P_Iss6-2011

The Practitioner Published by the Florida Association of Equine Practitioners, an Equine-Exclusive Division of the Florida Veterinary Medical Association Issue 6 • 2011

In this Issue 5 |

Dr. Michelle LeBlanc Receives FAEP Lifetime Achievement Award 6 | Diagnostics for Evaluating the Infertile Mare 12 | Assisted Reproductive Techniques for the Performance Mare 17 | Nutraceuticals for Enhancing Stallion Fertility 19 | Treatment of Placentitis: Where are We Now? 22 | The Ocala Equine Hospital

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Letter from the President December 2011 Dear Fellow FAEP Members, EXECUTIVE COUNCIL Gregory D. BonenClark, DVM, Diplomate ACVS FAEP Council President

gbonenclark@fevaocala.com

Anne L. Moretta, VMD, MS FAEP Council Vice President

maroche1@aol.com Jacqueline S. Shellow, DVM, MS FAEP Council Past President

docshellow@bellsouth.net Mr. Philip J. Hinkle Executive Director

phinkle@fvma.org

COUNCIL REPRESENTATIVES J. Barry David, DVM, Diplomate ACVIM

bdavid@emcocala.com

Amanda M. House, DVM, Diplomate ACVIM

housea@ufl.edu

Suzan C. Oakley, DVM, Diplomate ABVP (Equine) FAEP Council

oakleyequine@gmail.com Liane D. Puccia, DVM

pucciavet@aol.com

Ruth-Anne Richter, BSc (Hon), DVM, MS

rrichter@surgi-carecenter.com Corey Miller, DVM, MS, Diplomate ACT FAEP Council Representative to the FVMA Executive Board

cmiller@emcocala.com

The Practitioner is an official publication of the Florida Association of Equine Practitioners an EquineExclusive Division of the Florida Veterinary Medical Association.

Time is marching along and we at the FAEP/FVMA are doing so as well.

The FAEP Council should have a completed list of continuing education events, dates and speakers by early 2012. These will include (but are not limited to) the 8th Annual Promoting Excellence Symposium in the Southeast at the Naples Grande Beach Resort in Naples, FL from October 11-14, 2012; the 50th Annual Ocala Equine Conference at the Hilton Ocala (fall 2012), and the 3rd Biennial UF Student Appreciation Day in Ocala.

Membership invoices were mailed last week and should be on each of your desks by the end of the year. We have reduced our yearly dues and, as you make payment, please remember that this price includes membership in our combined organization that represents both your continuing education and legislative interests. The legislative session will start in January and several important issues are on the docket for discussion including regulation of non-licensed veterinarians.

The FAEP Council will be working with the FVMA in the upcoming year on a University of Florida student mentoring program that will include all four classes. FAEP members interested in participating in this program or who would like additional information are encouraged to contact Brenda Eggert Brader, FVMA Communications Director, at bbrader@fvma.org.

Thanks to all of you for your continued support. Our organization is stronger than ever and we are looking forward to a productive 2012. Please update your membership profile online at the FAEP website, www.FAEP.net, so that we may communicate with each of you in a timely manner.

The FAEP extends best wishes to you for a wonderful holiday season and a Happy New Year! We look forward to seeing you at some of our upcoming events in the next year.

Sincerely, Greg BonenClark, DVM, DACVS FAEP 2012 Council President

Florida Licensed Veterinarians Biennial License Renewal Deadline Is May 31, 2012 Members are reminded that 2012 is the next year to renew your veterinary medical licenses with the Board of Veterinary Medicine in the Department of Business and Professional Regulation in Tallahassee. Licenses are renewed every two years and always in the even year. Everyone renews at the same time.

4 The Practitioner

Issue 6 • 2011

Dr. Michelle LeBlanc Receives FAEP Lifetime Achievement Award

by Brenda Eggert Brader, Communications and Public Relations Director

D

r. Michelle LeBlanc is the recipient of the FAEP Lifetime Achievement Award for 2011 presented to her at the 7th Annual Promoting Excellence Symposium in the Southeast held on Amelia Island, September 29 to October 2.

The Lifetime Achievement Award is given to an FAEP member in recognition of significant contributions made to equine veterinary medicine in Florida.

“It was a great honor to present the FAEP 2011 Lifetime Achievement Award to Dr. LeBlanc,” said Dr. Jackie Shellow, FAEP immediate past president.

“She is most deserving and is not only a world renowned veterinarian and theriogenologist, but also my teacher, advisor, mentor, and is a dear and special friend.

She has taught and touched the lives of so many veterinarians and helped so many horses!”

One of the most deserving recipients of the award, Dr. LeBlanc is a respected peer, a wonderful mentor and a brilliant clinician, said Dr. J. Barry David, FAEP Council member.

“Dr. LeBlanc's contributions are not limited to the study of equine reproduction,” Dr. David said. “She continues to be an inspiration to students, clients and veterinarians throughout the country and the world.”

Dr. LeBlanc received her DVM degree from Michigan State University in 1977.

After graduation, she worked in a mixed animal practice in Elkton, MD, and in 1980, joined the faculty at the University of Florida College of Veterinary Medicine where she held the positions of professor and director of the equine research program.

While at UF, she received numerous awards including the Carl J. Nordon Distinguished Teacher and the McDaniels Clinical Research Award for her work with oxytocin in infertile mares. Dr. LeBlanc received the Theriogenologist of the Year Award from the ACT in 2000 for her www.faep.net

research, teaching and service efforts.

She is a 1982 Diplomate of the American College of Theriogenologists and is a past president of the college.

“The American College of Theriogenologists’ award was given in recognition to LeBlanc who developed the naturally occurring hormone oxytocin as the first effective treatment for a major cause of infertility in mares,” said Dr. Amanda House, FAEP Council member.

Dr. Michelle LeBlanc, left, accepts her Lifetime Achievement Award from Dr. Jackie Shellow, FAEP president at the time of the presentation at the 7th Annual Promoting Excellence Symposium in the Southeast held on Amelia Island, September 28 through Oct. 2. The award is given to an FAEP member in recognition of significant contributions made to equine veterinary medicine in Florida.

“Her findings have been of immense benefit to Florida’s equine industry because problems associated with endometritis – including the loss of offspring – are estimated to cost horse breeders millions of dollars.”

Dr. LeBlanc is published in the areas of mare infertility and perinatology, and holds the patent on the equine colostrometer. She is a member of the Committee for International Symposium on Equine Reproduction and is a past board member of the American Association of Equine Practitioners.

“Her genius lies in her ability to find simple solutions to complex problems,” said Dr. Suzan Oakley, a former student of Dr. LeBlanc and now a member of the FAEP Council. "She never loses touch with the animal as a whole. The elegance of Dr. LeBlanc’s treatment solutions lies in the fact that she utilizes cost effective methods that can easily be implemented in the field. She is a positive force in the industry and so giving of her knowledge.

Dr. Leblanc is a leader in her profession.”

Dr. LeBlanc joined Rood and Riddle Equine Hospital in Central Kentucky in January 2002. She is presently one of three theriogenologists on staff at RREH. Dr. LeBlanc divides her professional time between Lexington, KY and consulting on cases in Ocala, FL.

Dr. Amanda House, left; Dr. Michelle LeBlanc, Dr. Jackie Shellow and Dr. Chris Sanchez gather during the presentation of the Lifetime Achievement Award to Dr. LeBlanc.

The Practitioner 5

Diagnostics for Evaluating the Infertile Mare

1

The basic reproductive examination

A basic reproductive examination includes obtaining a history, conducting a physical examination, evaluating the perineal conformation, and performing a rectal/ultrasonographic exam of the reproductive tract, vaginal speculum examination and digital examination of the cervix. Ancillary aids include uterine cytology and culture, endometrial biopsy and endoscopic examination of the reproductive tract. The latter diagnostics are chosen on a case by case basis. The importance of obtaining a complete reproductive and performance history can not be over stated. Clinical signs are frequently repeated from one cycle to the next and these findings provide important information as to the primary cause of the infertility. If a reproductive case is a referral from another veterinarian, discussing previous diagnostics, treatments performed and the veterinarian’s opinion about the case provides valuable information on what should or should not be pursued. All clinical findings and treatment protocols should be recorded so if the mare does not become pregnant the data can be reviewed. A one page check off sheet that includes space (history, perineal conformation, physical exam etc.) to write one’s findings is helpful in ensuring that a complete examination is performed.

External exam The general physical condition of the mare and the farm management should be appraised before transrectal evaluation of the reproductive tract as systemic problems such as poor body condition, laminitis or pain may adversely affect fertility. Mares with laminitis may accumulate uterine fluid because they have limited mobility. Abnormal estrous cycle length or lack of estrous cycles during the mare’s natural cyclic season may be associated with dramatic drops in ambient temperature and subsequent weight loss, pain, uterine infection, or systemic endocrine abnormality such as Cushing’s Disease or metabolic syndrome. Feeding or management changes, dental care or parasite control may be needed. Race mares brought directly from the track or performance mares completing their career may not handle group dynamics of a brood mare band. Placing a maiden race mare in a small paddock with another mare may improve her ability to cope. Mares housed in northern temperate climates require more energy in January, February and March as they expend more calories in the cold. Mares that lose weight in the early spring tend not to cycle properly even when placed under 14.5 or more hours of artificial light in December.

Because most uterine infections are due to bacteria or yeast ascending through the vagina, perineal anatomy must be evaluated critically. Conformational characteristics that 6 The Practitioner

by Michelle LeBlanc, DVM, DACT, FAEP's 2011 Lifetime Achievement Award Recipient

correlate with high fertility include a long sloping hip, a sacroiliac joint located 3 or more inches dorsal to the tail setting (as viewed from the side) and a vulva that is no more than 10 to 20º off of vertical. Mares that pool intrauterine fluid after breeding often are flat over their croup with a tail setting level with the sacral iliac joint and a sunken anus. The perineum is best evaluated during estrus, when relaxation and elongation of the vulvar lips are greatest.

