Selection of patients for clomiphene citrate therapy.

Ninety-three infertile women were treated with clomiphene citrate alone or in combination with human chorionic gonadotropin (hCG) for absent or infrequent ovulation. The patients were divided into eight categories according to the diagnosis obtained: ovarian androgenic hyperplasia, adrenal androgenic hyperplasia, mixed ovarian and adrenal androgenic hyperplasia, hypothalamic anovulation, postpill anovulation, follicular phase defect, luteal phase defect, and amenorrhea-galactorrhea syndrome. Each group was analyzed individually to compare the ovulation and conception rates and the complications involved. A survey of the data presented in this study shows that the best response was noted in patients with ovarian androgenic hyperplasia. Patients with a functional pathologic adrenal component responded favorably when dexamethasone was used as an adjuvant to clomiphene therapy. Those with hypothalamic anovulation responded better when hCG was added to clomiphene therapy. Women with postpill anovulation as well as those with follicular phase defect were found to be good candidates for clomiphene therapy. In properly selected patients with poor luteal phase defect, hCG secured excellent results both in ovulation and conception. Patients with lactation amenorrhea failed to ovulate when treated with clomiphene alone.

Comparison between abdominal and hysteroscopic metroplasty.

Thirty-three patients were diagnosed by hysterosalpingography and laparoscopy as having septate uteri, which were assumed to be responsible for their infertility, recurrent abortions, or premature labor. Fourteen of these had Tompkins metroplasty (group 1) while the other 19 had their repairs done by hysteroscopic metroplasty (group 2). Post-operative hysterosalpingography for patients in group 1 revealed normal uterine cavities in 72%, incomplete septum excision in 14%, and intrauterine filling defects in 14%. The corresponding figures in group 2 were 88, 12, and 0%. In group 1, 71.0% became pregnant; of these, 70% continued to term (with delivery by cesarean section), 20% aborted, and 10% were tubal pregnancies. In group 2, 84% became pregnant; of these, 87% had term vaginal deliveries, and 13% miscarried. Patients in group 2 had less operative time, less blood loss, and shorter hospital stays. These findings demonstrate that hysteroscopic metroplasty may be preferable to the transabdominal procedure based on cost and morbidity considerations as well as on anatomic and reproductive outcome.

Short hospital stay for gynecologic reconstructive surgery via laparotomy.

OBJECTIVE: To evaluate the short hospital stay for different gynecologic reconstructive procedures performed by laparotomy. METHODS: Two hundred twelve patients who had tubal reanastomosis, 124 who had salpingoneostomy, and 148 who had myomectomy were studied retrospectively. The study evaluated pregnancy rates, adhesion formation, discomfort, and complications in each group. RESULTS: Pregnancy rates for the reanastomosis, salpingoneostomy, and myomectomy patients were 72, 34, and 63%, respectively. Twenty-three percent of salpingoneostomy patients developed flimsy periadnexal adhesions, whereas only 9% in the myomectomy group developed flimsy pelvic adhesions. No complications occurred in any of the three groups. Less than 1% of patients in the two tuboplasty groups complained of minimal abdominal discomfort before discharge, and 4% had similar complaints in the myomectomy group. CONCLUSION: Patients who have gynecologic reconstructive surgery can be discharged within 24 hours after the procedure with an excellent outcome.

Comparison of different treatment methods of endometriomas by laparoscopy.

In a prospective study designed to evaluate four methods of endometrioma treatment by laparoscopy, 26 patients had the endometriomas excised, 24 had them opened and the lining stripped off, 30 had them opened and the lining evaporated by CO2 laser, and 44 had them opened and drained. Only women who had laparoscopy because of pelvic pain and who had no immediate desire for pregnancy were included in this study. Those who did not undergo a second-look laparoscopy were excluded. Pain disappeared completely from all subjects regardless of the method of treatment. At second-look laparoscopy, all women in the excision group, nine (37%) in the group who had the lining stripped, nine (30%) in the group who had the lining evaporated, and 12 (27%) in the drainage group had periadnexal adhesions. Residual endometriosis was found in 23, 25, 33, and 30% of these groups, respectively. Because there was a statistical difference between the excision group and each of the remaining three groups in the formation of adnexal adhesions and because there was no statistical difference among the four groups regarding the presence of residual endometriosis, we conclude that laparoscopic treatment of endometriomas should not include excision but rather drainage with or without elimination of the inner lining.

