Different surgical techniques to reduce post-operative adhesion formation: a systematic review and meta-analysis

INTRODUCTION

Adhesion formation is the most common complication following peritoneal surgery and the leading cause of small bowel obstruction, acquired infertility and inadvertent organ injury at reoperation. Using a ‘good surgical technique’ is advocated as a first step in preventing adhesions. However, the evidence for different surgical techniques to reduce adhesion formation needs confirmation.

METHODS

Pubmed, Embase and CENTRAL were searched to identify randomized controlled trials that investigated the effect of various aspects of surgical technique on adhesion-related outcomes. Clinical outcomes and incidence of adhesions were the primary endpoints. Identification of papers and data extraction were performed by two independent researchers.

RESULTS

There were 28 papers with 27 studies included for a systematic review. Of these, 17 studies were eligible for meta-analysis and 11 for qualitative assessment only. None of the techniques that were compared significantly reduced the incidence of adhesive small bowel obstruction. In a small low-quality trial, the pregnancy rate increased after subserous fixation of suture knots. However, the incidence of adhesions was lower after laparoscopic compared with open surgery [relative risk (RR) 0.14; 95% confidence interval (CI): 0.03–0.61] and when the peritoneum was not closed (RR 0.36; 95% CI: 0.21–0.63).

CONCLUSIONS

None of the specific techniques that were compared reduced the two main adhesion-related clinical outcomes, small bowel obstruction and infertility. The meta-analysis provides little evidence for the surgical principle that using less invasive techniques, introducing less foreign bodies or causing less ischaemia reduces the extent and severity of adhesions.

Source:
http://humupd.oxfordjournals.org/cgi/content/short/19/1/12?rss=1

Metformin versus clomiphene citrate for infertility in non-obese women with polycystic ovary syndrome: a systematic review and meta-analysis

BACKGROUND

Recent studies suggest that metformin may be more effective in women with polycystic ovary syndrome (PCOS) who are non-obese. The objective here is to determine and compare the effectiveness of metformin and clomiphene citrate for improving fertility outcomes in women with PCOS and a BMI < 32 kg/m2 (BMI 32 kg/m2 was used to allow for international differences in BMI values which determine access to infertility therapy through the public health system).

METHODS

Databases were searched for English language articles until July 2011. Inclusion criteria: women of any age, ethnicity and weight with PCOS diagnosed by all current criteria, who are infertile; at least 1000 mg of any type of metformin at any frequency, including slow release and standard release, compared with any type, dose and frequency of clomiphene citrate. Outcomes: rates of ovulation, live birth, pregnancy, multiple pregnancies, miscarriage, adverse events, quality of life and cost effectiveness. Data were extracted and risk of bias assessed. A random effects model was used for meta-analyses of data, using risk ratios (relative risk).

RESULTS

The search returned 4981 articles, 580 articles addressed metformin or clomiphene citrate and four randomized controlled trials (RCTs) comparing metformin with clomiphene citrate were included. Upon meta-analysis of the four RCTs, we were unable to detect a statistically significant difference between the two interventions for any outcome in women with PCOS and a BMI < 32 kg/m2, owing to significant heterogeneity across the RCTs.

CONCLUSIONS

Owing to conflicting findings and heterogeneity across the included RCTs, there is insufficient evidence to establish a difference between metformin and clomiphene citrate in terms of ovulation, pregnancy, live birth, miscarriage and multiple pregnancy rates in women with PCOS and a BMI < 32 kg/m2. However, a lack of superiority of one treatment is not evidence for equivalence, and further methodologically rigorous trials are required to determine whether there is a difference in effectiveness between metformin and placebo (or no treatment) or between metformin and clomiphene citrate for ovulation induction in women with PCOS who are non-obese. Until then, caution should be exercised when prescribing metformin as first line pharmacological therapy in this group of women.

Source:
http://humupd.oxfordjournals.org/cgi/content/short/19/1/2?rss=1

Added value of ovarian reserve testing on patient characteristics in the prediction of ovarian response and ongoing pregnancy: an individual patient data approach

BACKGROUND

Although ovarian reserve tests (ORTs) are frequently used prior to IVF treatment for outcome prediction, their added predictive value is unclear. We assessed the added value of ORTs to patient characteristics in the prediction of IVF outcome.

METHODS

An individual patient data (IPD) meta-analysis from published studies was performed. Studies on FSH, anti-Müllerian hormone (AMH) or antral follicle count (AFC) in women undergoing IVF were identified and authors were contacted. Using random intercept logistic regression models, we estimated the added predictive value of ORTs for poor response and ongoing pregnancy after IVF, relative to patient characteristics.

RESULTS

We were able to collect 28 study databases, comprising 5705 women undergoing IVF. The area under the receiver-operating characteristic curve (AUC) for female age in predicting poor response was 0.61. AFC and AMH each significantly improved the model fit (P-value <0.001). Moreover, almost a similar accuracy was reached using AMH or AFC alone (AUC 0.78 and 0.76, respectively). Combining the two tests, however, did not improve prediction (AUC 0.80, P = 0.19) of poor response. In predicting ongoing pregnancy after IVF, age was the best single predictor (AUC 0.57), and none of the ORTs added any value.

