Responsiveness and maximum secretory capacity of isolated fetal lamb adrenocortical cells throughout the last third of gestation.

Although considerable evidence implicates increased fetal adrenal function as a major factor in the initiation of parturition in the sheep, the mechanism responsible for this increased activity has not yet been determined. We have investigated the development of the function of fetal lamb adrenal cortical cells dispersed in vitro. There was no change in the sensitivity of the cells to synthetic ACTH (ACTH1-24), as demonstrated by the concentraton of ACTH1-24 producing a 50% maximum response in corticoid secretion. This finding does not support the suggestion that there is a qualitative change in fetal adrenal receptor function as term approaches. No stimulation of corticoid was observed after the administration of alpha MSH or PRL in vitro at any gestational age or of alpha MSH in vivo in four fetuses at 125--130 days gestation. Both the maximum output and the 50% maximum response in corticoid secretion of adrenal cells from term fetuses were similar to those of adrenal cells from adult ewes. A significant increase in the maximum output of corticoids per cell in response to ACTH1-24 occurs as early as 107 days gestation and continues steadily to term.

Time-trend analysis of plasma cortisol concentrations in the fetal sheep in relation to parturition.

Using a cortisol RIA carefully validated for specificity in fetal ovine plasma, we studied plasma cortisol time-trend changes in eight chronically catheterized sheep fetuses in the last 22 days of gestation before the spontaneous onset of labor. Best fit exponential type curves were drawn for each individual fetus to define the time before the onset of labor at which fetal plasma cortisol was rising at different rates. Fetal plasma cortisol increased at a rate of 0.5 ng ml-1 day-1 as early as 17.1 days before labor in one fetus, whereas the mean value for all eight fetuses occurred 11.8 +/- 1.0 (SEM) days before labor. The rate of increase doubled to 1.0 ng cortisol ml-1 day-1 as early as 14.4 days before labor in one fetus, whereas the mean value for all eight fetuses occurred 9.3 +/- 0.9 days before labor. These findings suggest that the regulatory mechanisms responsible for the prelabor increase in fetal cortisol production are activated earlier in gestation than we previously thought.

Hypothalamic-pituitary-adrenocortical function after the dexamethasone-promethazine adhesion regimen.

Dexamethasone and promethazine are widely used as an antiadhesion regimen in infertility surgery. A major argument against the routine use of dexamethasone has been the concern that suppression of the hypothalamic-pituitary-adrenal axis may result. To investigate this concern, 25 healthy women undergoing surgery for infertility were administered dexamethasone and promethazine preoperatively, intraoperatively, and postoperatively for 48 hours. Insulin hypoglycemia testing was performed on postoperative day 6. A normal rise in cortisol of at least 7 micrograms/dl was observed in 19 of 21 women. Two women failed to achieve this rise, despite adequate hypoglycemia. Short-term suppression of the hypothalamic-pituitary-adrenal axis may occur after administration of the dexamethasone-promethazine regimen. Patients receiving this regimen should be carefully supervised during the postoperative period.

Dexamethasone suppression test in the management of hyperandrogenized patients.

The authors evaluated 86 hyperandrogenized women with measurements of serum cortisol, dehydroepiandrosterone sulfate, testosterone, and dihydrotestosterone in pooled sera before and after a dexamethasone suppression test. According to strict criteria, 70 (81%) of 86 women demonstrated a major glucocorticoid-suppressible component to their hyperandrogenism. Endocrine therapy was dictated by the results of the dexamethasone suppression test. To assess the predictive value of this test, we evaluated the clinical responses of the subgroup of 55 women who received appropriate endocrine suppression therapy for 6 to 15 months. Of this subgroup, 38 were identified as having adrenal hyperandrogenism; 3 had ovarian hyperandrogenism; and 14 had mixed hyperandrogenism. Of the 55 patients, 49 received dexamethasone alone; 3 received dexamethasone plus Ovral (an oral contraceptive containing the synthetic progestogen norgestrel 0.5 mg and ethinyl estradiol 0.05 mg); and 3, all with ovarian hyperandrogenism, received depomedroxyprogesterone acetate (Depo-Provera). Clinical response was assessed in terms of improvement or no improvement in menstrual status, acne, and hirsutism. Of 29 patients with adrenal or mixed hyperandrogenism associated with abnormal menses, the menstrual status of 17 (59%) improved after dexamethasone therapy. Acne improved in 39 (100%) of 39 subjects. Hirsutism showed moderate to marked improvement in 40 (73%) of 55 women after 6 to 15 months of endocrine suppression therapy. These results indicate the endocrine suppression therapy, particularly with repeated low-dose dexamethasone, prescribed on the basis of a dexamethasone suppression test, is an effective means of managing hyperandrogenism.

Pseudocorpus luteum insufficiency: a study of cytosol progesterone receptors in human endometrium.

This prospective, controlled study of 38 women was designed to compare the number of endometrial cytosol progesterone receptor (PRc) binding sites in infertile women with documented luteal phase defect with those of similar women without luteal phase defect. A 25% reduction in PRc binding sites was observed in women with luteal phase defect (P less than .05). Considerable overlap was noted between luteal phase defect and control groups; thus, no definite range of binding site numbers was predictive of luteal phase defect. The results of this study, therefore, suggest that an end-organ receptor defect may exist in some women with luteal phase abnormalities.

