Adenomyosis and endometriosis. Re-visiting their association and further insights into the mechanisms of auto-traumatisation. An MRI study

PURPOSE

In a series of publications, we had developed the concept that uterine adenomyosis and pelvic endometriosis as well as endometriotic lesions at distant sites of the body share a common pathophysiology with endometriosis constituting a secondary phenomenon. Uterine auto-traumatization and the initiation of the mechanism of tissue injury and repair (TIAR) were considered the primary events in the disease process. The present MRI study was undertaken (1) to corroborate this concept by re-visiting, in view of discrepant results in the literature, the association of adenomyosis with endometriosis and (2) to extend our views concerning the mechanisms of uterine auto-traumatization.

PATIENTS AND METHODS

MRI was performed in 143 women attending our center, in whom, on the basis of transvaginal sonography (TVS) and historical data, such as documented endometriosis and dysmenorrhea of various degrees of severity, the presence of uterine adenomyosis was suspected. In addition to the measurement of the diameter of junctional zone (JZ) of the anterior and posterior walls in the mid-sagittal plane, the diagnosis of adenomyosis was based on visualization, in that all planes were analyzed with scrutiny. By this method of "visualization" all transient enlargement of the JZ, such as peristaltic waves of the archimyometrium and sporadic neometral contractions that might mimic adenomyotic lesions could be excluded. At the same time, this method allowed to lower the limit of detection in terms of thickness of the JZ for assured diagnosis of adenomyosis. Furthermore, the localizations of the individual lesions, their shapes and patterns were described.

RESULTS

With the method of 'visualization', the diagnosis of uterine adenomyosis could be verified in 127 of the 143 patients studied. The prevalence of endometriosis in adenomyosis was 80.6% and the prevalence of adenomyosis in endometriosis was 91.1%. As concluded from their localization within the uterine wall, the adenomyotic lesions predominantly developed in the median region of the upper two-thirds of the uterine wall. Cystic cornual angle adenomyosis was a distinct phenomenon that was only observed in patients suffering from extreme primary dysmenorrhea. Aside from this, the majority of the patients complained of primary dysmenorrhea (80%). On the basis of these findings and the fact that particularly extreme primary dysmenorrhea is associated with high intrauterine pressure, menstrual 'archimetral compression by neometral contraction' has to be considered as an important cause of uterine auto-traumatization in addition to uterine peristalsis and hyperperistalsis. Both mechanical functions of the non-pregnant uterus exert their strongest power in the upper region of the uterus, which is compatible with the predominant localization of the adenomyotic lesions.

CONCLUSIONS

The data confirm our previous results of a high association of adenomyosis with endometriosis and vice versa. Our view of the mechanism of uterine auto-traumatization by mechanical functions of the non-pregnant uterus has to be extended, in that 'archimetral compression by neometral contractions' could be realized as the predominant cause of mechanical strain to the non-pregnant uterus. The data of this study confirm our concept of the etiology and pathophysiology of adenomyosis and endometriosis in that the process of chronic proliferation and inflammation is induced at the level of the archimetra by chronic uterine auto-traumatization. Furthermore, with respect to the diagnosis of uterine adenomyosis (and consequently endometriosis) this study shows a high degree of accordance between the findings in real-time TVS and MRI.

The pathophysiology of endometriosis and adenomyosis: tissue injury and repair

INTRODUCTION

This study presents a unifying concept of the pathophysiology of endometriosis and adenomyosis. In particular, a physiological model is proposed that provides a comprehensive explanation of the local production of estrogen at the level of ectopic endometrial lesions and the endometrium of women affected with the disease.

METHODS

In women suffering from endometriosis and adenomyosis and in normal controls, a critical analysis of uterine morphology and function was performed using immunohistochemistry, MRI, hysterosalpingoscintigraphy, videohysterosonography, molecular biology as well as clinical aspects. The relevant molecular biologic aspects were compared to those of tissue injury and repair (TIAR) mechanisms reported in literature.

RESULTS AND CONCLUSIONS

Circumstantial evidence suggests that endometriosis and adenomyosis are caused by trauma. In the spontaneously developing disease, chronic uterine peristaltic activity or phases of hyperperistalsis induce, at the endometrial-myometrial interface near the fundo-cornual raphe, microtraumatizations with the activation of the mechanism of 'tissue injury and repair' (TIAR). This results in the local production of estrogen. With ongoing peristaltic activity, such sites might increase and the increasingly produced estrogens interfere in a paracrine fashion with the ovarian control over uterine peristaltic activity, resulting in permanent hyperperistalsis and a self-perpetuation of the disease process. Overt auto-traumatization of the uterus with dislocation of fragments of basal endometrium into the peritoneal cavity and infiltration of basal endometrium into the depth of the myometrial wall ensues. In most cases of endometriosis/adenomyosis, a causal event early in the reproductive period of life must be postulated leading rapidly to uterine hyperperistalsis. In late premenopausal adenomyosis, such an event might not have occurred. However, as indicated by the high prevalence of the disease, it appears to be unavoidable that, with time, chronic normoperistalsis throughout the reproductive period of life leads to the same extent of microtraumatization. With the activation of the TIAR mechanism followed by infiltrative growth and chronic inflammation, endometriosis/adenomyosis of the younger woman and premenopausal adenomyosis share in principle the same pathophysiology. In conclusion, endometriosis and adenomyosis result from the physiological mechanism of 'tissue injury and repair' (TIAR) involving local estrogen production in an estrogen-sensitive environment normally controlled by the ovary.