CONCLUSIONS

This IPD meta-analysis demonstrates that AFC and AMH clearly add to age in predicting poor response. As single tests, AFC and AMH both fully cover the prediction of poor ovarian response. In contrast, none of the ORTs add any information to the limited capacity of female age to predict ongoing pregnancy after IVF. The clinical usefulness of ORTs prior to IVF will be limited to the prediction of ovarian response.

Source:
http://humupd.oxfordjournals.org/cgi/content/short/19/1/26?rss=1

A systematic review of sperm donors: demographic characteristics, attitudes, motives and experiences of the process of sperm donation

BACKGROUND

This systematic review aimed first to integrate the current body of knowledge on the demographic, institutional and psychosocial information on sperm donors, and second to provide insight into the actual experiences of men who donate and the attitudes towards potential donation.

METHODS

Electronic databases (PUBMED, CINAHL, PsycINFO, Embase and Web of Science) were searched with no date restriction using a specific search strategy followed by a snowball strategy. English language peer-reviewed abstracts and full texts were screened for eligibility and the risk of bias was assessed with 15 criteria. Eligibility, quality assessments and data extraction were performed by two independent researchers, resolving disagreement by discussion.

RESULTS

The initial search retrieved 857 studies and after quality assessment, 29 studies were retained for data extraction. Data from nine countries were obtained. The review synthesis revealed differences and similarities between actual and potential sperm donors on demographic characteristics, financial compensation and attitudes towards anonymity, disclosure and providing information to potential offspring. A number of methodological shortcomings have been identified in the studies investigating sperm donors.

CONCLUSIONS

Institutional factors (such as recruitment procedures, altruism versus compensation of sperm donors, anonymity versus open-identity donation) and the impact of changing legislation have largely dominated the studies on sperm donation. Furthermore, studies from countries with a bias towards white Western ideology and interpretation were over-represented. This has resulted in a profile of potential and actual sperm donors in terms of demographics, recruitment strategies, motivation for donation and attitudes regarding anonymity, disclosure, recipients and offspring. However, the psychosocial needs and experiences of the donor, and their follow-up and counselling are largely neglected. This review has identified key issues to inform current practice and the development of pathways of care for sperm donors that reflect the multidimensional nature of sperm donation.

Source:
http://humupd.oxfordjournals.org/cgi/content/short/19/1/37?rss=1

Culture of oocytes and risk of imprinting defects

BACKROUND

Follicle culture and oocyte in vitro maturation (IVM) are emerging assisted reproductive technologies with potentially important future applications in the fertility clinic. There is concern that these technologies might interfere at the epigenetic level and, in particular, with genomic imprinting. The timely acquisition of correct imprinting patterns in oocytes and the maintenance of genomic imprinting after fertilization are both required for normal embryonic development.

METHODS

A systematic literature search in Pubmed was performed and all publications reporting on the effects of follicle culture, IVM or ovarian tissue culture on genomic imprinting were retained.

RESULTS

Mouse ovarian tissue culture studies, mouse in vitro follicle culture studies and a single bovine IVM study generally showed correct imprinted DNA methylation establishment in oocytes. Influences of treatment and suboptimal culture conditions in mouse follicle culture indicate that imprinting establishment in oocytes is a robust process. This is in contrast with preimplantation embryo culture-induced epigenetic defects reported in mice. For human IVM, no definitive conclusion on imprinting establishment can be drawn as well-designed studies are currently not available.

CONCLUSIONS

Animal models provide reassuring data on imprinting establishment in cultured oocytes, but further studies should assess the effect of oocyte culture on imprinting maintenance. Optimized IVM procedures should be assessed in well-designed human studies. Finally, epigenetic analysis should be performed in children born from pregnancies after IVM to draw definitive conclusions on the epigenetic safety of human IVM.

Source:
http://humupd.oxfordjournals.org/cgi/content/short/19/1/52?rss=1

The ageing ovary and uterus: new biological insights

BACKGROUND

Advanced maternal age is associated with reduced fertility and adverse pregnancy outcomes. This review details recent developments in our understanding of the biology and mechanisms underlying reproductive ageing in women and the implications for fertility and pregnancy.

METHODS

Sociological online libraries (IBSS, SocINDEX), PubMed and Google Scholar were searched for relevant demographic, epidemiological, clinical and biological studies, using key words and hierarchical MeSH terms. From this, we identified and focused on key topics where it was judged that there had been clinically relevant advances in the understanding of ovarian and uterine ageing with implications for improved diagnostics and novel interventions.

RESULTS

Mapping of the ovarian reserve, follicular dynamics and associated biomarkers, across the reproductive lifespan has recently been performed. This now allows an assessment of the effects of environmental, lifestyle and prenatal exposures on follicular dynamics and the identification of their impact during periods of germ cell vulnerability and may also facilitate early identification of individuals with shorter reproductive lifespans. If women choose to time their family based on their ovarian reserve this would redefine the meaning of family planning. Despite recent reports of the potential existence of stem cells which may be used to restore the primordial follicle and thereby the oocyte pool, therapeutic interventions in female reproductive ageing at present remain limited. Maternal ageing has detrimental effects on decidual and placental development, which may be related to repeated exposure to sex steroids and underlie the association of ageing with adverse perinatal outcomes.

CONCLUSIONS

Ageing has incontrovertible detrimental effects on the ovary and the uterus. Our enhanced understanding of ovarian ageing will facilitate early identification of individuals at greatest risk, and novel therapeutic interventions. Changes in both ovary and uterus are in addition to age-related co-morbidities, which together have synergistic effects on reducing the probability of a successful pregnancy outcome.

