather simple variables.
Presentation and size. Combinations of presentation, comprising vertex (Vx),
breech and transverse, are usually grouped into four categories: Vx-Vx (~40%),
Vx-Non-Vx (~30%), Non-Vx-Vx (~20%), and Non-Vx- Non-Vx (~10%). [4]
Vx-Vx pairs are considered appropriate candidates for VD, with few exceptions related to size and/or gestational age. Vx-Non-Vx are considered conceivable candidates for VD, with many exceptions related to size and/or gestational
age.[10] Non-Vx-Vx and Non-Vx- Non-Vx are generally considered as an
indication for CS, mainly due to lack of evidence about the safety of VD in
breech-rst pairs. Studies, which showed no difference in outcome for VD
were criticized as having low statistical power or being non-randomized. In a
recent multi-center study of a large sample of breech-rst twin pairs delivered
in 13 European centers, we found that when breech-rst twin twins weighed
<1500 g, there was a 2.4-times higher risk of depressed (<7) 5-min Apgar
scores and a 9.5-times risk for neonatal mortality in VD as compared with CS.
However, CS did not improve outcome when breech-rst twin weighed >1500
g. Importantly, no case of locked twins has been encountered. [11]
It seems that the same criteria for singleton breech delivery should be applied
for twin breech delivery. In light of the new wave following recent observation
[5], it is doubtful if non-vertex twins are still eligible for VD.
VBAC. Studies on VBAC have shown that Vx-Vx and some Vx-Non-Vx pairs
may be candidates for VD. Expected intrapartum manipulations, such as podalic version have generally excluded cases from VBAC.
530
Discordance. Signicant inter-twin size differences, per se, do not indicate CS.
[12] Discordance, however, has been an argument against VD of Vx-Non-Vx
pairs in whom twin B is signicantly larger than twin A.
Labor induction. The important question in twin gestations is usually how to
arrest premature labor. Nevertheless, about 20% may need induction of labor.
The over-distended uterus in twin gestation is a relative contraindication for
labor induction and therefore twin pregnancy was often terminated by CS.
Recent studies have suggested that pre-induction ripening of the cervix is both
effective and safe. [13-14] .
Table 1:
Contribution of twins to the overall CS rate. Data from the Kaplan Medical Center,
Rehovot (IL).
1996
1997
1998
1999
2000
Average
14.3
14.5
15.5
14.9
17.1
15.3
1.8
2.5
2.7
2.4
2.3
63.9
58.7
51.4
69.2
60.2
60.7
Change in overall CS
rate if all twins delivered by CS
5.1
7.8
5.6
5.6
5.8
Change in overall CS
rate if all twins delivered vaginally
-8.9
-7.3
-8.3
-12.5
-8.4
-9.1
Overall CS rate
Twin rate
CS in twins
Conclusions
Data indicate that, currently, at least 50% of twin pregnancies end by cesarean
section. For the remaining twins, additional indications are constructed, mainly
because these pregnancies are considered as premium. Trends in operative
deliveries of non-vertex singletons undoubtedly decreased obstetrical skills and
led to higher rates of CS in twins.
If prophecy is permitted, one could expect that in the near future only term,
appropriate for gestational age, vertex-vertex, spontaneous twins of mothers
without any pregnancy complications will be candidates for VD.
531
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
BLICKSTEIN I. Cesarean section for all twins ? J Perinat Med 28:169-74, 2000.
LOOS R, DEROM C, VLIETINCK R, DEROM R. The East Flanders Prospective Twin Survey
(Belgium): a population-based register. Twin Res 1:167-175, 1998.
COLON JM, APUZZIO JJ, EVANS HE, SAMA JC, IFFY L. Obstetric considerations of
premium iatrogenic multiple pregnancy. In: Blickstein I, Keith LG (eds) Iatrogenic multiple
pregnancy. Parthenon Publishing, Lancs,; ch. 9, 2001.
BLICKSTEIN I. Delivery of twins. In Labor and delivery. Cosmi EV (ed), Parthenon
Publishing, Lancs, pp. 70-73, 1998.
HANNAH M, HANNAH WJ, HEWSON SA, HODNETT ED, SAIGAL S, WILLAN AR.
Planned caesarean section versus planned vaginal birth for breech presentation at term: a
randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet 356:1375-83,
2000.
BLICKSTEIN I, ZALEL Y, WEISSMAN A. Cesarean delivery of the second twin after the
vaginal birth of the rst twinmisfortune or mismanagement ? Acta Genet Med Gemellol
1991;40: 389-94.
BLEKER OP. Prophylactic measures against preterm delivery. In: Blickstein I, Keith LG (eds)
Iatrogenic multiple pregnancy. Parthenon Publishing, Lancs, ch. 7, 2001
BLICKSTEIN I, GOLDMAN RD, MAZKERETH R. Risk for one or two very low birth
weight twins: A population study. Obstet Gynecol 96:400-2, 2000
BLICKSTEIN I. Maternal mortality in twin gestations. J Reprod Med 42:680-4, 1997.
BLICKSTEIN I, SCHWARTZ Z, LANCET M, BORENSTEIN R. Vaginal delivery of the
second twin in breech presentation. Obstet Gynecol 69:774-6, 1987
BLICKSTEIN I, GOLDMAN RD, KUPERMINC M. Delivery of breech-rst twins: a multicenter retrospective study. Obstet Gynecol 95:37-43, 2000.
BLICKSTEIN I. The denition, diagnosis, and management of growth discordant twins: An
international census survey. Acta Genet Med Gemellol 40:345-51, 1991.
MANOR M, BLICKSTEIN I, BEN-ARIE A, WEISSMAN A, HAGAY Z. Case series of
labor induction in twin gestations with an intrauterine balloon catheter. Gynecol Obstet Invest
47:244-6, 1999.
SIMOES T, CONDECO P, CAETANO P, DIAS E, NOGUEIRA I, GONCALVES A, FARELO
A. Labor induction in twins. Isr J Obstet Gynecol 10:159-161, 1999.
532
Antepartum fetal surveillance

in pregnancies complicated
by diabetes mellitus
Anthony M. Vintzileos, MD
Department of Obstetrics, Gynecology and Reproductive Sciences University of
Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School New
Brunswick, New Jersey, USA
The goals of antepartum management in pregnancies complicated by diabetes

mellitus include prevention of congenital anomalies, prevention of fetal macrosomia, prevention of fetal death, prevention of respiratory distress syndrome
and prevention of hypertrophic cardiomyopathy.
First trimester
Fetal evaluation tests in the rst trimester aim to screen for fetal congenital
anomalies. Tests include HbA1c and an ultrasound evaluation (between 11
and 14 weeks gestation) for crown rump length measurement and nuchal
translucency (NT) evaluation. Prevalence of congenital anomalies in infants
of diabetic mothers varies (6% to 10%). The most common malformations are
cardiac (transportation of great vessels, VSDs/ASDs, coarctation of the aorta,
cardiomegaly, etc.), skeletal (caudal regression syndrome, neural tube defects,
hemivertebrae, microcephaly, etc.), renal (hydronephrosis, renal agenesis,
ureteral duplication, etc.), gastrointestinal (duodenal atresia, anorectal atresia,
small left colon, etc.) and other (single umbilical artery, etc.).
The incidence of congenital anomalies varies according to the HbA1c levels.
Women with HbA1c levels between 8 and 10 in the rst trimester of pregnancy
have congenital anomalies in 10% 13% of the cases. HbA1c levels >10 are
associated with congenital anomalies in approximately 5% 35% of the cases.
533
Smaller than expected crown rump length in the rst trimester has been also
associated with increased risk for congenital anomalies in fetuses of diabetic
mothers.
Nuchal translucency (NT) is primarily used as a screening test for fetal aneuploidy. However, it can also detect congenital heart disease. There is a positive correlation between the NT measurement and the risk for congenital heart
disease. NT thickness > 5.5 mm may be associated with a risk for congenital
heart disease of approximately 25%. However, the detection rate of congenital
heart disease by using NT is approximately 31%. The NT accuracy depends on
the nature of the cardiac malformation.
Second trimester
Fetal testing during the second trimester of diabetic pregnancies focuses again
in screening for congenital anomalies and it includes maternal serum analyte
testing (i.e. MSAFP), targeted ultrasound examination for fetal anomalies and
fetal echocardiography. Typically, a complete anatomic fetal survey is performed between 19 and 20 weeks gestation to conrm dates and to document
fetal anatomy. During this exam, the fetus is targeted to rule out cardiac, skeletal, CNS, renal and gastrointestinal anomalies. A fetal echocardiography is
done at the same time. If suboptimal, a repeat fetal echocardiography should
be attempted between 22 and 24 weeks gestation. MSAFP screening is usually
done as part of the maternal serum analyte screening for aneuploidy (triple or
quad screen).
Third trimester
Fetal testing during the third trimester aims to screen for fetal macrosomia, diabetic fetopathy changes and prevention of fetal death. During the third trimester, serial fetal growth assessments are indicated to rule out polyhydramnios,
placentomegaly, macrosomia (or fetal growth restriction in fetuses of mothers
with vasculopathy), evaluate the presence or absence of fetal fetopathy and
to rule out hypertrophic cardiomyopathy. Elective cesarean section for fetal
macrosomia is controversial. However, cesarean delivery may be considered
if the estimated fetal weight is over 4500 grams, especially in the presence of
diabetic fetopathy changes (decreased head to abdomen ratio, decreased femur
length to abdominal circumference ratio, etc.)
Another goal in the management during the third trimester of pregnancy is
to prevent fetal death. The pathophysiology of fetal death in fetuses of diabetic
534
mothers is unknown. However, it is believed that maternal hyperglycemia

results in fetal hyperglycemia which, in turn, causes fetal hyperinsulinemia.
Due to high glucose levels, the fetuses are prone to lactic acidemia and also
to reduced uteroplacental blood ow (if maternal vasculopathy is present).
Risk factors for fetal death include poor gylcemic control, fetal macrosomia,
polyhydramnios, maternal vascular disease and preeclampsia. The biophysical
monitoring tests used to detect the fetus at risk for fetal death include contraction stress test, non-stress test, amniotic uid volume assessment, biophysical
prole and Doppler velocimetry tests. It is rare to have a stillbirth after a negative contraction stress test. However, the false-positive rate of contraction stress
tests is very high (36%). The non-stress test has lower false-positive rate, but
the false-negative results may be as high as 2%. The use of fetal biophysical
prole in managing diabetic pregnancies has been reported by Dicker D et al1,
Johnson JM et al2 and Kjos SL et al.3 In general, these studies have reported
good outcomes in well-controlled patients and concluded that the surveillance
they used was appropriate. However, prediction of fetal acidemia in fetuses
of diabetic mothers by using biophysical prole score and computer-assisted
fetal heart rate monitoring has been somewhat disappointing.4 These studies
have shown that there is an inverse correlation between maternal glucose levels
and fetal pH, an observation that would explain why biophysical monitoring
methods have high-false negative rates when applied to fetuses of diabetic
mothers. Doppler velocimetry is useful only in cases complicated by fetal
growth restriction or preeclampsia.
Conclusion
In summary, NT may not be reliable as a screening test for aneuploidy, especially
in women with uncontrolled diabetes, since increase NT may be the result of a
congenital heart disease, rather than aneuploidy. Ultrasound is not reliable in the
diagnosis of fetal macrosomia, which is frequently seen in uncontrolled diabetes. Finally, fetal biophysical activities (i.e. breathing, movement) and amniotic
uid volume may not reliable in the presence of high maternal blood sugars.
535
References
1.
2.
3.
4.
Dicker D, Feldberg D, Yeshaya A, Peleg D, Karp M, Goldman JA. Fetal surveillance in insulin-dependent diabetic pregnancy: predictive value of the biophysical prole. Am J Obstet
Gynecol 1998;159:800-4.
Johnson JM, Lange IR, Harman CR, Torchia MG, Manning FA. Biophysical prole scoring in
the management of the diabetic pregnancy. Obstet Gynecol 1998;72:841-6.
Kjos SL, Leung A, Henry OA, Victor MR, Paul RH, Medearis AL. Antepartum surveillance in
diabetic pregnancies: predictors of fetal distress in labor. Am J Obstet Gynecol 1995;173:15329.
Salvesen DR, Freeman J, Brudenell JM, Nicolaides KH. Prediction of fetal acidaemia in pregnancies complicated by maternal diabetes mellitus by biophysical prole scoring and fetal
heart rate monitoring. Br J Obstet Gynaecol 1993;100:227-33.
536
Second trimester miscarriage

Pregnancy loss: evaluation and
treatment
Department of Obstetrics, Gynecology and Reproductive Sciences, University of
Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School,
New Brunswick, New Jersey, USA
The clinical classication of pregnancy losses includes the following periods:

preembyonic (conception to 4 weeks), embryonic (5-9 weeks), fetal (10 weeksdelivery) and neonatal (0-28 days of life). Pregnancy loss rates vary according
to gestational age (inverse correlation). Indications for workup include:
1. History of three or more consecutive rst trimester miscarriages; or
2. At least one second or third trimester loss (neonatal or fetal loss).
The etiologic factors for pregnancy loss can be environmental, genetic,
uterine/cervical, infectious, hormonal, autoimmune, alloiummune, acquired/
congenital thrombophilias and idiopathic.
Environmental factors
Documented environmental factors that cause pregnancy loss include alcohol,
aminopterin, cocaine, CVS, coumarin, cyclophosphamid, herpes simplex 2,
syphilis, parvovirus B19 infection, therapeutic radiation, retinoids, smoking/
nicotine and excessive caffeine intake (6 cups/day).
Genetic etiologic factors

In early spontaneous abortions, the prevalence of early chromosomal abnormalities is >50%, whereas in stillbirths is approximately 5% and in live births
only 0.5%. In rst trimester pregnancy losses, the most common genetic ab-
537
normalities include autosomal trisomy (50%), monosomy X (20%-25%), triploidy (16%), tetraploidy (8%) and other structural cytogenetic abnormalities
(3%). In 2-3% of couples with recurrent rst trimester pregnancy losses, one
of the partners may have a balanced translocation. The most frequent balanced
translocation is a reciprocal or simple. In such cases, the risk for recurrent
pregnancy loss depends on whether the male or female partner is a carrier and
it also depends on the specic type of cytogenetic abnormality. Recent data
has suggested that the overall risk for karyotypic abnormalities in spontaneous
abortions is approximately 70% in the rst trimester and 22% in the second
trimester. These risks also depend on maternal age.1 Transcervical embryoscopy and cytogenetic analysis of 233 missed abortion cases revealed that the
karyotype was abnormal in 75% of the cases and in an additional 18% of the
cases there was abnormal fetal morphology with normal karyotype. In summary, in only 7% of the cases no abnormality was documented.2
Uterine/cervical (etiologic factors)

There is an increased risk of pregnancy loss or prematurity in the presence of a
congenital uterine anomaly. A septate uterus carries the highest risk for spontaneous abortion and a didelphys uterus carries the highest risk for prematurity.
Without treatment, successful pregnancy rates had been reported between
30%85%.
Metroplasty has been associated with successful pregnancy
rates 50%88%, whereas cerclage has been associated with successful pregnancy rates 80%. Another possibility is an impacted uterus. The characteristic
triad of an impacted uterus includes:
1. Retroverted/retroexed uterus associated with large broids and/or adhesions;
2. Pregnancy loss at 14-16 weeks gestation; and
3. Normal placental histology.
These patients usually present with lower pelvic discomfort, urinary symptoms (inability to void) and sometimes constipation. The treatment is elevation
of the uterus out of the pelvis using adequate analgesia, anesthesia or even CO2
insufation.
Abnormal cervical competence should be ruled out in patients with a history
of mid-trimester pregnancy loss or spontaneous preterm delivery <28 weeks
gestation. These patients should be followed with transvaginal cervical sonography starting at 16 18 weeks. High-risk patients (previous second trimester
loss or spontaneous preterm delivery) and a short cervix (cervical length <1.6
cm) are considered for cerclage.
538
Infectious etiologic factors

There is no good evidence that infectious evaluation is useful in patients with
recurrent rst trimester losses. If there is a history of abnormal cervical competence, mid-trimester loss or intraamniotic infection, then testing for bacterial
vaginosis, trichomonas or mycoplasma species may be indicated in the following pregnancies.
Hormonal etiologic factors

Uncontrolled diabetes mellitus increases the risk for spontaneous abortion by
2-3-fold. Uncontrolled thyroid disease (hypo/hyperthyroidism) is rare and the
presence of thyroid antibodies may be found among women with increased risk
for recurrent pregnancy loss.
Autoimmune etiologic factors

Antiphospholipid syndrome is implicated for 5%-15% of pregnancy losses.
The diagnosis requires at least one clinical and one laboratory criterion.
Clinical criteria include: venous or arterial thrombosis, at least one unexplained fetal death, delivery <32 weeks due to several preeclampsia or growth
restriction and three or more consecutive rst trimester spontaneous abortions (atypical antiphospholipid syndrome). The laboratory criteria include:
positive lupus anticoagulant and positive anticardiolipin antibodies (mediumto-high >20 units IgG or IgM). Untreated pregnancies are associated with
overall pregnancy loss in 90% of the cases. Fetal deaths account for 40% of
these losses and they usually occur in the second or early third trimester of
pregnancy. Treated pregnancies will end up having live births (60%-80%),
preeclampsia (50%), fetal distress (50%) and low birth weight (30%-35%).
Treatment for antiphospholipid syndrome should include heparin and aspirin.
Prednisone is contraindicated because it is associated with a 4.8-fold increase
in prematurity.3
Alloimmune etiologic factors

Treatment for alloimmune factors is not advisable and it is only experimental
at this point.
539
Congenital thrombophilias
The prevalence of fetal losses in women with congenital thrombophilias is increased by 3.6- fold. These thrombophilias include Factor V Leiden, prothrobin
gene mutation, antithrombin III deciency, protein C deciency, protein S deciency and perhaps homozygous homocystinemia.
Diagnostic workup for pregnancy loss

We offer parental karyotyping (especially in recurrent rst trimester losses),
sonohysterography/hysteroscopy (in all cases), cycle day 3 FSH and estradiol,
TSH (in rst trimester recurrent spontaneous abortions), lupus anticoagulant
and anticardiolipin antibodies (2nd/3rd trimester growth restriction/placental
thrombosis), congenital thrombophilia testing (2nd/3rd trimester growth restriction/placental thrombosis), early screening for mycoplasma species, bacterial
vaginosis, trichomonas (if prior pregnancy loss was associated with intraamniotic infection) and review of all placental/fetal pathology slides (in all cases). In
or experience, the most frequent causes of pregnancy loss <13 weeks include
abnormal conceptions, polyps, uterine septum and rarely environmental factors (i.e. diabetes); for losses between 14-16 weeks (impacted uterus, chronic
endometritis); losses between 17-28 weeks (intraamniotic infection, cervical
insufciency, ischemia and abruptio) and losses >28 weeks could be due to a
variety of causes. A complete workup will identify possible etiologic factors
in the majority of cases.
References
1.
2.
3.
Philipp T, Philipp K, Reiner A, et al. Embryoscopic and cytogenetic analysis of 233 missed
abortion factors involved in the pathogenesis of developmental defects of early failed pregnancies. Human Reprod 2003:18:1724-32.
Hogge WA, Byrnes AL, Lanasa MC, Surti U. The clinical use of karyotyping spontaneous
abortions. Am J Obstet Gynecol 2003;189:397-400; discussion 400-2.
Empson M, Lassere M, Craig JC, Scott JR. Recurrent pregnancy loss with antiphospholipid
antibody: a systematic review of therapeutic tasks. Obstet Gynecol 2002;99:135-44.
540
The use of new ultrasonographic

technologies in the evaluation of uterine
anomalies
Nazzaro G. Locci M. De Placido G.
Recent advances in diagnostic ultrasounds have greatly improved the possibility to study uterine morphology. In particular, the role of three dimensional
sonography seems to play a critical role in the evaluation of uterine malformations. The coronal view of the uterus, plane of scanning undetectable by
two dimensional sonography, and the three dimensional reconstruction of this
organ provide an exact relationship between two uterine emicavities in all cases
of duplication (septatate uterus, bicornuate, arcuate). Recent studies and our
experience show that three dimensional study of uterine morphology is more
accurate than radiographic evaluation and, sometimes, this technique should be
preferred even to magnetic nuclear resonance. In addition, the possibility offered by some ultasonographic devices, to obtain multiple slices of the scanned
volume provides a precise description of a lesion i.e., uterine miomas, polyps,
tumors- giving information about its extension, in the three planes, its relation
with other tissues and its echogenicity: all these data are of fundamental importance for the surgical approach. Furthermore, some post processing effects,
such as the magnetic resonance effect, included in some 3D ultrasound equipments, provides suggestive images that facilitates the differentiation between
different types of tissues.
Another method to obtain important information in case of uterine anomalies is given by 3D sonohisterography. The three dimensional reconstruction
and the visualization of the coronal view of a sonohisterographic scan greatly
emphasize the information obtained by saline infusion sonography alone.
Recently, we have reported our experience in the use of color and power
Doppler sonography in differentiating bicornuate from sepatate uterus. We have
541
shown that in the former two main branches of the uterine artery join at the
midline of the uterus, between the two emicavities, giving rise to a single vessel
that ows across the uterine body. On the contrary, an irregular vascularization
of the midline, with different case-related degrees of intensity, is found in case
of septate uterus. Of course, three dimensional sonography greatly improves
the nal depiction of these data, giving crucial information about the type of
therapeutic approach.
Maybe, in the near future, advances in ultrasound diagnostic equipments
could make transvaginal sonography the only uninvasive diagnostic technique
to study some types of uterine anomalies prior to submit patients i.e., in case
of infertility to surgical treatment.
542
Clinical controversies in the

management of Preterm Labor
Tocolytic efcacy what is the
evidence?
Khalid S Khan, MBBS, FCPS, MSc, MRCOG, MMEd
University of Birmingham Birmingham Women's Hospital, Birmingham B15 2TG, UK
Background
Spontaneous preterm labour (SPTL), which results in preterm birth (PTB), is
the major cause of neonatal mortality1 and morbidity2 in the developed world
and imposes a huge drain on health care resources3,4. Spontaneous PTB prior
to 37 weeks' gestation occurs in 711% of pregnancies and occurs in 37%
of pregnancies before 34 weeks gestation. Preterm delivery, particularly that
before 34 weeks gestation, accounts for three-quarters of neonatal mortality
and one-half of long term neurologic impairment in children. Many of the
surviving infants suffer serious morbidity such as broncho-pulmonary dysplasia, intraventricular haemorrhage, retrolental broplasia and developmental
problems. Advances in perinatal healthcare have not reduced the incidence
of SPTL, but there are some effective treatments. The decision regarding the
institution of these interventions requires timely and accurate screening and
diagnosis of pregnant women for the risk of preterm birth. The primary aim of
treating preterm labour is to delay delivery for 48 hours long enough to allow
corticosteroid administration, to facilitate fetal lung maturation, and to permit
transfer to the NICU where the newborn baby can receive optimal care.
There are two target populations of pregnant women that need to be tested
and treated for PTB. The rst is a population of antenatal asymptomatic women
having routine care. In this population, women are generally in a healthy state,
anticipating a normal course of pregnancy. There might be antecedent factor(s)
or current history that might increase the risk of preterm birth. Even when there
is no apparent predisposing factor(s) (e.g. risk scoring systems), routine ante-
543
natal test(s) undertaken for a different reason (e.g. multiple serum screening
test for Downs syndrome risk assessment) may be utilised to uncover hitherto
unknown risks of preterm birth. Additionally, there may be specic tests (e.g.
transvaginal ultrasonographic measurement of cervical length, cervico-vaginal
fetal bronectin detection or bacterial vaginosis (BV) screening) which may
help identify those women at higher risk of preterm birth. If testing could
predict risk of spontaneous preterm birth among these women, interventions
such as progesterone (tocolysis), antibiotics (for BV), cervical cerclage (for
short cervix on scan) and closer surveillance (to optimise antenatal care) may
be considered as preventative measures.
The second population group is that of symptomatic women who present with threatened preterm labour. For these women, there is a need to
delineate who among them will go on to deliver preterm. Many tests have
claimed to predict the risk of preterm delivery in this group of women
(e.g. cervico-vaginal fetal bronectin, corticotrophin-releasing hormone, and
salivary estriol). If testing could predict imminent spontaneous PTB among
these women before advanced cervical dilatation, therapies like antenatal
steroids, tocolytics and in-utero transfer (to optimise neonatal care) may
be used. Antenatal steroids have maximal effectiveness among neonates
delivered within 27 days after administration, and tocolytics are known
to effectively delay birth for at least 2 days (to allow use of steroids and
in-utero transfer).
This presentation will focus on the issues surrounding the controversies in
determining the need for tocolysis and the choice of tocolytic agents.
Controversies in determining the need for tocolysis

Prediction of pregnant womens risk for PTB both for screening or diagnosis is
based on a combination of patients characteristics, symptoms, physical signs
and investigations. I consider all of these variables to be tests. Without accurate tests clinicians are handicapped in the management of pregnant women.
Wrong or delayed diagnosis can put mother and baby at risk of an adverse
outcome whereas the correct prediction of preterm birth provides an opportunity to institute effective therapeutic interventions. There is, therefore, a need
for guidance about the best testing strategies with which to predict the risk of
spontaneous PTB. This presentation will summarize evidence on prediction of
PTB in both asymptomatic and symptomatic pregnant women, which would
have implications for tocolysis.
544
Controversies in the choice of tocolytic agents

Several clinical trials and their systematic reviews have shown that tocolytic
agents can inhibit preterm uterine contractions and hence delay labour and
prolong gestation.5-9 Study quality is the Achilles heel of primary research, as
well as systematic reviews. In systematic reviews and meta-analyses, where
study quality assessment is not comprehensive, the conclusion reached may be
invalid.10 Although advice exists on the assessment of method-specic items
of quality, little guidance is available on topic-specic items, since they cannot
be generalized across therapeutic areas. In tocolytic trials, such items include
maternal risk factors, diagnostic techniques, methods of conrming gestational
age as well as dose, preparation and route of administration of the intervention,
all of which impact on study validity directly.
A tool to assess the method- and topic-specic quality of comparative trials
of tocolytic efcacy will be presented. We have recently used this tool to evaluate 40 method- and topic-specic items of quality with respect to selection,
performance and measurement bias in 31 comparative tocolytic trials with nifedipine identied by an exhaustive literature search. We found that the quality
of studies of tocolytic efcacy of nifedipine was generally poor when assessed
using the quality tool. Very few of the studies complied with adequacy criteria
of quality for either method- or topic specic items and there was no improvement in study quality over time. Compliance with quality items was poorer for
method-specic items compared with topic-specic items. Evidence collated
from poor quality studies may unduly inuence clinical practice guidelines.
A recent meta-analysis of randomised trials of progestational agents found
them effective in reducing the risk of preterm delivery below 37 weeks amongst
asymptomatic pregnant women. As many trials are old and perceived to be of
poor methodology, consideration of the quality of methods is critical before
valid inferences can be drawn. In a systematic review of all studies of progestational agents in the prevention of PTB using sound methods, we performed
cumulative meta-analyses for the most commonly reported outcome of delivery
below 37 weeks. In the rst cumulative meta-analysis, the results were updated
whenever a new relevant trial became available for inclusion in the review.
In the second cumulative meta-analysis, we started with the highest quality
studies, and added lesser quality studies progressively, to explore the effect
of study quality on the results. Progestational agents are effective in reducing
various clinically relevant outcomes. Many studies over the years have been
consistent in showing this benet. The statistical signicance for the benet
of progesterone was reached in mid-seventies, and as the p-value is presently
545
so small for the outcome of delivery below 37 weeks, the observed effect is
extremely unlikely to be a chance nding. The effects could not be discarded
on account of earlier poor quality studies, as limiting the analysis to the highest
quality studies still shows clear benet.
Until recently, beta-agonists have been recommended as the standard tocolytic for symptomatic pregnant women in the UK. They reduce the number of
deliveries that occur within 48 hours of commencing therapy, compared with
placebo or no treatment. Recently either the calcium channel blocker, nifedipine or the oxytocin antagonist, atosiban have been proposed as alternatives.11 A
meta-analysis of randomised controlled trials comparing nifedipine and betaagonists concluded that nifedipine was more effective at prolonging pregnancy,
had fewer maternal side effects and improved neonatal outcomes. Oxytocin antagonists have also shown a trend towards improved prolongation of pregnancy
and fewer maternal side effects compared with beta-agonists. However, no
randomised controlled trials directly comparing nifedipine with atosiban exist.
In the absence of a direct comparison of two therapies, a method of adjusted
indirect comparison could be performed. As both nifedipine and atosiban have
been evaluated against a common comparator, beta-agonists, it is possible to
carry out an indirect analysis comparing effects of nifedipine versus atosiban.
We performed such a meta-analysis and found that nifedipine tocolysis was associated with a signicant reduction in respiratory distress syndrome compared
with atosiban. When indirectly compared with atosiban, nifedipine tocolysis
seemed more effective. In the absence of a direct comparison, our analysis
provides a way to explore the attributes of nifedipine (unlicensed use) versus
atosiban (licensed use). A comprehensive clinical trial programme is required
to establish tocolytic efcacy in improving outcomes of preterm labour.
Conclusion
Systematic reviews and innovative meta-analytic techniques (cumulative metaanalysis and indirect comparison) are useful in gaining insight into the efcacy
of tocolysis. However, conclusions based on these are only as robust as the
quality of the original trials permit. Systematic reviews and meta-analyses
should employ items of quality as a measure of study validity and take into
account any deciencies in studies that inuence inferences.
546
References
Magowan BA, Bain M, Juszczak E, McInneny K. Neonatal mortality amongst Scottish preterm
singleton births (1985-1994). Br J Obstet Gynaecol 1998; 105: 10051010.
Wood NS, Marlow N, Costeloe K, Gibson AT, Wilkinson AR. Neurologic and developmental disability after extremely preterm birth. EPICure Study Group. N Engl J Med 2000; 343: 378384.
Keirse MJ. New perspectives for the effective treatment of preterm labor. Am J Obstet Gynecol 1995;
173: 618628.
Petrou S. Economic consequences of preterm birth and low birthweight. Br J Obstet Gynaecol 2003;
110 Suppl 20: 1723.
King JF, Grant A, Keirse MJ, Chalmers I. Beta-mimetics in preterm labour: an overview of the
randomized controlled trials. Br J Obstet Gynaecol 1988; 95: 211222.
Anotayanonth S, Subhedar N, Garner P, Neilson J, Harigopal S. Betamimetics for inhibiting preterm
labour. Cochrane Database Syst Rev 2004:CD004352.
Oei SG, Mol BW, de Kleine MJ, Brolmann HA. Nifedipine versus ritodrine for suppression of
preterm labor; a meta-analysis. Acta Obstet Gynecol Scand 1999; 78: 783788.
Tsatsaris V, Papatsonis D, Gofnet F, Dekker G, Carbonne B. Tocolysis with nifedipine or betaadrenergic agonists: a meta-analysis. Obstet Gynecol 2001; 97: 840847.
King JF, Flenady V, Papatsonis D, Dekker G, Carbonne B. Calcium channel blockers for inhibiting
preterm labour; a systematic review of the evidence and a protocol for administration of nifedipine. Aust N Z J Obstet Gynaecol 2003; 43: 192198.
Khan KS, Daya S, Jadad A. The importance of quality of primary studies in producing unbiased
systematic reviews. Arch Intern Med 1996; 156: 661666.
Royal College of Obstetricians and Gynaecologists. Tocolytic drugs for women in preterm labour.
Clinical Guideline No. 1(B) 2002.
547
Fetal growth: Implication for perinatal care
Cerebral palsy and fetal growth

Bo Jacobsson, M.D. Ph.D.
Perinatal Centre, Department of Obstetrics and Gynaecology Sahlgrenska University
Hospital / East SE 416 85 Gteborg, Sweden and North Atlantic Neuro-Epidemiology
Alliances (NANEA), University of Aarhus DK-8000 Aarhus C, Denmark
bo.jacobsson@obgyn.gu.se
Cerebral palsy (CP) is dened as a group of non-progressive, but often changing, motor impairment syndromes, secondary to lesions or abnormalities of
the brain, and arising in the early stages of development (1). CP diagnosed in
the rst two years of life may resolve during early childhood, especially when
functional impairment is mild (2-4). Mild CP had resolved in 72% of the cases
on re-examination at age seven in one study (2). Nonetheless, children with
resolved CP were almost 10 times more likely to be mentally retarded, which
indicates that the neurological abnormalities observed were a valid indication of antecedent brain damage rather than a variation on the normal (2, 5).
This indicates that the child must be at least 4 or 5 years old before a reliable
diagnosis can be made (6).
As an effect of the success of newborn intensive care during the last three
decades ensuring an increasing survival of children born very and extremely
preterm, the prevalence of CP among preterm children has risen (6, 7). The
aetiology of CP is still poorly understood and since CP is not a disease but a
symptom complex, it is not surprising that there are considerable problems
associated with epidemiological studies of CP aetiology: the long time-lag
between recognition of CP and the presumed brain damage, disagreements
among examiners about clinical ndings in patients and changes in clinical
ndings over time and, due to the lack of a denitive test for CP, multiple and
different possible causes (5). Some risk factors have been repeatedly observed
to be related CP: low gestational age (5, 6, 8), low Apgar scores (8, 9), male
gender (5), multiple gestation (10), intrauterine viral infections (e.g. rubella,
548
cytomegalovirus) (11-13), iodine deciency (14), exposure to methyl mercury

during pregnancy (12, 15) and maternal thyroid abnormalities (12, 16). The
higher risk of CP in multiple births is apparently related to preterm birth or to
antenatal death of a co-twin or co-triplet (10, 17, 18). This chapter will deal
with intrauterine growth as a risk factor for CP in term and preterm infants.
It is also important to bear in mind that the studies of the antecedent factors of CP poses challenges because of the long time-lag to its recognition,
the changes in clinical ndings over time, the lack of a denitive test and
the heterogeneous nature of the condition (5). In addition, cohorts need to be
large enough with sufcient numbers in each major diagnostic subgroup and
gestational age range. These reservations are certainly true when it comes to
intrauterine fetal growth as it is difcult to gather information retrospectively
on fetal growth and prospective studies pose a special challenge of the sample
size as CP only affect 2 per 1000 live births.
Intrapartal factors producing asphyxia have traditionally been assumed to
be the principal cause of CP, but this assumption has been reconsidered during
the 80- and 90-ties. Today, intrapartal asphyxia is still believed to account for a
relatively large proportion of CP in term and near-term born infants, around 10
% (5); some researchers feel that this gures is too low (6). Using indirect signs
of birth asphyxia, recent studies suggest that 1) birth asphyxia may sometimes
constitute one element of a multifactorial cause, 2) neonatal signs associated
with birth asphyxia may be early manifestations of CP from a variety of causes,
of which birth asphyxia is only one, 3) the majority of pathways to CP commence pre-delivery (5, 16, 19-21).
Small for gestational age (SGA) and intrauterine growth restriction (IUGR)
are on denition often mixed up, even by obstetricians. IUGR is commonly
accepted as a pathological process that affects normal fetal growth and results
in an infant smaller than its inherited potential. SGA is merely a denition
of a deviation from a calculated mean. Only some SGA infants are result of
a pathological process. The growth of a fetus may result in an infant that is
below the standard cut-off point, but in accordance with that specic individuals inherited growth potential and therefore completely normal and not part
of a pathological process. So SGA composes a mixed group of both normally
and pathologically grown children. Another problem is that the denition of
SGA often depends on a birth weight standard which gives a scew deviation
to the low in the preterm infants due to that preterm born infants are born after
a pathological process. Numerous growth curves and methods exist and differ from one another as they are based on different populations, time periods
and different ways of correcting for certain factors. Due to this shewness it is
549
recommended that deviation from estimated birth weight should be done from
a curve based on intrauterine fetal growth measurements (22). This standard
based on intrauterine measurements is especially better suited when studying
preterm infants. There is no agreement on what cut-off limit is acceptable for
dening SGA. The most widely used is infant birth weight below the tenth
centile for gestational age. Another denition of SGA often used is that of that
an infant whose birth weight is less than two standard deviations from the mean
for gestational age is SGA.
There are three ways of achieving information on true IUGR: by serial
ultrasound estimates and doppler measurements during pregnancy were a decreasing growth is detected, by paediatric indices and by using individualized
or customized growth standard. An individualized or customized growth standard (23) is able to make adjustments for constitutional variation, and provide
limits which separate IUGR from the small, healthy and normally grown SGA
infants (24, 25).
Some specic alterations in the brain of IUGR infants, including restriction of the volume of grey matter (26), reduced amount of total DNA in both
glia cells and neurons and changes in cerebral haemodynamics, have been
reported (27). This is also supported by animal studies showing reduced oxygen
delivery to the brain and retarded growth of the forebrain and cerebellum (28,
29). Therefore, IUGR has been hypothesized to be related to brain injury and
CP. A brain sparing mechanism has been suggested to prevent or reduce the
severity of brain injury in growth restricted children (30).
Several studies have found a relationship between CP in term infants and
SGA (31-35). No such association has been found in preterm infants (8), even
if there are two studies that suggests such relationship based on fetal weight
standards (32, 35). The problem with the latter two studies is that they do not
compare the growth between children that were born preterm with and without
CP, but just the birth weight deviation for children with CP.
We have performed a study to investigate the association between IUGR
as diagnosed by a low customised birthweight percentile with the subsequent
development of CP or not (36). Our ndings suggest that CP is linked to IUGR
in babies born at term, but not in those born preterm. An association between
preterm birth and CP is well known both regarding the type of CP (spastic
diplegia) and decreasing gestational age (37, 38). There is also a link between
spontaneous preterm labor and SGA (39) and also some studies indicate a link
between spontaneous onset of labor and CP (40, 41). However, our results
clearly show that preterm babies which were growth restricted measured by
low customized birth weight percentiles did not have an increased risk of devel-
550
oping CP compared to controls, i.e. babies born at similar preterm gestations.

