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Treatment of Tubal Pregnancy
5. WesthofG, WesthofKF, Hasegawa Y, Miyamoto K, diZerega GS: Inhibin secretion by individual porcine follicles perifused in vitro. Fertil Steril 54:718, 1990
Reply of the Authors: Dr. Zimmermann has focused his attention on a secondary part of our message. The main point of our study was to analyze the cytogenetic status of the unfertilized oocytes grouped according to the number of oocytes retrieved. By doing this we found cytogenetic signs of cytoplasmic immaturity, such as diploidy and premature condensation of sperm chromosomes. The biochemical observation of reduced estradiol (E2) production per follicle developed was an additional finding that seems to support our hypothesis of follicle and oocyte immaturity in patients with high ovarian response to gonadotropins. We fully agree with Dr. Zimmermann that each ultrasonographically visualized follicle does not contribute equally to the peripheral E 2 levels and one should never conclude that all visualized follicles are equal from an endocrinological standpoint. However, as Dr. Zimmermann pointed out, small follicles corresponding to early stages of development have shown decreased E 2 secretion in vitro in comparison with dominant follicles. Therefore, the fact that the size and the "theoretical" amount of E 2 produced per follicle were lower as the response to gonadotropins increased seems to be in agreement with our hypothesis. On the other hand, we find it very improbable that diploidy and prematurely condensed sperm chromosomes of the G 1 phase may be coincident with initial atresia, because as we state in our paper oocytes from atretic follicles are able to mature, fertilize, and cleave. Also, recent work performed in rats as models has shown that it is very improbable that follicles undergoing atresia respond to gonadotropins and return to the ovulatory pathway.
Antonio Pellicer, M.D. Juan J. Tarin, Ph.D. Department of Pediatrics, Obstetrics and Gynecology Valencia University School of Medicine Valencia, Spain Aprilll, 1991
374
Letters-to-the-editor
Treatment of Tubal Pregnancy
To the Editor: We were extremely interested to read the article by Tulandi and Guralnick1 in which they demonstrated that the best surgical treatment for ectopic pregnancy (EP) is salpingotomy without tubal suturing when it is desired to safeguard future fertility. This study is of particular merit in that, to our knowledge, it is the only one to have established this point based on a random study. The results, presented as cumulative rates of intrauterine pregnancy (IUP), confirm those found in the major series of laparoscopic treatment for EP. After conservative laparoscopic treatment, the rate of IUP achieved is comparable whether the tube has been sutured or not. After laparoscopic suture of the salpingotomy, Mecke et al. 2 reported an IUP rate of 56.7% (42 cases), which is not significantly different from the 64.4% (76 cases) that we obtained leaving the salpingotomy to heal by secondary intention.3 In both series the IUP rate is significantly higher than the 22.4% IUP rate achieved after radicallaparoscopic treatment of EP. 4 We wish to confirm the conclusions made by Tulandi and Guralnick, 1 that salpingotomy without tubal suturing is the technique that offers the best chance of obtaining IUP after surgical treatment of EP. However, provided that the surgeon has the specific training required, the fertility results for laparoscopic treatment of EP, which are comparable if not better with those found after treatment via laparotomy, combined with the advantages of endoscopy call for this technique to be carried out by laparoscopy now.
