Business models and provider satisfaction in in vitro fertilization centers in the USA.

PURPOSE: The number of in vitro fertilization (IVF) cycles is increasing and the majority of patients undergoing IVF pay out of pocket. Reproductive endocrinology and infertility practitioners employ different business models to help create financial pathways for patients needing IVF but details regarding the different types of business models being used and physician satisfaction with those models have not been described previously. METHODS: A cross-sectional survey was sent to members of the Society of Reproductive Endocrinology and Infertility. The survey included 30 questions designed to assess demographics, practice patterns, and business models utilized. RESULTS: A total of 222/736 (30%) physicians responded to the survey. The majority of physicians offer a-la-carte (67%), bundled services (69%), grants (57%), and cost/risk-sharing (50%). The majority answered that the single ideal business model is bundled services (53%). There was no significant association between financial package offered and region of practice or state-mandated insurance. The largest barrier to care reported was cost with or without state-mandated coverage (94% and 99%, respectively). The majority of practices are satisfied with their business model (75%). Higher physician satisfaction was associated with private practice [69% vs 27%; OR (95%CI) = 3.8 (1.7, 8.6)], male gender [59% vs 30%; OR = 2.4 (1.1, 5.4)], and offering bundled services [83% vs 59%; OR = 2.8 (1.2, 6.7)]. CONCLUSIONS: Physicians utilize a variety of business models and most are satisfied with their current model. Cost is the major barrier to care in states with and without mandated coverage.

Activin A increases invasiveness of endometrial cells in an in vitro model of human peritoneum.

The aim of this study was to investigate whether activin A has an effect on the attachment and/or invasion of endometrial cells in a modeled peritoneum in vitro. Cultured endometrial stromal cells (ESCs) and endometrial epithelial cells (EECs) were treated with activin A (6.25-50 ng/ml) and with activin A (25 ng/ml) with and without inhibin A or follistatin. Fluorescent labeled cells were added to confluent peritoneal mesothelial cells (PMCs) and to a monolayer of confluent PMCs grown in a Matrigel invasion assay. The rate of endometrial cell attachment and invasion through PMCs was assessed. The expression of cell adhesion proteins N- and E-cadherin was evaluated with real-time RT-PCR. Activin A (25 ng/ml) promoted invasion of the endometrial cells through the modeled peritoneum (>2-fold versus control) and this effect was partially reversed by inhibin A and follistatin. Activin A had no effect on the rate of attachment of the endometrial cells to the PMCs or in the rate of proliferation. In addition, activin A induced a decreased mRNA expression of E-cadherin in cultured EECs. In conclusion, activin A increases invasion of EECs and ESCs into modeled peritoneum. In EECs, this effect may be related to down-regulation of E-cadherin expression. Further studies are warranted to evaluate the role of activin-A in the genesis of the endometriotic lesion.

Effects of cocaine on basal and pulsatile prolactin levels in rhesus monkeys.

