A case report: Hypoxic ischemic encephalopathy & pneumonia in a neonate after SARS-CoV-2 intrauterine transmission

Severe acute respiratory coronavirus 2 (SARS-CoV-2) is primarily transmitted via respiratory droplet or aerosol route. However, there is mounting evidence for intrauterine transmission. We report on a late preterm infant with suspected intrauterine acquisition of SARS-CoV-2 who experienced birth depression, hypoxic ischemic encephalopathy, multisystem organ involvement, and late onset COVID-19 pneumonia [22].

Safe technique for laparoscopic entry into the abdominal cavity

STUDY OBJECTIVE

To evaluate and compare the safety and efficacy of a new method to enter the abdominal cavity at laparoscopy.

DESIGN

(Canadian Task Force classification II-2).

SETTING

Referral center for reproductive surgery in a teaching hospital affiliated with a university-based residency program.

PATIENTS

Twenty representative women of variable body habitus (body mass index 16.5-39 kg/m2).

INTERVENTION

Laparoscopy and laparotomy.

MEASUREMENTS AND MAIN RESULTS

We measured the thickness of the abdominal wall at the base of the umbilicus and just below its inferior border. We also measured distances traversed by the Veress needle or cannula from skin to peritoneal cavity at both sites when the piercing instrument was directed at 45- or 90-degree angle from the horizontal plane of the abdominal wall. Finally, we measured distances created between parietal peritoneum and underlying viscera when the abdominal wall was lifted manually or with towel clips placed laterally, 2 cm from the umbilicus and at the edges of the intraumbilical incision. Distances created between parietal peritoneum and underlying viscera while lifting the abdominal wall by each of these three techniques were measured with a calibrated probe inserted through the intraumbilical port and observed with a 5-mm laparoscope from the suprapubic port. These distances were measured before and after carbon dioxide insufflation at 15 mm Hg, as well as before and while inserting the cannula through the abdominal wall. Mean +/- SD thickness of the abdominal wall at the base of the umbilicus and lower border of the umbilicus were 1.4 +/- 0.5 and 3.0 +/- 1.1 cm, respectively (p <0.01). Distances traversed by piercing instruments through the abdominal wall at the umbilicus and lower border of the umbilicus when the angle of insertion was 45 degrees were 1.98 +/- 0.76 and 4.24 +/- 1.53 cm, respectively (p <0.01). Distances were significantly greater when the angle of insertion was 45 degrees rather than 90 degrees. Distances between parietal peritoneum and underlying viscera when the abdominal wall was lifted manually with towel clips 2 cm from the umbilicus, or at the edges of the intraumbilical incision were 3.5 +/-1.14, 5.14 +/- 1.04, and 6.8 +/- 0.94 cm, respectively (p <0.01). When force was applied on the abdomen at cannula insertion, these distances were reduced by 2.1 +/- 0.91, 1.03 +/- 0.32, and zero centimeters, respectively (p <0.01).

CONCLUSION

Our technique of inserting the cannula perpendicularly through the base of the umbilicus traverses the shortest distance to the abdominal cavity through the least vascular area of the abdominal wall. Lifting the abdominal wall with towel clips placed at the edges of the intraumbilical incision achieves the greatest distance between parietal peritoneum of the abdominal wall and underlying viscera, thus maximizing the margin of safety in protecting peritoneal organs and retroperitoneal vessels from injury.

Ectopic pregnancy from surgical emergency to medical management

During the past 25 years, the incidence of ectopic pregnancy has progressively increased while the morbidity and mortality have substantially decreased, and the treatment has progressed from salpingectomy by laparotomy to conservative surgery by laparoscopy and more recently to medical therapy. This therapeutic transition from surgical emergency to medical management has been attributed to early diagnosis through the use of sensitive assays for hCG and the high definition of vaginal ultrasound. By using these sensitive diagnostic tools, we are now able to select those patients who are most likely to respond to medical management versus those who are at high risk of rupture and require surgery. Besides being less invasive and associated with significantly lower risks, medical therapy with methotrexate results in significant cost savings, which have been calculated to be approximately $3,000 per treated patient. Our goal is to identify those patients with ectopic pregnancy who are most likely to respond to methotrexate therapy and least likely to develop significant side effects. Recent studies have helped us define the predictors of success with methotrexate treatment in women with ectopic pregnancy. The reported success rates of treating ectopic pregnancy with methotrexate vary from 71% to 100%. The highest success rates have been reported from institutions that have detailed diagnostic and therapeutic protocols, readily available assays for serum hCG levels, high-resolution vaginal probe ultrasound, and support staff that can closely monitor clinical response. The importance of developing specific protocols to create a clinical environment that supports the effective use of medical therapy for ectopic pregnancy is confirmed by the associated cost savings, decreased morbidity, and patient preference. Modern diagnostic advances and minimally invasive treatments coupled with improved success rates for assisted reproductive technologies should reduce the morbidity and mortality associated with ectopic pregnancy and offer the affected couple a much more optimistic outlook for subsequent reproductive potential.

