Effect of multiple follicular development on uterine perfusion in subsequent spontaneous cycles

OBJECTIVE

To investigate the effect of ovarian hyperstimulation on uterine perfusion during a subsequent natural cycle to evaluate if there is a long-term effect of treatment with gonadotropins.

STUDY DESIGN

Thirty-five infertile couples were subjected to three cycles of multiple follicular development. Uterine blood flow was determined during the follicular phase, ovulation and luteal phase of the spontaneous cycle preceding and the one following the stimulated cycles.

RESULTS

No significant difference was present among pulsatility index (PI) values in the two cycles. PI values (+/- SD) were 2.05 +/- 0.5, 2.28 +/- 0.4, 2.18 +/- 0.5, 2.13 +/- 0.4 and 2.00 +/- 0.5, respectively, in the pretreatment cycle and 2.32 +/- 0.5, 2.56 +/- 0.6, 2.42 +/- 0.3, 2.37 +/- 0.4 and 2.29 +/- 0.5, respectively, in the posttreatment cycle. An inverse correlation was found between PI values and estradiol in the follicular phase of the first spontaneous cycle. As for radial and subendometrial arteries, no significant difference was present for PI values in the two cycles.

CONCLUSION

Multiple follicular development seems not to have a long-term effect on uterine perfusion in the subsequent spontaneous cycle.

Treatment with flutamide improves hyperinsulinemia in women with idiopathic hirsutism

OBJECTIVE

To investigate insulin metabolism and its modifications induced by the administration of flutamide, a specific antiandrogen compound, in women with idiopathic hirsutism (IH) and in nonobese women with polycystic ovary syndrome (PCOS).

DESIGN

Prospective, randomized trial.

SETTING

Endocrinological Centre of the Department of Obstetrics and Gynecology, University of Caligari, Caligari, Italy.

PATIENT(S)

Thirty-two women with normal body mass index participated in the study: 11 with clinical and hormonal features of PCOS and 21 age- and weight-matched normally cycling women with IH (n = 11) and without IH (n = 10, controls).

INTERVENTION(S)

Each subject with PCOS or IH was assigned randomly to receive either flutamide tablets (250 mg twice a day) or placebo for > or =5 months. Twelve subjects (6 with PCOS, 6 with IH) received flutamide and 10 (5 with PCOS, 5 with IH) received placebo. All subjects ingested 75 g of glucose and then underwent an oral glucose tolerance test (OGTT), 3-7 days after spontaneous or medroxyprogesterone acetate (5 mg daily for 5 days)-induced menses. In women with PCOS or IH, the OGTT was repeated at the fourth month of treatment.

MAIN OUTCOME MEASURE(S)

Fasting and OGTT-stimulated levels of glucose, insulin, and C peptide.

RESULT(S)

Both fasting and OGTT-stimulated levels of insulin and C peptide were significantly higher in women with PCOS and in those with IH than in controls. Placebo did not modify parameters of glucose metabolism. Flutamide was capable of significantly blunting fasting and OGTT-stimulated secretion of insulin only in women with IH.

CONCLUSION(S)

Hyperinsulinemia exists in women with IH as well as in nonobese women with PCOS. Treatment with flutamide can completely reverse hyperinsulinemia only in women with IH, which suggests that the efficacy of the drug is dependent on peripheral androgen hyperactivity.

Clinical applications of colour Doppler energy imaging in the female reproductive tract and pregnancy

This review describes the usefulness of colour Doppler energy (CDE) (or power Doppler) imaging to measure vascularization in the female reproductive tract. CDE imaging is characterized by an increased sensitivity to flow, and thus may be useful in low-flow states and when optimal Doppler angles cannot be obtained. In addition, longer segments of vessels and more individual vessels can be visualized with CDE imaging. The role of CDE imaging in the evaluation of stromal vasculature in normal and in polycystic ovaries is described, and the relationship between follicular vascularity and outcome following in-vitro fertilization are discussed, together with the findings obtained from the evaluation of thecal arteriole of corpus luteum in early pregnancy. The fundamental role of CDE imaging in differentiation among ovarian masses is also reviewed. We summarize the role of CDE imaging in pregnancy, and describe two new applications of three-dimensional power Doppler sonography and the use of ultrasound contrast media. In conclusion, CDE imaging can replace conventional colour Doppler when the information on the direction of flow is not useful. Moreover, the technique appears superior to others for describing microvascular architecture and determining the presence or absence of flow.

Effect of chronic administration of cabergoline on uterine perfusion in women with polycystic ovary syndrome

OBJECTIVE

To confirm whether patients with polycystic ovary syndrome (PCOS) have a reduction in uterine perfusion and to verify whether chronic administration of cabergoline can decrease this high vascular resistance.

DESIGN

Prospective randomized trial.

SETTING

Endocrinological Centre of the Department of Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy.

PATIENT(S)

Thirty patients were enrolled in the study: 20 affected by PCOS and 10 healthy controls. Patients with PCOS were randomly assigned to one of two treatments for 3 months: oral administration of cabergoline (0.5 mg) every week or oral administration of placebo every week.

INTERVENTION(S)

All patients underwent transvaginal ultrasonography associated with Doppler flow measurement of the uterine artery, and serum hormone concentrations were determined during the early follicular phase. In women with PCOS, Doppler flow measurement and hormonal assessment were repeated in the early follicular phase of the third month of treatment.

MAIN OUTCOME MEASURE(S)

Pulsatility index of the uterine artery before and during treatment.