The integrity of the vulvar lips, the angulation of the vulva and the location of the dorsal commissure of the vulva in relation to the pelvis need to be evaluated. If the dorsal aspect of the vulva is more than 4 cm above the pelvis, or the vulvar lips are more than 20° off vertical, air and/or feces may be aspirated into the vestibule during estrus. The lips of the vulva should be parted to determine the integrity of the vestibulo‐vaginal sphincter. The sphincter is intact when the labia can be spread slightly without air entering the cranial vagina. By parting the labia, the color and moisture of the vestibular walls can be assessed. Estrus produces a glistening pink to slightly red mucosa that is uniform in color and wet.

Anestrus generally is reflected by a pale, dry mucosa; dark‐ red, muddy color or a splotchy color suggests inflammation.

A white, tacky mucosa indicates progesterone dominance.

The perineal body may be defective in older, pluriparous mares. Damage may occur after repeated foalings, delivering a large foal, after a dystocia, or from poor reproductive conformation. The integrity of the perineal body can be assessed by placing one finger into the rectum (usually the second finger) and the thumb into the vestibule. A vestibuloplasty or “deep caslick’s” may be required to prevent contamination of the anterior reproductive tract especially if the vestibulovaginal seal is lost.

Rectal/ultrasonographic examination of the reproductive tract Repeated ultrasonographic evaluation of the reproductive tract during the estrus cycle is routine in many reproductive practices. Correlations between uterine edema, cervical dilation and follicle dynamics should be made and inconsistencies such as excessive edema early in estrus (lack of cervical dilation or endometritis), a narrow long cervix during estrus or free intra‐luminal fluid (uterine drainage problem or endometritis) need to be noted. With the advent of ultrasonography, veterinarians can time breeding more closely with ovulation and can identify pathologies such as anovulatory follicles, granulosa cell tumors, intra‐luminal fluid and uterine cysts. However, ultrasonography does not replace good manual skills. The tone and consistency of the uterus and dominant follicle and the length and width of the cervix can only be identified by a veterinarian skilled in rectal palpation. Inconsistencies such as a turgid, firm Issue 6 • 2011

uterus during estrus or a narrow, long cervix in a mare on the day of ovulation indicate problems such as endometritis and cervical incompetence. A grading system for uterine edema, fluid accumulation and follicular dynamics should be developed so veterinarians within a practice can follow up on each other’s cases if needed. Reviewing the ultrasonographic findings over a number of cycles in an infertile mare can provide valuable information on possible causes of the infertility.

Vaginal speculum Vaginal speculum examination is an integral part of the breeding soundness examination. Findings include determining the integrity of the vestibulo‐vaginal sphincter, identifying abnormal fluids in the vaginal vault such as pus or urine, finding a discrepancy between cervical relaxation and stage of estrous cycle or finding a cervical tear or cervical adhesion to the vaginal fornix. In addition, vaginal varicosities or an imperforate hymen may be identified.

Mares with endometritis may have an edematous red cervix that is located midway up the vaginal wall. Maiden mares with cervical incompetence may have a pale, puckered, closed cervix that is located high on the vaginal wall during estrus.

Color of the vaginal walls and cervix should be noted as color is correlated with stage of cycle or inflammation.

Cervical examination Cervical tears or fibrosis. Proper cervical function is needed for a successful pregnancy. Trauma that results in a cervical tear, fibrosis or adhesions of the external os to the vaginal fornix can render a mare infertile. Afflicted mares frequently accumulate intra‐uterine fluid and have micro‐organisms isolated repeatedly from their uterus, even after repeated treatment with uterine lavage, intra‐uterine antibiotic or anti‐mycotic drugs. Some mares can clear the infection during winter anestrus, only to have the infection flare in the spring once the mare starts to exhibit estrous behavior. Cervical defects or adhesions between 4 and 8 o’clock are the most difficult to identify as vaginal exams are most commonly conducted during estrus when the cervix is lying on the vaginal floor. These lesions tend to be associated with chronic uterine infections as the cervix is pulled open www.faep.net

ventrally during diestrus allowing bacteria access into the cervical canal and uterus. If a cervical defect is suspected during estrus, the cervix should be re‐examined when the mare is under the influence of progesterone. A digital exam of the external os and the entire length of the cervical canal should be conducted. Fibrotic lesions associated with a previous foaling injury may be identified during rectal palpation of the cervix and reproductive tract. The cervical canal may be bent laterally to the right or left, likely as a result of tearing and subsequent scarring of the muscle on one side of the cervical canal during foaling. A common history in mares with cervical fibrosis is delivery of a large foal, manual assistance during foaling, dystocia or abortion in late gestation.

Determining what lesions need to be repaired surgically is based on clinical history‐persistent uterine infections or pregnancy loss‐and the clinical experience of the veterinarian. Cervical tears longer than one third the length of the canal usually need to be repaired to ensure an adequate seal.

Treatment for cervical adhesions (adhesion of the external os to the vaginal fornix) must be determined on an individual basis as their removal may result in additional adhesion formation. The length of time needed between surgical repair and breeding varies. If the tear has occurred within the last 60 days, fibrosis and chronic infection are less severe than if the lesion is 2 to 3 years old. The former group of mares may be bred 3 to 4 weeks after surgery, whereas, the latter group will require 45 or more days for the edema and inflammation to subside. In addition, long standing cervical lesions are commonly associated with chronic bacterial or fungal endometritis. The infection may flare after a cervical repair because air and blood contaminate the uterus during surgery. The cervix tends to lose its pliability after surgery and a stricture may form within the canal at the cranial aspect of the repair. These complications can delay physical drainage of the uterus. Therefore, mares that have undergone a cervical repair should be treated after breeding with uterine lavage, ecbolics and possibly intra‐uterine antibiotics. Mares mated by natural service should be re‐enforced with semen after the horse dismounts. A surgically repaired cervix will likely tear again when the mare foals so cesarean section is recommended.

Inadequate cervical dilation during estrus. Incomplete dilation of the cervical canal during estrus is most commonly seen in older (> 10 yrs of age) maiden mares retired from a performance career. Clinical impression is that it occurs more commonly in Saddlebreds and Morgan mares. In some cases, mares may present with a partial relaxed external os but the cranial aspect of the canal and the internal os will be tightly closed. In other cases, the entire cervical canal is tight and it may be difficult to pass a finger through the cervix. Incomplete dilation results in chronic endometritis, fluid retention in the uterine body cranial to the cervix, and decreased pregnancy rates. As most mares are bred artificially with cooled or frozen semen, an adequate amount of semen can be deposited in the uterus as there is not great difficulty in passing an artificial insemination pipette through the cervical canal. However, these mares tend to retain intra‐uterine fluid and if not treated promptly after breeding for fluid retention, they can have decreased embryo The Practitioner 7

recovery rates, poor quality embryos recovered or decreased 14 day pregnancy rates. If mares are bred by natural service, there is the additional problem of decreased semen deposition within the uterus.

Cervical fibrosis results from trauma at foaling, severe metritis or infusion of a caustic drug or chemical into the uterus. Diagnosing cervical fibrosis can be difficult and many times requires a number of examinations before the diagnosis can be made. A fibrotic cervix is narrow, not pliable and is snug around a finger. In some mares, the canal can be tortuous and may bend laterally, dorsally, or ventrally. Some defects can be identified on rectal palpation when the mare is in diestrus as the cervix may bend laterally by 20 to 45 degrees. The reproductive history may include delivery of a large foal with or without assistance. The mare may deliver a few foals after the initial trauma before she experiences chronic endometritis. The repeated stretching of the cervix at foaling will cause tearing of the fibrotic tissue and additional scarring. Repeated embryo transfer attempts over a number of years may also result in cervical fibrosis. Histological descriptions of cervical pathology are limited because it is difficult to properly prepare cervical tissue for histological evaluation.

Mares with cervical fibrosis may develop uterine infections that require prolonged intra‐uterine and systemic treatment, especially if the lesion is more than a year old and the mare has been bred repeatedly before the defect is diagnosed. Once the infection is cleared, sexual rest for 30 or more days is recommended so that the chronic uterine inflammation can resolve. Aggressive post breeding management may be required to assist with physical uterine clearance. We recommend uterine lavage between 4 and 8 hrs after breeding, repeated use of ecbolics and intra‐uterine antibiotics in the first 48 hrs after breeding. Systemic antibiotics around the time of breeding and a single dose of dexamethasone (40 mg IV) at the time of breeding, or infusion of 30 ml of N‐acetylcysteine 24 h before breeding have also been used.

2

Laboratory Analyses Introduction

In addition to the physical examination, laboratory diagnostics: uterine cytology, culture and endometrial biopsy, are extremely helpful in identifying the cause of infertility.

Swabbing the endometrium on the 1st or 2nd day of estrus is the most commonly used method for identifying Thoroughbred mares with endometritis, however, recent work from Denmark indicates that a uterine culture swab may not identify all uterine pathogens. Neilsen (2005) reported that only 38 of 84 mares (45%) with bacteria isolated from the surface of an endometrial biopsy, had bacteria isolated from a uterine culture swab.

Uterine culture swab and endometrial cytology Evaluation of cytological specimens in conjunction with endometrial swabs has been promoted since the early 1980s as a technique that enhances the accuracy of endometrial 8 The Practitioner

culture in identifying mares with endometritis. Correlation between the presence of neutrophils in cytological specimens and the isolation of uterine pathogens is high when a sample is collected with a guarded uterine swab. Isolation of a microorganism from the uterus of a mare during estrus in the absence of cytological evidence of endometrial inflammation has been considered to be a contaminant. However, recent work indicates that some of these tenets may not be correct. Riddle et al evaluated 2123 endometrial cytology and culture specimens collected concurrently with a guarded uterine culture instrument from 970 mares (738 barren, 1230 foaling and 155 maiden mares) during the 2001‐2004 breeding seasons and compared findings to 28 day pregnancy rates.

