Variant progesterone receptor mRNAs are co-expressed with the wild-type progesterone receptor mRNA in human endometrium during all phases of the menstrual cycle.

Progesterone receptor (PR) variant mRNAs in human endometrium could encode proteins with the potential to alter progesterone action in states of normal and abnormal endometrial development. We have assessed the expression levels of mRNA for the wild-type PR and splice variants of PR mRNA lacking exon 4 (del-4 PR), exon 6 (del-6 PR), exons 4 and 6 (del-4&6 PR), and part of exon 4 (del-p4 PR) or part of exon 6 (del-p6 PR) in the human endometrium throughout menstrual cycle development. Eighty-eight endometrial specimens (47 proliferative, 41 secretory) were collected from patients undergoing hysterectomy for benign gynaecologic causes. Measurements by RT-PCR indicated that mRNAs for wild-type PR, and splice variants del-4 PR, del-6 PR, del-4&6 PR, del-p6 PR, and a novel del-p4 PR were detected in all endometrial specimens throughout the menstrual cycle. Higher levels of wild-type PR and all PR variant mRNAs were found in the early and mid-proliferative endometrial phases than in secretory endometrium. The relative expression of mRNA for all PR variants compared to wild-type PR mRNA, however, did not change through all stages of endometrial development. We, therefore, found no evidence of differential co-expression of the PR variants compared with wild-type PR during normal menstrual development. Future studies will determine if the expression profile of PR variant mRNAs will be different in the endometrium of patients with infertility, recurrent pregnancy loss, or endometrial adenocarcinoma.

Uterine artery embolization for symptomatic uterine myomas.

OBJECTIVE: To evaluate the role of uterine artery embolization as treatment for symptomatic uterine myomas. DESIGN: Medline literature review, cross-reference of published data, and review of selected meeting abstracts. RESULT(S): Results from clinical series have shown a consistent short-term reduction in uterine size, subjective improvement in uterine bleeding, and reduced pain following treatment. Posttreatment hospitalization and recovery tend to be shorter after uterine artery embolization compared with hysterectomy. Randomized controlled trials have not been conducted, and long-term efficacy has not been studied. A limited number of deliveries have been reported following uterine artery embolization for uterine myomas. CONCLUSION(S): Uterine artery embolization is a unique new treatment for symptomatic uterine myomas. Even without controlled studies, demand for this procedure has increased rapidly. Uterine artery embolization may be considered an alternative to hysterectomy, or perhaps myomectomy, in well-selected cases. At the present time, however, uterine artery embolization should not be routinely recommended for women who desire future fertility.

Progesterone metabolism in human endometrial stromal and gland cells in culture.

Metabolism of progesterone by human endometrium has been described, but the rapidity and extent of progesterone metabolism is incompletely documented in cellular fractions of normal endometrium. Therefore, we evaluated progesterone metabolism in separated stromal and gland cells in culture obtained from normal human endometrium by thin-layer chromatography. We find that in both cell types, the most abundant metabolite is 3beta-hydroxy-5alpha-pregnan-20-one (70%), followed by 5alpha-pregnane-3,20-dione (15%), and 3alpha-hydroxy-5alpha-pregnan-20-one (10%). A small amount is metabolized to 5alpha-pregnane-3alpha/3beta,20alpha-diols and to 3beta,6alpha-dihydroxy-5alpha-pregnan-20-one. The metabolism of progesterone in cultured endometrial cells occurs rapidly; 70% of progesterone is metabolised in 8 h, and 90% by 24 h. We conclude that when in vitro experiments are conducted utilizing progesterone treatment, the rapidity and the extent of the metabolism of this steroid should be taken into account.

A prospective study of transvaginal hydrosonography in the evaluation of abnormal uterine bleeding.

