Effects of progesterone on decidual prolactin production by organ cultures of human endometrium.

The effects of progesterone on decidual PRL (dPRL) production by human endometrium were investigated by culturing explants of proliferative (n = 20) and secretory (n = 12) endometrium in Dulbecco's Modified Eagle's Medium supplemented with 10 mM HEPES buffer, 0.1% gelatin (wt/vol), and antibiotics for 6 days and in medium containing 50 ng/ml of progesterone for 6-28 days. The culture medium was replaced daily, and the spent medium was assayed for dPRL. Representative explants were fixed for histological examination after 1, 2, 7, 14, and 28 days in vitro. When explants of endometrium obtained throughout the cycle were cultured in the presence of progesterone, dPRL production was stimulated. Proliferative endometria required 2-5 days in culture before dPRL was measured in the medium. Thereafter, dPRL production increased gradually for the duration of the experiment. Progesterone also induced glandular secretion and stromal differentiation (decidualization) in these tissues. Cultures of proliferative endometrium that did not receive progesterone did not produce detectable amounts of dPRL. When explants of secretory endometrium were cultured in DMEM without exogenous progesterone, dPRL was released into the medium for 2-5 days; however, dPRL production by the cultures that did not receive progesterone declined to undetectable levels, while that by the progesterone-treated cultures increased steadily. Explants of both proliferative and secretory endometrium that were fixed for histological examination after 28 days of culture in the presence of progesterone were composed predominately of large stromal cells that resembled the decidual cells of pregnancy endometrium.

Inhibition of premature labor by terbutaline.

Terbutaline was administered to 50 women, all diagnosed as being in labor prior to 36 weeks' gestation. In 47, uterine activity was initially arrested with intravenous therapy. The infusion rate required to arrest uterine activity ranged from 10 to 80 microgram/min and 21 of the 50 patients (42%) required more than one intravenous infusion. The average prolongation of gestation was 3.7 weeks in those successfully treated. Twenty-four delivered within 48 hours after the terbutaline was discontinued. Treatment failures occurred in 11 (22%). Not a single infant died of the respiratory distress syndrome. Side effects were mild and well tolerated.

Bacterial endocarditis due to Listeria monocytogenes in a pregnant diabetic.

A case of bacterial endocarditis due to Listeria monocytogenes in a pregnant, Class D diabetic patient is presented. The importance of obtaining proper cultures and instituting appropriate antibiotic therapy promptly is emphasized. A favorable outcome was achieved in spite of the combined risk to the fetus of maternal diabetes and listeria endocarditis.

Prospective bacteriologic study of women undergoing hysterectomy.

A prospective bacteriologic study on 67 women undergoing either vaginal or abdominal hysterectomy was done to elucidate causes of debrile morbidity. Forty-one percent of the vaginal and 35% of the abdominal hysterectomy patients met the criteria for febrile morbidity postoperatively. Preoperative and 24-hour postoperative urine samples were obtained by transvaginal bladder tap, and the freshly cut edge of the vaginal cuff was routinely swabbed following removal of the uterus. In addition, the subcutaneous layer was cultured during closure of the abdominal wound. Escherichia coli, Enterococcus, and alpha- and beta-Streptococcus were the predominant organisms recovered. The importance of routine vaginal cuff cultures at the time of surgery for the treatment of postoperative morbidity is discussed.

Sonographic evaluation of cervical length in pregnancy: diagnosis and management of preterm cervical effacement in patients at risk for premature delivery.

Sonographic measurement of cervical length during pregnancy can provide an objective, noninvasive assessment of anatomical shortening associated with premature labor and delivery. One hundred fifty normal women underwent serial sonographic cervical length measurements during uncomplicated pregnancy. The mean cervical length was 52 +/- 12 mm until 34 weeks' gestation, when gradual effacement and cervical length shortening began. Using these data, we managed 88 pregnant women with previous second-trimester pregnancy losses by a combination of cerclage placement for cervical length less than 40 mm and aggressive therapy for premature uterine contractions. The results showed the following: 1) 97% of women with diethylstilbestrol exposure and 80% of women with müllerian abnormalities exhibited cervical length shortening; 2) only 60% of women with a normal uterine cavity showed cervical lengths of less than 40 mm; and 3) all three groups of high-risk patients, independent of cervical length, showed significant premature uterine activity. These observations suggest that sonographic cervical length measurement may be a useful adjunct in the assessment of anatomical cervical integrity and the decision for cerclage placement. Furthermore, the presence of both premature cervical length shortening and preterm uterine activity in 65% of high-risk patients suggests that "cervical incompetence" and premature labor may not be distinct entities, but common symptoms associated with an increased risk of preterm delivery.