Source:
http://humupd.oxfordjournals.org/cgi/content/short/19/1/67?rss=1

ARBS1 Commodification – Video


ARBS1 Commodification
Group Members: Harrison Hancock Natalie Hopkins Michael Jennings James Kent Ida Hallin Henriksen This video is educational purposes and is non-profitable. We believe that it agrees with YouTube #39;s policies and will not bring third parties into dispute. Sources: Adler, K. (2011, October 18). BBC News, Spain. Retrieved November 10, 2012 from BBC: http://www.bbc.co.uk Alinaqian, S. (2007, December 20). Blogspot. Retrieved November 15, 2012 from Culture and Communication: 3.bp.blogspot.com BrainyQuote. (2012). Tim Robbins. Retrieved November 15, 2012 from BrainyQuote: http://www.brainyquote.com Fox, D. Paying for Particulars in People-to-Be: Commercialisation, Commodification and Commensurability in Human Reproduction. Journal of Medical Ethics. Vol. 34, No. 3 (Mar., 2008) (pp. 162-166) Gylendal Norsk Forlag AS. (2012). Bi2 Grunnbok. Retrieved November 27, 2012 from Gylendal: web2.gyldendal.no Marxists.org. (2012). Archive. Retrieved November 10, 2012 from Marxists.org: http://www.marxists.org Occupy* Posters. (2011, November 1). The Evolution of the Commodification of Man. Retrieved November 15, 2012 from Flicker: farm7.staticflickr.com Red Commisar. (2010, August 18). Gramsci Group. Retrieved November 10, 2012 from RevLeft: http://www.revleft.com West, W. (2012, February 14). Remembering Antonio Gramsci. Retrieved November 27, 2012 from Liberation News: http://www.pslweb.orgFrom:Ida HallinViews:72 9ratingsTime:04:02More inNonprofits Activism

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ARBS1 Commodification - Video

Best practices of ASRM and ESHRE: a journey through reproductive medicine

BACKGROUND

The American Society for Reproductive Medicine (ASRM) and the European Society of Human Reproduction and Embryology (ESHRE) are the two largest societies in the world whose members comprise the major experts and professionals working in the field of reproductive medicine and embryology. These societies have never before had a joint scientific meeting.

METHODS

A 3-day meeting was planned and took place in March of 2012. The goal was to present and debate key topics, as well as modes of practice in reproductive medicine and to discuss recent developments in the field.

RESULTS

Presentations by members of ASRM and ESHRE were of three types: ‘state of the art’ lectures, ‘back-to-back’ presentations of two points of view and debates.

CONCLUSIONS

For the first time, ASRM and ESHRE held a joint meeting where a special emphasis was given to presentations on the hottest topics in the field. Although different opinions and approaches sometimes exist on the two sides of the Atlantic, an appreciation and acceptance of these differences was evident, and there was more commonality than divergence of opinion.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/27/12/3365?rss=1

Donor identification ‘kills gamete donation’? A response

Two Australian government inquiries have recently called for the release of information to donor-conceived people about their gamete donors. A national inquiry, recommended ‘as a matter of priority’ that uniform legislation to be passed nationwide. A state-based inquiry argued that all donor-conceived people should have access to information and called for the enactment of retrospective legislation that would override donor anonymity. This paper responds to an opinion piece published in Human Reproduction in October 2012 by Professor Pennings in which he criticized such recommendations and questioned the motives of people that advocate for information release. I answer the arguments of Pennings, and argue that all parties affected by donor conception should be considered, and a compromise reached. The contact veto system is one such compromise. I discuss the education and support services recommended by the Victorian government and question Pennings' assertions that legislation enabling information release will lead to a decrease in gamete donation. Finally, I rebut Pennings' assertion that there is a ‘hidden agenda’ behind the call for information release. There is no such agenda in my work. If there is from others, then it is their discriminatory views that need to be addressed, not the move toward openness and honesty or the call for information by donor-conceived people.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/27/12/3380?rss=1

Semen quality is influenced by androgen receptor and aromatase gene synergism

STUDY QUESTION

Does synergism between AR(CAG)n and CYP19(TTTA)n polymorphisms influence the quality of sperm?

SUMMARY ANSWER

AR(CAG)n and CYP19(TTTA)n polymorphisms had a synergistic effect on sperm concentration and motility.

WHAT IS KNOWN ALREADY

Androgens exert their action in the testicular tissue by binding to androgen receptor (AR), while their action is mediated by the aromatase P450 enzyme (CYP19). AR(CAG)n alleles are associated with sperm motility and CYP19(TTTA)n allelic variants have implications for sperm concentration and motility.

STUDY DESIGN, SIZE, DURATION

Two hundred oligozoospermic and 250 normozoospermic men who presented for infertility investigation were examined during a period of 2 years.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Conventional semen analysis was performed. DNA was extracted from spermatozoa and both polymorphisms were genotyped by polymerase chain reaction. Serum hormone levels were determined.

