Preservation of pulsatile luteinizing hormone release during postpartum lactational amenorrhea.

To evaluate the pulsatile mode of immunoactive LH release during physiological lactational amenorrhea, we withdrew blood samples at 10-min intervals for 24 h from breastfeeding women (n = 9) at both 3 weeks and 3 months postpartum. Nonlactating women (n = 7) were sampled similarly in the early follicular phase of the normal menstrual cycle. Objective LH pulse analysis revealed that the mean frequencies of pulsatile LH release were similar at both times postpartum and in menstruating young women. By 3 months postpartum, mean serum PRL concentrations had declined 50%, and serum LH peak areas doubled. In contrast, LH interpulse interval, peak duration, and maximal, incremental, and fractional LH pulse amplitude did not change significantly. When deconvolution analysis was used to assess pituitary responses to two pulses of exogenous GnRH at 3 months (vs. 3 weeks) postpartum, we found significant increases in maximal LH secretory rates and the total mass of LH secreted. There was no change in the duration or timing of the evoked LH secretory burst and/or the estimated half-life of endogenous LH. In summary, during lactational amenorrhea, pulsatile LH release occurs at a mean frequency no different from that in the normal early follicular phase. As hyperprolactinemia wanes, there is increased pituitary responsiveness to exogenously administered GnRH and a doubling of spontaneous serum LH concentration peak areas. Such amplitude changes are consistent with the hypothesis of increased endogenous GnRH drive (e.g. augmented GnRH secretion per burst and/or increased pituitary responsiveness to available GnRH) during recovery of the postpartum hypothalamopituitary-ovarian axis.

Dynamics of pulsatile prolactin release during the postpartum lactational period.

To investigate the pulsatile nature of PRL release in the physiologically hyperprolactinemic postpartum period, we sampled blood at 10-min intervals for 24 h in each of 6 healthy lactating women at both 3 weeks and 3 months postpartum. The subsequent immunoactive PRL time series were subjected to episodic peak detection (Cluster analysis) and multiple parameter deconvolution analysis. The 24-h mean serum PRL concentrations were significantly higher at 3 weeks than at 3 months postpartum; viz. 113 +/- 12 vs. 66 +/- 15 micrograms/L (P = 0.003). Assessment of episodic PRL pulsatility revealed significantly higher maximal PRL peak heights (296 +/- 63 vs. 141 +/- 44 micrograms/L), fractional peak heights (863 +/- 150 vs. 374 +/- 58%), incremental peak amplitudes (250 +/- 60 vs. 96 +/- 3 micrograms/L), and peak areas (13 +/- 3 vs. 4 +/- 1 mg/L.min) in the earlier postpartum period. In contrast, PRL peak frequencies and interpulse intervals were not different in the early and late postpartum sessions. Deconvolution analysis revealed that the mean mass of PRL secretory bursts was significantly greater at 3 weeks (182 +/- 4.1 micrograms/L) than 3 months (15 +/- 1.6 micrograms/L). There were no changes in the calculated half-life of endogenous PRL viz. 29 +/- 2.5 min (3 weeks) vs. 26 +/- 3.0 min (3 months). We conclude that physiological postpartum hyperprolactinemia is achieved by selectively altering the endogenous secretory rate in each PRL release episode, with no change in the number of bursts of PRL discharged or the PRL half-life.

Intravasation during hysterosalpingography using oil-base contrast medium--a second look.

Hysterosalpingography is a study performed commonly to assess the upper reproductive tract in infertile women. A risk with hysterosalpingography is either lymphatic and/or venous intravasation with or without embolization. Of 593 consecutive hysterosalpingograms performed with a low-viscosity oil-base medium, intravasation occurred in 41 cases (6.9%). Embolization was documented in six patients. There were no recognized adverse sequelae from either intravasation or embolization. Intravasation was frequently associated with pathology of the upper genital tract, and suspected tubal occlusion was the most common abnormality detected. Proper timing of the procedure and avoidance of excessive instillation pressure will diminish the incidence of this complication. The use of both a low-viscosity oil-base medium and high-resolution fluoroscopic image intensification may increase the detection of intravasation.

Vaginal sonography findings and hCG dynamics of early intrauterine and tubal pregnancies.

