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Endometriosis is a common condition affecting a significant proportion of women in their reproductive age. Apart from the impact of endometriosis on the quality of life of these patients, it also can have an impact on the potential of these women to have a family. The options for treating women with endometriosis desiring a family include surgery or assisted reproduction techniques. The choice of treatment will depend on the stage of disease and the characteristics of the couple seeking help. We review here the latest evidence on the management of endometriosis in women desiring fertility and describe our current practice.

Effective tubal transport of ova, sperm and embryos is a prerequisite for successful spontaneous pregnancy. Although there is much yet to be discovered about the mechanisms involved, it is evident that tubal transit is a far more complicated process than initially thought. Propulsion of gametes and embryos is achieved by complex interaction between muscle contractions, ciliary activity and the flow of tubal secretions. Evidence is accumulating of the important and possibly pre-eminent role of ciliary motion in this process; and this review describes current knowledge about ciliary activity and its physiological regulation. There is also a description of the effects on ciliary function of cigarette smoking and various pathological states, including endometriosis and microbial infection, with consideration given as to how altered ciliary activity may impact upon fertility.

The cyclical changes in ciliary structure and motion within the human Fallopian tube are well documented. Previous investigators have studied ciliary beat frequency (CBF) in relation to menstrual cycle and anatomical site, but with conflicting results.

BACKGROUND: The cyclical changes in ciliary structure and motion within the human Fallopian tube are well documented. Previous investigators have studied ciliary beat frequency (CBF) in relation to menstrual cycle and anatomical site, but with conflicting results. METHODS: Using a technique that records variations in light intensity, we have studied the changes in CBF in relation to the menstrual cycle and anatomical site. Fallopian tubes were collected from 26 women who underwent hysterectomy for benign conditions. Menstrual history, hormone profile and endometrial biopsy results were used to determine the stage of the cycle. Fourteen women were in the proliferative phase, and 12 women in the secretory phase. RESULTS: Mean CBF for all subjects was 5.3 ± 0.2 Hz. There was no significant difference in CBF in relation to anatomical site. In the fimbrial region the ciliary beat was faster in the secretory (5.8 ± 0.3 Hz) as compared with the proliferative phase (4.9 ± 0.2 Hz), P < 0.02. CONCLUSIONS: It is possible that this increase in fimbrial CBF may contribute to ovum retrieval and transport after ovulation. However, the reproductive significance of the changes in CBF in relation to the menstrual cycle needs further investigation.

A prospective randomized control trial was designed to assess the effectiveness of single dose, 800 microg misoprostol administered p.v. compared with surgical evacuation for the treatment of early pregnancy failure. A total of 80 women with a diagnosis of early pregnancy failure were randomized to study (vaginal misoprostol) and control (surgical curettage) groups. Success of treatment, side-effects as assessed during, immediately after and 10 days after treatment, and patient satisfaction were compared. Intravaginal misoprostol was successful in 82.5% (33 out of 40) of the patients. None of the control group patients required a repeat evacuation. The number of patients who experienced significant abdominal pain following treatment did not differ between the groups. The duration of pain was shorter in the control group; however, they required more analgesics during this short period. The number of patients with significant vaginal bleeding, the duration or severity of bleeding did not show any significant difference between the groups. All 33 patients in the study group who had successful treatment expressed satisfaction, whereas only 58% of the control group did so. In conclusion this randomized control study demonstrated the efficacy and safety of the administration of 800 microg of misoprostol p.v. for the management of early pregnancy failure.

The oviduct provides a specialized environment for the survival and transport of the mammalian gametes to the site of fertilization within well defined time limits. The oviduct environment facilitates the process of fertilization and development of the preembryo. Furthermore, the spermatozoa and the pre-embryo, which differ antigenically from the mother, are not attacked by the immune system, which differentiates them from pathogens. The mechanisms by which all these complex processes are controlled are not fully understood. The disadvantage of cell culture systems for physiological study is that the original histological appearance is lost along with some endocrine and paracrine activities. Cells cultured on glass or plastic surfaces lose the polarization normally present in intact tissues. Premature senescence and de-differentiation may occur. It has been shown that extracellular matrix may stimulate proliferation and prevent dedifferentiation. The use of polarized cell cultures also enable the study of cellular orientation and protein secretion. Culture systems for polarized and non-polarized Fallopian tube epithelial cells have been developed in our laboratory. The subsequent experimental studies have shown that the presence of oviduct epithelial cells has a specific and significant stimulatory effect on sperm capacitation, reversing effects on the blockage of blastocyst formation. The exact mechanism of how the co-culture system achieves this is yet to be elucidated and in this regard, the unique oviduct proteins are possible candidates. Further studies of the epithelial cell cultures directed at the nature of the secretory behavior of these cells, are necessary in order to determine how these cells behave in vitro.