MAIN RESULTS AND THE ROLE OF CHANCE

Six combined genotypes were identified between the 18 AR(CAG)n alleles with 12–32 repeats and the 6 CYP19(TTTA)n alleles with 7–12 repeats. A gradual reduction in the sperm concentration (106/ml) and motility (%) from long AR allele–non-CYP19(TTTA)7 allele carriers to long AR alleleCYP19(TTTA)7 homozygotes and from short AR allele–non-CYP19(TTTA)7 carriers to short AR alleleCYP19(TTTA)7 homozygotes was observed in normozoospermic men (means ± SD; concentration: 93 ± 53.1 versus 65 ± 48.6 and 85 ± 60.1 versus 37 ± 17.2l, P < 0.002; motility: 63 ± 10.3 versus 55 ± 14.5 and 52 ± 19.6 versus 41 ± 13.7, P < 0.001, respectively). Similar associations were observed in oligozoospermic men (concentration: 10 ± 4.2 versus 9 ± 5.9 and 10 ± 6.3 versus 6 ± 3.1, P < 0.03; motility: 47 ± 17.1 versus 39 ± 6.2 and 39 ± 22 versus 27 ± 18.3, P < 0.003, respectively). The above associations of the combined genotypes with sperm concentration and motility were confirmed in the total study population (P < 0.006 and P < 0.001, respectively).

LIMITATIONS, REASONS FOR CAUTION

Our study population was limited to Greek Caucasian adult males, residents of Northwest Greece.

WIDER IMPLICATIONS OF THE FINDINGS

The confirmation of our findings in other populations would verify the significance of AR and CYP19 genes for spermatogenesis.

STUDY FUNDING/COMPETING INTERESTS

This study did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector. The authors declare no conflicts of interest.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/27/12/3385?rss=1

Semen apoptotic M540 body levels correlate with testis abnormalities: a study in a cohort of infertile subjects

STUDY QUESTION

What are the associations between semen apoptotic M540 bodies and other parameters of semen quality and sonographic alterations of the male genital tract in a cohort of infertile subjects?

SUMMARY ANSWER

In infertile subjects, semen M450 bodies are highly correlated with ultrasound and clinical signs of testis abnormalities but not with alterations of other parts of the male genital tract, suggesting a testicular origin of M540 bodies.

WHAT IS KNOWN ALREADY

We have reported the presence in semen of round anucleate elements, named ‘M540 bodies’, resembling apoptotic bodies as they contain several apoptotic markers.

STUDY DESIGN AND SIZE

A consecutive series of 130 males with couple infertility were evaluated, during the same day session, for clinical, scrotal and transrectal color-Doppler ultrasound characteristics, and hormonal and semen parameters, including interleukin 8 (sIL-8) and M540 body levels.

PARTICIPANTS/MATERIALS, SETTING METHODS

Semen parameters were analyzed by WHO recommended procedures. CDU was performed using the ultrasonographic console Hitachi H21. sIL-8 and serum hormones were evaluated by ELISA methods.

MAIN RESULTS AND THE ROLE OF CHANCE

The average percentage value of M540 bodies was 24.6 ± 18.3. After adjusting for possible confounders (age, waist, calculated free testosterone and smoking habit), M450 body levels negatively correlated with sperm number/ejaculate, progressive motility, normal morphology and sIL-8 levels (adj.r = –0.455, P < 0.0001; adj.r = –0.464, P < 0.0001; adj.r = –0.430, P < 0.001; adj.r = –0.236, P < 0.05, respectively). In a subset of patients with a history of cryptorchidism (n = 8), M540 bodies were higher than in non-cryptorchid men (40.5 ± 14.8 versus 23.6 ± 18.2%; P < 0.02). A negative correlation was found between M540 and ultrasound testis volume (adj.r = –0.241, P < 0.05), whereas a positive association was found with testis inhomogeneity [HR = 1.06 (1.02–1.09); P = 0.002], hypoechogenicity [HR = 1.05 (1.01–1.08); P < 0.02] and FSH levels (adj.r = 0.309, P < 0.01). No relationships were found with CDU characteristic of the prostate, seminal vesicles, epididymis and vas deferens. In a multivariate model, testis inhomogeneity and history of cryptorchidism were independently associated with M540 body levels (adj.r = 0.355, P < 0.01 and adj.r = 0.223, P < 0.05, respectively). Receiver operating characteristic analysis demonstrated that at the threshold of 27%, M540 bodies discriminate subjects with testis inhomogeneity with a sensitivity of 72% and specificity of 73%.

LIMITATIONS, REASONS FOR CAUTION

The increased M540 body semen levels in men with a history of cryptorchidism should be confirmed in a larger number of patients.

WIDER IMPLICATIONS OF THE FINDINGS

M540 bodies may be considered a semen marker of altered testis function and thus their evaluation may be helpful in the diagnosis of male infertility.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by grants from Ministry of University and Scientific Research (Prin project to E.B. and FIRB project to S.M.) and Regione Toscana (to G.F.).

Source:
http://humrep.oxfordjournals.org/cgi/content/short/27/12/3393?rss=1

Diagnostic delay for endometriosis in Austria and Germany: causes and possible consequences

STUDY QUESTION

What is the length of the diagnostic delay for endometriosis in Austria and Germany, and what are the reasons for the delay?

SUMMARY ANSWER

The diagnostic delay for endometriosis in Austria and Germany is surprisingly long, due to both medical and psychosocial reasons.

WHAT IS KNOWN ALREADY

Diagnostic delay of endometriosis is a problematic phenomenon which has been evaluated in several European countries and in the USA, but has not been reported for Germany and Austria.