OBJECTIVE: The purpose of this study was to determine whether the intrauterine instillation of saline solution during transvaginal ultrasonographic imaging (hydrosonography) improves the diagnostic accuracy in detecting intrauterine abnormalities determined by direct visualization of the intrauterine cavity with either hysteroscopy or after hysterectomy. STUDY DESIGN: This study was a prospective, blinded study of 39 women referred with the diagnosis of abnormal uterine bleeding after failing medical management. A routine vaginal probe ultrasonographic examination was followed by a blinded transvaginal hydrosonography in patients proceeding to either hysteroscopy or hysterectomy. RESULTS: Twelve of the 39 patients had masses that impinged on the intrauterine cavity at hysteroscopy or hysterectomy. In 4 of the 12 patients with confirmed masses, an intrauterine lesion was detected by hydrosonography that was not seen on routine vaginal probe ultrasonography. In no case was an intrauterine mass detected by the hysteroscopy or after hysterectomy when hydrosonography indicated a normal intrauterine cavity. In 4 cases hydrosonography suggested that masses were present that were not confirmed at direct visualization. Although hydrosonography always recognized when intracavitary pathologic conditions existed in a patient, hydrosonography sometimes underestimated the number of intracavitary lesions present. CONCLUSIONS: Hydrosonography is a simple, minimally invasive, and effective tool to use in the evaluation of patients with abnormal uterine bleeding who have not responded to medical treatment. In no case did hydrosonography fail to indicate when pathologic conditions existed in a given patient, and a normal hydrosonography always indicated a normal intrauterine cavity at hysteroscopy or after hysterectomy. For these reasons hydrosonography is a sensitive tool to triage women with abnormal uterine bleeding to operative or conservative management.

Oral contraceptive pills, gonadotropin-releasing hormone agonists, or use in combination for treatment of hirsutism: a clinical research center study.

The effectiveness of oral contraceptive pills (OCPs), GnRH agonist (GnRH-a), and a combination of OCPs and GnRH-a in the treatment of hirsute women was compared and the impact of these treatments on hormonal and Ca metabolism was investigated. Thirty-three women were prospectively enrolled and randomized into three treatment groups (11 in each group). The serum levels of LH, estradiol, testosterone, free testosterone, androstenedione, and 17-hydroxyprogesterone declined in all 3 treatment groups, whereas the inclusion of GnRH-a treatment tended to promote a more rapid decrease in these hormone levels. Total cholesterol, low density lipoprotein, and high density lipoprotein levels remained unchanged. The assessment of hirsutism by the Ferriman-Gallwey score revealed a similar 25% reduction in score by all three treatment groups by 6 months. In addition, no difference was detected between groups with respect to hair diameters and the vellus index. Clinical assessment of hirsutism at 3 months by the patients revealed that the GnRH-a and the OCPs-plus-GnRH-a groups had better responses than the group on OCPs alone, but by 6 months all three groups were similar. The symptoms of hot flashes and vaginal dryness were greatest in subjects treated with GnRH-a alone. Serum Ca, phosphorus, alkaline phosphatase, osteocalcin, and 2-h fasting and 24-h urinary Ca excretion levels all increased significantly in subjects treated with the GnRH-a alone, whereas a decrement or no changes occurred for these measurement in the other two groups. The estimated Ca balance was unchanged in the OCPs and the OCPs-plus-GnRH-a groups but declined by 90 mg/day from baseline in the GnRH-a-treated women (p < or = 0.001). Bone density significantly decreased in the lumber spine in women treated with GnRH-a alone, with a less marked decline in the femoral neck. In contrast, women receiving OCPs plus GnRH had increased bone density in the lumbar spine. It is concluded that: 1) clinical measures of hirsutism are not different after 6 months of treatment with OCPs alone, GnRH-a alone, or a combination of the two; 2) the decline in gonadotropins and steroid hormones and improvement in clinical response were more rapid and pronounced when GnRH-a treatment was added to OCP administration; and 3) the negative impact of GnRH-a alone on Ca balance and bone loss limits its usefulness as a single agent for long-term therapy of hirsutism.

