- Email: [email protected]
DIRECT INTRAPERTTONEAL INSEMINATION: FIRST RESULTS CONFIRMED
1468 The system described is a development of those of Khalil and Mac Keith3and Ledingham et al.4 It requires no specially trained personnel, it achieves central rewarming (as evidenced by the close relation between rectal and tympanic temperatures), and the precautions against overheating and water leakage make the system safe. Department of Anaesthesia, Hospital, University of Copenhagen,
Herlev
DK-2730 Herlev, Denmark
GERT KRISTENSEN NIELS ERIK DRENCK HENRIK JORDENING
1. Kristensen G, Gravesen H, Benveniste D, Jordening H. An oesophageal thermal tube
for rewarming in hypothermia. Acta Anaesthesiol Scand 1985; 29: 846-48. 2. Kristensen G, Guldager H. Gravesen H. Prevention of peroperative hypothermia in abdominal surgery. Acta Anaesthesiol Scand 1986; 30: 314-16. 3. Khalil HH, Mac Keith RC. A simple method of raising and lowering body temperature. Br Med J 1954; ii: 734-36. 4. Ledingham IMcA, Routh GS, Douglas IHS, et al. Central rewarming system for treatment of hypothermia. Lancet 1980; i: 1168-69.
DIRECT INTRAPERTTONEAL INSEMINATION: FIRST RESULTS CONFIRMED
SIR,—That direct intraperitoneal insemination (DIPI) might be alternative to gamete intrafallopian transfer (GIFT) or intrauterine insemination in cases of unexplained or cervical . infertility was proposed by some of us in a previous letter to The Lancet, which summarised the indications and technique and gave an
first results.1 These results have now been confirmed in 56 cycles in 40 patients. 8 pregnancies have been achieved (4 singletons, 3 twin pregnancies,1 first trimester abortion). 5 patients so far have been delivered of healthy babies. These patients were all considered "desperate cases" and the mean duration of their infertility was 6-5 years (range 4-9). The average was 32 (range 28-33). All had been treated by at least three different medical teams before being referred to our department. Investigations, including salpingography, diagnostic laparoscopy, and hormone assays, had been done and considered normal. Cervical mucus had been repeatedly examined and sperm-mucus interaction had been tested both in vivo and in vitro. However, penetration of sperm to the pouch of Douglas, as suggested by Templeton and Mortimerwas not studied. Antibodies against husband’s sperm were not detected. After extensive work-up, the infertility was ascribed predominantly to poor cervical mucus penetration by the husband’s sperm. Sperm, at three or more examinations, was consistently suboptimal with normal counts, but the initial rate of motility (below 45%) dropped rapidly (5-35%) at 3 h and the frequency of normal morphology was usually below 40%. Several treatments, including superovulation with human menopausal gonadotropins and/or clomiphene with close supervision of hormone levels, follicle growth, and cervical mucus, had been attempted without success, and more complex procedures such as in-vitro fertilisation (IVF) or GIFT were being considered. 1 patient had already completed ten IVF cycles. The DIPI protocol’ was adhered to. Ovulation was induced and insemination was done 35 h after human chorionic gonadotropin. Sexual activity in the days before and after insemination was prohibited so that any resulting pregnancy could be attributed to the treatment. 0 6-18 million sperm were deposited in the peritoneal fluid of the pouch of Douglas. The sole modification in the second series was control of follicular rupture by ultrasound 24 h post-insemination. In the absence of follicle rupture DIPI was repeated. No complications have been registered. A 14 % pregnancy rate per treatment cycle is good for patients of this type.3 An explanation for the failures is equally important, and may be had from a close comparison of the histories of successful and unsuccessful cases. We have not so far been successful in women over 37 years of age or in women with uncorrected major ovulatory dysfunction. Some patients were accepted into the programme because several donor insemination attempts had failed. These women were considered normal but we have had no successes-perhaps because of insufficient capacitated motile sperm (the use of fresh donor sperm might alleviate this). No successes were achieved when the husband’s sperm was very poor; our
treatment
500 000 motile capacitated sperm or more seem to be needed. Nor any pregnancies achieved when sperm did not survive in the woman’s peritoneal fluid for at least 24 h, when tested in vitro in a previous cycle. Patients with a negative test might fare better with IVF. Further studies on this peritoneal fluid motility test are now under consideration, and these may explain some of the failures. Our experience with DIPI is encouraging and a controlled study now seems warranted. Simple as the method seems, it should be reserved for difficult cases with cervical infertility or male subfertility and for some cases of unexplained infertility. were
Obstetrics and Gynaecology Service, Centre Médico-Chirurgical et Obstetrical de la Sécurité Sociale, 67300 Schiltigheim, France
A. FORRLER E. BADOC L. MOREAU P. DELLENBACH
Embryology Laboratory, Faculty of Medicine, Strasbourg
CL. CRANZ A. CLAVERT Y. RUMPLER
1. Forrler A, Dellenbach P, Nisand I, Moreau L. Direct intraperitoneal insemination in unexplained and cervical infertility. Lancet 1986; i: 916. 2. Templeton AA, Mortimer RD. The development of a clinical test of sperm migration to the site of fertilization. Fertil Steril 1982; 3: 410-15. 3. Kerin JFP, Kirby C, Peek J, et al. Improved conception rate after intrauterine insemination of washed spermatozoa from men with poor quality semen. Lancet 1984; i: 533.
