Use of medroxyprogesterone acetate in the prevention of postoperative adhesions

OBJECTIVES

To evaluate the efficacy of a commonly used progestogen, medroxyprogesterone acetate (MPA), in the prevention of postoperative adhesion formation.

DESIGN

A double-blind, controlled study evaluated the efficacy of MPA to reduce postoperative adhesion formation and compared it with other adjuvants and controls in a rat model.

SETTING

Animal Care Facility of an academic research setting.

SUBJECTS

Seventy-five Sprague-Dawley female rats randomly divided into five groups.

INTERVENTIONS

Three weeks before surgery, the animals from each group were administered an IM injection of one of the following regimens: [1] 15 mg MPA; [2] both 15 mg MPA and 0.75 mg leuprolide acetate (LA); [3] 0.75 LA; or [4] and [5] comparable volumes of sterile saline. A standardized surgical trauma was inflicted in all animals. Before abdominal closure, 2 mL of Ringer's Lactate was instilled in the abdominal cavity of all groups except group 5 (controls). Three weeks after surgery, the rats were killed and the adhesions were scored on a scale of 0 to 3 according to their size, thickness, and vascularity.

MAIN OUTCOME MEASURE

Postoperative adhesions.

RESULTS

The preoperative administration of MPA resulted in the least number and the least severe adhesions. The combination of LA and MPA did not reduce postoperative adhesion formation. Both Ringer's Lactate and LA reduced postoperative adhesions but not to the same extent as MPA.

CONCLUSION

The preoperative administration of MPA in our laboratory animal model results in the most significant reduction of postoperative adhesion formation. This action of MPA may be mediated by the induction of both a progestational and a hypoestrogenemic milieu. However, the ultimate role of MPA in a clinical situation requires further investigation.

Bilateral atresia of the proximal ampullary segment of the fallopian tubes

An infertile woman had segmental defects of the proximal ampullae of both fallopian tubes. At laparoscopy, its appearance was similar to that of bilateral tubal electrosurgical sterilization. We believe this is the first description of this congenital anomaly.

Power sources

The rapid development of endoscopic surgery has created an ever-increasing demand for new instruments, such as lasers of various wavelengths, and new applications of high-frequency electrosurgery. The technology has advanced rapidly and it is sometimes difficult to understand the different applications of these new instruments and take full advantage of these developments. This article has reviewed the basic principles of the various power sources commonly utilized in gynecologic surgery and described the clinical applications of each of them.

A case of splenosis masquerading as endometriosis

Splenosis represents the autotransplantation of splenic tissue after splenic trauma or surgery. Characterized by bluish implants diffusely scattered throughout the peritoneal cavity, splenosis is frequently mistaken for endometriosis. A 19-year-old woman was referred for "extensive endometriosis" found at diagnostic laparoscopy by her gynecologist. After extensive resection of peritoneal, pelvic, and intestinal implants of typical and "atypical" endometriosis, the "atypical" endometriosis was reported by the pathologist to be splenosis. Because splenosis is not a pathologic process but may actually be beneficial to the patient, it is important to recognize splenosis and not confuse it with endometriosis, malignancy, or hemangioma.

Efficacy of oral micronized progesterone in the treatment of luteal phase defects

OBJECTIVE

Vaginal progesterone suppositories are an accepted treatment for infertility attributed to luteal phase defects. Although oral micronized progesterone may be preferable to suppositories for many patients, there are no studies on its use for patients with luteal phase defects. This study evaluated the efficacy of oral micronized progesterone for the treatment of luteal phase defects.

STUDY DESIGN

Seven women with luteal phase defects previously corrected by vaginal suppositories were administered oral micronized progesterone (200 mg by mouth three times a day). Endometrial biopsies were performed to evaluate treatment efficacy. Questionnaires were used to assess side effects, including sedation.

RESULTS

On oral micronized progesterone, all patients had in-phase endometrial biopsies. Despite complaints of drowsiness, the majority of patients preferred the oral formulation over the vaginal route of administration.

