- Email: [email protected]
AIH After Induction of Multiple Ovulation
for our scientific vitality. It is the hearty fare on which we all depend for our sustenance. I am sure the correspondents will agree. Paul G. McDonough, M.D., Editor, Letters
"proximal" to refer to the end nearer to the testis, while English writers 5 use it in the opposite sense, to refer to the end nearer the mid-point ofthe body. It would be preferable for writers to use instead the terms "testicular" and "prostatic" to refer to the severed ends of vas.
Open-Ended Vasectomy
Bruce B. Errey, M.B. Brisbane, Australia Ian S. Edwards, M.B. Cronulla Private Medical Clinic Cronulla, Australia June 6, 1987
To the Editor: We reported1 that, in 4330 open-ended vasectomies performed by one of us, the rate of recanalization was not increased when compared with 3867 standard vasectomies. We emphasized that closure of the sheath over the prostatic end of vas is essential if recanalization is to be prevented. We have now seen the report elsewhere of Temmerman et al., 2 who had a 3% rate of recanalization in 100 open-ended vasectomies, and who concluded that failure rates are always likely to be greater with open-ended techniques. As this conflicts with our experience, we make the following comments. The technique used by Temmerman et al. 2 may lend itself to recanalization for two reasons. A long section (10 mm) of the prostatic end of vas was not only cauterized, but was ligated. As has been pointed out by Schmidt, 3 the originator of cautery for vas closure, ligation of ducts that do not carry blood is likely to result in necrosis and sloughing. Ligation negates the benefits of vas cautery. Of perhaps more importance, the sheath was closed over the "proximal" (presumably testicular) end of vas. Instead of spermatozoa being dispersed into the scrotal tissues, as when the open testicular end of vas is left outside the sheath, such a technique could result in them being directed toward any defect in the closure of the sheath, and then along the sheath toward the prostatic end of vas. As long ago as 1924, Rolnick4 pointed out the role of the sheath as a splint in promoting spontaneous recanalization of the vas. It was this observation that led Schmidt3 to promote the technique of closure of the sheath over the prostatic end of vas. Unfortunately, this technique has become commonly known as "fascial interposition," with the implication that it does not matter which end of vas is closed over by suturing the sheath. It may not matter when both ends of vas are to be cauterized, but if the testicular end is to be left open, then it could be critically important to close the sheath over the prostatic end, and to leave the open testicular end outside the sheath. A source of confusion is the use of the terms "proximal" and "distal" to describe the ends of vas severed at vasectomy. American writers 3 use 380
Letters-to-the-editor
REFERENCES 1. Errey BB, Edwards IS: Open-ended vasectomy: an assessment. Fertil Steril 45:843, 1986 2. Temmerman M, Cammu H, Devroey P, Amy J-J: Evaluation of one-hundred open-ended vasectomies. Contraception 33:529, 1986 3. Schmidt SS: Prevention of failure in vasectomy. J Urol 109:296, 1973 4. Rolnick HC: Regeneration of the vas deferens. Arch Surg 9:188, 1924 5. Yeates WK: In Urology, Edited by Blandy. Oxford, Blackwell, 1976, p 1276
AIH After Induction of Multiple Ovulation
To the Editor: We wish to comment on an article recently published regarding pharmacologic induction of multiple follicular development in artificial insemination for male-related or unexplained infertility. In the article by Melis et al./ conclusions are drawn regarding the effectiveness of multiple follicular development in the treatment of male-related or unexplained infertility with whole semen insemination. Two main factors seem important in order to understand their success: the 17 patients who were included in the last group (multiple follicular development) might have been a highly selected group since 120 patients began the first series of inseminations and only a minority reached the last trial. The authors point out that these patients had a long history of infertility and that the spontaneous pregnancy rate would have been expected to be <1%. 2 The second factor that should be clarified is the definition of male subfertility; not everyone would agree that a sperm count between 20 and 40 X 106 /ml should be classified as oligospermic. They also talk about motility, but they do not specify that this is total motility or rapidly progressive motility, a fact that may help to analyze their results. Finally, the success rate of this pharFertility and Sterility