Oxytocin--a stimulator of directed sperm transport in humans

Rhythmic peristaltic contractions of the muscular wall of the non-pregnant uterus, as well as rapid sperm transport from the vagina to the Fallopian tubes, have long been documented by means of vaginal sonography and hysterosalpingoscintigraphy. Uterine peristaltic activity reaches a maximum before ovulation and is controlled via oestradiol secretion from the dominant follicle systemically and into the utero-ovarian countercurrent system; it is also enhanced by oxytocin. In this study, the effect of oxytocin and its receptor antagonist atosiban on uterine peristalsis and thus directed sperm transport during the mid and late follicular phases was examined. Atosiban did not show any effect either on frequency or on pattern of the peristaltic contractions. However, oxytocin significantly increased the rapid and directed transport of radiolabelled particles representing spermatozoa from the vagina into the Fallopian tube ipsilateral to the site of the dominant follicle (P = 0.02, 0.04 and 0.02 after 1, 16 and 32 min of documentation respectively). It seems reasonable to assume that oxytocin plays an important, although not critical, role in the mechanisms governing rapid sperm ascension that, at least in humans, were developed to rapidly preserve an aliquot of spermatozoa following intercourse.

Physiology of Upward Transport in the Human Female Genital Tract

The uterus and fallopian tubes represent a functionally united peristaltic pump under the endocrine control of ipsilateral ovary. We have examined this function by using hysterosalpingoscintigraphy (HSS), recording of intrauterine pressure, electrohysterography, and Doppler sonography of the fallopian tubes. An uptake of labeled particles into the uterus was observed during the follicular and luteal phases of the cycle after application into the vagina. Transport into the oviducts, however, could only be demonstrated during the follicular phase. Furthermore, the predominant transport was into the tube ipsilateral to the ovary containing the dominant follicle. The pregnancy rate following spontaneous intercourse or insemination was higher in those women in whom ipsilateral transport could be demonstrated. The amount of material transported to the ipsilateral tube was increased after oxytocin administration, as demonstrated by radionuclide imaging and by Doppler sonography following instillation of ultrasound contrast medium. An increase in the basal tone and amplitude of contractions was observed after oxytocin administration. These results support the idea that the uterus and fallopian tubes act as a peristaltic pump, which increases transport of sperm into the oviduct ipsilateral to the ovary bearing the dominant follicle. Oxytocin appears to play a critical role in this peristaltic pump. A failure of the peristaltic mechanism is possibly responsible for infertility. We propose the term tubal transport disorder (TTD) as a nosological entity. Results from HSS could be a useful adjunct for choosing treatment modalities in patients with patent fallopian tubes suffering from infertility. These patients may be better served with in vitro fertilization (IVF).

Uterotubal transport disorder in adenomyosis and endometriosis—a cause for infertility

OBJECTIVE

Uterine hyperperistalsis and dysperistalsis are common phenomena in endometriosis and may be responsible for reduced fertility in cases of minimal or mild extent of disease. Since a high prevalence of adenomyosis uteri has been well documented in association with endometriosis, we designed a study to examine whether hyperperistalsis and dysperistalsis are caused by the endometriosis itself or by the adenomyotic component of the disease.

DESIGN

A prospective observational study.

SETTING

University hospital, Department of Obstetrics and Gynaecology, Division of Reproductive Medicine and Gynaecologic Endocrinology with 300 in vitro fertilisation/intracytoplasmatic sperm injection cycles and 350 intrauterine insemination cycles/year.

POPULATION

Forty-one subjects with infertility and with laparoscopically proven endometriosis and patent fallopian tubes. Thirty-five subjects (85%) additionally showed signs of adenomyosis.

METHODS

All subjects underwent T2-weighed magnetic resonance imaging (MRI) and hysterosalpingoscintigraphy (HSSG) during the subsequent menstrual cycle. MRI revealed the extent of the adenomyotic component of the disease and the integrity of uterotubal transport capacity was evaluated by HSSG.

MAIN OUTCOME MEASURES

Influence of adenomyosis on uterotubal transport capacity in endometriosis.

RESULTS

In 35 of the 41 subjects (85%) with endometriosis, signs of adenomyosis were detected using T2-weighed MRI. Two of six (33%) subjects with no adenomyosis (group I) showed dysperistalsis and hyperperistalsis, compared with 14 of 24 (58%) women with focal adenomyosis (group II) and 10 of 11 (91%) women with diffuse adenomyosis (seven showed a failure in transport capacity and two contralateral transport).

CONCLUSIONS

Our data suggest that endometriosis is associated with impeded hyperperistaltic and dysperistaltic uterotubal transport capacity. However, adenomyosis is of even more importance, especially when diffuse adenomyosis is detected. Both forms of adenomyosis are commonly found in subjects with mild to moderate endometriosis. We suggest that the extent of the adenomyotic component in subjects with endometriosis explains much of the reduced fertility in subjects with intact tubo-ovarian anatomy.

Control and function of uterine peristalsis during the human luteal phase

Rhythmic peristaltic contractions of the muscular wall of the non-pregnant uterus can be demonstrated throughout the menstrual cycle, with a maximum just before ovulation. However, not only during the follicular phase but also during the luteal phase, the uterus shows remarkable contractile activity. The present study was conducted in order to examine uterine peristaltic activity and its function during the luteal phases of the human menstrual cycle. The results of vaginal sonography of uterine peristalsis, of hysterosalpingoscintigraphy and of the documentation of the sites of embryo implantation in natural and artificial cycles have shown that uterine peristalsis during the luteal phase is controlled by systemic and probably even more by local hormonal secretion from the fresh corpus luteum, and facilitates the fundal implantation of the blastocyst predominantly ipsilateral to the site of the dominant ovarian structure. Furthermore, this study suggests that the defence against the infiltration and inflammation of the upper genital tract, and thus the degradation of the implanted embryo, represents a further and phylogenetically old and genuine function of the archimetra, which in placentalia was modified in order to participate in the control of invasion of the endometrium by the trophoblast.