RESULT(S)

The mean pulsatility index of the uterine artery in patients with PCOS was significantly higher than that of the control group (3.29+/-0.5 and 2.01+/-0.2, respectively). Patients with PCOS treated with cabergoline showed a significant increase in uterine perfusion, with a pulsatility index of 3.14+/-0.6 before and 2.39+/-0.5 during the treatment. No difference was found in patients with PCOS treated with placebo.

CONCLUSION(S)

Patients with PCOS have high resistance in the uterine arteries, but chronic administration of cabergoline can increase uterine perfusion.

The diagnosis of endometriomas using colour Doppler energy imaging

We studied the role of colour Doppler energy (CDE) (or power Doppler) imaging in the differentiation between endometriomas and other adnexal masses in premenopausal non-pregnant women. A total of 170 consecutive patients with persistent adnexal masses was submitted to B-mode transvaginal ultrasonography associated with CDE imaging evaluation. Plasma concentrations of CA125 were measured before surgery. Using CDE imaging evaluation of vessel distribution, the occurrence of one of the following findings was considered to indicate the likely presence of endometrioma: (i) a round-shaped homogeneous hypoechoic 'tissue' of low-level echoes without papillary proliferations associated with 'poor' vascularization; (ii) a round-shaped homogeneous hypoechoic 'tissue' of low-level echoes with an echogenic portion in which no flow was detected. The overall agreement between the test result and the actual outcome was calculated using the k index. The CDE imaging evaluation was more accurate in the diagnosis of endometriomas compared with B-mode ultrasonography alone (k = 0.88 and 0.80 respectively). According to the logistic regression equation obtained, the probability of the presence of endometrioma varied between a minimum of 1.4% for patients with no risk factors to a maximum of 95.6% for patients with two risk factors (CDE result and value of CA125 >25 IU/ml).

Diagnosis of adnexal malignancies by using color Doppler energy imaging as a secondary test in persistent masses

The purpose of this prospective study was to compare the accuracy of B-mode transvaginal ultrasonography alone and in combination with color Doppler energy (or power Doppler) imaging in differentiating benign from malignant adnexal masses. A total of 192 consecutive persistent adnexal masses (159 benign, 33 malignant) were studied before surgery by B-mode transvaginal ultrasonography with and without color Doppler energy. In addition, CA-125 plasma levels were determined and spectral Doppler analysis was performed. By color Doppler energy imaging, a mass was considered malignant when arterial flow was visualized in an echogenic portion of a mass defined as malignant by B-mode. Intratumoral arterial blood flow could be readily detected by color Doppler energy imaging in all malignant tumors and in 94% of the benign tumors. The combined use of transvaginal B-mode ultrasonography and color Doppler energy imaging has greater accuracy in the diagnosis of ovarian malignancies than transvaginal ultrasonography alone (value of kappa: 0.81 and 0.63, respectively), reducing the number of false-positive results. The use of spectral Doppler analysis was of limited diagnostic value, with a kappa value of 0.17 for the pulsatility index (< 1) and of 0.41 for the resistance index (< 0.4). Also, the association with CA-125 increased the number of false-negative results. In conclusion, the use of color Doppler energy imaging seems to be a useful secondary test when a mass is suspected to be malignant by B-mode ultrasonography.

Transvaginal ultrasonography in the diagnosis of pelvic adhesions

We studied the role of transvaginal ultrasonography and clinical factors in the diagnosis of pelvic adhesions in a population of 139 consecutive pre-menopausal non-pregnant women submitted to diagnostic and/or operative laparoscopy between February 1995 and November 1996. All patients underwent transvaginal ultrasonography and were interviewed within 2 days of their laparoscopy. The ultrasonographic impressions were then compared with the laparoscopic diagnosis. Patients were classified as having tuboperitoneal abnormalities if evidence of fimbrial, peritubal and/or peri-ovarian adhesions was encountered during surgery. The overall agreement between the ultrasound test result and the surgical findings was calculated using the kappa index. The adhesion of the ovary to the uterus, as evaluated by transvaginal ultrasonography, is most accurate in diagnosing pelvic adhesions (kappa = 0.5) in comparison with the other ultrasonographic findings and clinical parameters. According to the logistic regression equation that was obtained, the probability of the presence of pelvic adhesions varied between a minimum of 12% for patients with no risk factors to a maximum of 93% for patients with three risk factors (previous pelvic surgery and transvaginal ultrasound findings of blurring of the margins of the ovary and adhesion of the ovary to the uterus).

Color Doppler energy imaging in the diagnosis of fetal intracranial hemorrhage in the second trimester

Unlike conventional color Doppler imaging; color Doppler energy (or power Doppler) displays the intensity of the returning Doppler signal, is less dependent on the orientation of the blood vessel, and is therefore better able to detect low blood velocities. For these reasons it could be useful in some investigations which are difficult to perform, such as transvaginal evaluation of fetal brain vessels. We report a case of a fetal intracranial hyperechoic lesion detected at 26 weeks by transabdominal sonography in a severely growth-retarded fetus. There was absence of diastolic flow in the umbilical artery and low impedance to diastolic flow in the middle cerebral arteries. The fetus was further investigated by transvaginal sonography for the evaluation of the nature and localization of the lesion and an intraventricular hemorrhage in the right brain parenchyma with disorganized supratentorial brain structure was observed. As color Doppler energy imaging is more sensitive to slow flow, it was more reliable than conventional Doppler imaging in confirming the absence of flow within and around the hyperechoic lesion in contrast to the normal vascularity of the contralateral ventricular system. After informed parental counselling, the mother, for psychological reasons, asked to be delivered by Cesarean section. The fetus died 24 h after birth. The autopsy corroborated the ultrasonographic diagnosis. This case report confirms the accuracy of transvaginal ultrasonography in the diagnosis of intracranial hemorrhage and suggests a specific role for color Doppler energy imaging.