CONCLUSION

We conclude that oral micronized progesterone is efficacious in the treatment of luteal phase defects.

The use of topical anesthesia in diagnostic hysteroscopy and endometrial biopsy

OBJECTIVE

To show that intrauterine anesthesia is a reliable method for reducing pain associated with endocavitary procedures.

DESIGN

A prospective, randomized, double-blind study.

SETTING

The Department of Obstetrics and Gynecology, Tor Vergata University of Rome, Rome, Italy.

PATIENTS

Forty-five patients undergoing diagnostic hysteroscopy (n = 27) or hysteroscopy and endometrial biopsy (n = 18).

INTERVENTIONS

Five milliliters of 2% mepivacaine or saline solution were injected transcervically into the uterine cavity before performing the procedures.

MAIN OUTCOME MEASURES

Evaluation of pain reduction on a visual analogue scale.

RESULTS

Pain expectation and pain reported were reduced during and after the procedures.

CONCLUSION

Topical anesthesia effectively reduces pain during hysteroscopy and endometrial biopsy.

Gonadal hormones and semen quality in male runners. A volume threshold effect of endurance training

Eleven high mileage runners (HR) (108.0 +/- 4.5 km.wk-1), 9 moderate mileage runners (MR) (54.2 +/- 3.7 km.wk-1) and 10 sedentary controls (SC) of similar age (28.3 +/- 1.5 yr) were studied to evaluate the effects of volume of endurance training on reproductive function in male runners. Levels of reproductive, adrenal and thyroid hormones were measured during a 1-hr period of serial blood sampling (q20 min) and urinary excretion of 24-hr luteinizing hormone (uLH) was determined on two separate days. Semen exams and sperm penetration of standard cervical mucus (Penetrak) were performed 2-5 times. Levels of total testosterone (TT) and free testosterone (FT) were significantly lower in HR (15.3 +/- 1.3 nmol.l-1 and 60.2 +/- 5.1 pmol.l-1) compared to MR (21.4 +/- 1.6 nmol.l-1 and 86.0 +/- 6.1 pmol.l-1) and SC (19.5 +/- 0.9 nmol.l-1 and 75.9 +/- 3.6 pmol.l-1). No differences (p > 0.05) were found in uLH, serum LH, follicle-stimulating hormone (FSH), and prolactin (PRL) among the three groups. No other hormonal differences (p > 0.05) were observed among the groups. Total motile sperm count and density were lower (p < 0.05) in HR than SC. Decreased (p < 0.0006) sperm motility and an increased (p < 0.004) population of immature sperm and round cells were observed in HR compared to MR and SC. Sperm penetration of bovine cervical mucus was also decreased (p < 0.024) in HR compared to SC. Volume of training, defined by km.wk-1 run, was significantly correlated to sperm motility, density and number of round cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopy versus laparotomy for ovarian conservative surgery: a randomized trial in the rabbit model

OBJECTIVE

Our purpose was to compare postoperative adhesion formation and reproductive outcome after the same ovarian surgical procedure performed by laparoscopy or laparotomy by means of microsurgical techniques.

STUDY DESIGN

Twenty-eight New Zealand White female rabbits were randomly assigned to laparotomy or laparoscopy for the same standardized surgical procedure: both ovaries were grasped with atraumatic forceps and longitudinally incised on the antimesenteric side from the cortex to the hilum with a microelectrode delivering a tissue power density of 66,666 W/cm. The rabbits were then mated, and 2 weeks later a second-look laparotomy was performed by a blinded observer for the evaluation of postoperative adhesions, number of corpora lutea in each ovary, number of embryos in the ipsilateral uterine horn, and nidation index for each side.

RESULTS

At second look no statistically significant differences were found in postoperative adhesion formation, number of corpora lutea, number of embryos, and nidation index between the laparoscopy and the laparotomy groups.

CONCLUSION

Laparoscopy or laparotomy for ovarian conservative surgery do not appear significantly different in postoperative adhesion formation and reproductive outcome in the rabbit model.