Endometriose und Adenomyose

Peristaltic activity of the non-pregnant uterus serves fundamental functions in the early process of reproduction. Hyperperistalsis of the uterus is significantly associated with the development of endometriosis and adenomyosis. In women with hyperperistalsis fragments of basal endometrium are detached during menstruation and transported into the peritoneal cavity. Fragments of basal endometrium have an increased potential of implantation and proliferation resulting in pelvic endometriosis. In addition, hyperperistalsis induces the proliferation of basal endometrium into myometrial dehiscencies. This results in endometriosis-associated adenomyosis with a prevalence of about 90%. Adenomyosis results in impaired directed sperm transport and thus constitutes an important cause of sterility in women with endometriosis. The principal mechanism of endometriosis/adenomyosis is the paracrine interference of endometrial estrogen with the cyclical endocrine control of archimyometrial peristalsis exerted by the ovary thus resulting in hyperperistalsis. Minimal endometriosis of the fertile women, endometriosis and adenomyosis of the infertile women and adenomyosis of the parous peri- and postmenopausal women are considered as phenotypes of a pathophysiological continuum with uterine peristalsis playing a prominent role.

Adenomyosis in endometriosis--prevalence and impact on fertility. Evidence from magnetic resonance imaging

BACKGROUND

The hypothesis is tested that there is a strong association between endometriosis and adenomyosis and that adenomyosis plays a role in causing infertility in women with endometriosis. METHODS. Magnetic resonance imaging of the uteri was performed in 160 women with and 67 women without endometriosis. The findings were correlated with the stage of the disease, the age of the women and the sperm count parameters of the respective partners.

RESULTS

The posterior junctional zone (PJZ) was significantly thicker in women with endometriosis than in those without the disease (P<0.001). There was a positive correlation of the diameter of the PJZ with the stage of the disease and the age of the patients. The PJZ was thicker in patients with endometriosis with fertile than in patients with subfertile partners. The prevalence of adenomyotic lesions in all 160 women with endometriosis was 79%. In women with endometriosis below an age of 36 years and fertile partners, the prevalence of adenomyosis was 90% (P<0.01)

CONCLUSIONS

With a prevalence of up to 90%, uterine adenomyosis is significantly associated with pelvic endometriosis and constitutes an important factor of sterility in endometriosis presumably by impairing uterine sperm transport.

Endometriosis results from the dislocation of basal endometrium

BACKGROUND

The hypothesis is tested that both adenomyotic and endometriotic lesions are derived from basal endometrium.

METHODS

Normal uteri and uteri with adenomyosis obtained by hysterectomy, excised endometriotic lesions and menstrual blood of women with and without endometriosis were used. Estrogen receptor (ER), progesterone receptor (PR), progesterone receptor B isoform (PR(B)) and P450 aromatase (P450A) immunohistochemistry was performed with the use of specific monoclonal antibodies.

RESULTS

With respect to the parameters studied there was a fundamental difference between the cyclical patterns of the basalis and the functionalis of the eutopic endometrium. The endometrium of endometriotic and adenomyotic lesions mimicked the cyclical pattern of the basalis. The peristromal muscular tissue of endometriotic and adenomyotic lesions displayed the same cyclical pattern of ER and PR expression as the archimyometrium. There was a significantly higher prevalence of fragments of shed basalis in menstrual blood of women with endometriosis than in healthy controls.

CONCLUSIONS

These data suggest that ectopic endometrial lesions result from dislocation of basal endometrium. Dislocated basal endometrium has stem cell character resulting in the ectopic formation of all archimetrial components such as epithelial and stromal endometrium as well as peristromal muscular tissue.

Structural abnormalities of the uterine wall in women with endometriosis and infertility visualized by vaginal sonography and magnetic resonance imaging

In women with endometriosis, the peristaltic activity of the uterus is significantly enhanced and may even become dysperistaltic at midcycle. Since uterine peristalsis is confined to the endometrium and the subendometrial myometrium with its predominantly circular arrangement of muscular fibres it was assumed that this dysfunction might be associated with structural abnormalities that could be visualized by high resolution ultrasonography and magnetic resonance imaging (MRI). Therefore, the uteri of women with and without endometriosis were subjected to endovaginal sonography (EVS) and to MRI. In EVS, women with laparoscopically proven endometriosis and infertility exhibited an infiltrative expansion of the archimetra in that the halo surrounding the uterine endometrium and representing the subendometrial myometrium was significantly enlarged compared with controls. The expansion was more pronounced in older than in younger women. There was, however, no relationship between the width of the expansion and the severity of the endometriotic disease. Similar data were obtained by MRI in that the 'junctional zone' in women with endometriosis and infertility was expanded in comparison with controls. The results of this study provide further support to the notion that endometriosis is primarily a uterine disease.