PIP: The effectiveness of oral contraceptive pills (OCPs), GnRH agonist (GnRH-a), and a combination of OCPs and GnRH-a in the treatment of hirsute women (modified Ferriman-Gallwey score 10), 20-39 years old, was compared and the impact of these treatments on hormonal and Ca metabolism was investigated. 33 women were prospectively enrolled and randomized into 3 treatment groups (11 in each group): 1) OCPs [35 mcg ethinyl estradiol plus 1 mg norethindrone administered cyclically]; 2) GnRH-a, 3.75 mg im, every 4 weeks for 24 weeks; or 3) a combination of both OCPs and GnRH-a at the above doses taken concurrently. All medications were administered for 6 months. The serum levels of LH, estradiol, testosterone, free testosterone, androstenedione, and 17-hydroxyprogesterone declined in all 3 treatment groups. The assessment of hirsutism by the Ferriman-Gallwey score revealed a similar 25% reduction in score by all 3 treatment groups by 6 months. The symptoms of hot flashes and vaginal dryness were greatest in subjects treated with GnRH-a alone. Serum Ca, phosphorus, alkaline phosphatase, osteocalcin, and 2-h fasting and 24-h urinary Ca excretion levels all increased significantly in subjects treated with the GnRH-a alone. In the OCP groups there was significant decline in serum Ca from baseline to 24 weeks (p or = 0.01). There was significant urinary loss of Ca in the GnRH-a group with respect to 24-hour excretion (p or = 0.001). The estimated Ca balance was unchanged in the OCPs and the OCPs-plus-GnRH-a groups, however, it declined by 90 mg/day from baseline in the GnRH-a-treated women from 111 +or- 43 to 21 +or- 58 mg/day (p or = 0.001). Bone density significantly decreased (by 2.7%) in the lumber spine in women treated with GnRH-a alone (p or = 0.02), with a less marked decline in the femoral neck. The negative impact of GnRH-a alone on Ca balance and bone loss limits its usefulness as a single agent for long-term therapy of hirsutism.

Hirsutism and virilization. A systematic approach to benign and potentially serious causes.

A woman with excessive body hair may visit a physician with concerns about fertility and general health as well as appearance. Fortunately, the cause is usually benign, most often polycystic ovarian syndrome. However, life-threatening causes must be quickly ruled out. Hirsutism secondary to endocrinopathies and tumors can typically be recognized by the rapid progression of hair growth; patients should be referred for prompt evaluation and treatment. Benign causes can usually be treated effectively with medical and mechanical methods.

Interaction of heparin with antiphospholipid antibodies (APA) from the sera of women with recurrent pregnancy loss (RPL).

PROBLEM: To determine if heparin may act directly with antiphospholipid antibodies (APA) to prevent recurrent pregnancy loss (RPL). METHOD: Patients were seen at the University of Texas Southwestern Medical Center. Twenty women with a history of RPL (> or = 3 miscarriages), positive APA, and an otherwise normal evaluation were treated with heparin in two daily subcutaneous dosages during a successful pregnancy. APA levels were obtained prior to conception and again at 6, 20, and 30 weeks. RESULTS: Heparin reduced APA binding to cardiolipin and phosphatidylserine in a dose-dependent fashion in ELISA. Heparin affinity chromatography absorbed over 80% of the IgG anticardiolipin antibody in serum from women with high levels of APA. Women treated with increasing dosages of heparin during pregnancy had inversely decreasing levels of IgG anticardiolipin antibody. CONCLUSION: Heparin may act by directly binding APA in vivo, thereby decreasing the adverse effects of APA in women with APA associated RPL.

Infertile couples with a normal hysterosalpingogram. Reproductive outcome and its relationship to clinical and laparoscopic findings.

The purpose of this study was to retrospectively investigate the clinical course of infertile couples following a normal hysterosalpingogram (HSG) to determine the reproductive outcome and assess the diagnostic value of subsequent laparoscopy (LSC). The infertile couples (N = 132) were aged 29 +/- 0.5 SD years, with 3.2 +/- 0.4 years of infertility, and were followed for an average of 17 +/- 1.5 months after the HSG. Twenty-nine percent of patients became pregnant after a normal HSG performed with water-soluble contrast medium. There was a fourfold greater rate of pregnancy during the first three months after a normal HSG than during any other three-month interval up to one year. Thirty-four of the initial 132 patients required laparoscopy because of failure to conceive or suspected pelvic disease based on symptoms or the results of a pelvic examination. Among the 34 patients receiving LSC, pelvic pathology was found in 19 (56%). Corrective surgery and/or a change in therapy occurred in 60% of cases after LSC. There was an increased proportion of abnormal findings with increasing time intervals between HSG and LSC but not with increasing intervals of infertility before HSG. Abnormal uterine bleeding was predictive of abnormalities at LSC, while prior use of oral contraceptives correlated negatively with pelvic pathology. In women in infertile couples who have a normal HSG: (1) LSC should not be performed before three months after a normal HSG because of the potential therapeutic effect of HSG, (2) LSC should be performed after a normal HSG if pregnancy has not occurred by at least one year because of the high incidence of pelvic pathology, and (3) HSG using water-soluble contrast media has a therapeutic effect comparable to that described for oil-soluble contrast media.