Management of benign ovarian cystic teratomas: laparoscopy compared with laparotomy

STUDY OBJECTIVE

To determine the outcomes of laparoscopic management of benign ovarian cystic teratomas (dermoids) compared with traditional laparotomy and excision.

DESIGN

A retrospective analysis of patients treated from October 1988 to May 1993.

SETTING

University of Connecticut Health Center-affiliated hospitals.

PATIENTS

Thirty-eight women with dermoid cysts that were managed either by laparotomy or laparoscopy, 19 matched patients in each group. The majority of lesions in both groups were diagnosed at routine pelvic examination.

INTERVENTIONS

The two groups were assessed with respect to age, gravidy, parity, size of lesions, and estimated blood loss at surgery.

MEASUREMENTS AND MAIN RESULTS

Two values were significantly different in the group treated by laparoscopy: more dermoids ruptured intraoperatively, and the mean hospital stay was significantly shorter (p</=0.01). In most cases cystectomy was performed with preservation of the involved ovary. After a mean follow-up of 11 months no complications such as severe chemical granulomatous peritonitis or persistent pelvic pain have been encountered in the laparoscopy group.

CONCLUSIONS

Laparoscopic management of dermoids is safe and cost effective, and provides patients the benefit of a shorter hospital stay and recovery time.

The use of topical anesthesia in diagnostic hysteroscopy and endometrial biopsy

STUDY OBJECTIVE

To determine whether the pain and discomfort of routine hysteroscopy with endometrial biopsy to diagnose infertility and endometrial pathology can be minimized by topical application of mepivacaine.

DESIGN

Prospective, randomized, double-blind study.

SETTING

The Department of Obstetrics and Gynecology at a teaching hospital in Rome, Italy.

PATIENTS

Eighteen women undergoing diagnostic hysteroscopy.

INTERVENTIONS

Hysteroscopy and endometrial biopsy were performed after transcervical injection of 5 ml 2% mepivacaine or 5 ml saline solution into the uterine cavity.

MEASUREMENTS AND MAIN RESULTS

Difficulty introducing the hysteroscope was rated by the operator on a scale of 1 to 3. An observer scored visible signs of each woman's distress using a three-point scale. The patients reported their pain 15, 30, 60, 120 minutes after the procedure on a visual analog scale. Mepivacaine was more effective than placebo according to all measurements.

CONCLUSIONS

Topical mepivacaine reduced the pain experienced during and after hysteroscopy and endometrial biopsy.

Pregnancy rates in a donor sperm program using cryopreservation: effects of total number of motile sperm inseminated and of a procedure to concentrate sperm

OBJECTIVE

To determine the relationship between the total number of motile sperm per insemination (TMSI) and pregnancy rates in a donor insemination program. To determine the effect of sperm concentration and resultant increase of TMSI on pregnancy rates.

DESIGN

Retrospective analysis of pregnancy rates.

SETTING

University hospital with tertiary service.

PATIENTS

179 women undergoing donor insemination.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Calculation of pregnancy rates according to TMSI.

RESULTS

The pregnancy rate with insemination of thawed donor sperm increases when the TMSI of unconcentrated sperm is > or = 80 x 10(6). Pregnancy rates with previously concentrated sperm are as good as or better than rates of unconcentrated specimens.

CONCLUSION

TSMI is important in determining pregnancy rates in donor insemination programs, and concentration of sperm prior to freezing may enhance pregnancy rates by increasing the TMSI.

