Spontaneous tumor cell killing by human blood monocytes and human peritoneal macrophages: lack of alteration by endotoxin or quenchers of reactive oxygen species.

Human mononuclear phagocytes (monocytes and macrophages) act as effectors in the destruction of tumor cells. Peritoneal macrophages from normal or infertile women killed a variety of tumor cells in vitro more efficiently than did blood monocytes from the same subjects. Lysis depended on the effector-to-target cell ratio and was neither reproduced by supernatants from nor lysates of the mononuclear phagocytes. Normal fibroblasts were not lysed. Lipopolysaccharide (10(1)-10(4) ng/ml) did not alter the monocyte- or macrophage-mediated tumor cell killing. The monocytes and macrophages had equivalent basal and phorbol 12,13-myristate acetate-stimulated H2O2 and O-2 production, and the reactive oxygen species scavengers or quenchers catalase, superoxide dismutase, mannitol, and L-histidine did not diminish the killing. These observations suggest that the spontaneous tumor cell killing by human mononuclear phagocytes was not mediated by reactive oxygen species.

Clinical trials with human tumor necrosis factor: in vivo and in vitro effects on human mononuclear phagocyte function.

The purpose of this investigation was to understand the biological effects of recombinant human tumor necrosis factor used as therapy for cancer. We studied changes in mononuclear phagocyte function following exposure to this cytokine in vitro or in vivo. Tumor necrosis factor increased phorbol myristate acetate-induced hydrogen peroxide production 8- to 20-fold in peripheral blood monocytes and peritoneal macrophages in vitro in a dose-dependent manner. Similarly, tumor necrosis factor increased phorbol myristate acetate-induced peroxide production 2.3-fold in monocytes isolated from nine patients following an i.v. infusion of this cytokine (40 to 200 micrograms/m2). In addition, tumor necrosis factor induced a 2.3-fold increase in tissue factor-like activity in mononuclear phagocytes in vitro. In vivo, tumor necrosis factor induced a trend toward higher procoagulant activity in monocytes, although this change was not statistically significant. We also noted a trend toward increased activated partial thromboplastin times and the presence of fibrin D-dimer in patients treated with tumor necrosis factor, demonstrating activation of the coagulation and fibrinolytic systems. Thus, in vivo treatment of humans with i.v. recombinant human tumor necrosis factor induced functional changes in mononuclear phagocytes similar to those noted with in vitro treatment.

Estrogen and progesterone production by granulosa cell monolayers derived from in vitro fertilization procedures: lack of evidence for modulation by androgen.

The role(s) of androgens in the steroidogenic regulation of human granulosa cell production of estrogen and progesterone during monolayer culture was studied. These cells were exposed in vivo to human menopausal gonadotropin and hCG gonadotropin with or without clomiphene citrate. Steroid production rates were compared between cells cultured in control medium and those cultured in medium containing a nonaromatizable androgen [dihydrotestosterone (DHT)] or an aromatizable androgen [androstenedione (A'D)]. Some cultures received A'D from 3-12 days; other cultures received DHT alone for 3, 6, or 9 days before the addition of A'D for 3 days. The effect on steroid production during the culture interval before the addition of A'D also was evaluated. Exposure to A'D increased estrogen production over 50-fold compared with that in control cells or those treated with DHT (P less than 0.001). DHT also failed to alter estrogen production when A'D was added to cultures. Furthermore, the delay in introducing A'D to the cultures for up to 9 days did not decrease subsequent estrogen production compared with that in cultures continually exposed to A'D or DHT plus A'D. Progesterone production was substantial for at least 12 days of culture and was unaffected by the presence of androgen. These results do not confirm previous studies using murine or porcine granulosa cells, which suggested that androgen receptor-dependent mechanisms were involved in increasing estrogen and/or progesterone production in vitro. Rather, they indicate that androgen may not be required to maintain aromatase capability per se in human granulosa-luteal cells previously exposed to ovulation-inducing quantities of gonadotropin.

The effect of leuprolide acetate on ovulation induction with human menopausal gonadotropins in polycystic ovary syndrome.

The use of exogenous gonadotropins for treatment of clomiphene-resistant chronic anovulation in women with the polycystic ovary syndrome (PCO) is hazardous and often ineffective, possibly because of the abnormal endogenous gonadotropin secretion characteristic of PCO. We evaluated the effect of leuprolide acetate, a long-acting GnRH agonist, on serum gonadotropin and sex steroid concentrations before and during human menopausal gonadotropin (hMG) induction of ovulation in women with PCO. In this controlled prospective randomized study, leuprolide was administered daily for 4 weeks, followed by concomitant hMG administration. Gonadotropin and steroid hormone concentrations were compared with those during ovulation induction cycles in women with PCO receiving hMG only. Daily administration of leuprolide for 4 weeks resulted in significantly decreased serum LH, estradiol, and testosterone concentrations, but no change in serum progesterone, FSH, and dehydroepiandrosterone sulfate. Compared to ovulation induction using hMG alone, leuprolide administration before and during hMG treatment prevented preovulatory rises in serum LH and P concentrations, while having no effect on serum FSH, testosterone, estradiol, and dehydroepiandrosterone sulfate. We conclude that leuprolide administered to women with PCO decreases gonadal steroid production and is capable of preventing premature luteinization during hMG induction of ovulation.