OBJECTIVES: Cocaine abuse is often associated with reproductive cycle dysfunction including altered menstrual cyclicity and decreased ovulation rates. Cocaine might also alter prolactin (PRL) secretion, presumably through the effects of this drug on hypothalamic dopamine, the primary factor regulating pituitary PRL secretion. We assessed basal and pulsatile PRL levels to determine whether hyperprolactinemia is associated with cocaine-induced disruption of menstrual cyclicity in rhesus monkeys. METHODS: Normally cycling, drug-naïve monkeys were studied. Cocaine-treated animals were pair-fed with controls to minimize cocaine-related differences in caloric intake. Twenty-eight monkeys were randomized to receive daily intravenous (iv) infusion of saline or cocaine (1, 2, or 4 mg/kg) on cycle days 2-14. Daily blood samples were obtained through indwelling catheters for measurement of ovarian steroids, gonadotropins, and PRL. Laparoscopy was performed 2 days after the midcycle estradiol surge to document ovulation. Sixteen other monkeys were randomized to receive daily iv infusion of saline or cocaine (4 mg/kg). Blood samples were obtained every 15 minutes for 8 hours in the early (cycle day 1-5), mid- (cycle day 6-10), and late (cycle day 11-15) follicular phase. Plasma was assayed for PRL, and pulses were identified by cluster analysis. RESULTS: All seven control monkeys had laparoscopically confirmed ovulation compared to two of seven monkeys receiving 1 mg/kg, three of seven monkeys receiving 2 mg/kg, and one of seven receiving 4 mg/kg of cocaine hydrochloride. Cycle length was normal in six of seven controls, and in one of seven, two of seven, and two of seven monkeys receiving the 1, 2, and 4 mg/kg of cocaine, respectively. Estradiol levels were significantly higher in controls versus cocaine-treated monkeys, but there was no difference in basal gonadotropin levels during treatment. Mean PRL levels during treatment were significantly lower (P <.05) in controls (4.6 +/- 0.2 ng/mL) as compared to monkeys receiving 1 (6.5 +/- 0.6 ng/mL), 2 (6.1 +/- 0.4 ng/mL), and 4 mg/kg (7.2 +/- 0.6 ng/mL) of cocaine. There was no significant difference in PRL pulse amplitude or frequency between controls and cocaine-treated monkeys during each cycle phase. CONCLUSIONS: Circulating PRL levels were slightly higher in monkeys receiving cocaine during the follicular phase. Although this increase was statistically significant, PRL levels remained well within the euprolactinemic range in cocaine-treated monkeys.

Cocaine impairs ovarian response to exogenous gonadotropins in nonhuman primates.

OBJECTIVE: Determine whether cocaine directly impairs ovarian steroid production and ovulation. METHODS: Normally cycling adult female rhesus monkeys received daily intravenous normal saline (control; n = 8) or cocaine (4 mg/kg; n = 8) through the follicular phase. Monkeys were injected daily with human menopausal gonadotropin (hMG; Pergonal) at a dose of 6 IU/kg intramuscularly beginning on cycle day 2. Daily blood samples were obtained, and serum estradiol (E(2)) and progesterone (P(4)) were measured by radioimmunoassay. When serum levels of E(2) declined, plateaued, or exceeded 600 pg/mL, laparoscopy was performed to count the number of follicles. If no new corpus luteum was present, monkeys were injected intramuscularly with 1000 IU of hCG. Laparoscopy was repeated 2 days later to document the number of ovulatory stigma. RESULTS: During ovarian stimulation, cocaine-treated monkeys required an average additional 1.5 days of hMG injections (P =.01), and this resulted in a greater total dose of hMG compared with control monkeys (351 +/- 16 IU versus 297 +/- 15 IU [mean +/- standard error of the mean], P =.03). For spontaneous and hCG-triggered ovulation, the number of ovulatory stigma was significantly lower (P <.003) in the cocaine-treated versus control monkeys (16 versus 31). Peak E(2) levels were significantly (P =.05) lower in cocaine-treated monkeys compared with controls. Luteal phase P(4) levels were lower in the cocaine-treated monkeys, but the difference was not statistically significant when compared with controls. CONCLUSION: Cocaine impaired ovarian responsiveness to exogenous gonadotropins and decreased ovulatory stigma in nonhuman primates. These findings suggest that cocaine has direct ovarian effects.

Effect of acute administration of cocaine on pituitary gonadotrophin secretion in female rats.