macologic trial needs further analysis since it is higher than in IVF-ET programs. 3 We have had experience treating normal ovulatory infertile women with human gonadotropins with a success rate of 71% and our preliminary results have been published elsewhere. 4 In summary, we believe that the results of Melis et al. respond to an improvement of folliculogenesis, looking at the high pregnancy rate achieved in patients with unexplained infertility; the definition of male sub fertility should be clarified. Edgardo Young, M.D. Raymond J. Oses, M.D. Instituto de Fertilidad Buenos Aires, Argentina September 8, 1987 REFERENCES 1. Melis GB, Paoletti AM, Strigini F, Menchini Fabris FM,
Canale D, Fioretti P: Pharmacologic induction of multiple follicular development improves the success rate of artificial insemination with husband's semen in couples with male· related or unexplained infertility. Fertil Steril 47:441, 1987 2. Aafjes JH, Vander Vijver JCM, Schenck PE: The duration of infertility: an important datum for the fertility prognosis of men with semen abnormalities. Fertil Steril 30:423, 1978. 3. Lopata A: Concepts in human in vitro fertilization and embryo transfer. Fertil Steril 40:289, 1983 4. YoungE, Gomez Rueda de Leverone N, Neuspiller N, Auge L, Vighi S, Marconi G, Foix A: El empleo de gonadotrofinas humanas en Ia paciente esteril ovuladora. Reproducci6n 1 1:4,1985
Reply of the Authors: We thank Drs. Young and Oses for their interest in our article. The criteria for inclusion of couples into the trial of induction of multiple follicular development (MFD) before artificial insemination with husband's semen (AIH) was mainly to minimize the possibility of treating independent pregnancies. Couples with a duration of infertility longer than 6 years have a very low incidence of spontaneous pregnancy. Moreover, all couples had failed to achieve pregnancy, despite different therapeutic attempts aimed to improve either male, female, or couple infertility. Although this selection limited the number of couples suitable for inclusion into the experimental protocol, we believed that it was important to establish the relationship between our treatment and the subsequent pregnancies. The definition of oligospermia has not yet been standardized. Many authors accept the definition of MacLeod and Gold, 1 who selected values lower Vol. 49, No.2, February 1988
than 20 X 106 /ml to define oligospermia. Accordingly, the World Health Organization (WH0) 2 reported that these values are commonly used, although it is preferable for each laboratory to establish its own normal range. Matthews et al. 3 set sperm concentrations higher than 50 X 106 /ml as a criterion for accepting semen samples for artificial insemination with donor semen, thus suggesting a possible reduction of male fertility for lower figures. The cut-off limit for oligozoospermia established in our laboratory (sperm concentration lower than 40 X 106 /ml) is derived from the study of a large population and takes into account the above data. However, we did not include isolated oligospermia among the causes of infertility in couples selected for induction of MFD before AIH. All couples with male-related infertility had alterations of both sperm density and motility. In particular, asthenospermia was defined as a percentage of rapidly progressive sperm lower than 30%. In fact, the range of rapidly progressive sperm in our patients was 10% to 30%. These figures are commonly accepted in the definition of asthenospermia and are similar to those recently suggested by WH0. 2 They are consistent with a reduction of male fertility, also supported by in vitro studies, demonstrating that the fertilizing capability of sperm is impaired by asthenospermia. 