Using a method that detects variations in light intensity we have studied the effect of ovarian steroids on human Fallopian tube epithelial ciliary beat frequency in vitro. We have found that baseline ciliary beat frequency averages between 5-6 Hz. Cilia from ampullary segments of the Fallopian tube beat significantly faster (5.4 Hz ± 0.2) than those from fimbrial segments (4.8 Hz ± 0.2). There was no significant difference in baseline ciliary beat frequency at any other anatomical site in the Fallopian tube. Incubation with progesterone (10 μmol/l) suppresses human Fallopian tube epithelial ciliary beat frequency by 40-50%. This inhibition was observed at similar magnitudes in all Fallopian tubes studied irrespective of anatomical site. Progesterone-induced reductions in ciliary beat frequency were concentration dependent and prevented by the progesterone receptor antagonist mifepristone (RU486). Oestradiol alone (10 μmol/l) had no effect on ciliary beat frequency at any anatomical site in the Fallopian tube but did prevent the reduction in ciliary beat frequency seen with progesterone when tissues were incubated with these two steroids together.Keywords:ciliary beat/Fallopian tube/ovarian steroids

The oviduct provides a specialized environment for the survival and transport of the mammalian gametes to the site of fertilization within well defined time limits. The oviduct environment facilitates the process of fertilization and development of the preembryo. Furthermore, the spermatozoa and the pre-embryo, which differ antigenically from the mother, are not attacked by the immune system, which differentiates them from pathogens. The mechanisms by which all these complex processes are controlled are not fully understood. The disadvantage of cell culture systems for physiological study is that the original histological appearance is lost along with some endocrine and paracrine activities. Cells cultured on glass or plastic surfaces lose the polarization normally present in intact tissues. Premature senescence and de-differentiation may occur. It has been shown that extracellular matrix may stimulate proliferation and prevent dedifferentiation. The use of polarized cell cultures also enable the study of cellular orientation and protein secretion. Culture systems for polarized and non-polarized Fallopian tube epithelial cells have been developed in our laboratory. The subsequent experimental studies have shown that the presence of oviduct epithelial cells has a specific and significant stimulatory effect on sperm capacitation, reversing effects on the blockage of blastocyst formation. The exact mechanism of how the co-culture system achieves this is yet to be elucidated and in this regard, the unique oviduct proteins are possible candidates. Further studies of the epithelial cell cultures directed at the nature of the secretory behavior of these cells, are necessary in order to determine how these cells behave in vitro.

Using a method that detects variations in light intensity we have studied the effect of ovarian steroids on human Fallopian tube epithelial ciliary beat frequency in vitro. We have found that baseline ciliary beat frequency averages between 5-6 Hz. Cilia from ampullary segments of the Fallopian tube beat significantly faster (5.4 Hz+/-0.2) than those from fimbrial segments (4.8 Hz+/-0.2). There was no significant difference in baseline ciliary beat frequency at any other anatomical site in the Fallopian tube. Incubation with progesterone (10 micromol/l) suppresses human Fallopian tube epithelial ciliary beat frequency by 40-50%. This inhibition was observed at similar magnitudes in all Fallopian tubes studied irrespective of anatomical site. Progesterone-induced reductions in ciliary beat frequency were concentration dependent and prevented by the progesterone receptor antagonist mifepristone (RU486). Oestradiol alone (10 micromol/l) had no effect on ciliary beat frequency at any anatomical site in the Fallopian tube but did prevent the reduction in ciliary beat frequency seen with progesterone when tissues were incubated with these two steroids together.

Objective To present our experience with the combined use of laparoscopy and hysteroscopy as the primary investigation for tubal and uterine factors in infertility. Design This is a prospective study of patients investigated for infertility using hysterolaparoscopy for evaluation of infertility. Setting Assisted Conception and Infertility Unit at Newham General Hospital, London. Subjects These were 117 consecutive patients, of whom 53 (45.3%) had primary and 64 (54.7%) had secondary infertility. Results Laparoscopic examination revealed at least one abnormal finding in 77 (66.3%) patients and 29 (26.6%) patients had abnormal findings at hysteroscopy. Concurrent laparoscopy and hysteroscopy were completed in 108 patients in whom eight (7.4%) had abnormal hysteroscopic findings but normal laparoscopic findings. Five out of six (83.3%) patients who had intrauterine adhesions had a history of previous uterine surgery. Out of 67 patients with abnormal laparoscopy, 21 (31.3%) had abnormal findings at hysteroscopy compared with eight out of 41 (20.0%) with normal laparoscopy (chi2 = 1.678; P > 0.05). There was no significant difference in the prevalence of intrauterine abnormality detected hysteroscopically between the patients with primary and secondary infertility (chi2 = 2.899; P > 0.05). Conclusions The findings of this study suggest that routine use of hysteroscopy adds little information to the management of infertile patients and its concomitant use should be based on the history or physical examination findings. However, certain intrauterine abnormalities do not have warning signs. Until the significance of these intrauterine abnormalities in infertility is proven, routine use of hysterolaparoscopy for infertility investigation will remain a controversial issue.