The cyclic pattern of the immunocytochemical expression of oestrogen and progesterone receptors in human myometrial and endometrial layers: characterization of the endometrial-subendometrial unit

Immunocytochemistry of oestrogen receptor (ER) and progesterone receptor (PR) expression of the whole uterine muscular wall and the endometrium was performed in order to obtain morphological and functional insights into the regulation of cyclic uterine peristalsis, which is confined to the endometrium and the subendometrial myometrium and serves functions such as rapid and sustained sperm transport. The study revealed that the subendometrial myometrium or stratum subvasculare with a predominantly circular arrangement of muscular fibres exhibits a cyclic pattern of ER and PR expression that parallels that of the endometrium, whereas the outer portion of the uterine wall composed of the stratum vasculare and supravasculare, which represents the bulk of the uterine musculature, does not exhibit a cyclic pattern of ER and PR expression. According to ontogenetic and phylogenetic data from the literature, the outer myometrium is of non-paramesonephric origin with functions confined to parturition, while the inner myometrial layer together with the glandular epithelium and the stroma of the endometrium is of paramesonephric origin with various functions during the cycle in addition to those during pregnancy and parturition. The inner quarter of the stratum vasculare adjacent to the stratum subvasculare constitutes a transitional zone in that the cyclicity of receptor staining becomes, in radial direction, gradually less expressed. Morphologically this zone corresponds to the inner part of the stratum vasculare where its muscular fibres blend with those of the stratum subvasculare.

Uterine peristalsis during the follicular phase of the menstrual cycle: effects of oestrogen, antioestrogen and oxytocin

Uterine peristalsis, directing sustained and rapid sperm transport from the external cervical os or the cervical crypts to the isthmic part of the tube ipsilateral to the dominant follicle, changes in direction and frequency during the menstrual cycle, with lowest activity during menstruation and highest activity at mid cycle. It was therefore suggested that uterine peristalsis is under the control of the dominant follicle with the additional involvement of oxytocin. To test this hypothesis, vaginal sonography of uterine peristalsis was performed in the early, mid and late proliferative phases, respectively, of cycles of women treated with oestradiol valerate and with human menopausal gonadotrophin following pituitary downregulation, with clomiphene citrate and with intravenous oxytocin, respectively. Administration of oestradiol valerate resulted in oestradiol serum concentrations comparable with the normal cycle with a simulation of the normal frequency of peristaltic contractions. Elevated oestradiol concentrations and bolus injections of oxytocin resulted in a significant increase in the frequency of peristaltic contractions in the early and mid follicular phases, respectively. Chlomiphene tended, though insignificantly so, to suppress the frequency of peristaltic waves in the presence of elevated oestradiol concentrations. In the late follicular phase of the cycle extremely elevated oestradiol concentrations as well as the injection of oxytocin resulted only in an insignificant further increase of peristaltic frequency. In the normal cycles, as well as during extremely elevated oestradiol concentrations and following oxytocin administration, the peristaltic contractions were always confined to the subendometrial layer of the muscular wall. The results and the review of literature indicate that uterine peristalsis during the follicular phase of the menstrual cycle is controlled by oestradiol released from the dominant follicle with the probable involvement of oxytocin, which is presumably stimulated together with its receptor within the endometrial-subendometrial unit and therefore acting in an autocrine/paracrine fashion. Since unphysiological stimulation with oestradiol and oxytocin did not significantly increase the frequency of uterine peristalsis in the late follicular phase of the cycle it is assumed that normal preovulatory frequency of uterine peristalsis is at a level which cannot be significantly surpassed due to phenomena of refractoriness of the system.

Endometriosis: a dysfunction and disease of the archimetra

Endometriosis is considered primarily a disease of the endometrial-subendometrial unit or archimetra. The clinical picture of endometriosis characterises this disease as a hyperactivation of genuine archimetrial functions such as proliferation, inflammatory defence and peristalsis. While the aetiology of the disease remains to be elucidated, a key event appears to consist in the local production of extraovarian oestrogen by a pathological expression of the P450 aromatase. The starting event may consist in a hyperactivity of the endometrial inflammatory defence, a hyperactivity of the endometrial oxytocin/oxytocin receptor system or in the pathological expression of the P450 aromatase system itself. Regardless of which of these levels the starting event is localized in, they influence each other on both the level of the archimetra and the endometriotic lesions. Locally elevated oestrogen levels inevitably up-regulate the endometrial oxytocin mRNA and increased levels of oxytocin result in uterine hyperperistalsis, increased transtubal seeding of endometrial tissue fragments and finally subfertility and infertility by impairment of the uterine mechanism of rapid and sustained sperm transport. Locally increased levels of oestrogen lead, on both the level of the endometrial-subendometrial unit and the endometriotic lesion, to processes of hyperproliferation. These processes result, on the level of the uterus, in an infiltrative growth of elements of the archimetra into the neometra and, on the level of the endometriotic lesion, in infiltrative endometriosis. There is circumstantial evidence that trauma might be an important initial event that induces the specific biochemical and cellular responses of the archimetra. This model is able to explain both the pleiomorphic appearance of endometriosis and the, up until now, enigmatic infertility associated with mild and moderate endometriosis.

Sonographic evidence for the involvement of the utero-ovarian counter-current system in the ovarian control of directed uterine sperm transport

Sperm transport from the cervix into the tube is an important uterine function within the process of reproduction. This function is exerted by uterine peristalsis and is controlled by the dominant ovarian structure via a cascade of endocrine events. The uterine peristaltic activity involves only the stratum subvasculare of the myometrium, which exhibits a predominantly circular arrangement of muscular fibres that separate at the fundal level into the fibres of the cornua and continue into the circular muscles of the respective tubes. Since spermatozoa are transported preferentially into the tube ipsilateral to the dominant follicle, this asymmetric uterine function may be controlled by the ovary via direct effects utilizing the utero-ovarian counter-current system, in addition to the systemic circulation. To test this possibility the sonographic characteristics of the uterine vascular bed were studied during different phases of the menstrual cycle. Vaginal sonography with the measurement of Doppler flow characteristics of both uterine arteries and of the arterial anastomoses of the uterine and ovarian arteries (junctional vessels) in the cornual region of both sides of the uterus during the menstrual phase of regular-cycling women demonstrated significant lower resistance indices of the junctional vessels ipsilateral to the side of the dominant ovarian structure as compared with the corresponding arteries contralaterally. By the use of the perfusion mode technique, it could be observed that vascular perfusion of the fundal myometrium was significantly increased ipsilateral to the dominant follicle during the late follicular phase of the cycle. These results show that the endocrine control of the dominant ovarian structure over uterine function is not only exerted via the systemic circulation but also directly, most probably utilizing the utero-ovarian counter-current system.

