Hydrosalpinx treated with extended doxycycline does not compromise the success of in vitro fertilization

OBJECTIVE

To determine if extended treatment with doxycycline before and after an in vitro fertilization (IVF) procedure can minimize the detrimental effect of a hydrosalpinx.

DESIGN

Retrospective analysis.

SETTING

University IVF program.

PATIENT(S)

Patients undergoing IVF, including 17 with a hydrosalpinx, 25 with adhesions or proximal tubal occlusion, and 22 with endometriosis or unexplained infertility.

INTERVENTION(S)

Women with a documented hydrosalpinx were prescribed doxycycline 100 mg twice daily starting 1 week before expected retrieval and continued until 6 days after retrieval. No antibiotics were prescribed in the other groups.

MAIN OUTCOME MEASURE(S)

Implantation rates and IVF outcomes.

RESULT(S)

Implantation rates were 30% for the doxycycline-treated group of patients with a hydrosalpinx, 27% for the group with tubal occlusion/adhesion, and 24% for the group with endometriosis or unexplained infertility. Eight (47%) of 17 patients with a hydrosalpinx had a live birth, compared with 11 (44%) of 25 for the group with tubal occlusion/adhesion and 12 (55%) of 22 for the group with endometriosis/unexplained infertility. There were no differences between the groups in patient age, number of oocytes retrieved, fertilization rate, or number of blastomeres of the transferred embryos.

CONCLUSION(S)

No detrimental effect of a hydrosalpinx was evident for patients treated with extended doxycycline. Tremendous cost savings can be realized if treatment with 2 weeks of an inexpensive antibiotic provides outcomes comparable to surgical correction of a hydrosalpinx before IVF.

Effects of chronic dietary exposure to genistein, a phytoestrogen, during various stages of development on reproductive hormones and spermatogenesis in rats

Developmental, hormonal, and gametogenic parameters were evaluated in male progeny following chronic dietary exposure to the phytoestrogen genistein. Twenty pregnant rats were fed a diet containing genistein (50 microg/d) from d 17 of gestation, and 12 were fed a control diet without genistein. Four litters each of control and genistein-fed rats were euthanized on d 21. The remaining pups were weaned on d 21 and only male rats were used in this study. On d 21, eight litters of genistein-fed rats were placed on control diet (gestational and lactational exposure alone [GL-G]), and the remaining eight continued on genistein diet (lifelong exposure group [LL-G]). These rats were euthanized (four litters/group) on d 70 or 130 of life. Serum testosterone, which was slightly reduced in genistein-exposed rats on d 21, did not differ among treatment and control groups on d 70 and 130. Serum luteinizing hormone of genistein-exposed rats was reduced on d 21 and 130, but not on d 70. Serum follicle-stimulating hormone did not vary among groups at any age. Treatment-related effects of dietary genistein were not observed on the weights of the testes of 21-d-old rats. Except for a slight decrease in testis weight of GL-G rats at 130 d, no significant effect of dietary exposure was observed on the weight of the testes in any other group. However, epididymal weights were significantly reduced in both treated groups at d 130. Testicular sperm count (on d 70 as well as 130) also was not affected in GL-G or LL-G rats. We conclude that gestational plus lactational exposure to genistein and subsequent dietary exposure to genistein have no adverse effects on gametogenic function in male rats.

Update on the medical treatment of endometriosis

The treatment of women with endometriosis can be a challenge. Therapeutic strategies must be tailored to the individual symptoms, age, and desire for fertility. Medical therapy continues to be based on endocrine treatment, such as oral contraceptives, progestins, danazol, and GnRH agonists. Unfortunately, recurrence rates are high after discontinuation of therapy. Recent clinical research on GnRH analogues plus add-back therapy has produced favorable results. Long-term treatment of patients using this approach has successfully reduced pain while minimizing symptoms of hypoestrogenism and adverse metabolic effects, such as loss of bone mineral density. Currently, GnRH analogues given with add-back therapy seems to be the most effective long-term approach to the treatment of symptomatic endometriosis. In the future, other modalities, such as medicated vaginal rings, inhibitors of steroidogenic enzymes, and GnRH antagonists, will most likely be options.

Delayed oral estradiol combined with leuprolide increases endometriosis-related pain

OBJECTIVES

To determine if low-dose estrogen replacement can be added to GnRH agonist therapy after three months to reduce hypoestrogenic symptoms while allowing continued relief of pain in patients with endometriosis.

MATERIALS AND METHODS

Thirteen women with endometriosis and pain were treated with six months of leuprolide acetate in a prospective, randomized double-blind placebo controlled study. After three months of therapy, six subjects initiated oral estradiol 1 mg daily, and seven received an identical placebo.

RESULTS

Dysmenorrhea improved in both groups, and dyspareunia significantly improved in the GnRH agonist plus placebo group. The mean pain scores of the oral estrogen group tended to be higher than the placebo group, and hot flushes tended to be less severe with estrogen treatment. However, differences observed between the study and placebo groups did not reach statistical significance.

CONCLUSION

In a prospective, randomized study, low-dose estrogen replacement increases endometriosis-related pain during GnRH agonist therapy. The study was terminated after the first 13 subjects due to the concerning trend toward recurrent symptoms in women who received oral estradiol during GnRH agonist therapy for endometriosis-related pain. With the trend toward increasing pain with estrogen add-back therapy, a larger study would not seem to be justifiable.

Extending the treatment boundaries: Zoladex and add-back

OBJECTIVE

To review the evidence that add-back hormone replacement therapy (HRT) can ameliorate the metabolic consequences of gonadotropin-releasing hormone (GnRH) agonist treatment in women with symptomatic endometriosis.

METHODS

A review of relevant literature.

RESULTS

Early studies suggested that add-back HRT maintained bone mineral density (BMD) without reducing the symptomatic benefit of GnRH treatment. Both high-dose progestogen and low dose progestogen plus cyclical etidronate are effective in maintaining BMD. Standard and low dose HRT add-back may be more effective in relieving the hypo-estrogenic side-effects of GnRH agonist therapy. Randomized controlled studies have shown that both low-dose and standard-dose add-back HRT reduce the side-effects of GnRH agonist therapy, and that this benefit extends to 12 months of treatment.

CONCLUSIONS

GnRH agonist treatment with add-back HRT seems to offer the hope of improved treatment for women with endometriosis, but the optimum treatment duration and time to start HRT have yet to be defined.