Animal surgery: an adjunct to training in obstetrics and gynecology.

A resident in obstetrics and gynecology obtains adequate experience in basic gynecologic surgery during a 3-year training program, but the technical skill acquired in surgery of the bowel, bladder, ureters, and pelvic vessels is limited by the clinical material available. A program is described in which 3 animal models (dog, rabbit, cat) were used to expand the surgical skills of gynecology residents. The increased surgical competence and professional stimulation provided the residents by this program are shown to be both cost- and time-effective.

Allergic reaction to protamine: a late complication of elective vasectomy?

Nucleoprotamines are a normal component of human sperm cells. Antibodies against these protamines develop in 22 to 33 per cent of patients undergoing elective vasectomy. These antibodies, in turn, have been shown to cross-react with medicinal protamines, which are extracted commercially from the testes of salmon and certain other fish. This cross-reactivity against protamines raises the possibility that patients who have undergone elective vasectomy may be at increased risk of an allergic reaction developing if they are later exposed to protamine as a medication. Since medicinal protamines currently enjoy widespread clinical use, this information should be borne in mind by those clinician using protamine and by urologists when counselling patients concerning elective vasectomy for sterilization.

Humoral sperm antibodies: a 10-year follow-up of vas-ligated men.

Fourteen men were studied over a period of 10 years before and after bilateral was ligation. Seven men (50%) continued to have demonstrable circulating sperm-agglutinating antibodies, and one man had persistent sperm-immobilizing antibodies at a low titer of 1:2. None of the 10 ejaculates submitted contained spermatozoa or antibody activity, although two of the seminal plasma specimens immediately immobilized donor spermatozoa upon contact. There were no adverse medical reactions or conditions noted in these men during the course of the study.

Effect of short-duration progesterone treatment on decidual prolactin production by cultures of proliferative human endometrium.

The effect of short-term progesterone (P) treatment in vitro on decidual prolactin (dPRL) production by human endometrium was investigated. Cultures prepared from proliferative endometrium received medium containing P for 3 hours, 1 day, or 3 days. The culture medium was then changed daily for 7 to 14 days, and the amounts of dPRL in the spent medium were measured by radioimmunoassay. The results of these experiments indicated that even a short exposure to elevated concentrations of P is adequate to stimulate dPRL production and that the resulting pattern of dPRL production is determined by the duration of the P treatment.

Testicular biopsy: sperm antibodies.

No circulating sperm-agglutinating or sperm-immobilizing antibodies were demonstrated in oligospermic or azoospermic men up to 14 days following bilateral testicular biopsies. Possible reasons for this lack of antigen-antibody response are discussed.

Early therapy for the incompetent cervix in patients with habitual abortion.

From a thorough evaluation of 66 couples with habitual abortion (HA), 42 were found to have a widened uterine isthmus at hysterosalpingography (HSG) as their only abnormality. First trimester cervical effacement occurred in 90% of these patients. A combination of medical (progesterone [P]), and surgical (McDonald cerclage) begun during the first trimester resulted in successful term pregnancy in 35 of the 36 HA patients (97%) who were treated. The results of this study suggest that (1) functional cervical incompetence may play a major role in HA; (2) a widened uterine isthmus at HSG and first trimester cervical effacement are clinical signs that may define this group of HA; (3) early recognition and therapy for the incompetent cervix can interrupt the progression of events leading to the loss of an otherwise normally developing fetus; and (4) increased perinatal morbidity demands continuous antepartum assessment of fetoplacental integrity in these patients.

Sperm antibodies in infertile couples.