[Controlled clinical study of the efficacy and tolerability of methoxybutropate compared to nimesulide in gynecology]

BACKGROUND

This study was conducted to evaluate the efficacy and tolerability of methoxibutropate, a non-steroidal antiinflammatory drug, in gynecology. Methoxibutropate has now been available for some years and has recently been prepared in a new formulation: oral granules.

MATERIALS AND METHODS

This was a double-blind study and enrolled 60 patients of childbearing potential (age: 19 to 42 years), with acute or sub-acute inflammatory diseases involving the genital system. Thirty women were treated for 20 days with 1200 mg/day of oral methoxibutropate. Thirty more women were treated with nimesulide as a control drug. Oral granules of nimesulide were administered in daily dosage of 200 mg. Efficacy was evaluated by assessing symptoms and signs at day 8, 15, 21 and 30 after the start of treatment. Symptoms assessed were: pelvic pain, bloated abdomen, breast tenderness, dysmenorrhea, etc. Signs assessed were: volume and consistency of uterus and adnexa, type and volume of vaginal discharge, pelvic tenderness, vaginal tenderness, etc.

RESULTS AND CONCLUSIONS

All the sixty patients enrolled completed the study, at the end of which the drugs were shown to be equally effective: between day 21 and day 30 after the beginning of treatment, resolution of the assessed signs and symptoms was almost complete, especially with methoxibutropate. Lastly, tolerability was remarkable: side effects were few and mild; also in this case methoxibutropate was slightly better.

Transvaginal ultrasound and computed tomography combined with clinical parameters and CA-125 determinations in the differential diagnosis of persistent ovarian cysts in premenopausal women

The purpose of this prospective study was to compare the accuracy of computed tomography (CT) and transvaginal ultrasonography in the differential diagnosis of persistent cystic ovarian lesions. The candidates for this study were 161 premenopausal non-pregnant women with an adnexal mass. After a 3-month follow-up, 83 masses persisted and were examined by both techniques before surgery. We also evaluated the CA-125 plasma levels. The CT and ultrasonographic diagnoses were then compared with the histopathological diagnosis. The overall agreement between the test results and the actual outcome was calculated by means of the kappa statistic. Transvaginal ultrasonography has a closer accuracy in the diagnosis of serous cysts and serous cystadenoma, ovarian carcinoma and endometrioma (value of kappa: 0.78, 0.73 and 0.80, respectively) than CT, even if the latter is associated with clinical and biochemical parameters such as patient's age and CA-125 plasma levels. Only in the diagnosis of cystic teratoma, is transvaginal ultrasonography less accurate than CT. In conclusion, in premenopausal women, transvaginal ultrasonography remains a cost-effective method in the diagnosis of most cystic ovarian lesions.

An open multicenter study to compare the efficacy of intraperitoneal insemination and intrauterine insemination following multiple follicular development as treatment for unexplained infertility

PURPOSE

This multicenter study was carried out to compare the efficacy of intrauterine insemination (IUI) and intraperitoneal insemination (IPI) associated with multiple follicular development as treatment for unexplained infertility.

METHOD

A total of 205 couples completed the trial. Sixty-seven couples underwent treatment with IPI (group A) and 138 couples underwent treatment with IUI (group B).

RESULTS

Clinical pregnancy was obtained in 23 couples in group A (pregnancy rate: 34.3%) and in 36 couples in group B (pregnancy rate: 26.1%). No significant difference was observed between group A and group B. As for the evolution of pregnancies and the incidence of twin pregnancies, no significant difference was observed between the two groups.

CONCLUSIONS

Because IUI and IPI allow us to obtain same results and IPI is more invasive than IUI, the latter technique can be considered the method of choice and IPI should be used when IUI is difficult to perform, as in the presence of a tight cervical canal.

Tumor markers and transvaginal ultrasonography in the diagnosis of endometrioma

OBJECTIVE

To evaluate the accuracy of CA 19.9 plasma levels (with or without CA 125 levels) combined with transvaginal ultrasonography in the differential diagnosis of endometrioma.

METHODS

One hundred eighteen consecutive premenopausal nonpregnant women had laparoscopy or laparotomy between November 1994 and November 1995 because of the presence of a persistent adnexal mass. They underwent transvaginal ultrasonography and measurement of CA 19.9 and CA 125 plasma levels within 2 days before surgery. The ultrasonographic impression and the tumor marker values were compared with the histopathologic diagnosis. The overall agreement between the test result and the actual outcome was calculated using the kappa statistic.

RESULTS

Transvaginal ultrasonography had a strong agreement between test result and surgery (kappa value 0.84), whereas the combined methods were associated with a lower kappa value (range 0.24-0.80).

CONCLUSION

Transvaginal ultrasonography used alone is the most cost-effective method in the preoperative differential diagnosis of endometrioma.

The screening of tubal abnormalities in the infertile couple

PURPOSE

Our goal was to assess, with a prospective study, the role of hysterosalpingo-contrast sonography (HyCoSy) with an echocontrast agent and transvaginal ultrasonography alone in the evaluation of tubal status.

METHODS

Thirty patients were included in the study. These patients underwent an initial plain transvaginal ultrasound examination the day before the HyCoSy. The findings obtained from both examinations were compared with laparoscopic diagnosis, performed in the same menstrual cycle.