In contrast, babies born at term with evidence of IUGR had a substantially elevated risk. Most instances of IUGR are associated with placental insufciency,
and it is tempting to hypothesise that a prolonged period of reduced intrauterine
nutrition will put the baby at increased risk of developing CP.
There is little doubt that, at term, the delivery of a fetus diagnosed with
IUGR should be expedited. However at preterm gestations there is also an argument that early delivery may lead to iatrogenic neonatal complications associated with preterm birth. Ideally the timing of delivery for the growth restricted
fetus ought to be addressed through prospective randomised trials large and
long enough to look at CP as outcome, but to our knowledge only one such trial
has been undertaken (42). This study indicates that a prompt preterm delivery
of IUGR children at does not decrease the risk of CP than a delivery a couple
of days later when several measurements indicate that delivery is essential for
survival. However, concerns has been raised about the external validity of the
study (43, 44). In the absence of evidence to the contrary, our ndings suggest
that birth at term following a period of poor intrauterine nutrition is associated
with substantial risk for an abnormal neurological development.
The inammatory/cytokine hypothesis one of the important prenatal hypotheses, proposed initially by Leviton and Adinol, according to which a maternal
infection may lead to elevated fetal blood and brain cytokine levels, which may
result in central nervous damage and subsequent CP (45-47). Clinical studies
have supported this hypothesis (8, 48). We have recently found that mice pups
exposed to intrauterine lipopolysacharide at day 15 of a 19-20 long pregnancy
showed a decreased weight at 14 days post partum. There were no difference
in the body/brain ratio between these pups and control pups that had a saline
solution injected (49). This suggests that intrauterine infections besides a direct
effect on the brain and increased vulnerability of the brain, also might affect
the growth of the fetus and infant after birth.
The mechanism how IUGR/SGA is related to CP is unclear. Different pathways have been suggested. The major hypotheses are that the brain of a fetus
with IUGR is more vulnerable, i.e. to asphyxia, or that an early insult is related
to a deviated growth of the fetus or a mixture of both.
551
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Mutch L, Alberman E, Hagberg B, Kodama K, Perat MV. Cerebral palsy epidemiology: where
are we now and where are we going? Dev Med Child Neurol 1992;34(6):547-51.
Nelson KB, Ellenberg JH. Children who "outgrew' cerebral palsy. Pediatrics 1982;69(5):52936.
Ross G, Lipper EG, Auld PA. Consistency and change in the development of premature infants
weighing less than 1,501 grams at birth. Pediatrics 1985;76(6):885-91.
Ford GW, Kitchen WH, Doyle LW, Rickards AL, Kelly E. Changing diagnosis of cerebral
palsy in very low birthweight children. Am J Perinatol 1990;7(2):178-81.
Blair E, Stanley F. Issues in the classication and epidemiology of cerebral palsy. Ment Retard
Dev Disabil Res Rev 2002;3:184-93.
Hagberg B, Hagberg G, Beckung E, Uvebrant P. Changing panorama of cerebral palsy
in Sweden. VIII. Prevalence and origin in the birth year period 1991-94. Acta Paediatr
2001;90(3):271-7.
Bhushan V, Paneth N, Kiely JL. Impact of improved survival of very low birth weight infants
on recent secular trends in the prevalence of cerebral palsy. Pediatrics 1993;91(6):1094-100.
Jacobsson B, Hagberg G, Hagberg B, Ladfors L, Niklasson A, Hagberg H. Cerebral palsy in
preterm infants: a population-based case-control study of antenatal and intrapartal risk factors.
Acta Paediatr 2002;91(8):946-51.
Nelson KB, Ellenberg JH. Apgar scores as predictors of chronic neurologic disability. Pediatrics
1981;68(1):36-44.
Nelson KB, Grether JK. Causes of cerebral palsy. Curr Opin Pediatr 1999;11(6):487-91.
Stanley FJ, Sim M, Wilson G, Worthington S. The decline in congenital rubella syndrome
in Western Australia: an impact of the school girl vaccination program? Am J Public Health
1986;76(1):35-7.
Stanley FJ. Prenatal determinants of motor disorders. Acta Paediatr Suppl 1997;422:92-102.
Hagberg H, Mallard C. Antenatal brain injury: aetiology and possibilities of prevention. Semin
Neonatol 2000;5(1):41-51.
Pharoah PO, Butteld IH, Hetzel BS. Neurological damage to the fetus resulting from severe
iodine deciency during pregnancy. Lancet 1971;1(7694):308-10.
Amin-Zaki L, Majeed MA, Elhassani SB, Clarkson TW, Greenwood MR, Doherty RA.
Prenatal methylmercury poisoning. Clinical observations over ve years. Am J Dis Child
1979;133(2):172-7.
Blair E, Stanley F. When can cerebral palsy be prevented? The generation of causal hypotheses
by multivariate analysis of a case-control study. Paediatr Perinat Epidemiol 1993;7(3):272301.
Pharoah PO, Adi Y. Consequences of in-utero death in a twin pregnancy. Lancet
2000;355(9215):1597-602.
Scher AI, Petterson B, Blair E, Ellenberg JH, Grether JK, Haan E, Reddihough DS, YearginAllsopp M, Nelson KB. The risk of mortality or cerebral palsy in twins: a collaborative population-based study. Pediatr Res 2002;52(5):671-81.
Blair E, Stanley FJ. Intrapartum asphyxia: a rare cause of cerebral palsy. J Pediatr
1988;112(4):515-9.
Stanley FJ, Blair E. Why have we failed to reduce the frequency of cerebral palsy? Med J Aust
1991;154(9):623-6.
Nelson KB. What proportion of cerebral palsy is related to birth asphyxia? J Pediatr
1988;112(4):572-4.
Marsal K, Persson PH, Larsen T, Lilja H, Selbing A, Sultan B. Intrauterine growth curves based
552
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.

on ultrasonically estimated foetal weights. Acta Paediatr 1996;85(7):843-8.
De Jong CL, Francis A, Van Geijn HP, Gardosi J. Customized fetal weight limits for antenatal
detection of fetal growth restriction. Ultrasound Obstet Gynecol 2000;15(1):36-40.
Clausson B, Gardosi J, Francis A, Cnattingius S. Perinatal outcome in SGA births dened by
customised versus population-based birthweight standards. Bjog 2001;108(8):830-4.
de Jong CL, Gardosi J, Dekker GA, Colenbrander GJ, van Geijn HP. Application of a customised birthweight standard in the assessment of perinatal outcome in a high risk population. Br
J Obstet Gynaecol 1998;105(5):531-5.
Toft PB, Leth H, Ring PB, Peitersen B, Lou HC, Henriksen O. Volumetric analysis of the normal infant brain and in intrauterine growth retardation. Early Hum Dev 1995;43(1):15-29.
Chase HP, Welch NN, Dabiere CS, Vasan NS, Buttereld LJ. Alterations in human brain
biochemistry following intrauterine growth retardation. Pediatrics 1972;50(3):403-11.
Jensen A, Klonne HJ, Detmer A, Carter AM. Catecholamine and serotonin concentrations
in fetal guinea-pig brain: relation to regional cerebral blood ow and oxygen delivery in the
growth-restricted fetus. Reprod Fertil Dev 1996;8(3):355-64.
Rees S, Mallard C, Breen S, Stringer M, Cock M, Harding R. Fetal brain injury following
prolonged hypoxemia and placental insufciency: a review. Comp Biochem Physiol A Mol
Integr Physiol 1998;119(3):653-60.
Scherjon SA, Oosting H, Smolders-DeHaas H, Zondervan HA, Kok JH. Neurodevelopmental
outcome at three years of age after fetal 'brain-sparing'. Early Hum Dev 1998;52(1):67-79.
Uvebrant P, Hagberg G. Intrauterine growth in children with cerebral palsy. Acta Paediatr
1992;81(5):407-12.
Thorngren-Jerneck K. Cerebral injury in perinatal asphyxia. Lund: Lund University; 2002.
Liu J, Li Z, Lin Q. [Intrauterine growth retardation and cerebral palsy]. Zhonghua Yu Fang Yi
Xue Za Zhi 2001;35(6):390-3.
Liu J, Li Z, Lin Q, Zhao P, Zhao F, Hong S, Li S. Cerebral palsy and multiple births in China.
Int J Epidemiol 2000;29(2):292-9.
Jarvis S, Glinianaia SV, Torrioli M, Platt M, Miceli M, Jouk P, Johnson A, Hotton J, Hemming
K, Hagberg G, Dolk H, Chalmers J. Cerebral palsy and intrauterine growth in single birth:
European collaborative study. Lancet 2003;362:1106-11.
Jacobsson B, Francis A, Hagberg G, Hagberg H, Gardosi J. Cerebral palsy is strongly associated with severe intrauterine growth restriction in term but not in preterm cases. Am J Obstet
Gynecol 2003;189(6):S74.
Hagberg B, Hagberg G. The changing panorama of cerebral palsy--bilateral spastic forms in
particular. Acta Paediatr Suppl 1996;416:48-52.
Stanley F, Blair E, Alberman E. Cerebral palsies: Epidemiology and Casual Pathways. London:
MacKeith Press; 2000.
Morken NH, Kllen K, Jacobsson B. Fetal growth and onset of delivery: a nationwide
population-based study on preterm infants. J Gynecol Invest 2005;Abstract for Society of
Gynecological Investigations; Los Angeles Mars 2005.
Morken NH, Kllen K, Jacobsson B. Type of onset of delivery and child outcome in a nationwide population-based study among preterm children: special focus on cerebral palsy. J
Gynecol Invest 2005;Abstract for Society of Gynecological Investigations; Los Angeles Mars
2005.
Dammann O, Allred EN, Veelken N. Increased risk of spastic diplegia among very low birth
weight children after preterm labor or prelabor rupture of membranes. J Pediatr 1998;132(3
Pt 1):531-5.
Thornton JG, Hornbuckle J, Vail A, Spiegelhalter DJ, Levene M. Infant wellbeing at 2 years of
age in the Growth Restriction Intervention Trial (GRIT): multicentred randomised controlled
trial. Lancet 2004;364(9433):513-20.
553
43.
44.
45.
46.
47.
48.
49.
Thornton J. GRIT: concern about external validity. Lancet 2005;365(9457):385.

Gardosi J. GRIT: concern about external validity. Lancet 2005;365(9457):384; author reply
385.
Dammann O, Leviton A. Infection remote from the brain, neonatal white matter damage, and
cerebral palsy in the preterm infant. Semin Pediatr Neurol 1998;5(3):190-201.
Adinol M. Infectious disease in pregnancy, cytokines and neurology impairment: an hypothesis. Dev Med Child Neurol 1993;35(6):549-553.
Leviton A. Preterm birth and cerebral palsy: is tumor necrosis factor the missing link? Dev
Med Child Neurol 1993;35(6):553-8.
Grether JK, Nelson KB. Maternal infection and cerebral palsy in infants of normal birth weight.
Jama 1997;278(3):207-11.
Wang X, Hagberg H, Mallard C, Hedtjarn M, Eriksson K, Rosen , Jacobsson B. Disruption
of IL-18, but not IL-1, increases vulnerability to preterm delivery and fetal mortality following intrauterine inammation. J Gynecol Invest 2005;Abstract for Society of Gynecological
Investigations; Los Angeles Mars 2005.
554
Intrauterine growth in twin

pregnancies
S. M. Kady, Andre Francis, Jason Gardosi
West Midland Perinatal Institute, Crystal Court, Aston Cross, Birmingham, UK
Introduction
Multiple pregnancies have always been the subject of intense medical and
social interest, representing a unique opportunity for determining the relative
contributions of genetic and environmental inuences upon human growth and
development.
Birth statistics for the year 2003 show that the multiple birth rate in England
& Wales is 1.5% of all maternities. In the past two decades it has increased
by 50% in England and Wales 1 and by 74% in the United States 2. Although
one-fourth of this is due to child bearing among women of older ages, threefourths is due to infertility treatments and assisted reproductive techniques 3.
The combined effects of congenital anomalies, premature deliveries, maternal
antenatal complications and low birth weight ensures that the perinatal mortality for multiple pregnancies remains considerably higher than that of singletons
despite advances in perinatal care. Preterm delivery and intrauterine growth
restriction are the leading causes of poor outcome in twin pregnancies 4. There
is a larger increase across weight categories for a given gestational age than
across gestational ages for a given birth weight 5. Twins are almost 10 times
more likely than singleton to have a low birth weight (<2500 g or <1500 g) and
their mean birth weight is approximately 1000 g less than that of singletons
(2400 compared with 3400 g). This weight difference compared with singletons
caused by slower growth and by birth at earlier gestations in approximately
equal measures. Controlled for gestational age, twins weigh approximately
500 g less at term. Hence accurate prenatal assessment of the size of twins
555
is essential in preventing perinatal death. There is a need for greater understanding of twin pathophysiology, including growth, and adoption of effective
management strategies.
Twins and length of pregnancy.

The study of fetal growth in twins needs to include a consideration of the
expected length of pregnancy. Twins are born on average 3 weeks earlier than
singletons. The typical (modal) length of gestation for twins is 37 weeks, for
spontaneous as well as induced deliveries. 5 Thus, if one uses the singleton
denition for premature birth (<37 weeks), half of all twin births are premature.
For triplets, the typical length of gestation is another 3 weeks earlier (i.e., approximately 34 weeks).
The lowest perinatal mortality rate for twins is at 37 weeks16, 7, 8, 9, (i.e., 3
weeks earlier than for singletons) and there is evidence that lung maturation in
twins also occurs earlier than in singletons 10.
Considerations of normal gestation length are important than when counseling a mother at the beginning of pregnancy, as Naegeles rule for determining
the expected date of connement does not apply in multifetal pregnancy. It is
also relevant when determining a date for elective delivery by cesarean section,
if this is indicated. If a date is set for 38 to 39 weeks, as is customary for singletons, then most twin pregnancies would have already commenced spontaneous
labour at this gestational age, and a planned elective procedure is more likely
to become an emergency procedure with its attendant increased risks. Based on
these considerations, the optimum time to plan an elective cesarean section in
twins is at about 37 weeks for sure dates based on an early dating scan.
Intrauterine growth of twins compared with singletons

The pattern of fetal growth in twin gestation has not yet been clearly characterised. Adequate measurement of prenatal growth of twins by using a standard growth curve for singletons is still controversial. Studies have indicated
that the pattern of intrauterine growth for multiple births differs from that of
singletons, although the point of differentiation has varied 11, 12. Naeye et al 13,
14
suggested that intrauterine growth of twins did not parallel singleton growth.
Extrapolating from live-born twin birthweight data, they concluded that the
weight of twins is similar to that of singletons until the 30th week of gestation,
at which time twin weight gain decreases throughout the rest of third trimester.
By term, weights of twins are on an average 10% lower than those of singletons
556
. Using necropsy data, they also showed a fall-off in weight at about 30 weeks
of gestation in twin fetal organs, including the heart, lungs, kidneys, liver,
spleen, adrenal glands and brain 14. Interestingly, the only anthropomorphic
parameter that remained at the singleton mean level throughout gestation was
fetal body length 13. Daw and Walker 15, again using birthweight data of live
born twins found that after about 30 weeks gestation, the total fetal weight gain
in a twin pregnancy was similar to the total singleton weight gain, resulting
therefore in diminished weight gain in each twin fetus in the latter part of the
third trimester.
13
Weight (grams)
S ingle t o n gro wt h - 5 0 t h c e nt ile (Hadlo ck/Wilco x)

(standard = superno rmal twin1fetal weight - no bwt )
4000
3500
3000
2500
2000
1500
1000
500
0
24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Gestatio n (weeks)
Biparietal diameter (BPD) has been the most widely studied growth parameter in twins. 16, 17, 18 Some investigators have found smaller BPDs in twin
gestation at all gestational ages 17, 18, while others have found a decrease in twin
BPD growth only during the third trimester 19. Very limited investigations have
been performed of other growth parameters, such as femur length (FL) and
abdominal circumference (AC). Grumbach et al 19 studied the growth pattern
of BPD, FL and AC in 103 twin pregnancies and compared them to singletons,
showing a decrease of BPD growth after 31 to 32 weeks of gestation relative
to singletons. Twin AC growth rate decreases after 32-33 weeks of gestation
557
relative to singletons, but the twin FL growth pattern does not deviate from
that of a singleton. The recent study by Ong et al 20 showed that the growth
of AC for twins appear to follow closely that for singletons until 32 weeks;
thereafter, there is a gradual but denite fall off in growth compared to the
singleton standard. The pattern of growth of FL is largely similar to that of
singletons, however from mid to early third trimester, the BPD of twin babies
was larger than that of singletons. Abdominal circumference growth and weight
gain were suggested to be slower in multifetal pregnancies. 21 However, these
studies tended to average growth in all pregnancies rather than dene a normal
standard.
Several growth curves have been developed 20, 22, showing that growth of
twins deviates from that of singletons. The use of such charts assumes that
deviation of twin weight from singleton is normal and not pathological, which
has not yet been proven. Other studies have suggested that the growth is similar.
23, 24, 25
The potential danger is that a chart expecting a slower growth trajectory
will not highlight if there is a pathological problem with fetal growth.
Normal growth in twins

To study the normal trajectory of expected weight gain in twin pregnancy,
we examined a dataset of 105 consecutive, normal-outcome twin pregnancies which all had early ultrasonographic dates. Normal outcome was dened
as pregnancies reaching at least 34 weeks of gestation, spontaneous onset of
labour, and inter-twin weight discordance at birth of less than 15%. Serial ultrasonographic estimations of fetal weight in twin A were curve tted according
to a previously described technique.17
The gure shows the resultant curves for the median, 90th and 10th percentiles of optimal fetal growth for twins. As can be seen, there is continued weight
gain and minimal attening towards the end of pregnancy. However the curve
ended at 37 weeks, as there was little data to allow reliable averaging at later
gestations.
This curve was compared with that for singletons derived by Hadlock 26
and showed that the slope of both curves was similar up to 37 weeks. This
suggests that, up to their respective normal gestation lengths, singletons and
twins had similar weight gain. However more twins which continued until
later gestations had lower birthweights, suggesting that a slowing of growth
tends to set in after the optimal length of gestation is reached. This may explain
why growth charts based on birthweights (rather than longitudinal ultrasound
measurements) show a attening of the curve at term.
558
These observations may also suggest that the shorter average length of gestation in twin pregnancy is an adaptive response to growth exceeding placental
function 27, which has implications for monitoring and management.
Singleton grow th - 50th centile
(standard = supernormal tw in1 fetal w eight - no bw t)
Weight (grams)
4000
3500
3000
2500
2000
1500
1000
500
0
23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Gestation (w eeks)
The red line is for twins

Monitoring growth
Prenatal recognition of deviation from normal growth is an important prerequisite to reducing prenatal morbidity and mortality. Assessment of fetal growth
is crucial in twin gestations, since the information gained often has an impact
on pregnancy management. Twin gestations have greater fundal heights and
larger intrauterine volumes than singleton gestations. Fundal height measurements may assess abdominal girth and detect rapid increases associated with
hydramnios, but by themselves are not indicative of fetal growth.
The slowing of growth is predominantly a third trimester phenomenon
28.
The standard method of surveillance is by regular ultrasonographic scan.
Various policies exist for serial scanning, but they should be done at least
559
every 4 weeks and preferably every 2-3 weeks in the 3rd trimester. The most
sensitive measurements for detecting growth disturbances are fetal abdominal
circumference and fetal weight assessment based on abdominal circumference,
femur length and head circumference.
Reports on the accuracy of weight prediction in twin pregnancies are mixed.
Several studies suggest that the errors are larger in twins than in singletons 29,
whereas others have maintained that with appropriate methods and formulas,
the range of error is similar. 30 There is evidence however that the detection of
intertwin discordance is often inaccurate 31, this may be related to problems
with measuring abdominal circumference in a crowded intrauterine environment, oligohydramnios and/or malposition.
The predominant cause of growth restriction in twins, as in singletons, is
placental failure. Intertwin disparities exist in monochorionic and dichorionic
twins. As most twin pregnancies are dichorionic, intertwin disparities are more
likely to be caused by fetal growth restriction than by intertwin transfusion. 32
Even in monochorionic twins who have weight discordance at birth, the smaller
twin has polycythemia in only a third of cases, suggesting that the cause of discordance is more often uteroplacental dysfunction rather than twin-twin transfusion. Surveillance of a fetus with slow growth requires further investigation,
including Doppler velocimetry to establish the optimum time for delivery.
Conclusion
Twin growth is different from that of singletons in that it has a shorter normal
length of pregnancy, with a modal length of 37 weeks. Up to this gestation, normal fetal weight gain is similar to that of singleton fetuses, and can be assessed
using the same growth charts. However, twins are more likely to develop fetal
growth restriction associated with placental insufciency or twin-twin transfusion, and should be monitored with serial ultrasound biometry throughout the
third trimester.
560
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
ONS London, GRO Scotland; GRO Northern Irland. 2003. www.statistics.gov.uk

Martin JA, Hamilton BE, Venture SJ, Menacker F, Birth: Final data for 2000. National vital statistics Reports, Vol. 50, no.5. Hyattsville, MD: National Center for Health Statistics, 2002.
Jewell SE, Yip R. Increasing trends in pleural births in the United States. Obstet Gynecol
1995:85:229-32.
Glinianaia S, Rankin J, Renwick M. Time trenda in twin Perinatal mortality in northern
England, 1982-94. Twin Reseach (1998) 1, 189-195
Gardosi J. Multifetal pregnancy. Scott B. Ransom, editor. Bombrowski M, Moghissi K,
McNeeley G, Munkarah A, associate editors. Practical Strategies in Obstetrics and Gynecology.
Philadelphia, Pennsylvania: Sounder 2000. 337-343.
Luke B, Minogue J, Witter FR, Keith LG, Johnson TR. The ideal twin pregnancy: patterns of
weight gain, discordancy, and length of gestation. Am J Obstet Gynecol. 1993 Sep;169(3):58897.
Minakami H, Sato I. Re-estimating the date of delivery in multifetal pregnancies. JAMA
1996;275:1432-4.
Cheung YB, Yip P, Karlberg J. Mortality of twins and singletons by gestational age: A varying-coefcient approach. American Journal of Epidemiology 2000; 152 (12): 1117-9
Cincotta RB, Flenady V, Hockey R, King J. When should twins be delivered? Gestational
agespecic stillbirth risk of twins vs. singletons. Perinatal Society of Australia and New
Zealand 5th annual Congress: 2001 March13-16: Canberra, Australia 2001:22.
Leveno KJ, Quirk JG, Whalley PJ, Herbert WN, Trubey R. Fetal lung maturation in twin
gestation. Am J Obstet Gynecol .1984 ; 15: 148(4): 405-11.
Schneider L. Bessis R. Tabaste JL. Sarramond MF. Papiernik E. Baudet J. Pontonnier G.
Echographic survey of twin fetal growth: a plea for specic charts for twins. Progress in
Clinical & Biological Research. 24 Pt C:137-41, 1978.
Grennert L. Persson PH. Gennser G. Intrauterine growth of twins judged by BPD measurements. Acta Obstetricia et Gynecologica ScandinavicaSupplement. 78:28-32, 1978.
Naeye RL, benirschke K, Hangstorn JWC, Marcus CC. Intrauterine growth of twins as estimated from live born birth weight data. Pediatrics 1966;37:409-416
Naeye RL. The fetal and neonatal development of twins. Pediatrics 1964;35:546-553
Daw E, Walker J. Growth differences in twin pregnancy. Br J Clin Pract 1975;29:150-152.
Grennert L, Persson P, Gerhard G. Intrauterine growth of twins judged by BPD measurements.
Acta Obstet Gynecol Scand 1978; 78 (Suppl.0;28-32
Leveno KJ, Santose-Ramos R, Duenhoelter JH, Reisch JS, Whalley PJ. Sonar cephalometry in
twins; a table of biparietal diameters for normal twin fetuses and a comparison with singletons.
Am J Obstet Gynecol 1979;135:727-730
Divers WA, Hemsell DL. The use of ultrasound in multiple gestations. Obstet Gynecol
1979;53:500-504
Grumbach K, Coleman B, Arger P, Mintz M, Gabbe S, Mennuti M. Twins and singleton growth
patterns compared using ultrasound. Radiology 1986; 158:237-241.
Ong S, Lim M, Fitzmaurice A, Campbell D, Smith A, Smith N. the creation of twin centile
curves for size. BJOG 2002; 109:753-758
Alexander GR, Kogan M, Martin J, Papiernik E. What are the fetal growth patterns of singletons, twins and triplets in the United States? Clin Obstet Gynecol 1998; 41: 114-125
Min S, Luke B, Gillespie B, Min L, Newman R, Mauldin J et al. Birth weight references for
twins. Am J Obstet Gynecol 2000; 182: 1250-7
Reece EA, Yarkoni S, Abdalla M, Gabrielli S, Holford T, O'Connor TZ, Bargar M, Hobbins
561
24.
25.
26.
27.
28.
29.
30.
31.
JC.A prospective longitudinal study of growth in twin gestations compared with growth in
singleton pregnancies. II. The fetal limbs. J Ultrasound Med. 1991 Aug;10(8):445-50.
Reece EA, Yarkoni S, Abdalla M, Gabrielli S, Holford T, O'Connor TZ, Bargar
M, Hobbins JC. A prospective longitudinal study of growth in twin gestations compared with growth in singleton pregnancies. II. The fetal head.
J Ultrasound Med. 1991 Aug;10(8):439-43.
Yarkoni S, Reece EA, Holford T, O'Connor TZ, Hobbins JC Estimated fetal weight in the
evaluation of growth in twin gestations: a prospective longitudinal study. Obstet Gynecol.
1987 Apr;69(4):636-9.
Hadlock F, Harrist R, Martinez-Poyer J. In utero analysis of fetal growth: A Sonographic
Weight Standard. Radiology 1991; 181: 129-133
Gardosi J, Kady SM, Francis A. Fetal Growth, maturity and preterm birth. Critchley H, Bennett
P, Thronton S, editors. Preterm Birth. London. RCOG, 2004. 61-72.
Luke B, Witter FR, Abbey H, Feng T, Namnoum AB, Paige DM, Johnson TR.Gestational
age-specic birthweights of twins versus singletons. Acta Genet Med Gemellol (Roma).
1991;40(1):69-76.
Caravello JW, Chauhan SP, Morrison JC, Magann EF, Martin JN Jr, Devoe LD. Sonographic
examination does not predict twin growth discordance accurately. Obstet Gynecol. 1997 Apr;
89(4):529-33.
Hill LM, Guzick D, Chenevey P, Boyles D, Nedzesky P..The sonographic assessment of twin
growth discordancy. Obstet Gynecol 1994 Oct;84(4):501-4.
Blickstein I, Manor M, Levi R, Goldchmit R. Is intertwin birth weight discordance predictable? Gynecol Obstet Invest. 1996;42(2):105-8.
Sebire NJ. D'Ercole C. Soares W. Nayar R. Nicolaides KH. Intertwin disparity in fetal size
in monochorionic and dichorionic pregnancies. Obstetrics & Gynecology. 91(1):82-5, 1998
Jan.
562

Performances of dinoprostone slow
release in the induction of labor
Fabio Facchinetti, Paolo Venturini, Annibale Volpe
Unit of Gynaecology and Obstetrics, Mother-Infant Department,
University of Modena and Reggio Emilia,
Via del Pozzo 71 41100 Modena Italy
Introduction
Induction of labor is an option that increased its popularity among obstetricians since the clinical availability of prostaglandins, the best agents actually
licensed for ripening the cervix. Indeed, cervical ripening is the main obstacle
for the induction of labor and dinoprostone, a prostaglandin E analogue, has
proven to induce both cervical softening and shortening, often activating labor
itself.
A recent U.S. study demonstrated that in a population exposed to increased
risk of Caesarean Section (CS), the active management of labor through labor induction was associated with increased induction and reduced CS (1).
However, selective group of patients such as nulliparous women and very unfavorable cervix still represent a challenge for clinicians, both conditions being
associated with more failures and therefore increased CS rate (2).
A slow-release dinoprostone vaginal insert is available worldwide since
some years. Despite two meta-analyses on its effects compared to other ripening agents no denite conclusions have been reached, also because of the
heterogeneity of patients selection performed in the different studies (3,4).
In a recent randomized clinical trial we compared two ways of dinoprostone
administration, i.e. the slow-release vaginal insert versus the intracervical gel
formulation, in nulliparous women with very unfavorable cervix. More women
in the gel group required the use of oxytocin and reported a longer stay at
563
hospital, possibly because of the increased CS rate (although this nding did
not reach a statistical signicant difference) (5).
On these grounds, we decided to retrospectively evaluate the performances
of slow-release dinoprostone vaginal insert in the induction of labor of women
with unripe cervix.

Subjects
This retrospective study collect data of labor induction carried out between
January 2002 and December 2004 and included consecutive patients with
singleton pregnancy, a gestational age >37 weeks (ascertained through a rst
trimester ultrasound evaluation) and a Bishop score <5. Exclusion criteria were:
previous uterine surgery, known hypersensitivity to prostaglandins, foetal malpresentation, suspected cephalopelvic disproportion, placenta previa, rupture of
membranes, any other condition contraindicating vaginal delivery.
According to antenatal surveillance protocol, low-risk women were monitored with obstetrics examination and non stress test starting around 280th day of
gestation. Then, they were examined also at 287-289 and 291 days of gestation
by adding the evaluation of the amniotic uid index (AFI). AFI was obtained
with the summation of the largest vertical pocket in 4 quadrants according
to Phelan et al (6). Once AFI was < 6 and/or length of gestation reached 292
days women underwent induction of labor. In high-risk women induction was
decided upon clinical ndings: the main reasons were late-onset hypertension,
chronic hypertension, cholestasis.
Patients were then divided into 3 subgroups according to indications: prolonged pregnancy (>286 days, group 1), oligohydramnios (AFI<6, Group 2)
and maternal indications (Group 3).
An informed consent was signed before treatment, as in every cases of labor
induction at our institution.
Protocol
The induction protocol was: 1) patients, admitted in the morning, signed informed consent and underwent Bishop scoring; 2) Fetal Heart Rate (FHR) and
uterine activity were monitored for 30 minutes; 3) slow-release dinoprostone
vaginal insert was then applied (Propess, Ferring, DK); 4) FHR and uterine
activity were monitored every 2 hours, for at least 20 minutes; 5) at 6th and 12th
hour a gynecological examination was performed to assess Bishop score; 6) the
next morning, at 24th hour, a vaginal application of 2 mg dinoprostone (Prepidil
564
gel, Upjohn, Kalamazoo MC, USA) was done in women not presenting with
regular uterine contractions; 7) 6 hours later, non-laboring women were induced with oxytocin infusion, according to standard protocol. Amniotomy
was performed only in laboring women with at least 5 cm cervical dilatation.
Oxytocin augmentation was done in the 2nd stage of labor, if necessary.
Tachysystole was dened when more than 7 contractions/10 min. were recorded. Hyperstimulation was dened when the tone of uterine activity did not
return to baseline for more than 5 min. Either conditions were mentioned only
if a pharmacological correction become necessary.
Statistical analysis
Continuous variables were evaluated by Student t test. Categoric variables were
evaluated by 2 analysis and Fishers exact test where appropriate. All statistical
analysis were performed with SPSS for Windows Release 11.0.
Results
A total of 142 inductions of labor fullling inclusion criteria were observed.
Overall, mean maternal age was 305.0 years and gestational age 282.911.2
days; 85.9% were nulliparous. Hundred and eighteen women (83.1%) underwent active labor after pre-induction cervical ripening. The remnant 24 cases
received a 2 mg vaginal dinoprostone. The rate of CS was 31.7% whereas 41%
of women had a vaginal delivery within 24 hour.
The clinical features at entry, according to the subgroups are reported in
Table 1. As expected, due for the grouping based on indications, gestational age
of women with prolonged pregnancy was higher than in the remnant groups.
The main difference among groups was the change in Bishop score within
12 hours which showed a trend to be statistically signicant (Chi Square=8.70,
P=0.069), women induced for prolonged pregnancy reporting the higher rate
of cervical changes (Fig. 1). Conversely, the rate of Caesarean Section was
lower in this group (26.4%) respect with women induced for oligohydramnios
(32.1%) or for maternal reasons (39.4%) (Fig 1).
Secondary outcome measures are reported in Table 2. The rate of vaginal
delivery within 12 and 24 hours was not signicantly different as well as the
rate of failures of induction. The interval from induction to vaginal delivery
was similar in the 3 different groups being 1215 598 min. in prolonged pregnancy, 1426 612 in oligohydramnios and 1362 710 min. in women induced
for maternal reasons.
565
Tab. 1:
Clinical features at induction, according to indications.
Prolonged
pregnancy
(53)
Oligohydramnios
(56)
Maternal
indications
(33)
Sig.
(2-tailed)
Age
29.45.3*
(17-41)
29.84.6
(20-39)
31.25.3
(22-41)
N.S.
Gestational age
291.6 1.5
(287-297)
281.810.5
(260-292)
270.78.6
(259-291)
0.001
Maternal weight
before pregnancy
62.49.3
(50-90)
64.314.9
(45-127)
66.414.4
(45-108)
N.S.
Maternal weight
at induction
76.211.2
(56-110)
78.215.3
(53-131)
80.915.6
(60-131)
N.S.
Pre-induction
Bishop score 1
64.2%
60.7%
69.7%
N.S.
N. of cases; * MeanSD with ranges in brackets;
50
45
% 40
35
30
25
20
15
10
Prolonged
Pregnancy
Oligohydramnios
Caesarean Section
Maternal
Indications
Delta Bishop>4 at 12 h
Fig 1: Rates of caesarean section and changes of Bishop score according to clinical indications *p=0.069.
566
Women requiring drugs in order to manage tachysistole/hyperstimulation

were similar in the 3 groups. Infectious complications (Temperature >38C),
mainly related to endometritis, are more prevalent in women undergoing induction for maternal reasons. The duration of stay at hospital was longer in women
induced for maternal reasons (Tab. 2).
Tab. 2:
Outcomes as well as adverse events of induction according to clinical indications.
Prolonged
pregnancy (53)
Oligohydramnios
(56)
Maternal
indications
(33)
Sig.
(2-tailed)
Vaginal delivery
within 12 h
10
(25.6%)
5 (13.2%)
3 (15.0%)
N.S.
Vaginal delivery
within 24 h
26
(66.7%)
20 (52.6%)
12
(60.0%)
N.S.
Changes in Bishop
score at 24th h > 4
36
(70.6%)
31 (63.3%)
14
(42.4%)
N.S.
Need of Oxytocin
11
(21.2%)
12 (21.4%)
6 (46.2%)
N.S.
Failure (Delivery >

48 h)
3 (5.7%)
4 (7.1%)
3 (9.1%)
N.S.
Infections
38C)
1 (1.9%)
3 (9.7%)
0.041
11
(21.2%)
9 (18.4%)
5 (16.1%)
N.S.
(T>
Tachysystole/hyperstimulations
N. of cases with percentage in brackets;
Discussion
These ndings demonstrate that the use of dinoprostone slow-release vaginal
insert for pre-induction cervical ripening is associated with a very high rate of
women entering active labor. This seems particularly true for women induced
because of prolonged pregnancy or oligohydramnios whereas patients induced
for maternal disorders required more pharmacological support, like oxytocin.
Such a good response rate was already reported also by Miller et al 1991, on a
smaller series of patients (7).
However, the best performances of vaginal insert were observed in women
undergoing induction because of pregnancy prolongation. Indeed, they showed
567
the lowest rate of CS concomitantly with the highest rate of vaginal deliveries
within the 12th hour. These ndings are easily explained by the faster changes
of Bishop score during dinoprostone treatment respect with the other subgroups
of patients.
In a previous study, utilizing dinoprostone applied in the form of intracervical gel (8), the number of women undergoing labor was lower (60%) and
the CS rate (32.7%) was slightly higher respect with our actual data. In the
same study we found that the higher was gestational age, the higher was the
probability of women entering active labor upon cervical ripening. It therefore
seems not unlikely that the good performance here reported in women induced
because of prolonged pregnancy could be dependent upon their higher gestational age, respect with other subgroups. Thus, whether or not slow-release
dinoprostone performs better than intracervical gel in such condition has to
be tested in an ad hoc randomized study. However, in a recent randomized,
controlled clinical trial we demonstrated that, independently from indication,
the slow-release device is associated with a reduction of obstetric interventions
(CS and oxytocin use) as well as with a shorter period of hospitalization respect
with intracervical gel (5).
An issue with the use of vaginal insert is represented by the onset of episodes
of abnormal uterine activity inducing fetal distress. Tachysystole/hyperstimulation episodes requiring a pharmacological management occurred in 17.6% of
cases in our actual series, a gure higher than the one reported in the metaanalysis of Sanchez-Ramos (3). This difference could be related to the different
denitions of uterine hyperactivity. Anyway, in our series, none of such cases
required an Emergency CS.
Of course, induction of labor is known to be associated with an overall
increased risk of CS respect with women undergoing a spontaneous onset of
labor (2,9), namely in women with a very unprepared cervix (10). However,
calculating the individual risk of CS exposure of selective clinical situations,
i.e. uteroplacental insufciency and cephalopelvic disproportion, the active
management through elective induction of labor is associated with less CS
intervention (1). Patients with prolonged pregnancy are exposed to either of
the previous factors and therefore could be considered good candidates for
induction of labor through the dinoprostone slow-release vaginal insert.
568
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Nicholson JM, Kellar LC, Cronholm PF, Macones GA. Active management of risk in pregnancy at term in an urban population: an association between a higher induction of labor rate
and a lower cesarean delivery rate. Am J Obstet Gynecol. 2004;191:1516-28
Maslow AS, Sweeny AL. Elective induction of labor as a risk factor for cesarean delivery
among low-risk women at term. Obstet Gynecol. 2000;95:917-22.
Sanchez-Ramos L, Kaunitz AM, Delke I, Gaudier FL. Cervical ripening and labor induction with a controlled-release dinoprostone vaginal insert: a meta-analysis. Obstet Gynecol.
1999;94:878-83
Hughes EG, Kelly AJ, Kavanagh J. Dinoprostone vaginal insert for cervical ripening and labor
induction: a meta-analysis. Obstet Gynecol. 2001;97:847-55.
Facchinetti F, Venturini P, Verocchi G, Volpe A. Comparison of two preparations of dinoprostone for pre-induction of labour in nulliparous women with very unfavourable cervical
condition: a randomized clinical trial. Eur J Obstet Gynecol Reprod Biol. 2005; in press.
Phelan JP, Smith CV, Broussard P, Small M. Amniotic uid volume assessment with the fourquadrant technique at 36-42 weeks' gestation. J Reprod Med. 1987;32:540-2.
Miller AM, Rayburn WF, Smith CV. Patterns of uterine activity after intravaginal prostaglandin
E2 during preinduction cervical ripening. Am J Obstet Gynecol. 1991;165:1006-9.
Facchinetti F, Neri I, Genazzani AR. Factors predicting labour onset in patients treated with
prostaglandin E2 for cervical ripening. Eur J Obstet Gynecol Reprod Biol. 1995;60:129-32
Rayburn WF. Prostaglandin E2 gel for cervical ripening and induction of labor: a critical
analisis. Am J Obstet Gynecol. 1989;160:529-34.
Yeast JD, Jones A, Poskin M. Induction of labor and the relationship to cesarean delivery: A
review of 7001 consecutive inductions. Am J Obstet Gynecol 1999;180:628-33.
569
Use of b-lynch suture technique for

postpartum haemorrhage-a case report
and review of literature
B.Vijayalakshmi,T.Doherty,P.Borrelli,D.Patil,S.F.Reynolds
Department of Obstetrics and Gynaecology,Bedford Hospital,United Kingdom
Case Report
A 31-year-old primigravida with Monochorionic Diamniotic twin had a uneventful pregnancy. She was induced at 37 weeks 3 days with 3mg prostin
pessary. Next day an articial rupture of membranes was performed and later
syntocinon infusion was started. The decision was made to perform caesarean
section was made as there was no progress in labour.
A lower segment caesarean section was performed under spinal anaesthesia.
Both the babies were delivered in good condition. An intravenous injection
of 10 units of syntocinon and antibiotics were given after the babies were
delivered. An infusion of 40 units syntocinon in 500ml of normal saline was
started at a rate of 125 ml per hour according to the protocal. Placenta was
delivered by controlled cord traction. The uterus was noted to be atonic. Inspite
of syntocinon, ergometrine, carboprost the uterus remained atonic and blood
loss was very brisk. The bleeding reduced with bimanual compression so we
proceeded to do the B-Lynch uterine compression suture. This immediately
reduced the haemorrhage. The total blood loss was over 4 litres and replaced
with paced cells. The postoperative period was uneventful .She was discharged
from the hospital in good condition.
570
Discussion
Massive post partum haemorrhage (PPH) though preventable is a potentially
life-threatening complication of both vaginal and caesarean delivery and a
major cause of maternal mortality and morbidity. Though common and preventable it is still an enigma to all obstetricians as it is sudden, often unpredictable, assessed subjectively and maybe catastrophic. The condition changes so
quickly that unless timely action is taken maternal deaths occurs within a short
time. This is the most important single cause of maternal death in the world;
it is estimated to claim 150 000 maternal lives annually, mainly in developing
countries (1,2). There were 10 deaths from PPH in the recent Condential enquiry report into materal deaths in the United Kingdom 2000-2002. (13) Most
of the cases of post partum haemorrhage is due to uterine atony which usually
responds to oxytocics drugs. When the conservative management including
bimanual compression and oxytocics fail to control the haemorrhage timely
operative intervention is necessary to prevent morbidity or even mortality.
Condential enquiries in to maternal deaths in the U.K 2000-2002 recommends
that On-call consultant obstetricians must consider all available interventions to
stop haemorrhage such as B-Lynch suture, embolisation of uterine arteries or
radical surgery and they should not hesitate to involve surgical or radiological
colleagues as required for the latter two techniques. There are several surgical
techniques for controlling atonic pph. Ligation of internal iliac arteries has been
used widely but it is rather difcult and and needs surgical expertise. It is only
50 % effective because of the extensive collateral circulation in the pelvis.Blynch suture is simple, easy to perform, quick, less complicated and effective.
No deaths were reported in women who had had interventional radiology or
B-Lynch suture(13)
B-lynch described this technique in 1997.The patient under general anaesthesia is catherised and placed in Lloyd Davies position for access to the
vagina to assess the control of bleeding objectively by swabbing. The abdomen
is the opened by pfannensteil incision of if the patient has had a caesarean
section following which she bled the same incision is re-opened. On entering the abdomen either a lower segment incision is made after dissecting the
bladder or sutures of the recent caesarean section are removed and the cavity
entered. The cavity is then evacuated of blood and then examined. It is easier
if the uterus is exteriorised and rechecked for any bleeding points. Haemostatic
points must be used to treat separate bleeding points. If the bleeding is profuse
due to uterineatony, coagulopathy or placental bed bleeding then bi manual
compression is tried and if the bleeding is controlled objectively then B-lynch
571
will be successful-lynch used no.2.chromic catgut (catgut is no longer used

in the U.K). The point of rst entry of the needle is 3cm from the right lower
edge of the uterine incision and 3cm from the right lateral border. The needle
is passed through the uterine cavity to emerge at the upper incision margin 3cm
above and approximately 4cm from the lateral border. The chromic catgut now
visible is passed over to compress the uterine fundus approximately 3-4 cm
from the right corneal border. The needle is then passed posterior to enter the
posterior wall of the uterine cavity at the same level as the upper anterior entry
point. The assistant then applies manual compression and the catgut is pulled
under moderate tension. The needle is then directed through the posterior wall
through the same surface marking for the right side then wrapped over the
fundus and then directed into and out of the anterior uterine wall in the same
fashion as the right 3 cm anterior and below the lower incision margin on the
left side. The uterus is then compressed by pulling the two lengths of the catgut
with the assistant applying bimanual compression. The perineum is checked to
ensure that bleeding is controlled and suture is tied across the lower segment.
The incision in the lower segment is then closed in two layers in the normal
way.
In our case we used no 1 vicry for the b-lynch suture . Different types of
sutures can be used but it should be absorbable in a reasonable time to prevent
intestinal entrapment The needle should be atraumatic and large
Since b-lynch et al described the use of uterine compression suture in 5 cases
there have been 38 cases reports from 10 different authours (3-12) and our case
report will make it 39 making a total of 44 reported cases. All but Hayman et
al (10) used exact technique described by b-lynch and his colleaques. Hayman
slightly altered this technique by using straight needle to pass from anterior to
posterior aspect of the uterus just above the bladder reection and then looped
over the fundus and tied at the top of the uterus with bimanual compression. In
the series all but two were used after unsuccessful medical management .In two
cases they were used after internal iliac artey and uterine artery ligation (5). All
but one case was successful and hysterectomy had to be performed (8).
In the report by B-lynch et al (3) 2 out of the 5 women had subsequent full
term deliveries .One had No major complications were reported. There was
one case report (4) where there was erosion through the uterine wall and found
protruding from the uterine cervical os and was removed successfully without
difculty. Followup sonohysterography at 6 months identied a very small
defect in the anterior wall of the lower uterine segment corresponding to the
probable site of suture erosion thus suggesting that absorbable is more desirable
spontaneous vertex delivery and the second had elective caesarean section and
572
found to have no uterine abnormalities .In one patient a hysterosalphingogram

and MRI showed no uterine cavity defects and she had patent tubes. (12). In
Hilda Holteman et al series (5) two patients become pregnant and had uneventful caesarean sections.
In conclusion, The B-Lynch suture technique is a good option for the treatment of post partum haemorrhage unresponsive to oxytocics before resorting
to other methods like Internal iliac artery, uterine artery ligation or even hysterectomy. It is simple, easy to perform, quick,cheap and effective. It is also
important as it preserves fertility.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
World Health Organization. The prevention and management of postpartum haemorrhage.