Suppression of growth hormone does not affect ongoing spermatogenesis in rats

Recent evidence suggests that growth hormone (GH) may enhance physiologic processes, such as spermatogenesis, in addition to causing classical anabolic effects. We have previously shown that testosterone restores spermatogenesis in rats that were made azoospermic by immunization against gonadotropin-releasing hormone (GnRH). In this study, we investigated whether suppression of GH affects spermatogenesis and the ability of testosterone to restore spermatogenesis following immunization against GnRH and/or growth hormone-releasing hormone (GHRH). Twelve rats were actively immunized against GnRH (anti-GnRH), twelve rats were actively immunized against GHRH (anti-GHRH), six rats were immunized against both GnRH and GHRH (anti-GnRH/GHRH), and six rats served as controls. Two weeks after the second booster, six rats each from the anti-GnRH and anti-GHRH groups as well as the six anti-GnRH/GHRH rats received 24-cm testosterone-filled Silastic implants (T), and the remaining six rats from each of these groups received empty Silastic implants. All rats were euthanized 2 months later. Weights of testes and testicular sperm counts were determined. Serum testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH), growth hormone (GH), and insulin-like growth factor-1 (IGF-1) concentrations were determined by radioimmunoassays. Serum GH and IGF-1 were suppressed in anti-GHRH rats. IGF-1 was partially restored by testosterone in anti-GHRH and in anti-GnRH/GHRH rats, but GH was restored to control value in anti-GnRH/GHRH rats. Serum LH and FSH were suppressed in anti-GnRH and anti-GnRH/GHRH rats, but only FSH was partially restored by testosterone. Suppression of GH did not affect maintenance of spermatogenesis. However, because T partially restored GH and IGF-1 levels in anti-GnRH/GHRH rats and because spermatogenesis was found to be restored in these rats, we conclude that GH does not play a role in the maintenance of spermatogenesis in adult rats, but it may be required for the replenishment of germ cells in experimentally induced regressed rat testes.

Diagnosing ovarian torsion with computed tomography. A case report

BACKGROUND

The diagnosis of adnexal torsion is difficult to make on the basis of symptoms, physical findings or radiologic techniques. Unfortunately, delayed intervention can lead to irreversible damage and loss of the adnexa. This report describes a finding seen on computed tomography (CT) that may increase suspicion of the diagnosis of ovarian torsion.

CASE

A 21-year-old woman was admitted with constant abdominal pain and a tender retrouterine mass. Ultrasound failed to provide a definitive diagnosis. CT showed a central, hypodense area consistent with fat and surrounded by a shell of intermediate density. At laparotomy the patient was found to have a necrotic left adnexa due to torsion. Bisection of the adnexal mass confirmed a dermoid cyst with overlying edematous ovarian cortex.

CONCLUSION

The observation of a round, hypodense central lesion (dermoid cyst) surrounded by thickened, edematous ovarian cortex on CT is a finding that may aid in the diagnosis of adnexal torsion. The finding is a thickened shell of ovarian cortex surrounding a central mass that has caused the torsion; in this case it was a dermoid cyst.

Reproductive sequelae in female rats after in utero and neonatal exposure to the phytoestrogen genistein

OBJECTIVE

To determine reproductive sequelae in female rats after in utero and lactational dietary exposure to genistein.

DESIGN

Experimental animal study.

SETTING

University laboratory.

ANIMAL(S)

Sprague Dawley rats.

INTERVENTION(S)

Pregnant rats were fed control rat chow or rat chow incorporated with genistein (approximately 50 microg/d) beginning on day 17 of gestation and continuing until the end of lactation (postpartum day 21). Genistein-exposed female pups were divided into two groups on day 21. One group continued to receive a genistein-added diet (G70); the other group was changed to a control diet (Ex-G). At necropsy (days 21 and 70), blood and reproductive tissues were collected.

MAIN OUTCOME MEASURE(S)

Serum levels of gonadotropins and gonadal steroids and histopathologic examination of the ovaries.

RESULT(S)

The weight of the ovaries and uterus and serum levels of E2 and progesterone in genistein-exposed rats on day 21 (G21) were significantly reduced compared with control rats. On day 70, serum levels of E2, progesterone, LH, and FSH were similar in all groups. Atretic follicles and secondary interstitial glands were more common in G70 and Ex-G rats compared with control rats. Cystic rete ovarii was observed in some G70 and Ex-G rats.

CONCLUSION(S)

Our data indicate that in utero and lactational exposure to dietary genistein adversely affects reproductive processes in the adult female rat.

Goserelin acetate (Zoladex) with or without hormone replacement therapy for the treatment of endometriosis

OBJECTIVE

To determine whether hormone replacement therapy (HRT) plus goserelin (Zoladex) is as effective as goserelin alone for the relief of pelvic symptoms of endometriosis and to determine whether it reduces both the loss of bone mineral density (BMD) and the physiologic side effects associated with goserelin therapy.

DESIGN

Prospective, placebo-controlled study, open label for goserelin therapy and double-blind for HRT.

SETTING

Forty-two teaching or community hospitals.

PATIENT(S)

Premenopausal women with symptomatic endometriosis.

RESULT(S)

Statistically significant mean decreases from baseline in the total pelvic symptom score and total subjective score were observed by week 24 for all three groups. There were no statistically significant treatment differences for change in total symptom score. Some degree of BMD loss occurred in the three groups; however, the percentage loss was consistently greater in the HRT0 group than in the HRT1 or HRT2 groups. When analyzed separately, no overall age effect on BMD change was seen in women >30 years of age versus women < or = 30 years. The HRT1 and HRT2 groups had fewer occurrences of hot flushes and vaginal dryness than did the HRT0 group.

CONCLUSION(S)

Goserelin plus HRT is as effective as goserelin alone in relieving pelvic symptoms of endometriosis and attenuates both the loss of BMD and the physiologic side effects of hot flushes and vaginal dryness associated with goserelin therapy.