RESULTS

The kappa values were 0.48 for patency evaluation and 0.67 for the diagnosis of the presence of at least one patent tube, suggesting a good agreement in both cases between HyCoSy and surgery. HyCoSy had a significantly lower sensitivity (50%), but not a significantly higher specificity (75%), than transvaginal ultrasonography alone in the diagnosis of tubal infertility-related abnormalities such as peritubal adhesions.

CONCLUSIONS

The study demonstrates that the HyCoSy is a useful test when scheduling the most suitable treatment for infertile couples.

Protein-tyrosine kinases activate while protein-tyrosine phosphatases inhibit L-type calcium channel activity in pituitary GH3 cells

The aim of this study was to evaluate the effect of protein-tyrosine kinase (PTK) and protein tyrosine phosphatase (PTP) inhibitors on Ca2+ channels in GH3 cells. The activity of Ca2+ channels was monitored either by single-cell microfluorometry or by the whole-cell configuration of the patch-clamp technique. Genistein (20-200 micron) and herbimycin A (1-15 micron) inhibited [Ca2+]i rise induced either by 55 mM K+ or 10 micron Bay K 8644. In addition, genistein and lavendustin A inhibited whole-cell Ba2+ currents. By contrast, daidzein, a genistein analogue devoid of PTK inhibitory properties, did not modify Ca2+ channel activity. The inhibitory action of genistein on the [Ca2+]i increase was completely counteracted by the PTP inhibitor vanadate (100 micron). Furthermore, vanadate alone potentiated -Ca2+-i response to both 55 mM K+ and 10 micron Bay K 8644. The possibility that genistein could decrease the [Ca2+]i elevation by enhancing Ca2+ removal from the cytosol seems unlikely since genistein also reduced the increase in fura-2 fluorescence ratio induced by Ba2+, a cation that enters into the cells through Ca2+ channels but cannot be pumped out by Ca2+ extrusion mechanisms. Finally, in unstimulated GH3 cells, genistein caused a decline of [Ca2+]i and the disappearance of [Ca2+]i oscillations, whereas vanadate induced an increase of [Ca2+]i and the appearance of [Ca2+]i oscillations in otherwise non-oscillating cells. The present results suggest that in GH3 cells PTK activation causes an increase of L-type Ca2+ channel function, whereas PTPs exert an inhibitory role.

Spontaneous reversibility of bone loss induced by gonadotropin-releasing hormone analog treatment

OBJECTIVE

To verify if a 6-month period of hypoestrogenism due to chronic treatment with GnRH analogue (GnRH-a) causes irreversible bone loss in young women.

DESIGN

Controlled clinical study in volunteer women.

SETTING

Department of Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy.

PATIENTS

Twenty-eight women (mean age +/- SE 81.1 +/- 0.99 years) with endometriosis diagnosed by laparoscopy and 25 healthy, normally cycling women of the same age (28.3 +/- 1.14 years).

INTERVENTIONS

In women with endometriosis, six SC implants of the GnRH-a compound, 3.6 mg goserelin acetate depot, were administered every 28 days starting within 15 days of laparoscopy. Compounds interfering with bone metabolism or hormonal formulations were not taken by control women during the entire period of the study.

MAIN OUTCOME MEASURE

Evaluation of lumbar bone mineral density at the start of the study and 6, 12, and 30 months later.

RESULTS

At the onset of the study, lumbar bone mineral density did not differ in women with endometriosis and control women. Lumbar bone mineral density values significantly decreased after 6 months of GnRH-a treatment. This reduction was still evident 6 months after GnRH-a interruption. However, 24 months after treatment withdrawal, bone mineral density reduction disappeared and bone mineral density values were completely superimposable (+/- O.4 percent) to those observed before treatment. In contrast, control women lumbar bone mineral density values did not change during the entire period of observation.

CONCLUSIONS

These data suggest that GnRH-a treatment for 6 months is not associated with long-term effects on lumbar bone density.

Laparoscopic versus abdominal myomectomy: a prospective, randomized trial to evaluate benefits in early outcome

OBJECTIVE

Our purpose was to investigate the advantages of laparoscopic myomectomy versus laparotomy.

STUDY DESIGN

A prospective, randomized trial was performed on 40 women, 22 to 44 years old, undergoing myomectomy. Patients were randomized to have laparoscopy (n=20) or laparotomy (n=20). The intensity of pain was assessed by a visual analog scale at 0, 1, 2, and 3 days postoperatively. The proportions of patients who were analgesic free on day 2, discharged from the hospital by day 3, and feeling fully recuperated on day 15 were also compared.

RESULTS

The intensity of postoperative pain was lower (p<0.05) after laparoscopy than after laparotomy. A higher (p<0.05) proportion of patients was analgesic free on day 2, discharged from hospital by day 3, and feeling fully recuperated on day 15 after laparoscopy compared with laparotomy.

CONCLUSION

Laparoscopic myomectomy may offer the benefits of lower postoperative pain and shorter recovery time in comparison with laparotomy.

Transvaginal ultrasonography combined with CA-125 plasma levels in the diagnosis of endometrioma

OBJECTIVE

To assess the role of transvaginal ultrasonography combined with CA-125 plasma levels in the diagnosis of endometrioma.

DESIGN

Prospective study with pathological confirmation of the diagnosis.

SETTING

Department of Obstetrics and Gynecology of the University of Cagliari, Italy.

PATIENTS

One hundred one consecutive premenopausal nonpregnant women submitted to laparoscopy or laparotomy, from November 1993 to October 1994, because of the presence of an adnexal mass.

INTERVENTIONS

Within 2 days before surgery all patients underwent transvaginal ultrasonography and evaluation of CA-125 plasma levels. The ultrasonographic impression and the CA-125 value were then compared with the histopathological diagnosis.