4 Conversely, studies now in progress in our department suggest that no pregnancy can be achieved with the above treatment in couples with sperm counts lower than 5 X 106 /ml and/or motility lower than 10%. Couples with similar values also have been excluded from in vitro fertilization -embryo transfer (IVFET) programs. 5 The pregnancy rate we reported is similar to that obtained by using IVF-ET for unexplained infertility and asthenospermia. It may seem higher because it is reported as pregnancy rate per patient, whereas studies on IVF-ET often report pregnancy rates per cycle. In fact, we repeated the treatment for six cycles in each couple, unless pregnancy was achieved, whereas IVF-ET is not usually repeated many times. The pregnancy rate obtained by Young and Oses seems to confirm our results. Their success rate, slightly higher than ours, might possibly depend on the inclusion in the trial of couples with a duration of infertility less than 6 years. It already has been reported that the chance of conception seems inversely related to the duration of infertility. In fact, we believe that the availability of multiple fertilizable oocytes, in addition to the improvement of oogenesis and the modified endocrine conditions, might increase the chance of conLetters-to-the-editor
381
ception in each cycle. Finally, we have been treating many other couples with male-related or unexplained infertility by means of induction of MFD before AIH, and the results (pregnancy rate per patient = 55.9%) are consistent with those we already reported. Gian Benedetto Melis, M.D. Francesca Strigini, M.D. Anna Maria Paoletti, M.D. Piero Fioretti, M.D. Department of Obstetrics and Gynecology University of Pisa Pisa, Italy October 20, 1987 REFERENCES 1. MacLeod J, Gold RZ: The male factor in fertility and infertility. II. Spermatozoon counts in 1000 cases of known fertility and 1000 cases of infertile marriage. J Urol 66:436, 1951. 2. World Health Organization: WHO Laboratory Manual for the Examination of Human Semen and Semen-Cervical Mucus Interaction. Cambridge, Cambridge University Press, 1987 3. Matthews CD, Ford JH, Peek JC, McEvoy M: Screening of karyotype and semen quality in an artificial insemination program: acceptance and rejection criteria. Fertil Steril 40:648, 1983 4. Testart J, Lassalle B, Frydman R, Belaisch JC: A study of factors affecting the success of human fertilization in vitro. II. Influence of semen quality and oocyte maturity on fertilization and cleavage. Biol Reprod 28:425, 1983 5. Sher G, Knutzen V, Stratton CJ, Montakhab MM, Allenson SG, Mayville J, Rubenstein JA, Glass MJ, Bilach SM: The development of a successful non-university-based ambulatory in vitro fertilization/embryo transfer program: phase I Fertil Steril 41:511, 1984
To the Editor:
RE: Kremer J, Dijkhuis JRH, Jager S: A simplified method for freezing and storage of human semen. Fertil Steril 47:838, 1987 In the Materials and Methods section, the quantities ofNaHC03 should be 30.95 mM and not 3095 mM as written. Jan Kremer, M.D. J. Ritva H. Dijkhuis, M.D. Siemen Jager, Ph.D. Fertility Unit of the Department of Obstetrics and Gynaecology University Hospital Groningen, The Netherlands Received November 19, 1987
To the Editor:
RE: Trounson A, Peura A, Kirby C: Ultrarapid freezing: a new low-cost and effective method of embryo cryopreservation. Fertil Steril 48:843, 1987 On page 844 it should read: 0.1324 gm CaCl2 • 2H2 0 not mg as printed. Alan Trounson, Ph.D. Centre for Early Human Development Monash Medical Centre Clayton, Victoria, Australia December 8, 1987
Errata
To the Editor:
To the Editor:
RE: Bateman BG, Nunley WC Jr, Kitchin JD III: Surgical management of distal tube obstruction-are we making progress? Fertil Steril 48:523, 1987
RE: Garcia AJ, Aubert JM, Sarna J, J osimovich JB: Expectant management of presumed ectopic pregnancies. Fertil Steril 48:395, 1987
We wish to acknowledge Drs. S. A. Halbert and D. L. Patton for the contribution of Figure 1 which appeared in the above article.
On page 396, 1st column, line 6, the phrase ". larger than 4 em" should read instead ". . . smaller than 4 em."