The aim of this study was to characterize the acute effects of cocaine administration on pituitary gonadotrophin secretion in adult female rats. Ovariectomized, oestradiol-treated rats were infused i.v. with 0.1 ml normal saline or 2 mg cocaine hydrochloride kg(-1). Blood samples were collected immediately before cocaine infusion and at 3, 10, 30 and 60 min after cocaine infusion. Circulating LH concentrations were increased by 10 min after cocaine administration (P < 0.05 versus saline-treated controls) and decreased thereafter. Serum FSH concentrations were not significantly different from those of saline-infused controls at any time. In a second experiment, oestradiol-treated, ovariectomized rats were infused i.v. with: saline only, 2 mg cocaine hydrochloride kg(-1) in saline, 200 ng synthetic GnRH in 100 microl PBS or 200 ng synthetic GnRH plus 2 mg cocaine hydrochloride kg(-1) in PBS. Blood samples were collected immediately before drug infusions and 20 min later. Cocaine had no effect on either GnRH-stimulated LH or FSH secretion. In a third experiment, pituitary cells were obtained from oestradiol-treated, ovariectomized rats. The cell cultures were exposed to 25 ng cocaine hydrochloride ml(-1), 10(-10)-10(-7) mol GnRH (-1) with and without 25 ng cocaine hydrochloride ml(-1), or vehicle only. Medium was collected before and after exposure to GnRH to determine concentrations of secreted LH and FSH. Similar to the results of the second study, cocaine had no effect on GnRH-stimulated LH or FSH secretion from pituitary cells in vitro. On the basis of these results it is suggested that acutely administered cocaine stimulates release of hypothalamic GnRH, which, in turn, stimulates pituitary gonadotrophin secretion. Acute administration of cocaine does not appear to affect pituitary gonadotrophin secretion directly.

Mesothelial cell-associated hyaluronic acid promotes adhesion of endometrial cells to mesothelium.

OBJECTIVE: To evaluate the role of hyaluronic acid in the attachment of endometrial cells to mesothelium. DESIGN: In vitro study of adhesion of endometrial stromal and epithelial cells to mesothelial cells. SETTING: University medical center. PATIENT(S): Reproductive-age women without endometriosis undergoing surgery for benign conditions. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The effect of hyaluronidase treatment of mesothelial cells or endometrial cells on adhesion of (51)Cr labeled endometrial stromal and epithelial cells to monolayers of mesothelium was evaluated. The expression of CD44, the hyaluronate receptor, was evaluated by western blot. RESULT(S): Hyaluronidase pretreatment of mesothelial cells decreased the binding of endometrial stromal and epithelial cells to mesothelium by 39% (P< .02) and 31% (P< .03), respectively. There was no effect on endometrial cell binding to mesothelial cells or to collagen IV when the endometrial cells were pretreated with hyaluronidase. CD44 expression by endometrial stromal and epithelial cells was demonstrated by western blot. CONCLUSIONS: This study demonstrates that mesothelial cell-associated hyaluronic acid is involved in attachment of endometrial stromal and endometrial epithelial cells to the mesothelium. We hypothesize that binding of hyaluronic acid by endometrial cells is involved in the pathogenesis of the early endometriotic lesion.

Composition of the extracellular matrix of the peritoneum.

OBJECTIVE: To localize the extracellular matrix proteins collagen I, collagen IV, fibronectin, and laminin in the peritoneal membrane. STUDY DESIGN: Peritoneal biopsies (n = 13) from the anterior abdominal wall and the uterine serosa (n = 3) were incubated with antibodies to collagen IV, laminin, collagen I, and fibronectin. Specimens were examined using light and confocal laser scanning microscopy. RESULTS: All of the extracellular matrix (ECM) proteins were present immediately under the mesothelium. Collagen (Col) IV and laminin (LM) were seen in the smooth muscle of microvascular structures, in the subendothelial basement membrane, and were present in a fascicular pattern in the peritoneal stroma. Collagen I was distributed diffusely in the peritoneal stroma. Fibronectin was also present in the subendothelial basement membrane. CONCLUSIONS: The resolution of the confocal microscope allowed for localization of extracellular matrix proteins in relation to the mesothelium. The presence of collagen IV, laminin, collagen I, and fibronectin under the mesothelium suggests that cells invading the peritoneum must have the ability to degrade and remodel this matrix.

Short-term culture of peritoneum explants confirms attachment of endometrium to intact peritoneal mesothelium.