Effect of age on response to human menopausal gonadotropin stimulation.

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

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

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

Immunohistochemical analysis of human uterine estrogen and progesterone receptors throughout the menstrual cycle.

Estrogen receptors (ER) and progesterone receptors (PgR) were studied immunohistochemically using specific antireceptor monoclonal antibodies in uterine tissue samples from 33 women in various stages of the menstrual cycle. Immunohistochemical localization was quantified as to intensity of staining and tissue distribution in glandular epithelium, stroma, and myometrium, and the results were compared with those of standard ligand binding assays. In all samples ER and PgR localized within the nuclei of target cells. The maximal concentrations of ER and PgR occurred in the mid- to late proliferative phase of the menstrual cycle. ER content declined throughout the secretory phase. In contrast, PgR content underwent unexpectedly complex and dyssynchronous fluctuations during the secretory phase of the menstrual cycle. Specifically, the glandular epithelium had diminished PgR content, while the stroma and myometrium maintained a significant PgR content. PgR and perhaps ER are not concordant in different cell types within the uterus. Segregation of function through alteration of receptor content may be an important mechanism in steroid-dependent growth and differentiation of target tissues.

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

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

Endocrine and anatomical correlations in human ovarian pathology.

Knowledge of normal gonadal hormone production and function provides the basis for understanding the ovarian pathologic effects resulting from perturbations in endocrine balance and feedback. A precisely timed, complex, and well-coordinated cascade of ovarian steroidogenesis accompanies normal cyclical follicular function. This cascade involves both estrogens and androgens. Alterations in the hormonal milieu are associated with specific morphological changes in the ovary. While predictable hormonal changes accompany commencement of menopause, several disease states are associated with ovarian dysfunction. These diseases include polycystic ovarian syndrome and hyperthecosis, both associated with androgenization. Ovarian tumors may also be associated with morphological and clinical alterations. While endocrinologically inert ovarian tumors are associated with morphologic evidence of stromal activation, endocrinologically active ovarian tumors may cause differentiation along either male or female lines as a consequence of differential productions of androgens and estrogens.

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

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

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

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

Bilateral tubal occlusion secondary to asymptomatic ectopic pregnancies.

An infertile woman with normal pelvic anatomy apparently underwent two consecutive asymptomatic tubal pregnancies without surgical intervention. Bilateral tubal obstruction resulted from destruction of the proximal segments of the fallopian tubes. These findings suggest that unrecognized ectopic pregnancies may cause destruction of segments of the fallopian tube and should be considered as an etiology of the rarely noted absence of tubal segments.

The sonolucent placenta in high-risk obstetrics.

Placental sonolucency has been reported to be a normal sonographic finding after 36 weeks' gestation. To further characterize this acoustic phenomenon, 15 placentas from previously scanned high-risk obstetric patients were studied in vitro. Placentas were obtained at delivery, and were washed, weighed, sonographically imaged in a water bath, x-rayed by xerography, and pathologically examined. Placental sonolucency occurred as early as 31 weeks' gestation and corresponded anatomically to cotyledons. The degree of septal calcification appeared to correlate best with the degree of sonolucency, and no unusual gross or microscopic placental features could be identified. Intrauterine growth retardation or intrauterine fetal death occurred in 8 of the 10 patients in whom there were sonolucent changes.

The pathologic spectrum of uterotubal junction obstruction.

Excised tubal segments from 42 women with uterotubal junction obstruction were studied histologically to evaluate the pathologic spectrum of disease and correlate this with clinical data. The most frequent lesion encountered was obliterative fibrosis (38.1%), confirmed by connective tissue stains, which was not associated with cornual nodularity. Other pathologic entities included salpingitis isthmica nodosa (23.8%), intramucosal endometriosis (14.3%), and chronic tubal inflammation (21.4%). Intramucosal endometriosis was distinguishable from salpingitis isthmica nodosa by virtue of its unique stroma confirmed by connective tissue staining. Women with previous pregnancies were included in all the groups. In all instances, the obstruction was present in the transmural portion of the tube and extended a variable distance into the isthmic segment. These observations on uterotubal junction obstruction demonstrate that: 1) There are multiple distinct histologic patterns, 2) Intraabdominal findings do not predict the histology of the uterotubal junction pathology, 3) Any histologic pattern can be associated with a previous intrauterine or ectopic pregnancy, and 4) The obstruction begins within the transmural portion of the oviduct, extends a variable distance into the isthmic segment, but does not obstruct the ampullary segment. These data suggest that the initiating process originates within the uterus and that fibrosis may represent a nonspecific response to chronic injury of the transmural and isthmic segments of the oviduct.

Does recommending timed intercourse really help the infertile couple?

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

Endometriosis: pathogenetic implications of the anatomic distribution.