Effects of estrone sulfate alone or with medroxyprogesterone acetate on serum lipoprotein levels in postmenopausal women

OBJECTIVE

To determine the effects of estrone sulfate alone or with different doses of medroxyprogesterone acetate on serum lipid and lipoprotein levels.

METHODS

A multicenter, double-masked, randomized trial for 1 year involved 682 postmenopausal women, aged 53.8 +/- 0.2 years (mean +/- standard deviation) with intact uteri. Subjects received fixed daily doses of 0.625 mg of estrone sulfate and one of the following regimens: placebo; 2.5 mg daily of medroxyprogesterone acetate; 5 mg daily of medroxyprogesterone acetate; or 10 mg of medroxyprogesterone acetate for the first 12 days of each 28-day cycle. Fasting lipid and lipoprotein levels were measured at baseline and weeks 12, 16, 24, 30, 36, and 52 of treatment. Absolute mean changes from baseline were determined by paired t test, and treatment effects were determined by analysis of variance.

RESULTS

Total cholesterol levels decreased significantly (P <.05) from baseline in all study groups; however, reduction was significantly greater (P <.001) in the 2.5-, 5-, and 10-mg groups (-13.3%, -15.2%, and -14.1%) than in the placebo group (-4.9%). Low-density lipoprotein cholesterol levels decreased significantly and equally in all groups (-10.1% to -12.3%). High-density lipoprotein cholesterol levels increased by 3.2% with unopposed estrogen (P <.05) and did not change from baseline with combined therapy. Triglyceride and very low-density lipoprotein cholesterol levels increased by 13.4% and 2.7%, respectively, in the placebo group, did not change in the 2.5-mg group, decreased by 10.2% and 2.0% and by 11.4% and 2.2% in the 5- and 10-mg groups, respectively (P <.05).

CONCLUSION

Estrone sulfate at the daily dose of 0.625 mg alone or with medroxyprogesterone acetate significantly improved lipoprotein levels. Combined therapy with medroxyprogesterone acetate and estrone sulfate was associated with statistically significantly greater reduction in total cholesterol and statistically significantly less increase in triglyceride levels than unopposed estrone sulfate therapy.

Sublingual administration of micronized estradiol and progesterone, with and without micronized testosterone: effect on biochemical markers of bone metabolism and bone mineral density

OBJECTIVES

The purpose of this investigation was to evaluate the relative efficacy of the sublingual administration of micronized estradiol (E2), progesterone (P4), and testosterone (T) on bone mineral density and biochemical markers of bone metabolism.

DESIGN

In this double-blind, prospective study, postmenopausal women were randomly assigned to one of four treatment groups: hysterectomized women were assigned to either 1) micronized E2 (0.5 mg) or 2) micronized E2 (0.5 mg) + micronized T (1.25 mg). Women with intact uteri were assigned to either 3) micronized E2 (0.5 mg) + micronized P4 (100 mg) or 4) micronized E2 (0.5 mg) + micronized P4 (100 mcg) + micronized T (1.25 mg). For the purpose of this study, the four treatment groups were combined into two groups for all comparisons. The E2 and E2+P4 groups were combined into the HRT alone group (n=30), and the E2+T and E2+P4+T groups were combined into the HRT + T group (n=27). Hormones were administered sublingually as a single tablet twice a day for 12 months. Bone mineral density was measured in the anterior-posterior lumbar spine and total left hip via dual energy x-ray absorptiometry. Bone metabolism was assessed via serum bone-specific alkaline phosphatase and urinary deoxypyridinoline and cross-linked N-telopeptide of type I collagen, both normalized to creatinine. Data were analyzed via a repeated measures analysis of variance and a Student's t test (alpha=0.05).

