Serious complications of uterine artery embolization for conservative treatment of fibroids

OBJECTIVE

Document major complications following treatment of fibroids by uterine artery embolization (UAE).

DESIGN

Two case reports.

SETTING

University medical center.

PATIENTS

Two women with symptomatic fibroid uteri.

INTERVENTION(S)

Selective bilateral uterine artery embolization.

MAIN OUTCOME MEASURE(S)

Complications attributable to UAE.

RESULT(S)

Two patients experienced significant morbidity requiring hysterectomy due to infection and/or partial bowel obstruction resulting from UAE.

CONCLUSION(S)

Reports of the management of symptoms related to fibroids with UAE infrequently include adverse outcomes and/or complications. The two cases we managed reinforce that UAE is not free of the risk of life-threatening complications that require emergency hysterectomy. Increasing surveillance for complications may help define the selection criteria that decrease the risks of UAE.

Embolic microspheres within ovarian arterial vasculature after uterine artery embolization

BACKGROUND

Adverse events after uterine artery embolization, including hysterectomy and premature ovarian failure, are concerning for women who desire future fertility.

CASE

A 39-year-old woman underwent emergency hysterectomy after uterine artery embolization embolic microspheres found within the ovarian arterial vasculature.

CONCLUSION

Uterine artery embolization for the treatment of uterine fibroids has been associated with loss of ovarian function in up to 14% of patients. This case report demonstrates that embolic microspheres injected into the uterine artery can unintentionally migrate through anastomotic channels into the ovarian arterial vasculature and potentially compromise ovarian blood flow. Hypoxic tissue injury may be the mechanism of premature ovarian failure observed after uterine artery embolization. Understanding the etiology of premature ovarian failure after uterine artery embolization might allow better patient selection.

Inducible nitric oxide synthase expression by peritoneal macrophages in endometriosis-associated infertility

OBJECTIVE

Determine whether peritoneal macrophages from women with endometriosis-associated infertility express more inducible nitric oxide synthase (NOS2) and produce more NO than fertile controls.

DESIGN

Unblinded clinical study.

PATIENT(S)

Nine infertile women with endometriosis and nine normal fertile women undergoing laparoscopy.

INTERVENTION(S)

Peritoneal fluid and macrophages were collected. Cells were also cultured with the NOS2 inducers interferon-alpha (IFN-alpha) or IFN-gamma plus lipopolysaccharide (LPS).

MAIN OUTCOME MEASURE(S)

Peritoneal fluid NO levels, peritoneal macrophage NOS activity, and peritoneal macrophage NOS2 protein expression.

RESULT(S)

NOS enzyme activity was higher in peritoneal macrophages from endometriosis patients. Immunoblots demonstrated NOS2 protein only in peritoneal macrophages from women with endometriosis. Peritoneal fluid NO concentration was similar in the two groups, but total peritoneal fluid NO content was higher in endometriosis patients. After 3 days' culture, peritoneal macrophages from women with endometriosis produced more NO in response to IFN-alpha or IFN-gamma plus LPS than controls.

CONCLUSION(S)

Peritoneal macrophages from women with endometriosis-associated infertility express higher levels of NOS2, have higher NOS enzyme activity, and produce more NO in response to immune stimulation in vitro. As high levels of NO adversely affect sperm, embryos, implantation, and oviductal function, reducing peritoneal fluid NO production or blocking NO effects may improve fertility in women with endometriosis.

Malignancy in endometriosis: frequency and comparison of ovarian and extraovarian types

One thousand consecutive cases of surgically proven endometriosis were reviewed to evaluate the frequency and types of pelvic cancers that were associated with ovarian and extraovarian endometriosis. The frequency and types of histologic abnormalities present in the eutopic endometrium when cancers were noted in endometriosis were also evaluated. In the large subset of cases for which the authors were the primary pathologists and all foci of endometriosis were recorded, the frequency of malignancy was 10.8%. In contrast, the frequency was only 3.2% in cases diagnosed by others previously in our institution. Cancers were more commonly found in ovaries when endometriosis was present in that ovary (5%) compared to when endometriosis was present at other sites (1%). Clear cell and endometrioid carcinomas were the malignancies most commonly seen in ovaries containing endometriosis, while clear cell adenocarcinoma and adenosarcoma were most commonly seen in conjunction with extraovarian endometriosis. The association of endometriosis with endometrioid and clear cell carcinoma was much stronger than that of serous and mucinous tumors (p < .01). Concurrent endometrial pathology was commonly seen in cases of malignant transformation of endometriosis (32% of cases).

Clinical decision making regarding leiomyomata: what we need in the next millenium

Leiomyomata represent the most common gynecologic tumors and are responsible for over 200,000 hysterectomies per year. They are almost invariably benign and represent clonal expansion of individual myometrial cells. They can cause a variety of symptoms including menometrorrhagia, dysmenorrhea, pelvic pain, reproductive failure, and compression of adjacent pelvic viscera, or be totally asymptomatic. Leiomyomata are more common in African-American women and have a non-Mendelian inheritance pattern with up to a 50% recurrence rate after surgical removal. The therapeutic choices depend on the goals of therapy, with hysterectomy most often used for definitive treatment, and myomectomy when preservation of childbearing is desired. Intracavitary and submucous leiomyomata can be removed by hysteroscopic resection. Laparoscopic myomectomy is now technically possible but apparently with an increased risk of uterine rupture during pregnancy. Although gonadotropin-releasing hormone-agonist-induced hypogonadism can reduce the volume of leiomyomata, the severe side effects and prompt recurrences make them useful only for short-term goals such as reversing anemia or shrinking an intracavitary tumor prior to hysteroscopic resection. Nonextirpative approaches such as myolysis and uterine artery embolization are being evaluated, and may provide more options if they prove to be safe and efficacious in long-term follow-up. Ultimately, if the genetic basis for fibroid development and/or the molecular mechanism(s) of myometrial proliferation are understood, additional nonsurgical therapeutic interventions may be forthcoming. Current clinical needs are to a) determine an effective prevention strategy in genetically predisposed individuals; b) slow the growth of leiomyomata; c) identify the mechanisms of infertility; d) improve early detection; e) develop better surgical techniques; f) reduce recurrences after myomectomy; g) develop nonextirpative options; and h) evaluate their long-term results.

Identification of macrophages at the site of peritoneal injury: evidence supporting a direct role for peritoneal macrophages in healing injured peritoneum

OBJECTIVE

To determine if peritoneal macrophages are present at the site of a surgical injury to the peritoneum during wound healing.

DESIGN

Controlled research study.

SETTING

Academic research laboratory. EXPERIMENTAL MODEL: A murine model of peritoneal wound healing.

INTERVENTION(S)

Intraperitoneal injection of polystyrene beads 1 hour after a surgical peritoneal injury to identify peritoneal macrophages.

MAIN OUTCOME MEASURE(S)

Presence of peritoneal macrophages at the site of the healing wound as determined by intracellular polystyrene beads on transmission electron microscopy 1, 3, 7, and 14 days after injury.

RESULT(S)

Peritoneal macrophages were easily distinguished from other cell types by the phagocytosis of polystyrene beads. One day after injury, peritoneal macrophages were adherent to the wound surface. By 3 days, mesothelial cells began covering the peritoneal macrophages at the wound surface and peritoneal macrophages were identified deep within the wound. Seven days after injury, the mesothelial layer was completely reconstituted, but peritoneal macrophages persisted within the healing would below the surface mesothelium.