Accuracy of the Ovulon fertility monitor to predict and detect ovulation

The purpose of this pilot study was to correlate the three biologic markers of the Ovulon fertility monitor (a long-term predictive peak about 6 days before ovulation, a short-term predictive peak about 1 day before ovulation, and a nadir at the time of ovulation) with the peak in cervical mucus and the luteinizing hormone (LH) surge in the urine. Ten volunteer subjects (mean age 30.2 years) monitored their cervical-vaginal mucus, the surge of LH in the urine with a home assay test, and their vaginal electrical readings (with Ovulon monitors) on a daily basis for one to four menstrual cycles. In 19 of the 21 cycles that indicated a LH surge, there was a strong positive correlation between the LH surge and the peak of cervical-vaginal mucus (r = 0.96, P < or = .01), and between the LH surge and both the Ovulon nadir and Ovulon short-term predictive peak (r = 0.84, P < or = .01), and a modest positive correlation between the long-term Ovulon predictive peak and the LH surge (r = 0.62, P < or = .01). The time of optimal fertility as determined by the peak in cervical mucus, the LH surge, and the Ovulon was similar. The Ovulon has potential as a reusable device to help women determine their fertile period.

Assisted hatching does not enhance IVF success in good-prognosis patients

PURPOSE

The role of assisted hatching in good-prognosis IVF patients was evaluated in a prospective, randomized, controlled pilot study, which was followed by a retrospective observational series.

METHODS

After assisted hatching was proved successful in a mouse embryo study, 20 good-prognosis IVF patients were randomly assigned to either assisted hatching (13) or no assisted hatching (7; the controls). Following this series, 27 good-prognosis IVF patients were retrospectively evaluated to determine the outcome with assisted hatching.

RESULTS

In the prospective study, clinical pregnancies resulted from 3 (23%) of 13 patients in the hatching group, compared to 3 (43%) of 7 in the control group. Implantation rates were similar: 9.6% in the hatching group and 10.7% in the controls. In the retrospective series, the 11.1% implantation rate with assisted hatching was significantly less than the 42.9% implantation rate seen with traditional IVF.

CONCLUSIONS

Implantation and pregnancy rates are high in young women undergoing traditional IVF. Assisted hatching is not beneficial in these patients.

Neonatal exposure to coumestrol, a phytoestrogen, does not alter spermatogenic potential in rats

The objective of this study was to determine the effects of neonatal exposure to phytoestrogens on male reproductive function as adults. Male rats were injected either with 100 micrograms coumestrol or DMSO (controls) daily during their first 5 d of life. Pituitary gland, testes, sex accessory organs, and blood were collected on d 60 of life. Serum testosterone, LH, and FSH levels were determined by RIA. Levels of steady-state mRNA for gonadotrophin subunits (LH beta and FSH beta were determined by Northern blot analysis and quantified by a scanning densitometer. Coumestrol had no effect on weights of testes and sex accessory organs, or sperm count. Similarly, there were no significant differences among serum concentrations of testosterone, LH beta and FSH of coumestrol-treated rats and those of controls. Whereas steady state levels of LH beta mRNA in coumestrol-treated rats did not differ from those of controls, steady state levels of FSH beta mRNA increased (37%) in treated animals. However, the augmented FSH beta mRNA expression in coumestrol-treated rats did not negatively affect reproductive potential in male rats. We conclude that neonatal exposure to coumestrol does not alter reproductive organ structure or spermatogenic potential in male rats.

Preprogrammed, unmonitored ovarian stimulation reduces expense without compromising the outcome of assisted reproduction

OBJECTIVE

To determine if a novel, preprogrammed, unmonitored stimulation protocol could reduce the cost of assisted reproductive technology (ART) without compromising outcome or safety.

DESIGN

Prospective, nonrandomized study of unmonitored ART versus traditional monitoring.

SETTING

University ART program.

PATIENT(S)

Infertile women aged < 39 years, with a basal FSH level < 15 mIU/mL (conversion factor to SI unit, 1.00) and regular menstrual cycles, undergoing ART.

INTERVENTION(S)

Oocyte retrieval was performed at a predetermined time in 72 unmonitored cycles based on age and basal FSH level. No monitoring of any type was performed before retrieval. There were 86 monitored control cycles.

MAIN OUTCOME MEASURE(S)

The number of oocytes, and embryos; complications including ovarian hyperstimulation.

RESULT(S)

The total cost for unmonitored ART was significantly less than for monitored cycles. There was no difference between groups for patient age, number of oocytes obtained, or number of metaphase II oocytes. For non-male-factor patients, the number of oocytes fertilized, number of embryos transferred, and the clinical pregnancy rates were comparable. There was one case of severe hyperstimulation requiring hospitalization in the unmonitored group.

CONCLUSION(S)

This novel, unmonitored ovarian stimulation protocol provides ART at a significantly lower cost than is incurred with traditional monitoring, with no apparent compromise in outcome.

Transcervical gamete and zygote intrafallopian transfer. Does it enhance pregnancy rates in an assisted reproduction program?

OBJECTIVE

To evaluate the role of early tubal transfer procedures, we compared outcomes of transcervical gamete intrafallopian transfer (TC-GIFT) and transcervical zygote intrafallopian transfer (TC-ZIFT) versus in vitro fertilization/embryo transfer during the first two years of our assisted reproduction (AR) program.

STUDY DESIGN

Prospective, nonrandomized, concurrent, controlled comparison of TC-GIFT and TC-ZIFT pregnancy outcomes versus those after IVF-ET. All cycles for patients less than age 39 undergoing transfer of at least three viable oocytes, zygotes or embryos in the first two years of our program were included. Patients with normal fallopian tubes underwent TC-GIFT (n = 9) or TC-ZIFT (n = 12), whereas those with tubal compromise underwent IVF-ET (n = 28).

RESULTS

Implantation rates were 4.2% for TC-ZIFT, 2.8% for TC-GIFT and 3.7% for combined TC procedures as compared to 7.4% for IVF-ET. Delivery rates were no different for the TC procedures than the IVF-ET procedures (14%). Patients ages, number of oocytes retrieved and number transferred were comparable between the TC and IVF-ET groups.

CONCLUSION

TC-GIFT and TC-ZIFT did not enhance the pregnancy outcome as compared to IVF-ET in the first two years of our AR program. Ultrasound-directed tubal catheterization is harder to learn and more difficult and expensive to perform than simple uterine embryo transfer. Since we could not demonstrate an improved outcome for TC transfers even in a new AR program, IVF-ET and laparoscopic GIFT are now our procedures of choice.