Geneva,WHO 1990
Li XF, Fortney JA, Kotelchuck M, Glover LH. The postpartum period: the key to maternal
mortality. Int J Gynecol Obstet 1996; 54: 1-10
B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch surgical technique for
the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases
reported. Br J Obstet Gynaecol. 1997 Mar;104(3):372-5.
Grotegut CA, Larsen FW, Jones MR, Livingston E Erosion of a B-Lynch suture through the
uterine wall: a case report. J Reprod Med. 2004 Oct;49(10):849-52
Holtsema H, Nijland R, Huisman A, Dony J, van den Berg PP. The B-Lynch technique for
postpartum haemorrhage: an option for every gynaecologist. Eur J Obstet Gynecol Reprod
Biol. 2004 Jul 15;115(1):39-42
Pal M, Biswas AK, Bhattacharya SM. B-Lynch Brace Suturing in primary post-partum hemorrhage during cesarean section. J Obstet Gynaecol Res. 2003 Oct;29(5):317-20
Mazhar SB, Yasmin S, Gulzar S. Management of massive postpartum hemorrhage by "BLynch" brace suture. J Coll Physicians Surg Pak. 2003 Jan;13(1):51-2.
Smith KL, Baskett TF. Uterine compression sutures as an alternative to hysterectomy for
severe postpartum hemorrhage. J Obstet Gynaecol Can. 2003 Mar;25(3):197-200.
Wergeland H, Alagic E, Lokvik B. Use of the B-Lynch suture technique in postpartum hemorrhage. Tidsskr Nor Laegeforen. 2002 Feb 10;122(4):370-2.
Hayman RG, Arulkumaran S, Steer PJ. Uterine compression sutures: surgical management of
postpartum hemorrhage. Obstet Gynecol. 2002 Mar;99(3):502-6.
Vangsgaard K. B-Lynch suture in uterine atony. Ugeskr Laeger. 2000 Jun 12;162(24):3468.
Ferguson JE, Bourgeois FJ, Underwood PB. B-Lynch suture for postpartum hemorrhage.
Obstet Gynecol. 2000 Jun;95(6 Pt 2):1020-2.
Why Mothers Die 2000-2002Report on condential enquiries into maternal deaths in the
United Kingdom,London :RCOG Press 2001.
573
Growing importance of laparoscopic

procedures during pregnancy
Marek Klimek
Gyneacology and Infertility Clinic, Jagiellonian University,
23 Kopernika Str, 31-501, Krakow, Poland
Laparoscopy is the surgical procedure carrying the minimal invasion and trauma
for the patient. For this reason it has appeared to be useful during pregnancy.
Similar to the general population, parturients (and their fetuses) could benet
from the reduced manipulation associated with laparoscopy [1]. Previous surgery, obesity, and pregnancy should no longer be considered contraindications
to laparoscopic surgery [2]. Over 2% of pregnancies are complicated by nonobstetrical surgical problems [3]. Nevertheless the laparoscopic intervention
implicates the question of the risk for the fetus. Among major advantages of
laparoscopy are small abdominal incisions result in rapid postoperative recovery and early mobilization (thus minimizing the increased risk of thromboembolism associated with pregnancy), early return of gastrointestinal activity due
to less manipulation of the bowel during surgery (which may result in fewer
postoperative adhesions and intestinal obstruction), smaller scars, fewer incisional hernias, decreased rate of fetal depression due to decreased pain and less
narcotic use, shorter hospitalization time and prompt return to regular life [4].
This obvious facts have to be considered in relation to its disadvantages connected with the eventual risk for the fetus. Possible injury of the uterus, difculties with using laparoscopic equipment due to enlarged uterus, enterotomy at an
open laparoscopy, miscarriage, preterm labor, hypothetical pneumoperitoneum
and carbon dioxide effect to the fetus have to be also taken into account [4,5].
To elucidate the problems concerning the safety of laparoscopic procedures
and laparotomy during pregnancy multicenter retrospective chart review was
performed by Oelsner G et al in 2003. No intraoperative complications, no
574
signicant difference in abortion rates were found for either procedure. Mean
gestational age at delivery and mean birthweight were comparable. No signicant difference was found in frequency of fetal anomalies between groups or
when compared with the Israel register of anomalies. This study revealed that
operative laparoscopy seems to be as safe as laparotomy in pregnancy [6].
The well-known advantages of laparoscopy are particularly important during the pregnancy. Despite the obvious advantages of laparoscopy the negative
inuence on the mother and fetus, which was demonstrated on animals have
to be taken into consideration. Carbon dioxide pneumoperitoneum in pregnant
ewes caused maternal and fetal acidosis, decreased uterine blood ow, and
fetal hypertension. Curet MJ et al. have revealed that He might be a safer gas
than carbon dioxide to use for laparoscopic procedures in pregnant patients [7].
Maternal end-tidal carbon dioxide should be monitored and kept within normal
range by manipulating the ventilatory rate, especially as the fetus is typically
slightly more acidotic than the mother. Nevertheless, end-tidal carbon dioxide
may not be sensitive enough to reect acute changes in arterial pCO2, and continuous transcutaneous CO2 pressure measurements is recommended [8]. The
current extension of laparoscopy into the eld of intensive care medicine is still
a human experiment that must be performed with high responsibility, extensive
monitoring, and according to the rules of a clinical study [9].
Nongynecologic surgery is required in approximately 2 of each 1000 pregnancies [10]. The most commonly preformed operations in pregnancy are cholecystectomy and appendectomy, which occur in 0.05% and 0.1%, respectively.
Pregnancy has been associated with an increased incidence of cholelithiasis,
and although most women are asymptomatic, biliary colic occurs in approximately 0.05% to 0.1% of pregnant women. Patients with obstructive jaundice,
acute cholecystitis unresponsive to medical management, or peritonitis should
undergo prompt operative intervention in any trimester. The morbidity and
mortality seen in the pregnant patient with appendicitis usually comes from a
delay in diagnosis and treatment. Patients with suspected appendicitis should
undergo immediate exploration, no matter which trimester of pregnancy the
symptoms occur [4].
Laparoscopic management of symptomatic cholelithiasis and appendicitis
during pregnancy has become a routine procedure and is now widely performed. This indication represented about 10% of all cases in our group. It
was reported to be a useful technique in the rst, second and even in the third
trimester of pregnancy. Recently laparoscopy was successfully used in acute
appendicitis after 30th week of gestation [11]. However, some authors have
suggested a gestational age of 26-28 weeks to be the upper gestational limit
575
for successful completion of laparoscopic surgery [12]. The factors which were
considered to conne the use of this surgical method were connected with the
restriction of operative led (height of uterine fundus and adiposity) actually
should be no longer contraindication for laparoscopy. Nowadays laparoscopy
seems to become the standard of care for managing symptomatic cholelithiasis
and appendicitis during pregnancy without signicant increase in morbidity or
mortality [13].
Gynecological procedures performed during pregnancy include adnexal
torsion and adnexal tumors. Torsion of the adnexa has been described as a
complication of ovarian hyperstimulation syndrome (OHSS). It has been found
that 75% of patients with OHSS complicated by torsion were pregnant. This
observation emphasizes the importance of applying a minimally invasive therapeutic approach in these cases [4,14]. Growing number of ovarian stimulation in human reproduction increases the number of possible complications
and widens the laparoscopic management. Adnexal torsion was represented
by three cases in our material. It is an emergency condition requiring early
diagnostic and therapeutic laparoscopy to preserve the adnexa, and to avoid
negative unnecessary laparotomy. Emergent laparotomy carries higher mortality than elective operation.
Laparoscopic treatment was also useful in adnexal tumors during pregnancy.
The incidence of adnexal mass complicating pregnancy ranges from 1 in 81
to 1 in 2500 live births with an average of 1 in 600 [15]. Corpus luteum cysts
account for one third of the adnexal masses; benign cystic teratomas contribute to another third. Malignancy may occur in 2% to 5% of these patients.
Laparoscopy is useful for diagnostic procedures enabling histopathological
verication of the tumor. Conservative management of simple cystic masses
is recommended until the second trimester. Masses that persist into the second
trimester are removed to prevent torsion or rupture during pregnancy, prevent
possible obstruction at delivery, and to rule out malignancy. Elective removal
of an adnexal mass during pregnancy decreases the removal of a symptomatic
mass in an emergency setting. According to M. Fatum elective removal of
any adnexal mass >6 cm that persists to the 16th week of gestation, regardless
of its ultrasonic appearance is recommended to avoid the potential risks of a
surgical emergency [4]. The use of laparoscopic procedures during pregnancy
enables to diagnose nally, treat and rule out consequences of malignancy. It
was recently described to be used in resection of adnexal tumors in the course
of last two trimesters of pregnancy [16]. Laparoscopy was also successfully
performed in removal of pheochromocytoma tumor in pregnant woman. The
pregnancy progressed normally to term [17].
576
Pregnancy outcomes appear to be similar after laparoscopy and laparotomy,

laparotomy can be avoided, which means that pregnant patients managed safely
by operative laparoscopy, with shorter hospital stay [18]. Similarly to the suggestions of Boughizane S et al. the author also insisted, that this method has to
be used only by experienced surgeons, to be safe and successful. Lachman E et
al. analyzed 518 laparoscopic procedures during pregnancy and demonstrated
that the use of this technique is a denite trend, indicating that laparoscopy in
pregnancy appears to be safe when performed by experienced practitioners
[16,19].
In conclusion, the data from literature and authors own experience suggest
that laparoscopy does not carry additional risk for the pregnant woman and
for the fetus in comparison to laparotomy. It seems therefore to be a standard
surgical technique during pregnancy.
Acknowledgments
We wish to thank Professor R. Klimek, Professor J. Schenker for advice, helpful discussions and for the friendly words of support.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Reynolds JD, Booth JV, de la Fuente S et al. A review of laparoscopy for non-obstetric-related
surgery during pregnancy. Curr Surg 2003;60:164-173.
Curet MJ. Special problems in laparoscopic surgery. Previous abdominal surgery, obesity, and
pregnancy. Surg Clin North Am 2000;80:1093-1110.
Melnick DM, Wahl WL, Dalton VK. Management of general surgical problems in the pregnant
patient. Am J Surg 2004;187:170-180.
Fatum M, Rojansky N. Laparoscopic Surgery During Pregnancy. Obstet Gynecol Surv
2001;56:50-59.
Klimek M, Langie T, Wojtys A, Skamla K. Laparoscopic procedure during pregnancy.
Abstracts of the 10th Congress of the European Society for Gynecological Endoscopy. Lisbon,
2001:p.64.
Oelsner G, Stockheim D, Soriano D et al. Pregnancy outcome after laparoscopy or laparotomy
in pregnancy. J Am Assoc Gynecol Laparosc 2003;10:200-204.
Curet MJ, Weber DM, Sae A, Lopez J. Effects of helium pneumoperitoneum in pregnant ewes.
Surg Endosc 2001;15:710-704.
Soriano D, Yefet Y, Seidman DS et al. Laparoscopy versus laparotomy in the management of
adnexal masses during pregnancy. Fertil Steril 1999;71:955-960.
Holthausen UH, Nagelschmidt M, Troidl H. CO(2) pneumoperitoneum: what we know and
what we need to know. World J Surg 1999;23:794-800.
Curet MJ, Allen D, Josloff RK et al. Laparoscopy during pregnancy. Arch Surg 1996; 31:
546-551.
Barnes SL, Shane MD, Schoemann MB, Bernard AC, Boulanger BR. Laparoscopic appen-
577
12.
13.
14.
15.
16.
17.
18.
19.
dectomy after 30 weeks pregnancy: report of two cases and description of technique. Am Surg
2004;70:733-736.
Guttman R, Goldman RD, Koren G. Appendicitis during pregnancy.
Can Fam Physician 2004;50:355-7.
Rollins MD, Chan KJ, Price RR. Laparoscopy for appendicitis and cholelithiasis during pregnancy: a new standard of care. Surg Endosc 2004;18:237-241.
Shalev E. Laparoscopic unwinding of hyperstimulated ovaries during the second trimester of
pregnancy. Hum Reprod 1996;11: 460.
Yuen PM, Chang AMZ. Laparoscopic management of adnexal mass during pregnancy. Acta
Obstet Gynecol Scand 1997; 76: 173-176.
Boughizane S, Naifer R, Hafsa A et al. Laparoscopic management of adnexal tumors after the
rst trimester of pregnancy. J Gynecol Obstet Biol Reprod (Paris) 2004;33:319-324.
Wolf A, Goretzki PE, Rohrborn A et al. Pheochromocytoma during pregnancy: laparoscopic
and conventional surgical treatment of two cases. Exp Clin Endocrinol Diabetes 2004;112:98101.
Carter JF, Soper DE. Operative laparoscopy in pregnancy. JSLS 2004;8:57-60.
Lachman E, Schienfeld A, Voss E et al. Pregnancy and laparoscopic surgery. J Am Assoc
Gynecol Laparosc 1999;6:347-351.
578
Pre-eclampsia
The mode of delivery and anesthesia
in preeclampsia
Turgay Sener, MD
Division of perinatology department of obstetrics & gynecology,
Osmangazi University, Eskisehir, Turkey
Denitions and general considerations

The term preeclampsia describes the developement of hypertension and proteinuria after 20th week of gestation. Edema is also present in almost all cases.
Hypertension is dened as systolic blood presure of at least 140 mm Hg or
diastolic blood pressure of at least 90 mm Hg on 2 measurements taken 6 hours
apart. Proteinuria is the excretion of protein of 300 mg or more in 24-hour urine
collection (1).
Other hypertensive disorders of pregnancy are chronic hypertension and
gestational hypertension. Gestational hypertension is a transient and generally benign condition that develops during the last weeks of pregnancy.
Superimposed preeclampsia is the developement of preeclampsia in chronic
hypertensive patients.
Preeclampsia is accepted mild when no condition given in Table I is present. Severe preeclampsia is a serious clinical entity that requires aggressive
management in most cases. Eclampsia is dened as convulsions and/or coma
which occurs in pregnant woman with preeclampsia.
Table I: Symptoms, Signs, and laboratory ndings of severe preeclampsia
Symptoms
1. Symptoms of central nervous system dysfunction (blurred vision, scotomata, and/or severe headache)
2. Symptoms of liver capsule distention or rupture (right upper quadrant
and/or epigastric pain)
579
Signs
1. Severe elevations in BP (dened as BP >160/110 on two separate measurement 6 hours apart)
2. Pulmonary edema
3. Eclampsia (dened as generalized seizures and/or unexplained coma in
the setting of preeclampsia and in the absence of other neurologic conditions)
4. Cerebrovascular accident
5. Cortical blindness
6. Fetal intrauterine growth restriction
Laboratory ndings
1. Proteinuria (>5 grams per 24 hours)
2. Renal failure or oliguria (<500 ml per 24 hours)
3. Hepatocellular injury (serum transaminase levels 2 x normal)
4. Thrombocytopenia (<100,000 platelets/mm3)
5. Coagulopathy
6. HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets) syndrome
The incidence of preeclampsia is 2-10%. Hypertensive disorders account for 1519% of maternal deaths in developed countries (2). Predisposing factors are nulliparity, maternal age over 40, obesity, diabetes mellitus, ertyhroblastosis fetalis,
polyhydramnios, multiple pregnancy, molar pregnancy, previous preeclampsia,
family history of previous pregnancy induced hypertension, history of chronic
hypertension, chronic renal disease, lupus erythematosus, Protein S deciency,
Activated Protein C resistance, and circulating anticardiolipin antibodies.
Although the mechanisms responsible for the initiation and progression of
the preeclampsia are not well-dened, genetic, immunologic and vascular-endothelial factors are accused in the pathogenesis of preeclampsia. Preeclampsia
most likely is a disease with heterogeneous causes of both maternal and placental origin (3). Maternal cardiovascular, central nervous, and genitourinary
systems are the most affected systems.
Preeclamptic patients generally have normal heart rate. Increased heart rate
variability and blood pressure lability is the result of increased sensitivity to endogenous pressor hormones. Blood volume is decreased 10-40% depending on
the severity of the disease. Intravenous uids can have more increasing effect
on central venous pressure (CVP) in preeclamptic patients than normotensive
controls as capacitance vessel compliance is decreased (4). Intravenous uids
should be given cautiously, as CVP may not reect the pulmonary capillary
wedge pressure (PCWP). Large amounts of uid can also provoke pulmonary
580
edema. Hemodynamic balance may change considerably during pregnancy.

The ndings changes from high cardiac output state to high systemic vascular
resistance state as severity of preeclampsia increased (5). Low collloid oncotic
pressure, together with increased vascular permiability increases the risk of
pulmonary edema (6). That important hemodynamic lability can have profound
effect on pregnancy and should be taken into account during management of
labor and delivery of preeclamptic women.
Delivery
There is not a standart mode of delivery in preeclamptic women. Gestational
age, fetal growth and weight, fetal well-being, cervical maturation, maternal
preference, hospital facilities, and the availability of antenatal-neonatal care
units are the most important determinants.
Mild preeclampsia
Primary elective cesarean section is advocated only in minority of cases of mild
preeclampsia. Cesarean delivery is indicated in the presence of obstetrical indications such as cephalopelvic disproportion, previous abdominal delivery, or
signs of fetal distress on fetal monitorization. Fetal well-being is not seriously
affected in mild preeclampsia cases. Placental functions are well preserved
and Doppler ultrasound indices of fetal vessels are generally in normal range.
However, fetal heart beats should be closely monitorized during labor.
The decision to induce the labor should be taken after demonstration of
fetal maturation. There is no need to wait spontaneous labor after a determined
gestational week, as the severity of preeclampsia may worsen after that time.
Fetal maturity is best determined by lung maturity tests. The gestational week
that fetal maturity is almost completed is around 32. gestational weeks. The
best time for the delivery of babies depends on NICU quality of neonatology department, and is between 32-37 gestational weeks. It was reported that
deliveries in tertiary hospitals may allow greater attemps and success with
vaginal delivery among women with preeclampsia compared with primary or
secondary hospitals (7).
Severe preeclampsia
Debate on timing and mode of delivery continues in severe preeclampsia.
Severe pre-eclampsia is a major cause of mortality and morbidity both in
581
mother and child, particularly when it develops before term. The only known
cure is delivery. Some obstetricians advocate early delivery to prevent the development of serious maternal complications, such as eclampsia attacks and
kidney failure. Some clinics prefer a more expectant approach in an attempt to
delay delivery and reduce the mortality and morbidity for the child associated
with being born too early (8).
Wait or not
The Cochrane review data supports expectant policy in severe preeclampsia that
develops before term. Babies whose mothers had been allocated to the interventionist group had more hyaline membrane disease (RR=2.3, 95% CI= 1.39
to 3.81), more necrotising enterocolitis (RR=5.5, 95% CI=1.04 to 29.56) and
were more likely to need admission to neonatal intensive care unit (RR=1.32,
95% CI=1.13 to 1.55) than those allocated to the expectant policy group (8). In
another study, most women (81.5%) were delivered by cesarean section with
fetal distress being the most common reason for delivery. Neonatal intensive
care was necessary in 40.7% of cases, with these babies staying a median of
six days in intensive care. It is concluded that, expectant management of early
onset, severe pre-eclampsia and careful neonatal care led to high perinatal and
neonatal survival rates. It also allowed the judicious use of neonatal intensive
care facilities (9).
On the contrary, more than half of severe preeclamptic patents deliver in 48
hours (10). Pregnancies complicated by severe preterm preeclampsia and the
presence of intrauterine growth restriction at admission may not benet from
expectant management beyond the 48 hours needed for betamethasone to act
(11). In pregnancies managed expectantly, some maternal complications can
also be expected. In a study, twenty-seven percent of women experienced a
major complication, but few had poor outcomes. No maternal deaths occurred
in that study (12).
Induce or not
In women with severe pre-eclampsia remote from term, attempted labor induction did not appear to increase neonatal morbidity, but was rarely successful at < 28 weeks. Labor induction was successful in 0%, 6.6%, 35.3% and
68.5% of cases at 24-26, 27-28, 29-31 and 32-34 weeks' gestation, respectively.
Induction attempt, failed induction and delivery mode were not associated with
increased neonatal morbidity (13). So it may be more appropriate to wait until
582
completion of 28th gestational weeks to induce the labor, if there is no maternal

or fetal contraindication to expectant management. The babies born after induction/labor, were 1.6 weeks older (p<0.0001) and 352 gram heavier (p<0.0001)
than those delivered before labor. Babies exposed to labor needed intensive
care less often (RR=0.4, 95% CI=0.27-0.58), had lower rates of severe hyaline
membrane disease (RR=0.26, 95% CI=0.11-0.59) and sepsis (RR=0.56, 95%
CI=0.33-0.93), and were discharged earlier (P<0.0001). It was concluded that
exposure to induction/labor in selected patients is not detrimental to neonatal
outcome in early, severe pre-eclampsia (14). If it is decided to induce labor
and deliver the baby, intravaginal misoprostol is an efcacious, cheap and safe
method of induction of labor in toxemia of pregnancy. It was found that misoprostol is signicantly superior to oxytocin for induction of labor in toxemia
of pregnancy with modied Bishop score of < or = 4 without increasing the
maternal and perinatal complication rates (15).
Vaginal or not
It was shown that maternal and neonatal morbidity do not decrease by cesarean
delivery. Furthermore, pulmonary complications can be seen more frequently
in abdominal delivery (16). The effects of labor induction was compared with
the effects of cesarean delivery without labor on neonatal outcome in pregnancies complicated by severe preeclampsia and delivery of very low birth weight
infants. Neonatal outcomes, including respiratory distress syndrome, grade 3
or 4 intraventricular hemorrhage, sepsis, seizures, and neonatal death, were
found similar in the two groups. Only, Apgar scores of 3 or less at 5 minutes
were more likely in the induced-labor group (6 versus 2%, p = .04). It was
concluded that induction of labor in cases of severe preeclampsia is not harmful
to very low birth weight infants (17). In another study, induction of labor and
cesarean delivery have similar effects on neonatal outcomes. Apgar scores of
< or = 3 at ve minutes was more common in the labor-induced group (6%
versus 3%, P = .04); however, other neonatal outcomes, including respiratory
distress syndrome, ventricular hemorrhage, sepsis, seizures and neonatal death,
were similar in the two groups (18). Controversialy, in a study carried out in
a developing country, elective cesarean section contributed to a better perinatal outcome than vaginal delivery or emergency cesarean section following
induction of labour. Severe pre-eclampsia remote from term was found to be
associated with a high cesarean section rate. The elective cesarean rate is 63%,
and emergency cesarean rate after induction of labor is high (35%). Perinatal
mortality was highest for the babies delivered following induction of labour
583
(vaginal delivery vs. cesarean section after induction of labour, p = 0.0004;

vaginal delivery vs. elective cesarean section, p = 0.002) (19).
Anesthesia
Vaginal delivery
Epidural analgesia is claimed to be superior to other analgesic methods during labor and delivery. Cardiac output is stable with epidural analgesia (20).
Epidural analgesia is successful in relieving pain, so exagerated response to
pain is decreased considerably. It is shown that epidural analgesia reduces
circulating levels of catecholamines and stress-related hormones, which facilitates blood pressure control (21). It may also improve intervillous blood ow
in preeclamptic women (22). Administration of epidural analgesia during labor
did not increase the overall rate of cesarean section, the incidence of cesarean
section for fetal distress of dystocia, or the incidence of pulmonary edema
(23). Epidural catheter should be inserted and maintained properly during labor
and delivery. Early administration of catheter facilitates the subsequent analgesia in cases an emergency cesarean section needed. Bupivacaine provides
potent analgesia with less motor block than lidocaine. Fentanyl can be added in
proper dose. Maintanence is obtained either with continuous infusion epidural
analgesia or patient-controlled epidural analgesia. Mild hypotension can be
encountered in some cases. Perfusion of a crystalloid solution before analgesia
is a good preventive measure against hypotension. Blood pressure should be
measured frequently during rst 30 minutes. An additional bolus of uid can
be given if hypotension develops. Lateral positioning of the patient and oxygen
supplementation recovers the patient quickly. Ephedrine can be given 5-10 mg
dose to provide an acceptable blood pressure. General anesthesia or saddle
block (low subarachnoid) should be avoided in vaginal delivery as both may
have important side effects, such as hypotension (24)
Abdominal delivery
Preoperative assessment of the patient should include airway examination.
In cases with mild preeclampsia non-invasive blood pressure measurements
are obtained at regular intervals. In severe preeclampsia, CVP or pulmonary
capillary wedge pressure catheter is advised. Urine output should be assessed
continously by an indewelling urinary catheter. Invasive monitoring of blood
pressure with arterial catheter is desirable especially for those patients who will
be delivered under general anesthesia.
In severe preeclampsia, systemic and pulmonary arterial pressures are shown
584
to be increased signicantly during tracheal intubation, tracheal suction and

extubation periods of general anesthesia. No signicant change in pulmonary
arterial pressure, and a slight decrease in mean arterial pressure is observed in
epidural anesthesia (25). Epinephrine and norepinephrine levels shown to be
increased during general anesthesia, while did not change or decreased during
epidural anesthesia. Neonatal depresion that dened with 1st minute Apgar
score was more likely during general anesthesia (21).
Epidural anesthesia is the preferred technique for elective cesarean section.
Blood pressure should be monitored frequently as a slight decrease (20-30 mm
Hg systolic or 10-15 mm Hg diastolic) is expected. A volume of 200-500 ml
Ringers lactate solution can be infused additionally. Ephedrine can be given
in 5-10 mg doses if hypotension persists. Methylergonovine must be avoided
unless life-threatening atony is encountered during postpartum period. Twenty
units of Oxytocin in 1 lt Ringers lactate solution should be infused to control
postpartum bleeding. In urgent situations that a cesarean section is mandatory, preexisting epidural block is augmented with 3% chloroprocaine or 2%
lidocaine with epinephrine.
Spinal anethesia is an acceptable choice in mild preeclampsia. A crystalloid solution is infused (10-15 ml/kg) in advance. Hyperbaric bupivacine and
fentanyl is given intrathecally. Since catheters are not used in spinal anesthesia
technique, spinal anesthesia can be preferred to epidural analgesia in women
with incipient coagulopathy. But the use of spinal anesthesia is controversial
in severe preeclampsia. The advantages of spinal anesthesia includes the
avoidance of drawbacks of general anesthesia, quick onset of analgesia in
urgent situations, more predictable and reliable anesthesia, and less risk of
trauma in the epidural space. Hypotension secondary to sympathetic blockage and its effect on already compromised fetus is a major concern in spinal
anesthesia. Several studies shown that blood pressure drop is not signicantly
different in spinal anesthesia cases from epidural anesthesia cases (26,27).
Even there is at least one study that shows severely preeclamptic patients had
a less frequent incidence of clinically signicant hypotension (16.6% versus
53.3%; P = 0.006), which was less severe and required less ephedrine. The
risk of hypotension was almost six times less in severely preeclamptic patients
(odds ratio, 0.17; 95% condence interval, 0.05-0.58; P = 0.006) than the risk
in healthy patients (28). If there is no epidural catheter administered already,
spinal anesthesia provides rapid analgesia in urgent cesarean deliveries. A 5
mg dose of prophylactic intravenous ephedrine is given after the intrathecal
injection of bupivacaine (24).
Combined spinal-epidural anesthesia is gaining a wide acceptance and ap-
585
pears to be a safe anaesthetic technique for preeclampsia and severe preeclampsia (29).
General anesthesia can be preferred in abdominal delivery when clinical
situation of the patient is not suitable for regional anesthesia, such as placental
ablation, DIC, severe fetal distress, unsuccessful regional anesthesia. Risks
of general anesthesia includes difcult endotracheal intubation, aspiration
of gastric contents, increase in blood presssure during endotracheal intubation, increase in maternal intracranial pressure, increased maternal oxygen
consumption, cardiac arrhytmias, pulmonary edema, and signicant reduction in intervillous blood ow (22,30,31). Labetolol can be used to control
the hypertensive attack during induction, tracheral aspirations and extubation.
One to three microgram/kg intravenous fentanyl is an alternative to control
the hypertensive attacks. Continous antihypertensive medication may also be
necessary to control postoperative hypertensive attacks.
Eclampsia
Epidural anesthesia is recommended for cesarean section of eclamptic patients.
Contraindications to epidural anesthesia include patient refusal, DIC and placental ablation. Unconscious patients should have a neurosurgical anasthesia
and deliberate hyperventilation. The patient should be extubated while in the
left lateral positon and when fully conscious.
Magnesium sulfate is continued 24-48 hours postpartum. Corticosteroids
proved to be useful to resolve the symptoms of severe preeclampsia-eclampsia
more quickly (32).
586
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
American College of Obstetricians and Gynecologists. Hypertension in Pregnancy. ACOG

Technical Bulletin No.219, Washington, D.C., January 1996
Berg CJ, Atrash HK, Koonin LM, Tucker M. Pregnancy-related mortality in the United States,
1987-1990. Obstet Gynecol 1996; 88:161-7
Ness RB, Roberts JM: Heterogenous causes constituing the single syndrome of preeclampsia:
a hypothesis and its implications. Am J Obstet Gynecol 1996; 175:1365-70
Pouta A, Karinen J, Vuolteenaho O, Laatikainen T. Preeclampsia: the effect of intravenous uid
preload on atrial natriuretic peptide secretion during cesarean section under spinal anaesthesia.
Acta Anaesthesiol Scand 1996; 40:1203-9.
Easterling TR, Watts DH, Schmucker BC, Benedetti TJ. Measurement of cardiac output during
pregnancy: validation of Doppler technique and clinical observations in preeclampsia. Obstet
Gynecol 1987; 69:845-50.
Zinaman M, Rubin J, Lindheimer MD. Serial plasma oncotic pressure levels and echoencephalography during and after delibery in severe pre-eclampsia. Lancet 1985; 1:1245-50
Mostello D, Droll DA, Bierig SM, Cruz-Flores S, Leet T. Tertiary care improves the chance for
vaginal delivery in women with preeclampsia. Am J Obstet Gynecol. 2003 Sep;189(3):824-9
Churchill D, Duley L. Interventionist versus expectant care for severe pre-eclampsia before
term (Cochrane Review). The Cochrane Library, Issue 4, 2004.
Hall DR, Odendaal HJ, Kirsten GF, Smith J, Grove D. Expectant management of early onset,
severe pre-eclampsia: perinatal outcome. BJOG. 2000 Oct;107(10):1258-64.
Blackwell SC, Redman ME, Tomlinson M, Berry SM, Sorokin Y, Cotton DB. Severe preeclampsia remote from term: what to expect of expectant management. Matern Fetal Neonatal
Med. 2002 May;11(5):321-4.
Chammas MF, Nguyen TM, Li MA, Nuwayhid BS, Castro LCExpectant management of
severe preterm preeclampsia: is intrauterine growth restriction an indication for immediate
delivery? Am J Obstet Gynecol. 2000 Oct;183(4):853-8.
Hall DR, Odendaal HJ, Steyn DW, Grove D. Expectant management of early onset, severe
pre-eclampsia: maternal outcome. BJOG. 2000 Oct;107(10):1252-7.
Blackwell SC, Redman ME, Tomlinson M, et al. Labor induction for the preterm severe preeclamptic patient: is it worth the effort? J Matern Fetal Med. 2001 Oct;10(5):305-11.
Hall DR, Odendaal HJ, Steyn DW. Delivery of patients with early onset, severe pre-eclampsia.
Int J Gynaecol Obstet. 2001 Aug;74(2):143-50.
ahin HG, Sahin HA, Kocer M. Induction of labor in toxemia with misoprostol. Acta Obstet
Gynecol Scand. 2002 Mar;81(3):252-7.
Coppage KH, Polzin WJ. Severe preeclampsia and delivery outcomes: is immediate cesarean
delivery benecial? Am J Obstet Gynecol. 2002 May;186(5):921-3)
Alexander JM, Bloom SL, McIntire DD, Leveno KJ. Severe preeclampsia and the very low
birth weight infant: is induction of labor harmful? Obstet Gynecol. 1999 Apr;93(4):485-8.
Chibber RM. Severe preeclampsia and the very-low-birth-weight infant. The controversy over
delivery mode continues. J Reprod Med. 2002 Nov;47(11):925-30
Mashiloane CD, Moodley J. Induction or caesarean section for preterm pre-eclampsia? J
Obstet Gynaecol. 2002 Jul;22(4):353-6.
Newsome LR, Bramwell RS, Curling PE. Severe preeclampsia: hemodynamic effects of lumbar epidural anesthesia. Anest Analg 1986; 65:31-6.
Ramanathan J, Coleman P, Sibai B. Anesthetic modication of hemodynamic and neuroendocrine stress responses to cesarean delivery in women with severe preeclampsia. Anesth Analg
1991; 73:772-9.
587
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
Jouppila P, Jouppila R, Hollmen A, Koivula A. Lumbar epidural analgesia to improve intervillous blood ow during labor in severe preeclampsia. Obstet Gynecol 1982; 59:158-61.
Hogg B for the NICHD MFMU Network. Safety of a labor epidural in women with severe
preeclampsia (PE) or severe pregnancy induced hypertension (PIH) (abstract). Am J Obstet
Gynecol 1999; 180:S378
Gambling DR, Writer D. Hypertensive disorders. In: Obstetrics anesthesia: Principlers and
Practice. Chestnut DH (ed). Mosby Inc, 1999
Hodgkinson R, Husain FJ, Hayashi RH. Systemic and pulmonary blood pressure during caesarean section in parturients with gestational hypertension. Can Anaesth Soc J. 1980; 27:38994.
Hood DD, Boese PA. Epidural and spinal anesthesia for elective cesarean section in severely
preeclamptic parturients (abstract). Reg Anesth 1992; 17(1S):35
Karinen J, Rasanen J, Alahuhta S, et al. Maternal and uteroplacental haemodynamic state in
pre-eclamptic patients during spinal anaesthesia for caesarean section. Br J Anaesth 1996;
76:616-20
Aya AG, Mangin R, Vialles N, et al. Patients with severe preeclampsia experience less hypotension during spinal anesthesia for elective cesarean delivery than healthy parturients: a
prospective cohort comparison. Anesth Analg. 2003 Sep;97(3):867-72
Van de Velde M, Berends N, Spitz B, Teunkens A, Vandermeersch E. Low-dose combined
spinal-epidural anaesthesia vs. conventional epidural anaesthesia for Caesarean section in
pre-eclampsia: a retrospective analysis. Eur J Anaesthesiol. 2004 Jun;21(6):454-9
Wallace DH, Leveno KJ, Cunningham FG, et al. Randomised comparison of general and
regional anesthesia for cesaran delivery in pregnancies complicated by severe preeclampsia.
Obstet Gynecol 1995; 86:193-9)
Jouppila P, Kuikka J, Jouppila R, Hollmen A. Effect of induction of general anesthesia for
cesarean section on intervillous blood ow. Acta Obstet Gynecol Scand 1979; 58:249-53
Yaln T, ener T, Hassa H, zalp S, Okur A. Effects of postpartum corticosteroids in patients
with HELLP syndrome. Int J Gynecol Obstet. 1998; 61:141-8
588
Prenatal screening and diagnosis

3D/4D: contribution to anomaly
detection or scan for parental
entertainment?
N. Vrachnis
Obstetrician and Gynecologist, Aretaieion University Hospital, Athens, Greece
In this session the 3D/4D(three/four dimensional) scanning contribution to

anomaly detection and parental pleasure are explored.
3D/4D ultrasound allows the acquisition of a volume and display of any
plane of that volume regardless of the orientation that was used to obtain an
image. 3D is a 2D imaging acquired as a volume and then displayed in various
ways. 4D is a 3D real time acquisition (moving image of the fetus). Training
of the sonographer who performs 3D/4D includes evaluation of the anatomy
in different orientations than the initial plane. Volumes can be viewed in a
standard way and in multiple planes1.
3D ultrasound can be used with diagnostic results comparable to 2D, although
the reconstructed 3D image has lower quality than 2D image2. Differences in
the interpretations of various sonographers in the same data volume underlines
the need for standardization of acquisition and the presence of reviewing protocols.
3D can be helpful in demonstrating fetal defects and Merz et al3 demonstrated that it was helpful in 62% of the patients while in 36% was disadvantageous due to artifacts and technical problems. Dyson et al4. reported that 3D
rarely affects the management of the cases scanned. Thus 3D is an adjunctive
tool to 2D that provides a comprehensive image that can be used to compliment
2D scans.
3D is most helpful in the imaging of the brain. The area of the corpus callosum is more easily demonstrated by 3D5,6. Surface rendering of the scull in
589
cases of craniosynostosis is a simpler procedure and the cause of an abnormal

scull is easier determined7. 3D/4D surface rendering is also useful in the visualization of the fetal ears, which are not easily visualized by 2D scanning.
Imaging of the fetal face is the most studied area in the 3D surface-rendering mode, and parents together with the lay press are able to see the fetal face
in the way they are used to see it after birth8. Even though sonographers can
diagnose cleft lip and palate by using 2D alone, the pregnant and the plastic
surgeon can benet from the image rendering. The multiplanar 3D view is more
conclusive for the sonographer while the rendering view is more important for
the pregnant and the plastic surgeon so as to understand the decit9 The three
orthogonal planes of the face (multiplanar reconstruction) are important if the
fetus has an unusual position. The sonographer can reorient the face and get a
perfect prole. In 2D scanning the midsagital prole is achieved in 69% of the
cases compared with 100% of the 3D reconstructed10. Its still not possible to
detect dysmorphologic features by 3D, but this is expected to improve in the
future11.
Skeletal dysplasias have been studied excessively by using multiplanar reconstruction and surface rendering. 3D provided extra information compared
to 2D in small case series12. However if 3D is useful in the imaging of normal
and abnormal extremities requires further investigation.
3D technique is not necessary for the diagnosis of spina bida. Scoliosis
due to vertebral anomalies was more easily recognized on a single 3D rendered
image where multiple 2D images were needed to make the diagnosis13.
The anterior abdominal wall abnormality diagnosis is not improved compared with the 2D view. However it may help the pediatric surgeon14.
Beyond 2D artifacts, new artifacts have come forward with the advent of
3D/4D. A common acoustic artifact may look different in 3D/4D and this is
usually overcome by acquiring volume from a different orientation in these
cases15.
The current debate if 3D/4D scans should be used for reassurance or entertainment of the pregnant and the family continues. The European Committee
for Medical Ultrasound, the FDA (Food and Drug Administration) and the
AIUM (American Institute of Ultrasound in Medicine) issued a number of
statements, while the ultrasound leaders have varying opinions with a number
of them advocating that 3D/4D offers better bonding than 2D (bonding refers
to the parental bond for the child).
The European Committee for Medical Ultrasound stated: The embryonic period is known to be particularly sensitive to any external inuences.
Until further scientic information is available, investigations should be carried
590
out with careful control of output levels and exposure times. With increasing
mineralization of the fetal bone as the fetus develops, the possibility of heating fetal bone increases. The user should prudently limit exposure of critical
structures.
The FDA advocates: Persons who promote, sell or lease ultrasound equipment for making fetal videos should know that this an unapproved use of a
medical device and that we are prepared to take regulatory action against
those who engage in such misuse of medical equipment. Also FDA notied
the medical community and the ultrasound industry in August 1994 regarding its concerns about the misuse of diagnostic ultrasound equipment for non
medical purposes, and asked them to discourage their patients from having
sonograms for non-medical reasons.
The AIUM(American Institute of Ultrasound in Medicine) issued a position Statement in October 1999: Currently, two-dimensional (2D) gray-scale
real-time sonography is the primary method of medically indicated anatomic
imaging with ultrasound. While tree-dimensional (3D) sonography may be
helpful in diagnosis, it should not be considered more than a developing technology. Its role is restricted to an adjunct of, but not a replacement for, 2D
ultrasound. As with any developing technology, its diagnostic value may improve and its diagnostic role will be periodically re-evaluated. The AIUM also
issued in May 1999 a statement about Prudent Use: The AIUM advocates the
responsible use of diagnostic ultrasound. The AIUM strongly discourages the
non-medical use of ultrasound for psychological or entertainment purposes.
The use of either two-dimensional (2D) or tree-dimensional (3D) ultrasound
to only view the fetus, obtain a picture of the fetus or determine the fetal gender without a medical indication is inappropriate and contrary to responsible
medical practice. Although there are no conrmed biological effects on patients
caused by exposures from present diagnostic ultrasound instruments, the possibility exists that such biological effects may be identied in the future. Thus
ultrasound should be used in a prudent manner to provide medical benet to
the patient.
3D/4D imaging is time consuming for the sonographer. Detailed images of
fetal faces shown can be achieved in only 20% of cases16. Concerning maternalfetal bonding, randomized studies show that 2D enhances it, at least in the short
term17. Ultrasound leads to a personication of the fetus and has contributed
to a new image of the fetus18. The effect of US on bonding is explained in the
mothers feelings of being closer and more attached to the baby18.
Campbell notes that the term 4D scanning for entertainment surely is an
insulting one with which to desire of parents to see and know and love their
591
baby before the birth16. Chudleigh reported that evidence supports scanning
for parental pleasure, i.e. bonding and benets. However the additional time
that was required effected to cut productivity by 25%. It also requires highly
trained sonographers19.
In contrast the negative effect of 3D/4D on several patients was described as
showing an unclear picture (i.e. distorted or ambiguous images by shadowing
or poor scanning angles) that can result in negative consequences with damaging effects20.
In summary, the 3D/4D in the near future is not expected to take the place
of 2D. However 3D/4D is important as an adjunct to 2D in many cases. The
sonographers do have concerns for biohazards if 3D/4D is performed without
medical indications. There are as well concerns for overpayment or misdiagnosis if non-skilled personnel perform 3D/4D scans. Further research is required
to establish among others the degree that pregnants like the 3D/4D pictures, the
feeling of seeing the baby, and the effected sense of bonding.
592
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Lee A. Four-dimensional ultrasound in prenatal diagnosis: leading edge in imaging technology.