Bruce G. Bateman, M.D. Department of Obstetrics and Gynecology University of Virginia School of Medicine Charlottesville, Virginia October 14, 1987
Alfredo J. Garcia, M.D. Department of Obstetrics and Gynecology University of Medicine and Dentistry of New Jersey Newark, New Jersey 07103-2757 December 14, 1987
382
Letters-to-the-editor
Fertility and Sterility
"proximal" to refer to the end nearer to the testis, while English writers 5 use it in the opposite sense, to refer to the end nearer the mid-point ofthe body. It would be preferable for writers to use instead the terms "testicular" and "prostatic" to refer to the severed ends of vas.
Open-Ended Vasectomy
Bruce B. Errey, M.B. Brisbane, Australia Ian S. Edwards, M.B. Cronulla Private Medical Clinic Cronulla, Australia June 6, 1987
To the Editor: We reported1 that, in 4330 open-ended vasectomies performed by one of us, the rate of recanalization was not increased when compared with 3867 standard vasectomies. We emphasized that closure of the sheath over the prostatic end of vas is essential if recanalization is to be prevented. We have now seen the report elsewhere of Temmerman et al., 2 who had a 3% rate of recanalization in 100 open-ended vasectomies, and who concluded that failure rates are always likely to be greater with open-ended techniques. As this conflicts with our experience, we make the following comments. The technique used by Temmerman et al. 2 may lend itself to recanalization for two reasons. A long section (10 mm) of the prostatic end of vas was not only cauterized, but was ligated. As has been pointed out by Schmidt, 3 the originator of cautery for vas closure, ligation of ducts that do not carry blood is likely to result in necrosis and sloughing. Ligation negates the benefits of vas cautery. Of perhaps more importance, the sheath was closed over the "proximal" (presumably testicular) end of vas. Instead of spermatozoa being dispersed into the scrotal tissues, as when the open testicular end of vas is left outside the sheath, such a technique could result in them being directed toward any defect in the closure of the sheath, and then along the sheath toward the prostatic end of vas. As long ago as 1924, Rolnick4 pointed out the role of the sheath as a splint in promoting spontaneous recanalization of the vas. It was this observation that led Schmidt3 to promote the technique of closure of the sheath over the prostatic end of vas. Unfortunately, this technique has become commonly known as "fascial interposition," with the implication that it does not matter which end of vas is closed over by suturing the sheath. It may not matter when both ends of vas are to be cauterized, but if the testicular end is to be left open, then it could be critically important to close the sheath over the prostatic end, and to leave the open testicular end outside the sheath. A source of confusion is the use of the terms "proximal" and "distal" to describe the ends of vas severed at vasectomy. American writers 3 use 380
Letters-to-the-editor
REFERENCES 1. Errey BB, Edwards IS: Open-ended vasectomy: an assessment. Fertil Steril 45:843, 1986 2. Temmerman M, Cammu H, Devroey P, Amy J-J: Evaluation of one-hundred open-ended vasectomies. Contraception 33:529, 1986 3. Schmidt SS: Prevention of failure in vasectomy. J Urol 109:296, 1973 4. Rolnick HC: Regeneration of the vas deferens. Arch Surg 9:188, 1924 5. Yeates WK: In Urology, Edited by Blandy. Oxford, Blackwell, 1976, p 1276
AIH After Induction of Multiple Ovulation
To the Editor: We wish to comment on an article recently published regarding pharmacologic induction of multiple follicular development in artificial insemination for male-related or unexplained infertility. In the article by Melis et al./ conclusions are drawn regarding the effectiveness of multiple follicular development in the treatment of male-related or unexplained infertility with whole semen insemination. Two main factors seem important in order to understand their success: the 17 patients who were included in the last group (multiple follicular development) might have been a highly selected group since 120 patients began the first series of inseminations and only a minority reached the last trial. The authors point out that these patients had a long history of infertility and that the spontaneous pregnancy rate would have been expected to be <1%. 2 The second factor that should be clarified is the definition of male subfertility; not everyone would agree that a sperm count between 20 and 40 X 106 /ml should be classified as oligospermic. They also talk about motility, but they do not specify that this is total motility or rapidly progressive motility, a fact that may help to analyze their results. Finally, the success rate of this pharFertility and Sterility