Virilization in Turner syndrome.

A case of gonadal dysgenesis in a phenotypic female associated with neoplastic changes is presented. The patient typified a classic case of Turner syndrome with a 45, XO chromosomal compliment, becoming virilized as a result of the development of bilateral hilar cell hyperplasia in her dysgenetic gonads. The malignant potential of the dysgenetic gonad is stressed in this report. Early diagnosis and appropriate management are emphasized as the two factors that make the difference in the outcome of the patient with gonadal dysgenesis.

Assessment of the role of laparoscopic ovarian biopsy.

Seventy-four patients with either endocrine and/or infertility problems were subjected to laparoscopic ovarian biopsy. The patients were divided into 4 categories: those with primary amenorrhea, secondary amenorrhea, ovarian androgenic hyperfunction, and infertility. The results were critically examined to evaluate the procedure in the investigation and treatment of each of these disorders. It was concluded that laparoscopic ovarian biopsy is most helpful in primary amenorrhea but justified in secondary amenorrhea only if a histologic diagnosis of premature ovarian failure is though to be essential. Patients with ovarian androgenic hyperplasia should not be candidates for the procedure as the laparoscopic appearance of the ovaries offered equally valuable information and the hazards of biopsy in this particular group of patients outweighed its diagnostic and therapeutic usefulness. The ovarian biopsy offered very little benefit for the infertility patients.

Ovarian pregnancy.

Two cases of primary ovarian pregnancy are described. The etiologic, clinical, and pathologic findings and management are discussed briefly with a review of pertinent literature. Routine removal of all bleeding corpora lutea and careful examination of the tissue and blood clots is recommended as this should reveal more cases of early ovarian pregnancies.

Management of premature rupture of the membranes.

A 14-month prospective study of patients with premature rupture of the membranes was performed. The purpose of the study was to determine the effect of different therapeutic regimens for management of premature rupture of the membranes (PROM) on perinatal morbidity and mortality, as well as on maternal morbidity. Maternal and fetal risk factors and predictive factors in pregnancy outcome were prospectively defined. In patients with PROM whose gestational age was 34 weeks or more, induction within the first 12 hours of membrane rupture resulted in minimal maternal and fetal morbidity and mortality. Patients with gestational age of less than 34 weeks had an improved maternal and fetal outcome if left alone until spontaneous labor or 34 weeks' gestation was reached unless signs of sepsis developed. Respiratory distress syndrome (RDS) was the leading cause of morbidity and mortality in the infants of patients who delivered prematurely due to premature rupture of the membranes. Incidence of fetal infection was significantly less than that of RDS as a cause for fetal morbidity and mortality.

An assessment of the role of operative laparoscopy in tuboplasty.

Eighty-three patients had tuboplasty by means of operative laparoscopic techniques. The procedures performed included salpingolysis, whereby only peritubal adhesions were lysed; ovariolysis, whereby only periovarian adhesions were lysed; salpingoovariolysis, whereby peritubal and periovarian adhesions were lysed; fimbrioplasty, whereby the partially agglutinated fimbrial end was teased open; and salpingoneostomy, whereby the completely blocked fimbrial ends were opened. Patency rates were, respectively, 100%, 100%, 100%, 64%, and 31%; and pregnancy rates were, respectively, 67%, 72%, 50%, 35%, and 10%. The only complication encountered was minimal bleeding in the patients in whom salpingoneostomy was performed. These results suggest that operative laparoscopy may be the method of choice for tubal operations that involve any of the first three categories, whereas the last two categories should be used in open laparotomy techniques.

The use of CA-125 in the diagnosis and management of endometriosis.