The uterine peristaltic pump. Normal and impeded sperm transport within the female genital tract

Rapid as well as sustained sperm transport from the cervical canal to the isthmical part of the fallopian tube is provided by cervico-fundal uterine peristaltic contractions that can be visualized by vaginal sonography. The peristaltic contractions increase in frequency and presumably also in intensity as the proliferative phase progresses. As shown by placement of labeled albumin macrospheres of sperm size at the external cervical os and serial hysterosalpingoscintigraphy (HSSG) sperm reach, following their vaginal deposition, the uterine cavity within minutes. In the early follicular phase a large proportion of the macrospheres remains at the site of application, while a smaller proportion enters the uterine cavity with even a smaller one reaching the isthmical part of the tubes. In the mid-follicular phase of the cycle with increased frequency and intensity of the uterine contractions the proportion of macrospheres entering the uterine cavity as well as the tubes has significantly increased. In the late follicular phase with maximum frequency and intensity of uterine peristalsis the proportion of macrospheres entering the tube increases further at the expense of those at the site of application as well as within the uterine cavity. The transport of the macrospheres into the tube is preferentially directed into the tube ipsilateral to the dominant follicle, which becomes apparent in the mid-follicular phase as soon as a dominant follicle can be identified by ultrasound. Since the macrosphere are inert particles the directed sperm transport into the tube ipsilateral to the dominant follicle is not functionally related to a mechanism such as chemotaxis but is rather provided by uterine contraction of which the direction may be controlled by a specific myometrial architecture in combination with an asymmetric distribution of myometrial oestradiol receptors. Women with infertility and mostly mild endometriosis display on VSUP a uterine hyperperistalsis with nearly double the frequency of contractions during the early and mid- as well as midluteal phase in comparison to the fertile and healthy controls. During midcycle these women display a considerable uterine dysperistalsis in that the normally long and regular cervico-fundal contractions during this phase of the cycle have become more or less undirected and convulsive in character. Hyperperistalsis results in the transport of inert particles from the cervix into the tubes within minutes already during the early follicular phase, and may therefore constitute the mechanical cause for the development of endometriosis in that it transports detached endometrial cells and tissue fragments via the tubes into the peritoneal cavity. Moreover, dysperistalsis may contribute to the infertility in these patients since it results in a break down of sperm transport within the female genital tract.

[Comparison of laparoscopically assisted vaginal hysterectomy with abdominal hysterectomy. Technique and results]

Technique and Results: The aim of this prospective randomised study was to compare laparoscopy-assisted vaginal hysterectomy (LAVH, group A) with abdominal hysterectomy (abd. HE, group B). Therefore, 35 hysterectomies due to non-malignant diseases such as uterine fibroma were performed in each group. A rather simple technique of LAVH was developed. In respect of the indication for hysterectomy, mean duration of operation and the size of the excised uteri there were no statistical differences between the two groups. One severe complication of haemorrhage was observed after LAVH in a patient suffering from a coagulopathy. The requirements for analgesics were significantly lower after LAVH compared to abd. HE during the postoperative period. A significantly lower serum concentration of the c-reactive protein on the first and third days after operation was found in group A. The patients of group A were discharged on the average 5 days after operation and 11 days in group B, respectively. Hence LAVH should replace abd. HE in most cases with the advantages of shorter hospitalisation, minimised requirements for analgesics and cost reduction.

Uterine hyperperistalsis and dysperistalsis as dysfunctions of the mechanism of rapid sperm transport in patients with endometriosis and infertility

Women suffering from infertility in association with mostly mild endometriosis were subjected to vaginal sonography of uterine peristalsis during the menstrual period, the early, mid- and late follicular phases, and the mid-luteal phase of the menstrual cycle. The data obtained were compared with those of healthy controls. Women with endometriosis displayed a marked uterine hyperperistalsis that differed significantly from the peristalsis of the controls during the early and mid-follicular and mid-luteal phases. During the late follicular phase of the cycle, uterine peristalsis in women with endometriosis became dysperistaltic, arrhythmic and convulsive in character, while in controls peristalsis continued to show long and regular cervico-fundal contractions. Hysterosalpingoscintigraphy during the early, mid- and late follicular phases revealed that hyperperistalsis in the early and mid-follicular phases of patients with endometriosis resulted in a dramatic increase in the transport of inert particles from the vaginal depot, through the uterus into the tubes and also into the peritoneal cavity. During the late follicular phase of the cycle, the dysperistalsis observed in women with endometriosis resulted in a dramatic reduction of uterine transport capacity in comparison with the healthy controls. We consider uterine hyperperistalsis to be the mechanical cause of endometriosis rather than retrograde menstruation. Dysperistalsis in the late follicular phase of patients with endometriosis may compromise rapid sperm transport. Uterine hyperperistalsis and dysperistalsis are considered to be responsible for both reduced fertility and the development of endometriosis.

From physiology to clinics--20 years of experience with pulsatile GnRH

The physiological and the pathophysiological basis of unvariant pulsatile administration of gonadotrophin-releasing hormone (GnRH) as well as the clinical results are reviewed. Pulsatile administration of GnRH not only proved to be a very effective treatment mode but also became an important tool for research in the central control of pituitary and ovarian function under normal and disease conditions.