Persistence of infertility in GnRH immunized male rats treated with subdermal implants of dihydrotestosterone (DHT)

Male hormonal contraception has been limited to date because two fundamental requirements have not been concurrently satisfied, these are, consistent and dependable azoospermia and infertility coupled with maintenance of libido. The objective of this study was to determine the extent to which implants of potent androgen (DHT) will restore androgenization and spermatogenesis in hypogonadotropic infertile male rats. Twenty-five sexually mature male rats of proven fertility were actively immunized against gonadotropin releasing hormone (GnRH) to induce azoospermia. After azoospermia was achieved, GnRH immunized rats received subdermal DHT-filled Silastic implants of 2, 4, 6, or 8 cm, or empty implants (n=5/group). Five untreated control rats received empty capsules. Eight weeks later, fertility was evaluated, sperm number was obtained from the testis, and weights of androgen-dependent organs were measured. The results indicate that immunoneutralization of GnRH induced complete azoospermia, and subsequent treatment with DHT implants of 2 or 4 cm for 8 wk restored accessory organ weights, but did not restore spermatogenesis or fertility. In addition, DHT implants of 6 to 8 cm partially restored spermatogenesis, but not fertility. We conclude that low-dose DHT supplementation of GnRH-immunized rats may be a suitable alternate therapy able to maintain androgenization in the face of persistent azoospermia in the rat. This may be an effective model for development of a male contraceptive.

Endoscopic ultrasound. A new instrument for laparoscopic surgery

OBJECTIVE

Although laparoscopy is an important tool for evaluating pelvic pathology, visualization is limited to the surface of structures. A method of seeing below the surface during laparoscopy could be useful. We report on our early experience with new laparoscopic ultrasound.

STUDY DESIGN

Following diagnostic laparoscopy the pelvis is filled with fluid to obtain optimal imaging. A 10-mm ultrasound probe is introduced through the umbilical trocar and the uterus and adnexa examined.

RESULTS

High-resolution images can be obtained to delineate such abnormalities as suspected ovarian cysts and uterine myomata.

CONCLUSION

Endoscopic ultrasound is a new instrument that allows the surgeon to evaluate and define pelvic pathology suspected at the time of laparoscopy. Endoscopic ultrasound may augment the diagnosis of subtle pathologic findings during laparoscopy.

Hypoprolactinemia does not prevent restoration of normal spermatogenesis in gonadotropin-suppressed, testosterone-replaced rats

We have previously shown that suppression of gonadotropins and spermatogenesis can be produced in rats by immunization against gonadotropin releasing hormone (GnRH). Administration of testosterone (T) alone is effective in restoring complete spermatogenesis in these rats, although it is not effective in doing so in chronically treated hypophysectomized rats. This suggests that a pituitary factor(s) other than luteinizing hormone (LH) and follicle-stimulating hormone (FSH) is required to restore normal spermatogenesis. The studies described herein test the hypothesis that prolactin (PRL) is the additional requirement for complete restoration of spermatogenesis. Twenty rats were immunized against GnRH, and four groups of five each received either 1) 24-cm T-filled Silastic implant (TSl), 2) TSl plus bromocriptine pellet (B), 3) B plus empty Silastic implant (Sl), or 4) Sl alone. Five nonimmunized rats received Sl alone and served as controls. All rats were sacrificed 2 months after treatment. GnRH immunization and B administration suppressed gonadotropins and PRL levels, respectively, and advanced spermatids were not detectable in these rats. Testis weight was suppressed to about 19% of controls. The number of advanced spermatids in control rats was 220 +/- 23 x 10(6). TSl administration restored advanced spermatids to numbers comparable to controls in GnRH-immunized rats whether the rat received B (191 +/- 17 x 106) or not (217 +/- 18 x 10(6)). Additionally, we determined mRNA levels for PRL and FSH beta subunit (FSH beta) in the pituitary by Northern blot and densitometric scanning. The mRNA levels of PRL mirrored serum PRL levels, and the same was true for FSH beta subunits and serum FSH levels. These data show that suppression of PRL has no effect on the ability of T to restore complete spermatogenesis in GnRH-immunized rats. This observation mitigates against the hypothesis that PRL is the pituitary factor required to allow complete restoration of spermatogenesis to occur.

Evaluation of synthetic serum substitute versus serum as protein supplementation for mouse and human embryo culture

PURPOSE

Our purpose was to determine the effect of Synthetic Serum Substitute (SSS) versus serum supplementation on fertilization rates and subsequent development of embryos from patients undergoing IVF.

PROCEDURE

Experiment I compared the effects of SSS to human serum on mouse embryo development. Two hundred one-cell B6D2F1 mouse embryos were cultured in 100-microliter droplets of human tubal fluid (HTF) containing either (1) no protein (control; n = 37), (2) 15% serum from women with tubal infertility (n = 44), (3) 15% serum from women with endometriosis (n = 49), (4) 15% fertile donor serum (n = 33), or (5) 15% SSS (n = 37). Experiment II compared the effects of SSS to human serum on the development of embryos from patients undergoing IVF. Thirty-three women were included in this study. A total of 371 oocytes was cultured in HTF containing either (1) maternal or donor serum (n = 140) or (2) 15% SSS (n = 231). Embryo development was evaluated 48 hr after fertilization.

RESULTS

In Experiment I, the rate of blastocyst development was evaluated at 48, 72, and 96 hr of culture. Sixty-four and nine-tenths percent of embryos cultured in SSS were morulae at 48 hr of culture (versus 5.4, 0, 8.2, and 6.1 in Groups 1, 2, 3, and 4, respectively). By 72 hr, 29.7% of these embryos had developed into blastocysts (versus 0, 0, 8.2, and 3.0, for Groups 1, 2, 3, and 4, respectively). This percentage increased to a total of 83.7 after 96 hr (versus 27.0, 20.4, 38.8, and 39.4 for Groups 1, 2, 3, and 4, respectively). Forty-three and two-tenths percent of the blastocysts cultured in SSS had hatched from their zonae by 96 hr. With the exception of Group 5, which had a rate of 9.1%, embryo hatching was not observed in any of the groups at the termination of culture (96 hr). In Experiment II there were no differences in cell stage or quality of human embryos cultured in SSS or serum, but fertilization rates tended to be better (P = 0.07) for oocytes inseminated in media containing SSS (70.0%, vs 55.0% for serum).

CONCLUSIONS

SSS appears to be a superior protein source for mouse embryo growth and is as good as serum from fertile donors in promoting in vitro human embryo development.