Charles Chapron, M.D. Jean-Luc Pouly, M.D. Hubert Manhes, M.D. Gerard Mage, M.D. Michel Canis, M.D. Arnaud Wattiez, M.D. Maurice-Antoine Bruhat, M.D. Department of Gynecology and Obstetrics Human Reproductive Medicine Polyclinique Clermont-Ferrand University Hospital University of Clermont-Ferrand I Clermont-Ferrand Cedex France March 21, 1991
Fertility and Sterility
REFERENCES 1. Tulandi T, Guralnick M: Treatment of tubal ectopic pregnancy by salpingotomy with or without tubal suturing and salpingectomy. Fertil Steril 55:53, 1991 2. Mecke H, Semm K, Lehmann-Willenbrock E: Results of operative pelviscopy in 202 cases of ectopic pregnancy. Int J Fertil 34:93, 1989 3. Pouly JL, Mahnes H, Mage G, Canis M, Bruhat MA: Conservative laparoscopic treatment of 321 ectopic pregnancies. Fertil Steril 46:1093, 1986 4. Dubuisson JB, Aubriot FX, Foulot H, Bruel D, Bouquet de Joliniere J, Mandelbrot L: Reproductive outcome after laparoscopic salpingectomy for tubal pregnancy. Fertil Steril 53:1004, 1990
Reply of the Author:
I appreciate Chapron et al.'s interest in our study. 1 We neglected to mention in the article that our study took place between 1986 and 1989. Currently, laparoscopic removal of ectopic pregnancy (EP) is my first choice of surgical treatment for EP. In fact, I have been doing laparoscopic removal of EP since 1987.2 Confirming your group's observations,3 laparoscopic removal of EP is associated with less physical stress than laparotomy, does not require hospitalization, and is more economical. However, due to the possibility of "persistent ectopic pregnancy," a follow-up serum ,8-human chorionic gonadotropin determination should be done postoperatively. The incidence of "persistent ectopic pregnancy" appears to be 5% to 10%.4 I agree with Chapron et al. that nowadays laparoscopic removal of EP should be the first line of surgical treatment. Togas Tulandi, M.D. McGill University Montreal, Quebec Canada April 4, 1991 REFERENCES 1. Tulandi T, Guralnick M: Treatment of tubal ectopic pregnancy by salpingotomy with or without tubal suturing and salpingectomy. Fertil Steril 55:53, 1991 2. Tulandi T, Ferenczy A, Berger E: Tubal occlusion as a result of retained ectopic pregnancy: a case report. Am J Obstet Gynecol 158:1116, 1988 3. Pouly JL, Mahnes H, Mage G, Canis M, Bruhat MA: Conservative laparoscopic treatment of 321 ectopic pregnancies. Fertil Steril46:1093, 1986 4. Vermesh M: Conservative management of ectopic gestation. Fertil Steril 51:559, 1989
Vol. 56, No. 2, August 1991
Electromagnetic Fields and Reproduction: Further Evidence Against An Association*
The following letter from Dr. Jauchem is in followup to previous letters to the editor that appeared in January, 1990 and in November, 1990. (53:185, 1990 and 54:955, 1990) Paul G. McDonough, M.D., Letters To the Editor:
Last July, I responded to comments in this journal that suggested a link between exposure to video display terminals (VDTs) and reproductive mishaps. 1 I mentioned studies that indicated no VDT-associated occupational health problems. Since that time, several additional reports have appeared showing no association. Nielsen and Brandt2•3 studied a source population of 214,108 commercial and clerical workers. These investigators found that, in women working with VDTs, there were no increased risks of spontaneous abortions (relative risk, 0.94) or congenital malformations among their children (relative risk, 0.96). Another recent study by Windham et al. 4 did not show a significant excess of VDT use among women with spontaneous abortions (odds ratio, 1.2). Schnorr et al. 5 also found no excess risk among telephone operators who had used VDTs (odds ratio, 0.93). Their study was strengthened by several factors: the similarity of the VDT-user group and the comparison group of operators who did not utilize VDTs; the application of record-based data to determine the degree of VDT use during each pregnancy; and the direct measurement of electromagnetic fields. In this study, there wasn't even a trend toward increased risks with increasing durations of VDT use. Considering earlier reports of clusters of adverse reproductive outcomes associated with VDT use Foster6 has stated that "in a sufficiently large num~ her of groups, clusters are likely to be found. The 'expected-unexpected cluster' is a phenomenon well known to epidemiologists (and also to gamblers)." Foster also noted that the Centers for Disease Control have calculated that if 7 million VDT workers were arbitrarily assigned to 100,000 groups of 70 workers, 2,500 groups could be expected to contain an unlikely (P < 0.05) cluster of abnormal pregnan* These views and opinions are those of the author and do not necessarily state or reflect those of the United States Government.