CONCLUSION(S)

These data indicate that peritoneal macrophages are present at the peritoneal injury site throughout the healing interval and are consistent with these macrophages having a critical role in peritoneal wound healing.

The temporal efficacy of early second-look lysis of adhesions in reducing postoperative adhesions in a murine model

OBJECTIVE

Our aim was to determine whether early second-look lysis of adhesions reduces postoperative adhesions.

STUDY DESIGN

With the murine uterine horn model, early second-look lysis of adhesions was performed 5, 7, 14, and 21 days after an electrocautery injury. Sites with adhesions (between 36 and 46/time point) underwent lysis of adhesions. Fourteen days later, a reviewer blinded to the treatment assessed adhesion formation, including adhesions not present at early second-look lysis of adhesions (eg, de novo adhesions).

RESULTS

The rate of adhesion formation was 49% of control sites, unchanged when the early second-look lysis of adhesions was performed at 5 (44.4%) and 7 (39.5%) days, reduced at 14 days (28.6%), and increased at 21 days (74%). The pattern of de novo adhesions was similar, 17.6% when the early second-look lysis of adhesions was performed at 5 days, 10% at 7 days, 0% at 14 days, and 28.6% at 21 days. The only histologic difference between the groups was neovascularity at day 21.

CONCLUSIONS

Early second-look lysis of adhesions was effective in reducing postoperative adhesions only when performed at 14 days in this model, suggesting that the specific cellular events occurring at the time of the early second-look lysis of adhesions are critical to efficacy.

A barrier composed of chemically cross-linked hyaluronic acid (Incert) reduces postoperative adhesion formation

OBJECTIVE

To test whether a barrier of chemically cross-linked pure hyaluronic acid reduces postoperative adhesion formation.

DESIGN

The material was evaluated in the murine uterine horn model using excision and electrocautery injuries and in animals who had amounts of material inserted into the abdomen to evaluate toxicity.

SETTING

Academic medical center.

SUBJECT(S)

Mice.

INTERVENTION(S)

Insertion of the barrier between uterine horns and into the peritoneal cavity.

MAIN OUTCOME MEASURE(S)

Adhesion formation at 14 days; the histology of the peritoneum, liver, and spleen at 42 days; and the number, differential count, morphology, and flow cytometry of peritoneal leukocytes 3 days postoperatively.

RESULT(S)

Fewer adhesions were present when excision injuries were separated by the barrier (12 of 28 sites [43%] versus 23 of 26 control sites [88%]), whereas the number of adhesions was unchanged after electrocautery injuries (14 of 26 sites [54%] versus 17 of 26 control sites [65%]). The uterine horn sites covered by the barrier were histologically indistinguishable from controls. No adverse impact on the peritoneum and peritoneal fluid leukocyte population was observed with barrier insertion.

CONCLUSION(S)

The use of a barrier composed of a chemically cross-linked hyaluronic acid derivative (Incert, Anika Therapeutics, Inc., Woburn, MA) reduced postoperative adhesion formation in this model without any adverse impact on the peritoneum and peritoneal leukocyte population. This barrier material shows promise in preventing postoperative adhesions and deserves clinical evaluation.

Removal of surgical barriers of expanded polytetrafluorethylene at second-look laparoscopy was not associated with adhesion formation

OBJECTIVE

To evaluate whether the surgical trauma required for the laparoscopic removal of a polytetrafluoroethylene (PTFE) surgical barrier would cause postoperative adhesions.

DESIGN

Two case reports.

SETTING

Tertiary academic medical center.

PATIENT(S)

Two women who had undergone myomectomy with placement of a PTFE surgical barrier and who were free of adhesions with the barrier in place.

INTERVENTION(S)

Removal of the PTFE barrier by laparoscopy 11 days after myomectomy.

MAIN OUTCOME MEASURE(S)

Adhesions at the site of removal of the PTFE barrier at the time of incidental laparoscopy several years later.

RESULT(S)

Adhesions were not present at the site of PTFE barrier removal.

CONCLUSION(S)

The surgical trauma required to remove PTFE barriers at early second-look laparoscopy was not associated with postoperative adhesions.

Evaluation of the postcoital test in cycles involving exogenous gonadotropins

OBJECTIVE

To evaluate the hypothesis that a postcoital test, optimally performed in the periovulatory period of cycles in which gonadotropin-induced superovulation was used, correlates with cycle fecundity.

METHODS

Of 1135 total consecutive cycles, 367 first cycles were analyzed from the reproductive endocrinology and infertility service of a university medical center. This referral population had a mean age of 34.6 years for the female partner, a nulliparity rate of 81%, and a mean length of infertility of 4.8 years. Postcoital tests were performed 36-40 hours after hCG administration in gonadotropin-stimulated cycles. Clinical pregnancy was defined as fetal cardiac activity as seen on transvaginal ultrasound examination.

RESULTS

Couples with no sperm observed per high-power field in the cervical mucus achieved a 16% fecundity rate (21 pregnancies in 129 cycles), one to ten sperm a 18% fecundity rate (28 pregnancies in 154 cycles), and more than ten sperm a 15% fecundity rate (13 pregnancies in 84 cycles). There was no significant difference between groups (n = 367, P = .85); the power to detect a statistically significant difference was .82. As validation of optimal cervical mucus, fecundity rates were compared with these postcoital test values across the entire range of peak periovulatory serum estrogen levels, and no correlation was seen (P = .61, .86, and .96 for estrogen levels of 201-500, 501-1500, and 1501-3433 pg/mL, respectively).

CONCLUSION

With precise periovulatory timing and supraphysiologic estrogen levels optimizing qualitative cervical mucus characteristics in gonadotropin-induced cycles, the number of sperm observed per high-power field does not correlate with cycle fecundity.

The peritoneal response to expanded polytetrafluoroethylene and oxidized regenerated cellulose surgical adhesion barriers

OBJECTIVE

To determine the peritoneal response to the surgical adhesion barriers expanded-polytetrafluoroethylene (ePTFE) and oxidized regenerated cellulose (ORC).

STUDY DESIGN

The barriers were retrieved from the peritoneal cavities of women and mice 2 hours to 14 days after insertion and subjected to histology and electronmicroscopy.

RESULTS

Macrophages and mesothelial cells rapidly appeared on the surface of both materials. ePTFE was covered by 3 days, with the macrophages gradually being replaced by mesothelium and disappearing thereafter. By 7 days, a delicate membrane with surface mesothelial cells completely enveloped the ePTFE, creating a "pseudoperitoneum". The membrane was difficult to recover as it was fragile and not adherent to the ePTFE. ORC was rapidly infiltrated and degraded by leukocytes and disappeared by 5 days in mice and from all but 1 of 20 women by 11 days.

CONCLUSIONS

ePTFE is rapidly encapsulated by a non-adherent membrane resembling peritoneum while ORC is rapidly infiltrated and degraded by peritoneal fluid leukocytes.

Nitric oxide inhibition of human sperm motility

OBJECTIVE

To determine the effect of nitric oxide (NO) on sperm motility in vitro.

DESIGN

Normal human sperm separated by centrifugation through a discontinuous Percoll gradient and subsequent swim-up were incubated for up to 24 hours with NO donors, with and without the known NO quencher hemoglobin, as well as with agents that raise intracellular cyclic 3',5'-guanosine monophosphate (cGMP). Sperm respiration was determined by a tetrazolium-formazan spectrophotometric assay.