Assessing the acceptability of Norplant contraceptive in four patient populations

The object of this study was to review the experience of Norplant implants insertion at the University of Colorado Health Sciences Center with specific attention to the potential impact of source of care and/or clinic site of of insertion. Norplant implants were inserted at four different office sites, namely, adolescent-teen, resident, certified nurse midwife, and faculty physician. The charts of all patients who had Norplant implants inserted between April 1991 and September 1992 were reviewed and we attempted to contact each patient by telephone to assess clinical course and acceptability of Norplant contraceptive. We were able to contact 254 of 414 women (61%) who had Norplant implants inserted. The average length of time since Norplant implants insertion was 13.2 months. The only significant demographic difference between groups was that the adolescent-teen patients were younger, of lower parity, less educated, and were more likely to be single than the other three groups. The overall removal proportion was 14.6%, and removal proportions were not significantly different between any of the four groups. The primary reason for removal was unacceptable bleeding (32% of removers). Only 59% of patients returned for follow-up care. Faculty physician patients were significantly more compliant with follow-up compared to adolescent-teen and resident patients (p < 0.01). Patient retention of Norplant contraceptive is unrelated to age or the clinic setting in which the device was inserted. Since similar side effects are experienced by retainers and removers, it is unclear what other factors prompt women to seek removal. Particularly in the teen and resident groups, follow-up is poor.

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.

Preoperative sonographic measurement of endometrial pattern predicts outcome of surgical repair in patients with severe Asherman's syndrome

OBJECTIVE

To assess the predictive value of preoperative endometrial sonography in the diagnosis and surgical treatment of women with amenorrhea due to severe Asherman's syndrome.

DESIGN

Patient series.

SETTING

Academic clinical practice.

PATIENTS

Seven women with severe Asherman's syndrome characterized by amenorrhea despite normal ovulatory function and complete obstruction of the uterine cavity at the level of the cervix or lower uterine segment at hysterosalpingogram.

MAIN OUTCOME

Ability of vaginal sonography to predict successful hysteroscopic treatment as assessed by resumption of menstrual cyclicity and normalization of the uterine cavity.

RESULTS

Transvaginal sonography demonstrated a well-developed endometrial stripe in three of seven women, while three others had virtually no endometrium seen. All women with well-developed endometrium were found to have adhesions occluding the lower uterine segment and had resumption of normal menses and normalization of the cavity after hysteroscopy. The women with minimal endometrium had no cavity identified and derived no benefit from surgery. A seventh woman with endometrium seen only on one side of the cavity had patency successfully established only on that side.

CONCLUSION

The endometrial pattern seen with transvaginal sonography is highly predictive of surgical and clinical outcome in women with severe Asherman's syndrome characterized by complete obstruction of the cavity at hysterosalpingogram.

Maintenance of sexual function with testosterone in the gonadotropin-releasing hormone-immunized hypogonadotropic infertile male rat

We have previously shown that active immunization against GnRH in the mature male rat can predictably produce hypogonadotropic hypogonadism and azoospermia and, further, that normospermia and normal fertility can be restored by testosterone (T) administration alone. The objective of this study was to explore the hypothesis that GnRH-immunized azoospermic rats could be supplemented with T doses sufficient to restore sexual behavior, but insufficient to support adequate spermatogenesis or to allow restoration of fertility. Adult male rats of proven fertility were immunized against GnRH and supplemented with 2-, 4-, or 8-cm T implants or with empty implants. Eight weeks later, fertility was evaluated; concentrations of serum T, LH, FSH, growth hormone (GH), prolactin (PRL), and thyroid-stimulating hormone (TSH) were determined; sperm number was obtained from the testis; and weights of androgen-dependent organs were measured. GnRH immunization and T supplementation resulted in restoration of organ weights and of fertility in a dose-dependent manner. GnRH immunization with or without T supplementation resulted in the absence of circulating gonadotropins, but had no effect on serum GH, PRL, or TSH levels. Whereas all control animals were fertile, rats that received either empty or 2-cm T implants were completely infertile. Rats that received 4-cm or 8-cm T implants were fertile in 60% and 100% of cases, respectively. Sexual behavior of rats with empty and with 2-cm T implants was compared at 10-18 wk after immunization with GnRH. GnRH-immunized rats given empty implants displayed negligible sexual activity, but those with 2-cm T implants displayed sexual activity equivalent to that of untreated controls despite complete infertility.(ABSTRACT TRUNCATED AT 250 WORDS)

Conversion from a failed transcervical zygote intrafallopian transfer to a successful delayed uterine embryo transfer

Transcervical ZIFT is an alternative to IVF-ET and laparoscopic GIFT. However, tubal catheterization cannot be accomplished in all cases. We describe a successful twin pregnancy that resulted from delayed uterine transfer of four embryos following unsuccessful TC-ZIFT transfer. Further data are needed to determine optimal management in cases of failed transcervical tubal transfer procedures.

Recent advances in the understanding of the pathophysiology and treatment of hyperprolactinemia

Hyperprolactinemia is frequently diagnosed in patients with infertility and menstrual cycle irregularities. Control of prolactin secretion is complex and involves inhibition by dopamine and possibly endothelins, as well as stimulation by serotoninergic and opioidergic pathways, gonadotropin-releasing hormone, and possibly galanin. Some patients with hyperprolactinemia have underlying functional disorders, but by using magnetic resonance imaging, a microprolactinoma can be found in most. Prolactin circulates in a low-bioactivity glycosylated and a nonglycosylated form, and an antibody-bound form is found in a few hyperprolactinemic patients who are relatively asymptomatic. The majority of patients, particularly those with macroprolactinomas, will benefit from treatment with bromocriptine. Available alternatives for intolerant patients include vaginal administration of bromocriptine and pergolide mesylate. Other compounds, monthly injectable and slow-release forms of bromocriptine, quinagolide and carbegoline, are not yet available in the United States. Withdrawal of treatment during pregnancy is still recommended, with a low risk of tumor enlargement, and the need for life-long treatment is now being reconsidered.