Letters-to-the-editor
375
Reply of the Authors: Dr. Zimmermann has focused his attention on a secondary part of our message. The main point of our study was to analyze the cytogenetic status of the unfertilized oocytes grouped according to the number of oocytes retrieved. By doing this we found cytogenetic signs of cytoplasmic immaturity, such as diploidy and premature condensation of sperm chromosomes. The biochemical observation of reduced estradiol (E2) production per follicle developed was an additional finding that seems to support our hypothesis of follicle and oocyte immaturity in patients with high ovarian response to gonadotropins. We fully agree with Dr. Zimmermann that each ultrasonographically visualized follicle does not contribute equally to the peripheral E 2 levels and one should never conclude that all visualized follicles are equal from an endocrinological standpoint. However, as Dr. Zimmermann pointed out, small follicles corresponding to early stages of development have shown decreased E 2 secretion in vitro in comparison with dominant follicles. Therefore, the fact that the size and the "theoretical" amount of E 2 produced per follicle were lower as the response to gonadotropins increased seems to be in agreement with our hypothesis. On the other hand, we find it very improbable that diploidy and prematurely condensed sperm chromosomes of the G 1 phase may be coincident with initial atresia, because as we state in our paper oocytes from atretic follicles are able to mature, fertilize, and cleave. Also, recent work performed in rats as models has shown that it is very improbable that follicles undergoing atresia respond to gonadotropins and return to the ovulatory pathway.
Antonio Pellicer, M.D. Juan J. Tarin, Ph.D. Department of Pediatrics, Obstetrics and Gynecology Valencia University School of Medicine Valencia, Spain Aprilll, 1991
374
Letters-to-the-editor
Treatment of Tubal Pregnancy
To the Editor: We were extremely interested to read the article by Tulandi and Guralnick1 in which they demonstrated that the best surgical treatment for ectopic pregnancy (EP) is salpingotomy without tubal suturing when it is desired to safeguard future fertility. This study is of particular merit in that, to our knowledge, it is the only one to have established this point based on a random study. The results, presented as cumulative rates of intrauterine pregnancy (IUP), confirm those found in the major series of laparoscopic treatment for EP. After conservative laparoscopic treatment, the rate of IUP achieved is comparable whether the tube has been sutured or not. After laparoscopic suture of the salpingotomy, Mecke et al. 2 reported an IUP rate of 56.7% (42 cases), which is not significantly different from the 64.4% (76 cases) that we obtained leaving the salpingotomy to heal by secondary intention.3 In both series the IUP rate is significantly higher than the 22.4% IUP rate achieved after radicallaparoscopic treatment of EP. 4 We wish to confirm the conclusions made by Tulandi and Guralnick, 1 that salpingotomy without tubal suturing is the technique that offers the best chance of obtaining IUP after surgical treatment of EP. However, provided that the surgeon has the specific training required, the fertility results for laparoscopic treatment of EP, which are comparable if not better with those found after treatment via laparotomy, combined with the advantages of endoscopy call for this technique to be carried out by laparoscopy now.