MAIN OUTCOME MEASURE

The overall agreement between the test result and the actual outcome was calculated using the kappa index for the transvaginal ultrasonography used alone and for the combination of transvaginal ultrasonography and CA-125 values, for each chosen cutoff and range.

RESULTS

Transvaginal ultrasonography has a strong agreement between test and surgery (kappa value 0.76) whereas the combined use of the two methods is associated with a lower kappa index, ranging from 0.40 to 0.69.

CONCLUSION

Transvaginal ultrasonography used alone has a better predictive capacity in differentiating endometrioma from other adnexal masses than combined methods.

Prevention of de-novo adhesion formation after laparoscopic myomectomy: a randomized trial to evaluate the effectiveness of an oxidized regenerated cellulose absorbable barrier

To evaluate the effectiveness of the oxidized regenerated cellulose absorbable barrier (Interceed, TC7) in the prevention of de-novo adhesion formation after laparoscopic myomectomy, a prospective and randomized study was performed at the Department of Obstetrics and Gynaecology of the University of Cagliari, Cagliari, Italy. A total of 50 pre-menopausal non-pregnant women, aged 23-42 years, who submitted to laparoscopic myomectomy from January 1993 to June 1994, were randomized to surgery alone (control group, n = 25) or surgery and oxidized regenerated cellulose barrier (Interceed group, n = 25). Neither group received any other treatment for adhesion prevention. A second-look laparoscopy was performed 12-14 weeks after laparoscopic myomectomy. The incidence of adhesion-free patients was assessed at second-look laparoscopy by an investigator not informed of the treatment. The numbers of adhesion-free patients were three out of 25 (12%) in the control group and 15 out of 25 (60%) in the treatment group (P < 0.05). In conclusion, the oxidized regenerated cellulose absorbable barrier significantly reduced de-novo adhesion formation after laparoscopic myomectomy.

Ovulation induction with gonadotropins as sole treatment in infertile couples with open tubes: a randomized prospective comparison between intrauterine insemination and timed vaginal intercourse

OBJECTIVE

To assess if ovulation induction with gonadotropins alone is an appropriate treatment in couples affected by unexplained and mild male factor-related infertility and if the concomitant IUI improves the pregnancy rate (PR).

DESIGN

Prospective and randomized trial.

SETTING

Infertility Centre of Department of Obstetrics and Gynecology of the University of Cagliari, Cagliari, Italy.

PATIENTS

Two hundred couples affected by unexplained or mild male factor-related infertility were assigned randomly to one of two treatment groups: group A (n = 100), treated with three consecutive cycles of ovulation induction with gonadotropins associated with timed vaginal intercourse; group B (n = 100), treated with three consecutive cycles of ovulation induction with gonadotropins associated with IUI.

MAIN OUTCOME MEASURE

Pregnancy rate.

RESULTS

The PRs obtained with ovulation induction with gonadotropins associated with IUI were similar to those obtained with ovulation induction with gonadotropins associated with timed vaginal intercourse.

CONCLUSION

Ovulation induction with gonadotropins alone may be as effective as ovulation induction with gonadotropins associated with IUI in couples with unexplained and mild male factor infertility and can represent the initial treatment option for its minimal invasivity and reduced cost and organizational problems.

Treatment of nonendometriotic benign adnexal cysts: a randomized comparison of laparoscopy and laparotomy

OBJECTIVE

To compare laparoscopy and laparotomy in the management of benign adnexal cysts, with particular attention to postoperative convalescence.

METHODS

Forty premenopausal, nonpregnant women, 18-40 years of age and without acute pelvic symptoms, were scheduled to undergo surgical management of anechoic, unilateral, unilocular, persistent adnexal cysts from January 1993 through June 1994 at the Department of Obstetrics and Gynecology of the University of Cagliari, Cagliari, Italy. After ultrasonographic examination, followed by the completion of 6 months' expectant management with repeat ultrasonographic evaluations, subjects were randomized to undergo operative laparoscopy (n = 20) or laparotomy (n = 20). The patients were reviewed postoperatively at the out-patient clinic at 15, 30, 90, and 180 days. The intensity of pain was assessed by completion of a visual analogue scale on the results of the two groups were compared. We also compared the proportions of patients who were analgesic-free on day 2, discharged from hospital within 3 days, and feeling fully recuperated on day 15.

RESULTS

The intensity of postoperative pain was significantly lower (P < .05) in the operative laparoscopy group than in the laparotomy group. A significantly higher (P < .05) proportion of the laparoscopy patients was analgesic-free on day 2, discharged from the hospital within 3 days, and feeling fully recuperated on postoperative day 15.

CONCLUSION

After careful patient evaluation, management of anechoic, unilocular adnexal cysts by operative laparoscopy significantly reduces both the intensity of postoperative pain and the length of convalescence compared with laparotomy.

Reduction of adhesion reformation after laparoscopic endometriosis surgery: a randomized trial with an oxidized regenerated cellulose absorbable barrier

OBJECTIVE

To evaluate the effectiveness of an oxidized regenerated cellulose absorbable barrier (Interceed [TC7] Absorbable Adhesion Barrier) in the reduction of adhesion reformation after laparoscopic surgery for endometriosis.

METHODS

Thirty-two premenopausal nonpregnant women who had severe endometriosis and complete posterior cul-de-sac obliteration and were undergoing laparoscopic surgery were randomly assigned to either surgery alone or surgery and Interceed. None of the subjects received any other treatment for adhesion prevention. Second-look laparoscopy was performed 12-14 weeks after laparoscopic surgery by an investigator blinded to the treatment, and the incidence of adhesion-free subjects was assessed.

