Letters-to-the-editor Paul G. McDonough, M.D., Associate Editor FERTILITY AND STERILITY Copyright
©
Intraperitoneal Insemination-Does it Help?
To the Editor: My colleagues and I read with great interest the paper from Oxford looking at direct intraperitoneal insemination techniques (1). We were relieved to learn that there was no increase in the immune response to the spermatozoal antigenic stimulus but were disappointed to see that their pregnancy rate after direct intraperitoneal insemination was so low. As the authors are no doubt aware, we have looked at large numbers of cycles in similar infertility couples from an area not so far geographically from their own, comparing intraperitoneal insemination, intrauterine insemination, and natural intercourse in a similar rotating fashion (2). In contrast to the results from Oxford, we achieved a 16% pregnancy rate per cycle in the unexplained infertility group, which was significantly better than the other two methods of insemination. There are several possible reasons for this difference. First, it has been reported previously that a combination of human menopausal gonadotropin (hMG) and clomiphene citrate (CC) results in a higher pregnancy rate than CC alone (3). Second, the sperm recovery after washing appears to have been somewhat lower than we noted. Third, the method of checking that the needle was located within the pouch of Douglas before insemination differed from our study. Although the use of the transvaginal probe and needle guide is logical, if a little uncomfortable, the aspiration or loss of fluid from the pouch by allowing it to drip from the needle may have been detrimental. Because these women were all 36 to 48 hours postadministration of human chorionic gonadotropin, they had presumably ovulated, and the fluid aspirated or lost may well have contained the oocytes. Since finishing our study (2), we have continued to use intraperitoneal insemination as an alternative to gamete intrafallopian transfer and have continued to achieve an ultrasonically proven pregnancy rate of 33% using CC and hMG as stimulation. We recently have changed the ovarian stimulation to busere lin acetate 500 JLg for 3 days and hMG daily and have found our pregnancy rate per treatment increased to 66%, although on small numbers. We would applaud the authors' call for studies to validate these new techniques but would be hesitant 858
Vol. 58, No.4, October 1992
1992 The American Fertility Society
Letters-to-the-editor
Printed on acid-free paper in U.S.A.
to condemn a technique on the basis of 25 cycles, especially when other authors have reported differently (2, 4, 5).
Janet Evans, M.B., B.Ch. Andrew Booth, M.B., B.Ch. Catherine Wells, Ph.D. Assisted Reproduction Unit Department of Obstetrics and Gynaecology University Hospital of Wales Cardiff, United Kingdom May 5, 1992
REFERENCES 1. Campos-Liete E, Insull M, Kennedy SH, Ellis JD, Sargent I, Barlow DH. A controlled assessment of direct intraperitoneal insemination. Fertil Steril 1992;57:168-73. 2. Evans J, Wells C, Gregory L, Walker S: A comparison of intrauterine insemination, intraperitoneal insemination and natural intercourse in superovulated women. Fertil Steril 1991;56:1183-7. 3. Kemmann E, Bohrer M, Sheldon R, Fiasconaro G, Beardsley L: Active ovulation management increases the monthly probability of pregnancy occurrence in ovulatory women who receive intrauterine insemination. Fertil Steril 1987;48: 916-20. 4. Forrler A, Badoc E, Moreau L, Dellenbach P, Cranz CL, Clavert A, et al. Direct intraperitoneal insemination: first results confirmed. Lancet 1986;2:1468. 5. Hovatta 0, Kurunmaki H, Tiitinen A, Lahteenmaki P, Koskimies A: Direct intraperitoneal or intrauterine insemination and superovulation in infertility treatment: a randomized controlled study. Fertil Steril1990;54:339-41.
Reply of the Authors: Evans et al. drew our attention to their recent paper (1). They report a 16% pregnancy rate per cycle in their unexplained infertility group and comment that they hesitate to condemn direct intraperitoneal insemination on the basis of our data (2). Our point is that an invasive technique such as direct intraperitoneal insemination should only be pursued if proponents can demonstrate a significant benefit in closely controlled studies. In our randomized controlled crossover study, there was no reasonable possibility of the direct intraperitoneal inFertility and Sterility
semination treatment arm producing a significantly better pregnancy rate than timed intercourse using the same ovarian stimulation in both arms. We therefore concluded that direct intraperitoneal insemination was offering no benefit. In our paper, we mentioned that pregnancy rates of approximately 16% per cycle have been achieved by others using direct intraperitoneal insemination. We would argue that because Evans et al. had to combine in their comparison the cycles of both natural intercourse and intrauterine insemination to show a statistically significant benefit for direct intraperitoneal insemination in the fully controlled portion of their study, the case for direct intraperitoneal insemination remains unproven in a strictly randomized study controlled against natural intercourse.