Early intrauterine gestational sac recognition by ultrasound is useful for discriminating between intrauterine and tubal pregnancies. Transvaginal ultrasound offers improved resolution in the imaging of the uterus and adnexa. Seventy-four women with normal intrauterine pregnancies, 18 women with spontaneous abortions, and 34 women with tubal pregnancies were evaluated by transvaginal ultrasound and serial hCG determinations. Intrauterine pregnancies were followed within the first 50 days of gestation. In women with a normal uterus and singleton pregnancy, sacs were consistently recognized in association with an hCG level greater than 2004 mIU/mL (First International Reference Preparation). Two-to three-millimeter sacs were recognized in association with an hCG level of 2032 +/- 1253 on cycle day 36.1 +/- 2.0. When sacs were less than 5 mm in mean diameter, 33% exhibited a prominent echogenic rim, 38% exhibited a partial echogenic rim, and 29% exhibited no echogenic rim. Fetal cardiac activity was recognized in association with an hCG level of 27,284 +/- 11,479 on cycle day 45.0 +/- 2.9. The hCG doubling time was 1.46 +/- 1.0 days. Apparent loss of multiple gestational sacs was observed in five normal pregnancies. Apparent bleeding in the intrauterine cavity was observed in eight patients and associated with a 38% abortion rate. One false-positive sac was observed among 34 tubal pregnancies (3%). The extrauterine sonographic finding of a solid adnexal mass or cul-de-sac fluid was specific but not sensitive for the diagnosis of tubal pregnancy. The hCG doubling time in tubal pregnancies was 7.69 +/- 9.8 days. Transvaginal ultrasound and serial hCG determinations are useful for the early recognition of tubal pregnancy.

Congenital atresia of the uterine cervix with pelvic endometriosis.

Congenital atresia of the uterine cervix is a rare Müllerian anomaly. About half of the reported cases are associated with pelvic endometriosis. We describe a 20-year-old woman with congenital cervical atresia and pelvic endometriosis whose manifesting symptoms were primary amenorrhea and pelvic pain. Surgical treatment consisted of excision of bilateral ovarian endometrial cysts and hysterectomy. A review of the literature suggests that successful surgical management with regard to preservation of reproductive potential may be possible in some cases, but treatment must be individualized and hysterectomy is sometimes indicated.

Homologous insemination.

Between July 1, 1969, and October 31, 1977, 619 patients were evaluated for infertility. Homologous insemination (AIH) was employed in 53 patients, many of whom had other contributory causes of infertility. There have been 14 single pregnancies in 11 women, including 4 spontaneous abortions, 1 ectopic pregnancy, 8 term deliveries, and 1 pregnancy in progress. Twenty women are currently under treatment. Another 16 women had unsuccessful AIH prior to beginning donor insemination. Seven subsequently conceived with donor semen. Specific indications for AIH and the recommended technique are discussed in detail as well as the occurrence and management of concomitant infertility factors in this study group. It is concluded that AIH does have a role in the management of certain infertile couples.

Effects of dexamethasone therapy on serum immunoglobulin levels and peripheral cell counts in women undergoing conservative benign gynecologic surgery.

Twenty women undergoing conservative gynecologic surgery were treated perioperatively with high-dose dexamethasone (DEX) for 72 hours. Serum immunoglobulin levels (IgG, IgM, IgA) and peripheral cell counts, including lymphocyte subpopulations, were measured in each patient during the immediate preoperative and postoperative periods as well as 5 to 8 weeks later. These results were compared with the levels of a control population of 16 women undergoing conservative, non-pregnancy-related gynecologic surgery for benign conditions. There was a decrease in the level of all serum immunoglobulins measured in the immediate postoperative period in both groups, with a greater statistical decrease in the control group (P less than 0.001). statistically significant transient alterations in the peripheral cell counts occurred in the DEX group, as compared with the control group (P less than 0.001). The use of DEX was not associated with any postoperative infectious morbidity.

Exogenous estrogen therapy for treatment of clomiphene citrate-induced cervical mucus abnormalities: is it effective?

Clomiphene citrate (CC) may have an adverse effect on cervical mucus (CM) quality and quantity. A placebo-controlled study was performed to assess the effect of exogenous follicular phase estrogen (E) on CM. Subjects qualified for inclusion by repeated demonstration of poor CM while on CC therapy as judged by spinnbarkeit, quantity, and viscosity. Subjects were treated by a randomized, placebo-controlled format using: (1) oral micronized estradiol (E2), 2 mg; (2) conjugated Es, 5 mg, or (3) placebo administered on cycle days 9 to 14. Cervical mucus was scored blindly during therapy within 48 hours before ovulation. Twelve subjects were observed through 36 treatment cycles with mean (+/- SD) CM scores: micronized E2, 4.2 +/- 1.8; conjugated Es, 4.3 +/- 1.7; and placebo, 4.7 +/- 2.9. There was no significant difference in mean values (P = 0.96, analysis of variance) or frequency of CM score greater than 4 (P = 0.85, Fisher exact test). We conclude that therapy with the E preparations tested did not improve the quality or quantity of CM in CC-treated patients.

Intravasation during hysterosalpingography using oil-base contrast media.