Ultrasound Rev Obstet Gynecol 1:144-148, 2001.
Nelson TR, Pretorius DH, Lev-Toaff AR, Bega G, Budorick NE,, Hollenback KA, Needleman
L, Feasibility of performing a virtual patient examination using three-dimensional ultrasonographic data acquired at remote locations. J Ultrasound Med 20:941-952, 2001.
Merz E, Bahlmann F, Weber G. Volume scanning in the evaluation of fetal malformations: a
new dimension in prenatal diagnosis. Ultrasound Obstet Gynecol 5:222-227, 1995.
Dyson RL, Pretorius DH, Budorick NE, Johnson DD, Sklansky MS Cantrell CJ, Lai S, Nelson
TR. Three-dimensional ultrasound in the evaluation of fetal anomalies. Ultrasound Obstet
Gyncecol 16:321-328, 2000.
Monteagudo A. Timor-Tritsch IE. Mayberry P. Three-dimensional transvaginal neurosonography of the fetal brain: 'navigating' in the volume scan. Ultrasound in Obstetrics & Gynecology.
16(4):307-13, 2000
Timor-Tritsch IE. Monteagudo A. Mayberry P. Three-dimensional ultrasound evaluation of the
fetal brain: the three horn view. Ultrasound in Obstetrics & Gynecology. 16(4):302-6, 2000
Krakow D, Santulli T, Platt LD. Use of three-dimensional ultrasonography in differentiating
craniosynostosis from severe fetal molding. J Ultrasound Med 20:427-431, 2001.
Chmait RH, Hull AD, James G, Nelson TR, Pretorius DH. Three-dimensional ultrasound
evaluation of the fetal face. Ultrasound Rev Obstet Gynecol 1:138-143, 2001.
Lee W, Kirk JS, Shaheen KW, Romero R, Hodges AN, Comstock CH. Fetal cleft lip and palate detection by three-dimensional ultrasonography. Ultrasound Obstet Gynecol 16:314-320,
2000.
Merz E, Weber G, Bahlmann F, Miric-Tesanic D,. Application of transvaginal and abdominal
three-dimensional ultrasound for the detection or exclusion of malformations of the fetal face.
Ultrasound Obstet Gynecol 9:237-243, 1997.
Devonald KJ,. Ellwood DA, Grifths KA, Kossoff G, Gill RW, Kadi AP, Nash DM, Warren
PS, Davis W, Picker R. Volume imaging: three-dimensional appreciation of the fetal head and
face. J Ultrasound Med 14:919-925, 1995
Garjian KV, Pretorius DH, Budorick NE, Cantrell CJ, Johnson DD, Nelson TR,. Fetal skeletal
dysplasia: three-dimensional USinitial experience. Radiology 214:717-723, 2000.
Blaas HGK, Eik-Nes SH, Isaksen CV. The detection of spina bida before 10 gestational weeks
using two- and three-dgestational-age fetus. Ultrasound Obstet Gynecol 16:25-29,2000.
Bonilla-Musoles F, Machado LE, Bailao LA, Osborne NG, Raga F. Abdominal wall defects:
two- versus three-dimensional ultrasonographic diagnosis. J Ultrasound Med 20:379-389,
2001
Bailey JE, Bude RO, Tuthill T. US artifacts: effects on out-of-plane- US images reconstructed
from three-dimensional data sets. Radiology 218:592-597, 2001.
Campbell S. 4D, or not 4D: that is the question. Ultrasound Obstet Gynecol 19:1-4, 2002
Cambell, J Psychosom Obst Gyn,1982:1.57
Zechmeister I. Foetal images: the power of visual technology in antenatal care and the implications for women's reproductive freedom. Health Care Anal 2001: 9.387
Chudleigh T. Scanning for pleasure. Ultrasound Obstet Gynecol 1999: 14:369
Ciatti S, The psychological impact of 3-D ultrasound on pregnant women, Auntminnie 2003
(http://www.auntminnie.com)
593
Ethics of First-Trimester Risk

Assessment for Down Syndrome
Stephen T. Chasen, MD
The rst clinical ethical question to be asked about rst-trimester risk assessment for Down syndrome is whether it is medically reasonable. If not, then,
even though it is technically possible, there would be no ethical obligation to
offer it to pregnant women. On other hand, if rst-trimester risk assessment
is medically reasonable, then disclosure of this option to pregnant women is
warranted.
For many decades, rst-trimester risk assessment was based on maternal age
at expected date of delivery, with age 35 being the arbitrary cut off. At this age,
the risk of occurrence of trisomy 21 has been believed to be about equal to the
risk of pregnancy loss from an invasive diagnostic test. In 1992 Nicolaides and
his colleagues described an association between rst-trimester nuchal edema
and aneuploidy.1 Techniques for measurement of nuchal translucency were
standardized by the Fetal Medicine Foundation, and multiple sonographers
received training. In 1998 the Fetal Medicine Foundation reported on the collaborative experience of its centers in over 100,000 pregnancies screened for
rst-trimester nuchal translucency with high-quality ultrasound, showing it to
be an effective screening tool.2
Subsequently, the science of rst-trimester risk assessment has evolved to
incorporate the results of biochemistry with those of ultrasound examination,
utilizing likelihood ratios generated from nuchal translucency measurements
and biochemical markers to generate risk assessments that are far more reliable than those based on age alone. In a recent review in 2004 of about 44,000
pregnancies Nicolaides and his colleagues described a detection rate of 87%
with a false-positive rate of 5%.3 A multicenter trial in the United States using
identical risk assessment techniques also revealed high detection rates.4
594
These results clearly document that rst-trimester risk assessment, using

ultrasound and biochemistry in high-quality centers, is medically reasonable.
This is especially true if provision of its results reduces the incidence of invasive tests, and thus the rate of procedure-related pregnancy loss. Indeed, this
outcome has been well documented. It follow from the ethics of informed
consent as described above that obstetricians have an obligation to offer pregnant high-quality rst-trimester risk assessment when available as a medically
reasonable component of prenatal care.
Doing so is not only ethically obligatory because rst-trimester risk assessment is clearly medically reasonable and thus supported by the ethical principle
of benecence, which requires physicians to seek the greater balance of clinical
goods over clinical harms in patient care. First-trimester risk assessment is
also supported by the ethical principle of respect for autonomy, which requires
physicians to acknowledge the patients values and beliefs, provide her with
information needed to make decisions based on those values and beliefs, and
to implement the patients decision unless there are compelling reasons not to
do so.5 This more precise risk assessment can be used by pregnant women and
it signicantly enhances their autonomy.
Recent studies indicate that women can, indeed, incorporate sophisticated
risk assessments into their decisions about whether to have subsequent invasive
diagnostic testing. In studies in Sardinia and the United States, the overall rates
of invasive testing were lower when rst-trimester risk assessment became
available.6,7
The decision to continue or terminate ones pregnancy is a quintessential
example in medical ethics of an autonomy-based decision.5 A womans decision is based, in large measure, on her values and beliefs drawn from many
sources, including religion and upbringing, economic and family circumstances. Physicians have no special competence with regard to such decisions
because they involve broader human and social concerns. Physicians do have
an important role to play in enhancing autonomy by providing women with
the best available information about medically reasonable alternatives.8,9 There
should be no remaining reasonable doubt that rst-trimester risk assessment,
in a quality setting, provides pregnant women with far more precise, reliable,
and usable information than age alone.
Some screening strategies routinely withhold the results of rst-trimester
risk assessment until information is obtained from second-trimester screening.
That information can then be integrated with the results of rst-trimester risk
assessment, in order to obtain an even more precise risk assessment.10,11 We
believe that this strategy is ethically awed, for two reasons.
595
First, this strategy is based on the awed assumption that integrated screening is the only medically reasonable form risk assessment. The improvement
in screening performance of integrated risk assessment, if any, is only slightly
incremental, is not nearly enough to categorize rst-trimester risk assessment
as medically unreasonable.3 Second, withholding rst-trimester results as a
routine practice violates the reasonable person standard of the ethics of the
informed consent process. This paternalistic practice deprives women of the
opportunity to make an informed decision about rst-trimester invasive testing.
Many women value rst-trimester invasive testing because, if the results are
abnormal, they can then elect early termination of pregnancy, enhancing the
privacy of their decision to do so.12,13
Conclusion
The ethics of informed consent is an essential component of rst-trimester risk
assessment for trisomy 21. Adherence to the standards of the ethics of informed
consent requires routinely offering rst-trimester risk assessment in centers that
are qualied to provide it. These standards render protocols involving nondisclosure of rst-trimester risk assessment results as ethically unacceptable.
596
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Nicolaides KH, Azar G, Byrne D et al. Fetal nuchal translucency ultrasound screening for
chromosomal defects in rst trimester pregnancy. BMJ 304:867-869, 1992.
Snijders RJM, Noble P, Sebire N et al. UK multicentre project on assessment of risk of trisomy
21 by maternal age and fetal nuchal translucency thickness at 10-14 weeks of gestation. Lancet
351: 343-346, 1998.
Nicolaides KH. Nuchal translucency and other rst-trimester sonographic markers of chromosomal abnormalities. Am J Obstet Gynecol 191:45-67, 2004.
Wapner R, Thom E, Simpson JL et al. First-trimester screening for trisomies 21 and 18. N Engl
J Med 349:1405-1413, 2003.
McCullough LB, Chervenak FA. Ethics in Obstetrics and Gynecology. New York, Oxford
University Press, 1994.
Zoppi MA, Ibba RM, Putzolu M et al. Nuchal translucency and the acceptance of invasive
prenatal chromosomal diagnosis in women aged 35 and older. Obstet Gynecol 97:916-920,
2001.
Chasen ST, McCullough LB, Chervenak FA. Is nuchal translucency screening associated
with different rates of invasive testing in an older obstetric population? Am J Obstet Gynecol
190:769-764, 2004.
Chasen ST, Skupski DW, McCullough LB, Chervenak FA. Prenatal informed consent for sonogram: the time for rst-trimester nuchal translucency has come. J Ultrasound med 20:11471152, 2001
Chasen ST, Skupski DW, Chervenak FA, McCullough LB. First-trimester nuchal translucency
screening: reply. J Ultrasound Med 21:481,483-487, 2002.
Hackshaw AK, Wald NJ. Assessment of the value of reporting partial screening results in
prenatal screening for Down syndrome. Prenat Diag 21:737-740, 2001.
Wald NJ, Rodeck C, Hackshaw AK et al. First and second trimester antenatal screening for
Downs syndrome: the results of the Serum, Urine, and Ultrasound Screening Study (SURUSS).
J Med Screen 10:56-104, 2003.
Kornman LH, Wortelboer MJM, Beekhuis JR et al. Womens opinions and the implications of
rst- versus second-trimester screening for fetal Downs syndrome. Prenat Diag 17:1011-1018,
1997.
Mulvey S, Wallace EM. Womens knowledge of and attitudes to rst and second trimester
screening for Downs syndrome. Brit J Obstet Gynecol 107:1302-1305, 2000.
597
Breast cancer
Consensus and controversies regarding
screening for breast cancer.
P. Neven, E. Van Limbergen,
C Van Ongeval, A. Van Steen MBC, UZ
Gasthuisberg, Leuven, Belgium
Introduction
Breast cancer is an important health care problem accounting for 1/3 of cancer
deaths in developed countries and about 10-15 % in developing countries.
The incidence of the disease varies in Europe. In Belgium it is 161.9/100.000.
The age-related breast cancer incidence in Belgium at age 50, 60 and 70 is
326.3/100.000, 389.2/100.000 and 312.0/100.000 respectively (1). An increase
in incidence has been noted over the last decades, reecting a real increase of
the incidence by ageing of the female population, changes in living and nutritional habits and environmental factors as well as by a higher detection rate
by the implementation of screening programmes. The mortality rate of breast
cancer varies between 23-38/100.000. Over the last decade, there is a decrease
in the breast cancer mortality. Most authors recognise that part of this decrease
is related to early detection but also to better adjuvant treatments like radio,
chemo and hormonotherapy (2).
Primary prevention of breast cancer should be given the highest priority in
the ght against the disease, but the environmental, nutritional and gestational
factors inuencing the incidence of the disease are so complex and not so
easy to inuence in Western countries. Currently WHI is testing prospectively
whether different health measures can reduce breast cancer incidence (3). This
clinical trial is designed to allow randomized controlled evaluation of three
distinct interventions: a low-fat eating pattern, hypothesized to prevent breast
and colorectal cancer and, secondarily, coronary heart disease; hormone re-
598
placement therapy, hypothesized to reduce the risk of coronary heart disease

and other cardiovascular diseases and, secondarily, to reduce the risk of hip
and other fractures, with increased breast cancer risk as a possible adverse
outcome; and calcium and vitamin D supplementation, hypothesized to prevent
hip fractures and, secondarily, other fractures and colorectal cancer.
The new EU code against cancer (EU code against cancer third version)
advocates a healthy lifestyl : stop smoking, increase physical activity, increase
intake of fruit and fresh vegetables, decrease alcohol consumption. The only
short term hope for primary prevention is to decrease the incidence of breast
cancer in high risk patients by anti-oestrogen treatment. Those with lobular
carcinoma in situ and atypical ductal hyperplasia will benet most . Tamoxifen
and raloxifene are both effective in lowering the oestrogen receptor positive
breast cancer risk but not without side effects like increased risk of tromboembolic events and hotashes; tamoxifen also increased the endometrial cancer
risk (4,5). Based on promising data involving reduction of contralateral breast
cancer risk in adjuvant studies, several aromatase inhibitors, including letrozole, anastrozole, and exemestane, are being incorporated into trials evaluating
their efcacy as preventive agents in women at increased risk (6).
In the meantime early detection has been advocated : by screening mammography, physical examination by a physician or trained nurses, breast selfexamination, ultrasound, CAT, MRI. Apart from screening mammography
none of these methods has been proven to reduce mortality rates from breast
cancer. Many countries started national screenings programs for breast cancer
following the 1985 publication by the Swedish Two Counties-Study (7). This
trial from Kopparberg en stergtland did show a decrease in breast cancer
mortality of 31% at the 7 year follow-up point in women with an age between
40 and 74 year at the beginning of the study. These ndings were a conrmation of Shapiros ndings from an earlier screening program (8). Finland and
Sweden started their screening program in 1986, United Kingdom in 1988
and the Netherlands in 1989. In 1997 and 2000, there were European recommendation for breast cancer screening in the age group 50-69 and an increasing
number of European countries followed these guidelines (9,10). The benet of
screening for breast cancer was doubted following the publication of 2 reports
(11,12). The European parlement organised an open discussion whether the
recommendations needed being reviewed but they were not. Our discussion
will give current arguments on the benets and possible risks of population
screening for breast cancer.
599
Epidemiologic benets : potential efciency

The rst requirement for the justication of a population based screening programme is the importance of the public health problem caused by the disease, i.e.
the disease should be relatively frequent and have serious consequences, which
is of course true for breast cancer in western countries. Before implementation
of a breast cancer screening programme, national morbidity and mortality rates
should be considered. Cost-effectiveness of screening clearly depends on the
prevalence of the disease (number of undiagnosed cases in the population at
the time of screening). The higher the prevalence, the higher the detection rate
at the same cost. A low incidence will give a low prevalence and then, the cost
for the whole population could become unacceptable. Many countries, would
exclude breast cancer screening programmes with mammography from their
priorities on the simple grounds of efciency, due to the epidemiological situation. Society should not use resources for cancer screening programmes unless
there is strong evidence that there is a clear benet for the population.
Medical benets of breast cancer screening

The major aim of any screening programme, and thus also in breast cancer is
to reduce mortality. Early detection of small invasive, or even not yet invasive
lesions increases the probability to offer more curative treatments to these patients and hence decrease mortality. Early detection also increases the use of
breast conservative surgery, such as quadrantectomy wide excisions or lumpectomy and terms of offering less morbidity and mutilation at the same mortality
rate. Axillary staging using the less morbid sentinel lymph node procedure can
also be done in case lesions are detected in an earlier stage.
Adverse effects of screening: Medical adverse effects

Adverse effects of screening for breast cancer have also to be considered. In
the rst place a screening programme could create an over medicalisation of
healthy people : by being confronted with too many preventive and diagnostic
procedures, women belonging to the target population could be overconcerned
with health and medical issues (13).
In the second place, participation in screening programmes might
cause undue anxiety : the confrontation with the possibility of having breast cancer is frightening: anxiety is particularly increased in
women presenting with a false-positive result, i.e. when abnormalities detected by mammography are subsequently found to be benign.
600
However, documentation on these aspects is scarce. The few studies dealing

with worry and anxiety show that such reactions seem relatively infrequent
and, when present, tend to regress rapidly (14). According to one report, women undergoing false-positive mammography at rst screen were less likely
to reattend for subsequent screens than were nonassessed women, yet they
were more likely to develop interval cancers or cancers at second screen, and
their cancers were larger (15). The prevalence of anxiety has been reported
to be signicantly greater in women with false-positive results (29%) than
in those with negative results (13%). Furthermore, mammography involves
compression of the breasts, which can cause physical discomfort : 10 % to 20
% of women reported moderate or severe discomfort. Surgical biopsy, when
necessary, involves a risk of infection, scaring, haematoma, pain and breast
abnormalities are also possible. However, anxiety before screening or resulting
from supplementary imaging work-up, short-term follow-up, cyst aspiration,
and biopsy has not dampened the enthusiasm of most women for the value of
early detection (16).
Another problem with screening programs reporting up to 5-year survival
data is that most detected breast cancers would not become apparent if screening did not take place (17). The time shift in detection of breast cancer to the left
means survival from such cancers will artifactually increase when considering
time from detection to death (Lead-Time Bias).
It has also to be considered that some screen-detected cancers would never
have become clinically apparent during the womans lifetime (Length Bias).
Screening is good at detecting cancers with a more favourable diagnosis and
a cancer natural history may be longer than the womans life expectancy.
Cancerous tumors detected by mammography screening are associated with
a better prognosis than tumors of similar size found outside of screening (18).
The possible magnitude of Length Bias is uncertain but predictions give as
many as 70 % of breast cancers remaining clinically unapparent, and it is certainly possible that not all in situ cancers become invasive (17).
Another problem is that women from a higher socioeconomic and educational strata are more likely to accept the invitation to screen and to participate
in other health promoting patterns of behavior (Class Bias) (17). Social class
is a powerful prognosticator in breast cancer (19).
Finally screening can result in a large burden of unnecessary investigations
and treatments when the quality of such intervention is not assured. False positives based on histology have been reported for small lesions. The difculty
to classify minimal or borderline lesions as benign or malignant is now recognized and should result in the review of pathological procedures. It has also
601
been suggested that women with a false-negative result, might subsequently

delay seeking treatment if symptoms develop, because of false sense of security
(20). This could ultimately result in greater morbidity and poorer prognosis.
The increase of life time risk of radiation-induced breast cancer from mammography (if the dose is 0.12 rad per two-view lm-screen examination) has
been estimated to be less than 1 % (21). Some do stress the importance of this
gure especially now a meta-analysis of screening trials has observed that an
equivalent of 1224 women between 50-70 need being screened for 14 years
for every life saved (22).
Economical Cost
Effects on health should be considered in relation with the resources allocated
for establishing those effects. The main aim of an economic assessment is to
assist the relevant decision makers for an optimal use of the available health
care resources. The analysis of the costs components should take into account,
the size of the target population, the investments (equipment), the operation
costs (mammography, diagnostic examinations, quality control, call-recall
system, data collection and analysis, information and training, evaluation, ).
Generally, in developed countries, organized screening would replace current
spontaneous practices. Considering the problem from this angle totally modies the approach of costs and their evaluation.
In Flanders, the estimate of the yearly cost of screening considering a
population of 480.000 women aged 50-69 a 50 % participation rate, a 2-year
periodicity and a 10 % recall rate reaches 16,5 million EURO, i.e. 70 EURO
per woman screened.
In the Netherlands where screening is applied since 1980 and participation
rates have increased up to 80 %, the cost per woman screened has gone down
to 49 EURO per woman screened.
The decrease in cost observed with the organized programme is due to the
targeting of the programme to a limited population for whom breast cancer
screening has proved effective on one hand and on the second hand a better use
of quality controlled health structures, thus reducing unnecessary examinations
to the minimum. Furthermore, the cost of breast cancer screening will be partly
compensated, by the subsequent decrease in the costs of management of latestage diagnosed breast cancers. An important item, which does not facilitate
the problem, is that costs occur long before favourable effects and savings are
actually observed.
602
Success of a screening programme

Several factors play an important role and contribute to the success of a programme. The reduction of mortality rates obtained with clinical trials with
population-based routine programmes, when efcient participation rates (at
least 70 %) and high quality level of procedures are implemented : mammography (technique and reading), follow-up of women with abnormalities, biopsies,
pathological interpretation and treatments. The rate of participation depends
mainly on the womans age, the place of residence, the socio-economic status
and modalities of screening (call-recall system, facilities and access to mammography). For this reason, mammobile units have been used in many countries including the Netherlands, Flanders, Germany. Also the accessibility by
having screening facilities in large towns, close to the main railway station or
shopping centres may improve participation rates.
Finally cultural aspects and womens emancipation play an important role.
Scandinavian countries and the Netherlands have now over 80 % participation
rates (23). Compliance is also of crucial importance in women with mammographic abnormalities, if there are too many women lost to follow-up after
the mammographic test, then the benet of the programme will be null and the
intervention in itself will become unethical.
Quality control of a screening programme

Because of the potential adverse effects and the high economic costs involved,
it is mandatory to implement quality assurance and control over all the levels
of the screening process as is recommended by the European Guidelines for
mammographic screening (24).
This implies :
Assure sufcient participation rate
Continuously adapted quality control of the mammographic machines,
developers, negatoscopes, reading room facilities etc.
Quality control and individually adapted training of positioning of
mammograms, by radiographers and/or radiologists.
Training and education on quality control of the participating radiologists
with continuous check on discordanting rates, reporting and corrective
measures.
Fail-safe mechanism to follow-up the screening positive cases up to diagnosis and treatment.
Quality assurance of the whole programme by checking performance
603
parameters to the European Guidelines.

Measurement of reduction in breast cancer mortality in the screened
population.
Recently it was shown that raising the annual volume requirements in the
Mammography Quality Standards Act might improve the overall quality of
screening mammography (less false positive and less false negative) in the
United States (25).
Evidence of Medical effectiveness of breast cancer

screening
After the start of the Health Insurance Project in New York in 1963, 8 randomized trials have been conducted where the impact of breast cancer screening on
mortality was studied: In total, more than 500.000 women participated in these
trials. The results of the individual trials are shown in table 1.A meta-analysis
conducted in 1995 on these 8 randomized trials calculated a 25 % reduction
in mortality of women 50 to 74 year old, showing up 7 to 9 year after start of
screening (26)
Table 1:
Breast cancer screening: Randomised trials
Study (26)
Start
Age
Group
n
n
patients controls
Ca
SG
CA
CG
N e w 1963
40-64
30.131
30.565
153
196 0,79 (0,69-0,98)
Edinburgh
1978
45-64
22.926
21.342
156
167 0,87 (0,70-1,08)
Canada
1980
40-69
44.925
44.910
120
111 1,08 (0,84-1,40)
Malm
1982
40-74
21.088
21.195
63
66
Kopparberg
1977
40-74
34.589
18.582
126
104 0,58 (0,45-0,76)
stergtland
1978
40-74
38.491
37.403
135
173
0,76 (0,61-0,95
Stockholm
1976
40-74
40.318
19.943
66
45
0,73 (0,50-1,06)
Gteborg
1976
40-74
11.724
14.217
18
40
0,55 (0,31-0,95)
HIP
York
RR (95%-BI)
0,96 (0,68-1,35)
Ca: number detected cancers; SG: study group; CG: control group; RR: relatief risico; 95% -BI
95%-Condence interval.
All but two trials showed a signicant reduction in mortality ranging from
13 % to 45 %. No signicant reduction in mortality however were noted in the
Canadian trial, and in the Malm trial.
604
The Canadian trial (CNBSS) suggested even a higher mortality rate in the
screened population (12). However criticism has been formulated to this trial
because of the quality of the mammographics used at screening. Also, a benet
of mammography screening is supported by modeling of the CNBSS results
(27).The Malm trial on the other hand is the only Swedish trial where no
reduction in mortality could be demonstrated (28). This trial was the latest trial
to start up in Sweden, and suffered both from a very low participation rate in
the study group and a very high contamination rate in the control group; women
having a mammogram on their own initiative or their general practitioner after
the rst results of the other Swedish trials were published.
Based on these trials, and on a meta-analysis of the results, a group of experts
generated the European Guidelines. Population based breast cancer screening
was advocated for the target group 50-69 years, with quality controlled, double
reading mammography with a 2 to 3 year interval. Extensive criteria for quality
assurance on all levels were published in the rst and second edition of the
European Guidelines for mammographic screening (24).
Some serious criticism has been formulated to the conclusion by P.C.
Gtsche and O. Olsen (11), who performed a meta-analysis on 2 of the 8
trials, after having excluded 6 of them because of discutable randomisation
techniques, a number of base line deviations in 6 and inconsistencies in the
number of randomized exams in 4 of these trials.
The only studies without any bias for randomisation procedures were the
Canadian and the Malm trials, both with a non signicant mortality reduction
(RR 0.96 1.08). These were taken for the meta-analysis leading to the conclusion that breast cancer screening is not effective.
A storm of criticism has been raised in the literature on their meta-analysis.
The exclusion of the Kopperberg, stergtland, and the Gteborg trial based
on differences in age between study and control group is not justied: the differences are very small (less than 1 year) and globally these 3 trials have older
patients (with a higher incidence rate because of age and a higher mortality
(because of age). Nevertheless they show an improved survival rate of 24-42
% better than the control group. Other factors, important for outcome such as
participation rate, contamination rate, quality of the mammographic imaging,
false positive or negative were not considered to include or not include a trial
in the meta-analysis.
It is clear that criticism can be formulated to each of the 8 trials. However
focusing only on 1 aspect such as randomisation technique and unrelevant
base-line inconsistencies without taking account of other important predictors
605
for outcome is dangerous and methodologically incorrect. Finally does the

conclusion not take account of the mortality reduction that is seen now in
Sweden, the United Kingdom, Finland and the Netherlands 7 to 9 years after
start of their screeningprogrammes (9,10,29,30). Recently this has also been
observed in Copenhagen following the introduction of mammographic screening in 1991 (31).
Breast cancer screening in the age group 40-50 years

The Consensus Development Conference claimed in January 1997 that there
is no clear benet of population based breast cancer screening in the age group
40-50 year. This age group has rstly a lower incidence of breast cancer (0.5
versus 1.5/1000/per year). On the other hand is breast tissue in this age group
more dense, leading to more false positive reading results and a signicantly
higher (x 2.5) number of biopsies taken, per detected breastca. Also the false
negative reaching rate is increased. Interval cancers are noted in 25% in stead
of 10%, due to lower detection rates of the early lesions in dense breasts, but
also due to the faster growing and shorter subclinical period of breast cancer
in young women. On conclusion the Consensus Development Conference
decided that only young women with a high risk prole (family history or
antecedents) could be selected for screening. The same year however 3 new
publications (32-34) showed a mortality reduction of 16 to 45%, conform to
the already published 30% reduction of mortality in the age group 40-44 in the
HIP study (table 2).
Table 2:
Reduction in mortality by breastscreening in the age group 40-50.
Trial
Mortality reduction
R.R.
HIP (8)
30%
0.7
Gotheburg (31)
45%
0.55
Malm (32)
35%
0.65
Meta-analysis (33)
(5 Swedish, HIP,
Edinburgh, Canada)
16%
0.84
Meta-analysis (28)
(5 Swedish)
20%
0.8 (0.63-1.01)
606
Trial
Canadian NBCSS I
(12)
Mortality reduction
R.R.
3%
0.97 (0.74-1.27)
This reduction in mortality appears already after 5 to 7 years, earlier thus,

than in the 50-69 age group. The reduction was not related to whether or not
a clinical examination was performed (34). Despite these data the Consensus
Conference, held in Vienna 2002, did still not recommend population based
screening for breast cancer in women aged 40-50 years. The main reason for
this is economical: the cost of screening in this age group increases up to 2.5-5
times the cost in the age group 50-69 (34).
New controversial data have been published since then: the updated Swedish
meta-analysis on screening in the age group 40-50 years (28) showed a reduction of 20% (RR 0.80 (0.63-1.01)) after a median follow up of 14.5 years and
conrmed the earlier data. These data were confronted in the same year with
the data of the Canadian National BC Screening Study I in the same age group
(6=12). After a follow-up time of 11 to 16 years, no signicant reduction in
breast cancer mortality was discovered (RR= 0.97 (0.74-1.27)).
However the study group had a worse prognosis (82 more breast ca), and
the control group a very high (25%) contamination rate. However the strongest criticism to the Canadian study is their evaluation method. While in the
Swedish study the evaluation method only the mortality of patients with breast
cancer detected during the trial period was considered, the Canadian trial took
all breast cancer mortality, also from breast cancers detected outside the 5
years screening period, and there for achieving strongly the effect of screening. Implementation of the Canadian follow-up method to the Swedish data
would strongly diminish the mortality reduction from 0.80 (0.63-1.01) to 0.95
(0.76-1.09).
Conclusion
Population based screening is indicated in the Western countries in the age
group 50-60 year. Population based screening in the younger age group 4050 years remains controversial. Although there is increasing evidence that
screening might reduce mortality also in this age group. There is no consensus
because of the high costs, and the high false positive and false negative results
to apply this to the overall population.
Breast cancer screening can only be successful if applied to the right target
group, achieving a high participation rate (> 70%), with strict control of physi-
607
co-technical parameters, positioning techniques, quality of 1st and 2nd reading,

follow-up with fail safe mechanism, registration and epidemiologic quality
control of the whole programme, conform to the most modern guidelines.
Abstract
Consensus and controversies on breast cancer screening:
The value of breast cancer screening programmes in general and especially in
young women (> 50 years old) has been recently questioned in the literature.
This paper resumes the published data. Randomised studies as well as data of
mortality reduction in countries which have implemented high-quality breast
cancer screening with mammography in the past, reveal the unquestionable
benet of mammography screening in women between 50-69 years old.
There is also evidence that screening in younger women (40-50y) may lead
to reduction in the mortality of breast cancer, but the burder for the screened
women as well as the expenses for the government are signicantly higher. For
this reasons breast cancer screening is the non-high risk general population of
women under 50 is not recommended.
608
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Vlaamse Liga Tegen Kanker. Kanker in Vlaanderen. 2000.

Jones AL. Reduction in mortality from breast cancer. BMJ 2005; 330: 205-6.
Morimoto LM, White E, Chen Z et al. Obesity, body size and risk of postmenopausal breast
cancer Womens Health Initiative (US). Cancer Causes Control 2002; 13: 741-51.
Cuzick J, Powles T, Veronesi U et al. Overview of the main outcomes in breast-cancer prevention trials. Lancet 2003; 361: 296-300. Review.
Dunn BK, Wickerham DL, Ford LG et al. Prevention of hormone-related cancers: breast
cancer. J Clin Oncol 2005; 23: 357-67. Review.
Lonning PE. Aromatase inhibitors in breast cancer. Endocr Relat Cancer 2004; 11: 179-89.
Review.
Tabar L, Fagerberg C, Gad A, Baldetorp L, Holmberg L, Grntoft O et al. Reduction in mortality from breast cancer after mass screening with mammography: randomised trial from the
breast cancer screening working groups of the Swedish National Board of Health and Welfare.
The Lancet 1985; i: 829-832.
Shapiro S, Veret W, Shax P, Veret L and Roesner. Ten to fourteen year effect of screening on
breast cancer mortality. J Natl Cancer Inst 1982; 69: 349-355.
Blanks R, Moss S, M Gohar C, Quinn M, Babb P. Effect of NHS breast screening programm
on mortality from breast cancer in England and Wales, 1990-1998. Comparison of observed
and predicted mortality. Brit Med J 2000; 321: 665-669.
Dean P, Pamulo M. Screening mammography in Finland 1.5 million examinations with 97
percent specicity. Mammography Working Group. Radiology Society of Finland. Acta Oncol
1999; 38: 47-54.
Gotzsche P and Olsen O. Is screening for breast cancer with mammography justiable? The
Lancet 2000; 355: 129-134.
Miller A, Miller M, To T, Baines C and Wall C. The Canadian National Breast Screening
Study 1: Breast Cancer Mortality after 11 to 16 years of follow-up. Ann Int Med 2002; 137:
305-315.
Ustun C, Ceber E. Ethical issues for cancer screenings. Five countriesfour types of cancer.
Prev Med 2004; 39: 223-9.
Barton MB, Morley DS, Moore S et al. Decreasing women's anxieties after abnormal mammograms: a controlled trial. J Natl Cancer Inst 2004; 96: 529-38.
McCann J, Stockton D, Godward S. Impact of false-positive mammography on subsequent
screening attendance and risk of cancer. Breast Cancer Res 2002; 4: R11. Epub 2002
Feig SA. Adverse effects of screening mammography. Radiol Clin North Am. 2004
Sep;42(5):807-19, v. Review.
Baum M. Breast cancer screening comes full circle. J Natl Cancer Inst 2004; 96: 1490-1491.
Joensuu H, Lehtimaki T, Holli K et al. Risk for distant recurrence of breast cancer detected by
mammography screening or other methods. JAMA 2004; 292: 1064-73.
Kaffashian F, Godward S, Davies T, Solomon L, McCann J, Duffy SW. Socioeconomic effects
on breast cancer survival: proportion attributable to stage and morphology. Br J Cancer 2003;
89: 1693-6.
Baines CJ. Are there downsides to mammography screening? Breast J. 2005 Jan;11 Suppl 1:
S7-S10.
Law J, Faulkner K. Concerning the relationship between benet and radiation risk, and cancers
detected and induced, in a breast screening programme. Br J Radiol 2002; 75: 678-84.
Humphrey LL, Helfand M, Chan BK, Woolf SH. Breast cancer screening: a summary of the
evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002; 137: 347-60.
609
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
Vejborg I, Olsen AH, Jensen MB, Rank F, Tange UB, Lynge E. Early outcome of mammography screening in Copenhagen 1991-99. J Med Screen 2002; 9: 115-9.
European Guidelines for quality assurance in mammography screening, 3rd ed (2001). Perry
N, Broeders M, de Wolf C and Trnberg S, Luxemburg.
Smith-Bindman R, Chu P, Miglioretti DL et al. Physician predictors of mammographic accuracy. J Natl Cancer Inst 2005; 97: 358-67.
Kerlilowske K, Grady D, Rubin S, Sandrock C, Ernster VL. Efcacy of screening mammography. A meta-analysis. JAMA 1995; 273: 149-154.
Rijnsburger AJ, van Oortmarssen GJ, Boer R et al. Mammography benet in the Canadian
National Breast Screening Study-2: a model evaluation. Int J Cancer 2004; 110: 756-62.
Nystrm L, Andersson I, Bjurstam N, Frigell J, Nodershjld B and Rutquist L.Long term
effects of mammography screening: updated overview of the Swedish randomised trials. The
Lancet 2002; 359: 909-919.
Tabar L, Vitak B, Chen H, Yen M, Duffy S and Smith R. Beyond randomised controlled trials.
Organized mammographic screening substantially reduced breast cancer mortality. Cancer
2001; 91: 1724-1731.
Van den Akker-Van Mark E, De Koning H, Boer R and van der Maas P. Reduction in breast
cancer mortality due to introduction of mass screening in the Netherlands: comparison with
the United Kingdom. J Med Screening 1999; 6: 30-34.
Olsen AH, Njor SH, Vejborg I et al. Breast cancer mortality in Copenhagen after introduction
of mammography screening: cohort study. BMJ 2005; 330: 220-2.
Bjurstam N, Bjrveld L, Duffy S et al. The Gtherburg Breast Cancer Screening Trial: preliminary results on breast cancer mortality for women ages 39-49. J Natl Cancer Inst Monogr
1997; 22: 53-55.
Andersson I, Janzon L. Reduced breast cancer mortality in women under age 50: updated
results from the Malm Mammographic Screening Program. J Natl Cancer Inst Monogr 1997;
22: 63-67.
Salzman P, Kerlikowske K and Philips K. Cost effectiveness of extending screening mammography guidelines to include women 40 to 49 years of age. Ann Int Med 1997; 127: 955-965.
610
Breast cancer and pregnancy

Christos Markopoulos, MD, MPhil
Athens University Medical School
Breast cancer is the most common cancer in pregnant and postpartum women,
occurring in about 1 in 1,5003,000 pregnant women and accounts for approximately 10% of breast cancers diagnosed in premenopausal women. It
is anticipated that this frequency will increase as the birth rates for women in
their 30s continue to rise.
There are certain difculties in early diagnosis of breast cancer during pregnancy. The natural tenderness and engorgement of the breasts of pregnant and
lactating women may hide discrete masses, and therefore, delays in diagnoses
are common, with an average reported delay of 5 to 15 months from the onset
of symptoms (1,2,3). Because of this delay, cancers are typically detected at a
later stage than in a non pregnant, age-matched population (4).
If a breast abnormality is found during pregnancy, diagnostic approaches
such as ultrasound and mammography may be used. With proper shielding,
mammography poses little risk of radiation exposure to the fetus (5). Diagnosis
may be safely accomplished with a ne-needle aspiration, core biopsy or excisional biopsy under local anaesthesia (6).
Breast cancer pathology is similar in age-matched pregnant and non pregnant women. Hormone receptors are usually negative in pregnant breast cancer
patients but, when evaluated by using immunohistochemical techniques, the
steroid receptor content does not differ signicantly from that of aged-matched,
non pregnant control women (7).
Overall survival of pregnant women with breast cancer may be worse than
in non pregnant women (8). The unfavourable prognosis is due to more advanced stage at presentation and not directly attributable to the hormonal milieu
of pregnancy (9).
Termination of pregnancy has not been shown to have any benecial effect
611
on breast cancer outcome and is not usually considered as a therapeutic option

(3,5). However, termination of pregnancy may be considered, based on the age
of the fetus, and if maternal treatment options, such as chemotherapy and radiation therapy, are signicantly limited by the continuation of the pregnancy.
Modied radical mastectomy remains the preferred surgical management
but, treatment options, including radiotherapy and systemic chemotherapy, are
related to the stage of the disease and the trimester of pregnancy.
For early stage breast cancer (Stage I and II), surgery is recommended as the
primary treatment and modied radical mastectomy is the treatment of choice,
since radiation in therapeutic doses may expose the fetus to potentially harmful
scatter radiation and result in radiation-induced fetal malformation. However,
conservative surgery with postpartum radiation therapy may be also used, if
delay of radiotherapy for pregnancy completion does not place the mother at
undue risk. Adjuvant chemotherapy is indicated in the majority of patients and
can safely be administered after the rst trimester (1). Studies using adjuvant
hormonal therapy alone or in combination with chemotherapy for breast cancer
in pregnant women are so far very limited.
In pregnant women with late stage breast cancer (Stage III and IV) chemotherapy may be given after the rst trimester, as well as radiation therapy.
Even though therapeutic abortion does not improve prognosis, issues regarding
continuation of the pregnancy should be discussed with the patient and her
family, as in most studies, 5-year survival rate of pregnant patients with stages
III and IV disease is around 10%.
Some other considerations with breast cancer and pregnancy are those related to possible effect of cancer on the fetus, lactation and subsequent pregnancy
safety in women with a history of breast cancer.
No damaging effects on the fetus from maternal breast cancer have been
demonstrated, and there are no reported cases of maternal-fetal transfer of
breast cancer cells.
Suppression of lactation does not improve prognosis but, if surgery is
planned, lactation should be suppressed to decrease the size and vascularity
of the breasts. Lactation should also be suppressed if chemotherapy is to be
given, because antineoplastic drugs such as cyclophosphamide and methotrexate, when given systemically, may occur in high levels in breast milk.
Finally, based on limited retrospective data, pregnancy does not appear to
compromise the survival of women with a previous history of breast cancer
(10,11). Some physicians recommend that patients should wait 2 years after diagnoses before attempting to conceive. This allows early recurrence to become
manifest, which may inuence the decision to become a parent.
612
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Gwyn K, Theriault R: Breast cancer during pregnancy. Oncology (Huntingt) 15 (1): 39-46;
2001
Moore HC, Foster RS Jr: Breast cancer and pregnancy. Semin Oncol 27 (6): 646-53, 2000
Rugo HS: Management of breast cancer diagnosed during pregnancy. Curr Treat Options
Oncol 4 (2): 165-73, 2003
Clark RM, Chua T: Breast cancer and pregnancy: the ultimate challenge. Clin Oncol (R Coll
Radiol) 1 (1): 11-8, 1989
Barnavon Y, Wallack MK: Management of the pregnant patient with carcinoma of the breast.
Surg Gynecol Obstet 171 (4): 347-52, 1990
Novotny DB, Maygarden SJ, Shermer RW, et al.: Fine needle aspiration of benign and malignant breast masses associated with pregnancy. Acta Cytol 35 (6): 676-86, 1991
Elledge RM, Ciocca DR, Langone G, et al.: Estrogen receptor, progesterone receptor, and
HER-2/neu protein in breast cancers from pregnant patients. Cancer 71 (8): 2499-506, 1993
Guinee VF, Olsson H, Mller T, et al.: Effect of pregnancy on prognosis for young women
with breast cancer. Lancet 343 (8913): 1587-9, 1994
Petrek JA, Dukoff R, Rogatko A: Prognosis of pregnancy-associated breast cancer. Cancer 67
(4): 869-72, 1991
Kroman N, Jensen MB, Melbye M, et al.: Should women be advised against pregnancy after
breast-cancer treatment? Lancet 350 (9074): 319-22, 1997
Gelber S, Coates AS, Goldhirsch A, et al.: Effect of pregnancy on overall survival after the
diagnosis of early-stage breast cancer. J Clin Oncol 19 (6): 1671-5, 2001
613