The effects of chronic administration of pyrimethamine on spermatogenesis and fertility in male rats

The present study examines whether the antifertility effects of pyrimethamine (PYR), an inhibitor of dihydrofolate reductase, are mediated by a reduction in intratesticular testosterone (T) concentrations or whether PYR exerts its effect by a cytotoxic insult to spermatogenic cells that is independent of intratesticular testosterone. Adult male rats were treated daily with 100 mg/kg (n = 16) or 400 mg/kg (n = 16) of PYR in honey for 8 weeks. Control rats (n = 16) received honey without PYR. Eight weeks after treatment, five rats from each PYR-treated group and five control rats were mated with normal cycling female rats, and fertility was assessed. These rats were euthanized after the fertility trial; testis weight, testicular sperm, and epididymal sperm counts were determined, and serum levels of T, LH, FSH, and seminiferous tubule fluid T (STF-T) concentrations were measured by RIA. Testes from three rats per group were perfusion-fixed for histological evaluation. PYR was discontinued in the remaining rats for 8 weeks and similar parameters were evaluated after 8 weeks of recovery. PYR (100 mg/kg/day) treatment for 8 weeks did not have any effects on organ weights, testicular and epididymal sperm counts, and hormone levels when compared to controls. In contrast, PYR (400 mg/kg/day) treatment significantly reduced testis and epididymis weights, testicular and epididymal sperm counts, and fertility. Despite these effects, serum T, LH, FSH, and STF-T concentrations were not altered.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of epidermal growth factor in human granulosa cells varies with follicle size

EGF decreases aromatase activity and stimulates the proliferation of granulosa cells. To determine if EGF affects follicles of different maturity differently, human granulosa cells obtained from 6 patients at the time of IVF were pooled according to size and cultured in serum free medium with or without EGF. Estrogen production at 72 h was determined by measuring tritiated water formed in a 1-h culture with 1 beta [3H] androstenedione. The change in estrogen production with EGF was compared for cells from the smallest and largest follicles for each patient. Estrogen production in response to EGF decreased with increasing follicular size in all six observations. EGF may mediate luteinized granulosa cell aromatase activity in vivo, and may be a factor responsible for the relative decline in estrogen production in the preovulatory follicle.

Ultrasound-guided transcervical tubal catheterization for assisted reproduction: a learning program using laparoscopy for confirmation

The result of this pilot study confirmed that the US-directed transcervical tubal catheterization procedure for assisted reproduction can be learned over a short period of time and may well produce comparable PRs as seen with laparoscopic transfer. However, practice in the technique with confirmation of placement by laparoscopy is advised before incorporating this procedure into a program of assisted reproduction.

Use of granulosa-luteal cell culture to evaluate low and high clinical responses to menotropin stimulation

The cause of a poor response to human menopausal gonadotropin (hMG) remains unexplained. To determine whether aromatase activity of cultured granulosa cells obtained from relatively low estradiol (E2) responders (serum E2 < 1000 pg/ml) to hMG therapy differed from that of good responders (E2 > or = 1000 pg/ml), we prospectively compared serum E2 on the day of human chorionic gonadotropin administration to in vitro aromatase activity following a 72-h culture. Granulosa cells were obtained from seven women undergoing hMG therapy and oocyte aspiration. Follicle stimulating hormone (FSH) was added to one-half of the cultures. Serum E2 was determined by radioimmunoassay, and aromatase activity was determined indirectly by measuring tritiated water formed by aromatization of 1-beta [3H] androstenedione to estrogen in 1 h. In this study, luteinized granulosa cells from patients with a relatively low serum E2 produced less estrogen in cultures when compared to cells from higher responders (p < 0.01). Aromatase activity was not significantly increased by FSH in the relatively high responders, whereas FSH stimulated a significant increase in aromatase activity in cells from lower responders (p < 0.001). Our results indicate that the clinical response to hMG is at least partly due to the "quality" of granulosa cell aromatase activity. A clinically relevant "block" to FSH action may be present in vivo in low responders which can be reversed in culture by addition of FSH.

Application of the cavitron ultrasonic surgical aspirator (CUSA) for gynecological laparoscopic surgery using the rabbit as an animal model

OBJECTIVE

To study the potential application of the cavitron ultrasonic surgical aspirator (CUSA) in gynecological laparoscopic surgery using a rabbit animal model.

DESIGN

Twenty-six rabbits were prospectively randomized into two groups. Laparoscopically directed standard injuries were made on the randomly assigned horn and sidewall in all animals with the CUSA. Contralateral injuries were made with a contact neodymium-yttrium aluminum garnet (Nd:YAG) laser in group 1 and with bipolar cautery in group 2. Adhesion and inflammation scores were assessed for two animals in each group at 24, 48, and 72 hours, and seven animals in each group at 14 days.

SETTING

University animal research facility.

MAIN OUTCOME MEASURES

Adhesion and inflammation scores were compared between animals in the CUSA versus Nd:YAG study and the CUSA versus bipolar cautery at 14 days.

RESULTS

No significant difference in uterine or sidewall adhesion scores was noted between the CUSA versus Nd:YAG or the CUSA versus bipolar cautery. Bipolar cautery produced significantly less inflammation on the uterine horn compared with the CUSA (3.0 +/- 0.2 versus 5.3 +/- 0.7, P = 0.0001), but no difference in sidewall inflammation was noted between the CUSA compared with bipolar cautery. No difference in inflammation was observed between the CUSA and the Nd:YAG laser.

CONCLUSIONS

The bipolar cautery appears to be preferable to the CUSA for coagulation of uterine lesions, although dissection of the uterus is not possible with bipolar cautery. The CUSA and the Nd:YAG appear to be comparable for uterine horn dissection. Because the CUSA causes similar adhesion formation and tissue inflammation at the sidewall when compared with the Nd:YAG laser and bipolar cautery and may be less likely to damage blood vessels, ureters, or other collagen-rich tissues, the CUSA may represent a promising new surgical tool for laparoscopically directed peritoneal dissection.

Immunoneutralization of gonadotropin-releasing hormone and subsequent treatment with testosterone Silastic implants in rats: an approach toward developing a male contraceptive

STUDY OBJECTIVE

To determine the extent to which increasing doses of exogenous testosterone (T) administered via Silastic implants can restore spermatogenesis and fertility to rats made azoospermic by active immunization against gonadotropin-releasing hormone (GnRH).

DESIGN

Male rats were made azoospermic by active immunization against GnRH. Increasing doses of exogenously administered T (via Silastic implants) were administered for 8 weeks, and testicular sperm concentration and ability to impregnate female rats were evaluated.

SETTING

Reproductive Endocrinology Laboratory, Department of Obstetrics and Gynecology, University of Colorado Health Sciences Center, Denver, Colorado.

ANIMALS

Sexually mature male Sprague Dawley rats (SASCO, Omaha, NE).

RESULTS

Suppression of gonadotropins and azoospermia was achieved by actively immunizing rats against GnRH. Testosterone was capable of restoring quantitatively complete spermatogenesis and fertility in GnRH-immunized azoospermic rats. This relationship was dose-dependent, as evidenced by the partial restoration of spermatogenesis and fertility observed in animals replaced with smaller T Silastic implants.