The dynamics of rapid sperm transport through the female genital tract: evidence from vaginal sonography of uterine peristalsis and hysterosalpingoscintigraphy

Vaginal ultrasonography of uterine peristalsis during the follicular phase of the menstrual cycle demonstrates an increasing frequency and intensity of subendometrial and myometrial peristaltic waves as the follicular phase progresses. During this time the numbers of contraction waves with a fundo-cervical direction decrease considerably in favour of waves of contraction with a cervico-fundal direction. There is evidence that rapid sperm transport through the female genital tract is passive and is provided by these uterine contractions. Using hysterosalpingoscintigraphy, rapid sperm transport was studied by placing technetium-labelled albumin macrospheres of sperm size at the external os of the uterine cervix and following their path through the female genital tract. Ascension of the macrospheres occurred immediately following deposition at the external os of the cervix. As early as 1 min thereafter, the macrospheres had reached the intramural and isthmical part of the tube. Quantitatively, the extent of ascension increased with progression of the follicular phase. While only a few macrospheres entered the uterine cavity and even fewer the tubes during the early follicular phase, the proportion of macrospheres that entered the uterine cavity increased dramatically during the mid-follicular phase despite continuing limited entry into the tube. During the late follicular phase there was considerable ascension of the macrospheres which was directed preferentially into the tube ipsilateral to the dominant follicle. These data indicate that rapid transport of the spermatozoa through the female genital tract is under the endocrine control of the dominant follicle, ensuring the preferential accumulation of spermatozoa at the site of fertilization.

Luteinizing hormone (LH) pulsatility during the oestradiol- and oestradiol/progesterone-induced LH surge in the human female

Positive feedback reactions were induced in five female volunteers with regular menstrual cycles on the pituitary secretion of luteinizing hormone (LH) during the follicular phase of the cycle by the i.m. administration of oestradiol benzoate ('oestradiol study'), or by oestradiol benzoate followed by progesterone ('oestradiol/progesterone study'). Prior to the administration of the steroids (basal profiles) and during the LH surges following the administration of the steroids (stimulation profiles), blood was drawn at 10-min intervals and the LH pulsatility assessed. The LH pulses occurred at hourly intervals in basal and stimulation profiles, which concurs with data obtained during the normal proliferative phase and the spontaneous mid-cycle surge of the cycle in both the human and the rhesus monkey. Our findings are, however, in sharp contrast with those obtained in the rhesus monkey by the determination of hypothalamic multi-unit activity.

Pulsatile administration of gonadotrophin releasing hormone as a diagnostic tool to distinguish hypothalamic from pituitary hypogonadism following neurosurgery

Nine patients suffering from severe amenorrhoea following neurosurgical or radiotherapy for pituitary tumour or craniopharyngeoma were treated with pulsatile gonadotrophin releasing hormone (GnRH) administration. Seven patients did exhibit ovulatory cycles when GnRH was administered i.v. at a dose of 20 micrograms/pulse, but not at lower doses or when GnRH was administered s.c. Pulsatile GnRH administration may be used to assess the functional integrity of pituitary gonadotrophs and to distinguish pituitary from hypothalamic site of lesion resulting in hypogonadotrophic hypogonadism. It may also be used successfully for treatment of infertility in such patients.

Pulsatile administration of gonadotrophin releasing hormone and oral administration of naltrexone in hypothalamic amenorrhoea

Between 1979 and 1990, 73 patients suffering from hypothalamic amenorrhoea were treated by pulsatile administration of gonadotrophin releasing hormone (GnRH) in 359 treatment cycles. Seventy-two pregnancies were achieved. In 64 favourable patients in whom hypothalamic amenorrhoea constituted the only reason for infertility, a pregnancy rate of 29% per cycle could be obtained. Patients who conceived during pulsatile GnRH required an average of only 2.4 cycles per conception. Twelve out of 24 patients with hypothalamic amenorrhoea who exhibited an ovulatory response to pulsatile GnRH, ovulated during oral administration of naltrexone; such responsiveness to opioid antagonism was, however, restricted to the less serious grades. In conclusion, pulsatile administration of GnRH continues to be a highly effective mode of treatment of infertility due to hypothalamic amenorrhoea of various aetiologies. A subgroup of these patients may be successfully treated by the oral administration of naltrexone.

Opiate antagonist treatment of ovarian failure

One-hundred-and-thirty-eight women suffering from hypothalamic or hyperandrogenic ovarian failure were treated with daily doses of 25-150 mg of the opiate antagonist naltrexone for 4-100 weeks. In patients with hypothalamic ovarian failure, treatment with naltrexone alone was followed by an increase of gonadotrophins and by normalization of the menstrual cycle in approximately 70% of patients. Eight of 10 patients who did not respond to naltrexone and had not previously ovulated in response to clomiphene administration exhibited ovulatory cycles when both compounds were administered. Twenty-four pregnancies were achieved in 22 women, corresponding to an overall pregnancy rate of 26%, with a cumulative pregnancy rate closely resembling that of a normal population. In contrast, in hyperandrogenic insulin-resistant patients, the pattern of gonadotrophin secretion did not seem to change dramatically during naltrexone treatment. However, the rise of insulin in plasma following an oral load of glucose (oGTT) was blunted considerably, resulting in normalization of previously elevated circulating insulin levels. Since the time course of plasma glucose after oGTT did not appear to be affected by treatment, this indicates an increase in insulin sensitivity (or a decrease in insulin resistance) during naltrexone therapy. Side-effects of naltrexone treatment were negligible in patients with hypothalamic ovarian failure. Hyperandrogenic patients, however, did experience more intense and prolonged side-effects, such as nausea and dizziness.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment with naltrexone in hypothalamic ovarian failure: induction of ovulation and pregnancy