Fifteen hundred and thirty seven of the 2123 (72.4%) paired cytology and culture samples evaluated were normal (0‐2 neutrophils and no bacteria isolated). Four hundred twenty three cytology samples were positive for inflammation (> 2 neutrophils) while 231 cultures had microorganisms recovered. Sixty four percent of the positive cultures (147/231) had inflammation on cytology smears. Pregnancy rates per cycle in mares with positive cytology or culture results were 50 or more percent lower than mares with normal cytologies and no bacteria isolated. Lowest pregnancy rates were recorded for mares with severe endometrial inflammation (23%). Isolation of gram positive organisms was associated with more positive cytologies than isolation of gram negative organisms. Based on these data, positive cytologies (set at >2 neutrophils) were twice as common as positive cultures. Degree of inflammation was more important in diagnosing infertility than mere presence or absence of inflammation (set at > 2 neutrophils). Isolation of microorganisms was associated with reduced pregnancy rates, even in the apparent absence of inflammation. Our findings indicate that if one solely relies on culture results 55% of mares with decreased fertility due to inflammation may be missed. Conversely if one solely relies on cytology results, 17% of mares with decreased fertility due to inflammation may be missed. Our findings contrast with the dogma that if bacteria are isolated from the uterus of mares with normal cytological findings, the organism should be considered a non‐ pathogen as mares in our clinical investigation had lower pregnancy rates than control mares.

Small volume uterine flush for uterine cytology and culture Obtaining a uterine swab from the uterine body during estrus may not be the most accurate method for evaluating the bacterial status of the uterus as the swab only comes in contact with a small area of endometrium. This may be especially true in older mares with a pendulous uterus as fluid pools in the uterine horns. Flushing the uterus with a small volume of sterile saline or lactated ringers identifies a higher number of subclinical infections because the fluid infused into the uterus comes in contact with the majority of the endometrium. Uterine problems can be identified immediately as the efflux collected from mares with infections or severe inflammation is cloudy or has strains of particulate matter. We have modified the technique first described by Issue 6 • 2011

Dr Barry Ball (1986; Theriogenology) for ease of use in the field. A 150 ml bag of saline is attached to the end of a uterine catheter and the bag is squeezed to express the fluid. The operator then removes his arm from the vagina and performs a rectal examination. After the uterus is sufficiently balloted the fluid is drained back into the bag. Efflux can then be poured into a clear 50 ml conical tube and assessed for fluid clarity. Cloudy efflux or efflux with strains of mucus is associated with isolation of bacteria or inflammation. In order to perform a culture and cytology, the efflux is allowed to settle for 1 or more hrs or the tube can be centrifuged for 10 min. If centrifuged the supernatant is discarded, the pellet at the bottom of the tube is cultured and a cytology smear is made by placing a second sterile swab in the pellet and rolling the swab on a glass slide.

Between June of 2004 through July 2006, we collected 401 small volume uterine flushes from 308 chronically infertile mares to diagnose endometritis. Mares evaluated were either barren after 3 or more breedings or had two or more unsuccessful embryo recovery attempts during consecutive cycles. Culture results were compared with cytological and histological findings, efflux clarity and pH to substantiate that the micro‐organisms recovered were truly pathogens.

Cytological specimens were evaluated for presence of epithelial and inflammatory cells, bacteria, yeast and debris.

Endometrial biopsies (n = 110) were examined for the presence of neutrophils in the stratum compactum. Microorganisms were recovered in 282/401 (70%) of low‐volume flushes; E coli was most frequently isolated (42.2%), followed by β hemolytic Streptococcus (37.6%). Efflux clarity of 318 flushes was clear (n = 109), cloudy (n = 149) or mucoid (n = 60). Isolation of micro‐organisms was highly associated with cloudy and mucoid effluxes (P < 0.001), debris on cytological specimens (P < 0.001), increased efflux pH (P < 0.003), and neutrophils on endometrial biopsy (P < 0.01). E coli was associated with debris on cytological smear whereas β hemolytic Streptococcus was associated with increased efflux pH. Using the presence of neutrophils in a tissue specimen as the “best standard” for diagnosing endometritis, the sensitivity of flush culture was 0.71 and for flush cytology was 0.8, whereas the specificity was 0.86 and 0.67, respectively.

Neutrophils in uterine flushes under‐reported inflammation; only 86/282 positive cultures were positive on cytology. The clinical estimate of a contaminated (false positive) flush culture was 11%, if a false positive was defined as positive culture with clear efflux and no debris or neutrophils on cytology (26/228).

Flush culture was twice as sensitive as swab culture estimated by Neilsen (0.71 versus 0.34) when the same “best standard” was used (presence of neutrophils in a tissue specimen). Therefore, flush culture doubled the ability to detect infected mares based on culture alone. The improved sensitivity appeared to result from improved detection of gram negative organisms as recovery of β hemolytic Streptococcus from uterine flush did not differ from previous reports nor from swab results obtained from Thoroughbred mares in central Kentucky (38% of positive flush cultures; 39% of positive swab cultures from RREH medical laboratory during the years 2005 and 2006). The technique is a rapid, accurate www.faep.net

and practical method for diagnosing endometritis in chronically infertile mares based on sensitivity and specificity estimates approaching 0.75 and 0.9, respectively.

Endometrial biopsy Endometrial biopsies provide valuable information on the integrity of the endometrium. However, endometrial biopsies have lost favor as a diagnostic technique because the current grading system rarely provides a change in management strategy. The grading system was designed to determine the likelihood of a mare carrying a foal until term and not to determine treatment strategies. Endometrial biopsy interpretations can direct treatment protocols and management strategies if the pathological description and diagnoses are reviewed, regardless of Kenney grade. Emphasis should be placed on the severity and location of inflammation, the type and degree of fibrosis, glandular density, whether or not there is a mucus layer overlying the endometrium, degree of endometrial edema, lymphatic lacunae and/or angiosis.

A thick ribbon of mucus is seen more commonly in barren mares than reproductively healthy mares and may require mucolytic agents to clear before antibiotic therapy is begun as it can interfere with antibiotic penetration. Endometrial edema and lymphatic lacunae are associated with cervical incompetence, inflammation or angiosis. If observed on the biopsy, one needs to review their findings from the breeding soundness examination to determine which of the three may be contributing to the histological changes. Angiosis, the fraying and hypertrophy of elastic tunics of the vessels, results in excessive edema within the uterine wall and has been associated with a decrease in blood flow. It is also is a marker for uterine arteries susceptible to rupture. Fibrosis has been recently categorized into destructive and non‐ destructive, active and not active fibrosis. The former is associated with a severe, acute or chronic inflammatory response and significantly lower pregnancy rates than non‐destructive fibrosis. If identified, the source of the inflammation needs to be corrected. Obtaining an endometrial biopsy after treatment for chronic endometritis or metritis will determine if treatment was successful or additional therapy is needed. If mares have focal lesions, an endoscopy should be considered as focal plaques may require removal by laser.

3

Endoscopy

Endoscopy is a helpful tool in identifying mares with uterine adhesions, foreign material in the uterine lumen, endometrial cysts, fetal remnants, endometrial tears and fungal or bacterial plaques. It is reserved for select cases and is usually conducted during diestrus on an estrous cycle that the mare will not be bred or after the breeding season as infusion of air into the uterus can be irritating. The endoscope should always be properly cold sterilized for a minimum of 20 minutes to prevent contamination of the uterus with bacteria that may reside within the channels of the scope.

Before placing the endoscope into the uterus, the outside of the endoscope and the port lines are rinsed with sterile saline. The procedure is best performed when the mare is in The Practitioner 9

diestrus. If performed during estrus, the air or saline infused into the uterine lumen can leak out through an open cervix thereby impeding visualization of the endometrium. The mare should be sedated with a combination of xylazine and torbugesic or detomidine and torbugesic as the procedure can be irritating. Once the endoscope is placed into the uterine body, it is filled quickly with air by placing an open line attached to an aerator used to aerate fish tanks down the port. Once the endometrium is visualized, the endoscope can be slowly advanced through the uterine body and into each horn. Plaques of bacteria or yeast can be of various sizes from pinpoint to dime size and are most commonly identified in the uterine body. After the procedure is completed, residual air is removed with either a pump or by placing a large bore catheter such as a Bivona catheter in the uterine lumen and allowing the air to be expelled.

The uterus should be lavaged with saline or lactated ringers as the air is irritating to the endometrium. Antibiotics or disinfectants may be infused for 2 to 3 days if the mare is prone to bacterial endometritis.

References

1. Blanchard TL, Varner DD, Schumacher J et al. Manual of Equine Reproduction 2nd ed. St Louis, MO: Mosby, 2003; 31‐58.

2. Pycock JF. Breeding management of the problem mare. In: Samper JC, ed. Equine Breeding Management and Artificial Insemination. Philadelphia: WB Saunders Co, 2000; 195‐228.

3. Nielsen JM. Endometritis in the mare: a diagnostic study comparing cultures from swab and biopsy. Theriogenology 2005;64:510‐518.

4. Riddle TW, LeBlanc MM, Pierce SW et al. Relationships between pregnancy rates, uterine cytology, and culture results in a Thoroughbred practice in central Kentucky, in Proceedings. Am Assoc Equine Pract 2005; 51: 198‐201.

10 The Practitioner

5. LeBlanc MM, Magsig J, Stromberg AJ. Use of a low‐volume uterine flush for diagnosing endometritis in chronically infertile mares. Theriogenology 2007; In Press.

6. Kenney RM. Cyclic and pathologic changes of the mare endometrium as detected by biopsy, with a note on early embryonic death. J Am Vet Med Assoc 172:241‐262, 1978.