The role of antisperm antibodies in infertility.

OBJECTIVE: To discuss the role of antisperm antibodies (Ab) in infertility, including proposed mechanisms of antisperm Ab formation, assays for their detection, and treatments for immune-mediated infertility. DESIGN: Major studies in the published literature and data from The University of Texas Southwestern Medical Center, Division of Reproductive Endocrinology. Reports were reviewed that investigated the development and impact of alloimmunity and autoimmunity to spermatozoa in men and alloimmunity in women and the current methods of treatment for resultant subfertility. RESULTS: The exposure of spermatozoal antigens to the mucosal and systemic immune systems results in development of immunity to a multiplicity of spermatozoal epitopes. The evaluation of studies that examine the role of antisperm Ab in infertility is complicated by the lack of standardization of antisperm Ab assays and the difficulty in identifying those epitopes for antisperm Ab binding that are responsible for subfertility. Sperm-associated antisperm Ab and antisperm Ab in cervical mucus (CM) reduce sperm mobility and may also impair sperm-ovum interaction. The clinical significance of serum antisperm Ab in both men and women, however, is controversial. Current therapy for antisperm Ab associated infertility is empiric and largely unproven. CONCLUSIONS: Antisperm Ab on the sperm surface and in CM are implicated in the pathogenesis of a subset of patients with infertility. Further studies that determine the clinically relevant sites of antisperm Ab interaction will aid in directing the treatment of subfertility mediated by antisperm Ab.

Laparoscopic removal of gonads containing on occult seminoma in a woman with complete androgen resistance.

A 20-year-old woman with complete androgen resistance (AR; 46,XY), underwent prophylactic laparoscopic gonadectomy because of the known increased risk of gonadal malignancy. The procedure was performed with electrocoagulation using a four-puncture technique. Pelvic and abdominal inspection revealed no gonadal or metastatic tumor. The testes and attached structures were retracted medially, and the peritoneum and gonadal vessels were incised after electrocoagulation, thereby removing the gonads from the sidewalls. The gonads were individually placed into a specimen retrieval bag and removed through the suprapubic cannula site. Pathologic examination revealed an occult 8-mm seminoma in the let gonad, as well as bilateral Sertoli cell hamartomas, fallopian tube remnants, and smooth muscle tissue (mullerian remnants) adjacent to the gonads. Postoperatively, tumor markers were normal, and abdominal and pelvic computerized tomographic scans and chest radiographs were negative for possible metastatic disease. This case confirms that laparoscopic removal of testes in women with AR is effective, safe, and quick. Because of normal-appearing gonad may contain an occult tumor, we recommend using a retrieval bag, which may prevent dissemination of potentially malignant cells that may occur with unprotected morcellation.

Expression of transforming growth factor-beta 1 messenger ribonucleic acid and the modulation of deoxyribonucleic acid synthesis by transforming growth factor-beta 1 in human endometrial cells.

OBJECTIVE: The purpose of this study was (1) to evaluate the potential sites of transforming growth factor-beta 1 synthesis in human endometrium by analyzing separated endometrial glands and stromal cells for transforming growth factor-beta 1 messenger ribonucleic acid by Northern analysis of total ribonucleic acid and (2) to investigate the effects of transforming growth factor-beta 1 on deoxyribonucleic acid synthesis in endometrial epithelial and stromal cells in culture. STUDY DESIGN: Endometrial glands and stroma from proliferative and secretory endometrium were isolated after collagenase treatment of endometrial tissue minces and were analyzed for transforming growth factor-beta 1 messenger ribonucleic acid by Northern analysis. We studied the effects of estradiol-17 beta and transforming growth factor-beta 1 on deoxyribonucleic acid synthesis in endometrial epithelium and transforming growth factor-beta 1 on stromal cells in culture by evaluating tritiated thymidine incorporation into trichloroacetic acid-precipitable material. RESULTS: Transforming growth factor-beta 1 messenger ribonucleic acid was detected for Northern analysis in separated endometrial stromal cells in levels that were greatest during the secretory phase and in greater levels than in epithelial cells from that same tissue. Transforming growth factor-beta 1 messenger ribonucleic acid in glandular epithelium in culture was not increased to detectable levels by treatment with transforming growth factor-beta 1. Deoxyribonucleic acid synthesis in endometrial glandular epithelium was inhibited by transforming growth factor-beta 1, but transforming growth factor-beta 1 stimulated deoxyribonucleic acid synthesis in endometrial stromal cells in culture. After treatment for 5 days with estradiol-17 beta (10(-8) mol/L), deoxyribonucleic acid synthesis in endometrial glands in culture was decreased by 40%. Transforming growth factor-beta 1 (1 ng/ml) did not alter this effect of estradiol-17 beta on deoxyribonucleic acid synthesis. CONCLUSIONS: Transforming growth factor-beta 1 acts to decrease deoxyribonucleic acid synthesis in epithelial cells and to increase it in stromal cells isolated from human endometrium and maintained in monolayer culture. Transforming growth factor-beta 1, potentially of stromal cell origin, could participate in the regulation of endometrial cell proliferation and differentiation in vivo.