SETTING

Andrology laboratory.

MAIN OUTCOME MEASURES

Absolute sperm motility and respiration.

RESULTS

Sperm incubated with the NO donors 1 mM nitroprusside, 100 to 125 microM 3-morpholinosydnonimine, and 25 to 125 microM pure nitric oxide gas dissolved in buffer were inhibited in motility in a dose-dependent fashion. The inhibition could be reversed by the NO quencher hemoglobin. Agents that raise cellular cGMP (dibutyryl cGMP or 8-bromo-cGMP) did not inhibit motility. Nitric oxide inhibited sperm respiration, as measured by the tetrazolium-formazan assay.

CONCLUSIONS

Nitric oxide reduces sperm motility, possibly by a mechanism involving inhibition of cellular respiration independent of an elevation of intracellular cGMP. Nitric oxide elaborated in the female or male genital tract in vivo could adversely influence sperm function and fertility.

Differential effects of interleukin-1 alpha, tumor necrosis factor-alpha, indomethacin, hydrocortisone, and macrophage co-culture on the proliferation of human fibroblasts and peritoneal mesothelial cells

OBJECTIVE

We sought to determine whether human fibroblasts and peritoneal mesothelial cells (PMC) are under comparable proliferative controls.

METHODS

Human PMC and human fibroblasts were obtained from primary culture of excised explants from infertile women. The proliferation of PMC, as determined by tritiated thymidine incorporation, was compared with that of fibroblasts in the presence of human peritoneal macrophages, interleukin-1 alpha (IL-1), tumor necrosis factor-alpha (TNF), indomethacin, and hydrocortisone. Data were analyzed by one-way and multifactorial analyses of variance, with Bonferroni adjustments for multiple comparisons.

RESULTS

Disparate proliferation was observed between fibroblasts and mesothelial cells with the additives studied. Proliferation of fibroblasts was inhibited (P < .001) when co-cultured with macrophages, IL-1, and TNF. Indomethacin and hydrocortisone overcame the inhibitory effects of macrophage co-culture. By contrast, PMC increased proliferation when cultured with macrophages (P < .001) but were unaffected by IL-1 or TNF and were not altered when indomethacin or hydrocortisone was added to the macrophage co-culture.

CONCLUSION

Human PMC and fibroblasts differentially proliferate in response to putative regulatory controls. This suggests that these cells, which play critical roles in peritoneal wound repair, should be considered separately in developing medical strategies to prevent postsurgical adhesions.

Dietary intervention study to assess estrogenicity of dietary soy among postmenopausal women

We tested the hypothesis that postmenopausal women on a soy-supplemented diet show estrogenic responses. Ninety-seven postmenopausal women were randomized to either a group that was provided with soy foods for 4 weeks or a control group that was instructed to eat as usual. Changes in urinary isoflavone concentrations served as a measure of compliance and phytoestrogen dose. Changes in serum FSH, LH, sex hormone binding globulin, and vaginal cytology were measured to assess estrogenic response. The percentage of vaginal superficial cells (indicative of estrogenicity) increased for 19% of those eating the diet compared with 8% of controls (P = 0.06 when tested by ordinal logistic regression). FSH and LH did not decrease significantly with dietary supplementation as hypothesized, nor did sex hormone binding globulin increase. Little change occurred in endogenous estradiol concentration or body weight during the diet. Women with large increases in urinary isoflavone concentrations were not more likely to show estrogenic responses than were women with more modest increases. On the basis of published estimates of phytoestrogen potency, a 4-week, soy-supplemented diet was expected to have estrogenic effects on the liver and pituitary in postmenopausal women, but estrogenic effects were not seen. At most, there was a small estrogenic effect on vaginal cytology.

Expanded polytetrafluoroethylene (Gore-Tex Surgical Membrane) is superior to oxidized regenerated cellulose (Interceed TC7+) in preventing adhesions

OBJECTIVE

To compare the impact of expanded polytetrafluoroethylene (PTFE; Gore-Tex Surgical Membrane; W. L. Gore & Associates, Inc., Flagstaff, AZ) and oxidized regenerated cellulose (Interceed TC7, Johnson & Johnson Medical, Inc., Arlington, TX) on the development of postsurgical adhesions.

DESIGN

A multicenter, nonblinded, randomized clinical trial.

SETTING

University medical centers.

INTERVENTIONS

Each barrier was allocated randomly to the left or right sidewall of every patient.

PATIENTS

Thirty-two women with bilateral pelvic sidewall adhesions undergoing reconstructive surgery and second-look laparoscopy.

MAIN OUTCOME MEASURES

Adhesion score (on a 0- to 11-point scale), the area of adhesion (cm2), and the likelihood of no adhesions.

RESULTS

The use of both barriers was associated with a lower adhesion score and area of adhesion postoperatively. However, those sidewalls covered with PTFE had a significantly lower adhesion score (0.97 +/- 0.30 versus 4.76 +/- 0.61 points, mean +/- SEM) and area of adhesion (0.95 +/- 0.35 versus 3.25 +/- 0.62 cm2). Overall, more sidewalls covered with PTFE had no adhesions (21 versus 7) and, when adhesions were present on the contralateral sidewall, the number of sidewalls covered with PTFE without adhesions was greater than those covered with oxidized regenerated cellulose (16 versus 2).

CONCLUSION

Expanded polytetrafluoroethylene was associated with fewer postsurgical adhesions to the pelvic sidewall than oxidized regenerated cellulose.

Increased levels of laminin in ascitic fluid of patients with ovarian cancer

Laminin is a component of the extracellular matrix and is associated with tumor cell metastasis. Present studies show that the ovarian cancer cell lines produce significant amounts of laminin (54-140 ng/ml) in culture. Since ovarian cancer is associated with ascites production, laminin levels were then determined in ascites and serum. The results indicate that the ascites from patients with serous adenocarcinoma of the ovary had higher levels of laminin than the normal peritoneal fluid (P < 0.0001). However, the serum levels of laminin did not differ significantly between the control population and ovarian cancer patients.

Does recommending timed intercourse really help the infertile couple?

Timed sexual intercourse is a frequently prescribed component in the treatment for infertile couples. This recommendation is based on a combination of intuition and data from studies often lacking in methodology. With increasingly sophisticated and expensive methods available to time coitus with the presumptive evidence of ovulation, such as the urinary LH kits, the already significant stress of timed intercourse is compounded by the expense of these timing modalities. There is a complete lack of data demonstrating an increased chance of pregnancy with use of such devices. Yet there is evidence that the stress of timed intercourse is a major problem for infertile couples and may even hinder normal reproductive functioning. Available data suggest that much of the period of peak fertility during the menstrual cycle is missed if coitus is timed with the menstrual calendar, basal body temperature thermometer, or LH kit. In addition, the recommendation of a coital frequency of at least a couple of times per week would not only help reduce stress, but also ensure coitus during the period of the menstrual cycle with the greatest chance of resulting in a pregnancy.

An elicited intraperitoneal inflammatory response has no effect on the establishment of pregnancy in the mouse

OBJECTIVE

To determine the impact of intraperitoneal inflammation on reproduction in the mouse.