Michelle M. LeBlanc DVM, DACT ++ Received DVM Degree from Michigan State University in 1977 ++ Professor and Director of the Equine Research Program at the College of Veterinary Medicine, University of Florida, 1980-2002 ++ Rood and Riddle Equine Hospital, January 2002 ++ Diplomate of the American College of Theriogenologists,1982, and a past president ++ Received numerous awards including the Carl J. Nordon Distinguished Teacher and the McDaniels Clinical Research Award for her work with Oxytocin in Infertile Mares while at UF ++ FAEP Lifetime Achievement Award Winner ++ Received the Theriogenologist of the Year Award from the ACT in 2000 ++ Holds the Patent on the Equine Colostrometer ++ One of three Theriogenologists on staff at RREH in Central Kentucky, divides her professional time between Lexington, KY and consulting on cases in Ocala ++ Published in the areas of Mare Infertility and Perinatology ++ Member of the Committee for International Symposium on Equine Reproduction, past board member of the American Association of Equine Practitioners.

Issue 6 • 2011

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Both depend on which therapy you choose.

So choose the only FDA-approved I.V. joint therapy for equine non-infectious synovitis.

Federal law restricts this drug to use by or on the order of a licensed veterinarian. For use in horses only. Do not use in horses intended for food.

E11959n

Assisted Reproductive Techniques for the Performance Mare

by Margo L Macpherson, DVM, MS, DACT; Alana King, DVM, DACT; and Mats Troedsson, DVM, PhD, DACT, ECAR

Introduction Assisted reproductive technologies offer alternative options to the horse owner wishing to use his or her mare for performance purposes while also producing valuable offspring. The most common reproductive procedure utilized in mares is embryo transfer. This technology is well accepted and can be performed on the farm or in a hospital setting. Less common procedures, such as oocyte transfer and intracytoplasmic sperm injection, require skilled personnel, equipment and special laboratory conditions. Oocyte retrieval and transfer is the rising technology in equine reproduction thus warranting discussion in this manuscript.

Embryo Transfer Embryo transfer (ET) enables genetiDr. Mats Troedsson and an assistant prepare for a procedure. cally desirable mares to produce more foals in a year. In the case of the performance animal, ET allows a mare to subfertile animals are used for embryo connected with a Y-junction to the flushcontinue in training or work while still transfer, the live foal rate is closer to 25% ing solution container on one end and proving reproductively functional. Breed per cycle. to a filter on the other end. The tubing registries may be restrictive on foals It is important to note that producing system and the filter are filled with the allowed per year therefore it is important a foal using ET can be significantly more flushing solution to avoid introduction to know the regulations in a particular expensive than a traditional breeding of air into the mare’s reproductive tract. breed registration when using assisted program. An owner can expect to spend The catheter is passed through the cervix technologies. It should also be noted that between $3,000- $6,000 for a live foal and into the body of the uterus. The balET is not a cure for donor subfertility, but following ET depending on the program loon cuff is filled with 35-60 ml of air or a treatment. Embryo transfer has little they choose and whether they provide distilled water and then gently pulled or no affect on fertility issues resulting their own mares. posteriorly creating a seal at the internal from oviductal or ovarian causes. cervical os. Warm (37°-39° C) flushing Embryo Recovery and Transfer Overall, success rates with ET are solution is infused into the uterus. Most Embryo recovery is performed between highly dependent on the animals being people use commercially prepared ‘com6.5 to 8 days post-ovulation. Day-7 recovused. Live foal rates are influenced plete’ flush media (non-PBS) that utilizes eries are most common, with the highest by both conception/recovery rate of a Zwitterion-based buffer system and overall success rates. Day-8 recoveries an embryo and pregnancy establishcontains antibiotics and purified albumay be beneficial in older donor mares or ment after transfer. When using fertile men (e.g. EquiPro TM Recovery, Minimares inseminated with frozen-thawed mares and stallions, embryos are recovtube of America, Verona, WI, EmCareTM, semen. Day-6 embryo recoveries are necered from approximately 70% of cycles.

ICP, Auckland, NZ or ViGroTM, AB essary if embryonic cryopreservation is Transferred embryos can be expected Technology Inc., Pullman, WA). Comthe goal. to result in pregnancy for about 70% of mercially prepared flush fluids are far Prior to embryo flush, the donor mares. When using fertile animals, clieasier to use and result in similar embryo mare’s perineum is aseptically prepared. ents should expect a 45-60% live foal survival rates as other fluid types. The A sterile, silicone, balloon-tipped cathrate when using embryo transfer. When amount of fluid used for each flush is eter (usually 8 mm internal diameter) is 12 The Practitioner

Issue 6 • 2011

dependent on the size of the uterus and can range from 500 to 2000 ml. The goal is to expand the endometrium enough to allow fluid to effectively reach all parts of the endometrium, including the area between the endometrial folds. The mare often becomes mildly uncomfortable upon stretching of the perimetrium, and this can be used to indicate that sufficient infusion of fluid into the uterus has occurred. The flush medium is then allowed to flow back out of the catheter by gravity flow through an in-line embryo filter. The uterus of the mare is usually massaged per rectum during the infusion and recovery of the final liter of media. Some practitioners believe it is advantageous to leave the final liter of media within the uterine lumen for 3-5 minutes prior to recovering the efflux.

Complete recovery of the uterine lavage fluid is monitored by collecting the fluid in a graduated cylinder, and/or ultrasonographic examination of the uterus at the end of the procedure. Additionally, 10-20 units of oxytocin can be administered, IV, prior to recovery of the final liter of fluid to facilitate uterine contraction and emptying.

Prior to removing the catheter from the mare, the vulva and perineal area should be carefully washed to avoid contamination of equipment as it is removed from the mare. Further, the catheter and tubing should be “rinsed” with flushing media several times after removal from the mare. Rinsing the lines aids in recovery of embryos which may be adhered to the tubing.

www.faep.net

Once the uterine flush is completed, Loading the Embryo for Transfer the filter and cap are rinsed with flush- Embryos are generally loaded into 0.5 ing solution and the contents are poured cm straws used for cryopreservation. into search dishes. Overfilling dishes can The embryo is then aspirated into the result in spills, fluid adhering to the dish straw, catheter or pipette in the followtop and difficulty in searching through ing fashion: media -air- media+embryo various fluid planes. A stereoscopic, dis- -air- media -air. This loading procedure secting microscope is used to search for minimizes the movement of the embryo the embryo, and using dishes with grids and provides a strong back pressure from can aid in this process. the Cassou gun to make sure the embryo has left the straw and entered the uterus.

Embryo Classification Embryos are classified by their stage of Recipient Selection development and graded on their qual- Synchronized recipient mares are evaluity. A day-5 or day-6 embryo is a morula ated via transrectal palpation and ultrawith a thick zona pellucida. Usually a sound prior to use for embryo transday-7 or day-8 embryo is an expanded fer. The mare with a tight cervix, and blastocyst with a capsule. McKinnon toned uterus free of fluid should be and Squires established a quality score used. Beyond the synchronization proof 1-5: grade 1 = excellent and grade tocol, cervical tone is one of the most 5 = degenerated or dead. Grade 1 or 2 important measures to selecting the best embryos have the highest success rates recipients. for transfer.

A donor embryo can be successfully transferred into a recipient mare that Handling the Embryo ovulates the day prior to (+ 1), the same Recovered embryos should be transday (0) or up to 3 days (-3) after the ferred to holding media and washed donor mare. It is recommended that 2 prior to transfer. A 4-well dish works to 3 recipients be synchronized along well for washing embryos. A drop of with the donor in order to have at least holding media is placed in each of the one recipient mare ovulating during the wells of the dish and the embryo is critical time window. Ideally, the recipimethodically moved from well to well, ent mare would have ovulated 1-2 days with the aid of a stereomicroscope. The after the donor mare. Large scale embryo embryo is transferred to the dish using transfer programs maintain large numa tomcat catheter, a 10-20Φl unipet bers of recipients and consequently have needle connected to a 1 cc (tuberculin) several mares ovulating on any given day. syringe or a Drummond microdispenser This option is often not well understood (Series 300) tool. The size of the Drumby an owner, but provides excellent conmond tool to be used is dependent upon ditions for transferring embryos under the size of the embryo.

The Practitioner 13

Oocyte Transfer and Gamete Intrafallopian Transfer (GIFT) During oocyte transfer, an oocyte is harvested from the preovulatory follicle of a donor mare, and placed in the oviduct of a recipient mare. Intrauterine artificial insemination (AI) may then be used in the recipient mare for fertilization of the transferred oocyte. Alternatively, sperm may be placed directly in the oviduct at the time of oocyte transfer; this procedure is called GIFT. GIFT may be selected over oocyte transfer in cases where the quantity of sperm available is limited, since much lower numbers of sperm are required than for standard AI techniques (as low as 1x105 compared with 1x109).

Dr. Alana King aspirating follicle.

ideal conditions. Synchronization of an individual donor and recipient mare is often requested by owners, but is discouraged.

Embryo Transfer Nonsurgical embryo transfer is most commonly used today due to improved efficiency and reduced costs. The technique consists of transcervical deposition of the embryo into the uterine body.

Embryos are loaded into 0.5 cc straws (for frozen semen). The straw is fitted onto a French Cassou gun and covered by a sterile chemise. The transfer gun should be > 53-56 cm long depending on the size and parity of the recipient. The recipient mare’s perineum is prepared as for any vaginal manipulation. The operator dons a sterile sleeve and lubricant, and guides the gun and straw to the external os of the cervix. Minimal invasion of the cervix is recommended, but speed can also be an important factor. It is recommended that the gun is inserted into the cervix without introduction of any digits. After passing the gun through the cervix, the operator can palpate the gun tip, per rectum, to verify placement in the uterine body or guide the gun into the uterine horn. After deposition of the embryo into the uterus, the gun/straw should be rinsed with media to ensure that the embryo was not adhered to the equipment.