RESULTS

The subjects were of similar age (54.0 +/- 0.8 years), height (64.0 +/- 0.3 in), weight (157.6 +/- 4.2 lb), and had similar baseline follicle-stimulating hormone (66.4 +/- 3.2 mIU/L), E2 (26.4 +/- 1.5 pg/ml), P4 (0.3 +/- 0.1 ng/ml), total T (19.0 +/- 1.5 ng/dL), and bioavailable T (3.7 +/- 0.3 ng/dL) levels. During therapy, serum levels increased (p < 0.05) for each hormone. Bone mineral density and bone markers at baseline were similar for each treatment group. Bone-specific alkaline phosphatase decreased (p < 0.05) by -14.3 +/- 4.1% in the HRT alone group and by -8.2 +/- 4.6% in the HRT + T group. Deoxypyridinoline levels decreased significantly in the HRT alone and HRT + T groups, - 14.4 +/- 6.8% and -26.9 +/- 7.6%, respectively. Significant reductions (p < 0.05) in cross-linked N-telopeptide of type I collagen were also observed in both groups, -24.4 +/- 6.5% and -39.5 +/- 8.6%, respectively. Bone mineral density in the lumbar spine increased (p < 0.05) by +2.2 +/- 0.5% the HRT alone group and by + 1.8 +/- 0.6% in the HRT + T group. Total hip bone mineral density was maintained in the HRT alone group (+0.4 +/- 0.4%) and increased (p < 0.05) in the HRT + T group (+ 1.8 +/- 0.5%).

CONCLUSIONS

Sublingual micronized HRT favorably decreases serum and urine markers of bone metabolism, prevents bone loss, and results in a slight increase in spine and hip bone mineral density. Although the addition of testosterone to HRT for 1 year did not result in added benefit to the spine bone mineral density, it did result in a significant increase in hip bone mineral density. Longer duration of therapy may have further improved these outcomes.

Surgical management of interstitial pregnancy

Interstitial pregnancy is a rare and potentially dangerous event. Standard treatment involves laparotomy with cornual resection or hysterectomy, with few reported cases of laparoscopic management. A 14-week, 6-cm interstitial pregnancy was treated laparoscopically, without cornual resection or hysterectomy. Gestational products were removed from the fetal side of the implantation site through a salpingotomy incision through myometrium. In selected patients, this procedure can be accomplished safely and efficaciously while preserving reproductive function and avoiding laparotomy.

Development of a DeltaglnA balanced lethal plasmid system for expression of heterologous antigens by attenuated vaccine vector strains of Vibrio cholerae

We have previously shown that more prominent immune responses are induced to antigens expressed from multicopy plasmids in live attenuated vaccine vector strains of Vibrio cholerae than to antigens expressed from single-copy genes on the V. cholerae chromosome. Here, we report the construction of a DeltaglnA derivative of V. cholerae vaccine strain Peru2. This mutant strain, Peru2DeltaglnA, is unable to grow on medium that does not contain glutamine; this growth deficiency is complemented by pKEK71-NotI, a plasmid containing a complete copy of the Salmonella typhimurium glnA gene, or by pTIC5, a derivative of pKEK71-NotI containing a 1. 8-kbp fragment that directs expression of CtxB with a 12-amino-acid epitope of the serine-rich Entamoeba histolytica protein fused to the amino terminus. Strain Peru2DeltaglnA(pTIC5) produced 10-fold more SREHP-12-CtxB in supernatants than did ETR3, a Peru2-derivative strain containing the same fragment inserted on the chromosome. To assess immune responses to antigens expressed by this balanced lethal system in vivo, we inoculated germfree mice on days 0, 14, 28, and 42 with Peru2DeltaglnA, Peru2DeltaglnA(pKEK71-NotI), Peru2(pTIC5), Peru2DeltaglnA(pTIC5), or ETR3. All V. cholerae strains were recoverable from stool for 8 to 12 days after primary inoculation, including Peru2DeltaglnA; strains containing plasmids continued to harbor pKEK71-NotI or pTIC5 for 8 to 10 days after primary inoculation. Animals were sacrificed on day 56, and serum, stool and biliary samples were analyzed for immune responses. Vibriocidal antibody responses, reflective of in vivo colonization, were equivalent in all groups of animals. However, specific anti-CtxB immune responses in serum (P </= 0.05) and bile (P </= 0. 001) were significantly higher in animals that received Peru2DeltaglnA(pTIC5) than in those that received ETR3, confirming the advantage of higher-level antigen expression in vivo. The development of this balanced lethal system thus permits construction and maintenance of vaccine and vector strains of V. cholerae that express high levels of immunogenic antigens from plasmid vectors without the need for antibiotic selection pressure.