The use of oil-base contrast media for hysterosalpingography provides detailed imaging and the added information of a delayed film. Intravasation with possible embolization of oily media is often cited as a morbid complication. There are reports of significant morbidity associated with the use of high-viscosity oil media such as Lipiodol. Ethiodol has a significantly lower viscosity than Lipiodol. The incidence of intravasation can be reduced by proper timing of the study and avoidance of excessive pressures during instillation. With fluoroscopy, the early manifestations of intravasation can be detected, allowing the operator to limit the volume of embolized medium. We report 13 cases of intravasation (6 with embolization) with no morbidity during hysterosalpingography performed with Ethiodol. These data suggest that embolization of low-viscosity oil contrast media in low volumes is a relatively benign process. The text of this paper contains data on the clinical histories and courses of the 13 cases cited.

Quantitative effects of intraperitoneal 32% dextran 70 on serum immunoglobulin levels in women undergoing gynecologic surgery.

The use of intraperitoneal 32% dextran 70 results in quantitative postoperative changes in human IgG and IgA levels that are statistically different from the alterations induced by the surgical procedure alone.

Utility of the 24-hour delay hysterosalpingogram film.

Controversy exists regarding the ideal contrast media for hysterosalpingography. A unique property of oil-base contrast media is the availability of a 24-hour delay radiograph for further assessment of tubal patency and adhesions. A review was undertaken of the delay films in 131 cases performed by use of oil-base contrast media with subsequent surgical confirmation of pelvic findings. A 97% predictive accuracy was achieved with regard to distal obstruction and a 79% accuracy with regard to pelvic adhesions. Objective criteria for the evaluation of 24-hour delay hysterogram films were developed and are illustrated.

Subclinical pregnancy loss in clomiphene citrate-treated women.

OBJECTIVE: To ascertain the subclinical pregnancy loss rate in clomiphene citrate (CC)-treated infertile women compared with women of normal fertility. DESIGN: Following a prospective format, serum samples were taken during the luteal phase of 92 menstrual cycles associated with CC treatment and 47 cycles in normal women. Human chorionic gonadotropin (hCG) assay sensitivity was 0.25 IU/L. Human chorionic gonadotropin assay was validated against 95 nonpregnant cycles. Criterion for pregnancy was a single serum sample greater than or equal to 0.5 IU/L. SETTING: All subjects were under clinical management at the University of Virginia Health Sciences Center. PATIENTS AND PARTICIPANTS: Patients undergoing CC induction of ovulation with satisfactory ovulatory response were candidates for the study group (n = 34). Control subjects of proven normal fertility were recruited (n = 22). Nonpregnant control subjects were sexually abstinent or had been surgically sterilized (n = 89). INTERVENTION: A serum sample was taken during the late luteal phase of all subjects. RESULTS: Thirteen percent of CC-treated cycles and 4.3% of normal control cycles were subclinical losses (P = 0.09). Fifty percent of CC-induced pregnancies were subclinical losses compared with 16.6% of normal control pregnancies (P = 0.05). Of CC patients who had at least one subclinical loss 47.6% later conceived a term pregnancy compared with 15.3% who did not have a subclinical loss (P = 0.06). CONCLUSION: Subclinical pregnancy loss is more common in CC-treated women than normal women and may be a predictor of subsequent normal conception.

Oocyte retention after follicle luteinization.

Indirect evidence supports the existence of the luteinized unruptured follicle syndrome in infertile women. To seek direct evidence of oocyte retention, infertile and normal women were studied in the early and midluteal phase by visual documentation of ovulation stigma, needle aspiration of ovarian follicles, and peritoneal fluid collection for estradiol and progesterone assay. Luteal phase was confirmed by endometrial biopsy (postovulation day 2 to 8). In normal control subjects (n = 16), 25% of test cycles were stigma-negative and no oocytes were recovered. In infertile group (n = 23), 43% of test cycles were stigma-negative. Five oocytes were recovered including one from a stigma-bearing follicle. Peritoneal fluid steroid levels failed to discriminate stigma-positive from stigma-negative cycles in either group. Oocyte retention after luteinization occurs in infertile women.

Hypergonadotropic ovarian failure in young women.

The purpose of this study is to evaluate 13 patients with primary ovarian failure (POF). All patients were less than 35 years of age. Serum FSH, performed by RIA, was in the post-menopausal range in all patients. Karyotype with Q-banding was performed on peripheral leukocytes and/or ovarian tissue. All patients had 46XX karyotype. Eleven patients had laparoscopy or laparotomy and ovarian biopsy. Two of the 11 patients had ovarian follicles. One patient had Graves' disease. Based on our data, we offer these conclusions. A thorough evaluation of patients with premature ovarian failure is essential. Testing for autoimmune endocrinopathies should be considered in POF patients who exhibit any signs of endocrine dysfunction. A peripheral karyotype with banding should be performed on all patients. The resistant ovary syndrome may occur with greater frequency than has previously been reported and a review of the literature on the resistant ovary syndrome is presented.