STUDY DESIGN, SIZE, DURATION

A cross-sectional, questionnaire-based multicentre study was conducted in tertiary referral centers in Austria and Germany. From September 2010 to February 2012, 171 patients with histologically confirmed endometriosis were included.

PARTICIPANTS, SETTING, METHODS

Patients with a previous history of surgically proven endometriosis, internal diseases such as rheumatic disorders, pain symptoms of other origin, gynecological malignancy or post-menopausal status were excluded from the analysis. Patients with histologically confirmed endometriosis completed a questionnaire about their psychosocial and clinical characteristics and experiences. Of 173 patients, two did not provide informed consent and were excluded from the study.

MAIN RESULTS AND THE ROLE OF CHANCE

The median interval from the first onset of symptoms to diagnosis was 10.4 (SD: 7.9) years, and 74% of patients received at least one false diagnosis. Factors such as misdiagnosis, mothers considering menstruation as a negative event and normalization of dysmenorrhea by patients significantly prolonged the diagnostic delay. No association was found between either superficial and deep infiltrating endometriosis or oral contraceptive use and the prolongation of diagnosis.

LIMITATIONS AND REASONS FOR CAUTION

There was a possible selection bias due to inclusion of surgically treated patients only.

WIDER IMPLICATIONS OF THE FINDINGS

Several factors causing prolongation of diagnosis of endometriosis have been reported to date. The principal factors observed in the present study are false diagnosis and normalization of symptoms. Teaching programs for doctors and public awareness campaigns might reduce diagnostic delay in Central Europe.

STUDY FUNDING/COMPETING INTEREST(S)

No competing interests exist.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/27/12/3412?rss=1

Integrity of the blood-testis barrier in healthy men after suppression of spermatogenesis with testosterone and levonorgestrel

STUDY QUESTION

Do exogenous male hormonal contraceptives that suppress intratesticular testosterone and spermatogenesis interfere with the blood–testis barrier integrity in men?

SUMMARY ANSWER

When spermatogenesis was suppressed by testosterone alone or combined with levonorgestrel (LNG) treatment in men, the structural appearance of Sertoli cell tight junctions remained intact in the human testis.

WHAT IS ALREADY KNOWN

Testosterone promotes the integrity of the blood–testis barrier. Intratesticular androgen deprivation induced by exogenous testosterone plus a progestin to suppress spermatogenesis in a contraceptive regimen may disturb the structural and functional integrity of the blood–testis barrier.

STUDY DESIGN, SIZE AND DURATION

Testicular biopsies were obtained from a sub-study of a randomized clinical trial of 36 healthy Chinese men who were treated for 18 weeks and followed for at least a 12-week recovery period.

PARTICIPANTS/MATERIAL, SETTING, METHODS

Healthy Chinese male volunteers (27–48 years) were randomized to two treatment groups (n = 18/group) for 18 weeks: (1) testosterone undecanoate (TU) 1000 mg i.m. injection followed by a 500 mg injection every 6 weeks and (2) TU + LNG 250 μg orally daily. Blood samples were obtained from all participants before and during treatment and at the end of the recovery phase. Open testicular biopsies for this study were obtained from four men before treatment and from four men in each of the TU and TU + LNG groups at 2 and 9 weeks of treatment. The presence of antisperm antibodies was checked in the archived serum samples of the subjects at baseline, during treatment and at the end of the recovery period. Stored testicular biopsy samples from cynomolgus monkeys treated with either sub-cutaneous testosterone or placebo for 12 weeks were used for additional protein expression studies.

MAIN RESULTS AND ROLE OF THE CHANCE

Expression of blood–testis barrier associated proteins quantified by immunohistochemistry (claudin 3, claudin 11, junctional adhesion molecule-A, zonula occludens-1) remained unchanged despite a significant decrease in the numbers of pachytene spermatocytes and round spermatids in the seminiferous tubules at 9 weeks in the TU + LNG group. This was confirmed by immunoblots showing a lack of quantitative change in these tight junction proteins in monkeys after testosterone treatment. There were no increases in serum antisperm antibodies in the volunteers during the study.

LIMITATIONS/REASONS FOR CAUTION

The duration of the study was short and the long-term effects of male hormonal contraceptive treatments on the integrity of the blood–testis barrier remain to be determined.

WIDER IMPLICATIONS OF THE FINDINGS

This study supports the safety of male hormonal contraceptive treatment and does not corroborate the previous findings of disturbed immunological integrity of the blood–testis barrier from animal studies such as androgen receptor knockout mice and exogenous hormonal treatment in rats.

STUDY FUNDING/COMPETING INTEREST

The study was supported by grants from the Contraceptive Research and Development Program and the Mellon Foundation (MFG-02-64, MFG-03-67), Endocrine, Metabolism and Nutrition Training Grant (T32 DK007571), the Clinical and Translational Science Institute at Los Angeles Biomedical and Harbor-UCLA Medical Center (UL1RR033176 and UL1TR000124) and the Los Angeles Biomedical Research Institute Summer High School Student Program.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/27/12/3403?rss=1

MR-guided focus ultrasound (MRgFUS) for symptomatic uterine fibroids: predictors of treatment success

STUDY QUESTION

What are the factors associated with long-term success in patients with symptomatic uterine fibroids treated by magnetic resonance-guided focus ultrasound (MRgFUS) and can they be employed to create a clinically useful index that predicts long-term efficacy?