Neonatal sepsis after single vs multiple
courses of antenatal betamethasone
therapy
S.Landolfo,, S.Porcaro, A.Scarcella
Neonatal Intensive Care Unit, Department of Paediatrics,
University Federico II of Naples, Italy
The decit of surfactant, brought about by its disimproved production or secretion or deciency for its increased destruction, is the primary cause of respiratory distress syndrome (RDS). RDS is more frequent in preterm infants with
low gestational age and low birth weight as the fetal lung mature levels of
surfactant are present only after 34 weeks gestation.
Since 1972 Liggins and Howie 1,2,3 reported that antenatal glucocorticoids
treatment given to women at high risk of preterm delivery induces the fetal lung
maturation and reduces the incidence of RDS. Repetitive trials4 were performed
because of a skepticism that antenatal glucocorticoids were safe and effective. In 1994, the National Institutes of Health (NIH) sponsored a Consensus
Development Conference5,6 on the effect of glucocorticoids for fetal maturation
on perinatal outcomes to assess the effectiveness of antenatal glucocorticoids
therapy. Based on data reviewed at the consensus conference, an appropriate
treatment regimen was dened as a single course of betamethasone given as
two 12-mg doses intramuscularly 24 hours apart, or a single course of dexamethasone, given as four 6-mg doses 12 hours apart. Maximum effectiveness
for reducing RDS was found between 24 hours and 7 days after initiating treatment. So this obstetric intervention is now the standard of care7,8,9,10,11,12,13,14,15.
The 1994 consensus conference panel noted that optimal benet of antenatal
glucocorticoids therapy lasts 7 days. The consensus conference panel also noted that the potential benets and risks of repeated administration of antenatal
614
glucocorticoids 7 days after the initial course are unknown and are called for
additional research on this issue. In 2000 the NIH organized a day conference to
present research on repeated courses of antenatal glucocorticoids therapy16. The
major question about the strategy to induce fetal lung maturation with antenatal
glucocorticoids was whether repeated courses of treatment are benecial and
safe17,18,19,20,.
The purpose of this study is to compare the effects of single vs multiple courses of antenatal betamethasone therapy on the frequencies of neonatal sepsis.
Material and metods

The study was carried out 18 months. All the preterm infants born between
24 and 36 weeks gestation admitted to the Neonatal Intensive Care Unit,
Department of Paediatrics, University FEDERICO II of Naples Italy, were
selected.
Neonatal parameters analysed included birth weight, gestational age at delivery, early-onset and late-onset neonatal sepsis. Early-onset and late-onset
neonatal sepsis were diagnosed on the basis of a positive results of blood or
cerebrospinal uid culture, supportive radiographic evidence, complete blood
count and blood clotting tests. Neonatal infections were diagnosed on the basis
of the bio-humoral index of CDS of Atlanta21,22 . Gastmeiers standards23 were
used for the diagnosis of clinical sepsis.
Early ruptured membranes and infections developed during the pregnancy
were the parameters considered for pregnants. Pregnants were categorized into
three groups according to betamethasone exposure:
1) Two 12-mg doses in a 24-hours interval on admission (SINGLE-COURSE
GROUP).
2) Repeated dosing after the initial single course (MULTIPLE-COURSES
GROUP)
3) No betamethasone therapy (CONTROL GROUP)
The three patients groups were not similar with respect to maternal demographic characteristics, mean gestational age at delivery, birth weight, modes
of delivery.
Data were analyzed with X2 test.
Results
A total of 130 newborns were included. 28 (21.53%) developed infectious complications: 23 (17.69%) developed sepsis and 5 ( 3.84%) developed localized
615
infections. The medium weight was 2465 g (range 680-4250) and the medium
gestational age was 30 weeks (range 24-36).
Tab. I:
Antenatal glucocorticoids treatment in pregnants
Single course
Courses
Doses
1 course
1 dose
N Pregnants
%
23
Multiple courses
Control
1course 2 courses 3 courses 4 courses group
2 doses 4 doses 6 doses 8 doses
37
(19,82%) (31,89%) (6,03%)

60 ( 51,71%)
Total
pregnants
Tab. II:
1
(0,86%)
46
(1,72%) (39,65%)
46
(39,65%)
10 ( 8,61%)
116
Antenatal glucocorticoids therapy and neonatal sepsis
Antenatal glucocorticoids therapy
Single course
1 course 1 dose
23 pregnants
1 course 2 doses
37 pregnants
Pregnants Newborns with

N
sepsis N (%)
60
12 (20%)
10
3 (30%)
46
13 (28.26%)
116
28
2 courses 4 doses
7 pregnants
Multiple courses
3 courses 6 doses
1 pregnants
4 courses 8 doses
2 pregnants
Control group
Total
616
Pregnants considered were 116 for twin pregnancies: 60 (51,71%) in the

single course group, 10 (8,61%) in the multiple course group and 46 (39,65%)
in the control group. (Tab. I)
During the pregnancy, 12 (10.3%) patients had early ruptured membranes
and received antibiotic therapy and 2 (1.7%) patients developed infections.
The group that received multiple courses of betamethasone therapy had the
greater frequency of neonatal sepsis. (Tab. II)
Conclusions
From several trials published after the NIH Consensus Conference of 2000
antenatal glucocorticoids determine reduction of incidence of RDS, but the
issue on the possible risks on neonatal outcomes still remains controversial.
French et al.24 reported that 2 or more courses of antenatal glucocorticoids
decreased birth weight, head circumference, and length without decreasing
the incidence of RDS more than a single course. The risks of severe chronic
lung disease tended to increase with repeated courses. There was no increase
in the incidence of cerebral palsy or overall disabilities in the infants treated
with repeated courses. However, French and colleagues also reported increased
behavorial abnormalities in the infants treated with repeated courses of glucocorticoids.
Banks et al.25 reanalyzed the antenatal glucocorticoids exposure of infants
randomly assigned to thyreotropin-releasing hormone and found lower birth
weights for infants exposed to 2 or more courses of antenatal glucocorticoids,
and an increase mortality rate for 3 more exposures. There was no decreased
risk of RDS. Vermillion et al. 26,27,28 found that repeated courses of glucocorticoids were not associated with a decreased birth weight or a decreased incidence of RDS relative to a single course of glucocorticoids. However, the
infectious complications of preterm delivery chorioamniositis, endometritis,
early neonatal sepsis, and sepsis-associated neonatal death were all associated
with repeated courses of antenatal glucocorticoids.
In contrast to these adverse outcomes, Abbassi et al. 29,30,31 found that repeated courses of antenatal glucocorticoids decreased the incidence of RDS
and patent ductus arteriosus more than a single course without increasing the
rates of mortality or other morbidities. The infants exposed to repeated courses
had a small decrease in head circumference, and the mothers had an increased
incidence of endometritis. In another report, repeated courses of glucocorticoids were associated with increased birth weight and were not associated
with maternal or neonatal infections or death. Thorp et al32 found that antenatal
617
betamethasone therapy was not associated with higher risks of antenatal maternal fever, chorioamniositis, reduced birth weight, neonatal adrenal suppression,
neonatal sepsis and neonatal death. Elimian at al33 found that compared with
single course, multiple courses of antenatal steroids reduced signicantly the
incidence of RDS with no apparent increase in neonatal sepsis.
Results of our study show an increase in neonatal sepsis and other infectious complications among neonates exposed to multiple courses compared
with single course. Since newborns of multiple course group had the highest
gestational age and the highest birth weight (protective factors for infections
onset) at delivery, the greater frequency of infections in this group might be
related to protracted exposure to antenatal glucocorticoids instead of neonatal
immunodeciency. A randomized controlled trial designed specically to address this issue is therefore necessary.
618
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Liggins G. C., M. B., Ph.D., F.R.C.O.G., and Howie R.N., M.R.A.C.P. A controlled trial of
antepartum glucocorticoid treatment for prevention of the respiratory distress syndrome in
premature infants. From the postgraduate school of obstetrics and gynaecology, University of
Auckland, New Zealand. Pediatrics, Vol. 50, N4;515-525, 1972
Liggins G.C.: Premature delivery of foetal lambs infused with glucocoticoids. J. Endocr., 45515, 1969
Liggins GC, Howie RN: A controlled trial of antepartum glucocorticoid treatment for prevention of RDS in premature infants. Pediatrics 50:515-525, 1972Derks JB, Giussani DA, Van
Dam LM, et al: Differential effects of betamethasone and dexamethasone fetal administration
of parturition in sheep. Jsoc Gynecol Investig 3:336-341, 1996
Crowley PA: Antenatal corticosteroids therapy: A meta-analysis of the randomized trials, 1972
to 1994. Am J Obstet Gynecol 173:322-335, 1995
Ballard RA, Ballard PL: Effect of corticosteroids for fetal maturation on perinatal outcomes.
Report of the NIH Consensus Conference. JAMA 273:413-418, 1995
National Institutes of Healt: Report of the consensus development conference on the effect
of corticosteroids for fetal maturation on perinatal outcomes: Bethesda, Maryland, National
Institute of child health and human development. NIH publication no. 95-3784, nov. 1994
Egerman RS, Mercer BM, Doss JL, et al: A randomized, controlled trial of oral and intramuscular dexamethasone in the prevention of neonatal respiratory distress syndrome. Am J Obstet
Gynecol 179:1120 1123, 1998
Morales WJ, Diebel ND, Lazar AJ, et al: The effect of antenatal dexamethasone administration on the prevention of respiratory distress syndrome in preterm gestations with premature
rupture of membranes. Am J Obstet Gynecol 154:591-595, 1986
Ballard PL, Ballard RA: Scientic basic and therapeutic regimens for use of antenatal glucocorticoids. Am J Obstet Gynecol 173:254-262, 1995.
Frank L, Roberts RJ: Effects of low-dose prenatal corticosteroid administration on the premature rat. Biol Neonate;36:1-9. 1979
Gamsu HR, Mullinger BM, Donnai P, Dash CH: Antenatal administration of betamethasone
to prevent respiratory distress syndrome in preterm infants: report of a UK multicentre trial.
J obstet Gynecol. 96:401-410. 1989
Garite TJ, Freeman RK, Linzey EM, et al: Prospective randomized study of corticosteroids in
the management of premature rupture of the membranes and the premature gestation. Am J
Obstet Gynecol 180:114-121, 1999
Goldenberg RL, Wright LL: Repeated courses of antenatal corticosteroids. Obstet Gynecol
97:316-317, 2001
Jobe AH, MD,PhD: Indication for and Question About Antenatal Steroids. Advances in
Pediatrics vol 49:227-243,2002
Spencer G, Neales K: Antenatal corticosteroids to prevent neonatal respiratory distress syndrome. BMJ;320:325-6. 2000
National Institutes of health consensus development statement: Antenatal corticosteroids revisited: repeat courses. August 17-18,2000 National Institutes of Health Consensus Development
Panel, Obstet&Gynecol,vol.98 n1; 144-150, 2001
Pratt L, Washbusch L, Ladd W, Gangnon R, Hendricks SK: Multiple vs single betamethasone
therapy: neonatal and maternal effects. J Reprod Med;44:257-64. 1999
Smith LM, Qureshi N, Chao Gr: Effects of single and multiple courses of antenatal glucocorticoids in preterm newborns less than 30 weeks gestation. J Matern Fetal Med;9:131-5. 2000
Stewart JD, Sienko AE, Gonzales CL, Christensen HD, Rayburn WF: Is a multidose of be-
619
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
tamethasone more benecial than a single dose in accelerating fetal lung maturation? Am J
Obstet Gynecol;178:S182.1998
Stone J, Lapinsky R, Eddleman K, Gallousis F, Berkowitz R: Single vs multiple courses of
steroid for fetal maturation: Is more better? Am J Obstet Gynecol;176:S48. 1997
Center For Disease Control and Prevention: National Nosocomial Infections Surveillance
(NNIS) report, date Summary from October 1986-April 1988. Am J Infect Control;26:52233.1988
Garner JS,Jarvis WR,Emori TG,Horon TC,Hungles JM:CDC denition for Nosocomial infections.Am J Infect Control;16:128-140.1988
Gastmeier J Hosp.Infect. 57,126-31;2004
French NP, Hagan R, Evans SF, et al: Repeated antenatal corticosteroid: Size at birth and
subsequent development. Am J Obset Gynecol 180: 114-121, 1999
Banks BA, Cnaan A, Morgan MA, Parer JT, Merril JD, Ballard PL, et al: Multiple courses
of antenatal corticosteroids and outcome of premature neonates. Am J Obstet Gynecol;3:19,1999
Vermillion ST, Soper DE, Bland ML, et al: Effectiveness of antenatal corticosteroid administration after preterm premature rupture of the membranes. Am J Obstet Gynecol 183:925-929,
2000
Vermillion ST, Soper DE, Chasedunn-Roark J.: Neonatal sepsis after betamethasone administration to patients with preterm premature rupture of membranes. Am J Obstet Gynecol
181:320-7,1999
Vermillion ST, Soper DE, Newman RB: Neonatal sepsis and death after multiple courses of
antenatal betamethasone therapy. Am J Obstet Gynecol 183:810-814, 2000
Abbasi S, Hirsch D, Davids J, et al: Effect of single versus multiple courses of antenatal
steroids on neonatal outcome of very low birthweight infants. Pediatr Res;45:179(abstract
1048),1999
Abbasi S, Hirsch D, Davids J, et al: Effect of single versus multiple courses of antenatal corticosteroid on maternal and neonatal outcome. Am J Obstet Gynecol 182:1243-1249, 2000
Abbasi S, Sivieri E, McGowan M, Gerdes J. Effects of multiple courses of antenatal steroids as
compared to single course on neonatal lung mechanics. Pediatr Res;45:292A.(abstract 1048),
1999
Thorp JA, Jones AM, Hunt C, et al: The effect of multidose antenatal betamethasone on maternal and infant outcomes. Am J Obstet Gynecol 184:196-202, 2001
Elimian A, Verma U, Visintainer P and Tejani N: Effectiveness of multidose antenatal steroids.
Obstetrics & Ginecology ;182:34-6. 2000
620
New objective method for the

continuous assessment of fetal activity
Kauyski Krzysztof 1, Czajkowski Krzysztof 2, Kret Tomasz 1,
Sieko Jacek 2, Pako Tadeusz 1, Leniak Beata 1
Institute for Precision and Biomedical Engineering, Warsaw University of Technology,
Warsaw, Poland. 2 2nd Department of Obstetrics and Gynecology,
Medical University of Warsaw.
1
Summary
Fetal activity is an important indicator of fetal well-being. An attempt to create
an objective and automatic method to assess this activity consists in using a
Continuous Wave (CW) Doppler method to collect fetal movement data and a
LabVIEW software for the on-line processing of this data. The system outputs
the information on the presence of fetal breathing movements, the histogram of
the general movements velocity and acceleration and its parameters, as well as
the fetal heart rate (FHR) trace. The system is intended to supplement the existing biophysical methods in the area of fetal movement analysis. The system
was validated in clinic by simultaneous echographic observation.
Introduction
Fetal activity is an important indicator of fetal well-being [1,2,3]. The introduction of fetal activity monitoring was expected to reduce the incidence of
cerebral palsy that has been commonly ascribed to intrauterine asphyxia. The
assessment of this activity includes various techniques that start with basic fetal
movement counting performed by mothers and end up with multiple technical
means for the detection of these movements, e.g. inductive transducers [4] or
electrical impedance method [5]. The technique dominating now is the echog-
621
raphy [6]. The Doppler ultrasound also plays an important role in the detection
of fetal movements [7-14].
One of the most widely used tools for the assessment of fetal well-being
is cardiotocography or electronic fetal monitoring. This technique, created to
trace fetal heart rate and uterine activity, can be supplemented with fetal gross
body movement detection. Unfortunately, no detailed information about the
fetal movement characteristics is available. Furthermore, electronic fetal monitoring is of uncertain value in predicting cerebral palsy [15,16].
The biophysical prole (BPP) is another noninvasive test introduced to
predict more accurately the presence or absence of asphyxia [3,17,18]. Three
out of ve parameters integrated in BPP describe fetal motor activity: fetal
breathing movements, gross body movements, and the tone. BPP has become
a standard tool for providing antepartum fetal surveillance. It ensures high
sensitivity, specicity and negative predictive value but is time-consuming and
lacks positive predictive value [19,20].
The fetal gross body movements (termed also General Movements, rolling
or stretching movements) may be analysed with respect to their frequency
(number of bursts per hour), movement burst duration and inter-burst interval
[21,22,23]. Real time ultrasonographic recordings of the fetal movements are
processed with specialized software to assess fetal behavior. Such examination lasts 1 to 2 hours [21]. Unfortunately, this approach does not include the
analysis of fetal movement velocity and accelerations.
Fetal activity analysis is an important but not the exclusive way of the fetal
well-being assessment. Other data can be obtained from fetal arterial or venous
Doppler velocimetry, fetal pulse oximetry or ST-waveform analysis of the fetal
electrocardiogram. The computerized analysis of fetal heart rate tracings or the
application of stress tests brings additional information on fetal well-being [24].
Doppler ultrasonography is a valuable tool in high risk pregnancy surveillance
[25]. ST-waveform analysis, an invasive method limited to intrapartum period,
seems to help improve perinatal outcome [26,27]. The benets of transvaginal
pulse oximetry usage are rather ambiguous [28]. Its non-invasive transabdominal modality needs further investigation [29], as does indirect transabdominal
fetal electrocardiography [30].
Summarizing, majority of the methods applied to evaluate fetal well-being present either unsatisfactory accuracy, require a qualied human observer,
prone to subjectivity, are time-consuming or limited in use. Usually they concern only a part of what may be called fetal motor activity. Therefore, it would
be of interest to elaborate a method of fetal well-being assessment, based on a
quantitative, objective, continuous and automated analysis of the fetal motor
622
activity. It might supplement the existing methods of fetal surveillance or even

replace them in the area of fetal movement analysis. An attempt to create such
a method is presented below.
Methods
The methodology employs the CW Doppler technique to obtain information
on fetal movement velocity and uses LabVIEW software environment for the
detection and classication of fetal movements and extraction of features of
these movements.
System hardware description

A 2MHz CW Doppler device is used. The total acoustic power introduced into
the maternal body does not exceed 10mW. The probe comprises two semi-circular transducer, one working in the emission, the other in the receive mode,
the diameter of each being 20mm. The device features two quadrature outputs
of the audio signals, with bandwidth of 20-200Hz. The output signals of the
monitor are fed to the line inputs of the soundcard of a laptop PC computer.
The 16 bits resolution offered by the A/D converter of the sound input of the
laptop provides signal dynamics of over 80dB and enables recording of both
the cardiac and thoracic fetal Doppler signals using the same signal path even
when the distance between the transducer and the fetal heart reaches 15cm.
The system uses battery supply instead of mains supply and thus provides the
requested patient safety.
Signal processing description

Signal processing is carried out using a dedicated LabVIEW software. The
software allows to acquire and to analyse Doppler signals in quasi-on-line
mode or off-line. Normal delay between sampling data and displaying results
is about 0.5-1 sec. Analysis parameters may be changed on the y without
disrupting the acquisition. The program has an oscilloscope function, which
displays the analogue inputs of the soundcard in real time. Acquired data and
results can be written to les. It is possible to simulate acquisition process by
reading data from previously acquired examination.
The program is designed as three independent parallel tasks: data acquisition task (DAQ), the digital signal processing (DSP) task and the user interface
task (GUI). GUI communicates with user, displays data and results, allows to
623
change acquisition and analysis parameters, starts and stops others tasks. DAQ
having the highest priorityacquires data and stores them in a local buffer.
The data are sent to the DSP and GUI tasks.
The signal processing is implemented in the DSP task. The processing comprises detection of individual types of fetal movements (gross body and pseudobreathing movements) and calculation of the FHR. The FHR is computed using
the autocorrelation method. It is to be noted here, that the FHR analysis is not
the principal objective and the issue of the FHR analysis is not addressed. The
distinction between the signals due to different kinds of movements is based
on their time-frequency structure. The ltering applied uses this structure, thus
the FHR is detected in the upper band of the signals (>=60Hz), whereas the
pseudobreathing movementsin the lower band (<=40Hz). The velocities of the
movements are computed from mean frequencies of the consecutive spectra
of the ltered Doppler signals. The accelerations are computed as smoothed
derivatives of the velocities. The presence of the breathing movements is detected on the basis of the spectral analysis of the movement velocity data. The
velocities and accelerations of movements are presented as histograms and
their features are computed median, standard deviation, skewness and kurtosis. The histograms are continuously updated. The parameters of histograms
and the result of the detection of breathing movements will be passed to the
classication system as a feature vector, describing the activity pattern of a
given fetus.
Fig.1: Diagram of the examination setup.
624
Experimental material and methods

At the rst stage of validation the algorithms were tested using test data le,
comprising quadrature signals resulting from a predened displacement pattern, and then on real fetal data acquired in the 2nd Department of Obstetrics
and Gynecology, Medical University of Warsaw. The protocol was accepted
by the Human Investigation Committee. The probe of the monitor was placed
on the maternal abdomen, pointing towards fetal heart and diaphragm, localized using a cardiotocograph just prior to the positioning of the transducer
(Fig.1).
Fig.2:. A screenshot showing quadrature Doppler signals, the displacement trace, the FHR trace, the fetal movement accelerations
trace and the spectrogram of the fetal movement velocity.
20 normal pregnancies were examined. The recordings lasted about 15 minutes. The Doppler signals from the monitor were fed to the sound input of the
laptop and analysed. In a number of cases these signals were recorded on the
audio track of the VCR with a concurrent video recording of ultrasonographic
625
images. Such video recordings served the reference and facilitated the verication of the results of the Doppler signal processing. The movements detected
with the software environment were compared with the concurrent B and M
mode images. M mode images were computed from B mode movie in the
Matlab environment.
Results
An example of the laptop screenshot shows the quadrature Doppler signals,
the displacement, the FHR trace, the fetal movement velocity trace and the
spectrogram of this velocity, showing a pseudobreathing activity with a rhythm
of about 60-70/min (1.1 1.2Hz) (Fig.2). The system allows the detection of
the gross body movements and the creation of the histogram of movement
properties (Fig.3).
Fig.3: A screenshot showing quadrature Doppler signals corresponding to the fetal gross body movements, the displacement trace, the
movement velocity and acceleration histograms
(for approximately 1.5 sec duration).
626
All visible on the video recordings episodes of the fetal pseudobreathing

were detected in the Doppler signals. Cardiac rhythm was detected on the basis
of Doppler data in the majority of the recording time. Both off-line and on-line
functioning of the software was tested, yielding identical results for identical
analysis parameter settings.
Discussion and conclusions

The approach presented here, contrary to the majority of existing devices/methods for fetal monitoring, incorporates the detailed analysis of the fetal movement features. Our preliminary studies show that the proposed methodology
enables automatic detection of the fetal breathing movements, determination
of general movement velocity and acceleration, as well as the detection of the
fetal heart rate (which, however, is not the main objective in this study, but
a complementary information). Artifacts resulting from maternal movements
may be partly removed on the basis of their amplitude. Other movements present in the measurement environment and giving rise to the Doppler signals may
be eliminated on the basis of their time-frequency features, like e.g. maternal
breathing or movements of arterial walls.
This solution seems to be a promising diagnostic tool for obstetricians. The
system enables the analysis in the on-line mode and concurrent input data storage, thus it allows also subsequent analyses with modied analysis parameters,
adding exibility.
The forthcoming studies will comprise further comparisons with ultrasonographic observation, cardiotocographic recordings and other tests, in normal
and pathological cases, in order to provide sufcient amount of data for the
subsequent step, which is the classication of fetal activity.
627
Bibliography
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Christensen F.C., Rayburn W.F. (1999) Fetal movement counts. Obstet.Gynecol.Clin. North
Am. 26(4), 607-21.
Geijn van H.P. (1989) Modern biophysical criteria of fetal well-being. in Achievements in
Gynecology, Mancuso S. (red), Contrib.Gynecol.Obstet., Karger, Basel, 17, 10-17.
Manning F.A., Platt L.D., Sipos L. (1980) Antepartum fetal evaluation: development of fetal
biophysical prole, Am.J.Obstet.Gynecol., 136, 787-795.
Goovaerts H.G., van Geijn H.P., Rompelman O., Mantel R., Swartjes J.M. (1991) Recording
fetal breathing movements with a passive transducer based on an inductive principle. Med.
Biol.Eng.Comput., 29, 358-364.
Ehrstrom C. (1979) Fetal movement monitoring in normal and high-risk pregnancy. Acta
Obstet.Gynecol.Scand. Suppl., 80, 12- 18.
Mc Nay M. B., Flemming J.E.E. (1999) Forty years of obstetric ultrasound 1957-1997: from
A-scope to three dimensions. Ultrasound Med.Biol., 25, 3-56.
Trudinger, B.J., Cook, C.M. (1989) Fetal breathing movementsA comparison of hard copy
records produced by M-mode and Doppler ultrasound, Early Hum.Dev., 20, 247-253.
Besinger R.E, Johnson T.R.B.(1989) Doppler recordings of fetal movement: clinical correlation with real-time ultrasound. Obstet.Gynecol., 74, 277-280.
DiPietro J.A., Costigan K.A., Pressman E.K. (1999) Fetal movement detection: comparison
of the Toitu actograph with ultrasound from 20 weeks gestation. J.Maternal-Fetal Med., 8(6),
237-42.
Kauyski K., Berson M., Pourcelot L., Pako T. (1993) Detection of fetal breathing and
cardiac signals and rhythms in the ultrasonic Doppler signal recorded on the surface of the
maternal abdomen, Med.Biol.Eng.Comput.,31, 405-411.
Karlsson B., Pourcelot D., Helgason T., Pourcelot L., Berson M. (1998) Distance of foetal
movement measured using the analytical signal derived from nondirectional Doppler sound.
Med.Eng.Phys., 20, 325-331.
Karlsson B., Foulquiere K., Kauyski K., Tranquart F, Fignon L., Pourcelot D., Pourcelot
L., Berson M. (2000) The DOPFET systema new ultrasonic Doppler system for monitoring
and characterization of fetal movement, Ultrasound Med.Biol., 26, 7, 11171124.
Maeda K., Tatsumura M., Utsu M. (1999) Analysis of fetal movements by Doppler actocardiogram and fetal B-mode imaging. Clin. Perinatol., 26(4), 829-51.
Yamakoshi Y., Otaki H., Shinozuka N., Masuda H. (1996) Internal tissue displacement measurement based on ultrasonic wave Doppler signal detection and its application to fetal movement monitoring, Ultrasonics, 34. 769-775.
Nelson K.B, Dambrosia J.M, Ting T.Y, Grether J.K. (1996) Uncertain value of electronic fetal
monitoring in predicting cerebral palsy. N.Engl.J.Med. 334(10), 613-8.
Thacker S.B., Stroup D.F., Peterson H.B. (1995) Efcacy and safety of intrapartum electronic
fetal monitoring: an update. Obstet.Gynecol. 86(4 Pt 1), 613-20.
Manning F.A., Bondaji N., Harman C.R., Casiro O., Menticoglou S., Morrison I. Berck D.J.
(1998) Fetal assessment based on fetal biophysical prole scoring. VIII. The incidence of
cerebral palsy in tested and untested perinates. Am.J.Obstet.Gynecol., 178(4), 696-706.
Kamel H.S., Makhlouf A.M., Youssef A.A. (1999) Simplied biophysical prole: an antepartum fetal screening test. Gynecol. Obstet. Invest., 47(4), 223-8.
Petrovic O., Frkovic A., Matejcic N. (1995) Fetal biophysical prole and vibratory acoustic
stimulation in high-risk pregnancies. Int J Gyn Obstet. 50 (1), 11-15.
Vintzileos A.M., Gaffney S.E., Salinger L.M., Kontopoulos V.G., Campbell W.A., Nochimson
D.J. (1987) The relationships among the fetal biophysical prole, umbilical cord pH, and
628
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.

Apgar scores. Am.J.Obstet.Gynecol. 157(3), 627-31.
ten Hof J., Nijhuis I.J., Nijhuis J.G., Narayan H., Taylor D.J., Visser G.H., Mulder E.J. (1999)
Quantitative analysis of fetal general movements: methodological considerations. Early Hum.
Dev. 56,(1), 57-73.
Prechtl H.F. (1997) State of the art of a new functional assessment of the young nervous
system. An early predictor of cerebral palsy. Early Hum. Dev., 50(1), 1-11.
Sival D.A., Visser G.H.A., Prechtl H.F.R. (1992) The effect of intra-uterine growth retardation
on the quality of general movements in the human fetus. Early Hum.Dev., 28, 119-132.
Strachan B.K., Sahota D.S., van Wijngaarden W.J., James D.K., Chang A.M. (2001)
Computerised analysis of the fetal heart rate and relation to acidaemia at delivery. BJOG.
108(8), 848-52.
Alrevic Z., Neilson J.P. (1995) Doppler ultrasonography in high-risk pregnancies: systematic
review with meta-analysis. Am J Obstet Gynecol.172(5), 1379-87.
Amer-Wahlin I., Hellsten C., Noren H., Hagberg H., Herbst A., Kjellmer I., Lilja H., Lindoff C.,
Mansson M., Martensson L., Olofsson P., Sundstrom A., Marsal K. (2001) Cardiotocography
only versus cardiotocography plus ST analysis of fetal electrocardiogram for intrapartum fetal
monitoring: a Swedish randomized controlled trial. Lancet, 358(9281), 534-8.
Westgate J., Harris M., Curnow J.S., Greene K.R. (1993) Plymouth randomized trial of cardiotocogram only versus ST waveform plus cardiotocogram for intrapartum monitoring in
2400 cases. Am.J.Obstet.Gynecol.169(5), 1151-60.
Garite T.J., Dildy G.A., McNamara H., Nageotte M.P., Boehm F.H., Dellinger E.H., Knuppel
R.A., Porreco R.P., Miller H.S., Sunderji S., Varner M.W., Swedlow D.B. (2001) A multicenter
controlled trial of fetal pulse oximetry in the intrapartum management of nonreassuring fetal
heart rate patterns. Am.J.Obstet.Gynecol. 183(5), 1049-58.
Vintzileos A.M., Nioka S., Lake M., Li P., Luo Q., Chance B. (2005) Transabdominal fetal
pulse oximetry with near-infrared spectroscopy. Am.J.Obstet.Gynecol. 192(1), 129-33.
Jeewski J., Cholewa D., Kamiski K., Matonia A., Kupka T., Horoba K. (2003) Progress in
fetal monitoringdirect or indirect electrocardiography. Arch. Perinat. Med. (1), 15-19.
629
Intrauterine growth restriction,

angiogenic factors and their possible
role in post-partum catch-up growth of
the neonate
Ariadne Malamitsi-Puchner, MD
Neonatal Division, Second Department of Obstetrics and Gynecology,
University of Athens
Introduction
Angiogenesis is dened as the formation of new blood vessels from pre-existing ones (1) and is initiated by growth factors, named angiogenic (2). Placenta
demonstrates two types of angiogenesis: a) Branching angiogenesis, characterized by the increase in the number of vessels by sprouting, which predominantly
takes place in the 1st and 2nd trimester and b) non-branching angiogenesis,
characterized by non sprouting vascularized villi, specialized in gas exchange
and predominantly taking place in the 3rd trimester (3, 4).
Intrauterine growth restriction (IUGR) expresses the failure of the fetus to
achieve his/her intrinsic growth potential (5). Several factors determine the
intrinsic growth potential and are related to the fetus (gestational age, gender,
number of fetuses in the uterus) to the mother (height and weight at the beginning of pregnancy, parity, ethnicity) and the environment (altitude at which
pregnancy evolves) (6).
Small for gestational age (SGA- dened as fetuses with BW <10th centile
for gestational age in a certain population) differ from IUGR fetuses as the
latter present anatomical and/or functional disorders or diseases in the feto- maternal-placental unit, resulting to increased morbidity and mortality in intra-and
extra-uterine life (7).
630
The majority of IUGR predisposing conditions (maternal anemia, maternal

cyanotic cardiac disease, preeclampsia with preserved end-diastolic ow, or
pregnancy at high altitude) are accompanied by decreased intra-placental oxygen concentrations. Branching angiogenesis mainly characterizes the above
situations. In contrast, non-branching angiogenesis and increased intra-placental oxygen concentrations is predominantly found in preterm IUGR with
umbilical absent end-diastolic ow velocity. Nevertheless, in all above cases
the fetus is hypoxic (8).
On the other hand, placental oxygen concentrations are responsible for the
up-or down regulation of the various angiogenic factors, implicated in placental angiogenesis (9). Thus, low placental oxygen concentrations upregulate
vascular endothelial growrh factor (VEGF), angiopoietin 1 and 2 (Ang-1,
Ang-2), and downregulate placental growth factor (PlGF) and endostatin, the
latter being a potent angiostatic factor (3). In contrast, high placental oxygen
concentrations upregulate PlGF and endostatin, and downregulate VEGF, Ang1 and Ang-2 (10-12).
The studies subsequently reported were based on the hypothesis that circulating levels of angiogenic factors should differ between IUGR and appropriate
for gestational age (AGA) fetuses and neonates as the former suffer from in
utero hypoxia and present restricted growth and development. Therefore, it was
aimed to determine circulating levels of Ang-2, VEGF, PlGF and End in IUGR
and AGA cases at time-points characteristic for intra- and extra-uterine life.

The studies, approved by the Ethics Committee of our teaching hospital were
performed after acquisition of informed consent by the mothers. We included
mothers at the rst stage of labor, or before anesthesia, in cases of elective cesarean section, as well as fetuses and neonates, either AGA or IUGR. As IUGR,
were characterized those infants with birthweight <10th customized centile, adjusted for gestational age, gender, maternal weight at the beginning of pregnancy,
maternal height, ethnic group and parity (6). All included in the studies IUGR
cases were of the asymmetrical pattern and IUGR resulted either from hypertension of pregnancy, pre-eclampsia or small and infarcted placentas. However,
fetal Doppler studies of the umbilical and middle cerebral artery showed normal
blood ows. In the group of AGA infants, mothers did not present pathological
symptoms. Neonates with intrauterine infection or genetic syndromes leading
to restriction were excluded from the studies. Apgar scores were in all IUGR
cases and AGA controls >7 and >8 in the rst and fth minute respectively. All
631
neonates were breast- fed (the IUGR infants every two to three hours, the AGA
babies every three to four hours) and received additional formula according to
requirements, starting at three hours after birth. Weight loss (ranging from 6 to
8% of birthweight) was already regained by day 7 of life.
Table 1:
Demographic data of participating( in the Ang-2 study) infants (intrauterine growth restricted-IUGR, or appropriate for gestational age-AGA) and of their mothers
IUGR n= 40
AGA n=20
Maternal age (years)
29.8 5.1*
29.3 4.0*
Gestational age (weeks)
38.5 1.2*
38.8 1.1*
Birthweight (g)
2409 316.8*
3448 193.4*
Gender (male/female)
16/24
12/8
Mode of delivery (VD/ECS)**
13+/26
8/12
Table 2:
Demographic data of participating (in the VEGF-PlGF study) infants (intrauterine growth
restricted-IUGR, or appropriate for gestational age-AGA) and of their mothers
IUGR n= 25
AGA n=25
30.9 5.5*
28.9 3.7*
Gestational age (weeks) 38.2 1.7*
38.9 1.8*
Birthweight (g)
2273 258.7*
3518 186.6*
12/13
14/11
Mode of delivery
(VD/ECS)**
15/10
12/13
Ang-2, VEGF, PlGF, and End were determined by enzyme immunoassays (human Angiopoietin-2 Duo Set ELISA Development System, Catalog
Number DY 623, R&D Systems, Minneapolis MN 55413, Quantikine human
VEGF, Catalog number DVEOO and Quantikine human PlGF, Catalog number
DPGOO, R&D Systems, Minneapolis MN 55413 and ChemiKineTM human
Endostatin, Catalog number CYT158, Chemicon International, Temecula,
CA 92590) in: the maternal serum (MS), the doubly clamped umbilical cord
serum (UC-mixed arteriovenous blood), representing fetal state, the neonatal
day 1 serum (N1), signifying transition, neonatal day 4 serum (N4), signifying stabilization to extrauterine life and neonatal day 7 (only for Ang-2 and
End) (Fig 1-6). Demographic data are presented in Tables 1-4. Parametric and
non-parametric tests were applied in the statistical analysis according to the
distribution of the data.
632
Table 3:
Demographic data of participating (in the endostatin study) infants (intrauterine growth
restricted-IUGR, or appropriate for gestational age-AGA) and of their mothers
IUGR n= 20
31.1 5.9*
Birthweight (g)
2249 259.0*
8/12
Mode of delivery
4/16
(VD/ECS)**
Table 4:
AGA n=20
29.3 4.0*
39.0 0.9*
3447 193.4*
12/8
8/12
Demographic data of participating seven days old neonates (intrauterine growth restricted-IUGR, or appropriate for gestational age-AGA- Ang-2 and End study)
IUGR n= 20
Birthweight (g)
2249 259.0*
8/12
Mode of delivery
4/16
(VD/ECS)**
AGA n=20
39.0 0.9*
3447 193.4*
12/8
8/12
* values are mean SD

** VD: vaginal delivery/ ECS: elective cesarean section
3500
3000
2500
2000
IUGR
1500
AGA
1000
500
0
MS
UC
N1
N4
Figure 1:: Mean circulating levels of Ang-2 (pg/ml) in the four investigated groups: maternal serum (MS), umbilical cord serum (UC),
neonatal day 1 serum (N1), neonatal day 4 serum (N4) for intrauterine
growth restricted (IUGR) and appropriate for gestational age
(AGA) infants.
633
800
MEDIAN VALUES
700
600
500
IUGR
AGA
400
300
200
100
0
VEGF MS
VEGF UC
VEGF N1
VEGF N4
Figure 2: Median circulating levels of vascular endothelial growth

factor (VEGF- pg/ml) in the four investigated groups: maternal serum
(MS), umbilical cord serum (UC), neonatal day 1 serum (N1), neonatal
day 4 serum (N4) for intrauterine growth restricted (IUGR) and appropriate for gestational age (AGA) infants.
200
180
MEDIAN VALUES
160
140
120
IUGR
AGA
100
80
60
40
20
0
PLGF MS
PLGF UC
PLGF N1
PLGF N4
Figure 3: Median circulating levels of placenta growth factor (PlGFpg/ml) in the four investigated groups: maternal serum (MS), umbilical
cord serum (UC), neonatal day 1 serum (N1), neonatal day 4 serum
(N4) for intrauterine growth restricted (IUGR) and appropriate for
gestational age (AGA) infants.
634
70
60
ng/ml
50
40
IUGR
AGA
30
20
10
0
MS
UC
N1
N4
Figure 4: Mean circulating levels of endostatin (End) in the four investigated groups: maternal serum (MS), umbilical cord serum (UC), neonatal day 1 serum (N1), neonatal day 4 serum (N4) for intrauterine growth
restricted (IUGR) and appropriate for gestational age (AGA) cases.
5000
4000
Mean +- 2 SD
3000
2000
1000
Ang-2 IUGR
Ang-2 AGA
Figure 5: Mean + SD levels of angiopoietin-2 (Ang-2) in 7 days old

intrauterine growth restricted (IUGR) and appropriate for gestational
age (AGA) ineonates
635
120
100
80
60
Mean +- 2 SD
40
20
0
End IUGR
End AGA
Fig 6: Mean + SD levels of endostatin (End) in 7 days old intrauterine

growth restricted (IUGR) and appropriate for gestational age (AGA)
ineonates
Results
Concerning Ang-2:
N4 and N7 Ang-2 were found higher in IUGR (p=0.03 and p=0.044 respectively)
UC and N1 Ang-2 were found suggestively higher in IUGR (p=0.07, and
p=0.06 respectively)
No correlation of circulating levels of Ang-2 with gender, gestational age and
mode of delivery was found in either group (IUGR and AGA). Concerning
VEGF-PlGF:
MS and N1 PlGF correlated with the centiles of the infants (r=0.39, p=0.007,
r=0.34, p=0.01 respectively)
UC VEGF negatively correlated with the centiles of the infants (r= -0.41,
p=0.004)
UC, N1, N4 VEGF were higher in girls (r=0.36, p=0.01, r=0.33, p=0.02,
r=0.41, p=0.005 respectively)
636
Concerning Endostatin (End):

UC, N1, N4 and N7 End were higher in AGA than IUGR (p<0.0000,
p=0.0006, p=0.024, p=0.024 respectively)
UC correlated with the centiles of the infants (r=0.69, p=0.00001)
No correlation of circulating levels of End with gender, gestational age and
mode of delivery was found in either group (IUGR and AGA).
Conclusions
* Intrauterine hypoxia does not up-regulate circulating Ang-2 levels in IUGR
fetuses and day 1 neonates.
* The signicant increase of Ang-2 on N4 and N7 after stabilization to extrauterine life, might signify the gradual initiation of catch-up growth-related
angiogenesis and stimulation of angiogenic factors, granted that Ang-2 is
critically involved in postnatal vascular remodeling (10).
* MS and N1 PlGF, and UC VEGF levels correlate with the centile of the
infant in positive and negative directions respectively, possibly due to the
impact of placental size and intrauterine oxygen concentrations (being
smaller and lower respectively, in IUGR cases) on the secretion of PlGF
and VEGF (11).
* UC, N1 and N4 VEGF levels are higher in girls, possibly due to the stimulating action of estrogens and the possible implication of the fetal ovary (13,
14).
* IUGR is characterized by lower circulating endostatin concentrations in the
fetus and neonate, as under lower oxygen concentrations, an unbalanced
state of angiogenesis stimulators vs. inhibitors- in favor of the former- possibly takes place (12).
* The down-regulation of endostatin on days 4 and 7 of life in IUGR infants
could signify the initiation of catch-up growth, since the latter presupposes
angiogenesis and thus, factors promoting vessel sprouting, and not inhibitors of vessel formation (e.g. the angiostatic factor End).
* Studies have shown (15) that once the placental constraint on growth is
lifted at birth, postnatal catch-up growth is rapid.
637
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
FOLKMAN J, SHING Y. Angiogenesis. J Biol Chem 267: 10931-10934, 1992