David H. Barlow, M.D. Stephen Kennedy, M.B., Ch.B. Ian Sargent, Ph.D. Nuffield Department of Obstetrics and Gynecology John Radcliffe Hospital, Maternity Department Headington, Oxford United Kingdom June 8,1992 REFERENCES 1. Evans J, Wells C, Gregory L, Walker S. A comparison of
intrauterine insemination, intraperitoneal insemination, and natural intercourse in superovulated women. Fertil Steril 1991;56:1183-87. 2. Campos-Leite E, Insull M, Kennedy SR, Ellis JD, Sargent I, Barlow DR. A controlled assessment of direct intraperitoneal insemination. Fertil Steril 1992;57:168-73 .
Treatment of Recurrent Ectopic Pregnancy
To the Editor: It is with great interest that we read the article by Vermesh and Presser (1) in which they showed from a random and prospective study that fertility after conservative treatment of ectopic pregnancy (EP) by salpingostomy is comparable whether carried out via laparoscopy or via laparotomy.. These results confirm those we presented based on retrospective series (2, 3) and enable us to state that laparoscopic surgery should now be considered as the first choice for surgical treatment of EP. However, we don't agree with Vermesh and Presser (1) when they state that conservative treatVol. 58, No.4, October 1992
ment is not indicated when a second EP occurs. We have studied fertility after laparoscopic treatment of EPs over a series of 16 patients who all received a conservative treatment for the first EP (4). Whatever the method of treatment for the second EP, the overall fertility results show that the rates of intrauterine pregnancy (lUP) and recurrence are, respectively, 25% (4 cases) and 31.2% (5 cases). The results are indeed better when the second treatment is also conservative. The rate of IUP after two conservative treatments of EP was 36.4% (4 cases), whereas no IUP occurred after salpingectomy for the second EP. Last but not least, 50% of these IUP after two consecutive conservative treatments were obtained when the recurrence was homolateral. Our results agree with those of De Cherney (5), who reports that 50% of IUP obtained after two EPs came after homolateral recurrence treated conservatively. It is true that there is a considerable risk of recurrence after two EPs, and the patients must be made aware of this, but likelihood of IUP is comparable with that of in vitro fertilization for tubal indications. These series may be short (4, 5), but they do show that indications exist for conservative treatment of a second EP even if it occurs homolateraly. In practice, we treat EP conservatively or radically according to the Therapeutic Scoring System (3). Thus, recurrent EP after conservative treatment will again be treated by laparoscopic 'salpingostomy if the therapeutic score indicates conservative treatment.
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 May 11,1992
REFERENCES 1. Vermesh M, Presser SC. Reproductive outcome after linear
salpingostomy for ectopic gestation: a prospective 3-year follow-up. Fertil Steril 1992;57:682-4. 2. Pouly JL, Manhes R, Mage G, Canis M, Bruhat MA. Con-
Letters-to-the-editor
859
©
Intraperitoneal Insemination-Does it Help?
To the Editor: My colleagues and I read with great interest the paper from Oxford looking at direct intraperitoneal insemination techniques (1). We were relieved to learn that there was no increase in the immune response to the spermatozoal antigenic stimulus but were disappointed to see that their pregnancy rate after direct intraperitoneal insemination was so low. As the authors are no doubt aware, we have looked at large numbers of cycles in similar infertility couples from an area not so far geographically from their own, comparing intraperitoneal insemination, intrauterine insemination, and natural intercourse in a similar rotating fashion (2). In contrast to the results from Oxford, we achieved a 16% pregnancy rate per cycle in the unexplained infertility group, which was significantly better than the other two methods of insemination. There are several possible reasons for this difference. First, it has been reported previously that a combination of human menopausal gonadotropin (hMG) and clomiphene citrate (CC) results in a higher pregnancy rate than CC alone (3). Second, the sperm recovery after washing appears to have been somewhat lower than we noted. Third, the method of checking that the needle was located within the pouch of Douglas before insemination differed from our study. Although the use of the transvaginal probe and needle guide is logical, if a little uncomfortable, the aspiration or loss of fluid from the pouch by allowing it to drip from the needle may have been detrimental. Because these women were all 36 to 48 hours postadministration of human chorionic gonadotropin, they had presumably ovulated, and the fluid aspirated or lost may well have contained the oocytes. Since finishing our study (2), we have continued to use intraperitoneal insemination as an alternative to gamete intrafallopian transfer and have continued to achieve an ultrasonically proven pregnancy rate of 33% using CC and hMG as stimulation. We recently have changed the ovarian stimulation to busere lin acetate 500 JLg for 3 days and hMG daily and have found our pregnancy rate per treatment increased to 66%, although on small numbers. We would applaud the authors' call for studies to validate these new techniques but would be hesitant 858
Vol. 58, No.4, October 1992
1992 The American Fertility Society
Letters-to-the-editor
Printed on acid-free paper in U.S.A.
to condemn a technique on the basis of 25 cycles, especially when other authors have reported differently (2, 4, 5).
