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We report a case of a patient with polycystic ovary syndrome and primary infertility who was admitted to our in-vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) programme because of her partner's severe oligozoospermia and asthenozoospermia. Ovarian stimulation was accomplished in the three treatment cycles using gonadotrophin therapy after a dual approach with ovarian suppression using oral contraceptive pills followed by gonadotrophin-releasing hormone agonist therapy. Oocyte retrieval was unsuccessful in the first two treated cycles despite the fact that human chorionic gonadotrophin (HCG) from three different batches was used. In the third treatment cycle, recombinant HCG was used and five oocytes were retrieved. This is the first report of recurrent empty follicle syndrome despite the use of different batches of commercially available urinary HCG, and of its successful treatment using recombinant HCG.

Immunopathophysiological mechanisms in endometriosis-associated reproductive failure were studied in appropriate populations: infertile and fertile women with and without endometriosis. The incidence of sera positive for any of the autoantibodies tested among infertile women with endometriosis (n = 25) was similar to that observed in the three control groups [unexplained infertility patients (n = 25) and fertile women with (n = 10) and without (n = 25) endometriosis]. The mean volume of peritoneal fluid was significantly elevated in women with endometriosis (both fertile and infertile) as compared with patients without endometriosis (fertile or infertile). The concentration of peritoneal fluid leukocytes and the percentage of cells positive for macrophage markers were significantly increased and the percentage of T lymphocytes significantly decreased in infertile women with endometriosis but not in patients with unexplained infertility and fertile women with endometriosis, as compared with fertile controls without endometriosis. Macrophages from infertile patients with endometriosis had higher sperm phagocytosis than did those from infertile women without endometriosis or fertile subjects with or without endometriosis. Incidences of serum and peritoneal fluid samples embryotoxic to the in-vitro development of 2-cell mouse embryos were significantly higher in infertile patients with endometriosis than in unexplained infertility patients and fertile women with or without endometriosis. It is concluded that immunological mechanisms of endometriosis-associated infertility exist but that these peritoneal immunological factors in infertile women with endometriosis are related to their subfertility rather than to the presence of ectopic endometrial implants. This is supported by the lack of immunological abnormalities observed among fertile women with endometriosis. These immunological abnormalities are lacking in patients with unexplained infertility.

Routine screening for circulating antiphospholipid antibodies (aPL), namely the lupus anticoagulant (LA) and anticardiolipin antibodies (aCL), was carried out in a total of 1273 women aged45 years. Of them, 822 were experimental subjects and 451 were controls. The former comprised the following three study groups: 498 infertile patients (group 1), 284 spontaneous recurrent aborters (group 2), and 40 patients with repeated failure of embryo transfer (group 3). Controls included five groups of women: 125 normal healthy women who had never been pregnant (group 4), 125 normal healthy parous women with no previous abortion (group 5), 52 women in labour after normal pregnancies at term (group 6), 49 infertile patients achieving a livebirth with their first in-vitro fertilization (IVF) and embryo transfer (group 7), and 100 female patients with systemic lupus erythematosus (positive controls, group 8). aPL positivity in the eight groups studied was as follows: 24, 9.2, 10, 0.8, 0, 0, 0 and 42% respectively for groups 1 to 8. There were no differences within groups 1 and 3 regarding incidence of aPL when patients were grouped according to infertility aetiological factors and indications of IVF respectively. Twenty-six out of 284 recurrent aborters (9.2%) tested positive for aPL, and the LA and/or a CL were identified as the aetiological factor in 12% of patients (24/199) with supposedly unexplained recurrent abortion. Incidence of positive sera for aPL in group 1 was similar to that observed in control groups 4, 5 and 6. On the contrary, incidence of aPL positivity in groups 2 and 3 was significantly higher than in control groups 4, 5 and 6 and among infertile women (group 1). The difference between groups 3 and 7 almost reached statistical significance. Interestingly, there was no difference between groups 2 and 3, but groups 2 and 7 resulted probably different regarding incidence of aPL positive sera. As expected, the highest incidence of patients testing positive for aPL was found in group 8. Seven infertile patients having circulating aPL and becoming pregnant spontaneously or after specific infertility treatment, successfully carried to term in spite of the fact that they did not receive immunotherapy. Among recurrent aborters, the live-born baby rate was significantly higher after treatment with low-dose aspirin than prior therapy. It is concluded that the presence of circulating aPL may be associated with recurrent abortion but with infertility. In addition, our results favour a possible role of aPL in failure of implantation after IVF embryo transfer.

On the basis that gonadotrophin-releasing hormone agonists (GnRHa) induce a significant but transient shrinkage of leiomyomas and that oral contraceptive use may be associated with a decreased risk of fibroids, we tested the hypothesis that sequential GnRHa/low-dose oral contraceptive treatment could be a therapeutic alternative in perimenopausal women with uterine fibroids. Six premenopausal women with leiomyomata uteri were treated with D-tryptophan-6-luteinizing hormone-releasing hormone (D-Trp-6-LHRH) depot (Decapeptyl 3.75) for 6 months and demonstrated a significant reduction in mean uterine volume. A low-dose oral contraceptive containing 30 micrograms of ethinyl oestradiol plus 150 micrograms of desogestrel was given during the ensuing 12 months. When GnRHa therapy was discontinued, there was a rapid regrowth of the uterine fibroids and the uterine volume had reached, or even exceeded, pretreatment values by the eighth to 12th month of contraceptive therapy. Sequential GnRHa/low-dose oral contraceptive treatment is not a useful tool for leiomyomata uteri.

Malignant struma ovarii is a very rare tumour, with considerable controversy concerning the necessary histologic features for malignancy. Still more infrequent is the condition termed 'metastatic ovarian strumosis' or simply 'benign strumosis or strumatosis' and characterized by the presence of peritoneal implants of mature thyroid tissue occurring in struma ovarii. 'Strumosis' should not be confused with malignancy. Presented is a case of 'metastatic ovarian strumosis' in a 36-year-old woman with primary infertility who underwent three in-vitro fertilization (IVF) cycles with ovarian stimulation. She received hormonal treatment for 6 months after her last IVF because of 'persistent enlarged ovarian follicles' which were in fact 'thyroid follicles'.

We report a case of a twin pregnancy at term obtained after five multiple embryo transfers in a patient who presented diethylstilbestrol (DES)-associated cervical and uterine structural abnormalities, a septate uterus and bilateral tuberculous salpingitis. The suitability of in-vitro fertilization/embryo transfer in DES-exposed women is discussed.

We have studied, prospectively, the incidence of several antiphospholipid antibodies (lupus anticoagulant, anticardiolipin, anti-phosphatidylserine, anti-phosphatidic acid, anti-phosphatidylinositol and anti-thromboplastin antibodies) in 65 consecutive patients with two or more (range 2-8, mean 3.1) abortions. Lupus anticoagulant activity was detected in seven (10.7%) patients and all of them exhibited other antiphospholipid antibodies. Of the previous pregnancies in these seven women, 88% had ended in spontaneous abortion. Four of them achieved pregnancy after low-dose aspirin therapy was started, and carried successfully to term. It is concluded that antiphospholipid antibodies, namely lupus anticoagulant, should be routinely screened in the recurrent spontaneous aborter.