CONCLUSION

Gonadotropin-releasing hormone immunization and T-filled Silastic implants may provide a model to study isolated gonadotropin deficiency and for the development of a reversible male contraceptive.

A comparison of the reproductive outcome between women with a unicornuate uterus and women with a didelphic uterus

OBJECTIVE

To compare the reproductive performance of women with a unicornuate uterus with the reproductive performance of women with a didelphic uterus.

DESIGN

Retrospective.

SETTING

Reproductive endocrinology service of a tertiary referral hospital.

MAIN OUTCOME MEASURES

The proportion of pregnancies resulting in spontaneous abortion, preterm delivery, term delivery, and living children was determined for each group.

RESULTS

Twenty-nine women with a unicornuate uterus and 25 women with a didelphic uterus were identified. Twenty women with a unicornuate uterus produced a total of 40 pregnancies, whereas 13 women with a didelphic uterus produced a total of 28 pregnancies. The 33% spontaneous abortion rate in the unicornuate group was not significantly different from the 23% rate in the didelphic group. The proportion of pregnancies resulting in preterm delivery, term delivery, and living children was similar in both groups.

CONCLUSIONS

The reproductive performance of women with a unicornuate uterus is similar to the performance of women with a didelphic uterus.

Exogenously administered testosterone maintains spermatogenesis quantitatively in adult rats actively immunized against gonadotropin-releasing hormone

The administration of testosterone via Silastic capsules has been shown previously to maintain advanced spermatid number quantitatively in intact rats in which LH but not FSH was suppressed, but not in hypophysectomized rats, indicating that pituitary factors in addition to LH are required for the quantitative maintenance of spermatogenesis in the rat. The objective of the present study was to examine whether testosterone is capable of maintaining quantitatively normal spermatogenesis in rats in which both LH and FSH are suppressed. Intact adult male rats were actively immunized against GnRH by intradermal injection of GnRH conjugated to human serum globulin; control rats received intradermal injections of saline and adjuvant. Four weeks after the primary immunization, GnRH-immunized rats received the first booster injection and, at the same time, received testosterone-filled polydimethylsiloxane (PDS) implants of 4, 8, 12, or 24 cm or empty implants. Booster injections were repeated every 2 weeks for 8 weeks. At that time, rats were killed, and serum levels of LH, FSH, and testosterone, testicular advanced spermatid number, and seminiferous tubule fluid testosterone concentrations were determined. Four weeks after the initial administration of GnRH immunogen, i.e. before the first booster injection, serum levels of testosterone, LH, and FSH and the number of advanced spermatids per testis were not different from those in controls. Eight weeks after the first booster injection, serum LH and FSH and advanced spermatids were undetectable in all GnRH-immunized rats. The administration of testosterone-filled PDS implants of 4 and 8 cm to GnRH-immunized rats for 8 weeks resulted in the maintenance of 105 +/- 6 and 161 +/- 5 x 10(6) advanced spermatid/testis, respectively, significantly less than the control value (237 +/- 19 x 10(6)). In GnRH-immunized rats that received testosterone-filled PDS implants of 12 or 24 cm, the advanced spermatid numbers per testis (228 +/- 4 and 229 +/- 8 x 10(6), respectively) were not significantly different from those in controls. These results indicate that testosterone is capable of maintaining spermatogenesis quantitatively in the adult rats testis, in the absence of both radioimmunoassayable LH and FSH.

Superovulation with or without intrauterine insemination for the treatment of infertility

Patients undergoing human menopausal gonadotropin (hMG) superovulation were reviewed retrospectively to determine whether fecundity was greater for intrauterine insemination (IUI) than timed intercourse. Forty patients with unexplained infertility, American Fertility Society I or II endometriosis, luteal phase defect and/or cervical factor were treated with hMG alone or hMG plus IUI. Twenty-eight underwent 52 cycles of hMG/IUI, and 19 underwent 31 cycles of hMG. The probability of pregnancy after four cycles was significantly better in the hMG/IUI group (.90) than the hMG group (.37, P = .049). There was a 54.5% multiple pregnancy rate, and one patient was admitted to the hospital for hyperstimulation. When traditional therapy fails, hMG/IUI significantly increases the pregnancy rates as compared to hMG with timed intercourse in a "good prognosis" group of patients.

Time-related effects of gonadotropin-releasing hormone analog treatment in experimentally induced endometriosis in the rat

The purpose of our study was to characterize the time-dependent effect of gonadotropin-releasing hormone analog (GnRH-a) therapy on endometriosis explant using the rat model. Endometriosis was induced in 60 mature female rats. One group of treated animals as well as controls were killed at 2, 4, 6 and 8 weeks of treatment at which time the explant was evaluated. Explant volume was significantly reduced in all treatment groups, an effect that was more significant in animals treated for greater than or equal to 4 weeks compared with those treated for only 2 weeks. We conclude that GnRH-a treatment caused gradual regression of endometrial explant that was effectively complete by 4 weeks of treatment. We further conclude that this experimental model may be useful in the evaluation of other modes of endometriosis therapy.

Laparoscopic cautery in the treatment of endometriosis-related infertility

Life table analysis and the two-parameter exponential method have been applied to pregnancy rates in 72 patients undergoing laparoscopic cautery exclusively. Patients with male factor infertility were excluded. Estimated cure rates for patients with stage I and II disease were 98.2% and 76.6%, respectively (not significantly different). No significant difference was seen when anovulation complicated the endometriosis (68.6%). When greater than one infertility factor was present, a significant difference was observed (50.6%). Patients with stage I disease had an average fecundity of 10.30% with decreasing values observed in stage II (7.59%), anovulation (6.67%), and more than one infertility factor (3.33%). We conclude that laparoscopic cauterization is an effective mode of therapy for the treatment of stage I and II endometriosis associated with infertility.

Neosalpingostomy for distal tubal obstruction: prognostic factors and impact of surgical technique

We reviewed the clinical records of all women who underwent microsurgical terminal neosalpingostomy for distal tubal obstruction between January 1983 and June 1988. We identified 95 women whose preoperative evaluation revealed no other contributory factors for infertility and analyzed their pregnancy outcome after this procedure. Pregnancy success was inversely related to the extent of tubal distortion (dilation, rugal integrity, and status of the fimbria) and degree of adnexal adhesions. Using our classification system for distal tubal obstruction, patients with mild disease had an 80% pregnancy rate, whereas patients with moderate and severe disease had a 31% and 16% success rate, respectively. We found no statistically significant difference in pregnancy outcome when we compared this series with our previous group, reported in 1978, where contemporary microsurgical technique was not used. Although we feel that optimal surgical technique is important to maximize success, we conclude that the most important prognostic factor in pregnancy outcome after neosalpingostomy for distal tubal disease is the anatomical and functional integrity of the tube.