14 The Practitioner

Transported Embryos

Case Selection These techniques are useful in mares that are unable to carry a pregnancy or produce viable embryos for collection due to oviductal, uterine or cervical pathologies. Common reasons for oocyte transfer include: • Ovulation failure • Oviductal blockages or adhesions • Severe degenerative changes of the uterus • Uterine infections • Urine pooling • Cervical lacerations Oocytes have also been successfully harvested from the ovaries of recently deceased mares and have produced live foals. Recovery of oocytes is best achieved when ovaries are transported to a facility equipped to handle the sensitive oocytes.

Ovaries are transported, at room temperature, in a traditional semen shipping device, such as an Equitainer ™. Time for ovarian harvest to procurement of the oocytes is critical to the viability of the oocytes. Generally, it is recommended that ovaries arrive within 7 hours of removal from the mare. However, for practical purposes, the ovaries should be shipped as quickly as possible (using counter to counter airline delivery often works best) which may mean a longer time interval. Colorado State University (Dr. Elaine Carnevale) and Texas A&M University (Dr. Katrin Hinrichs) are the two facilities in the United States routinely performing oocyte transfer with good success.

Cooled-transported embryo programs have made embryo transfer available to horse owners that do not want to ship a donor mare to a referral center. Further, new holding media for cooled transported embryos have been developed. These holding media are zwitterionic buffered solutions, with nutrients, growth factors, amino acids, and BSA added to the solution. The composition of the media allows the embryo to survive for an extended time. Research and clinical data collected over the past 2-3 years has suggested that alternative media, such as EquiPro Holding Media, EmCareTM Embryo Holding Solution or ViGroTM Holding Plus, that do not require gassing may be used successfully for short-term storage and shipment of equine embryos (McCue et al., 2000; Moussa et al., 2002). If an embryo is recovered it is packaged in a small (5 ml) plastic tube filled with holding media.

The small tube containing the embryo is placed within a larger (50 ml) conical tube filled with either flush or holding media.

Both tubes are sealed with parafilm strips and placed into a passive cooling system (Equitainer@, Hamilton-Thome Biosciences, Beverly, MA). In most instances, embryos maintained in holding solutions are shipped by counter-to-counter airline service and the embryo is transferred Oocyte Collection into a synchronized recipient within 12 When collecting oocytes from the to 16 hours of recovery. mare, the goal is generally to harvest

Issue 6 • 2011

the ovary, either by laparotomy, or colpotomy. Today, flank puncture and transvaginal ultrasound guided puncture are more commonly used.

Flank puncture: A trocar is placed through the flank musculature in the region of the ovary. The ovary is then manipulated transrectally so that its preovulatory follicle is positioned against the tip of the cannula. A needle is inserted through the cannula and into the follicle, where the follicular fluid and Dr. Mats Troedsson & Dr. Alana King oocyte are removed by gentle suction and performing aspirating procedure. lavage. This technique does not require the use of an ultrasound, although it can be used to visualize the follicle from the flank if necessary.

Transvaginal ultrasound-guided puncture (ovum pick up; OPU): A curvilinear ultrasound probe is placed in a casing containing a needle guide. The apparatus is inserted into the vagina, lateral to the cervix and ipsilateral to the ovary of interest. The ovary is palpated transrectally and positioned next to the probe. A needle is then placed through the vaginal wall to the ovary, and the follicular fluid and Dr. Mats Troedsson and Dr. Alana King puncturing follicle. oocyte are removed by suction and lavage.

Oocyte harvesting from excised ovaries: the oocyte as close to ovulation as pos- Three techniques can be used to harvest sible. This ensures that both nuclear and oocytes: ovarian slicing, follicular aspicytoplasmic maturation have occurred ration, or follicular scraping. Of these, and that the oocyte is viable. In some scraping yields the highest oocyte recovdomestic species, oocytes are harvested ery rate (~80%). In this technique, the at an earlier time and matured in vitro; follicles are sliced open with a scalpel however, this technique has limited success in the horse.

The donor mare is examined daily Needle in follicle. using transrectal palpation and ultrasonography. Follicular growth is monitored carefully and measurements recorded.

Cycling mares should also demonstrate signs of estrus, including uterine edema, relaxed uterine and cervical tone, and estrous behaviour. An ovulatory agent is then administered to the mare when she develops a follicle that is >35mm in diameter; this permits a more accurate prediction of ovulation time, and it also appears to loosen cumulus cells surrounding the oocyte, resulting in improved recovery rates. Ovulation is anticipated at 36 hours with administration of hCG, or at 40 hours with a GnRH analogue. Oocytes should be collected at 0 to 14 hours prior to the predicted ovulation time.

A variety of techniques exist for follicular aspiration. Many of the earlier methods involved surgical exposure of www.faep.net

blade and the follicular walls are scraped with a bone curette. The follicular cells are then washed from the curette into a petri dish.

Treatment of Oocytes Following collection, the follicular fluid is examined under a stereoscopic microscope for the presence of an oocyte.

The cumulus complex surrounding the oocyte is easily identified as a large (2-5mm), translucent structure. Morphology of the cumulus is examined carefully, as it is a reflection of changes in follicular fluid content that initiate oocyte maturation. Expansion of the cumulus cells and corona radiate indicate that maturation has occurred. Morphology of the oocyte itself is also examined as much as possible; however, it is often obscured by the cumulus. For oocyte transfer and GIFT, the cumulus is left intact to aid in fertilization.

Oocytes may then be cultured or they may be transferred directly to the recipient. Alternatively, oocytes can be vitrified for later use, using the same techniques as for embryo vitrification.

Transfer The recipient should undergo a complete breeding soundness evaluation prior to selection, as for embryo transfer.

Cyclic and non-cyclic mares have been used as recipients, with no difference in pregnancy rates.

The Practitioner 15

Cycling recipients: The cycling recipient should be synchronized to the donor mare (see embryo transfer notes for synchronizing protocols). The dominant follicle developing in the recipient should be ablated before transfer of the donor oocyte.

Non-cycling recipients: Recipients can be prevented from cycling using intramuscular administration of progesterone (P4 – 150mg IM q24h) and estradiol 17β (10mg IM q24h) in combination for at least 10 days. Alternatively, ovariectomized mares can be used. Estrus in these recipients can then be mimicked by administration of exogenous estradiol 17β (2-5mg IM q24h for 3-7d) when the donor mare comes into heat.

In standard oocyte transfer procedures, the recipient is inseminated as early as 12 hours prior to transfer. In some protocols, they are inseminated up to 2 hours post-transfer (or both).

Oocytes are then transferred to the recipient oviduct surgically. A standing flank incision is used to locate the infundibular os, into which the oocytes are placed. If GIFT is selected as the method of choice, a small dose of semen (2-5 x 105) is pulled into the transfer pipette containing the oocyte and infused into the oviduct.

oocytes carrying these types of defects increase dramatically as the mare ages, which is rather unfortunate since the reasons for oocyte transfer are often age-related problems (ovulation failure, degenerative uterine changes, etc). Pregnancy rates after oocyte transfer were found to be 92% among young, fertile mares, compared with just 31% among older mares (>20 yrs) in one study.

Collection of immature oocytes also reduces viability, as these gametes have not yet completed nuclear and cytoplasmic maturation. In vitro culture of equine oocytes has produced very low embryo development rates when compared directly to in vivo maturation (9% vs 82% respectively).

In addition, pregnancy rates can be reduced due to iatrogenic damage occurring during the aspiration procedure or handling of the oocytes.

Sperm Viability: The importance of stallion fertility on the outcome of an oocyte transfer or GIFT procedure should not be overlooked. Choosing a stallion with good fertility will improve success rates.

Fresh, cooled, and frozen sperm can be selected for use with oocyte transfer or GIFT procedures. However, the use of cooled or frozen sperm with GIFT results in lowered pregnancy rates compared with fresh semen; reasons for this difference are unknown.

In summary, alternative options for breeding in the performance mare can allow continued training while producing offspring. Providing owners with details regarding cost and expected outcomes can aid in making the best decision for their particular program.

Expected Pregnancy Rates The pregnancy rate for these procedures is highly variable with significant operator variation. Success of oocyte transfers is dependent on oocyte recovery rate and gamete viability, and can range from 7% to more than 90% depending on these variables.

Recovery rates: Oocyte recovery rates are higher for large, pre-ovulatory follicles compared to smaller, immature follicles. The cumulus complex in an imma- Suggested Reading: ture follicle is broad and firmly attached Squires E, et al., Embryo technologies in the to the antral granulosa layer; thus, it is horse. Theriogenology 2003;59(1):151-70. more difficult to remove. In the larger McCue PM and Troedsson MHT Commercial follicles, the cumulus grows away from equine embryo transfer in the United States.

Pferdeheilkunde 2003;19(6):689-692. the wall and is attached by a stalk, which is easier to disrupt during aspiration.

Allen WR. The development and application of the modern reproductive technoloThe use of an ovulatory agent further gies to horse breeding. Reprod Dom Anim improves oocyte recovery rate. Stimula2005;40(4):310-29. tion of LH receptors on the developing Carnevale EM. Clinical considerations follicle causes the cumulus cells to loosen, regarding assisted reproductive procedures and thus, the oocyte is more easily freed in horses. JEVS. 2008;28(11):686-690. from its attachment.

Carnevale EM and Maclellan LJ. Collection, Oocyte Viability: Oocytes, which have evaluation and use of oocytes in equine assisted reproduction. Vet Clin Equine chromosomal or structural defects, are 2006;22:843-856. usually non-viable. The percentage of 16 The Practitioner

Margo Macpherson, DVM, MS, DACT ++ DVM Degree in 1990 from Michigan State University ++ Master’s Degree in Equine Theriogenology at Texas A&M University ++ Spent time at the University of Pennsylvania and in private practice in Central Kentucky ++ Presently Associate Professor and Service Chief in the section of Reproduction at the University of Florida ++ Diplomate and Past President of the American College of Theriogenologists and is active in the American Association of Equine Practitioners.