Clinical tests explain blunted cortisol responsiveness but not mild hypercortisolism in amenorrheic runners

To investigate mechanisms of blunted adrenocortical responsiveness to exercise and mild hypercortisolism in amenorrheic runners, adrenocorticotropic hormone [ACTH-(1-24) 0.25 mg Cortrosyn] stimulation tests were performed in the presence and absence of overnight dexamethasone (1 mg) suppression (DX and NDX condition, respectively) in six eumenorrheic sedentary women (ES), nine eumenorrheic runners (ER), and nine amenorrheic runners (AR). Before the NDX stimulation test, plasma cortisol was higher (P < 0.001) in AR than in ER and ES. The cortisol response to the NDX stimulation test was blunted (P < 0.001) in AR but reached similar (P > 0.7) peak levels in all groups. Dexamethasone suppressed (P < 0.001) cortisol to similar (P > 0.5) levels (approximately 20 nmol/l) in all groups. In AR, cortisol responses to the DX test were larger (P < 0.03) than to the NDX test and similar (P > 0.6) in the three groups, again reaching comparable (P > 0.8) peak levels. The blunted cortisol response to stimulation in AR in the presence of their mild hypercortisolism appears to be due to a normal limitation in maximal adrenal secretory capacity. Extrapituitary modulators of adrenal responsiveness to ACTH may explain the mild hypercortisolism observed in AR, but limitations of these tests prevent a central negative-feedback defect or an intrinsic adrenal abnormality from being excluded until results of additional studies with even lower doses of dexamethasone and submaximal doses of ACTH-(1-24) are available.

The role of progesterone in regulating human granulosa cell proliferation and differentiation in vitro

To further elucidate the role of progesterone in regulating granulosa cell function, human granulosa and luteal cells were obtained from follicular aspirates of women undergoing in vitro fertilization and placed in culture. Cells plated at 5 x 10(3) cells/mL doubled after 3 days. In contrast, cells plated at 50 x 10(3) cells/mL did not proliferate, but differentiated, secreting high levels of progesterone. Cells plated at 5 x 10(3) cells/mL and cultured with spent medium from cells plated at 50 x 10(3) cells/mL did not increase in number over 3 days of culture. The growth-inhibiting action of the spent medium was removed by either RU 486 (a progesterone receptor antagonist) or charcoal extraction, but not by heat inactivation. The addition of progesterone to fresh medium also prevented cell proliferation. Progesterone's ability to inhibit cell division was attenuated by either RU 486 or aminoglutethamide, which blocked progesterone synthesis. Further, epidermal growth factor (EGF) stimulated cell proliferation, and continuous exposure to progesterone blocked EGF-induced mitosis. When progesterone was added 2 h after EGF, it did not block EGF-stimulated cell proliferation. Progesterone also increased the percentage of granulosa cells and decreased the percentage of large luteal cells present after 3 days of culture, indicating that progesterone inhibited differentiation. Progesterone's effect on differentiation was dose dependent, reversible, and could be overridden by hCG or 8-bromo-cAMP. These observations suggest that progesterone acts directly on granulosa cells through its receptor to inhibit mitosis and that progesterone mediates its antiproliferative effects within 2 h of mitotic stimulation. Progesterone also blocks differentiation, but this effect of can be overcome by hCG or cAMP analogs. These data indicate that progesterone plays a major role in controlling the number of luteal cells that ultimately develop within a corpus luteum by regulating both granulosa cell proliferation and differentiation.

Evaluation of low-dose estrogen and progestin therapy in postmenopausal women. A double-blind, prospective study of sequential versus continuous therapy

In this prospective, double-blind study, we evaluated the efficacy and safety of low-dose estrogen and progestin replacement therapy in 36 postmenopausal women who were administered oral medroxyprogesterone acetate (MPA) cyclically or continuously in combination with conjugated equine estrogen (CEE) 0.625 mg daily. In the sequential group, MPA (5.0 mg) was administered daily for 12 days of each 25-day treatment cycle. In the two continuous groups, MPA was administered without interruption at a daily dose of either 2.5 mg or 5.0 mg for 12 treatment cycles. Of the 36 women in the study, 29 women completed the one-year protocol. The clinical and metabolic responses were assessed before and every three cycles during the 12 cycles of treatment. Endometrial biopsies and lumbar bone density scans were performed before and during the last week of the 12th treatment cycle. Vasomotor and urogenital symptoms improved in all women. Cyclic menstrual bleeding occurred in all patients on sequential therapy, and proliferative endometrium was noted in two of these women. All patients in both continuous treatment groups experienced amenorrhea after the fifth cycle of therapy, and all endometrial biopsies were atrophic or inactive. From the 3rd through the 12th month of cycle, favorable lipid and lipoprotein changes occurred in all treatment groups. Lumbar bone mineral density improved significantly (P < .05) by an average of 6.41% in all patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Subclinical alterations in hormone and semen profile in athletes