DESIGN

The effect of an elicited sterile intraperitoneal inflammatory exudate and the passive intraperitoneal transfer of activated syngeneic leukocytes on mating efficiency and uterine implantations was evaluated in mice.

SETTING

Research laboratory.

INTERVENTIONS

Intraperitoneal injection of thioglycolate was used to elicit large numbers of activated peritoneal macrophages (mean 24.4 x 10(6) leukocytes/animal) in female CD-1 mice. The impact of this intraperitoneal exudate on mating efficiency and number of uterine horn implantations after gonadotropin-stimulated ovulation was determined. In separate experiments, the ovarian bursa present in this species was opened surgically to provide direct access of peritoneal constituents to the genital tract and the experiments repeated. Identical endpoints were evaluated in a third group of experiments using C3H/HEN syngeneic mice after passive transfer of 2, 5, and 10 x 10(6) similarly activated syngeneic peritoneal leukocytes.

RESULTS

Neither the elicitation of a peritoneal inflammatory exudate nor the passive transfer of up to 10 x 10(6) activated syngeneic peritoneal macrophages reduced the mating efficiency or the number of uterine implantations. Furthermore, surgically opening the ovarian bursa did not alter these results, although it was associated with anatomic distortion and lowered the number of implantations in all groups.

CONCLUSIONS

We could not confirm the previously published reports suggesting a profound adverse impact of intraperitoneal inflammation on reproduction in mice, even when providing direct continuity between the peritoneal cavity and the genital tract. Consequently, the usefulness of this model needs to be re-evaluated before considering it an adequate paradigm for evaluating potential mechanisms of infertility in women.

The formation of coalescing peritoneal adhesions requires injury to both contacting peritoneal surfaces

OBJECTIVE

To determine whether surgical trauma to one or both contacting peritoneal surfaces is necessary to cause coalescing adhesions.

SETTING

Research laboratory.

DESIGN

The abdominal wall peritoneum and one or both contacting medial peritoneal surfaces of surgically approximated uterine horns in mice were injured by electrocautery, cutting, scratching, or scraping. Adhesion formation was assessed visually and histologically 3 and 7 days later.

RESULTS

Regardless of the type of peritoneal injury, few adhesions resulted when only a single injury was made to the abdominal wall (< or = 6%) or to one uterine horn (< or = 13%). When both opposing uterine surfaces were injured, however, adhesions formed at 57% of the sites after electrocautery, 100% after cutting, 100% after scratching, but 0% after scraping. When previously created uterine adhesions were lysed, they reformed at 15 of 15 sites with and 12 of 13 (92%) sites without electrocautery for hemostasis at the time of lysis.

CONCLUSIONS

In this murine model, the development of postsurgical adhesions required surgical trauma to both contacting peritoneal sites, regardless of the type of injury, the mobility of the opposing peritoneal surfaces or whether hemostasis was achieved. The clinical implications are that more attention needs to be focused on protecting contacting normal peritoneal surfaces from inadvertent injury during surgery and that different therapeutic strategies may be required for prevention of adhesion formation and reformation because of the high probability of contact between injured peritoneal surfaces with the latter.

Endometriosis-associated infertility

Despite intense clinical interest and increasingly sophisticated diagnostic techniques, we know surprisingly little of the relationship between endometriosis and infertility or the mechanism of infertility in these couples. No therapy specifically directed toward the ectopic endometrial implants, medical or surgical, has been demonstrated to improve the likelihood of pregnancy for couples with endometriosis-associated infertility. This is consistent with the observation that, in the absence of mechanical distortion of the pelvic viscera, no therapy directed against the implants improves the likelihood of pregnancy in these couples. The reason for this lack of progress is most probably that the mechanism of infertility in these couples remains to be determined. At present, it would be more accurate to say that these couples have unexplained infertility. The most promising therapeutic approach is to treat women with endometriosis-associated infertility with a non-specific cycle fecundity enhancing technique. Typically this is one of the newer assisted reproductive technologies such as controlled ovarian hyperstimulation with intrauterine insemination of capacitated sperm. Since the fecundity of many of the women with endometriosis in the later reproductive years is rapidly declining, this may represent their most cost-effective option for establishing a pregnancy. Only with further effort directed towards determining the mechanisms of infertility in these couples will a more effective therapy be forthcoming.

Serum and ascitic fluid levels of interleukin-1, interleukin-6, and tumor necrosis factor-alpha in patients with ovarian epithelial cancer

BACKGROUND

Recent studies have shown that multiple cytokines are secreted by ovarian epithelial cancer cells. Previous studies have shown that the cancer cell lines secrete macrophage colony-stimulating factor (M-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-1 (IL-1), interleukin-6 (IL-6), and transforming growth factor-alpha (TGF-alpha). Concomitantly, the serum levels of one of the growth factors (M-CSF) was found to be significantly elevated in patients with primary ovarian cancer and in second-look patients. The authors evaluated the serum levels of IL-1 alpha, IL-1 beta, IL-6, and tumor necrosis factor-alpha (TNF-alpha) in patients with primary ovarian epithelial cancer. These levels were then compared with cytokine concentration found in normal peritoneal fluid.

METHODS

Enzyme-linked immunosorbent assay (ELISA) was used to determine the levels of cytokines in normal peritoneal fluid, ascites, and serum.

RESULTS

In serum, TNF-alpha and IL-6 were significantly increased in primary ovarian cancer patients when compared with control subjects (P < 0.0001 for both cytokines). TNF-alpha and IL-6 were also significantly higher than the levels found in second-look patients (P < 0.007 for TNF-alpha, and P = 0.0002 for IL-6). The levels of IL-1 alpha and beta were not elevated in ovarian cancer. TNF-alpha in the ascites was higher when compared with normal peritoneal fluid and was statistically significantly different when a cut-off point between 71-110 pg was selected (P < 0.005). The levels of IL-6 in ascites from patients with primary ovarian cancer also showed a marked increase (P < 0.0001) when compared with peritoneal fluid from control subjects.

CONCLUSIONS

Levels of IL-1, IL-6, and TNF-alpha were determined in normal peritoneal fluid, ovarian malignant ascites, normal serum, and serum from patients with ovarian cancer. This study showed that the patients with ovarian cancer have elevated levels of IL-6 and TNF-alpha in serum and ascitic fluid. A larger study would help in evaluating the potential use of cytokines as tumor markers in ovarian cancer.

Expanded-polytetrafluoroethylene but not oxidized regenerated cellulose prevents adhesion formation and reformation in a mouse uterine horn model of surgical injury

OBJECTIVE

To evaluate the ability of the two currently available surgical barriers, oxidized regenerated cellulose and expanded-polytetrafluoroethylene (PTFE), to prevent postsurgical adhesions.

DESIGN

Murine uterine horns were approximated in the midline and the contacting uterine surfaces injured by electrocautery, cutting, and scratching, with and without barriers interposed. Sham-operated and experimental animals had adhesions assessed visually and histologically 7 days postoperatively. In another group, adhesions were created and then lysed 7 days later with barriers interposed. Readhesion formation was assessed 14 days after lysis with the PTFE being removed 7 days after lysis.