Janet Evans, M.B., B.Ch. Andrew Booth, M.B., B.Ch. Catherine Wells, Ph.D. Assisted Reproduction Unit Department of Obstetrics and Gynaecology University Hospital of Wales Cardiff, United Kingdom May 5, 1992
REFERENCES 1. Campos-Liete E, Insull M, Kennedy SH, Ellis JD, Sargent I, Barlow DH. A controlled assessment of direct intraperitoneal insemination. Fertil Steril 1992;57:168-73. 2. Evans J, Wells C, Gregory L, Walker S: A comparison of intrauterine insemination, intraperitoneal insemination and natural intercourse in superovulated women. Fertil Steril 1991;56:1183-7. 3. Kemmann E, Bohrer M, Sheldon R, Fiasconaro G, Beardsley L: Active ovulation management increases the monthly probability of pregnancy occurrence in ovulatory women who receive intrauterine insemination. Fertil Steril 1987;48: 916-20. 4. Forrler A, Badoc E, Moreau L, Dellenbach P, Cranz CL, Clavert A, et al. Direct intraperitoneal insemination: first results confirmed. Lancet 1986;2:1468. 5. Hovatta 0, Kurunmaki H, Tiitinen A, Lahteenmaki P, Koskimies A: Direct intraperitoneal or intrauterine insemination and superovulation in infertility treatment: a randomized controlled study. Fertil Steril1990;54:339-41.
Reply of the Authors: Evans et al. drew our attention to their recent paper (1). They report a 16% pregnancy rate per cycle in their unexplained infertility group and comment that they hesitate to condemn direct intraperitoneal insemination on the basis of our data (2). Our point is that an invasive technique such as direct intraperitoneal insemination should only be pursued if proponents can demonstrate a significant benefit in closely controlled studies. In our randomized controlled crossover study, there was no reasonable possibility of the direct intraperitoneal inFertility and Sterility
semination treatment arm producing a significantly better pregnancy rate than timed intercourse using the same ovarian stimulation in both arms. We therefore concluded that direct intraperitoneal insemination was offering no benefit. In our paper, we mentioned that pregnancy rates of approximately 16% per cycle have been achieved by others using direct intraperitoneal insemination. We would argue that because Evans et al. had to combine in their comparison the cycles of both natural intercourse and intrauterine insemination to show a statistically significant benefit for direct intraperitoneal insemination in the fully controlled portion of their study, the case for direct intraperitoneal insemination remains unproven in a strictly randomized study controlled against natural intercourse.
David H. Barlow, M.D. Stephen Kennedy, M.B., Ch.B. Ian Sargent, Ph.D. Nuffield Department of Obstetrics and Gynecology John Radcliffe Hospital, Maternity Department Headington, Oxford United Kingdom June 8,1992 REFERENCES 1. Evans J, Wells C, Gregory L, Walker S. A comparison of
intrauterine insemination, intraperitoneal insemination, and natural intercourse in superovulated women. Fertil Steril 1991;56:1183-87. 2. Campos-Leite E, Insull M, Kennedy SR, Ellis JD, Sargent I, Barlow DR. A controlled assessment of direct intraperitoneal insemination. Fertil Steril 1992;57:168-73 .
Treatment of Recurrent Ectopic Pregnancy
To the Editor: It is with great interest that we read the article by Vermesh and Presser (1) in which they showed from a random and prospective study that fertility after conservative treatment of ectopic pregnancy (EP) by salpingostomy is comparable whether carried out via laparoscopy or via laparotomy.. These results confirm those we presented based on retrospective series (2, 3) and enable us to state that laparoscopic surgery should now be considered as the first choice for surgical treatment of EP. However, we don't agree with Vermesh and Presser (1) when they state that conservative treatVol. 58, No.4, October 1992
ment is not indicated when a second EP occurs. We have studied fertility after laparoscopic treatment of EPs over a series of 16 patients who all received a conservative treatment for the first EP (4). Whatever the method of treatment for the second EP, the overall fertility results show that the rates of intrauterine pregnancy (lUP) and recurrence are, respectively, 25% (4 cases) and 31.2% (5 cases). The results are indeed better when the second treatment is also conservative. The rate of IUP after two conservative treatments of EP was 36.4% (4 cases), whereas no IUP occurred after salpingectomy for the second EP. Last but not least, 50% of these IUP after two consecutive conservative treatments were obtained when the recurrence was homolateral. Our results agree with those of De Cherney (5), who reports that 50% of IUP obtained after two EPs came after homolateral recurrence treated conservatively. It is true that there is a considerable risk of recurrence after two EPs, and the patients must be made aware of this, but likelihood of IUP is comparable with that of in vitro fertilization for tubal indications. These series may be short (4, 5), but they do show that indications exist for conservative treatment of a second EP even if it occurs homolateraly. In practice, we treat EP conservatively or radically according to the Therapeutic Scoring System (3). Thus, recurrent EP after conservative treatment will again be treated by laparoscopic 'salpingostomy if the therapeutic score indicates conservative treatment.
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 May 11,1992
REFERENCES 1. Vermesh M, Presser SC. Reproductive outcome after linear
salpingostomy for ectopic gestation: a prospective 3-year follow-up. Fertil Steril 1992;57:682-4. 2. Pouly JL, Manhes R, Mage G, Canis M, Bruhat MA. Con-
Letters-to-the-editor
859