STUDY OBJECTIVE

To investigate the effects of two forms of exercise, endurance training (running) and resistance training (weight lifting), on reproductive function in male athletes.

DESIGN

Cross-sectional study.

SETTING

Reproductive Endocrinology and Exercise Laboratory.

SUBJECTS

Twenty-eight healthy male volunteers, 18 to 35 years of age, including 10 endurance-trained runners, 8 resistance-trained weight-lifters, and 10 sedentary controls.

MAIN OUTCOME MEASURE(S)

Hormonal evaluation included determination of plasma levels of total testosterone (T), serum levels of free T, luteinizing hormone (LH), follicle-stimulating hormone, prolactin, and estradiol, and urinary excretion of LH. Semen analyses included an evaluation of sperm characteristics in terms of density, count, motility, and morphology, and a determination of in vitro sperm penetration of standard bovine cervical mucus.

RESULTS

Compared with sedentary controls, endurance-trained and resistance-trained athletes presented with significantly lower levels of total and free T. There were no significant differences in the serum levels of all other circulating and urinary hormone measurements among the three groups. Sperm density, motility, and morphology were significantly altered only in the endurance-trained runners. In vitro sperm penetration of standard cervical mucus was significantly reduced in the endurance-trained runners.

CONCLUSION

Both endurance and resistance training modify the male reproductive hormone profile in a similar manner; however, only endurance training, in the form of running, is associated with subclinical modifications in semen characteristics.

Laser laparoscopy versus laparotomy in lysis of pelvic adhesions

Severe adhesions were induced at laparotomy by laser ablation of the surface of one uterine horn and 1 cm2 of pelvic sidewall in 20 rabbits. Three weeks later the rabbits were selected at random for laparoscopy or laparotomy. Adhesions at the horn, sidewall and incidental sites were scored and lysed with laser at similar power densities. Three weeks later animals were killed and adhesions were blindly scored. We found a significant and similar reduction in severe adhesions at uterine horns after either laser laparoscopy or laser laparotomy, better lysis of sidewall and incidental adhesions by laser laparoscopy and formation of de novo adhesions at nonoperative sites after laparotomy but not after laparoscopy. We conclude that (1) de novo adhesions are common after laparotomy; (2) severe uterine horn adhesions can be reduced equally well by both laparoscopy and laparotomy but laparoscopy is superior to laparotomy with less severe peripheral adhesions; (3) outcome of adhesiolysis depends on several variables, including adhesion density and location and approach (laparotomy or laparoscopy), even when the tool (laser) is constant.

A comparative analysis of adhesion reduction, tissue effects, and incising characteristics of electrosurgery, CO2 laser, and Nd:YAG laser at operative laparoscopy: an animal study

In this study, the relative efficacy and tissue effects of lasers and electrosurgery at operative laparoscopy were evaluated. Thirty rabbits underwent surgical procedures to create extensive intraperitoneal adhesions. The animals were then randomly assigned to laparoscopic adhesiolysis utilizing either electrosurgery, CO2 laser, or Nd:YAG laser exclusively for the assigned group. Each surgical tool was utilized at its optimal power density to achieve the best results. The depth of thermal injury on ovarian and uterine tissues, and the speed at which various segments of the uterine horn were transected were also compared. All three modalities significantly reduced (p < 0.01) intraperitoneal adhesions by approximately 50%. The depth of thermal injury was threefold greater with the Nd:YAG laser than either electrosurgery or the CO2 at both ovarian and uterine tissues (p < 0.001). The speed of transection across the uterine horn was significantly slower (p < 0.001) with the Nd:YAG (2.6 +/- 0.3 sec) than either the CO2 laser (1.4 +/- 0.2 sec) or electrosurgery (1.5 +/- 0.2 sec). From this study, the authors conclude that the Nd:YAG laser causes more tissue damage and is less efficient at incising tissue than either CO2 or electrosurgery, but that all three modalities are equally effective for laparoscopic adhesiolysis.