Sixty-six women suffering from various grades of hypothalamic ovarian failure were treated with the opiate antagonist naltrexone at doses ranging from 25 to 150 mg per day. This treatment resulted in complete normalization of the menstrual cycle in 49 of 66 patients, as indicated by the pattern of circulating levels of gonadotrophins and ovarian steroids. Five patients failed to respond, three of whom were suffering from primary hypothalamic amenorrhoea. In patients who responded to the administration of naltrexone, there was a dramatic increase in the amplitude and frequency of gonadotrophin pulses, reflecting disinhibition of the hypothalamic gonadotrophin-releasing hormone (GnRH) pulse generator. Eighteen pregnancies were achieved in 16 women who were also treated for infertility, resulting in a cumulative pregnancy rate closely resembling that of a normal population. There were only minor side-effects that could be attributed to the drug. These data demonstrate that chronic administration of an opiate antagonist will normalize ovarian function in women suffering from different grades of hypothalamic ovarian failure. The data therefore support the view that suppression of the activity of the hypothalamic pulse generator, that directs GnRH release, is mediated by endogenous opioids. Also, that hypothalamic ovarian failure is the consequence of an inappropriate increase in opioid tone impinging on neurons that release GnRH in a pulsatile manner into the pituitary portal circulation.

[Ganglioneuroma of the pelvis accompanying pregnancy]

Ganglioneuroma is an uncommon benign tumor of the sympathetic nervous system. In most cases it originates from the thoracic or lumbar portion of the gangliated cord or from the medulla of the suprarenal glands. It is the differentiated form of malignant neuroblastoma. The tumor often manifests itself in young adults by displacement of the surrounding structures. In the case presented the special diagnostic problems of locating the tumor in the pelvis in early pregnancy are discussed.

Frozen storage of Ham's F10 medium for human in-vitro fertilization

A method of frozen storage of Ham's F10 medium was investigated that provides 'ready-to-use' culture medium for human in-vitro fertilization, without the necessity of readjusting and testing the medium after thawing. Ham's F10 medium, without bicarbonate, was adjusted to 245 mOsm/kg and stored in aliquots of 33 ml at -20 degrees C. Aliquots of 1 ml of a 7.5% (w/v) sodium bicarbonate solution were stored separately at the same temperature. The two components were mixed together after thawing. In the first test series, mouse embryos were cultured in media stored frozen for varying intervals between 2 weeks and 6 months and no difference in the rates of blastocyst formation was detected. Frozen-stored Ham's F10 medium was then used for human IVF in 256 cycles performed within a 16-month period in two different IVF centres. The pregnancy rates were evaluated and correlated with the duration of the frozen storage (between 1 week and 3 months) and compared to the outcome of 24 cases in which non-frozen medium was used. There was no significant difference in the pregnancy rates in the different groups (19% with non-frozen medium and between 21 and 33% with frozen-stored medium). Thus it was shown that there is no loss of quality of the frozen-stored media within the tested period of 3 months. The prolonged storage interval offers the possibility of extended quality tests and cross-tests between different IVF laboratories.

Bone mass reduction after estrogen deprivation by long-acting gonadotropin-releasing hormone agonists and its relation to pretreatment serum concentrations of 1,25-dihydroxyvitamin D3

Estrogen deficiency results in bone mass reduction of largely varying extent in postmenopausal females, indicating that additional mechanisms influence the response of bone. They are by no ways identified in either the animal experiment or under clinical conditions. In search for factors, conditioning the response of bone to estrogen deficiency, we have conducted a study in females under treatment with the GnRH agonist decapeptyl (D-Trp6-LHRH). This drug blocks ovarian function and was administered for treatment of endometriosis or uterine leiomyoma. We determined spinal (dual photon absorptiometry) and forearm (single photon absorptiometry) bone mineral density before and 3 and 6 months after the onset of therapy and measured biochemical parameters of bone metabolism. Our results showed an increase in bone turnover after initiation of estrogen deficiency, as indicated by the elevation of alkaline phosphatase and osteocalcin. This resulted in a secondary decrease in serum intact PTH and 1,25-dihydroxy-vitamin D3. Furthermore, we found a positive correlation between pretreatment values of serum 1,25-dihydroxyvitamin D3 as well as its decrease and the reduction in bone mass during GnRH agonist treatment. This demonstrates that the patients' metabolic conditions predict their response to estrogen deficiency.

Influence of the duration of the oestradiol rise on the success rate in GnRH analogue/HMG-stimulated IVF cycles

The influence of the duration of the serum oestradiol (E2) rise before human chorionic gonadotrophin (HCG) injection on the outcome of in-vitro fertilization (IVF) cycles was investigated. Two different stimulation protocols were compared. In 218 cycles, the Norfolk protocol for stimulation with human menopausal gonadotrophin (HMG) was used (protocol A). In 235 cycles, pituitary function was suppressed by a single injection of a long-acting GnRH analogue ('Decapeptyl microcapsules') before HMG stimulation was started (protocol B). The overall pregnancy rates were significantly higher with protocol B (22% per puncture, 21% per started cycle) than with protocol A (14% per puncture, 9% per started cycle). For each interval of E2 rise duration (5-11 days), the fertilization rates (per oocyte) and the pregnancy rates (per puncture) were evaluated. There was a clear-cut maximum of the pregnancy rates for 6 and 7 days of E2 rise (21 and 16% respectively) for protocol A. For protocol B, pregnancy rates were generally higher than for protocol A. There was also a maximum of the pregnancy rates for 6 (32%) and 7 (29%) days of E2 rise but this maximum was not as clear-cut as for protocol A. The fertilization rates showed no significant differences for each interval of E2 rise in both groups (between 63 and 89%). Therefore, it is concluded that endometrial maturity, and not the oocyte's ability for fertilization, is the most critical factor for success in IVF cycles.(ABSTRACT TRUNCATED AT 250 WORDS)