Mats Troedsson, DVM, PhD, DACT ++ DVM Degree at the Royal Veterinary College in Stockholm, Sweden in 1975 ++ PhD Degree in Reproductive Immunology 1991 from University of California at Davis ++ Board-Certified by the American College of Theriogenologists and the European College of Animal Reproduction. ++ Served on faculty in Equine Reproduction at the University of Minnesota and the University of Florida ++ Currently serves as the Chairman of the Department of Veterinary Science and Director of the Maxwell H. Gluck Equine Research Center, University of Kentucky

Alana King, DVM, DACT ++ DVM Degree 2006 from Ontario Veterinary College ++ Diplomate of the American College of Theriogenologists, completing her residency in theriogenology at the University of Florida. ++ Currently working at a private practice in Saratoga Springs, NY

Issue 6 • 2011

Nutraceuticals for Enhancing Stallion Fertility

by Steven P. Brinsko, DVM, MS, PhD, DACT

Introduction Over the years, horsemen have been supplementing their animals’ diets with various products in an attempt to enhance performance and overall well being. Most of these products have been geared toward improving stamina, hair coat, joint function and hoof growth.

Historically, supplements touted to improve the breeding performance of stallions have not proven to be efficacious. Recently however, supplements have become available that show real promise in this regard.

Fatty Acids Semen from virtually all species examined contains relatively large amounts of lipid, which plays a major role in motion characteristics, sensitivity to cold shock and fertilizing capacity of sperm. In particular, docosahexaenoic acid (DHA; an Omega-3 fatty acid) and docosapentaenoic acid (DPA; an Omega-6 fatty acid) are the major polyunsaturated fatty acids (PUFAs) in semen. In men with poor sperm motility, the level of DHA in seminal plasma, as well as the ratio of Omega-3 to Omega-6 fatty acids in their sperm, was found to be significantly lower than in men with normal semen quality. Increasing the ratio of DHA to DPA in semen increases fertilizing capacity and semen quality. Conversely, higher levels of DPA relative to DHA results in reduced fertility.

Animals are unable to synthesize PUFAs and must acquire them from precursor PUFAs in their diet. Vegetable oils, such as corn and soybean oil, found in most equine diets, contain high levels of linoleic acid, the parent compound of DPA. while the precursors for Omega-3 fatty acids, such as DHA, are very low. A diet of this nature would favor the formation of DPA over DHA since conversion of precursors to DPA and DHA uses the same competitive enzymatic pathway. www.faep.net

Polyamines Omega-3 fatty acids cannot be converted to Omega-6 fatty acids or vice-versa.

Since high DPA to DHA ratios in semen are associated with reduced sperm quality and fertility, typical equine diets could have a negative impact on quality of stallion semen and its tolerance to cooling and freezing.

Many stallions do not produce semen that is able to provide acceptable fertility after undergoing cooling and storage.

Cryopreservation magnifies this reduction in fertility even further. Cooling and freezing of sperm can induce “cold shock,” which is associated with a disruption of membrane lipids.

Researchers at Texas A&M fed a supplement which resulted in a 3-fold increase in semen DHA levels and a doubling of the ratio of DHA to DPA in the semen. Beneficial effects, including increases in total motility, progressive motility and rapid motility, were most apparent after 48 hours of cooling and storage. The sperm concentration of stallions fed the supplement was almost double that of those fed the control diet.

Total motility, progressive motility, and percentage of sperm exhibiting rapid motility were also significantly higher in frozen-thawed semen of stallions being fed the supplement.

However, the level of DPA in semen remained higher than DHA. The stallions’ rations were typical equine formulations containing corn and soybean oils so, even more dramatic improvements in semen quality may be observed if the fat content of the stallion diets are modified and incorporated with the DHA supplement.

Subsequently, similar studies carried out at other institutions resulted in improved total numbers, morphology and percentages of live sperm. In all of these studies, the improvements were most noticeable for stallions that initially had poorest semen quality.

Spermine and spermidine are polyamines that are produced by the prostate and found in the semen of most mammals. In rams, ejaculates with sperm motility greater than 85% had almost 2X the spermine and total sperm polyamine content than ejaculates with lower motility. Lower levels of spermidine are found in the seminal plasma of men with idiopathic asthenozoospermia (poor sperm motility) as well as those with asthenozoospermia associated with diabetes.

Anecdotal information exists from practitioners using a herbal supplement called “SpermAid.” The active ingredients in this product are spermine and spermidine which are found in radish leaves, radish root, cucumber fruit and oats.

Feeding of the supplement is typically initiated three weeks prior to the breeding season. While significant improvements in sperm motility have not been reported with the use of this product, a number of slow breeding stallions have apparently shown dramatic improvements in libido.

Vitamins and Antioxidants Vitamins C and E are well known for their antioxidant properties and are those that have been the most extensively examined. In a number of species, dietary supplementation with Vitamin C, Vitamin E or a combination of these increased, total sperm output, sperm concentration and sperm motility while decreasing dead and abnormal sperm. In humans, Vitamin C was associated with higher sperm numbers and concentrations in ejaculates, whereas Vitamin E appeared to exert its effects by improving sperm motility. While the intake of high levels of antioxidant vitamins was associated with better semen quality, moderate intake did not appear to be effective. In semen from infertile men, supplementation with Vitamins C and E also resulted in a significant reduction in sperm DNA The Practitioner 17

fragmentation. German and Russian Conclusions investigators reported improved semen It is clear that dietary alterations quality by supplementing stallions with can have an effect on semen quality Vitamins A, D and E. and in some cases, fertility. Controlled Another antioxidant, showing prom- studies in stallions are few, but those ise for improving semen quality, is investigating fatty acids, in particular L-carnitine (levocarnitine). Along with Omega-3 fatty acids such as DHA, have its antioxidant properties, L-carnitine shown real potential. Further studies is essential for mitochondrial energy involving optimal levels of individual metabolism. Both L-carnitine and supplements and combinations of supL-acetyl-carnintine are found in high plements, which could act synergisticoncentrations in the epididymis and cally to improve stallion semen quality, both are accumulated by sperm. In men are needed. Supplementing the diet with asthenozoospemia, combined of highly fertile stallions or those that treatment with L-carnitine and L-ace- produce sperm that survive cooling and tyl-carnitine was effective in increasing freezing well does not appear warranted. sperm motility. The most significant However, stallions of marginal fertility improvements were seen in men with and those whose sperm have poor tolthe lowest numbers of motile sperm erance to cooling and freezing would be prior to treatment. Feeding L-carni- horses that might benefit most from tine to boars resulted in higher semen being fed dietary supplements. Optivolumes and sperm concentrations mizing levels of DHA and its precursors thereby increasing the total number of by altering the diet of marginally feravailable sperm in ejaculates for artifi- tile stallions, may improve their semen cial insemination. quality sufficiently enough to make them commercially viable for cooling or freezing.

Steven P. Brinsko, DVM, MS, PhD, DACT ++ Received his DVM Degree from the University of Florida in 1985. ++ Completed a combined Residency and Master’s Degree program in Theriogenology at Texas A&M University in 1990. ++ PhD from Cornell University, Cornell, NY, in 1995. ++ Four years on faculty at Colorado State University College of Veterinary Medicine and Biomedical Sciences ++ Professor and Section Chief of Theriogenology at Texas A&M University responsible for Teaching, Evaluation and Treatment of Mares and Stallions ++ Performs Research in Multiple Facets of Equine Reproduction ++ Author and Co-Author of more than 100 manuscripts related to Reproduction ++ Current President of the American College of Theriogenologists

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18 The Practitioner

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Issue 6 • 2011

Treatment of Placentitis: Where are We Now?

P

lacentitis continues to represent a significant cause of pregnancy loss for the mare. Placentitis is most commonly caused by bacteria ascending through the vagina.(1,2) Streptococcus equi subsp. zooepidemicus (S. zooepidemicus) is the bacteria most frequently isolated from clinical cases of placentitis.(1,3) Placental pathology is generally localized to the area of the cervical star with thickening and separation of the chorioallantois from the endometrium.

(1,3,4) Affected mares usually have a vulvar discharge, develop an udder, and deliver a premature, compromised or dead foal. In chronic placentitis, a foal may be born precociously mature for gestational age if premature labor is delayed.(5) Therefore, the treatment goal in mares with placentitis is to prolong gestation long enough to allow fetal maturation and delivery of viable neonate.

Information from a well-established model of placentitis has directed treatment approaches.(6-10) While bacterial infection is thought to initiate disease, secondary inflammation and prostaglandin production are likely culprits in premature delivery of foals. Mares with induced placentitis showed higher concentrations of IL-6 and IL-8 in their placentas, elevated concentrations of prostaglandins E2 and F2a (PGE2 and PGF 2a) in allantoic fluid and increased duration and intensity of uterine contractions when compared to uninfected, control mares.(6,7,11) Histopathologic findings from the placentitis model revealed bacteria on the chorionic surface, allantoic and umbilical inflammation, and bacterial colonization in fetal lungs.(4) It is postulated that fetal infection is established by passage of bacteria through fetal membranes and into amniotic fluid that the fetus inhales or swallows. Therefore, it is likely that both infection and inflammation are important in placentitis-induced preterm delivery. As such, treatment approaches are directed at bacterial eradication, control of inflammation and amelioration of uterine contractions.