macologic trial needs further analysis since it is higher than in IVF-ET programs. 3 We have had experience treating normal ovulatory infertile women with human gonadotropins with a success rate of 71% and our preliminary results have been published elsewhere. 4 In summary, we believe that the results of Melis et al. respond to an improvement of folliculogenesis, looking at the high pregnancy rate achieved in patients with unexplained infertility; the definition of male sub fertility should be clarified. Edgardo Young, M.D. Raymond J. Oses, M.D. Instituto de Fertilidad Buenos Aires, Argentina September 8, 1987 REFERENCES 1. Melis GB, Paoletti AM, Strigini F, Menchini Fabris FM,
Canale D, Fioretti P: Pharmacologic induction of multiple follicular development improves the success rate of artificial insemination with husband's semen in couples with male· related or unexplained infertility. Fertil Steril 47:441, 1987 2. Aafjes JH, Vander Vijver JCM, Schenck PE: The duration of infertility: an important datum for the fertility prognosis of men with semen abnormalities. Fertil Steril 30:423, 1978. 3. Lopata A: Concepts in human in vitro fertilization and embryo transfer. Fertil Steril 40:289, 1983 4. YoungE, Gomez Rueda de Leverone N, Neuspiller N, Auge L, Vighi S, Marconi G, Foix A: El empleo de gonadotrofinas humanas en Ia paciente esteril ovuladora. Reproducci6n 1 1:4,1985
Reply of the Authors: We thank Drs. Young and Oses for their interest in our article. The criteria for inclusion of couples into the trial of induction of multiple follicular development (MFD) before artificial insemination with husband's semen (AIH) was mainly to minimize the possibility of treating independent pregnancies. Couples with a duration of infertility longer than 6 years have a very low incidence of spontaneous pregnancy. Moreover, all couples had failed to achieve pregnancy, despite different therapeutic attempts aimed to improve either male, female, or couple infertility. Although this selection limited the number of couples suitable for inclusion into the experimental protocol, we believed that it was important to establish the relationship between our treatment and the subsequent pregnancies. The definition of oligospermia has not yet been standardized. Many authors accept the definition of MacLeod and Gold, 1 who selected values lower Vol. 49, No.2, February 1988
than 20 X 106 /ml to define oligospermia. Accordingly, the World Health Organization (WH0) 2 reported that these values are commonly used, although it is preferable for each laboratory to establish its own normal range. Matthews et al. 3 set sperm concentrations higher than 50 X 106 /ml as a criterion for accepting semen samples for artificial insemination with donor semen, thus suggesting a possible reduction of male fertility for lower figures. The cut-off limit for oligozoospermia established in our laboratory (sperm concentration lower than 40 X 106 /ml) is derived from the study of a large population and takes into account the above data. However, we did not include isolated oligospermia among the causes of infertility in couples selected for induction of MFD before AIH. All couples with male-related infertility had alterations of both sperm density and motility. In particular, asthenospermia was defined as a percentage of rapidly progressive sperm lower than 30%. In fact, the range of rapidly progressive sperm in our patients was 10% to 30%. These figures are commonly accepted in the definition of asthenospermia and are similar to those recently suggested by WH0. 2 They are consistent with a reduction of male fertility, also supported by in vitro studies, demonstrating that the fertilizing capability of sperm is impaired by asthenospermia. 