SUMMARY ANSWER

Hypo-intense fibroids on T2-weighted magnetic resonance imaging (MRI) and older age were associated with higher success rates and can be used to predict success rates on the basis of their presence or absence as pre-treatment parameters.

WHAT IS KNOWN ALREADY

The signal intensity of baseline T2-weighted MRI images and non-perfused volume at the end of the treatment can be correlated with MRgFUS outcome.

STUDY DESIGN, SIZE AND DURATION

This was a retrospective analysis of 81 patients who were treated by MRgFUS for symptomatic uterine fibroids, in an academic affiliated center between 2003 and 2008.

PARTICIPANTS/MATERIALS, SETTING AND METHODS

There was a post-treatment phone interview >6 months following MRgFUS for symptomatic uterine fibroids.

MAIN RESULTS AND THE ROLE OF CHANCE

The eighty-one patients completed a successful MRgFUS treatment during this period, of whom 74 were included in the final analysis (1 was post-menopausal at treatment and 5 were lost for follow-up). The mean time for the phone interview was 33.0 ± 15.1 months (range: 6–53 months) after the MRgFUS treatment. Fifty-five patients (69%) did not need any additional alternative treatment following MRgFUS. Nineteen patients (24%) underwent other surgical interventions. Hypo-intense fibroids were associated with a higher chance of success than hyper-intense fibroids [odds ratio = 2.96 (1.01–8.71); P = 0.04] for surgery in hyper-intense fibroids). Women with long-term treatment success were significantly older at the time of treatment [46.3 ± 3.8 (range: 37–53) years versus 43.6 ± 4.4 (range: 36–51) years, respectively; P = 0.02].

LIMITATIONS AND REASONS FOR CAUTION

Retrospective non-comparative studies are suboptimal and might overemphasize favorable outcomes.

WIDER IMPLICATIONS OF THE FINDINGS

This paper can contribute to selection of suitable candidates for the MRgFUS treatment for patients with uterine fibroids' and can serve as a guide for gynecologists for a better patient selection.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

N/A.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/27/12/3425?rss=1

How common is adenomyosis? A prospective study of prevalence using transvaginal ultrasound in a gynaecology clinic

STUDY QUESTION

What is the prevalence of adenomyosis in a population of women attending a general gynaecological clinic?

SUMMARY ANSWER

Adenomyosis was present in 206 of 985 [20.9%; 95% confidence interval (CI): 18.5–23.6%] women included in the study.

WHAT IS KNOWN ALREADY

Previous studies of occurrence of adenomyosis have been limited to women who underwent hysterectomy, which is likely to overestimate its prevalence compared with the general population of women. There are no large prospective studies on the prevalence of adenomyosis, either in the general population of women or in a general gynaecology clinic setting.

STUDY DESIGN, SIZE, DURATION

This was a prospective observational study set in the general gynaecology clinic of a university teaching hospital between January 2009 and January 2010.

PARTICIPANTS/MATERIALS, SETTING, METHODS

There were 985 consecutive women who attended the clinic and underwent structured clinical and transvaginal ultrasound examination in accordance with the study protocol. Morphological features of adenomyosis were systematically recorded with the ultrasound scan to determine its prevalence and factors which may affect its occurrence.

MAIN RESULTS AND THE ROLE OF CHANCE

Adenomyosis was present in 206/985 [20.9% (95% CI: 18.5–23.6%)] women included in the study. Multivariate analysis showed that the prevalence of adenomyosis was significantly associated with women's age, gravidity and pelvic endometriosis (P< 0.001). In women who subsequently underwent hysterectomy, there was a good level of agreement between the ultrasound and histological diagnosis of adenomyosis [ = 0.62 (P = 0.001), 95% CI (0.324, 0.912)].

LIMITATIONS, REASONS FOR CAUTION

Our estimate of prevalence of adenomyosis is likely to be higher than in the general population as we studied symptomatic women attending a gynaecology clinic.

WIDER IMPLICATIONS OF THE FINDINGS

Better estimates of the prevalence of adenomyosis can improve our understanding of the burden of the disease, help to identify women at high risk of developing the condition and facilitate the development of preventative strategies and effective treatment.

STUDY FUNDING/COMPETING INTEREST(S)

The authors have no competing interests to declare. The study was not supported by an external grant.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/27/12/3432?rss=1

Role of prostaglandin E2 in bacterial growth in women with endometriosis

STUDY QUESTION

Can prostaglandin E2 (PGE2) in menstrual and peritoneal fluid (PF) promote bacterial growth in women with endometriosis?

SUMMARY ANSWER

PGE2 promotes bacterial growth in women with endometriosis.

WHAT IS KNOWN ALREADY

Menstrual blood of women with endometriosis is highly contaminated with Escherichia coli (E. coli) compared with that of non-endometriotic women: E. coli-derived lipopolysaccharide (LPS) promotes the growth of endometriosis.

STUDY DESIGN, SIZE AND DURATION

Case-controlled biological research with a prospective collection of body fluids and endometrial tissues from women with and without endometriosis with retrospective evaluation.