RESULTS

Twelve of 16 (75%) women treated with the oxidized regenerated cellulose barrier were free of adhesions, compared with two of 16 (12.5%) controls, a statistically significant difference (P < .05).

CONCLUSION

The oxidized regenerated cellulose absorbable barrier significantly reduces adhesion reformation after laparoscopic surgery for endometriosis.

Involvement of ovarian factors magnified by pharmacological induction of multiple follicular development (MFD) in the increase in Ca125 occurring during the luteal phase and the first 12 weeks of induced pregnancies

OBJECTIVE

To evaluate the relationship of ovarian activity on Ca125 production, we studied whether Ca125 production varies during the menstrual cycle both in normal ovulatory women and in women whose ovarian factors are significantly stimulated by multiple follicular development (MFD). Furthermore, since the first 12 weeks of pregnancy is characterized by the enhancement of corpus luteum function mainly in MFD-induced pregnancies, Ca125 levels were also evaluated in the first quarter of pregnancy both in spontaneous and in MFD-induced pregnancies.

SUBJECTS

Subjects were normal ovulatory women in the late follicular phase (FP) (N = 20) and in the luteal phase (LP) (N = 20), 32 infertile women submitted to MFD with pure FSH, and 40 pregnant women in which pregnancy occurred spontaneously (N = 20) or after induction of MFD (N = 20).

RESULTS AND CONCLUSIONS

In regularly cycling women plasma Ca125 levels were constant during the menstrual cycle. In contrast, in stimulated cycles Ca125 levels were significantly higher (P < 0.0008) in the LP than in the FP. In addition, in these subjects Ca125 levels in the LP were significantly correlated (P < 0.0001, r = 0.686) with E2 plasma levels. These data strongly suggest that an increase in corpus luteum function could be involved in Ca125 production. Since granulosa cells have not been demonstrated to produce Ca125, it can be hypothesized that endometrial or peritoneal cells submitted to exaggerated stimulation by ovarian activity are the source of increased Ca125 secretion. In agreement with this hypothesis, Ca125 levels were significantly higher in the first weeks of spontaneous pregnancies than in the luteal phase and they were also higher in MFD-induced pregnancies than in spontaneous pregnancies (P < 0.001).

The role of follicle-stimulating hormone in the depletion of follicular reserve: menopause in a woman with hypogonadotropic hypoestrogenic amenorrhea: a case report

OBJECTIVE

To investigate the role of FSH in the depletion of follicular reserve in a human being.

DESIGN

Prospective evaluation of a very rare case.

SETTING

Academic research environment.

PATIENT

A 43-year-old woman with primary hypogonadotropic hypoestrogenic amenorrhea, with very low levels of plasma FSH throughout her life.

INTERVENTIONS

Pulsatile GnRH was administered IV at the dose of 4 micrograms every 90 minutes for 20 days. Blood samples were collected every 3 to 4 days.

MAIN OUTCOME MEASURES

Plasma levels of E2, FSH, and LH.

RESULTS

During the 20 days of treatment there was no increase in E2 plasma levels. On the contrary, FSH and LH levels began to rise after 3 days and reached postmenopausal levels within 20 days.

CONCLUSIONS

Depletion of follicular reserve may occur also when the levels of FSH are very low throughout a woman's life. Thus FSH seems only able to rescue follicles from atresia without interfering with the onset of menopause.

Transvaginal ultrasonography in the diagnosis of cystic teratoma

OBJECTIVE

To assess prospectively the role of transvaginal ultrasonography in screening for cystic teratoma and in differentiating cystic teratoma from other ovarian masses.

METHODS

Three hundred seventy-six premenopausal non-pregnant women underwent transvaginal ultrasonography 1 week before undergoing laparotomy or laparoscopy. The visualization of localized or diffuse echogenicity was chosen as the characteristic ultrasonographic finding of cystic teratoma. Endosonographic diagnosis was compared with surgical and pathologic findings.

RESULTS

Sensitivity and specificity for the ultrasonographic screening were 57.9 and 99.7%, respectively, calculated for each visualized ovary (n = 659), and 84.6 and 98.2%, respectively, for differentiating cystic teratoma from other ovarian masses, calculated for each visualized cyst (n = 123).

CONCLUSION

Transvaginal ultrasonography has a better predictive ability for differentiating cystic teratoma from other ovarian masses (kappa value 0.84) than in screening for cystic teratomas (kappa value 0.69).

Relationship between abnormally high levels of plasma CA 125 and resolution of acute pelvic pain in two women with endometrioma

Two premenopausal women presented with endometrioma and slightly elevated CA 125 plasma levels (42.5 and 39.0 U/ml). After initial evaluation, both patients had an episode of sudden onset of pelvic pain with rapid resolution after a few hours. During the pain episode, CA 125 plasma levels were similar to the initial evaluation (41.7 and 40.3 U/ml), while 12 h after resolution of the pain, very high levels were measured in both patients (630 and 575 U/ml). The absence of tubal abnormalities and the negative peritoneal fluid cultural evaluation demonstrated by laparoscopy suggested a retrospective clinical diagnosis of partial ovarian torsion with sudden spontaneous untwisting. Therefore, an abnormal elevation of CA 125 plasma levels in patients with benign adnexal masses may be correlated with episodes of partial ovarian torsion with subsequent detorsion.

Malabsorption of digoxin tablets, gel caps, and elixir in a patient with an end jejunostomy

OBJECTIVE

To report a case of malabsorption of digoxin from tablets, gel caps, and elixir in a patient with an end jejunostomy.