Clinical presentation of hyperprolactinemia

Prolactin is a polypeptide hormone essential for lactation. Its production in the lactotroph cells of the anterior pituitary is regulated primarily by the inhibitory action of hypothalamic dopamine. Hyperprolactinemia is the most common endocrine disorder of the hypothalamic-pituitary axis, occurring mostly in women and presenting most commonly with amenorrhea and galactorrhea. Causes of hyperprolactinemia include physiologic, pharmacologic and pathologic factors; pituitary adenoma is a common pathologic cause. Women may present with decreased libido, infertility, oligomenorrhea/amenorrhea and galactorrhea. Men may present with decreased libido, infertility, gynecomastia or impotence. In the absence of an identifiable and treatable underlying cause, hyperprolactinemia is generally treated with dopamine agonist medications.

High frequency of luteal phase deficiency and anovulation in recreational women runners: blunted elevation in follicle-stimulating hormone observed during luteal-follicular transition

The purposes of this investigation were to evaluate the characteristics of three consecutive menstrual cycles and to determine the frequency ofluteal phase deficiency (LPD) and anovulation in a sample of sedentary and moderately exercising, regularly menstruating women. For three consecutive menstrual cycles, subjects collected daily urine samples for analysis of FSH, estrone conjugates (E1C), pregnanediol-3-glucuronide (PdG), and creatinine (Cr). Sedentary (n=11) and exercising (n=24) groups were similar in age (27.0+/-1.3 yr), weight (60.3+/-3.1 kg), gynecological age (13.8+/-1.2 yr), and menstrual cycle length (28.3+/-0.8 days). Menstrual cycles were classified by endocrine data as ovulatory, LPD, or anovulatory. No sedentary women (0%) had inconsistent menstrual cycle classifications from cycle to cycle, but 46% of the exercising women were inconsistent. The sample prevalence of LPD in the exercising women was 48%, and the 3-month sample incidence was 79%. In the sedentary women, 90% of all menstrual cycles were ovulatory (SedOvul; n=28), whereas in the exercising women only 45% were ovulatory (ExOvul; n=30); 43% were LPD (ExLPD; n=28), and 12% were anovulatory (ExAnov; n=8). In ExLPD cycles, the follicular phase was significantly longer (17.9+/-0.7 days), and the luteal phase was significantly shorter (8.2+/-0.5 days) compared to ExOvul (14.8+/-0.9 and 12.9+/-0.3 days) and SedOvul (15.9+/-0.6 and 12.9+/-0.4 days) cycles. Luteal phase PdG excretion was lower (P < 0.001) in ExLPD (2.9+/-0.3 microg/mg Cr) and ExAnov (0.8+/-0.1 microg/mg Cr) cycles compared to SedOvul cycles (5.0+/-0.4 microg/mg Cr). ExOvul cycles also had less (P < 0.01) PdG excretion during the luteal phase (3.7+/-0.3 microg/mg Cr) than the SedOvul cycles. E1C excretion during follicular phase days 2-5 was lower (P=0.05) in ExOvul, ExLPD, and ExAnov cycles compared to SedOvul cycles and remained lower (P < 0.02) in the ExLPD and ExAnov cycles during days 6-12. The elevation in FSH during the luteal-follicular transition was lower (P < 0.007) in ExLPD (0.7+/-0.1 ng/mg Cr) cycles compared to SedOvul and ExOvul cycles (1.0+/-0.1 and 1.1+/-0.1 ng/mg Cr, respectively). Energy balance and energy availability were lower (P < 0.05) in ExAnov cycles than in other menstrual cycle categories. The blunted elevation in FSH during the luteal-follicular transition in exercising women with LPD may explain their lower follicular estradiol levels. These alterations in FSH may act in concert with disrupted LH pulsatility as a primary and proximate factor in the high frequency of luteal phase and ovulatory disturbances in regularly menstruating, exercising women.