Progesterone as an autocrine/paracrine regulator of human granulosa cell proliferation

The present study examined the role of progesterone in regulating human granulosa cell proliferation. Human granulosa and luteal cells were obtained from follicular aspirates of women undergoing in vitro fertilization. Cells were plated at 5, 10, or 50 x 10(3) cells/mL and cultured for up to 6 days. At specific times, cells were harvested and assessed for cell number and morphology. The medium was assayed for progesterone. Cells plated at 50 x 10(3) cells/mL did not increase in number after 3 or 6 days of culture, but rapidly differentiated, secreting high amounts of progesterone (> or = 320 nmol/L). Conversely, cells plated at 5 x 10(3) or 10 x 10(3) cells/mL doubled in number over the first 3 days of culture and subsequently differentiated. The addition of 100 ng/mL progesterone or more to the medium inhibited proliferation. Aminoglutethamide blocked progesterone secretion and increased the number of cells present after 3 days of culture. The antiproliferative effects of progesterone were not mimicked by estradiol, testosterone, dihydrotestosterone, or dexamethasone and could not be overridden by epidermal growth factor, a potent mitogen. These data suggest that progesterone plays an autocrine/paracrine role in regulating granulosa cell proliferation.

Evaluation of Astroglide, a new vaginal lubricant: effects of length of exposure and concentration on sperm motility

Traditional vaginal lubricants have been shown to adversely affect sperm motility. Astroglide, a new vaginal lubricant, and K-Y Jelly were tested at varying concentrations to assess their suitability for infertility patients requiring a lubricant. The vaginal lubricants tested impaired sperm motility in a concentration-dependent but not time-dependent manner. We conclude that all traditional vaginal lubricants should be avoided in patients desiring conception. Future studies should attempt to mimic in vivo conditions and focus on concentration-dependent effects.

Effect of the ratio of follicle-stimulating hormone to luteinizing hormone on rat granulosa cell proliferation and oestradiol-17 beta secretion

The present study examined the effects of the ratio of follicle-stimulating hormone (FSH) to luteinizing hormone (LH) on granulosa cell proliferation and oestradiol-17 beta secretion. For these studies, ovarian segments from either immature rats or those primed with pregnant mares serum gonadotrophin (PMSG) were incubated for 5 h with [3H]thymidine and FSH (0-100 mIU/ml) with or without equivalent doses of LH. After incubation, granulosa cells were isolated and their mitotic activity estimated by determining the amount of [3H]thymidine incorporated into the DNA. The amount of oestradiol secreted into the media was measured by radioimmunoassay. Compared to granulosa cells from immature ovaries, granulosa cells from PMSG-primed ovaries required significantly less FSH to stimulate incorporation of [3H]thymidine, had a 9-fold higher basal level of oestradiol production and increased oestradiol secretion in response to gonadotrophins. At pharmacological serum levels (10-20 mIU of total gonadotrophin), FSH:LH ratios of less than or equal to 2 increased oestradiol secretion from PMSG-primed ovaries but did not increase the rate of [3H]thymidine incorporation. Conversely, FSH:LH ratios of greater than or equal to 3 stimulated [3H]thymidine incorporation without altering oestradiol secretion. These data demonstrate that granulosa cells of immature follicles not secreting oestradiol are relatively unresponsive to gonadotrophins at any dose tested. Once the capacity for oestradiol secretion develops, then both the dose and ratio of FSH and LH play major roles in determining whether the follicle will grow or secrete oestradiol.