PARTICIPANTS/MATERIALS, SETTING AND METHODS

PF and sera were collected from 58 women with endometriosis and 28 women without endometriosis in an academic research laboratory. Menstrual blood was collected from a proportion of these women. Macrophages (M) from PF and stromal cells from eutopic endometria were isolated in primary culture. The exogenous effect of PGE2 on the replication of E. coli was examined in a bacterial culture system. Levels of PGE2 in different body fluids and in the culture media of M and stromal cells were measured by ELISA. The effect of PGE2 on the growth of peripheral blood lymphocytes (PBLs) was examined.

MAIN RESULTS AND THE ROLE OF CHANCE

The PGE2 level was 2–3 times higher in the menstrual fluid (MF) than in either sera or in PF. A significantly higher level of PGE2 was found in the MF and PF of women with endometriosis than in control women (P < 0.05 for each). Exogenous treatment with PGE2 dose dependently increased E. coli colony formation when compared with non-treated bacteria. PGE2-enriched MF was able to stimulate the growth of E. coli in a dilution-dependent manner; this effect was more significantly enhanced in women with endometriosis than in control women (P < 0.05). PGE2 levels in the culture media of LPS-treated M/stromal cells were significantly higher in women with endometriosis than in non-endometriosis (P < 0.05 for each). Direct application of PGE2 and culture media derived from endometrial M or stromal cells significantly suppressed phytohemagglutinin-stimulated growth of PBLs.

LIMITATIONS AND REASONS FOR CAUTION

Further studies are needed to examine the association between PGE2-stimulated growth of E. coli and endotoxin level and to investigate the possible occurrence of sub-clinical infection within vaginal cavity.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings may provide some new insights to understand the physiopathology or pathogenesis of the mysterious disease endometriosis and may hold new therapeutic potential.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by grants-in-aid for Scientific Research from the Ministry of Education, Sports, Culture, Science and Technology of Japan. There is no conflict of interest related to this study.

TRIAL REGISTRATION NUMBER

Not applicable.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/27/12/3417?rss=1

Are digestive symptoms in women presenting with pelvic endometriosis specific to lesion localizations? A preliminary prospective study

STUDY QUESTION

What are the types and frequency of digestive symptoms in patients with different localizations of pelvic endometriosis and which specific symptoms are related to rectal stenosis?

SUMMARY ANSWER

There is a high prevalence of digestive complaints in women presenting with superficial pelvic endometriosis and deep endometriosis sparing the rectum.

WHAT IS KNOWN ALREADY

Women presenting with pelvic endometriosis frequently report gastrointestinal complaints of increased intensity during menstruation, which are not necessarily linked to the infiltration of the disease into the rectal wall. Even though intrarectal protrusion of the nodule can have an impact on bowel movement, only a minority of women with rectal nodules seemed to be concerned by significant narrowing of the rectum.

STUDY DESIGN AND SIZE

This three-arm cohort prospective study included 116 women and was carried out over 22 consecutive months.

PARTICIPANTS, SETTING AND METHODS

Prospective recording of data was performed for women treated for Stage 1 endometriosis involving the Douglas pouch (n = 21), deep endometriosis without digestive infiltration (n = 42) and deep endometriosis infiltrating the rectum (n = 53). Patient characteristics, pelvic pain and data from preoperative standardized questionnaires The Gastrointestinal Quality of Life Index (GIQLI), the Knowles-Eccersley-Scott-Symptom Questionnaire (KESS) and the MOS 36-Item Short-Form Health Survey (SF-36) were compared according to endometriosis localization.

MAIN RESULTS

The values of total KESS and total GIQLI score were comparable for the three groups, as were a majority of the digestive complaints. Women presenting with rectal endometriosis were more likely to report an increase in intensity and length of dysmenorrhoea, while deep dyspareunia appeared to be more severe in women with superficial endometriosis. Women presenting with rectal endometriosis were more likely to present cyclic defecation pain (67.9%), cyclic constipation (54.7%) and a significantly longer stool evacuation time, although these complaints were also frequent in the other two groups (38.1 and 33.3% in women with Stage 1 endometriosis and 42.9 and 26.2% in women with deep endometriosis without digestive involvement, respectively). No independent clinical factor was found to be related to infiltration of the rectum by deep endometriosis. Among women with rectal endometriosis, only 26.4% presented with rectal stenosis. These women were significantly more likely to report constipation, defecation pain, appetite disorders, longer evacuation time and increased stool consistency without laxatives.

LIMITATIONS

Patients treated for pelvic endometriosis in a tertiary referral centre may not be representative of the general endometriosis population presenting with those lesions. Statistically significant differences were revealed between the three groups; however, the results were based on a small number of subjects, which carries an inherent risk of type II error particularly when comparing variables with closed values.

WIDER IMPLICATIONS OF THE FINDINGS

In women presenting with pelvic endometriosis, it seems likely that various digestive symptoms are the consequence of cyclic inflammatory phenomena leading to irritation of the digestive tract, rather than to actual infiltration of the disease itself into the rectum, with the exception of a limited number of cases where the disease leads to rectal stenosis.

STUDY FUNDING/COMPETING INTEREST

The North-West Inter Regional Female Cohort for Patients with Endometriosis (CIRENDO) is financed by the G4 Group (The University Hospitals of Rouen, Lille, Amiens and Caen). No financial support was specifically received for this study. The authors declare no conflict of interest.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/27/12/3440?rss=1

Surgical versus medical treatment for endometriosis-associated severe deep dyspareunia: I. Effect on pain during intercourse and patient satisfaction

STUDY QUESTION

Does surgical or medical treatment for endometriosis-associated severe deep dyspareunia achieve better results in terms of patients' satisfaction (main study outcome), variation of coital pain and frequency of intercourse?