FOLKMAN J, KLAGSBRUN M. Angiogenic factors. Science 235: 442-447, 1987
ZYGMUNT M, HERR F, MUENSTEDT K, LANG U, LIANG OD. Angiogenesis and vasculogenesis in pregnancy. Eur J Obstet Gynecol Reprod Biol 110: S10-S18, 2003
GEVA E, GINZINGER DG, ZALOUDEK CJ, MOORE DH, BYRNE A, JAFFE RB. Human
placental vascular development: Vasculogenic and angiogenic (branching and nonbranching)
transformation is regulated by vasculae endothelial growth factor-A, angiopoietin-1 and angiopoietin-2. J Clin Endocrinol Metab 87: 4213-4224, 2002
BERNSTEIN I, GABBE SG. Intrauterine growth restriction. In Gabbe SG, Niebyl JR, Leigh
Simpson J. Obstetrics- Normal and Problem Pregnancies 3rd ed, Churchill Livingstone, Inc
1996
GARDOSI J, MONGELLI M, WILCOX M, CHANG A. An adjustable fetal weight standard.
Ultrasound Obstet Gynecol 6: 168-174, 1995
MARSAL K. Intrauterine growth restriction. Curr Opin Obstet Gynecol 14: 127-135, 2002
KINGDOM J, HUPPERTZ B, SEAWARD G, KAUFMANN P. Development of the placental
villous tree and its consequences for fetal growth. Eur J Obstet Gynecol Reprod Biol 92: 35-43,
2000
AHMED A, DUNK C, AHMAD S, KHALIQ A. Regulation of placental vascular endothelial
growth factor (VEGF) and placenta growth factor (PlGF) and soluble Flt-1 by oxygen- A
review. Placenta 21, Suplement A, Trophoblast Research 14: S16-S24, 2000
JONES P. Not just angiogenesis-wider roles for the angiopoietins. J Pathol 201: 515-527,
2003
REGNAULT TRH, de VRIJER B, GALAN HL, DAVIDSEN ML, TREMBLER KA,
BATTAGLIA FC, WILKENING RB, ANTHONY RV. The relationship between transplacental
O2 diffusion and placental expression of PlGF, VEGF and their receptors in a placental insufciency model of fetal growth restriction. J Physiol 550: 641-656, 2003
WU, P, YONEKURA H, LI H, NOZAKI I, TOMONO Y, NAITO I, NINOMIYA Y,
YAMAMOTO H. Hypoxia down-regulates endostatin production by human microvascular
endothelial cells and pericytes. Biochem Biophys Res Commun 288: 1149-1154, 2001
KANG DH, YU ES, YOON KI, JOHNSON R. The impact of gender on progression of renal
disease: potential role of estrogen-mediated vascular endothelial growth factor regulation and
vascular protection. Am J Pathol 164: 679-688, 2004
ZACHOS NC, BILLIAR RB, ALBRECHT ED, PEPE GJ. Developmental regulation of baboon fetal ovarian maturation by estrogen. Biol Reprod 67: 1148-1156, 2002
CONSTANCIA M, HEMBERGER M, HUGHES J, DEAN W, FERGUSON-SMITH A,
FUNDELE R, et al. Placental-specic IGF-II is a major modulator of placental and fetal
growth. Nature 2002; 417: 945-948
638
Womens views of and preferences

regarding three approaches to
hospital care following rst trimester
miscarriage
Julia Shelley, 2Sonia Grove, 3David Healy
Australian Research Centre in Sex, Health and Society, La Trobe University,

Royal Womens Hospital, 3Monash University
1
2
Introduction
In the event of miscarriage, many women go directly to a hospital or to a medical practitioner who may refer them to hospital 1, 2. Many hospitals have policies
that inuence the care provided to patients and the procedures, if any, that
will be recommended. In the case of rst trimester spontaneous miscarriage,
curettage has been a standard form of care for over 50 years, and is still the approach recommended by many practitioners 1,3-5. There is increasing evidence,
however, that surgical intervention may not be necessary in many instances of
uncomplicated rst trimester miscarriage 6,7. Evidence is growing that medical
methods and expectant care are safe and effective alternatives to curettage
following rst trimester miscarriage6,8-12. Indeed, this evidence suggests that
curettage may carry a slightly greater risk of infection than expectant care 8,9.
Curettage involves a range of risks ranging from general anaesthesia and
surgical accidents, such as perforation of the uterus or bowel, to the vagaries
of availability of operating theatres and length of surgical lists. Potentially
offsetting this is a restricted period of pain and bleeding and the reassurance of
treatment using a long established method, seen by hospital staff as routine 13.
No anaesthetic or surgical intervention is required for expectant care (watchful
639
waiting) or medical management using synthetic prostaglandins. The process

of expelling the products of conception can take place in a supervised hospital
setting, or in the womans home.
In light of the growing consideration of medical methods of evacuating the
uterus and expectant care as possible alternatives to curettage, and the lack of
published research regarding womens preferences for these different methods
of care14, we conducted a cohort study of women who had received surgical,
medical (vaginally administered misoprostol) or expectant management following incomplete or inevitable miscarriage in Melbourne, Australia.
Methods
The Human Research Ethics Committees of La Trobe University and all participating hospitals approved the study.
Participants
Women presenting to the emergency departments of six Melbourne metropolitan hospitals and diagnosed with inevitable or incomplete rst trimester
miscarriage were eligible for inclusion in the study. The hospitals included
a specialist womens hospital, two general tertiary hospital and three general
suburban hospitals. These hospitals manage close to half of the women with
incomplete miscarriage treated in hospitals in metropolitan Melbourne 2.
Data collection
Womens reproductive history, demographic and treatment details were collected at recruitment. The women also completed a questionnaire at their 10
to 14 day clinical check up and a second mailed to them at 8 weeks. The latter
included questions on their views of the treatment they had received and their
preferences for treatment if time went backwards and you had to do it all over
again. They were asked what they liked, and what they disliked about the
method of management they had received. Six options were provided for each
question. Five of these varied for each of the three management approaches.
The options there was nothing I liked and there was nothing I disliked
were included in each form of the questionnaire. Space was provided, also,
for women to add other aspects of their management that they either liked or
disliked.
Results
A total of 230 women were recruited, of whom 162 (70.4%) completed the 8
640
week questionnaire. Their median age was 30 years (interquartile range 25 to

35 years), 95% were married or living with a partner. Seventy percent (113
women) had been pregnant previously and 55% had had at least one live birth.
This was the second or subsequent miscarriage for 23% of the women. For 57%
of women this was a planned pregnancy, with 12% of them having been trying
to conceive for twelve months or more.
Following recruitment to the study, 64% of the women were managed surgically, 17% were treated with misoprostol, while 19% had expectant care. There
was no difference in the treatment that women received in relation to their age
or reproductive history.
Of the 104 women who had surgical management, 76% liked having it over
and done with, 51% liked not having to be awake during treatment, and 38%
liked feeling cleaned out by the treatment. Features they disliked included:
having to wait to have surgery (52%), having to have an anaesthetic (29%),
worry about their health (23%), being away from their family (16%) and not
being sure that the pregnancy was lost (15%). Twelve percent said there was
nothing they disliked.
Factors liked by the 28 women who had medical management included: not
having to have an anaesthetic (77%), having a more natural treatment (58%),
being awake throughout the treatment (43%), the time it took for the treatment
to be completed (38%) and less worry about their health (18%). More than a
third (38%) disliked the pain and discomfort of treatment, 15% disliked the
time it took for the treatment to be completed, 12% disliked the worry about
having drug treatment and the worry about their health associated with medical
treatment. Almost one third (31%) said that there was nothing they disliked.
Of the 30 women who had expectant care, 64% liked having a more natural treatment, 60% not having to be in hospital, 59% not having to have an
anaesthetic, 50% being able to be with their family, while 33% nominated less
worry about their health as an aspect of expectant care that they liked. Worry
about not being cleaned out properly was an aspect of expectant care disliked
by 53%, with 40% nominating pain and discomfort, 37% worry about their
health and 7% the worry of not being in hospital.
In response to the question what did you like about (your mode of treatment)? 11% of women overall said that there was nothing that they liked.
This varied with the type of care they had received with 15% of women who
received surgical care responding that there was nothing that they liked compared with 4% of those who received medical treatment and 3% who were
managed expectantly.
Fifteen percent of women responded that there was nothing that they dis-
641
liked about their mode of treatment. Again, this varied substantially in relation
to the actual treatment they had received, with 12% of the surgical treatment
group, 29% of the medical treatment group and 13% of the expectant care
group saying that there was nothing they disliked about their treatment.
Womens responses to the questions what did you like and what did you
dislike about your mode of treatment did not differ with age, marital status, or
any aspect of their reproductive histories.
Around three quarters of the women, overall, would choose the same treatment if time went backwards and you had to do it all again. The same treatment was selected by 80% of women in the surgical treatment group, 69% in
the medical treatment group and 79% in the expectant care group. Of the 20
women treated surgically who would opt for a different treatment, 16 would
choose medical treatment, with only 4 (4%) opting for expectant care. Of the
30% women who received misoprostol but would choose a different form of
care next time, most (27%) would choose surgical treatment. Of the 21% of
women who had expectant care but would opt for a different treatment, 17%
would choose surgical treatment, with only 3% opting for medical care.
Discussion
Although there is a growing literature on womens experiences of and responses to miscarriage there has been very little exploration of womens views on
the actual experience of evacuation of the uterus. Even in the literature that
examines womens satisfaction with care and experience of the health system,
curettage is mentioned only rarely, a characteristic of the existing literature
commented on by Slade (1994)14.
In two studies that have considered womens preferences for either surgical
or expectant management of rst trimester incomplete miscarriage, the reasons
women provided for their preference were very similar to the aspects if care
liked or disliked by a high proportion of women in this study. Those who
preferred expectant care mentioned that it was a natural method that it was
less invasive and let the body handle it. Many of those who preferred D&C
mentioned get it over with as the reason for their preference 15, 16 . In contrast
to our ndings, neither of these studies specically mentioned anaethesia, yet
avoidance of an anaesthetic was the factor liked by the highest proportion of
women: 77% of those who had medical management and 59% of women who
had expectant care.
Lengthy waiting times for surgery have featured as a source of womens
dissatisfaction with hospital care in several studies 3,13, while the brevity of
the hospital stay was noted as a source of (unpleasant) surprise for women
642
in Cecils study in Northern Ireland 17. In our study, having to wait to have
surgery was the aspect of surgical care most frequently selected as one that
women disliked, with more than half the women who were managed surgically nominating this as a feature they disliked. This is one of few aspects of
management that potentially can be addressed by hospitals and emergency
departments.
Conclusions
Each management approach has features that some women like and features
some women dislike. This suggests that choice of management is desirable and
that descriptive information on aspects of each approach, such as those discussed here, is provided to women as part of their decision making process.
Acknowledgments
This study was funded by a Department of Human Services, Victoria, Best
Practice Initiatives Grant and an MBF Medical Research Award. We are grateful to the women who participated in the study, Site Research Nurses, Site
Investigators, Reference Group, and the staff of the VICMIST Coordinating
Centre.
643
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
MacLaren B, Shelley JM. Management of early pregnancy bleeding and miscarriage by general practitioners in Victoria. Med J Aust. 2002;176:63-66.
Hemminki E. Treatment of Miscarriage: Current Practice and Rationale. Obstet Gynecol.
1998;91:247-253.
Evans L, Lloyd D, Considine R, Hancock L. Contrasting views of staff and patients regarding
psychosocial care for Australian women who miscarry: a hospital based study. Aust N Z Obstet
Gynaecol. 2002;42:155-160.
Everett C, Ashurst H, Chalmers I. Reported management of threatened miscarriage by general
practitioners in Wessex. Brit Med J. 1987;295:583-586.
Prendiville W, O'Kelly F, Allwright S, McGuiness N. The management of rst trimester miscarriage by general practitioners in Ireland. Ir J Med Sci. 1997;166:3-6.
Ankum W, Wieringa-de Waard M, Bindels P. Management of spontaneous miscarriage in the
rst trimester: an example of putting informed shared decision making into practice. Brit Med
J. 2001;322:1343-1346.
Geyman JP, Oliver LM, Sullivan SD. Expectant, medical, or surgical treatment of spontaneous
abortion in rst trimester of pregnancy? A pooled quantitative literature evaluation. J Am Board
Fam Pract. 1999;12:55-64.
Nielsen S, Hahlin M. Expectant management of rst-trimester spontaneous abortion. Lancet.
1995;345:84-86.
Wieringa-de Waard M, Vos J, Bonsel G, Bindels PJE, Ankum WM. Management of miscarriage: a randomized controlled trial of expectant management versus surgical evacuation. Hum
Reprod. 2002;17:2445- 2450.
Chung, T, Lee D, Cheung L, Haines CJ, Chang AMZ. Spontaneous abortion: a randomized,
controlled trial comparing surgical evacuation with conservative management using misoprostol. Fertil Steril. 1999;71:1054-1059.
Demetroulis C, Saridogan E, Kunde D, Naftalin AA. A prospective randomized control
trial comparing medical and surgical treatment for early pregnancy failure. Hum Reprod.
2001;16:365-369.
Mufey P, Stitely M, Gherman, R.. Early intrauterine pregnancy failure: A randomized trial of
medical versus surgical treatment. Am J Obstet Gynecol. 2002;187:321-326.
Friedman T. Women's experiences of general practitioner management of miscarriage. J R Coll
Gen Pract. 1989;39:456-458.
Slade P. Predicting the psychological impact of miscarriage. J Reprod Infant Psychol.
1994;12:5-16.
Molnar AM, Oliver LM, Geyman JP. Patient preferences for management of rst-trimester
incomplete spontaneous abortion. J Am Board Fam Pract. 2000;13:333-357.
Ogden J, Maker C. Expectant or surgical management of miscarriage: a qualitative study.
BJOG 2004; 111:463-467.
Cecil R. Miscarriage: women's views of care. J Reprod Infant Psychol. 1994;12:21-29.
644
Modication of preterm uterine

contractile activity by inammation:
should we combine anti inammatory
drugs with anti-oxytocics
Laudanski T, Pierzynski P.
Department of Pathophysiology of Pregnancy, Medical University of Bialystok, Poland
Labor in humans is a nal effect of series of biologic changes and adaptations

that take place during pregnancy. When occurring prematurely, it may be a
cause of serious medical problems, mainly, neonatal prematurity. Preterm labor
is dened as either premature induction of systems involved in myometrial
contractility or an escape from the mechanisms advocating uterine quiescence,
and is generally thought to be inammatory-like process.
Oxytocin (produced locally) and prostaglandins (resulting from silent intraamniotic infection) are thought to be the most important contractile factors.
Blocking of the oxytocin receptors as well as inhibiting of the COX-2 activity serve as an interesting option of pharmacological targets to be utilized in
tocolysis. Recently, a growing attention is being paid to other factors such as:
progesterone, calcium signaling or vasopressin which may inuence the uterine
quiescence. Interelations between different contractile factors and oxytocin as
well as prostaglandins are still unclear but mututal dependency seems the most
probable scenario.
Central role of oxytocin in parturition was conrmed not only by the nding
of an increaseed levels near the labor but also by the possibility of evoking
labor by exogenous oxytocin supplementation, and by the opportunity to block
the progress of labor by the inhibition of oxytocin receptors (1, 2). Although elevated in the late phase of labor, oxytocin blood concentrations remain constant
at the time of initiation of labor (3). The elevation of oxytocin levels occurs
645
locally, as it is produced in the decidua, functioning as a paracrine hormone

(4). Decidual and myometrial concentrations of oxytocin receptor also increase
gradually throughout pregnancy, which is accompanied by an increase in responsiveness to oxytocin.
Interaction of oxytocin with its receptor triggers G-protein mediated activation of phospholipase C (PPLC) resulting in production of inositol trisphosphate (IP3) and diacylglycerol (DAG). The IP3 stimulates release of ionized
calcium from intracellular stores, evoking an increase in intracellular calcium
and stimulation of actin/myosin coupling, leading to muscle ber contraction.
Interrelations between oxytocin and prostaglandins are presented at the gure.
oxytocin antagonists
Oxytocin
COXCOX-2
COX-1,COXSynthase
Enzymes
Ca2+
channels
OTR
PGH2
PGG2
PG
Gap junctions
Ca2+ Mg2+
3
Arachidonic
acid
2
4
1- myometrium 2-chorion 3-amnion 4-cervix
Figure: Interrelations between oxytocin and prostaglandins in term

and preterm labor
Oxytocin is in a close, functional interaction with prostaglandins Elevation
of IP3 and DAG is connected to activation of phospholipase 2 and production
of arachidonate. Oxytocin may also promote PG production through the MAPK
pathway (5). It was demonstrated that oxytocin stimulates the release of PGF2
and arachidonate in human decidua and myometrium. Soloff et al. (6) proposed that ''a major action of oxytocin is to stimulate prostaglandin production
646
in reproductive tissues''. Oxytocin increases the production of PGs in human

decidua, myometrium and amnion-derived epithelial cells (5, 7). Additionally,
it was shown to initiate COX-2 gene transcription in myometrial cells, causing a sustained production of prostaglandins (5). Throughout the gestation,
an exponential rise in COX-2 activity in fetal membranes, myometrium and
especially decidua was observed (8, 9), with most of the increase developing
before the onset of labour. In preparation for labour, there is also a switch in
the synthesis of prostaglandins within the human uterus from utero-relaxant
prostacyclin production, to increased synthesis of utero-tonic prostaglandins
E2 and F2 (reviewed in (10)).
Among the treatment strategies for tocolysis, oxytocin receptor blockade
and inhibition of COX-2 are new options, which are thought to be at least
equally effective to beta mimetics. Inhibition of the oxytocin receptor has been
shown to result in tocolysis. Atosiban was shown to arrest premature uterine
contractions at least as effectively as beta mimetics, but with markedly reduced
side effects (11). The potency of atosiban towards the vasopressin V1a receptor
is even higher than to OTR, which may provide additional effect in promoting
tocolysis. Although present in decidua and myometrium, the V1a receptor concentration remains unchanged throughout the pregnancy (12). Despite failure
to observe potential, undesirable, hemodynamic effects of V1a stimulation in
case of atosiban (11), a search of novel, oxytocin-selective tocolytics continues
unabated.
One of the most recent examples is barusibana novel peptide oxytocin
antagonist. In an in vitro study we demonstrated that it decreased myometrial
contractility more effectively as compared to atosiban, both in case of term
and preterm labor (13). Barusiban, which shows more prolonged action as
compared to atosiban, might be more convenient to use in tocolysis, and phase
II clinical study on this agent is currently in progress (14).
SR49059, although less OTR-selective, also deserves an attention due to its
non-peptide character, which characteristic is of great importance as it facilitates oral use. In a clinical study we took part, it was shown to effectively inhibit
preterm myometrial contractions, already 30 minutes after the administration
(15). Applying new generations of orally active oxytocin antagonists could
possibly contribute to solving the problem of prolonged, supportive treatment
against the relapse of preterm labor, and possibly to its prevention.
In the presence of intraamniotic inammation, the effectivity of tocolysis
can be signicantly reduced (16). Intraamniotic inammation and detectable
levels of microorganisms in the amniotic uid were found in respectively
49% and 16% of women referring due to premature uterine contractions (17)
647
In such cases, as well as in concomitant pPROM, antibiotic use can eliminate

potential (or suspected) bacterial invasion. Treatment of infection can additionally increase the efcacy of tocolysis. As conrmed in the MRC Oracle
Study, in women with suspected preterm labor and pPROM, administration of
erythromycin prolonged the pregnancy, reducing the requirement for neonatal
surfactant treatment (18).
Although generally contraindicated in overt chorioamniotic infection, tocolysis may prolong the pregnancy in subclinical inammation,. Formation
of prostaglandins and other cytokines may be inhibited by applying COX-2
inhibitors. Jacobsson et al (17) have shown that only half of the patients with
an elevated amniotic uid IL-6 or IL-8 had detectable levels of microorganisms in the AF. In such a case, elevation of interleukins would not result from
overt infection and applying of cyclooxygenase inhibitors could be effective.
Indomethacin, a model drug for NSAIDs, applied in tocolysis causes a number
of fetal side effects, and has been generally abandoned as a tocolytic drug.
Sulindac, nimesulid or rofecoxibas more selective towards the COX-2 enzyme, are reported to be free of those life threatening effects.
Groom et al (19) in a preliminary, non controlled study reported the use of
nimesulide in 36 patients at high risk of preterm labor. In the group of patients
who had emergency cerclage, a neonatal survival was 100%, compared to 40%
reported in similar gestational age. The most common side effectoligohydramnios was found in 30% of cases.It took on average 14 days to develop and it
was resolving within 7 days of drug discontinuation. Doret et al (20) compared
tocolytic effects of rofecoxib with indomethacin, ritodrine, nicardipine and
atosiban alone as well as in combination with each other. They demonstrated
in vitro tocolytic effect of rofecoxib which occurred in effective concentrations
that were 1000 times lower than for indomethacin and signicantly lower than
ritodrine and atosiban. It has also synergic effect with ritodrine and additive
one with the rest of compounds.
Above cited results open a discussion for combined tocolytic therapy.
Combining a classical tocolytic beta mimetic or atosiban with a prostaglandin
synthesis inhibitor could allow a signicant dose reduction of the latter. On the
other hand, additional prostaglandin inhibition could improve the effectivity of
tocolysis. Applying COX-2 selective drugs could further reduce a possibility
of fetal/neonatal side effects. Such a combined treatment could also comprise
of progesterone supplementation, aiming to alleviate the effect of progesterone
functional withdrawal, being responsible for stimulating myometrial estrogen
responsiveness, leading to labor (21). Additionally, a broad spectrum antibiotics could provide a further improvement in the treatment of preterm labor
648
in selected cases. Although theoretically justied, such a complex treatment

should be based on appropriate clinical and laboratory diagnosis, and denitely
it requires conrmation in a properly designer clinical trials .
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Laudanski T, Pierzynski P. Oxytocin and fetal membranes in preterm labor: current concepts
and clinical implication. Gynecol Endocrinol 2003;17(3):261-7.
Mitchell B, Schmid B. Oxytocin and its Receptor in the Process of Parturition. J Soc Gynecol
Invest 2001;8:122-33.
Chard T. Fetal and maternal oxytocin in human parturition. Am J Perinatol 1989;2:145-82.
Chibbar R, Miller F, Mitchell B. Synthesis of oxytocin in amnion, chorion and decidua may
inuence the timing of human parturition. J Clin Invest 1993;91:185-92.
Molnar M, Rigo J, Romero R, Hertelendy F. Oxytocin activates mitogen-activated protein
kinase and up-regulates cyclooxygenase-2 and prostaglandin production in human myometrial
cells. Am J Obstet Gynecol 1999;181:42-9.
Soloff M, Jeng Y, Copland J, Strakova Z, et al. Signal pathways mediating oxytocin stimulation
of prostaglandin synthesis in select target cells. Exp Physiol 2000;85(51S-58S).
Pavan B, Buzzi M, Ginanni-Corradini F, Ferretti M, et al. Inuence of oxytocin on prostaglandin E2, intracellular calcium, and cyclic adenosine monophosphate in human amnion-derived
(WISH) cells. Am J Obstet Gynecol 2000;183:76-82.
Slater D, Allport V, Bennett P. Changes in the expression of the type-2 but not the type-1 cyclooxygenase enzyme in chorion-decidua with the onset of labour. BJOG 1998;105:745-748.
Elliott C, Dennis W, Poston L, Bennett P. Interleukin 8 expression in human myometrium:
changes in relation to labor onset and with gestational age. Am J Reprod Immunol 2000;43:2727.
Loudon J, Groom K, Bennett P. Prostaglandin inhibitors in preterm labour. Best Practice &
Research Clinical Obstetrics & Gynaecology 2003;17(5):731-44.
Group TWAvB-aS. Effectiveness and safety of the oxytocin antagonist atosiban versus betaadrenergic agonists in the treatment of preterm labour. BJOG: An International Journal of
Obstetrics & Gynaecology 2001;108(2):133-42.
Helmer H, Hackl T, Schneeberger C. Oxytocin and vasopressin 1a receptor gene expression
in the cycling or pregnant human uterus. Am J Obstet Gynecol 1998;179:1572-8.
Pierzynski P, Lemancewicz A, Reinheimer T, Akerlund M, Laudanski T. Inhibitory effect of
barusiban and atosiban on oxytocin-induced contractions of myometrium from preterm and
term pregnant women. J Soc Gynecol Invest 2004;11(8):384-7.
Goodwin T. The Gordian Knot of Developing Tocolytics. J Soc Gynecol Invest 2004;11(6):33941.
Steinwall M, Bossmar T, Brouard R, Laudanski T, et al. The effect of relcovaptan (SR 49059),
an orally active vasopressin V1a receptor antagonist, on uterine contractions in preterm labour.
Gynecol Endocrinol 2005;20.
Goldenberg R, Hauth J, Andrews W. Intrauterine infection and preterm delivery. N Engl J Med
2000;18(342(20)):1500-7.
Jacobsson B, Mattsby-Baltzer I, Andersch B, Bokstroem H, et al. Microbial invasion and
cytokine response in amniotic uid in a Swedish population of women in preterm labor. Acta
Obstet Gynecol Scand 2003;82:120-8.
Kenyon S, Taylor D, Tarnow-Mordi W. Broad-spectrum antibiotics for preterm, prelabour
649
19.
20.
21.
rupture of fetal membranes: the ORACLE I randomised trial. ORACLE Collaborative Group.
The Lancet 2001;357:979-88.
Groom K, Sawdy R, Shennan A, Bennett P. Experience of nimesulide a COX-2 selective NSAI
in the prevention of preterm delivery in high risk cases. J Soc Gynecol Invest 2000;7:60A.
Doret M, Melliera G, Benchaibb M, Piacenzac J, et al. In vitro study of tocolytic effect of rofecoxib, a specic cyclo-oxygenase 2 inhibitor. Comparison and combination with other tocolytic agents. BJOG: An International Journal of Obstetrics & Gynaecology 2002;109(9):983.
Mesiano S. Myometrial Progesterone Responsiveness and the Control of Human Parturition.
J Soc Gynecol Invest 2004;11:193-202.
650
Does Antenatal Iron-deciency Anemia

Have an Adverse Effect on Pregnancy
Outcome?
Terence T. Lao MBBS, MD, FRCOG, FHKAM, FHKOG 1,2,
Ben C.P. Chan MBBS, MRCOG 1,2
Wing-Cheong Leung MBBS, MRCOG 1,2, Lai-Fong Ho BSc, MSc 1
Department of Obstetrics & Gynaecology, Queen Mary Hospital1,
and The University of Hong Kong2, Hong Kong, China.
e-mail: laotth@hkucc.hku.hk
Abstract
The effect of maternal anemia on pregnancy outcome remains controversial.
One contributing factor is the failure to categorize patients according to the type
of anemia. We reviewed the outcome of 14921 singleton pregnancies managed
between 1998 and 2001 and compared those with iron deciency anemia (Hb
<10g/dl with low serum iron or ferritin, study group) against those without (control group), after excluding patients with thalassemia trait (screened by the MCV
value). The 214 (1.4%) pregnancies with iron deciency anemia had lower maternal age (28.15.8 years versus 30.65.3 years, p<0.001, more multiparas (52.3%
versus 41.9%, p=0.002) and LGA infants (19.2% versus 13.0%, p=0.008), and
less instrumental deliveries (15.4% versus 22.3%, p=0.029). There was no signicant difference in the maternal BMI (23.03.8 kg/m2 versus 23.03.8 kg/m2),
complications including pre-eclampsia (3.3% versus 2.9%), antepartum hemorrhage (4.2% versus 4.3%), preterm (<37 weeks) birth (8.9% versus 7.1%), cesarean delivery (18.2% versus 19.3%), SGA infants (7.9% versus 7.4%), or mean
gestation at delivery (38.72.0 weeks versus 38.82.0 weeks) and birthweight
(3214482g versus 3170497g). There was a trend towards decreased incidence
651
of gestational diabetes mellitus (7.5% versus 11.3%, p=0.081) and increased

perinatal mortality (14 per thousand versus 5 per thousand, p=0.081). Our results
indicated that iron deciency anemia was not associated with adverse pregnancy
outcomes in our population except a trend of increased perinatal mortality, the
mechanisms of which require further studies.
Introduction
Maternal anemia has always been regarded as an important antenatal complication, and a number of adverse pregnancy outcomes have been attributed
to it (1,2). However, apart from the increased incidence of preterm birth and
small-for-gestational age infants, the impact of maternal anemia on other adverse pregnancy outcomes is less certain. Indeed, the best pregnancy outcome
appears to be associated with a hemoglobin (Hb) concentration around 9-10
g/dl (3,4), a level that is usually regarded as anemic by consensus.
The controversy on the relationship between anemia and adverse pregnancy
outcome is largely related to an unclear denition of anemia. Most studies
classied patients as having anemia when their lowest Hb was below a certain
cutoff such as 10.0 g/dl, without dening the underlying cause of anemia.
Consequently anemic patients in most studies would have included a mixture
of problems including iron and other types of nutritional deciency, hemoglobinopathies, and hemodilution. Therefore there is little wonder that the effect
of anemia on pregnancy outcome remains controversial. To address the issue
of whether iron deciency anemia has an adverse effect on pregnancy outcome,
we performed a retrospective study on the singleton pregnancies managed in
out hospital over a 4-year period.

Our department takes charge of the obstetric service of two regional teaching
hospitals funded by the government. One is an obstetric hospital that caters
for both low-risk parturients as well as those with essentially obstetric risk
factors, and the annual delivery rate was around 4000 during the study period.
Parturients with multiple risk factors, especially underlying medical diseases
requiring active treatment and including pre-existing diabetes mellitus, are referred to the high risk service under the same university department but located
in the general hospital 4 kilometres away. The great majority of the parturients
are Hong Kong residents, about 95 percent of whom are ethnic Chinese. A
multivitamin preparation containing 29 mg of elemental iron is offered to all
652
women. Routine antenatal investigations at the booking visit include typing

for the maternal ABO and Rhesus blood groups and screening for antibodies,
and measurement of maternal Hb concentration and mean cell volume (MCV).
Those with a MCV of <80fL will have Hb electrophoresis and examination
of the blood smear for Hemoglobin-H inclusion bodies, and the partner will
also undergo the MCV screening. If both partners have low MCV, prenatal
diagnosis will be offered to determine if the fetus is affected by homozygous
- or -thalassemia, for which termination of pregnancy would be arranged.
Patients having Hb level < 10 g/dl during pregnancy are diagnosed to have
anemia, and they will be investigated to determine the cause of the anemia,
after which appropriate treatment is commenced. At 28 to 30 weeks, the Hb
level is repeated to identify patients who have subsequently developed anemia.
The management of anemia in our hospital has been described before (5).
For this study, we have utilized the Specialty Clinical Information System
(SCIS), which is a computer database set up by the Hong Kong Hospital
Authority for the collection of inpatient statistics, including diagnoses and
procedures, using a standardized template. For the Obstetric SCIS, patient
information is captured at the rst antenatal visit and then at every subsequent
admission up to delivery. Information on obstetric complications and maternal conditions, including relevant medical history, are captured, but detailed
information on indications for investigations and specic medical treatment
are not captured by the system. The diagnoses and procedures captured are
coded according to the International Classication of Diseases (ICD) coding.
After delivery, neonatal data includes gestational age, birthweight, sex, Apgar
scores, admission into the neonatal unit, and nal outcome is also captured, but
detailed information on neonatal complications and treatment is entered into a
separate pediatric database. The obstetric dataset is used by our department to
generate the annual statistics.
With the help of the Hospital Authority Head Ofce, we obtained the database for the years 1998 to 2001 of our department and selected for analysis
all the booked as well as non-booked singleton pregnancies delivered in our
hospitals. The database was converted into the format of the statistical program
used for analysis by one of the investigators. For this study, we selected patients
who were either non-anemic or having the diagnostic coding of iron deciency
anemia. Patients with hemoglobinopathies were excluded. We extracted the
data included maternal age, calculated BMI, parity, gestational age of infant,
birthweight, birthweight percentile ranking such as large- (LGA, birthweight
>90th percentile for gestation according to the local reference chart) and smallfor-gestational age (SGA, birthweight 10th percentile), perinatal mortality,
653
and major pregnancy complications including pre-eclampsia, gestational diabetes mellitus (GDM), antepartum haemorrhage (APH), preterm (<37 weeks)
birth, cesarean and instrumental delivery. For statistical analysis, a commercial
computer package (Statistical Package for the Social Sciences or SPSS for
Windows version 11.0, SPSS Inc., Chicago, Il) was used. Categorical variables
were compared with the 2 test and odds ratios (OR) with 95 % CI were generated. Continuous variables were expressed as mean SD and tested by the
oneway ANOVA test.
Results
There were 214 (1.4%) women diagnosed with iron deciency anemia that
formed the study group, and 14,707 women without anemia who formed the
control group. The maternal and infant characteristics, and pregnancy complications are shown in the Table. The study group had lower maternal age
(28.15.8 years versus 30.65.3 years, p<0.001, more multiparas (52.3% versus 41.9%, p=0.002) and LGA infants (19.2% versus 13.0%, p=0.008), and less
instrumental deliveries (15.4% versus 22.3%, p=0.029). There was no signicant difference in the maternal BMI (23.03.8 kg/m2 versus 23.03.8 kg/m2),
complications including pre-eclampsia (3.3% versus 2.9%), antepartum hemorrhage (4.2% versus 4.3%), preterm (<37 weeks) birth (8.9% versus 7.1%),
cesarean delivery (18.2% versus 19.3%), SGA infants (7.9% versus 7.4%), or
mean gestation at delivery (38.72.0 weeks versus 38.82.0 weeks) and birthweight (3214482g versus 3170497g). There was a trend towards decreased
incidence of gestational diabetes mellitus (7.5% versus 11.3%, p=0.081) and
increased perinatal mortality (14 per thousand versus 5 per thousand, p=0.081).
Re-examination of the records indicated that all the perinatal deaths in the study
group were stillbirths.
Table:
Maternal and infant characteristics and pregnancy complications between the Study and
Control Groups
Study Group
(n=214)
Control Group
(n=14707)
P value
Age (years)
28.1 5.8
30.6 5.3
<0.001
BMI (kg/m2)
23.0 3.8
23.0 3.8
NS
Maternal
characteristics
OR (95% CI)
654
Study Group
(n=214)
Control Group
(n=14707)
P value
OR (95% CI)
52.3
41.9
0.002
1.25
(1.10-1.42)
Pre-eclampsia
(%)
3.3
2.9
NS
GDM (%)
7.5
11.3
0.081
APH (%)
4.2
4.3
NS
Preterm birth
(%)
8.9
7.1
NS
Cesarean
section (%)
18.2
19.3
NS
Instrumental
delivery (%)
15.4
22.3
0.029
Gestation (wks)
38.7 2.0
38.8 2.0
NS
Birthweight (g)
3214 482
3170 497
NS
LGA infants
(%)
19.2
13.0
0.008
SGA infants (%)
7.9
7.4
NS
PMR (per 1000)
14
0.081
Multiparas (%)
Complications
0.64
(0.38-1.06)
0.64
(0.42-0.96)
Infant
characteristics
1.58
(1.12-2.23)
2.70
(0.85-8.63)
Please refer to text for abbreviations
Discussion
Measurement of Hb concentration has become a standard investigation in pregnancy. Maternal Hb concentration reects not only maternal nutritional status
but also the degree of hemodilution, both of which would impact on pregnancy
outcome as reected by the relationship between high and low Hb concentration
with adverse pregnancy outcome (1-5). To determine whether iron deciency
655
anemia does impact adversely on pregnancy outcome, it is important to study

only patients with conrmed iron deciency anemia and comparing them with
patients without anemia, as we have done in this study.
Our study group was younger but there were more multiparous women,
which might have explained the presence of iron deciency. However, the study
group did not have increased incidence of pregnancy complications, while the
incidence of LGA infants was actually increased, which agreed with what has
been reported before (3,4). On the other hand, there was an increased PMR in
the study group which were all accounted for by stillbirths. The explanation of
the increased stillbirths was not apparent and warrants further studies.
In conclusion, our ndings do not substantiate any adverse effect of iron deciency anemia on pregnancy outcome in our population. One likely explanation
is that our study group had only iron deciency but no other forms of nutritional
deciency, as their BMI was similar to that of the control group. Associated
nutritional deciency, as well as poor quality or unavailability of antenatal care,
are often found in women with iron deciency anemia in developing countries
and the inner city populations. These confounding factors probably play more
important roles in the association between iron deciency anemia and adverse
pregnancy outcome. Further studies are warranted to elucidate the nding of
increased stillbirth in women with iron deciency anemia
References
1.
2.
3.
4.
5.
Kaltreider DF, Johnson JCW. Patients at high risk for low-birth-weight deliveries. Am J Obstet
Gynecol 1976; 124: 251-256.
Duthie SJ, King PA, To WK, Lopes A, Ma HK. A case-controlled study of pregnancy complicated by severe maternal anaemia. Aus NZ J Obstet Gynaecol 1991; 31: 125-127.
Murphy JF, ORiordan J, Newcombe RG, Coles EC, Pearson JF: Relation of haemoglobin
levels in rst and second trimesters to outcome of pregnancy. Lancet i: 992-995, 1986.
Steer P, Alam MA, Wadsworth J, Welch A: Relation between maternal haemoglobin concentration and birth weight in different ethnic groups. Br Med J 310: 489-491, 1995.
Lao TT, Tam KF. Placental ratio and anemia in third-trimester pregnancy. J Reprod Med 2000;
45: 923-928.
656
Thrombophilia in Obstetrics and Gynecology
Thrombophilia 2005Overview
Hatzis Theodore
Haematology Department, Mitera Hospital, Athens, Greece
email: hatzisth@otenet.gr
The term thrombophilia derives its name from the Greek word =
+ , meaning tendency towards clot (formation), and pertains to
a vague predisposition to thromboses, under circumstances.
Inherited thrombophilia refers to certain anomalies (quantitative or qualitative) of natural anticoagulants or coagulation factors, that are carried and transferred by genes, passed on generations vertically and obey to natural selection
and evolution lows. We now know few of these factors and mapped their genes.
Antithrombin III, Protein C, Protein S, Fibrinogen, are well studied the last 20
years and their signicance in thromboembolic disease is well established. The
last couple of years Factor V Leiden, Homocysteine and Prothrombin mutations have gained a role to this circus of hypercoagulability.
Gynecology and Obstetrics have been for long a eld of interest for thromboses. Activation of coagulation is the main mechanism underlying thrombosis
associated with pregnancy and the use of estrogens (including oral contraceptives and various hormonal treatments). Laborious surgical procedures are
quite common in Gynecology and are also a reason for hypercoagulability.
An inherited predisposition to thrombosis, even when more than one gene is
affected, is probably insufcient to cause a clinical thrombotic event. Patients
with thrombophilia are at constant, lifelong risk of thrombosis, as biochemically veried by sensitive assays that demonstrate increased thrombin generation in plasma even during clinically symptom-free periods (1). Yet clinical
thrombosis occurs episodically, which suggests that an acquired thrombogenic
insult is the trigger that initiates a thrombotic event in a patient with thrombophilia. In fact, clinical studies have suggested that predisposing events (eg,
pregnancy, surgery) can be identied in most cases of thrombosis in patients
657
with thrombophilias (2). The striking phenotypic variability of the thrombophilias strongly suggests that multigene interactions are operative. It has been
proposed that inherited predisposition to thrombosis results from combinations
of prothrombotic mutations in two or more genes (3).
As described in the following picture, multigene interactions involving
prothrombotic mutations create an inherited predisposition to thrombosis (hypercoagulable state). In such patients a thrombotic event is triggered by an
acquired
prothrombotic stimulus (4):
(4):
2 or more
prothrombotic
mutations
(gene-gene
interactions)
acquired
prothrombotic
stimulus
thrombosis
hypercoagulable
state
Therefore thrombophilia is a tendency to thrombosis and inherited thrombophilia is a genetically determined tendency to venous thromboembolism. It
is characterised by early age of onset, frequent recurrence and positive family
history. While venous thrombosis has an overall annual incidence of ~1:1000,
the true prevalence of hereditary thrombophilia is not known, but genetic
causes are prominent in the etiology of venous thrombosis. Venous thrombosis
is caused by interaction between genetic and acquired risk factors: advanced
age, immobilisation, surgery, pregnancy, oestrogen-containing hormones, malignancies and antiphospholipid syndrome.
Antithrombotic pathways
Antithrombin
Antithrombin inhibits blood coagulation by inactivating not only thrombin but
also other serine proteases (activated clotting factors as XIIa, XIa, IXa and
Xa). Antithrombin deciency is an autosomal dominant disorder estimated to
occur in 0.2% to 0.4% of individuals in the general population.(5-6). There is
a wide range of prevalences of clinical thrombotic complications among different antithrombin decient kindreds, ranging from 15% to 100%, in different
families (2).
Heparin co-factor II is a physiological heparin-dependent plasma inhibitor
of thrombin that functions independently of antithrombin. Familial heparin
co-factor II deciency has been associated with venous thrombosis (7-8).
658
Protein C and protein S

These anticoagulant proteins are vitamin-K-dependent. The C/S complex inhibits coagulation by destroying activated factors V and VIII. The complex
works under the inuence of thrombomodulin, an endothelial cell receptor,
activated by thrombin binding. They are both inherited autosomally. The
prevalence of heterozygous protein C deciency is 0.1 to o.5 % in the general
population. Protein C Deciency is usually inherited in an autosomal dominant manner. The vast majority of heterozygotes are symptom-free. However,
50% of heterozygotes belonging to families with a history of symptomatic
thrombosis can be expected to have thrombotic complications (9-10). Protein
S Deciency is inherited in an autosomal dominant manner. The protein S
gene on chromosome 3p11.1-p11.2 (80 kb, 15 exons) encodes a plasma glycoprotein which serves as a cofactor of Activated Protein C in the inactivation
of factors Va and VIIIa. Protein S itself also inhibits the IXa-VIIIa and Xa-Va
complexes. 33 different mutations reported (1995) and account for ~5% of
inherited thrombophilia.
Fibrinolytic system
Hypoplasminogenemia and dysplasminogenemia (abnormal plasminogen,
increased histidine-rich glycoprotein), dysbrinogenaemia: these brinolutic
defects have all been implicated in the pathogenesis of thrombosis (12-15).
The effect of each of these abnormalities is impaired plasmin generation and a
blunted brinolytic response to brin formation.
Resistance to activated protein C (APC) and Factor V Leiden (FV
Leiden)
Resistance to Activated Protein C is inherited in an autosomal dominant manner. The factor V gene on chromosome 1q21-q25 (80 kb, 25 exons) encodes a
plasma glycoprotein (2196 amino acids), which activated by thrombin/factor
Xa is converted into factor Va. A single point mutation (G1691A, Arg506Gln),
called factor V Leiden, destroys one of the Activated Protein C cleavage sites
in factor Va, and is responsible for the Resistance to Activated Protein C in
the vast majority of affected individuals (16-18). It accounts for up to 50% of
inherited thrombophilia and for ~20% of unselected patients with deep-vein
thrombosis. It is the most important genetic predisposition to venous thrombosis. Heterozygotes have a 5-10 fold increased risk of thrombosis while homozygotes have a 50-100 fold increased risk of thrombosis. The allele frequency in
Europeans is 4.4%, but outside Europe the mutation is very rare. David Rees et
al, have analysed 3380 chromosomes (1690 unrelated individuals) from twenty-
659
four populations for the presence of factor V leiden. The allele frequency in 618
Europeans was 4.4%, with the highest prevalence among Greeks (7%). Factor
V Leiden was not found in any of 1600 chromosomes from Africa, Southeast
Asia, Australasia, and the Americas. This distribution may partly explain the
rarity of thromboembolic disease in these populations (19-26, 16-17).
The prothrombin-gene mutation
The Prothrombin Gene G20210A Variant is inherited in an autosomal dominant
manner. Prothrombin gene on chromosome 11p11-q12 (21kb, 14 exons) encodes a plasma glycoprotein, which is activated to thrombin by factors Xa and
Va. A point mutation G20210A in the 3' untranslated region is associated with
elevated prothrombin levels and accounts for ~18% of inherited thrombophilia.
It also accounts for ~6% of unselected patients with deep-vein thrombosis. It
is frequently co-inherited with other genetic risk factors like factor V Leiden.
Next to the mutation in the factor V gene, the prothrombin-gene mutation is
the most common genetic determinant of deep-vein thrombosis of the lower
extremities. Carriers have a 2-5 fold increased risk of venous thrombosis, including cerebral-vein thrombosis. Carriers using oral contraceptives have a
highly elevated risk of cerebral-vein thrombosis. There is a carrier frequency
of 1-4% in different populations and carrier frequency in southern Europe is
nearly twice as high as in northern Europe. This geographical distribution is
probably due to founder effect (27).
Mild hyperhomocysteinaemia
Mild hyperhomocysteinemia has been recognized as a risk factor for arteriosclerosis and thrombosis. Homocysteine is presumed to damage the endothelial cell, but the exact mechanism of its toxicity is unknown. Decient activity of cystatheionine-beta synthase, of methylene-tetrahydrofolatereductase
(MTHFR), as yet unknown enzyme defects and environmental factors, such
as deciency of vitamin B6, vitamin B12, and folic acid, are all causes of mild
hyperhomocysteinaemia (33-34).
MTHFR C677T Mutation
Homozygous individuals show reduced MTHFR activity, increased thermolability and hyperhomocysteinemia. It has a relatively high frequency throughout
the world. The allele frequency varies from 6% in Africa to 40% in some
European populations. Homozygotes may have an increased risk of cardiovascular disease and neural tube defects. There is the need to be a selective
advantage to explain such high frequency. An association between MTHFR
660
C677T homozygosity and recurrent miscarriage seems controversial, but studies are still few (35):
Genetic defects can now be detected in more than 50% of inherited thrombophilia. Many patients with recurrent thrombosis have more than one genetic
risk factor. Finding a genetic risk factor, which causes inherited thrombophilia,
should be followed by proper counselling by a geneticist and a hematologist.
An analysis was done at Mitera Surgical and Maternity Centre in order to
estimate the frequency of the factor V Leiden, the prothrombin G20210A and
the MTHFR C667T mutations in the Greek population: 160 healthy Greek
blood donors were studied by PCR amplication. Allele frequencies of 2.5%,
2.2% and 64.7% respectively, were detected (36).
Women with mild

hyperhomocysteinemia
Placental
abruption,
n=31
Intrauterine
fetal death,
N=18
Small for
gestational
age infants,
n=13
25 %
8%
38 %
heterozygotes
FV Leiden
Prothrombin
G20210A mutation
MTHFR mutation
87
homozygotes
0
Allele
Carrier
frequency rate
2.5%
5%
2.2%
4.4%
13
35.3%
62.5%
Inherited thrombophilia and fetal loss

A strong association exists between inherited thrombophilia and fetal loss.
Women with inherited thrombophilia, especially combined defects, have increased risk of fetal loss, particularly stillbirth. An association between factor V
Leiden and placental infarction has been demonstrated. An association between
factor V Leiden and second-trimester pregnancy loss has been reported, but
the association with recurrent miscarriage is still controversial. A successful
661
outcome of pregnancy requires an efcient uteroplacental vascular system.

