Newsletter

Table of Contents

15.09.2001

Newsletter No.11

Uterine artery immobilisation (UAE) for uterine fibroids.
Endometriosis: Implantation is not impaired
All infertile males should undergo urologic evaluation before assisted reproductive technologies
Effect of insemination/injection time on the results of IVF and ICSI.

1. Uterine artery immobilisation for uterine fibroids (UAE)

Transcatheter bilateral uterine artery immobilisation represents a fundamentally new approach to the treatment of fibroids. Immobilisation is a minimally invasive means of blocking the arteries that supply blood to the fibroids. It is a procedure that uses angiographic techniques to place a catheter into the uterine arteries. Small particles (polyvinyl alcohol) are injected into the arteries, which results in their blockage. The procedure was first used in fibroid patients in France as a means of decreasing the blood loss that occurs during myomectomy. It was discovered that after the immobilisation, while awaiting surgery, many patient's symptoms went away and surgery was no longer needed. The blockage of the blood supply caused shrinkage of the fibroids resulting in resolution of their symptoms. UAE is a fast increasing modality and is offered as an alternative to surgery for the treatment of symptomatic uterine fibroids. Since its introduction in 1995, it is estimated that over 5000 procedures have been performed, despite little objective evidence of its efficacy in comparison with more traditional surgical procedures, e.g. hysterectomy, abdominal or laparoscopic myomectomy or hysteroscopic procedures. The enthusiastic uptake of uterine artery immobilisation is partly due to the fact that it can be performed as a day case, and is a means of avoiding surgery especially hysterectomy. In a recent report heavy menstrual bleeding as a symptom of uterine fibroids improved in 87% of patients at 3 months and in 90% at 1 year after therapy. Bulk symptoms improved in 93% of patients at 3 months and in 91% at 1 year after treatment. However, the procedure is not without significant risks, and these are becoming clearer as more procedures are being reported. The postembolisation syndrome resulting from ischemia of large masses may result in fever, nausea and malaise. Complete recovery from the syndrome may take up to three weeks. Perimenopausal women might suffer from transient or permanent hypergonadotropic ovarian failure. The most serious complication is septicaemia resulting from inflammation that cannot be controlled due to local ischemia. Deaths have been reported. Postembolisation hysterectomy is necessary in up to five percent of the cases. Although uneventful pregnancies have been reported following UAE this procedure should not be performed in infertility patients and women that still wish to become pregnant. Presently, a vast amount of information is being gathered concerning the procedure, its results and potential hazards that will result in the establishment of criteria concerning the indications of that new procedure and its place within the spectre of different modalities.

Spies JB (Internet) Uterine artery immobilisation procedure

Ravina JH, Herbreteau D, Ciraru-Vigneron N, Bouret JM, Houdart E, Aymard A, Merland JJ (1995) Arterial embolisation to treat uterine myomata. Lancet. Sep 9;346(8976):671-2.

Goodwin SC, Wong GC. (2001) Uterine artery embolization for uterine fibroids: a radiologist's perspective. Clin Obstet Gynecol. 44: 412-24. No abstract available

Braude P, Reidy J, Nott V, Taylor A, Forman R. (2000) Embolization of uterine leiomyomata: current concepts in management. Hum Reprod Update.6: 603-8. Review.

Spies JB, Ascher SA, Roth AR, Kim J, Levy EB, Gomez-Jorge J (2001) Uterine artery embolization for leiomyomata. Obstet Gynecol. 98:29-34

2. Endometrial receptivity in is not impaired in women with endometriosis

A retrospective analysis of in-vitro fertilization (IVF) and oocyte donation programmes was carried out in order to gain clinical knowledge of the factors involved in the aetiology of the endometriosis-associated infertility. Comparison between the IVF outcomes from 96 cycles in 78 patients with tubal infertility and from 96 cycles in 59 women with endometriosis indicates that endometriosis patients have a poor IVF outcome in terms of reduced pregnancy rate per cycle, reduced pregnancy rate per transfer, and reduced implantation rate. The analysis of patients undergoing oocyte donation for different reasons, including low response with or without endometriosis, showed that patients with this disease have the same chances of implantation and pregnancy as other recipients when the oocytes came from donors without known endometriosis. However, when the results of oocyte donation were classified according to the origin of the oocytes donated, patients who received embryos derived from endometriotic ovaries showed a significantly reduced implantation rate as compared to the remaining groups. Taken together, all these observations suggest that infertility in endometriosis patients may be related to alterations within the oocyte, which in turn result in embryos with decreased ability to implant. In a recent study of the same group it could be shown that pinopode expression in women with endometriosis did not differ from that of patients without endometriosis undergoing artificial cycles. Similarly, the clinical outcome in these women was comparable to that of the general population included in the oocyte donation program. The results showed that the endometrial receptivity in women with endometriosis remains unaltered.

Simon C, Gutierrez A, Vidal A, de los Santos MJ, Tarin JJ, Remohi J, Pellicer A. (1994) Outcome of patients with endometriosis in assisted reproduction: results from in-vitro fertilization and oocyte donation. Hum Reprod. 9: 725-729.

Garcia-Velasco JA, Nikas G, Remohi J, Pellicer A, Simon C (2001) Endometrial receptivity in terms of pinopode expression is not impaired in women with endometriosis in artificially prepared cycles. Fertil Steril. 75: 1231-1233.

3. All infertile males should undergo urologic evaluation before assisted reproductive technologies.

Two cases of testicular cancer in patients presenting with infertility are reported. The authors stress the point that low sperm count in men should be regarded as a potential symptom for underlying severe disease such as testicular cancer. They suggest that a thorough evaluation should be completed not only in males with low sperm count but rather in all males in couples presenting with infertility.

Simon SD, Lee RD, Mulhall JP (2001) Should all infertile males undergo urologic evaluation before assisted reproductive technologies? Two cases of testicular cancer presenting with infertility. Fertil Steril. 75:1226-7.

4. Effect of insemination/injection time on the results of IVF and ICSI

The aim of this study was to investigate whether a pre-incubation time between oocyte retrieval and insemination or injection had any effect on the success rate of IVF or intracytoplasmic sperm injection (ICSI). Based on previously published data, many laboratories retain a time interval of several hours between oocyte retrieval and insemination/injection. In the setting of the authors, insemination and injection times are dependent only on the laboratory workload. Totals of 881 IVF and 432 ICSI cycles performed between 1997 and 1999 were analysed retrospectively. Oocyte retrieval occurred 36 h after human chorionic gonadotrophin administration, and insemination or injection took place 1-7 or 0.5-8 h after oocyte retrieval respectively. No statistically significant differences were found between these time periods and outcome of IVF and ICSI with respect to fertilization rate, embryo quality, implantation rate, abortion and ongoing pregnancy rates, except for the abortion rate after IVF. As this finding may be due to chance and no differences were found in the ongoing pregnancy rates, this finding was considered to be of less importance. It is concluded, if laboratory control and efficiency demands early insemination or injection, it could be performed without reservation.

Jacobs M, Stolwijk AM, Wetzels AM (2001) The effect of insemination/injection time on the results of IVF and ICSI. Hum Reprod. 16:1708-1713

Gerhard Leyendecker