4 Conversely, studies now in progress in our department suggest that no pregnancy can be achieved with the above treatment in couples with sperm counts lower than 5 X 106 /ml and/or motility lower than 10%. Couples with similar values also have been excluded from in vitro fertilization -embryo transfer (IVFET) programs. 5 The pregnancy rate we reported is similar to that obtained by using IVF-ET for unexplained infertility and asthenospermia. It may seem higher because it is reported as pregnancy rate per patient, whereas studies on IVF-ET often report pregnancy rates per cycle. In fact, we repeated the treatment for six cycles in each couple, unless pregnancy was achieved, whereas IVF-ET is not usually repeated many times. The pregnancy rate obtained by Young and Oses seems to confirm our results. Their success rate, slightly higher than ours, might possibly depend on the inclusion in the trial of couples with a duration of infertility less than 6 years. It already has been reported that the chance of conception seems inversely related to the duration of infertility. In fact, we believe that the availability of multiple fertilizable oocytes, in addition to the improvement of oogenesis and the modified endocrine conditions, might increase the chance of conLetters-to-the-editor
381
ception in each cycle. Finally, we have been treating many other couples with male-related or unexplained infertility by means of induction of MFD before AIH, and the results (pregnancy rate per patient = 55.9%) are consistent with those we already reported. Gian Benedetto Melis, M.D. Francesca Strigini, M.D. Anna Maria Paoletti, M.D. Piero Fioretti, M.D. Department of Obstetrics and Gynecology University of Pisa Pisa, Italy October 20, 1987 REFERENCES 1. MacLeod J, Gold RZ: The male factor in fertility and infertility. II. Spermatozoon counts in 1000 cases of known fertility and 1000 cases of infertile marriage. J Urol 66:436, 1951. 2. World Health Organization: WHO Laboratory Manual for the Examination of Human Semen and Semen-Cervical Mucus Interaction. Cambridge, Cambridge University Press, 1987 3. Matthews CD, Ford JH, Peek JC, McEvoy M: Screening of karyotype and semen quality in an artificial insemination program: acceptance and rejection criteria. Fertil Steril 40:648, 1983 4. Testart J, Lassalle B, Frydman R, Belaisch JC: A study of factors affecting the success of human fertilization in vitro. II. Influence of semen quality and oocyte maturity on fertilization and cleavage. Biol Reprod 28:425, 1983 5. Sher G, Knutzen V, Stratton CJ, Montakhab MM, Allenson SG, Mayville J, Rubenstein JA, Glass MJ, Bilach SM: The development of a successful non-university-based ambulatory in vitro fertilization/embryo transfer program: phase I Fertil Steril 41:511, 1984
To the Editor:
RE: Kremer J, Dijkhuis JRH, Jager S: A simplified method for freezing and storage of human semen. Fertil Steril 47:838, 1987 In the Materials and Methods section, the quantities ofNaHC03 should be 30.95 mM and not 3095 mM as written. Jan Kremer, M.D. J. Ritva H. Dijkhuis, M.D. Siemen Jager, Ph.D. Fertility Unit of the Department of Obstetrics and Gynaecology University Hospital Groningen, The Netherlands Received November 19, 1987
To the Editor:
RE: Trounson A, Peura A, Kirby C: Ultrarapid freezing: a new low-cost and effective method of embryo cryopreservation. Fertil Steril 48:843, 1987 On page 844 it should read: 0.1324 gm CaCl2 • 2H2 0 not mg as printed. Alan Trounson, Ph.D. Centre for Early Human Development Monash Medical Centre Clayton, Victoria, Australia December 8, 1987
Errata
To the Editor:
To the Editor:
RE: Bateman BG, Nunley WC Jr, Kitchin JD III: Surgical management of distal tube obstruction-are we making progress? Fertil Steril 48:523, 1987
RE: Garcia AJ, Aubert JM, Sarna J, J osimovich JB: Expectant management of presumed ectopic pregnancies. Fertil Steril 48:395, 1987
We wish to acknowledge Drs. S. A. Halbert and D. L. Patton for the contribution of Figure 1 which appeared in the above article.
On page 396, 1st column, line 6, the phrase ". larger than 4 em" should read instead ". . . smaller than 4 em."
Bruce G. Bateman, M.D. Department of Obstetrics and Gynecology University of Virginia School of Medicine Charlottesville, Virginia October 14, 1987
Alfredo J. Garcia, M.D. Department of Obstetrics and Gynecology University of Medicine and Dentistry of New Jersey Newark, New Jersey 07103-2757 December 14, 1987
382
Letters-to-the-editor
Fertility and Sterility