The authors have reassessed the anatomic distribution of ectopic endometrium by the laparoscopic study of the location of implants, adhesions, and uterine position in 182 consecutive patients with infertility and endometriosis. The ovary was the most common site of implants with 54.9% having either unilateral or bilateral involvement. This was followed, in order of frequency, by the posterior broad ligament (35.2%), the anterior cul-de-sac (34.6%), the posterior cul-de-sac (34.0%), and the uterosacral ligament (28.0%). Adhesion formation followed the same anatomic distribution. No patients were noted to have endometriosis of the cervix and vagina. Endometriosis of the anterior compartment (anterior cul-de-sac, anterior broad ligament, and anterior uterine serosa) was significantly more common in patients with anterior uteri (40.7%) versus patients with posterior uteri (11.8%, P less than .0005). Exclusive anterior compartment disease was found only in patients with anterior uteri, and significantly more commonly in patients with severely anteflexed uteri (P less than .005). These data suggest that factors influencing implantation of retrograde menstrual debris include: the dependent pooling of peritoneal fluid as affected by uterine position; epithelial cell type at the site of implantation; unique ovarian susceptibility; route of entry; and mobility of the pelvic structures. The data support the Sampson hypothesis of retrograde menstruation as the primary model of development of endometriosis.

Embolic microspheres within ovarian arterial vasculature after uterine artery embolization.

BACKGROUND: Adverse events after uterine artery embolization, including hysterectomy and premature ovarian failure, are concerning for women who desire future fertility. CASE: A 39-year-old woman underwent emergency hysterectomy after uterine artery embolization embolic microspheres found within the ovarian arterial vasculature. CONCLUSION: Uterine artery embolization for the treatment of uterine fibroids has been associated with loss of ovarian function in up to 14% of patients. This case report demonstrates that embolic microspheres injected into the uterine artery can unintentionally migrate through anastomotic channels into the ovarian arterial vasculature and potentially compromise ovarian blood flow. Hypoxic tissue injury may be the mechanism of premature ovarian failure observed after uterine artery embolization. Understanding the etiology of premature ovarian failure after uterine artery embolization might allow better patient selection.

Significance of biparietal diameter differences between twins.

Twins of dissimilar size have increased risks both at delivery and in the neonatal period. When dissimilar growth is severe, it should be reflected in birthweight and biparietal diameter (BPD) growth. Sonograms were done on 74 of 106 sets of twins delivered from July 1, 1973, to June 30, 1977. Excluding prematurity and birth trauma, the difference in BPD between twins with normal outcomes in the last scan prior to delivery was 1.32 +/- 0.20 mm (mean +/- SE) and the difference in birthweight was 250.3 +/- 31.4 g (mean +/- SE). In 7 sets of twins with poor outcomes (intrauterine fetal demise or severe intrauterine growth retardation) without central nervous system anomalies the difference in BPD between twins in the last scan, while both fetuses were alive, was 6.86 +/- 1.06 mm (mean +/- SE) and the difference in birthweight was 604.3 +/- 217.2 g (mean +/- SE). Both the BPDs and birthweights are significantly different at the P less than 0.01 level. Large differences in BPD between twins may possibly indicate compromise of one twin.

Unusual mullerian anomalies associated with distal extremity abnormalities.

A 13-year-old girl was evaluated with nonfamilial mullerian anomalies consisting of bilateral blind uterine horns, a separate cervical remnant, and total vaginal agenesis. The observed musculoskeletal abnormalities of the distal extremities differed from those usually associated with both nonfamilial mullerian agenesis (Rokitansky-Küster-Hauser syndrome) and the familial syndromes associated with mullerian anomalies. The pattern of mullerian dysgenesis is unusual in that the entire vagina is absent and a cervical remnant separate from the two blind uterine horns is present in the midline in the normal course of the paramesonephric ducts.

Compartmental ovarian steroidogenesis in polycystic ovary syndrome.

Compartmental ovarian steroidogenesis in vitro was investigated in polycystic ovary syndrome. Basal estrogen secretion by granulosa cells ranged from 60 to 284 pg/micrograms cell protein for 24 hours and progesterone secretion from 24 to 1646 pg/micrograms cell protein for 24 hours. In three of four specimens, the addition of either 10(-5)M testosterone or androstenedione significantly increased estrogen production, demonstrating the presence of aromatase activity. Treatment with human follicle-stimulating hormone (100 ng/mL) or human chorionic gonadotropin (100 ng/mL) significantly increased the progesterone production in three of four specimens. The thecal compartment of every patient secreted significantly more testosterone and androstenedione than the capsule and stroma and more estrogen in tissue from two of the four women. The androgen/estrogen ratio was significantly greater for the theca (16.9) than the capsule (1.1) or stroma (1.7). These data demonstrate that in polycystic ovary syndrome a portion of the follicles possess the qualitative characteristics of developing follicles, granulosa cell aromatase activity and gonadotropin responsiveness, and that the theca is likely the principal site of ovarian androgen synthesis. These findings suggest that the small follicles characteristic of polycystic ovary syndrome consist of a mixed population of developing and atretic follicles and that the peripheral androgen excess is attributable to the large mass of the thecal compartment from both follicle populations.