Since this system may be compromised by disorders of haemostasis associated
with a prothrombotic state, maternal thrombophilia might be a risk factor for
fetal loss.
1384 women enrolled in the European Prospective Cohort on Thrombophilia
were studied. Of 843 women with thrombophilia 571 had 1524 pregnancies;
of 541 control women 395 had 1019 pregnancies (37). Results, shown here are
expressed as odds ratio:
N=1384
Fetal
Pregnancies
loss
Stillbirth/
miscarriage
Stillbirth Stillbirth
combined FV
defects
Leiden
Thrombophilia
n=843
n=1524
1.35
3.6
14.3
Control
n=541
n=1019
The following table exhibits a more impressive outcome (38):

n=39,
women with
fetal losses
n=19
FV leiden
n=9
with APC-R
Pregnancies
1st trimester
abortions
Late
abortions
Intrautrine
Death
Live
births
50%
17%
47%
18%
128
56
Women with serious obstetrical complications have an increased incidence

of utations predisposing them to thrombosis and other inherited and acquired
forms of thrombophilia (40):
Use of low-molecular-weight heparins for thromboprophylaxis in pregnancy.
Low-molecular-weight heparins (LMWHs) comprise a group in the class of
antithrombotic medications, a class headed by unfractionated heparin (UFH).
The LMWHs, have a mean molecular weight of 4.0-6.0 kD. The LMWHs do
not signicantly cross the placenta of pregnant women (41).
662
Factor V
leiden
Prothrombin
gene variant
MTHFR
C677T
One
thrombophylic
mutation
110 women
with obstetrical
complications
22 (20%)
11 (10%)
24 (22%)
57 (52%)
110 women
with one or
more normal
pregnancies
7 (6%)
3 (3%)
9 (8%)
19 (17%)
Several studies conrm that LMWHs are safe and effective alternative to
unfractionated heparin for obstetric thromboprophylaxis in high-risk women.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Bauer KA, Rosenberg RD. The pathophysiology of the prethrombotic state in humans: insights
gained from studies using markers of hemostatic system activation. Blood 1987; 70: 343-50.
Demers C, Ginsburg JS, Hirsh J, Henderson P, Blajchman MA. Thrombosis in antithrombinIII-decient persons. Report of a large kindred and literature review. Ann Intern Med 1992;
116: 754-61.
Miletich JP, Prescott SM, White R, Majerus PW, Bovill EG. Inherited predisposition to thrombosis. Cell 1993; 72: 477-80.
Schafer AI. Hypercoagulable states: molecular genetics to clinical practice. Lancet 1994; 344:
1739-42.
Meade TW, Dyer S, Howarth DJ, Imeson JD, Stirling Y. Antithrombin III and procoagulant
activity: sex differences and effects of the menopause. Br J Haematol 1990; 74: 77-81.
Tait RC, walker ID, Davidson JF, Islam ISA, Mitchell R. Antithrombin III activity in healthy
blood donors: age and sex related changes and the prevalence of asymptomatic deciency. Br
J Haematol 1990; 75: 141-142.
Tran TH, Marbet GA, Ducker F. Associaiton of hereditary heparin co-factor II deciency with
thrombosis. Lancet 1985, ii: 413-14.
Sie P, Dupouy D, Pinchon J, Boneu B. Constitutional heparin co-factor II deciency associated
with recurrent thrombosis. Lancet 1985, ii: 414-16.
Miletich JP, Sherman I, Broze G. Absence of thrombosis in subjects with heterozygous protein
C deciency. N Engl J Med 1987; 317:991-96.
Allaart CF, Poort S, Rosendaal FR, Reitsma PH, Bertina RM, Briet E. Increased risk of venous
thrombosis in carriers of hereditary protein C deciency defect. Lancet 1993; 341: 134-38.
Alving BM. The hypercoagulable states. Hosp Pract 1993; 28: 109-21
Lottenberg R, Dolly FR, Kitchens CS. Recurring thromboembolic disease and pulmonary
hypertension associated with severe hypoplasminogenaemia. Am J Hematol 1985; 19: 18193.
Aoki N, Moroi M, Sakata Y, Yoshiba N, Marsuda M. Abnormal plasminogen. A hereditary
molecular abnormality found in a patient with recurrent thrombosis. J Clin Invest 1978; 61:
663
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
1186-95.
Engesser L, Kluft C, Briet E, Brommer EJ. Familial elevation of plasma histidine-rich glycoprotein in a family with thrombophilia. Br J Haematol 1987; 67: 355-58.
Koopman J, Haverkate F, Grimbergen J, et al. Molecular basis for brinogen Dusart and its
association with abnormal brinogen polymerization and thrombophilia. J Clin Invest 1993;
91: 1637-43.
Bertina R, Koeleman BPC, Koster T, et al. Mutation in blood coagulation factor V associated
with resistance to activated protein C. Nature 1994; 369: 64-67.
Greengard JS, Sun X, Xu X, Fernandez JA, Grifn JH, Evatt B. Activated protein C resistance
caused by Arg506Gln mutation in factor Va. Lancet 1994; 343: 1361-62.
Voorberg J, Roelse J, Koopman R, et al. Association of idiopathic thromboembolism with
single point mutation at Arg506 of factor V. Lancet 343:1535, 1994.
Grifn JH, Evatt B, Wideman C, Fernandez JA. Anticoagulant protein C pathway defective in
majority of thrombophilic patient. Blood 1993; 82: 1989-93.
Koster T, Rosendaal FR, de Ronde H, Briet E, Vanderbroucke JP, Bertina RM. Venous thrombosis due to poor anticoagulant response to activated protein C. Leiden Thrombophilia Study.
Lancet 1993; 342: 1503-06.
Svensson PJ, Dahlback B. Resistance to activated protein C as a basis for venous thrombosis.
N Engl J Med 1994; 330: 517-22.
Legnani C, Palareti G, Biagi R, Coccheri S. Activated protein C resistance in deep-vein thrombosis. Lancet 1994; 343: 541-42.
Dahlback B, Hildebrand B. Inherited resistance to activated protein C is corrected by anticoagulant cofactor activity found to be a property of factor V. Proc Natl Acad Sci USA 1994; 91:
1396-400.
Hatzis T, Petersen MB. Recently Discovered Genetic Determinants of Thrombophilia: the
Factor V Leiden, the Prothrombin-Gene Mutation and Hyperhomocysteinaemia: their Role
in Young Womens Thromboembolic Disease and in Complicated Pregnancies. Lecture at the
4th International Congress, The Young Woman at the Rise of the 21st Century: Gynecological
and Reproductive Issues in Health and Disease, Athens Hilton 1998.
T Hatzis, E Cardamakis, E Drivalas, Tsaggaris, Creatsa, M. Petersen, C Mantouvalos.
(Intr. by D. Loukopoulos). Study on the Hemostatic Abnormalities in Primary Unexplained
and Recurrent Abortions. Blood, vol 92, No 10, Supplement 1, p 119b, November 1998.
David C Rees, Martin Cox, John B Clegg. World distribution of factor V Leiden. Lancet 1995;
346: 1133-34.
Poort SR, Rosendaal FR, Reitsma PH, Bertina RM. A common genetic variation in the 3untranslated region of the prothrombin gene is associated with elevated plasma prothrombin
levels and an increase in venous thrombosis. Blood 1996;88:3698-703.
Domna S. Dizon-Townson, Lesa Nelson, Katrina Easton, and Kenneth Ward. The factor F
Leiden mutation may predispose women to severe preeclampsia. Am J Obstet Gynecol, vol
175, number 4, part 1, pages 902-905, 1996.
Margareta Hellgren, Peter J. Svensson and Bjorn Dahlback. Resistance to activated protein C
as a basis for venous thromboembolism associated with pregnancy and oral contraceptives.
Am J Obstet Gynecol, vol 173, number 1, pages 210-213-905, 1995.
Longstreth WT Jr, Rosendaal FR, Siscovick DS, Vos HL, Schwartz SM, Psaty BM, Raghunathan
TE, Koepsell TD, Reitsma PH. Risk of stroke in young women and two prothrombotic mutations: factor V Leiden and prothrombin gene variant (G20210A), Stroke, 1998 Mar, 29:3,
577-80
Ida Martinelli, Elisabetta Sacchi, Gianluca Landi, Emanuela Taioli, Francesca Duca, Pier
Mannuccio Mannucci. High risk of cerebral-vein thrombosis in carriers of a prothrombin-gene
mutation and in users of oral contraceptives. N Engl J Med, 1998 Jun, 338:25, 1793-1797.
664
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.

Rosendaal FR, Siscovick DS, Schwartz SM, Psaty BM, Raghunathan TE, Vos HL. A common prothrombin variant (20210 G to A) increases the risk of myocardial infarction in young
women. Blood, 1997 Sep, 90:5, 1747-50.
Mudd SH, Levy HL, Skovby F. Disorders of transsulfuration. In: Scriver CR, Beaudet AL, Sly
WS et al.,editors. The Metabolic Basis of Inherited Disease. New York: McGraw-Hill 1989;
693-734.
Van de Berg M, Franken DG, Boers GHJ, Blom HJ, Jacobs C, Stehouwer CDA, Rauwerda
JA. Combined Vitamin B6 plus Folic Acid Therapy in Young Patients with arteriosclerosis and
Hyperhomocysteinaemia. J Vasc Surg 1994; 20: 933-940.
J. I. P. de Vries, G. A. Dekker, P.C. Huijgens, C. Jacobs, B.M.E. Blomberg, H. P. van Geijn.
Hyperhomocysteinaemia and protein S deciency in complicated pregnancies. Br J Obstet
Gynaecol, 1997 Nov, 104:11, 1248-1254.
T. Antoniadi, T. Hatzis, C. kroupis, E. Economou-Petersen, M.B. Petersen. Prevalence of the
factor V Leiden, the prothrombin G20210A and the MTHFR C667T mutations in a Greek
population of blood donors. Submitted for presentation at the 31st Annual Meeting of the
European Society of Human Genetics, Geneva, Switzerland, 29 May-1 June 1999.
Preston FE; Rosendaal FR; Walker ID; Brit E; Berntorp E; Conard J; Fontcuberta J; Makris
M; Mariani G; Noteboom, W; Pabinger I; Legnani C; Scharrer I; Schulman S; van der Meer
FJ. European Cohort on Thrombophilia: Increased fetal loss in women with heritable thrombophilia. Lancet, 1996 Oct, 348:9032, 913-6.
Brenner B ; Mandel H; Lanir N; Younis J; Rothbart H; Ohel G; Blumenfeld Z. Activated
protein C resistance can be associated with recurrent fetal loss. Br J Haematol, 1997 Jun, 97:3,
551-4.
T Hatzis, E Cardamakis, E Drivalas, Tsaggaris, Creatsa, M. Petersen, C Mantouvalos.
(Intr. by D. Loukopoulos). Study on the Hemostatic Abnormalities in Primary Unexplained
and Recurrent Abortions. Blood, vol 92, No 10, Supplement 1, p 119b, November 1998. Data
updated Jan 1999.
Michael J Kupferminc, Amiram Eldor, Nitzan Steinman, Ariel Many, Amiram Bar-Am, Ariel
Jaffa, Gideon Fait, Joseph B. Lessing. Increased frequency of Genetic Thrombophilia in
women with complications of pregnancy. N Engl J Med 1999;340:9-13.
Frydman A, Rhone-Poulenc Rorer SA, Recherche et Developpement, Antony, France.
Haemostasis, 1996, 26 Suppl 2:, 24-38.
665
Thrombophilia: What is the evidence

for the relation with adverse pregnancy
outcomes?
B. Brenner, MD
Thrombosis and Hemostasis Unit, Department of Hematology and Bone Marrow
Transplantation, Rambam Medical Center and Technion Faculty of Medicine, Haifa,
Israel
e-mail: b_Brenner@rambam.health.gov.il
Abstract
Gestational vascular complications are a leading cause of maternal and fetal
morbidity and mortality.
Inherited thrombophilia has recently emerged as an important cause of these
complications. The evidence for association of thrombophilia with adverse
pregnancy outcome is presented and the potential prophylactic intervention
with anticoagulants is discussed in this review.
Key words: Pregnancy, thrombophilia, fetal loss, anti-coagulant therapy.
Inherited and acquired thrombophilia are the main cause of thrombosis in pregnant women. A growing number of reports over the last 4 years have suggested
that these disorders are also associated with an increased incidence of vascular
pathologies resulting in poor gestational outcome. This review covers recent
data concerning thrombophilia and vascular placental pathology, and discusses
available therapeutic modalities to prevent placental vascular thrombosis and
maximize successful gestational outcome.
666
Acquired venous thromboembolism

Pregnancy is a hypercoagulable state. The prevalence of venous thromboembolism (VTE) during gestation and puerperium is increased in women with
inherited thrombophilic states such as antithrombin III, protein C and protein
S deciencies [1,2]. Recent data suggest that t Factor V Leiden and factor
II G20210A mutations being the major causes for VTE in pregnant women.
However, most carriers will not develop clinical symptoms during gestation
[3]. Likewise, factor II G20210A is 35 times more prevalent in gestational
VTE (1020%) than in normal Caucasian pregnancy populations (25%).
Antiphospholipid syndrome can be found in 1020% of gestational VTE
cases.
The risk for rst episode of gestational venous thromboembolism (VTE) is
1/200 and 1/500 for factor II G20210A and factor V Leiden mutation, respectively [3]. The risk for gestational VTE in women who had experienced VTE
in the past is about 10 to 20-fold higher and is in the range of 5%.
Recurrent fetal loss

Recurrent fetal loss (RFL) dened as three or more pregnancy loss is a wellestablished nding in certain acquired thrombophilic disorders, such as antiphospholipid syndrome [4] and essential thrombocythemia [5].
A case-control study in 60 women with the inherited thrombophilias, antithrombin, protein C and protein S deciencies documented an increased risk
for RFL [6]. Of 188 pregnancies in women with thrombophilia, 42 (22%) resulted in pregnancy loss compared to 23/202 (11%) in controls: odds ratio (OR)
2.0; 95% condence interval (CI) 1.23.3 [6]. In addition, a high incidence of
gestational abnormalities was reported in 15 women with dysbrinogenemia
associated with thrombosis. Of 64 pregnancies, 39% ended by miscarriage and
9% by intrauterine fetal death [7].
A number of recent case-control studies has evaluated the prevalence of
factor V Leiden mutation in women with RFL. Despite differences in ethnic Caucasian subpopulations and selection criteria for RFL, three studies
documented signicantly increased prevalence of factor V Leiden mutation in
women with RFL.
In women with RFL of unknown cause, following exclusion of chromosomal abnormalities, infections, anatomic alterations, and endocrinologic dysfunction, studies by Grandone et al. [8] and by our group [9] have suggested
that evaluation for factor V Leiden mutation is highly warranted since a signicant percentage of women with RFL are found to be carriers of the mutation.
667
Nevertheless, it should be emphasized that other reports did not document an

association between factor V Leiden mutation and RFL [10]. The risk for RFL
is greater in homozygous carriers than in heterozygous carriers of factor V
Leiden [11].
Of interest, activated protein C (APC) -resistance in the absence of factor V
Leiden mutation has also been associated with pregnancy loss [12,13].
A potential explanation for the association between RFL and APC-resistance is that the APC-sensitivity ratio falls progressively throughout normal
pregnancy either in correlation with changes in factor VIII, factor V and protein
S levels [14], or without such a correlation [15].
Women with thrombophilia have an increased percentage of losses at
later stages of gestation. For example, second-trimester losses or intrauterine
fetal death accounted for 57 of 158 fetal losses (36%) in 37 women with
thrombophilia compared to only 23/135 (17%) in women with RFL without
thrombophilia (p = 0.0004) [16]. Activated protein C resistance and factor V Leiden mutation are more common in women with second-trimester
pregnancy loss [16] and in women with post-embryonic rst-trimester losses
[17].
Combinations of thrombophilic states may further increase the risk for RPL.
For example, coexistence of factor V Leiden and homozygous hyperhomocysteinemia [18] or a combination of factor V Leiden with familial antiphospholipid syndrome [19] was reported to result in thrombosis and recurrent fetal
loss. It is therefore not surprising that the European Prospective Cohort on
Thrombophilia (EPCOT) study documented the highest odds ratio for stillbirth
(OR=14.3, 95% CI 2.486) in patients with combined thrombophilic defects
[20]. In our recent study involving 76 women with RFL, 6 (8%) had a combination of thrombophilic polymorphisms compared to 1/106 (0.9%) of controls
(p < 0.02) [9]. Factor II G20210A and homozygosity for MTHFR C677T both
contribute to RPL when presenting in combination with other thrombophilic
defects.
Without therapeutic intervention, less than 20% of gestations in women
with thrombophilia and RFL result in live birth [9]. This is similar to rates
reported in women with the antiphospholipid syndrome who experience RFL.
Mechanisms responsible for the association of inherited thrombophilia with
RFL have not been elucidated. Pathologic studies of placentae obtained from
gestations terminated by fetal loss reveal thrombotic changes and infarcts.
These can be observed in the maternal vessels in a large proportion of placentae
of women with stillbirth [21].
668
Other gestational vascular complications

Activation of blood coagulation and endothelial cell stimulation are fundamental ndings in preeclampsia [22], clinically characterized by gestational hypertension, edema and proteinuria. Activation of the coagulation and brinolytic
systems is more marked in the uteroplacental circulation than in the systemic
circulation, and an abnormal pattern of hemostasis has been reported to operate
in the uteroplacental circulation in women with preeclampsia [23].
Several recent reports suggest an association between APC-resistance, factor V Leiden mutation and early onset of severe preeclampsia. In one study 14
of 158 women with severe preeclampsia (8.9%) were found to be heterozygous
for the factor V Leiden mutation compared with 17 of 403 normotensive gravida
controls (4.2%) (p = 0.03) [24]. Likewise, in another study, factor V Leiden
mutation was documented in 19% of women with preeclampsia compared to
7% of controls [25].
APC-resistance and factor V Leiden have recently been associated with
placental abruption. Seventeen of 27 women with placental abruption had
APC-resistance compared to 5/29 controls (OR-8.2, 95% CI 3.612.7) [26].
Factor V Leiden was documented in 8/27 patients (30%) compared to 1/29
controls (3%) [27].
Therapeutic regimens
Since up to 65% of vascular gestational abnormalities can be accounted for by
genetic thrombophilias [9,26], the implication is to screen for these mutations
in all women with vascular gestational abnormalities. Furthermore, this high
prevalence of genetic thrombophilias, which is similar to the ndings in women
with pregnancy-related venous thromboembolism [28], and the ndings of
thrombotic changes in the placentae of the majority of women with thrombophilia and stillbirth [21], suggest that antithrombotic drugs may have potential
therapeutic benet in women with gestational vascular complications.
The potential advantages of LMWH over unfractionated heparin are higher
antithrombotic ratio (meaning less bleeding for better antithrombotic effect),
longer half-life with a potential need for only one injection per day, smaller
injected volume, and less heparin-induced thrombocytopenia. A recent collaborative study has demonstrated the safety of using LMWH during 486
gestations [29]. Successful outcome was reported in 83/93 gestations (89%)
in women with recurrent pregnancy loss and in all 28 gestations in women
with preeclampsia in a previous pregnancy [29]. Administration of the LMWH
enoxaparin, 20 mg/day, to women with primary early RPL and impaired bri-
669
nolytic capacity resulted in normalization of impaired brinolysis, conception

in 16/20 (80%), and successful live birth in 13/16 (81%) [30].
We have used enoxaparin (Rhone Poulenc, France) during 61 pregnancies
in 50 women with thrombophilia who presented with RPL throughout gestation and for 4 weeks into the postpartum period [31]. Enoxaparin dosage
was 40 mg/day, except for patients with combined thrombophilia or in case
of abnormal Doppler velocimetry suggesting decreased placental perfusion,
where the dosage was increased to 40 mg twice daily. In the case of previous
thrombosis, LMWH therapy was continued for 6 weeks after delivery. Of the
61 pregnancies, 46 (75%) resulted in live births compared to a success rate of
only 20% of prior gestations without antithrombotic therapy in these 50 women
[31]. These preliminary results are encouraging. However, the optimal dosage
of LMWH is yet unknown and is currently being determined in a prospective
randomized trial in order to maximize successful gestational outcome. LIVEENOX is a multicenter prospective randomized trial comparing two doses of
enoxaparin, 40 mg daily and 40 mg twice daily, in women with thrombophilia
and recurrent pregnancy loss [32]. The study result demonstrated equal efcacy
-84% Vs. 78% live birth respectively suggesting that the 40mg /day dose is sufcient for women with standart risk . Women at higher risk such as combined
thrombophilia may need a higher dose [32]. Whether LMWH should be used
in women with thrombophilia and previous one or two fetal losses, is still not
widely accepted although a recent study support this notion [33].
The role of aspirin, if any, in the setting of thrombophilia and vascular
gestational abnormalities remains to be conrmed. In patient with inherited
thrombophilia the value of aspirin is limited [33]. In patients with antiphospholipid syndrome ,aspirin is given along with LMWH. However, whether
aspirin has an added benet to heparin or LMWH alone has not been evaluated. Prospective randomized, dose-nding studies are warranted to assess the
potential advantage of LMWH in women with thrombophilia and vascular
gestational abnormalities.
Unresolved Issues
Role for fetal genotype?
This is controversial. While there have been reports supporting that fetal thrombophilia is important [34], there are a number of reasons suggesting that this
may not be the case. First, most thrombophilic polymorphisms are mild risk
factors for gestational vascular complications (GVC) and gestational VTE.
Second, thrombotic changes are noted mainly on the maternal side of the utero-
670
placental unit. Third, LMWH that does not cross the placenta are benecial.
Thus, unless there is a severe thrombophilic defect (i.e., homozygous protein
C deciency), fetal thrombophilic state is probably not a major contributor for
GVC or VTE.
Is prediction of complications possible?
Only a fraction of women with thrombophilia experience GVC or gestational
VTE. Moreover, the same women can have a normal gestation but in a
subsequent pregnancy may experience complications. This may result from
involvement of acquired prothrombotic factors operating during certain
gestations in certain women. In addition, local hemostasis in the placenta
may be crucial for fetal growth and development. In vitro and ex vivo studies
from our laboratory suggest that alteration in placental hemostatic balance
is found in women with GVC.
Management of other GVC
The optimal management of women with late pregnancy complications
should be evaluated in prospective multicenter randomized trial.
Women with unexplained pregnancy loss
The panel of thrombophilia workup is constantly expanding, for example,
elevated factor VIII levels have recently been association with RFL. Where
current thrombophilia evaluation is negative, the idea is that yet undiscovered
thrombophilia may be implicated, since thrombotic changes can be found
in women with GVC even without thrombophilia. Following preliminary
experience with antithrombotic therapy in these women, a prospective
randomized multicenter trial comparing enoxaparin 40 mg/day and aspirin
75 mg/day has recently been performed in Israel.
671
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Hellgren M, Tengborn L, Abildgaard U. Pregnancy in women with congenital antithrombin

III deciency: experience of treatment with heparin and antithrombin. Gynecol Obstet Invest
1982; 14: 127-41.
Conard J, Horellou MH, Van Dreden P, Lecompte T, Samama M. Thrombosis and pregnancy in
congenital deciencies in ATIII, protein C or protein S. Thromb Haemost 1990; 63: 319-20.
Gerhardt A, Scharf RE, Beckmann MW et al. Prothrombin and factor V mutations in women
with a history of thrombosis during pregnancy and the puerperium. N Engl J Med 2000; 342:
374-9.
Triplett DA, Harris EN. Antiphospholipid antibodies and reproduction. Am J Reprod Immunol
1989; 21: 123-31.
Beressi AH, Tefferi A, Silverstein MN, Petitt RM, Hoagland WC. Outcome analysis of 34
pregnancies in women with essential thrombocythemia. Arch Intern Med 1995; 155: 121722.
Sanson BJ, Friederich PW, Simioni P et al. The risk of abortion and stillbirth in antithrombin,
protein C, and protein S-decient women. Thromb Haemost 1996; 75: 387-8.
Haverkate F, Samama M. Familial dysbrinogenemia and thrombophilia. Report on a study
of the SSC Subcommittee on Fibrinogen. Thromb Haemost 1995; 73: 151-61.
Grandone E, Margaglione M, Colaizzo D et al. Factor V Leiden is associated with repeated
and recurrent unexplained fetal losses. Thromb Haemost 1997; 77: 822-4.
Brenner B, Sarig G, Weiner Z, Younis J, Blumenfeld Z, Lanir N. Thrombophilic polymorphisms in women with fetal loss. Thromb Haemost 1999; 82: 6-9.
Dizon-Townson DS, Kinney S, Branch DW, Ward K. The factor V Leiden mutation is not a
common cause of recurrent miscarriage. J Reprod Immunol 1997; 34: 217-23.
Meinardi JR, Middeldorp S, de Kam PJ et al. Increased risk for fetal loss in carriers of the
factor V Leiden mutation. Ann Intern Med 1999; 130: 736-9.
Tal J, Schliamser LM, Leibovitz Z, Ohel G, Attias D. A possible role for
activated protein C resistance in patients with rst and second trimester pregnancy failure.
Hum Reprod 1999; 14: 1624-7.
Brenner B, Mandel H, Lanir N et al. Activated protein C resistance can be associated with
recurrent fetal loss. Br J Haematol 1997; 97: 551-4.
Clark P, Brennand J, Conkie JA, McCall D, Greer IA, Walker ID. Activated protein C sensitivity, protein C, protein S and coagulation in normal pregnancy. Thromb Haemost 1998; 79:
1166-70.
Kjelberg U, Andersson NE, Rosen S, Tengborn L, Hellgren M. APC resistance and other haemostatic variables during pregnancy and puerperium. Thromb Haemost 1999; 81: 527-31.
Rai R, Regan L, Hadley E, Dave M, Cohen H. Second-trimester pregnancy loss is associated
with activated protein C resistance. Br J Haemotol 1996; 92:489-90.
Younis JS, Brenner B, Ohel G, Tal J, Lanir N, Ben-Ami M. Activated protein C resistance and
factor V Leiden mutation can be associated with rst-as well as second-trimester recurrent
pregnancy loss. Am J Reprod Immunol 2000; 43: 31-5.
Mandel H, Brenner B, Berant M et al. Coexistence of hereditary homocysteinuria and factor
V Leiden effect on thrombosis. N Engl J Med 1996; 334: 763-8.
Brenner B, Vulfsons SL, Lanir N, Nahir M. Coexistence of familial antiphospholipid syndrome
and factor V Leiden impact on thrombotic diathesis. Br J Haematol 1996; 94: 166-7.
Preston FE, Rosendaal FR, Walker ID et al. Increased fetal loss in women with heritable
thrombophilia. Lancet 1996; 348: 913-16.
Gris JC, Quere I, Monpeyroux F et al. Case-control study of the frequency of thrombophilic
672
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.

disorders in couples with late foetal-loss and no thrombotic antecedent-the Nimes Obstetricians
and Haematologists Study 5 (NOHA5). Thromb Haemost 1999; 81: 891-9.
Cadroy Y, Grandjean H, Pichon J, Desprats R, Berrebi A, Boneu B. Evaluation of six markers
of haemostatic system in normal pregnancy and pregnancy complicated by hypertension or
preeclampsia. Br. J Obstet Gynecol 1993; 100: 416-20.
Higgins JR, Walshe JJ, Darling MR, Norris L, Bonnar J. Hemostasis in the uteroplacental and
peripheral circulations in normotensive and pre-eclamptic pregnancies. Am J Obstet Gynecol
1998; 179: 520-6.
Dizon-Townson DS, Nelson LM, Easton K, Ward K. The factor V Leiden mutation may predispose women to severe preeclampsia. Am J Obstet Gynecol 1996; 175: 902-5.
Nagy B, Toth T, Rigo J Jr, Karadi I, Romics L, Papp Z. Detection of factor V Leiden mutation
in severe pre-eclamptic Hungarian women. Clin Genet 1998; 53: 478-81.
Kupferminc MJ, Eldor A, Steinman N et al. Increased frequency of genetic thrombophilias in
women with complications of pregnancy. N Engl J Med 1999; 340: 9-13.
Wiener-Megnagi Z, Ben-Shlomo I, Goldberg Y, Shalev E. Resistance to activated protein C
and the Leiden mutation: high prevalence in patients with abruptio placentae. J Obstet Gynecol
1998; 179: 1565-7.
Grandone E, Margaglione M, Colaizzo D et al. Genetic susceptibility to pregnancy-related
venous thromboembolism: roles of factor V Leiden, prothrombin G20210A, and methylenetetrahydrofolate reductase C677T mutations. Am J Obstet Gynecol 1998; 179: 1324-8.
Sanson BJ, Lensing AWA, Prins MH, Ginsberg JS, Buller HR. The use of low molecular weight
heparin in pregnancy. Blood 1998; 92 (Suppl 1): 360a.
Gris JC, Neveu S, Tailland ML, Courtieu C, Mares P, Schved JF. Use of low-molecular weight
heparin (Enoxaparin) or of a phenformin-like substance (Moroxydine Chloride) in primary
early recurrent aborters with an impaired brinolytic capacity. Thromb Haemost 1995; 73:
362-7.
Brenner B, Hoffman R, Blumenfeld Z, Weiner Z, Younis J. Gestational outcome in thrombophilic women with recurrent pregnancy loss treated by enoxaparin. Thromb Haemost 2000;
83: 693-7.
Brenner B, Hoffman R, Carp H, Dulitsky M, Younis J et al. Effects of enoxaparin on late
pregnancy complications and neonatal outcome in women with recurrent pregnancy loss and
thrombophilia: results from the LIVE-ENOX study. JTH 2005; 3:227-9.
Gris JC, Mercier E, Quere I, Lavigne-Lissalde G, Cochery-Nouvellon E, Hoffet M, RipartNeveu S, Tailland ML, Dauzat M, Mares P. Low-molecular-weight heparin versus low-dose
aspirin in women with one fetal loss and a constitutional thrombophilic disorder. Blood. 2004
3695-9.
Dizon-Townson DS, Meline L, Nelson LM, Varner M, Ward K. Fetal carriers of the factor V
Leiden mutation are prone to miscarriage and placental infarction. Am J Obstet Gynecol 1997;
177: 402-5.
673
The value of LMWH treatment

in OB/GYN
D. Blickstein
Institute of Hematology, Rabin Medical Center, Beilinson Campus, Petach Tikva,
and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Anticoagulation is primarily indicated for treatment or prophylaxis of thromboembolism. Thromboprophylaxis is used in either patients at constant risk
or in those who are at increased risk of thrombosis for a limited duration.
At present, some inherited and acquired hypercoagulable conditions, termed
thrombophilia, are recognized as increasing the thromboembolic risk during
pregnancy and puerperium. In addition to DVT and PE, thrombophilia is also
associated with vascular pathologies in the uteroplacental unit leading to adverse pregnancy outcome and to a wide range of indications for anticoagulation
during pregnancy and puerperium.
Following the recognition of the adverse fetal and neonatal outcome related
to warfarin anticoagulation during pregnancy, its use is currently restricted to
specic indications when other anticoagulants are judged to be less adequate.
Treatment with heparin, although safe for the fetus, may cause maternal side
effects and needs close monitoring. During the last two decades a third preparation low molecular weight heparin (LMWH) has been introduced. The
currently used various regimens of unfractionated heparin and LMWH are
summarized in the Table.
Venous thromboembolism (VTE) in pregnancy occurs approximately 6
times more than in the non-pregnant state. PE occurs in about one sixth of the
patients with untreated DVT and is the most common cause of maternal mortality. The overall risk of DVT during pregnancy (0.05-1.8%) is higher in women
with a previous event of DVT, with a recurrence rate of 1:71 cases. Guidelines
regarding the management of VTE during pregnancy are regularly updated.
674
Recently, the 7th American College of Chest Physicians (ACCP) Consensus

Conference on Antithrombotic Therapy (2004) suggested that LMWHs are as
effective and safe as unfractionated heparin for the treatment of acute DVT.
The current recommendations for the treatment of VTE during pregnancy are
either (a) weight-adjusted dose LMWH throughout pregnancy, or (b) intravenous heparin for at least 5 days followed by PTT-adjusted dose of heparin,
or LMWH for the remaining pregnancy. Because the half-life of LMWH is
decreased during pregnancy and because most women gain weight, there is a
need for change in the dose of LMWH by either in proportion to weight or by
the level of anti-Xa. Postpartum anticoagulation therapy should be administered for at least 6 weeks.
Table:
Regimens of unfractionated heparin and LMWH.
Regimen
Dosage
Mini-dose unfractionated heparin
SC, 5000 U q 12 hrs
Moderate dose unfractionated

heparin
SC, q 12 hrs, anti Xa level of 0.1-0.3 U/mL
Adjusted-dose unfractionated
heparin
SC, q 12 hrs, PTT-adjusted dose
Prophylactic LMWH
SC, dalteparin 5000 U q 24 hrs

SC, enoxaparin 40 mg q 24 hrs
Intermediate dose LMWH
SC, dalteparin 5000 U q 12 hrs

SC, enoxaparin 40 mg q 12 hrs
Adjusted-dose LMWH
Weight-adjusted full treatment doses once a

day (i.e., tinzaparin 175 U/kg qd) or twice
daily (i.e., enoxaparin 1 mg/kg, q 12 hrs)
Postpartum anticoagulants
Warfarin with a target INR of 2-3, with initial

UFH or LMWH overlap
Currently, six groups of pregnant patients at increased risk of VTE have

been identied by the ACCP:
1. Single VTE associated with a transient risk factor (i.e., with bed-rest).
Management includes close observation during pregnancy and postpartum
anticoagulants. Antenatal thromboprophylaxis is recommended if the VTE
was associated with pregnancy or estrogens.
2. Single episode of idiopathic VTE. Management includes one of the options: (a) prophylactic LMWH, (b) mini- to moderate dose unfractionated
675
3.
4.
5.
6.
heparin, or (c) close observation. All patients should receive postpartum

anticoagulants.
Single episode of idiopathic VTE and thrombophilia or strong family
history. The same recommendations as in group 2, except that observation
alone is not advocated.
VTE and ATIII deciency, compound heterozygote for FII mutation +
FV Leiden, and homozygote for FII mutation or FV Leiden. (a) intermediate dose LMWH, or (b) moderate dose UFH prophylaxis.
No prior VTE and thrombophilia. These patients can be offered one of
the options: (a) close observation, (b) minidose unfractionated heparin, or
(c) prophylactic LMWH. All patients should receive postpartum anticoagulants. Thromboprophylaxis should be given to patients with ATIII deciency,
compound heterozygote for FII mutation + FV Leiden, and homozygote for
FII mutation or FV Leiden..
Multiple episodes of VTE and/or long term anticoagulation. Management
includes one of the options: (a) PTT-adjusted dose of UFH, or (b) weightadjusted LMWH. These patients should receive long-term anticoagulation
postpartum.
To recap, prophylactic treatment should be tailored according to the risk group.

Both heparin and LMWH are options, but it appears that LMWH will largely
replace unfractionated heparins because of its improved boiavailablity, a longer
half-life, ease of administration, no monitoring requirement, and fewer side
effects.
The risk of VTE is increased in patients undergoing cesarean section. Patients
with moderate risk should be offered graduated compression stockings whereas
high-risk patients should be given LMWH or UFH prophylaxis.
Studies suggested that inherited thrombophilias are not only associated
with increased risk of VTE during pregnancy and puerperium, but also with
an increased risk of vascular pathologies in the uteroplacental unit leading to
adverse pregnancy outcome, such as rst and second trimester miscarriages,
intrauterine growth restriction (IUGR), intrauterine fetal death, placental
abruption, and preeclampsia. Critical reading of the literature reveals two
nuances on these aspects. The data of the European Prospective Cohort On
Thrombophilia (EPCOT) study show a certain contribution of thrombophilia
to adverse perinatal outcome whereas numerous series show a denitive role
of thrombophilia in the pathogenesis of several adverse pregnancy outcomes.
There are at present two main controversies related to the validity of evidence
associating thrombophilia and gestational thromboembolic phenomena and to
676
the appropriate selection of patients and the timing of prophylactic anti-thrombotic therapy to prevent pregnancy loss and associated pregnancy complications. These conicting views may be claried by several ongoing multi-center
prospective studies. Data on treatment for women with inherited thrombophilia
and pregnancy loss is mostly uncontrolled and based on small series. The optimal dosage of LMWH to prevent thrombophilia-associated adverse pregnancy
outcome is also unknown.
The 2004 ACCP Consensus Conference on Antithrombotic Therapy recommends evaluation for inherited thrombophilia as well as for the acquired antiphospholipid antibody (APLA) syndrome in women with recurrent pregnancy
loss, prior severe preeclampsia, placental abruption, or otherwise unexplained
fetal demise. Management of pregnant patients is then subgrouped into ve
categories.
1. Pregnant patients with APLA and previous pregnancy complications.
Treatment should consist of low dose aspirin plus either of the following options: (a) mini- to moderate dose unfractionated heparin, or (b) prophylactic
LMWH.
2. Homozygous women for MTHFR. These should be treated with folic acid
before pregnancy or as soon as pregnancy is conrmed.
3. Women with thrombophilia and previous adverse pregnancy outcome.
One should consider low dose aspirin plus either (a) minidose heparin, or
(b) prophylactic LMWH. These patients should receive postpartum anticoagulants.
4. Women with APLA syndrome and history of VTE. Long-term anticoagulation (warfarin) should be switched to either adjusted-dose unfractionated
heparin or LMWH throughout pregnancy and resumption of the long-term
anticoagulant postpartum. Aspirin is given concomitantly.
5. Women with APLA syndrome but without history of VTE or pregnancy
loss. Four approaches have been suggested: (a) surveillance only, (b) mindose heparin,(c) prophylactic LMWH, or (d) low dose aspirin.
Persistent peripartum anticoagulation may complicate delivery. No signicant
difference in hemorrhagic complications was observed between LMWHs,
mainly enoxaparin and dalteparin, and unfractionated heparins. Although
bleeding complications appear to be very uncommon with LMWH, it was suggested to discontinue therapy 24 hours prior to invasive procedures or before
induction of labor.
The incidence of neurological complications from hemorrhage is estimated
to be less than 1:150,000 epidurals and less than 1:220,000 spinal blocks, and
677
obviously, traumatic needle or catheter placement may increase the risk of a

spinal hematoma. Because the anti-Xa level does not predict the risk of bleeding, the concern about regional anesthesia explains why labor induction or
cesarean birth should be a planned elective procedure in women receiving
LMWHs. To reduce the risk of anesthesia-related hematoma, regional blockade should start at least 12 hours after the last prophylactic LMWH dose and
longer (24 hours) if the patient receives weight-adjusted dose of LMWH. When
continuous epidural analgesia is performed, LMWH can be restarted 2 hours
after catheter removal.
Thromboprophylaxis in gynecological surgery is indicated to prevent VTE
in major surgery. Additional risk factors include previous VTE, age >60 years,
malignancy, and pelvic irradiation. No thromboprophylaxis is needed in procedures of <30 min for benign disease.
Suggested reading
1.
2.
3.
4.
5.
Brenner B. Clinical management of thrombophilia-related placental vascular complications.