OBJECTIVE: To evaluate the initial adhesion of endometrium to the peritoneum. DESIGN: Descriptive study using light and confocal laser-scanning microscopy, immunohistochemistry, and transmission electron microscopy. SETTING: University-based laboratory. PATIENT(S): Women without endometriosis undergoing surgery for benign conditions. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Explants of peritoneum (n = 20), prepared from four patients, were cultured for 1 hour with mechanically dispersed proliferative or secretory endometrium. Peritoneum was cultured with endometrium from the same patient. Specimens were fixed and serially sectioned for hematoxylin and eosin stain, immunohistochemistry using an anti-cytokeratin monoclonal antibody, and transmission electron microscopy. RESULT(S): In 17 of 20 explants, endometrium was adherent to intact mesothelium. There was no evidence of transmesothelial invasion at any sites of attachment. Although in most cases endometrium was adherent to mesothelium via endometrial stroma, there were many sites of endometrial epithelium-mesothelium attachment. Confocal laser scanning microscopy demonstrated an intact monolayer of cytokeratin-positive cells below the sites of endometrial implantation. Transmission electron microscopy demonstrated intact, viable, mesothelial cells below sites of attachment. CONCLUSION(S): This study demonstrates that endometrium rapidly adheres to intact peritoneal mesothelium. In addition, this study demonstrates that endometrial epithelial cells, as well as stroma, can attach to mesothelium. Further studies are needed that characterize the mechanism of endometrial-mesothelial cell adhesion.

Expression of the alpha2beta1 and alpha3beta1 integrins at the surface of mesothelial cells: a potential attachment site of endometrial cells.

OBJECTIVE: To localize alpha2beta1 and alpha3beta1 integrins in the cell membrane of peritoneal mesothelium in vivo and in vitro. DESIGN: Descriptive study using confocal and two-photon laser-scanning microscopy. SETTING: University-based laboratory. PATIENT(S): Women without endometriosis undergoing surgery for benign conditions. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Peritoneal biopsies (n = 9) and mesothelial monolayer cultures (n = 4) were incubated with antibodies to the alpha2 and alpha3 subunits and to the intact alpha2beta1 and alpha3beta1 integrins. Specimens were examined with laser-scanning microscopy. RESULT(S): The alpha2 and alpha3 subunits and the intact alpha2beta1 and alpha3beta1 integrins were identified at the base of the mesothelial cells (i.e., toward the basement membrane). There was also expression of the alpha2 and alpha3 subunits and the intact alpha2beta1 and alpha3beta1 integrins at the cell surface (i.e., toward the peritoneal cavity). CONCLUSION(S): The resolution of the confocal and two-photon laser-scanning microscope enabled localization of integrins in mesothelial cells. The presence of alpha2beta1 (collagen-laminin receptor) and alpha3beta1 integrins (collagen-laminin-fibronectin receptor) at the base of mesothelial cells suggests a role for these molecules in adhesion to the basement membrane. The presence of these molecules at the cell surface suggests a potential locus for cell adhesion in such processes as endometriosis and cancer metastasis.

Survival of cryopreservation and thawing with all blastomeres intact identifies multicell embryos with superior frozen embryo transfer outcome.

OBJECTIVE: To assess the impact of survival of cryopreservation and thawing with all blastomeres intact on the outcome of multicell frozen ET. DESIGN: Retrospective study. SETTING: Academic assisted reproductive technology program. PATIENT(S): One hundred sixteen exclusively multicell frozen ETs in 78 patients. INTERVENTION(S): Frozen ET. MAIN OUTCOME MEASURE(S): Relation of embryonic blastomere survival to the outcome of frozen ET (i.e., pregnancy). RESULT(S): When at least one embryo survived with all blastomeres intact, the total pregnancy rate (biochemical, clinical, or delivered) was 37.7%, the clinical pregnancy rate was 24.6%, and the delivered pregnancy rate was 18.8%. When no embryo survived with all blastomeres intact, the corresponding rates were 10.6%, 8.5%, and 6.4%. The differences in the total pregnancy rate and the clinical pregnancy rate were statistically significant. The delivered pregnancy rates approached statistical significance. CONCLUSION(S): Multicell embryonic survival of cryopreservation and thawing with all blastomeres intact identifies embryos with superior developmental potential.

Thrombin-stimulated increases in cytosolic Ca2+ level and gonadotropin-releasing hormone release in GT1-7 neurons.

