Objective To evaluate prospectively the role of endovaginal ultrasonography in the diagnosis of adenomyosis and to identify predictive characteristics. Setting In Vitro Fertilisation Unit, Hammersmith Hospital. Subjects Fifty‐six women with menorrhagia and dysmenorrhea. Design Endovaginal sonography was performed and uterine body morphometry and myometrial echogenicity were assessed. The sonographic suspicion of adenomyosis was scored high or low depending on the degree of uterine enlargement, uterine asymmetry not due to fibroids and heterogenicity of myometrial echoes. The sonographic diagnosis was compared either with the histological findings after hysterectomy (n= 34) or to the appearances on magnetic resonance imaging (n= 22). Results Adenomyosis was diagnosed in 28 patients: 15 by histology and 13 by magnetic resonance imaging. Endovaginal ultrasound demonstrated a sensitivity of 86%, a specificity of 50%, a positive predictive value of 86%, and a negative predictive value of 77%. Uterine morphometry alone did not predict adenomyosis: although the mean length of the longitudinal, antero‐posterior and transverse axis was larger in uteri with, compared with those without, adenomyosis, this did not reach statistical significance. The uterine asymmetry ratio was 1.43 (SD 0.6) and 1.34 (SD 0.4) (P= 0.26) in uteri with and without adenomyosis, respectively, but in the presence of adenomyosis the mean posterior wall was significantly thicker than the mean anterior wall: 25.6 (SD 66) mm compared with 21.8 (SD 5.0) mm, P= 0.02. Therefore, adenomyosis was best predicted on the basis of ill‐defined myometrial heterogeneity. However, leiomyomas and various echogenic shadows and artefacts often complicate subjective assessment of the myometrial echogenicity. Conclusion Endovaginal sonography in symptomatic patients can be a sensitive but not a specific procedure for the diagnosis of adenomyosis.

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The literature suggests that the results of in-vitro fertilization (IVF) for patients with endometriosis depend on the stage of the disease, and that patients with severe endometriosis have a higher failure rate. Miscarriage is said to be more prevalent in women treated for endometriosis. In the study reported here, 140 patients with endometriosis underwent 182 cycles of IVF using gonadotrophin-releasing hormone analogues (GnRHa). Patients with endometriosis only were allocated to one group (group 4). The results were compared with those of three other groups of patients undergoing the same treatment within the same period. Group 1 consisted of couples with male factor only (45 cycles), group 2, couples with unexplained infertility (196 cycles) and group 3, couples with a tubal factor only (1139 cycles). The mean age of the patients, mean number of human menopausal gonadotrophin (HMG) ampoules administered, oestradiol concentration on the day of human chorionic gonadotrophin administration, number of days of HMG, mean number of oocytes retrieved and retrieval rate were not significantly different. The fertilization rate was significantly lower in group 1; no difference was observed in the other three groups. The mean number of normally fertilized embryos was not significantly different. The number of transferred embryos in each cycle and the implantation rates were similar in the four groups. The overall pregnancy rate per transfer was 39% in group 1, 48% in group 2, 45% in group 3 and 40% in group 4.(ABSTRACT TRUNCATED AT 250 WORDS)

Polycystic ovary syndrome (PCOS) is closely associated with high miscarriage rates and, following in-vitro fertilization (IVF), with decreased fertilization rates, suggesting that oocytes and embryos are of poor quality. In this prospective study, we examined the development, metabolic activity and blastocyst cell number of embryos following IVF from 51 patients with either anovulatory PCOS, ovulatory PCOS or tubal disease. The number of oocytes retrieved and the fertilization rates were similar for patients with PCOS and tubal disease. Following embryo transfer, 46% of the patients with PCOS and 36% of patients with tubal disease became pregnant. A similar proportion of surplus embryos from patients with PCOS and tubal disease developed to the blastocyst stage (38% and 43% respectively). Patients with anovulatory PCOS had embryos with less fragmentation which cleaved faster, cavitated earlier and had more cells at the blastocyst stage than embryos from patients with tubal disease. While the profile of glucose uptake and lactate production was similar for all groups throughout preimplantation development, patients with tubal disease who underwent ovulation induction using the 'titrated' regimen optimized for PCOS patients resulted in embryos with reduced pyruvate uptake, in addition to low blastocyst cell numbers. This study demonstrates that with an optimized ovulation induction regimen, embryos from PCOS patients are of good quality and developmental potential.

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Using scanning electron microscopy we found differences in the fine structure of the zona pellucida between unfertilized and fertilized human pronuclear stage oocytes in an in-vitro fertilization programme. In unfertilized oocytes, the zona pellucida appeared porous, comprising a large number of ring-shaped structures, called hoops, randomly superimposed in several layers. Superficial pores had a mean diameter of 4 microns, with the diameter decreasing in more inner lying pores. In fertilized oocytes, the zona pellucida was compact; the hoops appeared to melt and the pores to be obliterated by an amorphous material emerging from the inner zona. The micrographs provide ultrastructural evidence of the zona reaction in human oocytes and give insights into the morphological and mechanical aspects of the polyspermy-blocking mechanism in humans.

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