SETTING

Research laboratory

RESULTS

Adhesions occurred at 58.5% of the electrocautery sites without barriers, 100% of the readhesion sites with recautery for hemostasis, and 92% of the recautery sites without hemostasis. None of the sham-operated sites developed adhesions. When oxidized regenerated cellulose was interposed, adhesions were observed at 36% of uninjured uterine horn sites, 62% with single and 92% with double electrocautery injuries and 90% of the reformation sites. The PTFE did not cause adhesions in uninjured controls and completely prevented adhesion formation and reformation, regardless of the type of injury or whether hemostasis was achieved. A thin cellular membrane, continuous with the uterine serosa, enveloped the PTFE.

CONCLUSIONS

Expanded-polytetrafluoroethylene, but not oxidized regenerated cellulose, prevents adhesion formation and reformation in this murine uterine horn model. Additionally, oxidized regenerated cellulose was adhesiogenic even without surgical injury.

The prognostic value of serum concentrations of progesterone, estradiol, and luteinizing hormone during superovulation with and without adjunctive leuprolide therapy

OBJECTIVE

To determine the predictive value of preovulatory serum concentrations of P, E2, and LH for pregnancy achieved with IUI after superovulation with and without adjunctive leuprolide acetate (LA) therapy.

DESIGN

Randomized, crossover study of superovulation with and without LA therapy.

SETTING

Infertility clinic.

PATIENTS

Subfertile patients referred for superovulation and IUI.

MAIN OUTCOME MEASURES

Preovulatory serum concentrations of P, E2, and LH on the day of hCG administration; pregnancy.

RESULTS

Preovulatory serum concentrations of P, E2, and LH had equivalent predictive value for pregnancy during cycles stimulated without LA therapy. No single parameter was particularly useful in clinical decision making. Threshold P concentrations proposed in other studies as useful in predicting pregnancy did not correlate with cycle fecundity. The predictive value of preovulatory concentrations of P during superovulation with adjunctive LA therapy was significantly worse than P concentrations during superovulation without LA therapy.

CONCLUSIONS

Preovulatory serum P, E2, and LH concentrations in superovulation and IUI are not helpful in determining prognosis for pregnancy. The relative utility of predictive parameters may vary for different treatment regimens.

Unwanted pregnancies: understanding contraceptive use and benefits in adolescents and older women

The highest percentages of unintended pregnancies and the largest increases in births reported in the United States in recent years were in adolescents and in women more than 35 years of age. Increasing numbers of these women will require contraception to avoid unintended pregnancy. In adolescents the combined oral contraceptive agents protect fertility indirectly and exert favorable actions on menstrual dysfunction and certain hormone-related disorders such as acne and hirsutism. To avoid sexually transmitted disease, barrier protection should be used along with oral contraceptives until mutually monogamous, stable relationships are established. Healthy older women who are nonsmokers may also safely use currently available contraceptives. These agents have little impact on metabolic parameters linked to the development of cardiovascular disease. In addition to providing reliable contraception, oral contraceptives offer noncontraceptive benefits to older reproductive-age women, including control of abnormal bleeding and a reduction in the incidence of ovarian and endometrial cancers and other gynecologic pathology. Intrauterine devices and progestin implants are safe, effective, and underused in the United States. Progestin implants may have an additional role in patients for whom estrogen preparations are contraindicated. Counseling is very important before insertion because of the high rate of nuisance side effects. The contraception selection process must consider the efficacy and acceptability of the specific method to avoid the probability of unintended pregnancy and the risk of sexually transmitted diseases.

Histologic features associated with hormonal responsiveness of ectopic endometrium

OBJECTIVE

To correlate histologic parameters of endometriosis with hormonal responsiveness.

DESIGN

Seven hundred sixty-eight unselected endometriotic implants and the corresponding intrauterine endometrium from 196 patients were classified by standard endometrial dating criteria. In addition, other histologic characteristics of endometriotic implants such as the amount of stroma, amount of fibrosis, the presence of surface epithelium, presence of focal hemorrhage, and gland characteristics were also noted.

SETTING

Academic tertiary referral center.

MAIN OUTCOME MEASURES

Comparison of histologic dating between endometriotic implants and the corresponding endometrium as a function of histologic parameters.

RESULTS

Implants that were synchronous with the corresponding eutopic endometrium had more stroma than those that were out of phase. The amount of fibrosis was inversely related to hormonal responsiveness. The presence of surface epithelium in implants was also associated with an impaired response (28.0% versus 48.0% in phase). Endometriomas were found to be in phase with the corresponding endometrium less often than other types of implants (21.7% versus 43.3%). Although endometriomas had similar amounts of stroma when compared with other implants, they had significantly more fibrosis (850.2 microns versus 195.0 microns).

CONCLUSIONS

These results suggest that the unpredictable response of endometriotic implants to cyclic endogenous hormones and hormonal therapy may be related to the architectural relationships between the cellular elements found in normal endometrium.

Comparison of the peritoneal cells elicited by oxidized regenerated cellulose (Interceed) and expanded polytetrafluoroethylene (Gore-Tex Surgical Membrane) in a murine model

OBJECTIVE

The peritoneal fluid cell responses to the available barriers used to prevent postoperative adhesions, oxidized regenerated cellulose (interceed) and expanded polytetrafluoroethylene (Gore-Tex Surgical Membrane), were compared.

STUDY DESIGN

Oxidized regenerated cellulose and expanded polytetrafluoroethylene were inserted into the peritoneal cavity of mice and the peritoneal fluid cell number, differential cell count, morphologic type, adherence to plastic, and phorbol-12,13-myristate acetate-stimulated hydrogen peroxide production evaluated. Peritoneal fluid cell attachment to oxidized regenerated cellulose and expanded polytetrafluoroethylene was evaluated by electron microscopy.

RESULTS

Oxidized regenerated cellulose promptly elicited increased numbers of large, morphologically activated peritoneal fluid macrophages that adhered more rapidly and produced more hydrogen peroxide than controls. Expanded polytetrafluoroethylene gradually increased the number of normal-appearing peritoneal fluid macrophages with increased hydrogen peroxide production but normal adherence. Macrophages rapidly attached to both materials in vivo, with oxidized regenerated cellulose being rapidly degraded.

CONCLUSION

Oxidized regenerated cellulose, to a greater extent than expanded polytetrafluoroethylene, elicits an acute peritoneal fluid inflammatory exudate in the mouse, which may contribute to the oxidized regenerated cellulose-induced peritoneal injury and de novo adhesions observed in this model.

Murine peritoneal injury and de novo adhesion formation caused by oxidized-regenerated cellulose (Interceed [TC7]) but not expanded polytetrafluoroethylene (Gore-Tex Surgical Membrane)

STUDY OBJECTIVE

To evaluate the impact of the materials contained in the available adhesion prevention barriers on the peritoneum. STUDY DESIGN, SETTING, PATIENTS: A murine paradigm was used, placing oxidized-regenerated cellulose (Interceed [TC7]) and expanded polytetrafluoroethylene (PTFE; Gore-Tex Surgical Membrane) in the peritoneal cavity for intervals up to 14 days.

INTERVENTIONS AND MAIN OUTCOME MEASURES

The appearance of the peritoneum on scanning and transmission electron microscopy and the presence of de novo adhesions were the end-points used.

RESULTS

Oxidized-regenerated cellulose caused localized sloughing of the mesothelial cell layer and leukocyte infiltration of the deeper tissue leading to the formation of adhesions to the bowel and liver in 58% of the animals. The surface of the oxidized-regenerated cellulose-injured peritoneum healed in 5 to 7 days. Neither peritoneal injury nor adhesions were noted in sham-operated animals or animals with PTFE.