SUMMARY ANSWER

Surgery and progestin therapy were equally effective in the treatment of deep dyspareunia in women with rectovaginal endometriosis, whereas medical therapy performed significantly better than excisional treatment in those without deeply infiltrating lesions.

WHAT IS KNOWN AND WHAT THIS PAPER ADDS

Conservative surgery and hormonal therapies have been used independently for endometriosis-associated deep dyspareunia with inconsistent results. This study reports a direct comparison between the two treatment options in women with severe pain during intercourse.

DESIGN

Patient preference, parallel cohort study with a 12-month follow-up. The effect of conservative surgery at laparoscopy was compared with treatment with a low-dose of norethisterone acetate per os (2.5 mg/day) in women with persistent/recurrent severe deep dyspareunia after first-line surgery.

PARTICIPANTS AND SETTING

A total of 51 patients chose repeat surgery and 103 progestin treatment. Patient satisfaction was graded according to a five-category scale. Variations in pain during intercourse were measured by means of a 100-mm visual analogue scale.

MAIN RESULTS AND THE ROLE OF CHANCE

In the surgery group, a marked and rapid short-term dyspareunia score reduction was observed, followed by partial recurrence of pain. The pain relief effect of the progestin was more gradual, but progressive throughout the study period. At a 12-month follow-up, the frequency of intercourse per month (mean ± SD) was 4.6 ± 1.8 in the surgery group and 5.3 ± 1.5 in the norethisterone acetate group (P = 0.02). A total of 22/51 (43%) women were satisfied in the surgery group compared with 61/103 (59%) in the progestin group [adjusted odds ratios (OR), 0.36; 95% confidence interval (CI), 0.16–0.82; P = 0.015]. Corresponding figures in women with and without rectovaginal endometriotic lesions were, respectively, 13/24 (54%) versus 18/35 (51%; adjusted OR, 0.77; 95% CI, 0.22–2.67; P = 0.68), and 9/27 (33%) versus 43/68 (63%; adjusted OR, 0.23; 95% CI, 0.07–0.76, P = 0.02).

BIAS, CONFOUNDING, AND OTHER REASONS FOR CAUTION

Treatments were not randomly assigned, and distribution of participants as well as of dropouts between study arms was unbalanced. However, the possibility of choosing the treatment allowed assessment of the maximum potential effect size of the interventions.

GENERALIZABILITY TO OTHER POPULATIONS

Caucasian patients able to choose their treatment.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by a research grant from the University of Milan School of Medicine (PUR number 2009-ATE-0570). None of the authors have a conflict of interest.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/27/12/3450?rss=1

Methodological quality of systematic reviews in subfertility: a comparison of Cochrane and non-Cochrane systematic reviews in assisted reproductive technologies

STUDY QUESTION

Are there differences in the methodological quality of Cochrane systematic reviews (CRs) and non-Cochrane systematic reviews (NCRs) of assisted reproductive technologies?

SUMMARY ANSWER

CRs on assisted reproduction are of higher methodological quality than similar reviews published in other journals.

WHAT IS KNOWN ALREADY

The quality of systematic reviews varies.

STUDY DESIGN, SIZE AND DURATION

This was a cross-sectional study of 30 CR and 30 NCR systematic reviews that were randomly selected from the eligible reviews identified from a literature search for the years 2007–2011.

MATERIALS, SETTING AND METHODS

We extracted data on the reporting and methodological characteristics of the included systematic reviews. We assessed the methodological quality of the reviews using the 11-domain Measurement Tool to Assess the Methodological Quality of Systematic Reviews (AMSTAR) tool and subsequently compared CR and NCR systematic reviews.

MAIN RESULTS AND THE ROLE OF CHANCE

The AMSTAR quality assessment found that CRs were superior to NCRs. For 10 of 11 AMSTAR domains, the requirements were met in >50% of CRs, but only 4 of 11 domains showed requirements being met in >50% of NCRs. The strengths of CRs are the a priori study design, comprehensive literature search, explicit lists of included and excluded studies and assessments of internal validity. Significant failings in the CRs were found in duplicate study selection and data extraction (67% meeting requirements), assessment for publication bias (53% meeting requirements) and reporting of conflicts of interest (47% meeting requirements). NCRs were more likely to contain methodological weaknesses as the majority of the domains showed <40% of reviews meeting requirements, e.g. a priori study design (17%), duplicate study selection and data extraction (17%), assessment of study quality (27%), study quality in the formulation of conclusions (23%) and reporting of conflict of interests (10%).

LIMITATIONS, REASONS FOR CAUTION

The AMSTAR assessment can only judge what is reported by authors. Although two of the five authors are involved in the production of CRs, the risk of bias was reduced by not involving these authors in the assessment of the systematic review quality.

WIDER IMPLICATIONS OF THE FINDINGS

Not all systematic reviews are equal. The reader needs to consider the quality of the systematic review when they consider the results and the conclusions of a systematic review.

STUDY FUNDING/COMPETING INTEREST(S)

There are no conflicts with any commercial organization. Funding was provided for the students by the summer studentship programme of the Faculty of Medical and Health Sciences of the University of Auckland.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/27/12/3460?rss=1