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Introduction: The first step in human implantation is the attraction of the blastocyst to the endometrium. We aimed to study attraction of the human blastocyst to the endometrium, and how this process is accomplished by chemokines secreted by the endometrium. Materials and methods: Blastocyst trophectoderm cells and other trophoblast lineage cells were subjected to attraction assays by IP-10 and other chemokines using transwell migration and chemotaxis assays. Chemokine expression and secretion were investigated using immunohistochemistry, ELISA, FACS analysis, and RT-PCR on material from flushing of the uterine cavity in endometrial biopsies. Chemokine receptor expression by blastocyst trophectoderm following PGD biopsy, trophectoderm derived from hES, placental villi, and other trophoblast lineage cells were characterized by the same methods. Results: IP-10 dramatically attracted trophectoderm derived from hES cells and other lineages by interaction with CXCR3 chemokine receptors, as shown by both chemotaxis and transwell migration. High levels of IP-10 were detected throughout the menstrual cycle at flushing of the uterine cavity. Immunohistochemistry, FACS analysis, and RT-PCR of endometrial biopsy detected IP-10 in glandular and stromal cells of the endometrium. High levels of IP-10 were detected in condition medium of the endometrial stromal and glandular cells. Of all of the chemokine/chemokine receptor combinations examined, the IP-10/CXCR3 interaction was the only cytokine that was significantly elevated. Discussion: While they await the wandering blastocyst, IP-10 is produced by many cells of the endometrium, but not by endometrial natural killer cells. Conclusion: Endometrial IP-10 may specifically attract human blastocyst trophectoderm cells early in implantation.

The surgeon who faces a patient with vaginal vault prolapse is dealing with a complex and intriguing challenge. Part of the complexity is due to the lack of standardization and routine application of tools to assess pre- and postoperative anatomical and functional outcomes. Patient satisfaction is a major endpoint for surgical success; thus all aspects of the prolapse pathology and the patient's lifestyle should be considered. The surgeon needs to be well versed and flexible in order to choose the most appropriate operative approach to achieve optimal results for an individual patient. In this chapter we present the vaginal and abdominal approaches for the correction of vaginal vault prolapse, with discussion of the surgical outcomes and complications for each technique. A comprehensive comparison of the various techniques is offered on the basis of current published literature. In addition, we focus on various controversies, including the prevention of vault prolapse at the time of hysterectomy, issues regarding uterine preservation, the management of overt or occult concomitant stress incontinence, and the place-if any-for combined anti-incontinence procedures at the time of prolapse surgery. New minimally invasive techniques for vault prolapse are also reviewed. We emphasize areas that call for further research and for standardized outcome criteria.

Objective(s): To correlate fertilization and clinical pregnancy rates (PRs) in low responders with their E 2 levels ( 800–1,000 pg/mL), age (20–30, 31–40, >40 years), number of follicles, and number of oocytes retrieved. Design: A retrospective study. Setting: The IVF unit of an academic hospital. Patient(s): One hundred forty-three women who failed to attain E 2 levels of 1,000 pg/mL on the day of hCG administration. Intervention(s): Controlled ovarian hyperstimulation, blood E 2 and progesterone measurements, ultrasonographic scanning of ovarian follicles, oocyte retrieval after hCG administration, and ET. Main Outcome Measure: Clinical PR. Result(s): Although E 2 levels, fertilization rates, age, and number of oocytes did not differ significantly between the three age groups, the PR achieved in the youngest group was approximately three times as high (19.3%) as that achieved in the two older groups. Conclusion: Young low responders represent a unique subset in that their age protects them from the deleterious effects of poor ovarian response.

Objective To assess the potential involvement of cytokines and nitrites in the hyperpermeability characterizing the ovarian hyperstimulation syndrome (OHSS). Design A controlled clinical study comparing peritoneal fluid (PF) from patients with severe OHSS and from non-OHSS controls. Setting Women hospitalized with severe OHSS in three tertiary medical centers. Patients Twelve patients with severe OHSS necessitating paracentesis and 20 non-OHSS controls. Interventions The criteria for ultrasound-guided paracentesis were tense ascites, hydrothorax, hemoconcentration, or oliguria. Main Outcome Measures Interleukin (IL) 1 β IL-1 receptor agonist, IL-2, IL-6, IL-8, and tumor necrosis factor α (TNF α ) levels in PF were assayed by ELISA; nitrites were measured by the "Griess" reaction. Estradiol and P were determined by RIA. Results Ovarian hyperstimulation syndrome patients had significantly higher PF IL-6 (3,523 versus 30 pg/mL), TNF α (14 versus 4.2 pg/mL), and IL-8 (1,695 versus 900 pg/mL). In the serum, only IL-6 levels were significantly higher (375 versus 11 pg/mL). Conversely, nitrite levels were significantly lower in PF of OHSS patients (0.5 versus 34 nmol/mL). Interleukin 1 levels were higher and IL-1 receptor antagonist levels were lower in OHSS patients, suggesting potentially increased biologic potency of IL-1. Conclusion These findings suggest that these substances could be involved in mediating the capillary hyperpermeability characterizing this syndrome.

Objective We evaluated rate of levator ani muscle (LAM) avulsion among primiparae using 3-dimensional transperineal ultrasound to identify possible risk factors for such trauma. Study Design We conducted a prospective observational study. Three-dimensional transperineal ultrasound was performed on all subjects. Primiparae were evaluated 24-72 hours after vaginal delivery. In all, 32 nulliparous gravidae (35-41 weeks) and 15 elective cesarean delivery primiparae were evaluated as methodological controls. We compared newborn head circumference (HC), birthweight, second stage duration, maternal age, baby sex, episiotomy, and instrumental delivery. Results LAM trauma was observed in 39 of 210 (18.8%) patients and no controls. Odds ratio for LAM trauma when newborn HC ≥ 35.5 cm was 3.343 (95% confidence interval, 1.33-8.42); when second stage duration ≥ 110 minutes, odds ratio was 2.27 (95% confidence interval, 1.07-4.81). Logistic regression showed that HC ≥ 35.5 and second stage duration ≥ 110 minutes increased odds of LAM trauma by a factor of 5.32. Conclusion Large HC and prolonged second stage duration are risk factors in LAM trauma. Elective cesarean delivery may prevent LAM trauma.

Objective Patients with vulvar vestibulitis syndrome (VVS) and control subjects were tested for a polymorphism in the gene coding for the NALP3 component of inflammasomes, cytoplasmic structures regulating interleukin (IL)-1β production. Study Design DNA from 143 women with VVS and 182 control women were tested for a length polymorphism in intron 4 of the gene ( CIAS1 ) that codes for NALP3. Vestibular tissue was examined for NALP3 expression. Whole blood cultures were tested for Candida albicans -induced IL-1β production. Results The allele 12 frequency was higher in control subjects than in the patients with VVS ( P = .02). Among patients with VVS and a self-reported history of recurrent vulvovaginal candidiasis (RVVC), the allele 7 frequency was 43.9% as compared with 30.8% in patients with no history of RVVC and 26.9% in control women ( P = .035 vs other patients and .001 vs control subjects). NALP3 was identified in vestibular tissue. C albicans -induced IL-1β production was reduced in samples from women with the 7,7 genotype ( P = .030). Conclusion Polymorphism in the CIAS1 gene may play a central role in the triggering of VVS in a subset of patients.