Reversible bone loss in women treated with GnRH-agonists for endometriosis and uterine leiomyoma

Oestrogen deficiency at the menopause is associated with changes in calcium and bone metabolism. Hypo-oestrogenism induced by the use of GnRH-agonists is clinically useful in the treatment of oestrogen-dependent diseases. This study was done to investigate calcium homeostasis and bone metabolism of pre-menopausal women in a GnRH-agonist-induced pseudo-menopause. Eighteen patients with endometriosis or uterine leiomyoma received monthly i.m. injections of 3.2 mg of long-acting D-Trp-6-LHRH over a 6-month period. Plasma oestradiol-17 beta and progesterone levels under treatment were significantly decreased to the levels of the early follicular phase. Plasma total calcium, serum osteocalcin and plasma alkaline phosphatase concentrations increased, while plasma phosphate levels did not change. Levels of 1,25-dihydroxyvitamin D3 decreased significantly, but 25-hydroxyvitamin D3 values remained constant. Trabecular bone mineral density of lumbar spine decreased continuously during the 6-month period. Nine women completed 6-9 months follow-up. In these women bone loss was reversible. Cortical bone measurements at the proximal radius showed no change during oestrogen deficiency. In conclusion, our findings demonstrate that GnRH-agonist-induced bone loss is reversible. Furthermore, they suggest that the state of pseudo-menopause induced by GnRH-agonist may serve as a model for further pathophysiological studies on calcium homeostasis and bone metabolism in the post-menopause.

[Early manifestation of severe gestosis (pre-eclampsia) in fetal triploidy--diagnosis and obstetrical management]

A case is reported of early-onset pre-eclampsia combined with severe malformations including holoprosencephaly and hydrocephaly caused by triploidy. By ultrasonic diagnosis, maternal risks caused by either prolonged pregnancy because of immaturity or inappropriate obstetrical management, i.e. by caesarean section, could be avoided. Ventriculocentesis of the macrocephalic fetus was performed and abortion induced.

Induction of ovulation by the chronic administration of naltrexone in hypothalamic amenorrhea

Ovulatory menstrual cycles were induced by the administration of the specific opiate antagonist naltrexone at a dose of 50 mg/day for 28 days in 3 women suffering from secondary hypothalamic amenorrhea. The occurrence of ovulation was based on demonstration of follicular growth and corpus luteum formation by ultrasonography and a LH midcycle surge and rise of progesterone. After discontinuation of treatment, the women became amenorrheic again and serum gonadotropins as well as estradiol declined to the low levels found before naltrexone administration. Naltrexone or other specific opiate antagonists may be useful agents for the induction of ovulation in patients with hypothalamic amenorrhea.

Clinical and endocrinological characterization of two subjects with Reifenstein syndrome associated with qualitative abnormalities of the androgen receptor

The androgen receptor in fibroblasts cultured from a biopsy of scrotal skin from 1 subject with Reifenstein syndrome has been found to be normal in amount and to bind dihydrotestosterone with normal affinity but to be qualitatively abnormal as evident by thermolability and instability upon ultracentrifugation. The family study of this subject and endocrine studies document androgen resistance in the index patient and his affected uncle. These findings provide evidence for X-linkage of this disorder, and suggest that the mutations that give rise to this phenotype are probably allelic to the mutations of the androgen receptor that cause testicular feminization.

Pulsatility of serum LH in pathological conditions

LH pulsatility changes throughout the normal menstrual cycle. The number of LH pulses increases during the first days after menstruation, remains unchanged thereafter until after ovulation and declines progressively during the luteal phase. LH pulse amplitude is highest during midcycle. In hypothalamic amenorrhea, gonadotropin levels are reduced. This appears to be a consequence of a reduction of hypothalamic Gn-RH secretion which is reflected by a diminished frequency and amplitude of LH pulses during the 24-hour span. Administration of an opiate antagonist, naloxone, increases LH pulse frequency in those patients, and in patients with secondary hypothalamic amenorrhea the daily oral administration of naltrexone, another specific opiate antagonist, induces ovulatory cycles. Patients suffering from hyperandrogenemia may present with eumenorrhea, oligomenorrhea or amenorrhea. There is an increase in mean LH levels and of the LH/FSH ratio with increasing severity of the ovarian disturbance. The increase in mean LH levels is a consequence of an increase in LH pulse amplitude while LH pulse frequency is not changed compared to the early follicular phase of the menstrual cycle.

Induction of puberty in a patient with hypogonadotropic hypogonadism: effect of sequentially applied hCG and pulsatile GnRH administration

Pulsatile substitution with GnRH appears to be the therapy of choice in patients with Kallmann's syndrome, a well defined type of hypogonadotropic hypogonadism. We tried to simplify the treatment and to limit the subcutaneous GnRH therapy to the period absolutely necessary to induce spermatogenesis. Therefore we applied in sequence first hCG to stimulate testicular growth and second pulsatile GnRH application to induce spermatogenesis. We herein report that with this mode of therapy testicular growth from infantile to adult size and normal spermatogenesis could be achieved. We conclude that pulsatile GnRH application is a new effective therapy of hypogonadotropic hypogonadism which can be simplified considerably by pretreatment with hCG.