The effects of thrombin on cytosolic calcium levels ([Ca2+]cyt), and on gonadotropin-releasing hormone (GnRH) release, were characterized in cultured GT1-7 neurons. GnRH release from GT1-7 neurons was pulsatile with an average pulse amplitude of 14.3+/-5.8 pg x min x ml(-1) and an average pulse duration of 21.3+/-4.2 min. The [Ca2+]cyt response to 0.005 to 0.2 U/ml thrombin was saturable and concentration dependent (EC50 = 0.0268 U/ml). Ethyleneglycotetraacetic acid (EGTA) chelation of extracellular Ca2+ resulted in an approximately 70% attenuation of thrombin-stimulated increase in [Ca2+]cyt. By use of a special superfusion system, a 5-min exposure to 0.1 U/ml thrombin significantly increased the amplitude (193.2+/-67.8 pg x min x ml(-1); P = 0.001) but not the duration (22.5+/-2.4 min; P = 0.8) of GnRH release. These results suggest that thrombin increases [Ca2+]cyt and GnRH release from GT1-7 neurons via specific membrane-bound receptors.

Pathophysiology and management of proximal tubal blockage.

OBJECTIVE: To review the physiology, pathology, and treatment of proximal tubal disease. DATA IDENTIFICATION: Relevant reports on the pathophysiology of proximal tubal disease were reviewed. All studies in English of microsurgery and macrosurgery, and of radiographic and hysteroscopic cannulation in women with proximal tubal blockage were identified through MEDLINE searches. STUDY SELECTION: All studies of therapy for proximal blockage that included pregnancy rates were considered. Series of sterilization reversals, series of unilateral or combined procedures, and series in which the location of tubal blockage was not given were excluded from the data analyses. DATA ANALYSIS: Raw data were assessed for homogeneity, then standardized and pooled. Total and ongoing pregnancy rates after microsurgery and macrosurgery, as well as radiographic and hysteroscopic transcervical cannulation, were compared by the chi2 test. Relative risks for total and ongoing pregnancies were calculated for all treatment methods. RESULT(S): This meta-analysis suggests that, overall, microsurgical anastomosis results in higher total and ongoing pregnancy rates than macrosurgery or radiographic tubal cannulation. However, pregnancy rates in selected series of transcervical tubal cannulation are similar to those reported for microsurgery. CONCLUSION(S): Ongoing intrauterine pregnancy rates near 50% can be achieved in patients with proximal blockage of the fallopian tube. Selective salpingography and transcervical cannulation under fluoroscopic guidance are effective at establishing patency in appropriately selected patients and are less invasive and costly than the surgical alternatives.

Low-dose follicular-phase cocaine administration disrupts menstrual and ovarian cyclicity in rhesus monkeys.

OBJECTIVE: To evaluate the effects of daily low-dose follicular-phase cocaine administration on menstrual cyclicity, ovulation rates, corpus luteum function, and hormone levels in rhesus monkeys. METHOD: Normally cycling, drug-naive, adult rhesus monkeys were randomized to receive either 1 mg/kg of cocaine (n = 7), 2 mg/kg of cocaine (n = 7), or normal saline (n = 7) daily on cycle days 2 to 14. Daily blood samples were obtained through indwelling catheters for measurement of serum gonadotropins and ovarian steroids. Daily vaginal swabs were obtained to determine onset of menses. Laparoscopy was performed 2 days after the midcycle estrogen peak to document ovulation. Daily caloric intakes as well as pretreatment and posttreatment weights were recorded. RESULTS: Two of seven monkeys receiving 1 mg/kg per day and two of seven monkeys receiving 2 mg/kg per day of cocaine had timely ovulation and normal menstrual cycle lengths. One monkey receiving the 2-mg/kg dose ovulated on cycle day 24 and had a short luteal phase (7 days) with a mean progesterone level of 2.4 ng/mL. All seven saline-treated control monkeys ovulated normally; the mean cycle length was 29 days and all had adequate luteal phases. The difference in ovulation rates between cocaine-treated and control monkeys was statistically significant (P = .003). There were no differences in basal levels of LH or FSH between treatment groups. There were no significant differences in weight change or caloric intake among groups. One third of the subsequent menstrual cycles in cocaine-treated monkeys were of abnormal duration. CONCLUSION: Daily low-dose follicular-phase cocaine administration disrupts menstrual cyclicity and folliculogenesis. This effect is independent of weight loss, caloric intake, and basal gonadotropin levels. Cocaine exposure may have a persistent effect on menstrual and ovarian cyclicity in some monkeys.