CA-125, a cell-surface antigen, was measured by a radioimmunoassay in the serum of 414 women to determine its potential usefulness in the diagnosis and management of endometriosis. In women with minimal, mild, moderate, and severe endometriosis, the mean levels (+/- standard deviation) were 13.6 +/- 6.8, 22.8 +/- 15.5, 27 +/- 17, and 50 +/- 28 U/ml, respectively, and were significantly higher than mean levels (7.8 +/- 4.1) in 46 women with a normal laparoscopic examination. Higher mean CA-125 values also were observed in acute pelvic inflammatory disease, unexplained fertility, and pregnancy and during menstruation. The mean CA-125 value in women with treated endometriosis and a negative second-look laparoscopy was significantly lower than in women with untreated endometriosis. With the use of the 95% upper limit of 16 U/ml, the test had a sensitivity of 53% and specificity of 93%. The frequencies of elevated levels in minimal, mild, moderate, and severe endometriosis were 27%, 68%, 73%, and 100%, respectively. Changes in the CA-125 levels correlated with the clinical course of endometriosis in 37 of 44 (84%) women (P less than 0.001). The determination of CA-125 levels may assist in the evaluation and treatment of women with endometriosis.

Infertility surgery of the oviduct: comparison between macrosurgery and microsurgery.

The purpose of this study is to compare the results of macrosurgical and microsurgical tuboplasty procedures performed on infertility patients after other causes of their infertility were ruled out. During a 6-year period from July 1971 through June 1977, 128 macrosurgical tuboplasties were performed, and from July 1977 through July 1979, 73 cases of microsurgical procedures were performed. The senior author was the actual or first assistant surgeon in every case. For comparison, the procedures performed were divided into seven categories: salpingolysis, fimbrioplasty, salpingoneostomy, midsegment anastomosis, tubouterine anastomosis, tubouterine implantation, and combined procedures. The results of both groups were analyzed and compared. Use of the microscope improved results in all categories, particularly in anastomosis procedures. It is concluded that the microscopic techniques have a definite advantage and are recommended for use in all tuboplasty procedures.

Spontaneous abortions in women with endometriosis.

Pregnancy outcomes were evaluated retrospectively in 350 women to investigate the relationship between endometriosis and spontaneous abortions. The frequency of spontaneous abortions in women with endometriosis was significantly higher than in both a fertile nonendometriosis group and an infertile group with tubal disease. There was no correlation between the severity of the endometriosis and the frequency of spontaneous abortions. After treatment, the frequency of spontaneous abortions was significantly decreased in both the endometriosis and the tubal disease group, but these values were not significantly different from each other. We conclude that high spontaneous abortion rates are a characteristic of other subgroups of women with secondary infertility and not just in women with endometriosis, and that the majority of spontaneous abortions associated with endometriosis are not caused by the condition.

Comparison of tubal surgery with the CO2 laser and the unipolar microelectrode.

The uterine horns of 40 New Zealand White female rabbits were resected and anastomosed to compare microsurgical anastomosis of the horns excised with microscissors, with a laser, and with a microelectrode. The rabbits were divided into four groups. In the first group of ten rabbits, 3 cm of tissue was resected by microscissors from each uterine horn; the cut ends were then anastomosed in one layer with 8-0 Vicryl sutures using the operating microscope. In the second group of ten rabbits, 3 cm of tissue was resected by laser from each uterine horn; the cut ends were then anastomosed in one layer with 8-0 Vicryl. In the third group of ten rabbits, 3 cm of tissue was resected by laser from each uterine horn; the cut ends were then anastomosed by "welding" the tissues with the laser. In the fourth group of ten rabbits, 3 cm of tissue was resected by a microelectrode; the cut ends were then anastomosed in one layer with 8-0 Vicryl sutures using loupe magnification. All the rabbits in the first and fourth groups became pregnant, only four became pregnant in the second group, and none became pregnant in the third group. It is concluded that the CO2 laser beam as used in this study has no place in tubal resection and reconstruction.

Comparison of patient reactions and diagnostic quality for hysterosalpingography using ionic and nonionic contrast media.