CASE SUMMARY

A 69-year-old man with 18 cm of functioning jejunum following a surgical end jejunostomy was receiving oral digoxin. The patient presented on referral for short bowel syndrome, secretory diarrhea, and malabsorption. He was receiving digoxin tablets 0.75 mg/d with a serum digoxin concentration of 0.5 ng/mL. Attempts to achieve therapeutic digoxin serum concentrations of approximately 1.0 ng/mL by administration of digoxin in the form of liquid-filled gel caps and elixir were unsuccessful.

DISCUSSION

Variable results have been presented in the literature regarding the ability to achieve therapeutic concentrations of digoxin following oral administration in patients with malabsorption syndromes. Several studies have suggested that changing the form of administered digoxin from tablet to elixir or liquid-filled gel caps may improve absorption in patients with small intestine malabsorption. Such changes in oral dosage form failed to achieve therapeutic digoxin serum concentrations in this case.

CONCLUSIONS

The markedly diminished length and the lack of continuity of this patient's small intestine and colon likely resulted in severe malabsorption of orally administered digoxin. Some patients with end jejunostomies may require intravenous forms of medication because of inadequate absorption of orally administered medications.

Effectiveness of cabergoline in reducing follicle-stimulating hormone and prolactin hypersecretion from pituitary macroadenoma in an infertile woman

Dopaminergic drugs have been reported to be effective in the treatment of FSH-secreting adenomas. We describe the case of a young woman suffering from amenorrhea with radiologic signs of pituitary macroadenoma. The enlargement of both ovaries with hemorrhagic and serous cysts suggest that FSH was active biologically. The short-term (13 weeks) chronic treatment with 0.5 mg cabergoline one time per week, a dopaminergic drug with long-lasting effect, was effective in reducing FSH and PRL hypersecretion and restoring the function of the pituitary ovarian axis, as confirmed by the occurrence of pregnancy.

The screening of embryonic viability in early asymptomatic pregnancy by a single endosonographic scan associated with plasma human chorionic gonadotropin determination

PURPOSE

Our purpose was to assess, with a prospective study with random assignment of the day of the first evaluation, whether a single transvaginal ultrasonographic evaluation together with the determination of plasma hCG levels could be used to screen embryonic viability in early asymptomatic pregnancy.

METHODS

In 260 pregnant women observed from January 1991 to November 1993 with spontaneous pregnancies where the exact date of ovulation was known, a single transvaginal ultrasonographic measurement of gestational sac with determination of plasma hCG levels, transformed to their natural logarithm (lnhCG), was performed. An abnormal result was defined as a value of lnhCG per mean gestational sac below the 95% lower confidence limit of the viable pregnancy group.

RESULTS

The sensitivity was 31%, with a specificity of 97%.

CONCLUSION

The study demonstrates that this method has a poor predictive capacity to distinguish viable pregnancy from nonviable pregnancy with a kappa value less than 0.4.

The efficiency of transvaginal ultrasonography in the diagnosis of endometrioma

OBJECTIVE

To assess the efficiency of transvaginal ultrasonography in the screening of endometriomas and in differentiating endometriomas from other ovarian masses.

DESIGN

Prospective study with surgical and pathological confirmation of the sonographic diagnosis.

SETTING

Department of Obstetrics and Gynecology at the University of Cagliari, Cagliari, Italy.

PATIENTS

All premenopausal nonpregnant women (n = 236) submitted to laparotomy or laparoscopy from May 1991 to December 1992.

INTERVENTIONS

Transvaginal ultrasonographic examinations were done within 1 week before surgery. Ultrasonographic diagnosis was compared with surgical and histopathological findings.

MAIN OUTCOME MEASURE

The visualization of round-shaped homogeneous hypoechoic "tissue" of low-level echoes within the ovary was chosen as characteristic ultrasonographic finding of endometrioma. Sensitivity, specificity, and predicted values were calculated for each visualized ovary (group A) to assess the efficiency in the screening, and for each visualized cyst (group B) to assess the efficiency in differentiating endometriomas from other ovarian masses.

RESULTS

Four hundred twenty-three of 466 ovaries were visualized. Of the 82 visualized cysts, 27 were suspected to be endometriomas, and the diagnosis was confirmed by pathology in 21. The sensitivity and the specificity were 75% and 99%, respectively, in group A, and 84% and 90%, respectively, in group B.

CONCLUSION

The study demonstrates that transvaginal ultrasonography has an efficiency of 88% in differentiating endometriomas from other ovarian masses with a specificity of 90%.

Bone metabolism in young women taking a monophasic pill containing 20 mcg ethinylestradiol: a prospective study

The present one-year prospective study was performed to evaluate the effects of an oral contraceptive containing 20 mcg ethinylestradiol plus 0.150 mg desogestrel on bone metabolism in young women. Nineteen women aged 20 to 30 years completed the trial. Bone density was measured in the distal radius by dual photon absorptiometry before starting pill use and at the 3rd, 6th and 12th cycle. At the same time intervals, urinary hydroxyproline-to-creatinine ratio and serum alkaline phosphatase were evaluated. Bone density showed a slight, but not significant, increase at the end of the trial. Both urinary hydroxyproline-to-creatinine ratio and serum alkaline phosphatase showed a significant decrease. The results suggest that bone resorption is reduced, although bone density in the distal radius is not significantly increased in young women using an oral contraceptive containing only 20 mcg ethinylestradiol for one year.