CONCLUSIONS

Oxidized-regenerated cellulose but not PTFE has a localized injurious effect on the peritoneum of the mouse, resulting in de novo adhesions. The impact of the barrier material itself on normal peritoneum may be an important consideration in designing surgical barriers for the prevention of postoperative adhesions.

Hormone-resistant endometriosis following total abdominal hysterectomy and bilateral salpingo-oophorectomy: correlation with histology and steroid receptor content

Endometriosis is rare after hysterectomy and oophorectomy for conditions unrelated to endometriosis. We present a case of delayed development of aggressive, hormone-resistant endometriosis temporally remote from hysterectomy and oophorectomy performed for chronic pelvic inflammatory disease. Treatment with depo-medroxyprogesterone acetate resulted in continued growth of the retroperitoneal endometrioma and necessitated posterior exenteration because of the endometrioma's location. Estrogen and progesterone receptor levels were measured to clarify why this woman's endometriosis was resistant to hormone therapy. Despite administration of large amounts of depo-medroxyprogesterone acetate, the progesterone receptor content was elevated while the estrogen receptor content was undetectable. Why this patient developed this particular type of aggressive endometriosis is unclear, but the lack of down-regulation of progesterone receptors in response to high-dose progestin therapy may indicate an alteration in basic regulatory and cellular processes within the endometriotic implant.

The stimulus responsible for the peritoneal fluid inflammation observed in infertile women with endometriosis

OBJECTIVE

We tested the hypothesis that menstrual debris from ectopic endometrium is the stimulus responsible for eliciting the peritoneal fluid (PF) inflammation observed in infertile women with endometriosis.

DESIGN, SETTING, PATIENTS

The extent of endometriosis was correlated with the PF volume and total PF cell count retrospectively in 135 infertile women with endometriosis.

RESULTS

The volume and total cell count were positively correlated, whereas the total cell count was negatively correlated with the extent of endometriosis. Despite a similar negative trend, no statistically significant correlation was noted between the volume and the extent of endometriosis. These relationships did not change when the data were reanalyzed deleting those pathological features contributing to the endometriosis score but not capable of producing intraperitoneal menstrual debris, i.e., adhesions and encapsulated ovarian endometriomas.

CONCLUSIONS

These findings indicate that menstrual debris from ectopic endometrium is probably not a major factor in the elicitation of the observed PF inflammation in infertile women with endometriosis and suggest an inverse relationship may exist between PF inflammation and the extent of endometriosis.

Serum human chorionic gonadotropin concentration for predicting multiple gestation in pregnancies conceived with superovulation and intrauterine insemination

Assisted reproductive technologies are associated with an increased incidence of multiple gestation. Because they provide precise information on the time of ovulation, those technologies afford an opportunity to analyze the association between multiple gestation and maternal serum human chorionic gonadotropin (hCG) concentrations during early pregnancy. We retrospectively evaluated this association in 76 pregnancies (26 multiple) conceived with superovulation and intrauterine insemination. Using multiple linear regression, we discerned that the number of fetuses surviving the first trimester was directly proportional to the log of the hCG concentrations. The mean + 1 SD for the estimated hCG values of singleton pregnancies was selected a priori as the threshold for detecting multiple pregnancies. This threshold value provided a sensitivity of 73%, specificity of 80% and overall accuracy of 78%. Nine of 11 pregnancies with three or more fetuses had hCG concentrations above the threshold values. Although there is a positive correlation between the number of fetuses surviving the first trimester and the hCG concentration early in pregnancy, the predictive value of the hCG concentration is useful only for excluding most triplet and quadruplet pregnancies.

Adjunctive leuprolide therapy does not improve cycle fecundity in controlled ovarian hyperstimulation and intrauterine insemination of subfertile women

Problems arising from controlled ovarian hyperstimulation for intrauterine insemination, such as premature luteinization and asynchronous ovarian follicular development, are identical to those encountered with controlled ovarian hyperstimulation for in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT). It has been suggested that the adjunctive use of GnRH agonists for controlled ovarian hyperstimulation improves the efficiency of GIFT and IVF cycles. We hypothesized that adjunctive use of leuprolide acetate, a GnRH agonist, would have a similarly beneficial effect on cycle quality and cycle fecundity in subfertile women treated with controlled ovarian hyperstimulation and intrauterine insemination. We randomly assigned the first cycle of controlled ovarian hyperstimulation and intrauterine insemination for each of 97 subfertile women to include either human menopausal gonadotropins (hMGs) alone or hMGs following midluteal pre-treatment with leuprolide. If a pregnancy did not occur in the first cycle, the woman was given the other treatment in the second cycle. Although the cycles that included leuprolide required a larger amount of hMGs and more days of stimulation per cycle, the mean estradiol concentrations and numbers of follicles were not different. Despite prevention of premature luteinization with leuprolide, the cycle fecundity was not different between groups (0.11 with adjunctive leuprolide treatment and 0.22 with hMGs alone). We conclude that in unselected subfertile patients, the adjunctive use of leuprolide for controlled ovarian hyperstimulation and intrauterine insemination does not improve cycle fecundity compared with treatment cycles that do not include adjunctive leuprolide therapy.

Lack of enhancing effect of human anti-human immunodeficiency virus type 1 (HIV-1) antibody on HIV-1 infection of human blood monocytes and peritoneal macrophages

The influence of human anti-human immunodeficiency virus type 1 (HIV-1) antibody on HIV-1 infection of freshly isolated normal human peritoneal macrophages and blood monocytes was examined. Each of 14 HIV antibody-positive human serum samples was found to block the infection of four virus isolates (human T-cell lymphotropic virus type IIIBa-L [HTLV-IIIBa-L], HTLV-IIIB, D.U. 6587-7, and D.U. 7887-8) at serum dilutions ranging from 10(-1) to 10(-2). Three of these isolates (HTLV-IIIBa-L, D.U. 6587-7, and D.U. 7887-8) infected cultures of monocytes and macrophages rapidly and produced high levels of virus reverse transcriptase and p24 antigen. A fourth virus isolate (HTLV-IIIB) infected the monocytes and macrophages more slowly and produced low levels of viral protein. More dilute HIV antibody-positive sera had no significant effect on the overall level or rate of virus infection or expression. Complement did not appear to influence the course of infection by any combination of antisera or virus examined. Successful HIV-1 infection of the peritoneal macrophages and blood monocytes under the conditions tested showed strict dependence on CD4 since a recombinant CD4 polypeptide and an anti-CD4 monoclonal antibody effectively blocked the process.