Several therapeutic agents that are commonly administered in clinical practice (antimicrobials, anti-inflammatories and progestins) have been tested in mares with experimentally-induced placentitis. Placental drug transfer in mares with placentitis was investigated using a novel in vivo microdialysis system to measure drug concentrations in allantoic fluid after administration.(12,13) Penicillin and trimethoprim sulfamethoxazole (TMS) achieved minimum inhibitory concentration (MIC) against S. zooepidemicus in allantoic fluid of mares with induced placentitis, while gentamicin was detectable at concentrations effective to treat Escherichia coli and Klebsiella pneumoniae (also implicated in placentitis). Drugs were present for up to 4 hours in allantoic fluid, but at concentrations lower than serum. Pentoxifylline was detected in allantoic fluid of experimentally-infected mares, but flunixin meglumine was not. The highly protein-bound nature of flunixin meglumine likely prevented passage of this drug www.faep.net

by Margo L Macpherson, DVM, MS, DACT

through the microdialysis membrane, thus rendering results regarding placental passage of the drug inconclusive. However, flunixin meglumine is still used as an anti-inflammatory drug of choice in clinical cases of placentitis.

Foal viability after mares were treated with a variety of drug combinations has also been assessed. Long-term administration of TMS and pentoxifylline tended (P = 0.07) (14) to extend gestational length in mares with placentitis when compared to infected, untreated mares. However, foal survival was not improved in treated animals (one live foal in each group). Interestingly, TMS and pentoxifylline were present in fetal and placental tissues. So, while TMS and pentoxifylline show good penetration of placental and fetal tissues, this drug combination was insufficient to prevent preterm delivery in this study.

Progestins (altrenogest; Regumate™) have also been combined with TMS and pentoxifylline to treat mares with induced placentitis.(15) Progestins are postulated to promote uterine quiescence through reduction in myometrial gap junctions and oxytocin receptors.(16,17) Administration of progestins in women with high risk pregnancies has shown to reduce the incidence of preterm labor, and this treatment has become standard practice.(18) When mares with induced placentitis were administered TMS, pentoxifylline and Regumate™ , 10 of 12 (83%) delivered viable foals.(15) All five untreated, infected mares aborted or delivered non-viable foals. Most live foals had negative blood cultures at birth and normal parameters for complete blood count, serum chemistry, cortisol and IgG. It was concluded, from these data, that mares with placentitis benefited from treatment using an antimicrobial, anti-inflammatory agent and progestin. The authors of this study were careful to note that early initiation of treatment after experimental infection (within 96 hours) likely contributed to the high number of live foals in this study.(15) Recently, workers from Mississippi used an evidencebased approach to evaluate different treatment protocols in mares with induced placentitis. Mares were administered TMS, alone, or combined with anti-inflammatory agents (dexamathasone and aspirin), and/or with progestins (altrenogest + aspirin).(19) Interestingly, mares administered TMS, alone, were as likely to deliver viable foals (4/6; 63%) as mares administered TMS in combination with dexamethasone, aspirin and altrenogest (13/18; 72%). These data prompt the question of whether anti-inflammatory agents are important to treatment of placentitis, or whether antibiotics (TMS) are sufficient to treat the disease. Interestingly, work in non-equine species suggests that multifaceted therapy is warranted for prevention of preterm delivery.

Using a non-human primate model of placentitis, workers examined the effects of anti-inflammatory agents (indomethacin(20), dexamethasone and interleukin-10 )(21) to stop The Practitioner 19

preterm delivery. In all experiments, treated monkeys had lower amniotic fluid prostaglandin concentrations and uterine contractions than untreated controls. None of the agents effectively inhibited production of pro-inflammatory cytokines. Administration of dexamethasone prevented preterm delivery of fetuses. The effect of antibiotic, alone, was also tested in the primate model. Monkeys inoculated with group B streptococci (in the amniotic cavity) were administered ampicillin alone, or in combination with dexamethasone and indomethacin.(22) Ampicillin effectively eradicated bacteria from the amniotic fluid of infected animals. However, amniotic fluid cytokines, prostaglandins and uterine contractions persisted in the face of maternal antibiotic treatment. When dexamethasone and indomethacin were added to ampicillin, cytokines and prostaglandins were suppressed as were uterine contractions. From these studies, one can speculate whether antimicrobials alone, are more effective early after infection and anti-inflammatory treatment becomes important in more chronic disease. Unfortunately, in a practical setting, it is often difficult to predict the onset of placentitis and treatment must be initiated quickly. In these cases, it can be difficult to select a conservative treatment approach.

Limitations in antimicrobial choices are also problematic for the practitioner treating mares with placentitis. Oral administration of drugs is ideal in a field setting. However, TMS-based therapy does not consistently result in delivery of a live foal. Additionally, more than 50% of uterine cultures obtained immediately postpartum from mares with induced placentitis were positive for S. zooepidemicus despite prolonged administration of TMS.(15) This is in contrast to negative uterine cultures obtained from normal foaling mares.(23) Studies have shown that TMS is not consistently effective in eradicating S. zooepidemicus, in vivo, despite in vitro susceptibility of pathogens and high concentrations of TMS at the site of infection.(24,25) However, few alternative oral preparations of antimicrobials are available, as are parenterally administered drug choices that can be used in field conditions. Ceftiofur, a third generation cephalosporin, has excellent bactericidal activity against streptococcal organisms, as well as many Gram negative aerobes and some anaerobes.(2628) Ceftiofur penetrates body fluids, the endometrium, joints and pulmonary sites of infection with concentrations that equal or rival ampicillin or potentiated sulfonamides.(29,30) Ceftiofur sodium, marketed as Naxcel®, is a commonly used antimicrobial in equine practice. While not as convenient as orally administered TMS, once daily, intramuscular injection of ceftiofur sodium provides a practical method of administering a parenteral drug. However, the effectiveness of ceftiofur sodium for treating mares with placentitis is unknown.

In 2010 Pfizer Animal Health (Kalamazoo, MI) received FDA approval for the use of long-acting ceftiofur crystalline free acid (CCFA; Excede®) for treatment of horses. Excede® has broad appeal for the equine practitioner because it provides therapeutic drug levels in horses for 10 days when administered at 4-day intervals. Additionally, CCFA (Excede®) is a potent antimicrobial against S. zooepidemicus.

In many ways, this exciting new drug would appear to be the perfect antimicrobial treatment for mares with placentitis. Consequently, Excede® was recently tested in mares to 20 The Practitioner

determine the ability of the drug to penetrate fetal membranes and the effectiveness of the drug for preventing abortion in mares with induced placentitis. Mares were administered Excede®, alone (n = 3) or in combination with pentoxifylline and altrenogest (n = 6). Three mares served as infected, untreated controls. Concentrations of ceftiofur metabolites were measured as an indicator of drug distribution in mares, foals and placental tissues using high performance liquid chromatography (HPLC, University of CA Davis).

Serum concentrations of ceftiofur metabolites in mares were consistent with expected profiles after administration of this drug (Giguere S, et al. J. Vet. Pharmacol. Therap, in press 2011; Pfizer Animal Health Technical Bulletin: Excede Feb. 2010). However, drug concentrations measured in fetal and placental tissues were considerably below therapeutic concentrations indicating low penetration of ceftiofur metabolites across fetal membranes. Further, foal survival was poor after treatment with this drug (live foals = 0/3 after Excede®, alone, and 2/6 after combination treatment). Bacterial eradication using this antibiotic was not achieved in uterine or foal samples from animals with confirmed bacterial infections after inoculation. It is likely that much higher serum concentrations of ceftiofur metabolites would be necessary in order to achieve therapeutic concentrations in placental and fetal tissue. However, since, Excede® is slowly released from the site of injection it does not tend to provide very high serum concentrations even with higher dose administrations. Therefore, ongoing work is investigating the ability of ceftiofur sodium to pass through fetal membranes and attain therapeutic concentrations in fetal fluids and tissues.

In summary, conscientious treatment of equine placentitis is challenging. Data regarding treatment are sometimes conflicting; and results, after treatment in a clinical setting, can be disappointing. Yet, salvaging a pregnancy can be enormously rewarding. Ongoing efforts by several investigators are focusing on earlier diagnostic methods, allowing for more rapid initiation of treatment, and hopefully, more consistent effects of treatment.

Reference List

1. Hong,C.B. et al. Etiology and Pathology of Equine Placentitis. Journal of Veterinary Diagnostic Investigation 5, 56-63 (1993).

2. Platt H. Infection of the horse fetus. J Reprod Fert Suppl 23, 605-610 (1975).

3. Giles,R.C. et al. Causes of Abortion, Stillbirth, and Perinatal Death in Horses - 3,527 Cases (1986-1991). Journal of the American Veterinary Medical Association 203, 1170-1175 (1993).

4. Mays,M.B.C., Leblanc,M.M. & Paccamonti,D. Route of fetal infection in a model of ascending placentitis. Theriogenology 58, 791-792 (2002).

5. Rossdale,P.D. et al. Effects of placental pathology on maternal plasma progestogen and mammary secretion calcium concentrations and on neonatal adrenocortical function in the horse. J Reprod Fertil Suppl 44, 579-590. 1991.

Ref Type: Journal (Full) 6. Leblanc,M.M. et al. Premature delivery in ascending placentitis is associated with increased expression of placental cytokines and allantoic fluid prostaglandins E-2 and F-2 alpha. Theriogenology 58, 841-844 (2002).

7. Hendry,J.M. et al. Patterns of uterine myoelectrical activity in reproductively normal mares in late gestation and in mares with experimentally induced ascending placentitis. Theriogenology 58, 853-855 (2002).

8. McGlothlin,J.A. et al. Alteration in uterine contractility in mares with experimentally induced placentitis. Reproduction 127, 57-66 (2004).

9. Kelleman,A.A., Luznar,S.L., Lester,G.D., Paccamonti,D.L. & Leblanc,M.M. Evaluation of transrectal ultrasonographic combined thickness of the uterus and placenta (CTUP) in a model of induced ascending placentitis in late gestation in the pony mare. Theriogenology 58, 845-848 (2002).

Issue 6 • 2011

10. O’Donnell,L.J. et al. 24-hour secretion patterns of plasma oestradiol 17 beta in pony mares in late gestation. Reprod Domest Anim 38, 233-235 (2003).

11. Stawicki,R.J. et al. Endocrinological findings in an experimental model of ascending placentitis in the mare. Theriogenology 58, 849-852 (2002).