An evaluation of the effect of gonadotropin-releasing hormone analogs and medroxyprogesterone acetate on uterine leiomyomata volume by magnetic resonance imaging: a prospective, randomized, double blind, placebo-controlled, crossover trial.

The purpose of this study was to prospectively compare the effectiveness of administering medroxyprogesterone acetate (MPA; 20 mg/day) in either the first (protocol A) or last (protocol B) 12-week period along with a 6-month course of the GnRH analog (GnRH-a; leuprolide acetate; 1 mg/day, sc) on uterine and leiomyomata volumes and hormone (estradiol, LH, and FSH) and serum lipid (total cholesterol, triglycerides, and high and low density lipoprotein) levels. Sixteen women were randomized into protocol A or B, received either MPA or placebo along with GnRH-a, respectively, and were then crossed over at 12 weeks to placebo or MPA, respectively, for the final 12-week interval of GnRH-a therapy. Total, myoma, and nonmyoma uterine volumes were determined by magnetic resonance imaging, and serum studies were performed at the beginning of the study and at 12 and 24 weeks. In both protocols, LH and estradiol levels declined by 80-90% (P < 0.03) and 55-72% (P < 0.02) of the baseline, respectively, at 12 weeks and remained at this level at 24 weeks. There were no significant changes in the other laboratory tests between protocols or longitudinally over time. Total uterine volume decreased to 73% of the baseline at 12 weeks in protocol B (P < 0.04), but did not change in protocol A. After crossover at 12 weeks, the total uterine volume of women in protocol A decreased to 74% of the baseline (P < 0.02) at 24 weeks. Between-protocol comparisons demonstrated a greater decline in total uterine volume in protocol B than A at 12 weeks, but after cross-over, MPA addition was associated with a significant increase in total uterine volume (protocol B) compared to a decrease in protocol A at 24 weeks (P < 0.005). In contrast, although myoma volume declined in both protocols, no significant changes in myoma volume were detected within or between groups over the treatment period. Nonmyoma volume changes in protocols A and B roughly paralleled total uterine volume changes, with MPA coadministration showing a correlation with a reversal in the GnRH-a-associated decrease in nonmyomatous tissue volume.(ABSTRACT TRUNCATED AT 400 WORDS)

Culture characteristics of human endometrial glandular epithelium throughout the menstrual cycle: modulation of deoxyribonucleic acid synthesis by 17 beta-estradiol and medroxyprogesterone acetate.

OBJECTIVE: The purpose of this study was to evaluate the culture characteristics and cell proliferation of human endometrial glandular epithelial cells in primary culture on extracellular matrix and to evaluate sex steroid modulation of this process. STUDY DESIGN: We examined the culture characteristics in 53 endometrial gland preparations obtained throughout the menstrual cycle and determined the incorporation of tritiated thymidine in endometrial epithelial cells as a measure of deoxyribonucleic acid synthesis (cell proliferation) in the presence and absence of 17 beta-estradiol and medroxyprogesterone acetate. RESULTS: Good culture maintenance of endometrial epithelial monolayers on extracellular matrix was observed from glands derived from proliferate phase endometrium (21 of 23), whereas poor adherence and culture maintenance was observed in all 30 of specimens from the secretory phase. With 17 beta-estradiol treatment for 22 hours, tritiated thymidine incorporation was not different from control, but medroxyprogesterone acetate treatment for 22 hours was associated with diminished tritiated thymidine incorporation by 36% (p < 0.004). When 17 beta-estradiol (10(-8) mol/L) was included in the incubation medium from the time of initial culture, tritiated thymidine incorporation on day 4 was 40% of control (p < 0.006), and tritiated thymidine was not suppressed further by 22 hours of treatment with medroxyprogesterone acetate (10(-7) mol/L). In spite of cellular spread of endometrial epithelial cells to subconfluence, deoxyribonucleic acid content per well did not increase over time in culture. CONCLUSIONS: We conclude that exposure of endometrial glands to progesterone in vivo inhibits adherence and the establishment of cell monolayers cultured on a thin layer of extracellular matrix. Because 17 beta-estradiol treatment in culture for 22 hours does not increase tritiated thymidine incorporation, it is possible that 17 beta-estradiol exerts its proliferative effect on the endometrial epithelium by an indirect action mediated by stromal cells. The effects of 17 beta-estradiol and medroxyprogesterone acetate on deoxyribonucleic acid synthesis in endometrial epithelial cells may represent an action on a stem cell population of dividing cells or a terminally differentiated cell population that undergoes programmed cell death.