The incidence of human immunodeficiency virus (HIV) in fetal cord samples utilized as serum supplements for in vitro fertilization

Prior to initiating routine fetal cord serum (FCS) supplementation in our in vitro laboratory, the incidence of HIV in 306 random fetal cord samples obtained at the Labor and Delivery Unit of the Johns Hopkins Hospital from July 1985 to January 1988 was determined from a cross-sectional patient sample. Of 306 samples, 3 (0.98%) were positive for HIV, and confirmed by Western blot analysis, enzyme immunoassay (ELISA), a prevalence significantly higher than a national sample (0.012%). The use of FCS in this setting was determined to be an unacceptable risk to patients undergoing in vitro fertilization. The 90-day quarantine period for verification of HIV seronegativity applied to semen donors may not be applicable to FCS sampling. Patient risk may also increase with pooling of FCS samples prior to HIV testing.

Effect of serum from patients with minimal to mild endometriosis on mouse embryo development in vitro

Two-cell mouse embryos were cultured at 37 degrees C in 5% CO2, 95% air with a 7.5% serum supplement from patients with minimal to mild endometriosis, (group I, n = 31), tubal factor (group II, n = 33), male factor (group III, n = 17), fetal cord samples (group IV, n = 37), and Ham's F-10 medium (Gibco, Grand Island, NY) without a serum supplement (group V, n = 30). The progression to blastocyst stage (mean percent +/- SE) at 96 hours in groups I, II, III, IV, and V was 29.9% +/- 3.7%, 60.6% +/- 4.9%, 56.2% +/- 5.2%, 61.7% +/- 5.8%, and 63.2% +/- 6.9%, respectively. Serum factors appear to be associated with an inhibition of early embryogenesis, which may explain the decreased fertility rates observed in patients with minimal to mild endometriosis.

The efficacy of presacral neurectomy for the relief of midline dysmenorrhea

The present study was undertaken to evaluate prospectively the efficacy of presacral neurectomy for the treatment of midline dysmenorrhea. All patients had moderate to severe dysmenorrhea and stage III-IV endometriosis. Of the patients undergoing presacral neurectomy (N = 17), only two had a recurrence of pain. The remainder of the patients undergoing presacral neurectomy remain pain-free at 42 months of follow-up. Of the patients undergoing resection of endometriosis but not presacral neurectomy (N = 9), none received relief of midline pain. Relief of lateral pain, back pain, and dyspareunia was variable in both groups. Our findings corroborate previous retrospective studies showing that presacral neurectomy is highly effective in the treatment of dysmenorrhea. We speculate that the most common reasons for failure of presacral neurectomy are inappropriate selection of patients and incomplete resection of the presacral nerve plexus.

Megestrol acetate for treatment of endometriosis

Between 1977-1989, 29 women with symptomatic endometriosis were treated with megestrol acetate by the Johns Hopkins Division of Reproductive Endocrinology. All had previously received one or more alternative medical treatments for endometriosis, in each case discontinued because of poor response or development of unacceptable side effects. Treatment consisted of a daily dose of 40 mg megestrol acetate orally for up to 24 months. Disease-related symptoms (dysmenorrhea, noncyclic pelvic pain, and dyspareunia) were relieved in 86% of the subjects treated with an adequate course of therapy. Side effects were fairly well tolerated, although eight women discontinued treatment within 2 months and two others stopped the drug by 4 months. These preliminary findings suggest that megestrol acetate may be an effective treatment for patients with endometriosis, even those who have been unresponsive to other modes of therapy.

A placebo-controlled trial of a depot gonadotropin-releasing hormone analogue (leuprolide) in the treatment of uterine leiomyomata

Several studies have shown that treatment with a gonadotropin-releasing hormone (GnRH) analogue can reduce uterine volume in women with leiomyomata. However, no study to date has used a controlled population for comparison, nor has any study delineated the physiologic mechanism of volume reduction. We performed a double-blind, placebo-controlled study of a depot form of a GnRH analogue (leuprolide) given monthly for 24 weeks in 11 patients with symptomatic uterine leiomyomata. Patients initially treated with placebo were subsequently treated with active drug for 24 weeks. Magnetic resonance imaging was used to identify specifically the total uterine volume, total myoma volume, and total non-myoma volume. Treated patients had a significant reduction in total uterine and non-myoma volumes as compared with placebo patients (P less than .02). Total myoma volume was also reduced, but only to a P = .06 level. Pre- versus post-therapy values for all 11 patients showed significant reduction in all three volumes (P less than .02). Most symptoms were markedly improved. By 24 weeks post-therapy, all volumes had returned to baseline levels, although symptomatic improvement commonly persisted. The non-myoma volume was proportionally reduced to a greater extent than the myoma volume (42.7 versus 30.4%), and we therefore could explain the reenlargement seen when treatment was discontinued. Side effects were well tolerated and there were no study dropouts. We conclude that temporary hypoestrogenism induced by GnRH analogues can produce significant though temporary reduction in uterine volumes, and that the non-myoma volume is responsible for much of the reduction and reenlargement.(ABSTRACT TRUNCATED AT 250 WORDS)

Interval bone mineral density with long-term gonadotropin-releasing hormone agonist suppression

Twenty-six patients of mean age 37 +/- 4.8 (SD) years, who received a 6-month course of gonadotropin-releasing hormone (GnRH) analogue, were selected for study. Bone mineral density (BMD) was measured by dual-photon absorptiometry before initiation and after completion of agonist therapy. Mean BMD (g/cm2) by dual-photon absorptiometry at L2 to L4, femoral neck, Ward's triangle, and the trochanteric area did not change significantly (P = not significant [NS]) after 6 months of GnRH analogue suppression. Mean percent (%) expected density as standardized for age, weight, and sex remained in the range of 89.3% to 94.2% (P = NS). The interval detectable change in BMD after therapy was 0.05 +/- 0.06 g/cm2. These findings are reassuring with respect to the use of long-term GnRH analogue regimens to induce a hypoestrogenic state in the treatment of hormone-dependent conditions.