BORDERLINE ANTIBODY RESPONSE IN INITIAL STAGES OF LYMPHOCYTIC MENINGITIS DOES NOT RULE OUT BORRELIOSIS
SIR,-In June, 1986, we examined a 10-year-old boy with a 1-week history of a stiff neck and tingling of both hypothenars. There was no history of fever, erythema migrans, or known tick bite. The cerebrospinal fluid (CSF) contained 141 leucocytes/µl (predominantly mononuclear cells) and protein 38-4 mg/dl. Besides routine bacteriological and virological tests, 1 ml CSF was inoculated into 11 ml of BSKII medium.1 This procedure is routine in our laboratory for all suspected cases of borreliosis. Indirect immunofluorescence assays (IFA) (polyvalent conjugate, code F200, Dako Immunreagenzien) to detect antibodies to Borrelia burgdorferi in serum and CSF were negative (figure). Only a slight increase in IgG class antibodies (240 IU) was found by ELISA,2 The child improved and he was discharged without treatment. 3 weeks later, spirochaetes were detected in the CSF culture and identified as B burgdorferi by IFA using monoclonal antibody 5332, specific for this species. The family doctor was notified and the child was readmitted. He had no symptoms but his physician reported that the child had continued to complain of a stiff neck and had been unusually irritable since he was last examined. Another lumbar puncture revealed 85 cells/µl CSF (predominantly lymphocytes) and protein content 94-9 mg/dl. Repeated antibody testing to B burgdorferi showed increases in both IFA (table) and ELISA (above 1200 IU) titres. Appropriate therapy was instituted.
Clinical course and antibody response in 10-year-old borrelia meningitis.
boy
with
Herlev
DK-2730 Herlev, Denmark
GERT KRISTENSEN NIELS ERIK DRENCK HENRIK JORDENING
1. Kristensen G, Gravesen H, Benveniste D, Jordening H. An oesophageal thermal tube
for rewarming in hypothermia. Acta Anaesthesiol Scand 1985; 29: 846-48. 2. Kristensen G, Guldager H. Gravesen H. Prevention of peroperative hypothermia in abdominal surgery. Acta Anaesthesiol Scand 1986; 30: 314-16. 3. Khalil HH, Mac Keith RC. A simple method of raising and lowering body temperature. Br Med J 1954; ii: 734-36. 4. Ledingham IMcA, Routh GS, Douglas IHS, et al. Central rewarming system for treatment of hypothermia. Lancet 1980; i: 1168-69.