Hormone replacement therapy. Protection against the consequences of menopause.

The time of menopause provides an excellent opportunity for physicians to educate their patients toward preventive care that involves life-style modification and disease screening. It is also the time to consider appropriate hormone replacement therapy. Most postmenopausal women are candidates for such therapy, which has beneficial effects on serum cholesterol levels and other cardiovascular risk factors and protects against osteoporosis, urogenital atrophy, and vasomotor symptoms. A small number of patients have specific risk factors for or contraindications to hormone replacement therapy. In general, however, hormone replacement therapy can be of great benefit to the expanding population of post-menopausal women.

Spermatozoal characteristics from fresh and frozen donor semen and their correlation with fertility outcome after intrauterine insemination.

OBJECTIVE: To determine if conventional sperm parameters, specific characteristics of sperm motion determined by computer-aided semen analysis (CASA), sperm penetration assay (SPA), and/or spontaneous acrosome reaction assay could best predict fertility outcome after intrauterine insemination (IUI) from frozen donor sperm. DESIGN: A retrospective analysis of 2,245 cycles of therapeutic donor IUIs were initially studied; 1,147 cycles that met selection criteria were used in this report. SETTING: A university-based assisted reproductive technology center. PATIENTS, PARTICIPANTS: All IUIs were performed on women with documented patency of at least one fallopian tube, ovulatory cycles, and who did not receive human menopausal gonadotropins. Sperm donors had to be used for at least four different recipients (mean of 15) and at least 14 different cycles of insemination (mean of 41). INTERVENTIONS: None. MAIN OUTCOME MEASURE: Pregnancy. RESULTS: Statistical comparisons were made between donors of different relative fertility by using the Mann-Whitney test, Spearman's rank correlation, and multiple regression analysis. These analyses demonstrated that the most significant predictors of the fertility of frozen-thawed donor sperm were curvilinear velocity, straight line velocity, and the total number of motile sperm inseminated. The number of sperm with spontaneous acrosome reactions negatively correlated with fertility outcome, and SPA provided no predictive value. CONCLUSIONS: Our study supports the hypothesis that the study of sperm motion characteristics using CASA after thawing and washing of cryopreserved sperm is a better predictor of fertile outcome after IUI than analysis of fresh semen.

Gas and steam sterilization of assembled versus disassembled laparoscopic equipment. Microbiologic studies.

Current recommendations specify disassembly of most laparoscopic equipment prior to sterilization. Surgical technicians, however, are often unfamiliar with the proper assembly of laparoscopic instruments, resulting in possible patient injury from equipment malfunction. Therefore, we tested the hypothesis that disassembled laparoscopic equipment is sterilized more thoroughly than assembled equipment. We inoculated internal sites on laparoscopic instruments prior to assembly with bacterial spores resistant to ethylene oxide and steam sterilization. We also manually cleaned the equipment after inoculation prior to steam sterilization of both the assembled and disassembled instruments. The control instruments were stored at room temperature during test sterilization runs. No vegetative bacteria survived ethylene oxide or steam sterilization in assembled equipment, but despite a significant reduction, spore-forming bacteria could be cultured from the assembled equipment. If the instruments were washed before steam sterilization, there was similar spore clearance in the assembled and disassembled instruments, with both groups attaining a high level of disinfection. Our data suggest that disassembly, cleaning and proper assembly of equipment prior to sterilization present no more risk of infection transmission than does disassembly during prevacuum steam sterilization. The method provides properly assembled and functioning equipment at the time of surgery.

