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-



servative laparoscopic treatment of 321 ectopic pregnancies. Fertil SterilI986;46:1093-7. 3. Pouly JL, Chapron C, Manhes H, Canis M, Wattiez A, Bruhat MA. Multifactorial analysis of fertility after conservative laparoscopic treatment of ectopic pregnancy in a series of 223 patients. Fertil Steril 1991;56:453-60. 4. Chapron C, Pouly JL, Mage G, Canis M, Wattiez A, Bassil S, et al. Rkcidives apres traitement coelioscopique conservateur d'une premiere grossesse extra-uterine. J Gynecol Obstet BioI Reprod (Paris) 1992;21:59-64. 5. De Cherney AH, Silidiker JS, Mezer HC, Tarlatzis BC. Reproductive outcome following two ectopic pregnancies. Fertil Steril 1985;43:82-5.

Reply of the Authors: The Bruhat group is certainly known for their contribution to the current management of ectopic pregnancy. Yet, contrary to their contention, our results are not confirmatory of theirs but rather original and unique. Our study, which is a temporal extension of the original trial published in 1989 (1), has done what is unfortunately so rarely done in surgical research. It has compared a new surgical technique with an established method in a prospective and randomized fashion. The Bruhat group's conclusions from their retrospective study, although important, were not based on solid scientific principles, and no comparison with any other established technique, conservative or nonconservative, was described. As to the comment regarding treatment of recurrent ectopic pregnancy, it is quite interesting to note that the Bruhat group's own study (2) and our study are similar in their results and conclusions. They found that 11 (46%) of 24 patients with history oftwo ectopic pregnancies had recurrences, whereas only 5 (21 %) had intrauterine pregnancy. They recommended that patients with one previous ectopic pregnancy and pelvic adhesions or solitary tube undergo salpingectomy rather than salpingostomy if they have access to an in vitro fertilization (IVF) program. We would like to emphasize that our small series of patients with recurrent ectopic pregnancies preclude any firm conclusions. However, as mentioned in the study, if IVF is an option, patients should be informed of the high risk of recurrence after two consecutive ectopics versus only a 5% chance with IVF.

Michael Vermesh, M.D. Department of Obstetrics and Gynecology University of Southern California School of Medicine Los Angeles, California 860


Steven C. Presser, M.D. Los Angeles Fertility Institute Beverly Hills, California June 16, 1992 REFERENCES 1. Vermesh M, Silva PD, Rosen GF, Stein AL, Fossum GT,

Sauer VM. Management of unruptured ectopic gestation by linear salpingostomy: a prospective, randomized clinical trial of laparoscopy versus laparotomy. Obstet Gynecol 1989;73: 400-4. ' 2. Pouly JL, Chapron C, Mahnes H, Canis M, Wattiez A, Bruhat MA. Multifactorial analysis of fertility after conservative laparoscopic treatment of ectopic pregnancy in a series of 223 patients. Fertil Steril 1991;56:453-60.

Capacitated or Acrosome-Reacted Sperm?

To the Editors: We read with interest the article by Margalioth et al. (1) in which they found that some human sera that were negative or had low levels of antisperm antibodies were positive or showed significantly higher levels of antibodies binding to the sperm after 18 hours of incubation with capacitating medium. From their studies, they stated that the capacitated sperm bound serum antibodies are different from those bound by freshly ejaculated sperm. It seems that this paper proposes for the evidence of antisperm antibodies that are specific to capacitated sperm in human sera. Because they defined capacitated sperm as samples achieving a >70% penetration rate of zona-free hamster eggs, it would be more likely that these spermatozoa are acrosome reacted and/or reacting instead of capacitated. It is known that the basis of the zona-free hamster oocyte penetration assay is that capacitated and acrosome-reacted sperm can fuse with the oolemma. Studies have shown that only acrosome-reacted human sperm bind to zonafree hamster eggs (2). The spontaneous acrosome reaction can occur in vitro. Mortimer et al. (3) reported that about 60% of the spermatozoa incubated in tissue culture medium for 12 hours had partly or completely lost their acrosome. In addition, acrosome-intact sperm during the early stage of the acrosome reaction may have undergone migration of limited amounts of acrosin from the acrosome to the sperm surface (4). Antisperm antibody binding specificity to human acrosin in human sera has been reported (5). Therefore, the antisperm antibodies that have reacted against "capacitated" sperm in their study are more likely to Fertility and Sterility

Treatment of recurrent ectopic pregnancy.

semination treatment arm producing a significantly better pregnancy rate than timed intercourse using the same ovarian stimulation in both arms. We th...
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