PIP: From October 1967 to August 1970 377 infertile couples were tested for sperm antibodies using both sperm-agglutination and sperm-immobilization techniques. 17.2% of the couples had demonstrable sperm antibodies, 11.4% in the wife and 5.8% in the husband. In 20.4% of the cases of primary infertility sperm antibodies were detected. This was 3 times higher than the rate in secondary infertility. Other factors which contributed to infertility in a recent series of 150 cases were low cervical mucus pH, poor liquefacation of the sperm semen sample, and poor sperm penetration of the cervical mucus.^ieng

Anthropomorphic, hormonal, and psychologic correlates of semen quality in endurance-trained male athletes.

Twenty male marathon athletes were evaluated by hormonal profiles, psychologic testing, anthropomorphic indices, and semen evaluations. Although total testosterone (T) was significantly decreased in 14 of 20 subjects, free testosterone (FT) was within the normal range in the majority. Ninety percent of subjects (18 of 20) had normal semen analyses. Running mileage, body fat, T, and FT values did not correlate with semen quality. Two athletes with severe oligospermia were found to have the lowest values of T and FT and significant differences in psychologic stress scores. From these data we conclude that (1) vigorous endurance training may be associated with significantly decreased T values but not sperm production; (2) a subgroup of severely oligospermic athletes may be characterized by an "anorectic" symptom complex including higher stress, increased body leanness, and significantly decreased T levels; (3) male endocrine evaluation should be interpreted within the context of physical activity; and (4) factors other than T levels need to be evaluated when one is formulating a therapy plan in oligospermic male athletes.

Sterilization failures with bipolar tubal cautery.

From a consecutive series of 105 patients undergoing bipolar tubal sterilization (BPS), ten pregnancies were reported, and a tubal patency rate of 16% was found at hysterosalpingography. There were no significant clinical variables separating the BPS failure patients from those with successful sterilization. Ninety percent of the BPS failures were intrauterine, and 90% occurred within three cycles of BPS. The results of this investigation suggest that (1) BPS tubal occlusion may be associated with an increased failure (pregnancy and tubal patency) rate; (2) the majority of BPS failures are intrauterine gestations; (3) delayed fibrosis, rather than immediate tubal destruction, may be the mechanism of BPS tubal occlusion; (4) for maximum effectiveness, patients undergoing BPS should use alternative contraception for two to three cycles; and (5) surgeons employing BPS require precise training in the application of this modality of female sterilization.

PIP: From a consecutive series of 105 patients undergoing bipolar tubal sterilization (BPS), 10 pregnancies were reported, and a tubal patency rate of 16% was found at hysterosalpingography. There were no significant clinical variables separating BPS failure patients from those successfully sterilized. 90% of the BPS failures were intrauterine, and 90% occurred within 3 cycles of BPS. The results suggest that 1) BPS tubal occlusion may be associated with an increased failure rate (pregnancy and tubal patency); 2) the majority of BPS failures are intrauterine gestations; 3) delayed fibrosis, rather than immediate tubal destruction, may be the mechanism of BPS tubal occlusion; 4) for maximum effectiveness, patients undergoing BPS should use alternative contraception for 2-3 cycles; and 5) surgeons employing BPS need precise training in the application of this modality of female sterilization.

Transcervical tubal cannulation: a comparison of two techniques.

Transcervical tubal cannulation using tactile guidance has a similar rate of successful cannulation compared with that with US guidance (78% versus 73%) but takes less time to perform (2.3 +/- 1.8 minutes versus 8.7 +/- 6.2 minutes, mean +/- SD) and is associated with less pain and bleeding. This appears to be because of the design of the Labotect tubal cannulation set that uses a special speculum and tenaculum to straighten the uterus before insertion of the guide cannula and a less traumatic ball-tipped guide catheter.

Kallmann's syndrome: pregnancy achieved through gamete intrafallopian transfer.

This case report describes the use of GIFT to achieve pregnancy for a man with Kallmann's syndrome who obtained only marginal sperm counts with both the pulsatile GnRH infusion pump and gonadotropin injections. Failure of this man to achieve a pregnancy with hormonal therapy alone and in combination with IUI suggests that assisted reproductive technologies should be considered in male patients with Kallmann's syndrome when suboptimal sperm concentrations are achieved despite exogenous hormonal stimulation.

Allergic reactions to penicillin during in vitro fertilization and intrauterine insemination.