RATIONALE AND OBJECTIVES: We compared adverse reactions and image quality for hysterosalpingography (HSG) performed with ionic (diatrizoate meglumine combined with iodipamide meglumine [DM + IM]) and nonionic (iohexol) contrast media. METHODS: We performed a study of 95 patients who had HSG and were randomly selected to receive DM + IM or iohexol. Patients reported episodes of abdominal pain and other adverse reactions immediately and 24 hr after the procedure and categorized severity of symptoms on a subjective scale. Two radiologists evaluated image quality for diagnosis. RESULTS: Prevalence of abdominal pain and other reactions both immediately and 24 hr after HSG was lower in patients who received iohexol than in patients who received DM + IM. Moderate or severe abdominal pain was significantly lower in the iohexol group than in the DM + IM group (p < .05). Visualization of the uterine cavity and ampullary rugae was judged excellent with both contrast media (87% with iohexol and 92% with DM + IM). CONCLUSION: Iohexol and DM + IM are excellent contrast media for use during HSG; iohexol 300 may cause fewer episodes of more severe and prolonged abdominal pain.

The pure gonadal dysgenesis syndrome.

Two cases of gonadal dysgenesis in phenotypic females associated with different chromosomal patterns are discussed. Both patients presented with primary amenorrhea and were characterized by tall stature and underdeveloped secondary sex characteristics and external and internal reproductive organs. The karyotype of the first patient was 46,XX with a satellite on chromosome 17. The second patient had a normal female chromosome composition (46,XX) with a past history of mumps. Laparoscopic bilateral gonadal biopsies in both patients revealed fibrous tissue without any primordial follicles. This report emphasizes the pathogenesis, clinical significance, diagnosis and management of gonadal dysgenesis.

Evaluation and treatment of patients with prolactin-secreting pituitary tumors.

Six women with secondary amenorrhea and hyperprolactinemia, four of whom had associated galactorrhea, were studied. Four were found to have prolactin-secreting pituitary microadenomas and two had macroadenomas. Suppression of prolactin secretion and stimulation of prolactin, serum growth hormone and thyroid-stimulating hormone secretion were studied, and gonadotropin and adrenocorticotropic hormone reserves were evaluated. The most sensitive techniques available for the diagnosis of pituitary adenomas in patients with amenorrhea and hyperprolactinemia appear to be the measurement of the magnitude of plasma prolactin elevation and hypocycloidal tomography of the sella turcica. The dynamic function tests proved to be of little diagnostic, but of great prognostic, value for patients with small pituitary tumors.

Postoperative hysterosalpingography. Radiographic appearances and clinical results following tubal surgery.

Medical records and postoperative hysterosalpingograms on 23 women following tubal surgery who failed to become pregnant within 2-28 months were reviewed. A total of 39 tubes were analyzed. The surgical indications were reversal of tubal ligation in 24 tubes and correction of tubal or perifimbrial disease in 15 tubes. Tubal ligation had been performed by a variety of methods. At surgery, tubal patency, as shown by chromotubation, was seen in 37 (95%) of 39 tubes. On postoperative hysterosalpingography, tubal spillage was present in 32 (82%) of 39 tubes. Radiographically, the tubes that spilled appeared normal except for occasional shortening after reversal of tubal ligation. The eventual pregnancy rate was 8 (35%) of 23 patients, with 7 intrauterine. Pregnancy occurred only in women under 35 years and was more likely in the group having reversal of tubal ligation. We conclude that among patients who do not initially become pregnant following tubal surgery for infertility, tubal patency is restored in most. During hysterosalpingography, tubes operated on may appear normal or shortened. On long-term follow-up, younger patients and those requiring tubal anastomosis only had a higher pregnancy rate.

Endometriosis and the infertile patient.

Approximately one-third of all patients who suffer from endometriosis may not be able to conceive. More than 10% of infertile patients have endometriosis as the causative factor of their infertility. The stressful effect of infertility on the couple's life may be devastating. The infertility and endocrinology nurse may play a major role in alleviating the painful experience of such unfortunate patients. The pathogenesis, pathophysiology, diagnosis, and therapy of endometriosis are described. The important role of the nurse in the management of patients with endometriosis is emphasized.

Operative laparoscopy for the treatment of localized chronic pelvic-abdominal pain caused by postoperative adhesions.

One hundred fifty-six patients with chronic abdominal pain associated with postoperative adhesions were treated with laser laparoscopy. Eighty-eight percent of these patients had complete relief, 9% had satisfactory relief, and 3% required a second laparoscopy to lyse recurrent adhesions. It is concluded that chronic abdominal pain associated with adhesions can be treated successfully with laser laparoscopy.