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.