Blood 2004; 103:4003-9
Bates SM, Greer IA, Hirsh J, Ginsberg JS. Use of antithrombotic agents in pregnancy. Chest
2004; 126:627S-644S
Geerts WH, Pineo GF, Heit GA, et al. Prevention of venous thromboembolism. Chest 2004;
126:338S-400S
Blickstein D, Blickstein I. Low molecular weight heparin in perinatal medicine. In: Kurjak
A, Papp Z, Chervenak FA (eds). The fetus as a patient: The evolving challenge. Parthenon
Publishing, London; 2002:261-266.
Kujovich JL. Thrombophilia and pregnancy complications. Am J Obstet Gynecol 2004;
191:412-424.
678
Emergency cases in pregnancy

Delivery of the impact fetal head:
instrumental vs. CS
Isaac Blickstein
Department of Obstetrics and Gynecology, Kaplan Medical Center, Rehovot,
and the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
Cesarean section (CS) is commonly perceived as an easier alternative to difcult vaginal birth. This statement is used to explain the increase in CS rates
in developed, resource-poor countries, and even in countries with a traditional
conservative approach to childbirth. However, the practicing obstetrician may
sometimes encounter difculty in disengaging a deeply impacted fetal head
during CS, with potentially serious consequences to the mother and child. This
obstetrical emergency is not new, but seems to be increasingly frequent in
recent years.
Contributing factors
It is clear that difcult delivery of the fetal head rarely, if ever, exists in elective
CSs, when problems are more frequently a result of a oating head. The situation is also not associated with cephalo-pelvic disproportion, when the fetal head
fails to descend in the maternal pelvis. Impaction of the fetal head is, therefore, a
second stage event and impaction seems to be more likely when the second stage
is unduly prolonged, and already exists when the clinician has to decide whether
to perform an instrumental delivery or a CS. Sometimes, both situations coexist,
as is the case with a CS after a failed instrumental delivery.
Some cases may result from the reluctance to perform instrumental deliveries. Landesman and Graber noted that with the greater use of CS and the decline
in rotational and midforceps deliveries, procedures to disengage an impacted
fetal head might have an increasingly important role in the obstetric arma-
679
mentarium. It follows that with the concurrent increase in CSs and decrease in
instrumental deliveries observed worldwide, many deeply engaged fetuses that
were managed in the past by either vacuum or forceps, are currently delivered
abdominally, at a stage when the fetal head might already be deeply wedged
in the pelvis.
A second contributing factor is longer permissible duration of the second
stage, particularly in patients under epidural anesthesia with a reassuring continuous fetal heart rate monitoring. In addition, the new trend of delayed
maternal pushing to preserve the pelvic oor is also associated with longer
durations of the second stage. It appears that the longer the second stage, the
higher is the likelihood of fetal head impaction. Signicant molding and the
formation of a caput a normal event during descent also add to impaction
of the head.
Another contributor is the frequent use of epidural anesthesia, leading to
decreased urge to push and to a consequent longer second stage. It is still
unknown whether epidural-related relaxation of the pelvic musculature leads to
faulty descent and contributes to the abnormal negotiation of the fetal head.
The vacuum extractor seems to be more signicant in producing head impaction because it allows larger head diameters to be pulled into the pelvis
compared with forceps. As is sometimes the case, the vacuum extractor may
cause further impaction by pulling on a large caput into the crowning stage.
Moreover, the vacuum may increase the size of an existing caput, further increasing the chance of difcult disengagement.
The clinical problem

The clinical problemarrest of descent occurs at a low stationstarts following
normal descent and after pushing for some time. At this stage, usually when a
sizeable caput has been already formed, a non-reassuring fetal heart rate pattern
is frequently seen. The obstetrician should decide between an assisted vaginal
delivery and a CS. If the rst choice fails, the situation may become urgent, and
clearly, further pulling of the undeliverable head produces more wedging.
At this time, signicant changes in the uterine segments obscure the anatomical landmarks of the vagina, cervix, and uterine body. Thus, the rst surgical problem is to carefully identify the location of the incision, because if made
too low, it is possible to incise the vagina rather than in the lower segment
(the so-called anterior vaginotomy). Alternatively, if the incision is made too
high, the presenting part of the fetus is usually the shoulder or even the fetal
chest. In any event, such incisions frequently lead to extension into the broad
680
ligament, profuse bleeding, and potential injury to the ureter. It is also common
to see how the upper uterine segment forcefully embraces the fetal body. The
attempt to deliver the fetal head may nd the lower pole of the molded head
(with or without an additional large caput) deeply impacted in the pelvis, and
practically undeliverable.
Management options
When the upper uterine segment rmly grasps the fetal bodya complication known during CS for breech presentation performed under conduction
anesthesiaextraction of the fetus may become quite difcult. When options
in this case are:
(1) When general anesthesia is used, relaxation can be achieved with halogenated anesthetics;
(2) When the patient is operated on under a pre-existing epidural block, uterine relaxants such as ritodrine and nitroglycerine have been used, and
both agents seem to be safe;
(3) One may allow the uterus to relax, but this solution is only practical when
fetal distress has been excluded prior to surgery;
(4) It is possible to switch to general anesthesia.
It should be remembered, however, that except for nitroglycerine, other
uterine relaxants might impair postpartum uterine contraction and increase the
risk of hypotonic uterine bleeding.
The disengagement of the impacted fetal head is the next clinical problem.
The choice is between pushing the fetal head from the vagina and pulling the
fetus by the legs.
The oldest procedure was described during the early 1980s suggests pushing the head by an assistants hand introduced through the vagina (so-called
abdominovaginal delivery). To accomplish this maneuver, the maternal legs are
abducted to allow the introduction of an assistants hand into the vagina. This
allows the assistant, to gently lift the wedged vertex with a cupped hand into
the open transverse uterine incision. The surgeon assists from above by steady
upward pressure on the fetal shoulders. It is unknown, however, what amount
of force is needed to push out the fetal head from the pelvis. To avoid this
problem, Lippert suggested that the surgeon himself/herself deliver the head
with one hand in the uterus (to avoid further deexion) and the other hand in
the vagina to press the head up, in a bimanual version that is quite similar to the
surgical approach in the Marshal-Marchetti or Burch colposuspension.
The inherent problem of the pushing maneuver is that difcult extraction
681
may not be anticipated and some kind of manual exploration to nd the patients
vagina is performed below the sterile covers. This problem is inevitably associated with the risk of contamination. In addition the initial attempt to disengage
the head and the subsequent attempt to extract the head combined with the thinning of the lower uterine segment, may cause extension of the uterine incision,
both downward into the vagina and sideward into the broad ligament. Hence,
extensive lacerations are common.
Pulling the fetus entails grasping the fetal feet, performing a semi-version,
and delivering the fetus by total breech extraction. The problem with this procedure might be that the primary incision may not be large enough. In this case, it
is advisable to transform the primary transverse incision into a J-shaped or into
an inverted-T incision. Kafali, for example, advocated an a priori low vertical
uterine incision to avoid the risk of extension.
Obviously, not every obstetrician is familiar with this unorthodox maneuver.
The procedure should be performed as gently as possible and with great care to
avoid fetal and maternal trauma. From my own experience, disengagement of
the impacted fetal head by pulling the fetal legs should be more like delivering
a breech-presenting fetus by CS than like uncorking a bottle of wine. It is also
unknown whether the procedures should be performed in sequence (i.e., rst
pushing from below and then pulling from above), simultaneously (i.e., pushing and pulling at the same time), or never in combination.
A single randomized study conducted to compare the effectiveness of push
to the pull methods of delivery of the impacted fetal head at CS showed that patients in the push group had signicantly longer operation time, more blood
loss, extension of the uterine incision, postpartum endometritis, longer hospital
stay and, consequently, higher hospital bills. In addition, the fetal morbidity
was worse in the push group. A comparative study conducted at the Kaplan
Medical Center (Levi R, et al. in press) also concluded that the pull method
is safer than the push method.
Suggested reading
Landesman R, EA Graber: Abdominovaginal delivery: modication of the cesarean section operation
to facilitate delivery of the impacted head. Am J Obstet Gynecol 1984; 148: 707
Ekele B: Disengaging impacted head at caesarean section for obstructed labour push or pull? Trop
Doct 2001;31:
Fasubaa OB, OC Ezechi, EO Orji, SO Ogunniyi, ST Akindele, OM Loto, FO Okogbo: Delivery of the
impacted head of the fetus at caesarean section after prolonged obstructed labour: a randomised
comparative study of two methods. J Obstet Gynecol 2002;22: 375
Fong YF, S Arulkumaran: Breech extraction an alternative method of delivering a deeply engaged
682
head at cesarean section. Int J Gynecol Obstet 1997; 56:183

Kafali H: Cesarean breech extraction for impacted fetal head in deep pelvis after a prolonged obstructed labor: a cesarean technique variation. Internet J Gynecol Obstet 2003;2: 2
Khosla AH, K Dahiya, K Sangwan: Cesarean section in a wedged head. Indian J Med Sci 2003;57:
187
Landesman R, EA Graber: Abdominovaginal delivery: modication of the cesarean section operation
to facilitate delivery of the impacted head. Am J Obstet Gynecol 1984;148:707
Lippert TH: Bimanual delivery of the fetal head at cesarean section with the fetal head in midcavity.
Arch Gynecol 1983;234: 59
Lippert TH: Abdominovaginal delivery in case of impacted head in cesarean section operation. Am
J Obstet Gynecol 1985; 151: 703
Acknowledgement
This proceeding has been adapted from: Blickstein I: Difcult delivery of the
impacted fetal head during cesarean section: intraoperative disengagement
dystocia. J Perinat Med 2004;32:465-9.
683
Condition-specic antepartum
fetal testing
Department of Obstetrics, Gynecology and Reproductive Sciences, University of
Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School,
New Brunswick, New Jersey, USA
In the past, many studies have used fetal biophysical testing regardless of the underlying pathophysiology. However, evidence-based observations have shown
that there are different pathophysiologic processes that may place the fetus at
risk and that the efcacy of the various fetal tests depends on the underlying
pathophysiology. The pathophysiologic processes that can cause fetal death
or damage are: decreased uteroplacental blood ow, decreased gas-exchange
at the trophoblastic membrane level, metabolic processes, fetal sepsis, fetal
anemia, fetal heart failure, and umbilical cord accidents.
Decreased uteroplacental blood ow

Fetuses at risk for decreased uteroplacental blood ow are those suffering
from early severe growth restriction, especially <32-34 weeks, and also those
from mothers with chronic hypertension, preeclampsia, or other vascular
disease.
Randomized controlled trials have demonstrated that the use of umbilical
artery Doppler velocimetry is associated with decreased fetal death and overall
perinatal mortality rate, especially in the subset of high risk pregnancies complicated by fetal growth restriction or maternal hypertension.
Some studies have suggested that changes in Doppler indices proceed FHR
or biophysical prole changes. This time sequence of changes in the fetal
Doppler velocimetry indices, as well as FHR and biophysical prole changes
684
may be useful in timing the delivery in cases of fetal growth restriction with
progressive hypoxia/ asphyxia.
In fetuses with growth restriction, as well as fetuses from mothers with
chronic hypertension, preeclampsia, or other vascular disease, Level II evidence suggests that serial ultrasounds for growth, non-stress tests and biophysical proles are also useful tools for fetal monitoring. Special emphasis should
be given to the amniotic uid volume component, since oligohydramnios is an
ominous nding in cases of fetal growth restriction.
Decreased gas-exchange
Fetuses at risk for decreased gas-exchange are those with postdates and also
some fetuses with growth restriction >32-34 weeks. In such cases, Doppler is
not predictive and many of these growth restricted fetuses end up having villitis in the placenta. Growth restricted fetuses with gas-exchange abnormalities
(placental transport problems) usually develop late growth restriction (> 32-34
weeks) and may have normal Doppler examinations, since the primary insult is
not related to reduced uteroplacental blood ow. Therefore, surveillance has to
include NSTs, amniotic uid assessments and/or biophysical proles,
In post-dates pregnancies (dened as duration longer than 294 days or 42
weeks), the perinatal risks are increased with every additional week of the
pregnancy after the fortieth week. Under these circumstances, it seems that
prolongation of pregnancy beyond 42 weeks is not logical.
Doppler ow velocimetry studies are of little benet as a tool of antenatal
surveillance for post-dates pregnancies, both because of a poor correlation
between the ndings and the fetal outcome, but also due to the low sensitivity
of the tests to detect complications 1,2.
Metabolic aberrations
Fetal damage or death can be the result of metabolic causes. Such metabolic
processes include fetal hyperinsulinemia (as seen in genetic disorders such as
Beckwith- Wiedman syndrome) and fetal hyperglycemia/hyperinsulinemia (as
seen in fetuses of diabetic mothers with uncontrolled blood sugars). In diabetic
patients, maternal blood sugar levels may discriminate the at-risk fetuses from
those who do not need further testing. The risk of fetal death is known to
be highly correlated with the level of maternal hyperglycemia during pregnancy. The presence of normal maternal blood sugars during the antepartum
period combined with normal fetal growth and absence of polyhydramnios
685
may require minimal, if any, fetal surveillance. In the presence of maternal

hyperglycemia, polyhydramnios or accelerated fetal growth, the fetus is at risk
for developing lactic acidemia. Moreover, in the presence of maternal vasculopathy (gestational diabetes classes R/F), the fetus is also at risk for hypoxic
acidemia. Although biophysical testing is routinely done in diabetic pregnancies, the predictive value of such testing in the presence of maternal diabetes
mellitus, where blood sugars may uctuate and inuence the results of testing,
is seriously questioned.
Most antepartum surveillance studies have been done in well-controlled patients. So, the question still remains if fetal biophysical assessment in diabetic
pregnancies is reliable, especially in the presence of poor diabetic control. It
is very well documented that elevated maternal blood sugar levels may alter
fetal biophysical assessment. Increased fetal breathing in diabetic mothers can
be misleading, since it can be seen in the presence of maternal hyperglycemia
even in the presence of lactic acidemia. 3 However, fetal breathing movements
are not the only component of the biophysical prole that can be altered. Fetal
body movements can also be increased with transient hyperglycemia, and the
amniotic uid volume is also increased when there is poor metabolic control.
Therefore, the entire fetal biophysical prole may be altered and those changes
depend on diabetic control.
Fetal sepsis
Conditions that place the fetus at risk for sepsis include premature rupture of the
membranes, preterm labor, maternal fever or primary subclinical intraamniotic
infection. Of these conditions, premature rupture of membranes (PROM) is the
one most frequently associated with increased risk for fetal sepsis. Our prospective study 4 showed that the frequent use of biophysical proles in patients with
PROM could be used as an early predictor of subclinical intra-amniotic infection. The rst manifestations of intra-amniotic infection were a non-reactive
non-stress test and absent fetal breathing. The best predictor of infection was
the overall biophysical score. The use of daily NSTs and biophysical proles
have been shown to improve pregnancy outcome in patients with PROM.
The use of quantitative amniotic uid assessment in patients with PROM
provides a noninvasive antepartum surveillance tool that may help identify
impending fetal infection in patients with PROM. Many studies have provided
Level II evidence showing a strong correlation between oligohydramnios and
variety of adverse perinatal outcomes including clinical amnionitis, histologic
funisitis, neonatal sepsis, low birth weight, and perinatal mortality.
686
An alternative approach, in identifying the fetus at risk for sepsis earlier,

may involve the use of transabdominal amniocentesis to rule out intraamniotic
infection by performing tests such as Gram Stain, glucose, white blood cell
count or IL-6, as well as culture (aerobes, anaerobes, and mycoplasma species). It is possible that by using amniocentesis, intraamniotic infection may be
identied before the biophysical assessment becomes abnormal.
Fetal anemia
Some examples of conditions that could possibly lead to fetal anemia include
maternal red cell alloimmunization (erythroblastosis fetalis), feto-maternal
hemorrhage and fetal parvovirus B 19 infection. The most current evidence
suggests that the most useful method to identify the at-risk fetus includes
Doppler studies of the middle cerebral artery waveform (peak systolic velocity) as a screening tool, and if abnormal, further follow up with amniocentesis
(for amniotic uid bilirubin studies) and/or cordocentesis (to assess the actual
fetal hemoglobin levels).
The most accurate marker for the detection of fetal anemia though, is
the measurement of the peak systolic velocity of the middle cerebral artery
(MCA-PSV) with sensitivity almost 100% and false positive rate 12% (for
gestations less than 34-35 weeks)5 . In a prospective multicenter trial 6, 125
alloimmunized patients were monitored and managed noninvasively by serial
MCA-PSV measurements. If the MCA-PSV values were above 1.5 multiples
of the median for gestational age, then fetal blood sampling was performed.
They reduced the invasive procedures by 66% and only one fetus was found
to be anemic at birth.
When combining fetal liver length (FLL) with MCA-PSV measurements
for the detection of fetal anemia, the sensitivity of FLL was found to be 93%
and the sensitivity of MCA-PSV 80% 7.It appears that FLL is more sensitive
for mild anemia, while MCA-PSV is more sensitive for moderate to severe
anemia.
Combining MCA-PSV and FLL is an efcient method of evaluating the
risk for fetal anemia and it has reduced the number of invasive procedures by
approximately two thirds in our institution.
Fetal heart failure

The presence of persistent severe fetal tachyarrhythmia or bradyarrhythmia,
nonimmune hydrops, placental chorioangioma, or aneurysm of the vein of
687
Galen, need surveillance for possible development of fetal heart failure. Only
fetuses who are at risk of becoming hydropic are in need of further intensive
biophysical surveillance. If the fetus has an arrhythmia, the rst step should
be M-mode echocardiography to determine the type of arrhythmia, followed
by continuous fetal heart rate monitoring to determine the time that the fetus
spends in sinus rhythm. Ultrasound should be used to evaluate for signs of
hydrops, and Doppler velocimetry studies should be used to evaluate the fetal
venous circulation. If hydrops is present in a very preterm fetus, NSTs and
biophysical proles, in addition to Doppler velocimetry studies, should be
performed for fetal monitoring until the time of delivery
Cord accident candidates

Conditions that could possibly lead to a cord accident are the presence of umbilical cord entanglement, as seen in monoamniotic twins, oligohydramnios,
velamentous cord insertion, funic presentation, and uncoiled umbilical cord.
When these conditions are suspected, their presence should be conrmed by
the use of color ow ultrasound imaging.
Based on level II and level III evidence, in cases of cord accident candidates
the best tests are color Doppler to verify the diagnosis, frequent NSTs, and
umbilical artery velocimetry to rule out the presence of a systolic notch in the
waveform.
Summary
The available evidence suggests that there is no ideal test for all high-risk
fetuses because there are several different pathophysiologic processes which
can result in fetal compromise, death or damage. By using condition-specic
fetal testing, it is expected that the number of fetal deaths will be lower than
the number of fetal deaths seen when the same biophysical assessment tests are
applied regardless of the underlying pathophysiologic process.
688
References
1.
2.
3.
4.
5.
6.
7.
Guidetti DA, Divon MY, Cavalieri RL. Fetal umbilical artery ow velocimetry in postdate
pregnancies. Am J Obstet Gynecol 1987;157:1521-3.
Zimmerman P, Alback T, Koskinen J, Vaalamo P, Tuimala R, Ranta T. Doppler
ow velocimetry of the umbilical artery, uteroplacental arteries and fetal middle cerebral artery in
prolonged pregnancy. Ultrasound Obstet Gynecol 1995;5:189- 97.
Salvesen DR, Freeman J, Brudenelli JM, Nicolaides KH. Prediction of fetal acidaemia in
pregnancies complicated by maternal diabetes mellitus by biophysical prole scoring and fetal
hear rate monitoring. BJOG 1993;100:227- 33.
Vintzileos AM, Campbell W, Nochimson DJ, Connolly ME, Fuenfer MM, Hoehn GJ. The fetal
biophysical prole in patients with premature rupture of the membranes-an early predictor of
fetal infection. Am J Obstet Gynecol 1985;152-510-6.
Mari G, Deter RL, Carpenter RL, Rahman F, Zimmerman R, Moise KJ Jr, et al. Noninvasive
diagnosis of Doppler ultrasonography of fetal anemia due to maternal red-cell alloimmunization: Collaborative Group for Doppler Assessment of the Blood Velocity in Anemic Fetuses.
N Engl J Med 2000;342-9-14.
Zimmerman R, Carpenter J Jr, Durig P, Mari G. Longitudinal measurement of peak systolic
velocity in fetal middle cerebral artery for monitoring pregnancies complicated by red cell
alloimmunisation: a prospective multicentre trial with intention-to-treat. BJOG 2002;109:74652.
Roberts AB, Mitchell JM, Lake Y, Pattison NS. Ultrasonographic surveillance in red blood cell
alloimmunization. Am J Obstet Gynecol 2001;184:1251-5.
Gestational diabetes treatment or over-treatment

Krzysztof Czajkowski
Since the investigations published by OSullivan, gestational diabetes has
become a worldwide recognized complication of pregnancy. There are big
differences in prevalence of gestational diabetes partly as the result of examined
populations and unsolved burden in screen and diagnostic criteria (10, 11, 14,
15, 16, 17). Proportion of pregnant patients who should have had a screening
test for gestational diabetes mellitus vary from 100% to about 20% of all
pregnant women in the dependence of country and guidelines. There are large
differences in employed methods and intensification of prenatal care too. In
many centers the care is so intensive that one may think that disease is horribly
dangerous. On the other hand some investigators, looking at good results, think
that GDM is a virtual disease diagnosed only by over fervors research workers.
They do not remember that untreated gestational diabetes can have some
unpleasant effects like stillbirths, sudden neonatal deaths or shoulder dystocia.
Among variety of management strategies for lowering blood glucose in women
with GDM, proper education, diet, exercise training, insulin regimes and
methods of glucose control are the key for decreasing incidence of maternal and
fetal complications (8).
Diagnostic process
The first main difference between approaches is screening population. In many
countries screening is recommended only for special groups of patients. In some
countries universal screening is recommended. Selective screening is performed
in patients cohorts with risk factors (10, 11, 14, 17). It is known that GDM is
often diagnosed in patients with different risk factors like age, great multiparity,
family history of diabetes mellitus, poor obstetric history, however there are
some evidences against selective screening. Prevalence of GDM in group of
patients with risk factors does not mean, that there is no gestational diabetes in
patients without these factors. According to our published data, risk factors are
present in about half of all women with GDM with unsatisfied sensitivity (c 2).
Selective screening would imply to miss about 50% of gestational diabetes
mellitus cases. Similar results were published by others (6). Patients age
exceeding twenty five, thirty, or even thirty five years, is in the different centers
accepted as a risk factor of GDM for selective screening. In our universally
screened population only 16,5% of patients were younger than 26 years, but
43,4% were older than 30 years. Screening women after 30 years only would
bring us to overlook more than half of gestational diabetes subjects. In Poland
great multiparity is very rare, 43,5% of all GDM women were multiparas. Body
mass index, which is increasing with womens age, seems to be the only one
important risk factor (12). Fetal macrosomia in previous pregnancies is another
important risk factor. Excessive fetal weight is not only a consequence of
maternal diabetes, but sometimes is a result of maternal obesity, age and genetic
factors. The same factors are connected with higher risk of GDM.
The most widely applied diagnostic approach of gestational diabetes
mellitus is 50 g glucose challenge test, followed by 100g or 75g diagnostic test
(16). Different cut-off levels can influence the rate of diagnosed GDM even in
universal screening. For example two diagnostic criteria of the same 100 g
OGTT by Carpenter and OSullivan can make a 10% difference in prevalence of
gestational diabetes mellitus (2). Ideal diagnostic guideline should detect GDM
in nearly all patients with glucose metabolism disturbances in pregnancy with
only few false positive results. Even with ideal guidelines no every doctor will
perform test in his patient with the same way. According to data presented from
USA ninety-six percent of the 60% responders for the questionnaire American
obstetricians routinely screen their patients for GDM (9, 13).
In Poland since 1994 universal screening for all pregnant women is
recommended. Theoretically every doctor should advice the patient to check:
fasting blood glucose level on the first antenatal visit, glucose challenge test between 24 and 28 weeks of pregnancy and eventually OGTT with 75 g of
glucose, when GCT result is equal or greater than 140mg%. If the GCT test
result is greater than 200 mg%, the diagnosis of GDM can be made without
additional diagnostic tests. Those women with positive GCT results and
negative OGTT results are rediagnosed again in 32 gestational week. The
interpretation of OGTT results is made using WHO recommendations.
We know, from other investigations, that prevalence of gestational diabetes
in Poland is 3,5% - 4% of all deliveries. Our clinic is one of the 15 special,
regional centers for diabetes and pregnancy in Poland. During three years in our
center 1213 patients with GDM delivered. It equals 12,5% of all deliveries in
our clinic during that period. The percentage exceeds the average in pregnant
population of Mazovian district, but our hospital is the III level center in
perinatal care.
If every doctor in our district will respect national
recommendations, about half of all GDM patients should live in Warsaw and a
quarter in small towns and villages. As you can see on figure1 our investigated
population is different than expected. Most of patients are from big towns and
only 16,8% from villages. Looking at these results one can doubt that the
universal screening is really performed.
Figure 1
Mazovian population with GDM (% )
17%
big town
small town
24%
59%
village
As we mentioned above, one of the fundamental terms of GDM diagnosis is

to perform tests between 24 and 28 weeks of pregnancy. In our group 45,8%
cases of GDM were diagnosed between 23 and 28 weeks of pregnancy and
42,2% between 29 and 34 weeks. Similar to another investigations, there are
some patients (5,2%) with diagnosis made before 23 weeks of pregnancy or
after 35 week (6,8%).
Maternal complications
There is a golden rule in the management of gestational or pregestational
diabetes number and intensity of pregnancy complications in DM are
proportional to the control of glucose homeostasis. The glucose level is a key to
success. In many centers classification system is based on diagnostic test results
only (10, 11). Sometimes further course of GDM, even with high glucose levels
at diagnosis, shows that diet is a sufficient treatment. Otherwise, in some cases
after few weeks, glucose levels rise and insulin treatment is introduced. In
Poland we divide GDM patients into two classes 9 treated with diet only and
- G2 - those who need diet and insulin to ensure that glucose levels stay within
normal range. 94,46% of our patients are classified as GDM 9.
Glucometers
are lend out to every GDM patient. Glucose levels are measured every day four
times daily - fasting and 1 hour after main meal. After one day education of low
carbohydrate diet and glucometer attendance, patients are followed up in our
out-patient clinic every third or second week. Glucose levels between 65 and
140 mg% (1 hour after meal) are set as a goal of treatment and that goal is
achieved in more than 90% of patients.
There are big differences in glucose levels monitoring between centers. In New
York Bronx Municipal Hospital Center all patients with gestational diabetes are
followed and assessed biweekly until delivery (3). The frequency of glucose
monitoring can be different according to the treatment - patients on diet or diet
and insulin (13). Only in 49% maternal-fetal medicine centers, diet controlled
patients use in-home glucometers as recommended, but only 20% of them check
glucose levels several times per week. Self glucose monitoring is recommended
in 89%-99% of insulin treated patients, in 63%-85% daily. In Texas University
all patients receive dietary counseling for daily caloric intake (35 kcal/kg) and
food types to avoid (5). In class 3 (patients on diet only) fasting serum sugar
measurements are repeated at each visit. Blood samples are examined
in
laboratory. Class 2 is diagnosed if fasting hyperglycemia and insulin treatment

has been introduced at initial visits. Fetal surveillance testing in diet controlled
and in insulin treated patients with GDM is similar, but many doctors monitor
patients with insulin few week earlier (13).
More than half of our patients (55,99%) had other medical complications
during pregnancy. Most of them had only one complication, few - more than
four. There were no differences between diet only and diet and insulin treated
patients.
Figure 2.
Number of other medical complications in GDM
pregnancy
100
80
no complications
1 complication
60
2 complications
40
3 complications
20
4 complications
0
numbers
The most common complication of pregnancy among our GDM patients was
anemia 271 (22,3%), threatened abortion 199 (16,4%), threatened premature
labor 174 (14,34%), pregnancy induced hypertension 78 (6,4%)
and urinary
tract infection
74 (6,1%).
Prevalence of medical complications in GDM
pregnancy was similar to that observed in general population. Those

complications occurred non significantly less frequently in patients treated with
diet only. Hedderson at all (10) from California showed selected perinatal
complications in a group of 1523 GDM patients. Some of them were
significantly more frequent than in general population pregnancy induced
hypertension and preeclampsia (9,2% versus 4,6%); polyhydramion (0,7%
versus 0,3%). Pregnancy induced hypertension is a complication, which is more
frequent even in diet only treated GDM patients than in general population
(17% versus 12%, p<0,001) (5).
Cesarean section rate in GDM group usually is higher than in general
population. Hedderson at all (10) performed caesarean section in 22,6% of
diabetic women and in 14,7% in healthy population (p<0,001). Ozumba et all
(14) performed 19,7% cesarean sections in GDM patients and 15,5% in control
group. In Texas University Hospital cesarean delivery rate was 30% in GDM
versus 17% in control group. Observed difference was statistically significant. In
our center caesarean section rate was 28,4% in GDM group and 26,5% in
general population. There were no differences between 9 and G2 gestational
diabetes patients. About 1/3 of operative deliveries was performed because of
fetal distress.
Spontaneous preterm birth is one of the most frequent complication of
GDM pregnancy. The risk of spontaneous preterm delivery grows with
increasing levels of results of screening and diagnostic tests (10). The incidence
of spontaneous preterm delivery in singleton pregnancy in gestational mellitus in
intensively treated diabetes mellitus can be similar to the general population (4).
In our center premature labor occurred in 156 (12,6%) cases of GDM group,
which was similar to the general population too. Most of these premature
deliveries (119) took place in 35 and 36 gestational week.
In opinion of many doctors GDM is a risk factor for placental

insufficiency and because of that they induce labor before term. In Texas
University even in diet only treated patients induction of labor is most frequent
than in control group (14% versus 10%, p<0,007) (5). In our clinic, if labor does
not start spontaneously, we induce delivery at 39 gestational week in GDM G2
and at term in GDM 9 (diagram).
Figure 3.
time of delivery
450
400
350
300
250
time of delivery
200
150
100
50
0
< 36
37
38
39
40
> 40
Hypertension in GDM patients is one of the most important factors which

exert an influence on labor induction.
Hypertensive women (with chronic
hypertension) with gestational diabetes are more likely to have induction of

labor (36,7% versus 6,6%) when compared with nonhypertensive GDM women
and they deliver earlier 38,5+-1,2 versus 39,6+- 1,2 weeks (3). Of course the
reason was iatrogenic - the staff believe that in case of PPH and GDM women
the labour should be induced earlier. In our series there were no differences in
preterm labor rate in PIH or PPH patients.
Neonatal complications
High glucose transport from mother to fetus produce fetal hyperinsulinemia,
macrosomia and
post labor hypoglycemia.
Prenatal care in many centers
depend of the class of the GDM. Usually uncomplicated patients with treated
with diet only GDM, were not considered for intervention and fetal testing.
There are some complications, which are more frequent in diet only treated
GDM patients than in general population (5): newborn weight 4001-4500 g
(18% versus 7%, p< 0,001), 4501-5000g (4% versus 0,9%, p<0,001), >5000
(1% versus 0,1%, p<0,001), LGA (35% versus 14%, p<0,001), fractured
clavicle
(2% versus 0,9%, p<0,017), shoulder dystocia (3% versus 0,9%,
p<0,001). In Hedderson at all (10) series selected perinatal complications were

significantly more frequent in GDM than in general population macrosomia
16,8% versus 13,9%. In presented by Ozumba et all (14) series neonatal weight
> 4000g was more than five times most frequent in GDM patients than in
control group (28,7% versus 5,5%). In our group of gestational diabetic women
there were 40 multiple pregnancies - 38 twins and 2 triplets. The incidence of
macrosomic infants (> 4000g) was only 10,13% which was more frequent than
in general population. All cases of macrosomia occurred in singleton
pregnancies, which make a 10,84% of this subgroup. Prepregnancy weight,
obesity is one of the important independent factor for macrosomia, even in
GDM pregnancy (V2).
In our series of GDM patients 69,4% of all newborns had not any
complications. Most neonatal complications occurred in neonates born by GDM
G2 patients.
In data presented by Aberg at all (1) total malformations rate in
gestational diabetes mellitus was 5,7% and it was similar to the population rate.
They suggest that in the group of gestational diabetes exists a subgroup with an
increased risk for diabetes embriopathy, perhaps due to preexisting but
undetected diabetes type 2. In our series 59 (4,7%) neonates born by GDM
mothers has malformations and 22 (1,75%) has PFO. We do not observe any
differences in GDM class and onset of diabetes.
Conclusions
As it is known from the literature, untreated gestational diabetes mellitus leads
to some perinatal complications.
Macrosomia, hypertension disorders,
prematurity and perinatal mortality in mothers with untreated gestational

diabetes mellitus are much more frequent than in treated GDM or in general
population (15). Even in treated GDM, macrosomia and hypertension disorders
are according to some investigations more frequent than in control groups. We
strongly believe that self monitoring of glucose levels is a gold standard in
monitoring gestational diabetes. In the first 2 weeks after diagnosis every patient
should check glucose levels four times daily. If the glucose levels are stable,
examination should be repeated every second or third day or even once a week.
We believed, that GDM patients, treated with diet only and with normal glucose
levels, can be managed as healthy pregnant women. Special attention is
necessary only for those with additional medical complications. Prenatal care for
insulin treated patients with gestational diabetes mellitus should be more
intensive with earlier fetal wellbeing tests.
Literature:
1 Aberg A., Westbom L., Kallen B Congenital malformations among infants
whose mothers had gestational diabetes or preexisting diabetes Early Hum
Devel 2001, 61: 85-95.
2 Agarval M.M., Punnose J. Gestational diabetes: implications of variation in
diagnostic criteria Gynecol Obstet 2002, 78: 45-46.
3. Anyaegbunam A.M., Scarpelli S., Mikhail M.S. Chronic hypertension In
gestational diabetes: influence on pregnancy outcome Gynecol Obstet Invest
!995, 39: 167-70.
4 Bar-Hava I., Barnhard Y., Scarpelli S.A., Orvieto R., Ben-Rafael Z., Divon
M.Y. Gestational diabetes and preterm labour: is glycaemic control a
contributing factor Obstet Gynecol 1997, 73: 111-114.
5. Casey B.M., Lucas M.J., McIntire D.D., Leveno K.J. Pregnancy outcomes in
women with gestational Diabetes compared with the general obstetric
population Obstetrics and Gynegology 1997, 90: 869-73.
6 Carr S.R. Screening for gestational diabetes Diabetes care 1998, 21 (suppl
2) 44-18.
7 Cajkowski K., Janczewska J., Jwicka E., Teliga-Cajkowska J. Gestational
diabetes confirmation of Chojen pisk factors Klin Piernat Gin 1993, 9: 90-6.
8 Fagen C., King J.D., Erick M. Nutrition management in women with
gestational diabetes mellitus: A review by ADAs Diabetes Care and Education
dietetic practice group Am J Diet Assoc 1995, 95: 460-7.
9 Gabbe S., Hill L., Schmidt L., Schulkin J. Management of diabetes by
obstetrician-gynecologist Obstet Gynecol 1998, 91: 643-7.
10 Hedderson M.M., Ferrara A., Sacks D.A. Gestational diabetes mellitus and
lesser degrees of pregnancy hyperglycemia: association with increased risk of
spontaneous preterm birth Obstet Gynecol 2003, 102: 850-6.
11 Jang H.C., Yim Ch-H., Han K.O., Yoon H.K., Han I.K., Kim M.J., Yang
J.H., Cho N.H. Gestational diabetes mellitus in Korea: prevalence and
prediction of glucose intolerance at early postpartum Diab Res Clin Pract 2003,
61: 117-124.
12 Khine M.L., Winkleistein A., Copel J.A. Selective screening for gestational
diabetes mellitus in adolescent pregnancies Obstet Gynecol 1999, 93: 738-42.
13 Owen J., Phelan S., Landon M.B., Gabbe Gable.G. Gestational diabetes
survey Am J Obstet Gynecol 1995, 172: 615-20.
14 Ozumba B.C., Obi S.N., Oli J.M. Diabetes mellitus in pregnancy in
African population Obstetric Gynecol 2004, 84: 114-119.
15 Poncet B., Touzet S., Rocher L., Berland M., Orgiazzi J., Colin C. Costeffectiveness analysis of gesttional diabetes mellitus screening in France Obstet
Gynecol 2002, 103: 122-129.
V2 Van Wootten W., Turner R.E. Macrosomia in neonates of mothers with

gestational diabetes is associated with body mass index and previous gestational
diabetes J Am Dietet Ass. 2002, 102: 241-3.
16 Vogel N., Burnand B., Vial Y., Paccaud F., Hohlfeld P. Sreening for
gestational diabetes: variation in guidelines Obstet Gynecol 1999, 91: 29-36.
17 Zargar A.H., Sheikh M.I., Bashir M.I., Masoodi S.R., Laway A., Wani A.I.,
Bhat M.H., Dar F.A. Prevalence of gestational diabetes mellitus in Kashmiri
women from the Indian subcontinent Diab Res Clin Pract 2004, 66: 139-145.

Controversies in O&amp;B and Infertility (Athens 14-17 April 2005)

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Controversies in O&amp;B and Infertility (Athens 14-17 April 2005)

Uploaded by

Copyright:

Available Formats

Controversies in Obstetrics

Gynecology and Infertility

Oren Publisher Ltd.

Proceedings of the congress:

Oren Publisher Ltd.

But Surely Not Me: Snakes, Bugs and Us

Transplantation of cryopreserved ovarian tissue

J. Donnez, M.M. Dolmans, D. Demylle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Why Give LH if FSH Works?

Overweight women: profertility effect of weight reduction.

P.G. Crosignani, M. Colombo, W. Vegetti, E. Somigliana, A. Gessati, G. Ragni. . . . . . . . . . . . . 60

Do we need insulin sensitizers?

Risks of ovarian stimulation

Is endometrial receptivity altered in COH cycles?

Increased risks of health problems in singleton ART babies:

Hot controversies in infertility

Metformin and PCOS: Should they always go together?

Controversies in Obstetrics, Gynecology and Infertility

Fresh ovarian tissue transplant: a propose of a place to implant it

A. Morales, G. Pons, O. Vidal, E. Trevio, D. Saldivar, L. Sordia, M. Merino,

A structured literature review to establish the effectivity

T. Siebert, T.F. Kruger, D.W. Steyn, S. Nosarka . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Pollution, infertility and carcinogenesis

Other Health Hazards of Hormone Disrupters and how to ght them.

Impact of the environment on reproductive health: a bitter lesson from Athens

D.A. Adamopoulos, E. Koukkou. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

J. Serna, A. Pellicer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

Induction of monoovulatory cycles for assisted

Neuroendocrine aspects of amenorrhea related to stress

A.D. Genazzani, C. Lanzoni, C. Strucchi, H. Mehemeti, F. Ricchieri,

IVF or surgery first?

B.W. Rackow, A. Arici, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

Treatment of tubal pathology or IVF?

Uterine septum resection or IVF - which comes rst ?

P.Cline, L. Pascale, J. Donnez . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180

A.L. Mikkelsen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188

IVM as an alternative in poor and over responders.

Hot controversies in Infertility

E.J. Margalioth, T. Eldar-Geva, M. Gal, A. Ben-Chetrit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208

Is There a Life for IUI after the Advent of ICSI?

M. Yemini , J. Hade, A. Birkenfeld . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224

Does PGD help in patients with repeated IVF Failure?

G.B. Maroulis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

Factors affecting Frozen Embryo Transfer program

H. Hashim, F. Al Salman , A. Felemban, H. Al Fozan., S. Hassan, M. Bugnah . . . . . . . . . . . . 231

The Use of Advanced Reproductive Technologies in Israel:

Y. Simon, B. Kaplan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

Review of non-surgical and surgical treatment, and the role of insulin-sensitizing

A.M. Saleh, H.S. Khalil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241

The peritoneal uid. A cause or a consequence of endometriosis?

J. Szamatowicz, P. Laudaski . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255

Should treatment with clomiphene citrate continue?

Prevention of pregnancy failure in IVF

Prevention of multiple pregnancies attributable to IVF/ICSI

D. Loutradis, P. Drakakis, A. Makrigiannakis, A. Antsaklis . . . . . . . . . . . . . . . . . . . . . . . . . . . 284

New technology and techniques

Immune testing in fertility practice: Truth or Deception?

C. Kallen, A. Arici . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305

Controversies in Obstetrics, Gynecology and Infertility

Androgen insufciency in women: Does it exist?

G. Mastorakos , C. Marios C. Markopoulos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330

Laparoscopic hysterectomy: Should we remove the cervix?

J. Donnez, J. Squifet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350

Laparoscopic myomectomy/myolysis : To whom should it be proposed ?

Controversies in O&B and Infertility (Athens 14-17 April 2005)

Controversies in O&B and Infertility (Athens 14-17 April 2005)