Two methods for assaying DNA double-strand break repair in mammalian cells by asymmetric field inversion gel electrophoresis

The rejoining of gamma-ray-induced DNA double-strand breaks (DSBs) in mammalian cells was measured after various doses of gamma rays by using a version of pulsed-field gel electrophoresis to elute fragments of DNA from an agarose plug into the lane of an agarose gel. Two approaches for measuring the kinetics of DNA repair were compared. In the first method, cells are irradiated and incubated at 37 degrees C in monolayers, after which the cells are suspended in agarose and DNA is isolated and subjected to electrophoresis. In the second approach, cells are suspended in agarose first, then irradiated and incubated for repair, and the DNA is isolated for electrophoresis. In both methods the kinetics of repair appears to be biphasic, with an initial fast phase and a second slow phase. At equal doses the t1/2 for fast repair is two-fold less in cells incubated in monolayers than in cells suspended in agarose (11 min compared to 20-23 min) and threefold less after subtracting the slow repair component. In the agarose method the t1/2 values for fast repair increase with increasing radiation dose, while in the monolayer method they are constant. In both methods t1/2 values for slow repair are approximately constant with radiation dose. At a given radiation dose, the level of initial damage is two- to threefold higher as assessed by the agarose method than by the monolayer method in which DNA repair can occur during the preparation of samples. The detection of higher levels of initial damage by the agarose method permits DNA repair to be assayed at doses as low as 8 Gy and enables fast repair processes to be assayed more readily. However, in the monolayer approach, repair occurs under normal growth conditions and is not subjected to the effects of prior manipulations and/or the rates of nutrient diffusion. Thus this approach might be more representative of normal intracellular repair kinetics.

[Randomized comparative study using carbocalcitonin i.m. vs carbocalcitonin nasal spray vs ipriflavone x os in the treatment of post-menopausal osteoporosis]

A comparative study of 90 post-menopausal osteoporotic women, has been carried out. The patients were divided in 3 homogeneous groups. According to 3 different schemes: Group A = 30 patients received carbocalcitonin i.m. 40 UMRC/day/1 month and 40 UMRC/alternating days/2 months followed by 1 month of wash-out for 11 months; Group B = 30 patients received carbolcitonin nasal-spray 80 UMRC/day/1 month and 80 UMRC/alternating day/2 months followed by 1 month of wash-out for 11 months; Group C = 30 patients received ipriflavone x os (600 mg/day/3 months followed by 1 month of wash-out for 3 times). BMC significantly was increased in all Groups after 7 and 11 months. In conclusion, carbocalcitonin and ipriflavone seem to show a similar improving densitometric effect in post-menopausal osteoporosis.

In vitro activities of antibacterial agents against clinical isolates of Escherichia coli and Klebsiella species from intensive care units

The susceptibility of 293 cultures of Escherichia coli and 160 cultures of Klebsiella species isolated consecutively from patients in intensive care units at 25 New York area hospitals to four antibiotic agents was determined. Susceptibility testing was performed with the reference agar dilution and broth microdilution procedures. At the minimum inhibitory concentration (MIC) breakpoints (specified in the prescribing information) of less than or equal to 4 micrograms/ml for imipenem, less than or equal to 16 micrograms/ml for cefoxitin, less than or equal to 8 micrograms/ml for ampicillin/sulbactam, and less than or equal to 64 micrograms/ml for ticarcillin/clavulanic acid, all isolates tested were susceptible to imipenem, 98% each of E coli and Klebsiella isolates were susceptible to cefoxitin, 75% and 83% to ampicillin/sulbactam and 96% and 92% to ticarcillin/clavulanic acid. At the recommended National Committee for Clinical Laboratory Standards MIC breakpoints (less than or equal to 4 micrograms/ml for imipenem, less than or equal to 8 micrograms/ml for cefoxitin, less than or equal to 8/4 micrograms/ml for ampicillin/sulbactam, and less than or equal to 16/2 micrograms/ml for ticarcillin/clavulanic acid) all isolates were susceptible to imipenem, 97% of E coli and 98% of Klebsiella isolates were susceptible to cefoxitin, 75% and 83% to ampicillin/sulbactam, and 86% each to ticarcillin/clavulanic acid. Of the 122 isolates with MICs greater than or equal to 128 micrograms/ml to ampicillin, only 19% were susceptible to ampicillin/sulbactam; and of the 150 isolates with MICs greater than 128 micrograms/ml to ticarcillin, 61% were susceptible to ticarcillin/clavulanic acid. The results suggest that, in the antibiotic combinations studied, high levels of penicillinases, capable of significantly affecting the utility of the enzyme inhibitors, are produced.

Repeated transient hypergonadotropic amenorrhea during pharmacologic induction of multiple follicular development with exogenous gonadotropins

Human gonadotropins are widely used for induction of ovulation in the treatment of anovulatory infertility and for induction of multiple follicular development (MFD) in in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), and artificial insemination with husband's semen (AIH) programs. Reported is a patient with normal menstrual cycles, who had two episodes of gonadal unresponsiveness to human gonadotropin therapy, followed by transient hypergonadotropic amenorrhea ("resistant ovary" syndrome), during induction of MFD in conjunction with AIH as treatment for unexplained infertility. The first episode occurred during the sixth cycle of a first series of MFD induction with daily intramuscular injections of exogenous gonadotropins. The second episode occurred during the second cycle of a second series of MFD induction with intravenous pulsatile administration of FSH. On both occasions, normalization of endogenous gonadotropin levels and reappearance of ovulatory cycles occurred spontaneously, after two and three months, respectively. A similar mechanism could occur in the failures of MFD induction observed in IVF programs.