Peritoneal fluid and plasma levels of human macrophage colony-stimulating factor in relation to peritoneal fluid macrophage content

The peritoneal fluid (PF) of women with infertility (especially in the presence of endometriosis) contains increased numbers of leukocytes, 90% to 95% of which are macrophages. The high numbers of peritoneal macrophages presumably result from an influx of blood monocytes into the peritoneum, and/or from local proliferation of peritoneal macrophages. Once in the peritoneal cavity, monocytes differentiate into tissue macrophages. Mononuclear phagocyte proliferation and differentiation are influenced by different cytokines, including macrophage colony-stimulating factor (M-CSF). The purpose of this study was to determine the relationship of M-CSF levels in human PF and plasma to the macrophage content, and to the patient diagnoses. Mean concentrations of PF M-CSF were higher than plasma levels (2.44 +/- 0.13 v 0.95 +/- 0.06 ng/mL, respectively). The mean concentrations of plasma M-CSF did not differ in samples from women of different diagnostic groups (normal, peritoneal adhesions, endometriosis, inactive pelvic inflammatory disease, uterine fibroids, and idiopathic infertility), but the PF concentration was slightly higher in normal women. The absolute (total) amount of PF M-CSF in normal women was lower than in those of the other diagnostic groups. The total amount of PF M-CSF in all women correlated closely with the total number of peritoneal macrophages. The tubal patency status (open versus closed) did not influence the plasma and PF concentrations of M-CSF, nor the PF absolute amount of M-CSF. The PF M-CSF may have come from peritoneal macrophages, fibroblasts, mesothelial cells, or endothelial cells. PF M-CSF may play important roles in the proliferation and/or the differentiation of peritoneal mononuclear phagocytes.

Controlled ovarian hyperstimulation and intrauterine insemination for treatment of infertility

Empirical therapy for subfertility using assisted reproductive technologies recently has gained popularity; however, the cost-effectiveness of these therapies, compared with an untreated control group, has not been established. Similarly, there has been no comparative cost analysis of the utility of controlled ovarian hyperstimulation and IUI in the management of the same condition. Significant PRs in untreated couples with subfertility mandate the design and execution of controlled trials to ascertain the role of controlled ovarian hyperstimulation and IUI in infertility therapy. Various disorders of subfertility have been treated with controlled ovarian hyperstimulation and IUI. The rationale for this therapy is the increase in gamete density at the site of fertilization, as with GIFT and IVF when used for management of the same problems. The live birth rate per initiated cycle and risk of complications are similar to results recently reported for GIFT and IVF. The utility of controlled ovarian hyperstimulation and IUI still remains controversial. When the relatively low direct and indirect costs of controlled ovarian hyperstimulation and IUI are considered, acknowledging the lack of prospective, controlled studies, this procedure appears to be at least as cost-effective as GIFT and IVF.

Effect of age on response to human menopausal gonadotropin stimulation

Conception rates decline in the latter part of the reproductive years. To examine which ovarian parameters are altered with aging, 486 cycles from 225 ovulatory infertile women undergoing human menopausal gonadotropin (hMG) superovulation and washed intrauterine insemination were analyzed. Infertility factors included endometriosis (68%), unexplained infertility (8.4%), male factor (12.9%), and ovulatory dysfunction (10.7%). Parameters that demonstrated a linear relationship with increasing age included numbers of ampules of hMG required per cycle (r = 0.79; P less than 0.05), days of stimulation (r = 0.73; P less than 0.01), estradiol level at the time of hCG (r = -0.92; P less than 0.0001), number of follicles larger than 15 mm (r = -0.61; P less than 0.05), and rate of rise of estradiol (r = -0.92; P less than 0.0001). These same age-dependent changes were observed in women receiving a standard stimulation protocol (3 ampules hMG beginning on cycle day 2). When standard cycles were limited to the first cycle only, the preovulatory estradiol (r = -0.92; P less than 0.005), slope of estradiol rise (r = -0.92; P less than 0.005), and number of preovulatory follicles (r = -0.92; P less than 0.005) still showed a significant decrease with age. Although the mean estradiol level per preovulatory follicle showed a slight decrease with maternal age, no statistically significant trend was noted. In addition, the cycle day of hCG administration was unaffected by age. With advancing age, there appears to be a decreased ovarian response to an increased amount of stimulation, as measured by steroidogenesis and follicular recruitment; yet the estradiol/follicle remains unaltered, indicating continued health of the follicle. These observations may explain in part the observed decrease in fecundity in older women.

The luteal phase in polycystic ovary syndrome during ovulation induction with human menopausal gonadotropin with and without leuprolide acetate

Little data exist on the effects of adjunctive therapy with leuprolide acetate (LA) in the luteal phase of women with polycystic ovary syndrome (PCOS) undergoing ovulation induction with human menopausal gonadotropin (hMG). Additionally, it is not known whether gonadal steroid concentrations in the luteal phase of induced cycles in PCOS are predictive of pregnancy. In this prospective, randomized study comparing cycles using hMG alone (n = 26) with cycles using hMG with LA (n = 33), no differences were noted between treatment groups in progesterone (P), estradiol (E2), and P:E2 ratios on luteal days 3, 6, and 9. When all treatment cycles were pooled, there were no differences in P, E2, or P:E2 ratios, comparing conception and nonconception cycles. We conclude that adjunctive therapy with LA in PCOS patients undergoing ovulation induction with hMG does not alter the luteal phase concentrations of P, E2, and P:E2. Furthermore, no correlation was found between the serum concentrations of these luteal phase steroids and cycle fecundity.

Vaginal condylomata acuminata after McIndoe neovagina creation

The author encountered vaginal condylomata acuminata in two women after McIndoe neovagina creations. By in situ DNA hybridization, the authors identified human papillomavirus type 6 in both women. The large exophytic pattern of growth in the neovagina was more characteristic of that encountered on the natural keratinized squamous epithelium of the vulva and perianal area than of the micropapillary and small flat lesions usually found on natural vaginal mucosa. These observations suggest that (1) this is not a rare infection, considering the low frequency of McIndoe neovagina creations; (2) the development of genital warts is probably related to contact with the etiologic virus; and (3) the intrinsic nature of the infected epithelium, as well as the new "vaginal" environment, may help determine the gross characteristics of the lesions. Women with neovaginas should be encouraged to have their sex partners use condoms, despite the lack of a need for contraception.

CA 125 in peritoneal fluid and serum from patients with benign gynecologic conditions and ovarian cancer

CA 125 was measured in peritoneal fluid from 200 patients with primary ovarian malignancies (35) and benign gynecologic conditions (165). In 86 patients CA 125 was measured both in peritoneal fluid and in serum. Patients with ovarian cancer had markedly greater serum CA 125 levels compared to patients with benign disease. CA 125 levels in peritoneal fluid were usually higher than serum levels. Twenty-six (93%) of 28 patients with ovarian cancer had peritoneal fluid levels which exceeded serum levels in paired samples. peritoneal fluid CA 125 values greater than 200 U/ml identified ovarian cancer patients with 96% sensitivity and 99% specificity. Serum CA 125 values greater than 35 U/ml identified ovarian cancer patients bearing ascites with a sensitivity of 99% and specificity of 94%. Only 2 of 165 patients with benign gynecological conditions had peritoneal fluid values above 200 U/ml. By contrast, only two values below 200 U/ml were found in ascitic fluids from 35 patients with ovarian cancer. CA 125 levels in peritoneal fluid deserve further evaluation for follow-up of patients with ovarian cancer.