45,X/46,XX mosaicism in patients with idiopathic premature ovarian failure

OBJECTIVE

To determine whether low-level 45,X/46,XX mosaicism may be present in some women with premature ovarian failure (POF).

DESIGN

Slide preparations were made from lymphocyte cultures stimulated with phytohemagglutinin, and fluorescence in situ hybridization (FISH) was then performed using a biotin-labeled X-chromosome probe.

SETTING

Cytogenetics laboratory.

PATIENT(S)

Fifteen women with idiopathic POF, 20 age-matched controls, and an additional 10 older control women with normal reproductive histories.

INTERVENTION(S)

Blood samples were collected.

MAIN OUTCOME MEASURE(S)

The number of X chromosomes present in each cell.

RESULT(S)

In patients with POF, the percentage of cells with a single X chromosome (mean, 5.50) was significantly greater than in the controls of similar age (mean, 2.42). For control subjects, there appeared to be a linear correlation between the number of cells with a single X chromosome and age.

CONCLUSION(S)

Some cases of POF may be attributable to low-level 45,X/46,XX mosaicism, which can be detected using FISH. In the lymphocytes from normal women, the rate of accumulation of cells with a single X chromosome was approximately 700 per 10(6) cells per year.

Bone health is not affected by luteal phase abnormalities and decreased ovarian progesterone production in female runners

The primary purpose of this study was to determine whether decreased ovarian progesterone production, associated with short and inadequate luteal phases in exercising women, was associated with decreased bone mineral density (BMD) and altered bone metabolism. Thirty-three eumenorrheic menstruating women participated in this study for 3 months. Subjects were required to collect daily urine samples for three consecutive menstrual cycles and have blood and urine collected weekly. Daily urine samples were analyzed for free LH, estrone conjugates (E1C), and pregnanediol 3-glucuronide (PdG), adjusted for creatinine, whereas weekly blood and urine samples were analyzed for bone markers, estradiol, progesterone, FSH, and LH. Based on the analyses of these samples, subjects were divided into three groups: sedentary ovulatory (SedOvul; n = 9), exercising ovulatory (ExOvul; n = 14), and exercising luteal phase defects (ExLPD; n = 10). The three groups were matched for age (27.6 +/- 1.0 yr), weight (60.6 +/- 1.9 cm), and reproductive maturity (14.5 +/- 1.0 yr), PdG production during the luteal phase was lower (P = 0.004) in the ExLPD women compared to that in the SedOvul group (2.4 +/- 0.4 vs. 5.1 +/- 0.6 ng/mL creatinine, respectively). The ExOvul group also had less (P < 0.01) PdG production during the luteal phase (3.5 +/- 0.3 ng/mL creatinine) compared to the SedOvul group. The total production of PdG, as assessed by area under the curve analysis, was also lower (P < 0.001) in the ExOvul and ExLPD groups compared to that in the SedOvul group. E1C production, however, was not different (P > 0.05) among the groups, except for E1C during the early follicular phase, which was lower (P = 0.043) in the ExLPD group than that in the SedOvul group. BMD and biochemical markers of bone metabolism were unaffected by and not associated with the compromised progesterone environment, but BMD values at the proximal femur (r = 0.354; P = 0.061) and total body (r = 0.359; P = 0.056) were associated with decreased early follicular E1C production. We conclude the following. 1) Luteal phase disturbances occur independent of training volume, and volume of training does not have to be severe to result in menstrual disturbances. 2) As a result of exercise, disturbance in progesterone production is not associated with decreased bone mass. 3) Long follicular phases are associated with reduced estrogen production during the early follicular phase, which are both associated with decreased bone mass. 4) Provided the estradiol status is adequately maintained, BMD is unaffected by decreased progesterone production associated with short and inadequte luteal phases in exercising women.

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.