Fertility rates in men with normal semen characteristics: spermatozoal testing by induction of the acrosome reaction and Wright-Giemsa staining for subtle abnormal forms.

Little is known about the fertility potential of semen from men who fulfill the accepted criteria of normal semen quality. We examined retrospectively the fertility rates of semen donors with normal semen quality. Donor performance was evaluated in women who had no known infertility factors or had only ovulatory dysfunction corrected by clomiphene. Cycles of therapeutic donor insemination were monitored for ovulation, and pregnancy outcome was followed up. Pregnancy resulted from therapeutic donor insemination with 21 donors and did not result in pregnancy with five (the range of the percentage of cycles in which pregnancy occurred was zero to 31). The comparison of donor semen analysis characteristics with pregnancy rates indicated that the total number of motile spermatozoa per ejaculate correlated with pregnancy rate (P = .04). Cox proportional hazard regression analysis showed that when the value for percentage of abnormal forms was combined with the total number of motile spermatozoa, a significant negative association was found between abnormal forms and conception (P = .04). Experiments comparing semen from high-fertility donors (top quartile of pregnancy rate) and low-fertility donors (lowest quartile) demonstrated a greater proportion of spermatozoa with inducible acrosome reactions in the high-fertility group (P less than .05). A Wright-Giemsa stain used to detect subtle abnormal forms in spermatozoa did not discriminate between the groups. These data suggest that differences in fertility potential exist among donors, even though all may exceed the accepted criteria for normal semen quality. Differences in the ability of spermatozoa to capacitate or undergo the acrosome reaction may be a mechanism for diminished fertility in donors with normal semen characteristics.

Blunt trauma of uterovaginal and vesical prolapse with associated bladder rupture.

A 71-year-old woman had complete uterovaginal and vesical prolapse associated with a large decubitus ulcer on the anterior vaginal wall. She sustained blunt trauma to the perineum after a fall, which resulted in rupture of the prolapsed bladder. The management of this rare problem is discussed.

Immunohistochemical localization of prostaglandin H synthase in the embryo and uterus of the mouse from ovulation through implantation.

Prostaglandins (PGs) in the embryo and endometrium are involved in processes that are important for implantation. Although the presence of PGs (PGE2, PGF2 alpha, PGI2) in decidualized endometrium has been widely reported, less is known about the capacity of the pre-implantation embryo to synthesize PGs. Prostaglandin H (PGH) synthase is necessary for the production of PGs. Using an immunohistochemical method, PGH synthase was localized in the mouse embryo and uterus from superovulation through embryo implantation. No PGH synthase was detected in oocytes at the time of ovulation or in single-cell embryos 1 day post-fertilization (PF). Circular areas of immunostaining became evident in the cytoplasm of blastomeres at the morula stage (day 3 PF). After implantation (day 5 PF), a low level of PGH synthase reactivity was observed in embryonic cells; no PGH synthase was detected in the embryo by day 7 PF. The endometrial glands exhibited maximal immunostaining by day 3 PF, and after implantation, PGH synthase appeared in decidual cells along the border of placentation. Low levels of PGH synthase reactivity were detected in myometrial cells during the period after superovulation through day 7 PF. This is the first demonstration of PGH synthase in the mouse embryo prior to apposition with glandular endometrial epithelium, supporting the hypothesis that the embryo has the potential to produce PGs that may mediate autocrine and/or paracrine responses at the time of nidation.

A simple irrigator-aspirator cannula for laparoscopy: the Stewart system.

An irrigator-aspirator cannula (Stewart system) that may be assembled from common operating room supplies is described for use during operative laparoscopy. The unit consists of a disposable three-way stopcock inserted into a standard 5-mm suction probe. One stopcock port is connected to an irrigation fluid source and pressurized with an inflatable cuff; the other stopcock port is attached to wall suction. Flow rates were determined comparing two types of influx tubing, two different heights of the fluid source, and a range of inflatable cuff pressures. The flow rate of this system with urologic irrigation tubing at pressures of 150 mmHg was comparable to that of a commercially available irrigator-aspirator system. The instrument has been used in 15 routine and emergency operative laparoscopy cases and provides adequate aquadissection, rapid and easy maintenance of a clean operative field, smoke evacuation during laser vaporization, and atraumatic suction traction of tissues.