Charles Chapron, M.D. Jean-Luc Pouly, M.D. Hubert Manhes, M.D. Gerard Mage, M.D. Michel Canis, M.D. Arnaud Wattiez, M.D. Maurice-Antoine Bruhat, M.D. Department of Gynecology and Obstetrics Human Reproductive Medicine Polyclinique Clermont-Ferrand University Hospital University of Clermont-Ferrand I Clermont-Ferrand Cedex France March 21, 1991
Fertility and Sterility
REFERENCES 1. Tulandi T, Guralnick M: Treatment of tubal ectopic pregnancy by salpingotomy with or without tubal suturing and salpingectomy. Fertil Steril 55:53, 1991 2. Mecke H, Semm K, Lehmann-Willenbrock E: Results of operative pelviscopy in 202 cases of ectopic pregnancy. Int J Fertil 34:93, 1989 3. Pouly JL, Mahnes H, Mage G, Canis M, Bruhat MA: Conservative laparoscopic treatment of 321 ectopic pregnancies. Fertil Steril 46:1093, 1986 4. Dubuisson JB, Aubriot FX, Foulot H, Bruel D, Bouquet de Joliniere J, Mandelbrot L: Reproductive outcome after laparoscopic salpingectomy for tubal pregnancy. Fertil Steril 53:1004, 1990
Reply of the Author:
I appreciate Chapron et al.'s interest in our study. 1 We neglected to mention in the article that our study took place between 1986 and 1989. Currently, laparoscopic removal of ectopic pregnancy (EP) is my first choice of surgical treatment for EP. In fact, I have been doing laparoscopic removal of EP since 1987.2 Confirming your group's observations,3 laparoscopic removal of EP is associated with less physical stress than laparotomy, does not require hospitalization, and is more economical. However, due to the possibility of "persistent ectopic pregnancy," a follow-up serum ,8-human chorionic gonadotropin determination should be done postoperatively. The incidence of "persistent ectopic pregnancy" appears to be 5% to 10%.4 I agree with Chapron et al. that nowadays laparoscopic removal of EP should be the first line of surgical treatment. Togas Tulandi, M.D. McGill University Montreal, Quebec Canada April 4, 1991 REFERENCES 1. Tulandi T, Guralnick M: Treatment of tubal ectopic pregnancy by salpingotomy with or without tubal suturing and salpingectomy. Fertil Steril 55:53, 1991 2. Tulandi T, Ferenczy A, Berger E: Tubal occlusion as a result of retained ectopic pregnancy: a case report. Am J Obstet Gynecol 158:1116, 1988 3. Pouly JL, Mahnes H, Mage G, Canis M, Bruhat MA: Conservative laparoscopic treatment of 321 ectopic pregnancies. Fertil Steril46:1093, 1986 4. Vermesh M: Conservative management of ectopic gestation. Fertil Steril 51:559, 1989
Vol. 56, No. 2, August 1991
Electromagnetic Fields and Reproduction: Further Evidence Against An Association*
The following letter from Dr. Jauchem is in followup to previous letters to the editor that appeared in January, 1990 and in November, 1990. (53:185, 1990 and 54:955, 1990) Paul G. McDonough, M.D., Letters To the Editor:
Last July, I responded to comments in this journal that suggested a link between exposure to video display terminals (VDTs) and reproductive mishaps. 1 I mentioned studies that indicated no VDT-associated occupational health problems. Since that time, several additional reports have appeared showing no association. Nielsen and Brandt2•3 studied a source population of 214,108 commercial and clerical workers. These investigators found that, in women working with VDTs, there were no increased risks of spontaneous abortions (relative risk, 0.94) or congenital malformations among their children (relative risk, 0.96). Another recent study by Windham et al. 4 did not show a significant excess of VDT use among women with spontaneous abortions (odds ratio, 1.2). Schnorr et al. 5 also found no excess risk among telephone operators who had used VDTs (odds ratio, 0.93). Their study was strengthened by several factors: the similarity of the VDT-user group and the comparison group of operators who did not utilize VDTs; the application of record-based data to determine the degree of VDT use during each pregnancy; and the direct measurement of electromagnetic fields. In this study, there wasn't even a trend toward increased risks with increasing durations of VDT use. Considering earlier reports of clusters of adverse reproductive outcomes associated with VDT use Foster6 has stated that "in a sufficiently large num~ her of groups, clusters are likely to be found. The 'expected-unexpected cluster' is a phenomenon well known to epidemiologists (and also to gamblers)." Foster also noted that the Centers for Disease Control have calculated that if 7 million VDT workers were arbitrarily assigned to 100,000 groups of 70 workers, 2,500 groups could be expected to contain an unlikely (P < 0.05) cluster of abnormal pregnan* These views and opinions are those of the author and do not necessarily state or reflect those of the United States Government.
Letters-to-the-editor
375