Concentration-dependent effects of muscimol to enhance pulsatile GnRH release from GT1-7 neurons in vitro.

Immortalized GT1-7 neurons were used to characterize the effect of muscimol, a GABAA receptor agonist, to enhance pulsatile gonadotropin-releasing hormone (GnRH) release. GT1-7 neurons were grown on Cytodex-3 beads and placed in special superfusion microchambers. The cells were superfused at a rate of 6.2 ml x h-1 with Media 199 (pH 7.35) using a commercially available perfusion system. After a pre-muscimol period of 120 min, the cells were exposed for 5 min to 0.35, 1, 5 or 10 microM muscimol or 5 microM muscimol+20 microM of the GABAA receptor antagonist, bicuculline. Following removal of the muscimol (and bicuculline, in the case of the latter experiment), the superfusion was continued for another 115 min. Sample fractions were collected at 5 min intervals throughout the perfusion. Basal GnRH release from the GT1-7 neurons was pulsatile with an average interpulse interval of 45.4+/-0.5 min and an average pulse amplitude of 191.5+/-22.6 pg x min x ml-1. Our results also demonstrated that the GABAA receptor agonist, muscimol, enhances pulsatile GnRH release from GT1-7 neurons in culture. The response to muscimol was saturable and concentration-dependent with an EC50 of 0.47 microM. The effects of 5 microM muscimol to increase GnRH pulsatility were blocked by co-exposure to the GABAA receptor antagonist, bicuculline. The average GnRH interpulse intervals were 41.7+/-1.8 min, 32.5+/-2.9 min, 30.6+/-0.7 min and 25.5+/-0.4 min in the period following exposure to 0.35, 1, 5 and 10 microM of muscimol, respectively (post-muscimol period). GnRH pulse amplitude (mean-area for each pulse) was increased during exposure to muscimol but not during the pre- or post-muscimol periods. The GABAA receptor antagonist, bicuculline, itself had no effect on pulsatile GnRH release. These results are consistent with previously published reports suggesting that activation of the GABAA receptor stimulates hypothalamic GnRH release in embryonic and neonatal animals.

Is there a risk of cytomegalovirus transmission during in vitro fertilization with donated oocytes?

OBJECTIVE: To define the risk of human cytomegalovirus (HCMV) transmission from donated oocytes. DESIGN: Prospective study. SETTING: University IVF program. PATIENT(S): Sixty-seven couples undergoing 72 cycles of IVF-ET. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Serum from both partners (women: n = 71; men: n = 60) was obtained for detection of antibodies to HCMV. Semen before preparation (n = 53), sperm after preparation (Percoll gradient; n = 47), cervical mucus aspirated at the time of oocyte aspiration (n = 70), and uninseminated oocytes and embryos not suitable for cryopreservation (n = 568) were frozen in liquid nitrogen. Polymerase chain reaction was used for detection of HCMV (immediate early 1 gene) in all samples collected. RESULT(S): Serum antibodies to HCMV were found in 62% of the women and 37% of the men tested. Human cytomegalovirus DNA was detected in 25% of the ejaculates and in 19% of the cervical mucus samples. There was no amplification of HCMV DNA from oocytes or embryos. CONCLUSION(S): Because we were unable to amplify HCMV DNA from any of the oocytes or embryos, it seems unlikely that HCMV is transmissible through oocyte or embryo donation.

Whole explants of peritoneum and endometrium: a novel model of the early endometriosis lesion.