12. Murchie,T.A., Macpherson,M.L., Leblanc,M.M., Luznar,S. & Vickroy,T.W. Continuous monitoring of penicillin G and gentamicin in allantoic fluid of pregnant pony mares by in vivo microdialysis. Equine Veterinary Journal 38, 520-525 (2006).

13. Rebello,S.A., Macpherson,M.L., Murchie,T.A., Leblanc,M.M. & Vickroy,T.W. Placental transfer of trimethoprim sulfamethoxazole and pentoxifylline in pony mares. Animal Reproduction Science 94, 432-433 (2006).

14. Graczyk,J. et al. Treatment efficacy of trimethoprim sulfamethoxazole and pentoxifylline in equine placentitis. Animal Reproduction Science 94, 434-435 (2006).

15. Bailey,C.S. et al. Treatment efficacy of trimethoprim sulfamethoxazole, pentoxifylline and altrenogest in experimentally induced equine placentitis. Theriogenology 74, 402-412 (2010).

16. Garfield,R.E., Rabideau,S., Challis,J.R.G. & Daniel,E.E. Hormonal-Control of Gap Junction Formation in Sheep Myometrium During Parturition. Biol Reprod 21, 999-1007 (1979).

17. Bishop,C.V. & Stormshak,F. Non-genomic actions of progesterone and estrogens in regulating reproductive events in domestic animals. Veterinary Journal 176, 270-280 (2008).

18. Meis,P.J. et al. Prevention of recurrent preterm delivery by 17 alpha-hydroxyprogesterone caproate. New England Journal of Medicine 348, 2379-2385 (2003).

19. Christiansen,D.L. et al. Evidenced-based medicine approach to develop efficacious therapies for late-gestation mares presenting with uterine infections using an experimentally-induced placentitis model. Animal Reproduction Science 121, 345-346 (2010).

20. Sadowsky,D.W., Haluska,G.J., Gravett,M.G., Witkin,S.S. & Novy,M.J. Indomethacin blocks interleukin 1beta-induced myometrial contractions in pregnant rhesus monkeys. Am. J. Obstet. Gynecol. 183, 173-180 (2000).

21. Sadowsky,D.W., Novy,M.J., Witkin,S.S. & Gravett,M.G. Dexamethasone or interleukin-10 blocks interleukin-1 beta-induced uterine contractions in pregnant rhesus monkeys. American Journal of Obstetrics and Gynecology 188, 252-263 (2003).

22. Gravett,M., Sadowsky,D., Witkin,S. & Novy,M. Immunomodulators plus antibiotics to prevent preterm delivery in experimental intra-amniotic infection (IAI).

American Journal of Obstetrics and Gynecology 189, S56 (2003).

23. Diaw M. et al. Characteristics of endometrial culture and biopsy samples taken immediately postpartum from normal mares compared with those from mares with induced placentitis. Anim Reprod. Sci. 121S, 369-370 (2010).

24. Ensink,J.M., Bosch,G. & van Duijkeren,E. Clinical efficacy of prophylactic administration of trimethoprim/sulfadiazine in a Streptococcus equi subsp zooepidemicus infection model in ponies. J Vet Pharmacol Ther 28, 45-49 (2003).

25. Ensink,J.M., Bosch,G. & van Duijkeren,E. Clinical efficacy of prophylactic administration of trimethoprim/sulfadiazine in a Streptococcus equi subsp zooepidemicus infection model in ponies. J Vet Pharmacol Ther 28, 45-49 (2005).

26. Salmon,S.A., Watts,J.L. & Yancey,R.J. In vitro activity of ceftiofur and its primary metabolite, desfuroylceftiofur, against organisms of veterinary importance.

Journal of Veterinary Diagnostic Investigation 8, 332-336 (1996).

27. Yancey,R.J. et al. Ceftiofur Sodium, A Broad-Spectrum Cephalosporin - Evaluation Invitro and Invivo in Mice. American Journal of Veterinary Research 48, 1050-1053 (1987).

28. Meyer,S. et al. Pharmacokinetics of intravenous ceftiofur sodium and concentration in body fluids of foals. J Vet Pharmacol Ther 32, 309-316 (2009).

29. Witte,T.S., Bergwerff,A.A., Scherpenisse,P., Drillich,M. & Heuwieser,W. Ceftiofur derivates in serum and endometrial tissue after intramuscular administration in healthy mares. Theriogenology 74, 466-472 (2010).

30. Folz,S.D. et al. Treatment of Respiratory-Infections in Horses with Ceftiofur Sodium. Equine Veterinary Journal 24, 300-304 (1992).

Margo Macpherson, DVM, MS, DACT ++ DVM Degree in 1990 from Michigan State University ++ Master’s Degree in Equine Theriogenology at Texas A&M University ++ Spent time at the University of Pennsylvania and in private practice in Central Kentucky ++ Presently Associate Professor and Service Chief in the section of Reproduction at the University of Florida ++ Diplomate and Past President of the American College of Theriogenologists and is active in the American Association of Equine Practitioners.

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The Practitioner 21

FAEP Member Practice Highlight

The Ocala Equine Hospital The Ocala Equine Hospital is a surgical referral center established in 1997 to treat elective surgical cases and orthopedic emergencies.

We have a full range of advanced surgical and diagnostic equipment enabling us to provide premiere surgical referral services for the region. Our swimming pool recovery system is unique to the region and compliments our expertise in fracture repair. We also provide ambulatory services for emergencies, preventative care, lameness, reproduction, radiography and general medical care.

Our veterinary staff consists of two board certified surgeons, nine ambulatory veterinarians and three interns. Our support staff consists of an office manager, three billing clerks/ receptionists, one surgical booking clerk, one pharmacy technician, three anesthesia technicians, three surgery technicians, seven veterinary technicians, five barn technicians and two lab technicians.

Our 25-acre facility includes a building that houses our office staff and in-house laboratory, as well as two surgical suites with four induction/recovery stalls and nuclear scintigraphy. We also have three barns.

We are located in the heart of North Central Florida horse country where the climate is conducive for year-round training and for the individual that enjoys the outdoors.

Ambulatory Services The ambulatory department focuses primarily on performance horse clientele, including lameness and full reproductive services.

The practice is equipped with digital radiography, digital ultrasonography, dynamic respiratory endoscopy, and shockwave therapy.

We also offer cell-based therapies for joints, tendons and ligaments. All of these treatments are processed in our in-house laboratory.

Therapies for Joints

IRAP: This product is used in place of traditional medical treatments for joints. IRAP is reported to have less detrimental effects on the joint than steroids and may have an anabolic effect that supports healing.

Stem Cell Treatments: This treatment is generally reserved for joints in which medical and

22 The Practitioner

surgical therapies have failed. Currently we are offering the Vet-Stem (www.vetstem.com) regenerative cells from fat or adipose tissue.

Therapies for Tendons/Ligaments

Platelet Rich Plasma (PRP): PRP is a blood product that can be prepared patient-side in the hospital. PRP is generally used in new injuries and is injected directly into the area where the tendon or ligament is torn. PRP is taken from the patient being treated therefore there is no graft vs. host reactions. Ultrasound is used to direct the needle and PRP directly into the lesion. The PRP then becomes activated forming a provisional matrix and releasing growth factors into the wound environment that facilitate healing.

Hospital Diagnostic Services Diagnostic Imaging

Nuclear Scintigraphy: Aka “Bone Scan” is used to diagnose stress fractures and other causes of lameness that may be difficult to diagnose by standard means.

Direct Digital Radiograph: We offer digital radiography for both our hospital and ambulatory patients. Digital radiographs provide an instant image obviating the need to wait for chemical development and retakes.

Digital Ultrasound: Ultrasound is used primarily to evaluate tendons and ligaments and in some instances bone and other soft tissues.

Endoscopy • • • •

Upper airway evaluation Reproductive tract Urinary tract Gastrointestinal tract

Lameness Evaluations

We offer complete soundness evaluations using the latest technology and techniques to evaluate your horse. We have a round pen and ample area to ride the horse under tack if needed. A farrier is available upon request.

Surgical Services We offer a wide variety of elective orthopedic and soft tissue surgical services as well as orthopedic emergency services. The majority of our surgeries are elective and outpatient.

Occasionally, depending on the type of surgery, horses will be hospitalized.

Orthopedic Surgery Highlights Conformation Evaluations and Surgery

Arthroscopic Surgery: Treatment of the joint for conditions such as OCD’s and chip fractures. This is generally an outpatient procedure.

Other Rigid Endoscopic Surgery: Treatment of injuries to digital flexor tendon sheath, carpal canal and other synovial structures.

Fracture Fixation: Many fractures in horses can be repaired. Over the past 10 years, improvements in orthopedic implants and recovery systems have improved our success with many fractures.

Swimming Pool Recovery

Patients at high risk of injuring themselves during recovery from anesthesia can be recovered in our swimming pool. Horses are placed into the pool while they are still anesthetized.

As they wake up and gain their balance and coordination the floor in the swimming pool gradually lifts them out of the water. This greatly diminishes the chances of injury during recovery and is invaluable in horses with long bone fracture repairs that are vulnerable to failure during recovery.

Soft Tissue Surgery Highlights

Upper Airway Surgery: We provide a complete array of upper airway diagnostic and surgical procedures. This includes flexible video endoscopy and LASER surgery.

Laparoscopic Surgery: We offer minimally invasive surgeries such as cryptorchidectomies and ovariectomies. These procedures often result in decreased patient discomfort and convalescent times.

The Ocala Equine Hospital is located at 10855 N. U.S. Highway 27 in Ocala, FL 34482. For questions or general inquires please call (352) 368-1616 or for a veterinary emergency, please call (352) 620-8900.

Issue 6 • 2011

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24 The Practitioner

Issue 6 • 2011

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26 The Practitioner

Issue 6 • 2011

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