Two cases are reported in which hypersensitivity reactions occurred after intrauterine placement of spermatozoa or embryos. Because the cells were processed and transferred in antibiotic-containing media, these reactions were suspected to be because of penicillin allergy. One patient had no prior penicillin allergy but was found to be penicillin allergic by skin testing. The other had a history of allergy to oral penicillin. In both cases, the allergy symptoms did not occur during subsequent cycles when antibiotics were removed from the transfer media. These reports suggest that in patients known to be penicillin sensitive, penicillin should not be used during transfer of gametes and embryos for assisted reproductive procedures. In addition, the routine use of antibiotics in these procedures should be scientifically evaluated.

Serum immunoglobulin levels in vasectomized men: preliminary report.

Seventy-five men undergoing vasectomy were tested by radial immunodiffusion assay prevasectomy and at 6 weeks and 3, 6, and 12 months postvasectomy for possible changes in serum immunoglobulin (Ig) levels. No significant changes occurred when the results were analyzed on a group basis per time period. However, when each individual's prevasectomy Ig level was considered as his norm, significant changes appeared to occur in serum IgG levels at 6 weeks, 6 months, and 12 months postvasectomy; in serum IgM levels at 6 weeks; but not, to date, in serum IgA levels. Seasonal, environmental, and infectious factors do not seem to be associated with the changes found. No significant seminal Ig changes have been demonstrated. Consideration of these findings and implications for possible immunopathology are briefly discussed.

Comparison of low-technology and high-technology monitoring of clomiphene citrate ovulation induction.

OBJECTIVE: To determine whether newer monitoring techniques, including urinary detection of the LH surge and vaginal ultrasound, offer an advantage over basal body temperature (BBT) charts alone in achieving pregnancy using clomiphene citrate (CC). DESIGN: Randomized clinical trial. SETTING: Infertility patients in an academic research environment. PATIENT(S): Forty-five women undergoing ovulation induction with CC. INTERVENTION(S): The women were assigned randomly to receive either low- or high-technology ovulation monitoring for a total of 3 ovulatory cycles. Both groups were followed with BBT charts. The high-technology group also was monitored with urinary LH kits and vaginal ultrasound. MAIN OUTCOME MEASURE(S): Cycle fecundity rates for each technique were compared statistically with use of life-table analysis. RESULT(S): Forty-five patients were studied during a total of 134 cycles. The overall cycle fecundity rate was 8%, 10% (8 of 81 cycles) for the low-technology monitoring group and 6% (3 of 53 cycles) for the high-technology monitoring group. These rates were not statistically significant when evaluated by Fisher's exact test (P = .53) or when using life-table analysis and a log-rank test (P = .48). CONCLUSION(S): These data suggest that, for initial attempts at ovulation induction with CC in unselected patients, high-technology monitoring of ovulation offers no increase in fecundity over low-technology monitoring.

Luteal support with both estradiol and progesterone after clomiphene citrate stimulation for in vitro fertilization.

OBJECTIVE: To determine if pregnancy rates (PRs) for clomiphene citrate (CC)-stimulated IVF-ET can be increased by luteal support with E2 and P. DESIGN: Prospective randomized crossover clinical study. SETTING: Infertile women volunteers in an academic research environment. PATIENTS: Ninety-three infertile women underwent a total of 143 IVF-ET cycle using CC for ovulation induction. INTERVENTIONS: Each woman received either no luteal support (control group) or luteal support with both oral E2 (2 mg three times daily) starting on the day of retrieval and vaginal P suppositories (100 mg twice daily) starting on the day of ET. MAIN OUTCOME MEASURE: Clinical PR. RESULTS: In 79 of 143 (55%) of the cycles, at least one embryo was transferred. Compared with the control group (n = 35 cycles), the luteal support group (n = 44 cycles) had a significantly higher PR per retrieval (control: 2% versus luteal support: 16%) and were older (control: 33 +/- 4 versus luteal support: 35 +/- 4 years; mean +/- SEM). They did not differ in terms of E2 or P levels, endometrial thickness on the day of hCG, number of follicles > 16 mm in diameter, mature oocytes retrieved, or embryos transferred. CONCLUSIONS: Luteal support with both E2 and P significantly increase the clinical PRs for CC-stimulated IVF-ET.