OBJECTIVE: To determine whether whole fragments of endometrium can adhere to peritoneum with intact mesothelium. DESIGN: Tissue culture and immunohistochemical study. SETTING: University medical center. PATIENT(S): Reproductive-age women undergoing surgery for benign conditions. INTERVENTION(S): Explants of human peritoneum from the anterior abdominal wall and the posterior surface of the uterus were cultured with whole fragments of mechanically dispersed endometrium. MAIN OUTCOME MEASURE(S): Adhesion of endometrial fragments to the surface of the peritoneum was evaluated. Adherent endometrium was identified with the use of the dissecting microscope and by the performance of serial sections of the peritoneum explants. Immunohistochemical staining of the mesothelium with antibodies to cytokeratin was used to ensure an intact layer of mesothelium beneath the endometrial implants. Transmission electron microscopy also was used to evaluate this adhesion process. RESULT(S): Endometrium was identified attached to the surface of the peritoneum. Most of the implants did not have identifiable mesothelium beneath them, but most had intact mesothelium running up to the point of attachment. Approximately 10% of the endometrial implants had intact mesothelium at the site of attachment. Endometrial stromal cells, and not epithelium, attached to the mesothelium. CONCLUSION(S): Endometrium can attach to the mesothelial surface of the peritoneum. Endometrial stromal cells are involved in this attachment. Invasion through the mesothelium seems to occur rapidly.

Noncommunicating accessory uterine cavity.

OBJECTIVE: To report a case of a noncommunicating accessory uterine cavity. DESIGN: Case report. SETTING: University-affiliated reproductive endocrinology practice. PATIENT(S): A 15-year-old nulligravida with increasing dysmenorrhea. INTERVENTION(S): Pelvic ultrasound, intravenous pyelogram, hysterosalpingogram, laparoscopy, laparotomy, and resection of noncommunicating accessory uterine cavity. MAIN OUTCOME MEASURE(S): Results of imaging studies, surgical examination, and resection of anomaly. RESULT(S): Complete resection of accessory cavity and resolution of dysmenorrhea. CONCLUSION(S): The patient had a müllerian anomaly in which the uterus contained two uterine cavities. One normal uterine cavity with communication to both fallopian tubes was present along with a noncommunicating, accessory uterine cavity.

Cocaine impairs follicular phase pulsatile gonadotropin secretion in rhesus monkeys.

OBJECTIVE: To assess cocaine's effect on follicular phase pulsatile gonadotropin secretion in normally cycling rhesus monkeys. METHODS: Sixteen monkeys were paired by body weight and randomized to receive intravenous saline (n = 8) or cocaine (4 mg/kg, n = 8) daily on cycle days 2 to 14. Monkeys were chronically cannulated to allow frequent blood collections without anesthesia. Blood samples were obtained every 15 minutes for 8 hours in early (EFP; cycle days 1 to 5), mid-(MFP; cycle days 6 to 10), and late (LFP; cycle days 11 to 15) follicular phase. Plasma concentrations of LH, FSH, and estradiol-17 beta (E2) were determined by radioimmunoassay. Pulses were identified by cluster analysis. Statistical differences were determined by analysis of variance (ANOVA) and Sidak's multiple comparison test. RESULTS: Seven out of eight monkeys in the control group demonstrated timely ovulation. Only one monkey in the cocaine-treated group ovulated. Similar gonadotropin pulse intervals (70 to 90 minutes) were observed throughout the follicular phase in both the controls and cocaine-treated monkeys. LH and FSH pulse amplitudes increased significantly from the EFP/MFP to the LFP in controls. In cocaine-treated monkeys, gonadotropin pulse amplitudes remained at EFP/MFP levels throughout the study period. The mean gonadotropin pulse amplitude and the mean E2 levels in the LFP were significantly greater in controls as compared with cocaine-treated monkeys (P < .001). CONCLUSION: These findings demonstrate that cocaine suppresses the normal increase in LH and FSH pulse amplitude seen in the LFP. Further studies are in progress to determine the mechanism of cocaine's disruption of the hypothalamic-pituitary-ovarian axis.