DIRECT INTRAPERTTONEAL INSEMINATION: FIRST RESULTS CONFIRMED
SIR,—That direct intraperitoneal insemination (DIPI) might be alternative to gamete intrafallopian transfer (GIFT) or intrauterine insemination in cases of unexplained or cervical . infertility was proposed by some of us in a previous letter to The Lancet, which summarised the indications and technique and gave an
first results.1 These results have now been confirmed in 56 cycles in 40 patients. 8 pregnancies have been achieved (4 singletons, 3 twin pregnancies,1 first trimester abortion). 5 patients so far have been delivered of healthy babies. These patients were all considered "desperate cases" and the mean duration of their infertility was 6-5 years (range 4-9). The average was 32 (range 28-33). All had been treated by at least three different medical teams before being referred to our department. Investigations, including salpingography, diagnostic laparoscopy, and hormone assays, had been done and considered normal. Cervical mucus had been repeatedly examined and sperm-mucus interaction had been tested both in vivo and in vitro. However, penetration of sperm to the pouch of Douglas, as suggested by Templeton and Mortimerwas not studied. Antibodies against husband’s sperm were not detected. After extensive work-up, the infertility was ascribed predominantly to poor cervical mucus penetration by the husband’s sperm. Sperm, at three or more examinations, was consistently suboptimal with normal counts, but the initial rate of motility (below 45%) dropped rapidly (5-35%) at 3 h and the frequency of normal morphology was usually below 40%. Several treatments, including superovulation with human menopausal gonadotropins and/or clomiphene with close supervision of hormone levels, follicle growth, and cervical mucus, had been attempted without success, and more complex procedures such as in-vitro fertilisation (IVF) or GIFT were being considered. 1 patient had already completed ten IVF cycles. The DIPI protocol’ was adhered to. Ovulation was induced and insemination was done 35 h after human chorionic gonadotropin. Sexual activity in the days before and after insemination was prohibited so that any resulting pregnancy could be attributed to the treatment. 0 6-18 million sperm were deposited in the peritoneal fluid of the pouch of Douglas. The sole modification in the second series was control of follicular rupture by ultrasound 24 h post-insemination. In the absence of follicle rupture DIPI was repeated. No complications have been registered. A 14 % pregnancy rate per treatment cycle is good for patients of this type.3 An explanation for the failures is equally important, and may be had from a close comparison of the histories of successful and unsuccessful cases. We have not so far been successful in women over 37 years of age or in women with uncorrected major ovulatory dysfunction. Some patients were accepted into the programme because several donor insemination attempts had failed. These women were considered normal but we have had no successes-perhaps because of insufficient capacitated motile sperm (the use of fresh donor sperm might alleviate this). No successes were achieved when the husband’s sperm was very poor; our
treatment
500 000 motile capacitated sperm or more seem to be needed. Nor any pregnancies achieved when sperm did not survive in the woman’s peritoneal fluid for at least 24 h, when tested in vitro in a previous cycle. Patients with a negative test might fare better with IVF. Further studies on this peritoneal fluid motility test are now under consideration, and these may explain some of the failures. Our experience with DIPI is encouraging and a controlled study now seems warranted. Simple as the method seems, it should be reserved for difficult cases with cervical infertility or male subfertility and for some cases of unexplained infertility. were
Obstetrics and Gynaecology Service, Centre Médico-Chirurgical et Obstetrical de la Sécurité Sociale, 67300 Schiltigheim, France
A. FORRLER E. BADOC L. MOREAU P. DELLENBACH
Embryology Laboratory, Faculty of Medicine, Strasbourg
CL. CRANZ A. CLAVERT Y. RUMPLER
1. Forrler A, Dellenbach P, Nisand I, Moreau L. Direct intraperitoneal insemination in unexplained and cervical infertility. Lancet 1986; i: 916. 2. Templeton AA, Mortimer RD. The development of a clinical test of sperm migration to the site of fertilization. Fertil Steril 1982; 3: 410-15. 3. Kerin JFP, Kirby C, Peek J, et al. Improved conception rate after intrauterine insemination of washed spermatozoa from men with poor quality semen. Lancet 1984; i: 533.
BORDERLINE ANTIBODY RESPONSE IN INITIAL STAGES OF LYMPHOCYTIC MENINGITIS DOES NOT RULE OUT BORRELIOSIS
SIR,-In June, 1986, we examined a 10-year-old boy with a 1-week history of a stiff neck and tingling of both hypothenars. There was no history of fever, erythema migrans, or known tick bite. The cerebrospinal fluid (CSF) contained 141 leucocytes/µl (predominantly mononuclear cells) and protein 38-4 mg/dl. Besides routine bacteriological and virological tests, 1 ml CSF was inoculated into 11 ml of BSKII medium.1 This procedure is routine in our laboratory for all suspected cases of borreliosis. Indirect immunofluorescence assays (IFA) (polyvalent conjugate, code F200, Dako Immunreagenzien) to detect antibodies to Borrelia burgdorferi in serum and CSF were negative (figure). Only a slight increase in IgG class antibodies (240 IU) was found by ELISA,2 The child improved and he was discharged without treatment. 3 weeks later, spirochaetes were detected in the CSF culture and identified as B burgdorferi by IFA using monoclonal antibody 5332, specific for this species. The family doctor was notified and the child was readmitted. He had no symptoms but his physician reported that the child had continued to complain of a stiff neck and had been unusually irritable since he was last examined. Another lumbar puncture revealed 85 cells/µl CSF (predominantly lymphocytes) and protein content 94-9 mg/dl. Repeated antibody testing to B burgdorferi showed increases in both IFA (table) and ELISA (above 1200 IU) titres. Appropriate therapy was instituted.
Clinical course and antibody response in 10-year-old borrelia meningitis.
boy
with