Use of human cumulus granulosa cells for in vitro screening of reproductive toxicants

We investigated the possibility that human granulosa cells from the cumulus mass obtained during human in vitro fertilization/embryo transfer (IVF/ET) might be useful for screening of potential reproductive toxicants in vitro. The cumulus granulosa cells detached from the zona pellucida after fertilization were allowed to spontaneously adhere to the incubation dish following transfer (removal) of the embryo. These cumulus cells survived in culture for at least four additional days, appeared on simple inspection to be morphologically normal luteinized granulosa cells, and produced large amounts of progesterone (P) over the culture interval. Production gradually declined during culture in the absence of human chorionic gonadotropin (hCG); however, inclusion of hCG (100 ng/mL) in the medium maintained P production at control (day 1) levels. Introduction of estrogenic agents previously shown to suppress P production in porcine or human culture systems using mural granulosa cells showed comparable effects in this human cumulus cell system. 17 beta-estradiol (10(-5) M), clomiphene citrate (10(-5) M), and o,p-DDT (10(-5)) significantly inhibited hCG-supported P production by human cumulus cells in vitro. This system has the advantages that (1) human cumulus granulosa cells are readily available from IVF/ET programs, (2) the techniques for maintaining the cells in culture are extremely simple, (3) a marker of highly differentiated granulosa cell function (P production) can be reliably measured, and (4) the cells respond predictably like other comparable granulosa cell systems. We conclude that human cumulus cells are a readily available and useful resource for in vitro screening of potential female reproductive toxicants.

Synthetic estrogens suppress granulosa cell progesterone production in vitro

We evaluated the effect of commonly used pharmaceutical estrogens and zeranol, an estrogenic growth-promoting agent used in livestock, on progesterone (P) production by cultures of highly differentiated porcine granulosa cells (GC). The compounds were added to GC cultures over a dose range of 10(-8) to 10(-5) M with P and cell protein measured after 24 h. P production was suppressed by estradiol (minimal suppressive dose: 10(-7) M; maximal suppression to 11% of control), ethinyl estradiol (10(-7) M, 15%), diethylstilbestrol (10(-5) M, 72%), clomiphene citrate (10(-6) M, 30%), nafoxidine (10(-7) M, 33%), tamoxifen (10(-6) M, 37%), and zeranol (10(-5) M, 83%). P production was not suppressed by mestranol. GC protein was suppressed by estradiol, ethinyl estradiol, nafoxidine, and zeranol. These data suggest that synthetic estrogens have the potential to suppress luteal P production by a mechanism unrelated to the usual measures of estrogenicity.

Clinical characteristics of ovulation induction with human menopausal gonadotropins with and without leuprolide acetate in polycystic ovary syndrome

Ovulation induction in polycystic ovary syndrome (PCOS) with human menopausal gonadotropins (hMG) results in suboptimal cycle fecundity and frequently is complicated by ovarian hyperstimulation. The use of a gonadotropin releasing-hormone agonist (Gn-RH-a) with hMG induction of ovulation may improve the therapeutic outcome. In this prospective, randomized trial, 27 women with PCOS underwent a total of 25 cycles of hMG alone and 33 cycles with adjunctive GnRH-a (leuprolide) treatment. Premature luteinization was seen less frequently in the leuprolide-treated cycles than in cycles treated with hMG alone. There were no differences between the treatments in ovarian sensitivity to hMG. Cycle fecundity was 0.16 for hMG alone cycles, and 0.27 for leuprolide with hMG cycles, which were not statistically different. We conclude that the sensitivity of the PCOS ovary to hMG is not affected by 4 weeks of leuprolide pretreatment.

Ovarian hyperstimulation in polycystic ovary syndrome during therapy with leuprolide acetate

Continuous exposure to GnRH eliminates the pituitary as a source of gonadotropins and may have direct suppressive effects on the ovary. A woman with PCO syndrome received leuprolide acetate (1 mg/d SC) for 4 weeks before and simultaneously with hMG stimulation. Human chorionic gonadotropin (5,000 IU) was administered IM on the 8th day of hMG therapy. There were 10 follicles greater than 15 mm and a polycystic appearance to the ovaries with 25 follicles measuring less than 10 mm. The serum E2 concentration was 2,280 pg/mL. She developed severe ovarian hyperstimulation and required hospitalization for 12 days for fluid management. A viable intrauterine pregnancy was present. Four weeks of pretreatment with leuprolide did not prevent hyperstimulation in the presence of an intrauterine pregnancy.

Etiology of endometriosis

The likelihood of developing endometriosis can thus be viewed as a quantitative phenomenon--that is, the probability of having large amounts of endometrium delivered to the peritoneal cavity and the inherent ability of the pelvic tissues to support transplantation, or a combination of the two. What part immunologic, genetic, and menstrual factors contribute to an individual woman's susceptibility to develop the disease has yet to be explored in detail. A substantial amount of research will be required to evaluate these areas to devise methods of preventing the development of endometriosis.

Immunohistochemical analysis of estrogen and progesterone receptors in endometriosis: comparison with normal endometrium during the menstrual cycle and the effect of medical therapy

Estrogen receptors (ER) and progesterone receptors (PgR) in 19 endometriotic implants from 16 normally cycling and hormonally treated women were measured using immunohistochemical techniques and compared with 34 samples of normal intrauterine endometrium. Endometriotic implants contained specific ER and PgR in both glandular epithelium and stroma. In contrast to intrauterine endometrium, receptor content among implants was noted to be more heterogeneous, and did not undergo predictable changes in response to endogenous hormones. In the endometriotic implants of patients treated with hormonal therapy, there were significant decreases in ER and PgR in both the glands and stroma relative to untreated patients. These data imply that endometriosis is unpredictable in its response to the cyclic hormonal milieu in terms of ER and PgR, but retains the ability to respond to hormonal suppression over a prolonged interval.

Bovine cervical mucus penetration by human spermatozoa: lack of association with conception

Penetration of bovine cervical mucus (BCMP) by human spermatozoa has been reported to be a test that may aid in assessment of male fertility. We determined the predictive value of BCMP for conception in 127 infertile couples. Fresh semen and swim-up specimens were tested with the Penetrak assay. Out of 127 patients 16 (13%) achieved pregnancy with 6 months to 2 years of follow-up. In the 62 men with sperm counts of greater than 20 million/ml and motility of greater than 60%, 55 (89%) had adequate BCMP while adequate penetration was found in only eight of 24 (33%) with both sperm count and motility below these values (p less than 0.001). A normal BCMP did not predict pregnancy, and a reduced BCMP had no prognostic value in designating couples not likely to conceive. The comparison of penetration values for semen following swim-up suggests that this preparation may improve the correlation of BCMP with fertility. These results indicate that the semen parameters of sperm density and percent motility predicted spermatozoal performance in the BCMP assay, and that the assessment of BCMP did not predict the likelihood of pregnancy.

Limited hormonal responsiveness of ectopic endometrium: histologic correlation with intrauterine endometrium

In order to assess the hormonal responsiveness of ectopic endometrium, 438 unselected endometrial implants and corresponding intrauterine endometrium from 196 patients were evaluated and classified by standard endometrial dating criteria. Only 13% of the endometrial implants were histologically synchronous with the corresponding intrauterine endometrium. Both proliferative and secretory implants were present in relatively constant proportions throughout the menstrual cycle, demonstrating a lack of correlation with cyclic endogenous hormones. A significant percentage (range, 25% to 49%) of endometrial implants displayed some form of local hemorrhage irrespective of the menstrual cycle timing. Sixty percent of the patients had evidence of hemorrhage in at least one implant. In women receiving hormonal therapy at the time of surgery, the proportion of endometrial implants that were histologically in concert with the corresponding endometrium ranged from 0% to 33%. In early pregnancy and menopause, 50% and 31% of endometrial implants were histologically similar, respectively. These data indicate that the hormonal responsiveness of endometrial implants is unpredictable and inconsistent.