Endoscopic treatment of endometriosis-associated infertility. Therapeutic, economic and social benefits

In this report on the therapeutic results in patients with moderate and severe endometriosis treated by operative laser laparoscopy, we also present a comparative analysis of cost and duration of hospitalization and of convalescence in comparable patients treated by laparoscopy versus laparotomy. Sixty patients treated by the same surgeon with operative laser laparoscopy were followed for a period of at least one year to calculate cumulative pregnancy rates, monthly fecundity rates, and monthly probability of pregnancy. The mean duration of hospitalization and incapacitation as well as physician and hospital costs incurred by the laparoscopy treated patients were compared with those incurred by 60 patients with similar degrees of endometriosis but treated by microsurgery at laparotomy. In the laparoscopy group, 36 patients had stage III and 24, stage IV endometriosis. Monthly fecundity rates (6.7%), monthly probability of pregnancy (12.6%) and cumulative pregnancy rates (70.5%) did not differ between patients with stage III and IV disease. The total number of hospital days required by the 60 laparoscopy patients was 72 versus 258 for the laparotomy patients (P less than .001). The total number of days' incapacitation for laparoscopy patients was 216 versus 1,284 for the laparotomy group (P less than .001). The total cost of medical care was $223,260 for the laparoscopy group and $424,500 for the laparotomy group (P less than .001). Our results validate the therapeutic efficacy of operative laparoscopy in the treatment of moderate and severe endometriosis and confirm the substantial economic and social benefits of laparoscopy surgery over laparotomy.

Reproductive outcome after ovarian surgery: microsurgery versus CO 2 laser

The present study was undertaken to compare CO 2 laser vs microsurgery in ovarian surgery, evaluating both postoperative adhesion formation and reproductive outcome. Eighteen female white New Zealand rabbits were anesthetized, and the ovaries were exposed. At random, one ovary was longitudinally bivalved with a scalpel and then reconstructed by microsurgery. The contralateral ovary was similarly cut, but with a CO 2 laser set at a superpulsed mode. Four weeks after surgery, the rabbits were mated, and two weeks later, the animals were evaluated for extent of postoperative adhesion formation, number of corpora lutea in each ovary, and number of embryos in each uterine horn. The nidation index was calculated. The present study shows no difference in postoperative adhesion formation or reproductive function following ovarian surgery by microsurgery or CO 2 laser.

Reproductive outcome after ovarian surgery: suturing versus nonsuturing of the ovarian cortex

The purpose of this study was to ascertain if microsurgical approximation of the ovarian edges after ovarian surgery alters postoperative results, as determined by both adhesion formation and reproductive outcome. Sixteen female white New Zealand rabbits were anesthetized, and the ovaries were exposed. Each ovary was longitudinally bivalved with a scalpel, but only one ovary was reconstructed microsurgically, whereas the contralateral ovary was left open. Four weeks after surgery, the rabbits were mated, and two weeks later, a laparotomy was performed to evaluate postoperative adhesions, the number of corpora lutea in each ovary, and the number of embryos in each uterine horn. The nidation index was calculated. No significant differences were found between the microsurgically sutured and the nonsutured ovaries for all the parameters evaluated. Our data suggest that not closing the ovarian incision does not alter either postoperative adhesion formation or reproductive outcome.

The relationship between alterations in spermatozoal deoxyribonucleic acid, heparin binding sites, and semen quality**Presented in part at the 7th World Congress on In Vitro Fertilization and Assisted Procreations, Paris, France, June 30 to July 3, 1991

OBJECTIVE

To assess the relationship between spermatozoal deoxyribonucleic acid (DNA) and fertilizing potential.

DESIGN

Semen samples were examined from nine fertile donors and six donors without a confirmed pregnancy. All samples were in the normal range for count, morphology, and motility. Spermatozoa from these specimens were stained with acridine orange or Feulgen's reagent. The presence of heparin binding sites was determined by counting the number of spermatozoa that bound to heparin-coated agarose beads.

RESULTS

Acridine orange staining demonstrated that in the fertile group 42% +/- 2% of the spermatozoa fluoresced green indicating that the DNA was intact, whereas only 25% +/- 3% of the spermatozoa fluoresced green in the nonfertile group (P less than 0.05). Feulgen's staining revealed that more spermatozoa from infertile donors showed a heterogeneous DNA distribution (P less than 0.05). The DNA content of spermatozoa with heterogeneous distribution of DNA was reduced by 10% compared with those with homogeneous DNA (P less than 0.05). Normal spermatozoa as well as those with DNA anomalies possessed heparin binding sites.

CONCLUSIONS

These data demonstrated that in donor specimens with normal counts, morphology, and motility, a higher percentage of spermatozoa possess less and/or denatured DNA in the infertile group compared with the fertile donors. In contrast, the surface membranes of spermatozoa with altered DNA have heparin binding sites as do spermatozoa with intact DNA.