The physiological factors which induce and maintain mammalian sperm maturation and motility generally remain unclear, although several agents are known to be involved. We describe here the application of immunocytochemical and immunoblotting methods to identify the angiotensin II type 1 (AT1) receptor in the tails of ejaculated rat and human sperm. Motility data on stimulated and unstimulated sperm from volunteers and patients attending fertility clinics showed that angiotensin II may increase both the percentage of motile sperm and their linear velocity, while the specific AT1 receptor antagonist DuP753 inhibited the action of angiotensin II on the percentage of motile sperm. In rat seminiferous tubules, AT1 receptors were present in primary spermatogonia and in spermatid tails, but immunoreactivity was not seen in sperm contained in caput or cauda epididymis, showing that AT1 receptor function is regulated during transit through the reproductive tract. Since local tissue reninangiotensin systems are present in both male and female tracts, the data suggest that angiotensin II has a role in the maintenance of sperm function and fertility.Journal of Endocrinology(1995) 144,369–

The continued acquisition of information on the distribution of expression of components of the renin-angiotensin system shows that it has functions in the tissues that are quite unrelated to its systemic actions. In particular, both type 1 and type 2 angiotensin receptors are found in many tissues of the reproductive system of both sexes. In addition, the widespread occurrence of (pro)renin, angiotensin converting enzyme and angiotensinogen suggests that the generation of angiotensin II within the tissues occurs at sites close to its sites of action. The data suggest that angiotensin II operates as an important paracrine agent with profoundly significant roles in several functions of the reproductive system, and in fertility.

We studied the in-vitro secretory function of non-polarized and polarized cultured Fallopian tube epithelial cells by measurement of the placental protein 14 (PP14) secretion in primary cultures and subcultures from Fallopian tubes obtained from eight premenopausal women in different phases of the ovarian cycle. Primary cultures were established in minimal essential medium in Earle's salts supplemented with fetal bovine serum and the cells were subcultured for six passages, in the polarized cell cultures, the cells being seeded on an extracellular matrix system. Cell freezing was carried out using 10% dimethyl sulphoxide. PP14 secretion into the culture media was measured by a radioimmunoassay using 125I-PP14 as label and rabbit anti-human PP14 serum. There was a large amount of PP14 secretion into the culture media in primary cultures, the secretion decreasing considerably after subculture 1. PP14 secretion after subculture 2 was not different from the control values. Polarized and non-polarized cells secreted similar amounts of PP14 and frozen-thawed cells did not appear to secrete PP14. Epithelial cells from Fallopian tubes obtained at different phases of the ovarian cycle did not appear to show any difference in PP14 secretion rates. Our data suggest that the in-vitro secretion of PP14 by human Fallopian tube epithelial cells is adversely affected by cell ageing and freezing.

In order to investigate the effect of human Fallopian tube epithelial cell co-culture on fertilization and cleavage rates in tubal, male and unexplained infertility, oocytes collected from 91 patients were randomized to wells containing Fallopian tube epithelial cell monolayers or conventional culture medium, and inseminated with spermatozoa. Fertilization and cleavage were assessed at 18 and 52 h, respectively. Co-culture significantly increased the fertilization rates over the control values in male infertility (41.67 versus 23.43%, P = 0.00005), but not in tubal infertility (69.33 versus 67.93%) or unexplained infertility (65.93 versus 54.36%). Cleavage rates were not different in co-culture and conventional in-vitro fertilization systems in any of the infertility subgroups. The number of blastomeres was significantly higher in the co-culture group on the day of embryo transfer (3.63 +/- 1.12 versus 3.04 +/- 1.26, P < 0.001). Pregnancy rates were similar in all infertility subgroups. There was no significant association between the number of co-cultured embryos transferred and the pregnancy, abortion and multiple pregnancy rates. It was concluded that human Fallopian tube epithelial cell co-culture clearly improves fertilization rates in male infertility but not in tubal or unexplained infertility. Improved fertilization rates in co-culture may be due to positive effect of co-culture on impaired sperm function.

The cause of polycystic ovary syndrome (PCOS), the commonest endocrine abnormality affecting women of reproductive age, remains in large part unknown, although studies to date suggest an intrinsic ovarian abnormality. Developing oocytes have an interdependent relationship with the surrounding granulosa cells, and it is possible that dysfunction of these cells contributes to the abnormal folliculogenesis characteristic of PCOS. This study tested the hypothesis that differences in granulosa-cell proliferation and apoptosis adversely affect follicular development. Granulosa cells were prepared from follicular fluid aspirated from 4- to 8-mm follicles of unstimulated ovaries in the course of routine laparoscopy or laparotomy. Fourteen women with anovulatory PCOS and 9 with regular ovulatory cycles were sampled. Immunocytochemical analysis was used to estimate rates of proliferation and apoptosis, and the real-time polymerase chain reaction technique to analyze gene expression profiles of apoptotic regulators.