Use of spinal anesthesia in laparoscopy for in vitro fertilization.

Regional anesthesia, in selected cases, is a useful alternative method of providing anesthesia for the retrieval of oocytes when general anesthesia is not indicated. We report our experience in managing anesthesia in four patients in whom we used a subarachnoid block. Ova were obtained in three patients, and two became pregnant and delivered healthy full-term infants. Although the high pregnancy rate was noted with delight, it is clearly a statistical happenstance. It would be interesting, however, to carry out prospective studies to determine whether a relationship between the incidence of pregnancy and anesthetic method might exist.

Correlation of serum estradiol levels and ultrasound monitoring to assess follicular maturation.

Thirty-eight patients underwent 38 cycles of induction of ovulation using stepwise human menopausal gonadotropin and human chorionic gonadotropin (hCG) administration. Ultrasonography was performed on the day of hCG injection. The mean age +/- standard error of the mean (SEM) of the patients was 32.9 +/- 0.8 years, and the duration of infertility ranged from 1 to 14 years (median, 2.8). Ultrasonographic measurements were obtained of the largest diameter and the volume of the dominant follicles as well as all other follicles in both ovaries. Data were analyzed by Student's t-test, regression analysis, and analysis of variance. The mean +/- SEM diameter of dominant follicles was 1.8 +/- 0.1 cm, and the volume of dominant follicles was 3.5 +/- 0.8 cm. The mean +/- SEM serum estradiol (E2) level before hCG administration was 659 +/- 62 pg/ml. Significant correlations were found between preovulatory serum E2 levels and the total follicular volume of both ovaries (r = 0.41, P less than 0.05) and follicular volume of the ovary containing the dominant follicle (r = 0.42, P less than 0.01). No significant correlation was observed between the diameter of the dominant follicle and serum E2 levels. These results suggest that ultrasound findings reflect growth, whereas serum E2 levels primarily detect functional activity of follicles.

Effect of general anesthesia on fertilization and cleavage of human oocytes in vitro.

To determine whether anesthesia affects in vitro fertilization (IVF), the authors examined 3 1/2 years' experience with IVF. Anesthesia length significantly predicted fertilization and cleavage at stage 0 of stepwise multiple logistic regression analysis, but not at the final step. Oocyte grade, retrieval order, and a quadratic term for grade remained significant for fertilization; cleavage, order, the interaction of order and grade, and the quadratic term for grade remained significant. Order correlated with anesthesia (r = 0.675, P less than 0.001). Also inherent in order are CO2 pneumoperitoneum, increased prolactin, decreased gonadotropins, ovarian trauma, and time. First oocytes of equivalent grade from contralateral ovaries were compared. Fertilization rates were equivalent, but significantly fewer mature oocytes from the second ovary cleaved. Anesthetic agents and CO2 appear to adversely affect fertilization and cleavage in vitro.

Follicular fluid concentrations of thiopental and thiamylal during laparoscopy for oocyte retrieval.

Because access into ovarian tissue of drugs used during anesthesia may be potentially harmful to the oocyte and/or follicular structure, we measured concentrations of thiopental (n = 15) and thiamylal (n = 9) in follicular fluid (FF) aspirates of 24 patients who underwent laparoscopic oocyte retrieval. In both groups, measurable amounts of the respective drug were found in all FF aspirates. Within individual patients, plasma concentrations of both drugs declined during the period of sampling between initial and final follicular aspiration. The mean plasma drug concentration was 7.99 +/- 3.97 micrograms/ml in the thiamylal group and 4.13 +/- 0.90 micrograms/ml in the thiopental group. Mean drug concentrations in FF were similar in both groups (thiopental 1.62 +/- 0.61 micrograms/ml; thiamylal 1.67 +/- 0.83 micrograms/ml). The mean FF/plasma concentration ratio during the sampling period was greater in the thiopental group (0.41 +/- 0.19) as compared with the thiamylal group (0.22 +/- 0.14). Several steps in the clinical management of these patients can be taken to reduce exposure of oocytes to drugs used during anesthesia.

Clinical value of prolactin bioassay in euprolactinemic reproductive disorders.

To examine the disparity between clinical presentation and prolactin (PRL) measured by radioimmunoassay (RIA), serum samples from 128 patients with galactorrhea and/or reproductive disorders were evaluated by RIA for immunoassayable PRL (RIA-PRL) and by Nb2 lymphoma cell proliferation assay for bioassayable PRL (bioassay-PRL). One hundred fifteen patients had normal RIA-PRL and 13 patients had high RIA-PRL (greater than 25 ng/ml). Twenty patients had galactorrhea, two of whom had hyperprolactinemia. The reproductive disorders in female patients included infertility, amenorrhea, oligomenorrhea, irregular menstrual cycles, and luteal phase defects. Six oligospermic males also were studied. Twenty-three male and female volunteers with no evidence of reproductive disorders served as controls. Appropriate comparisons showed that PRL bioassay/RIA ratio, an index of agreement between the two assay systems, did not differ for the various patient groups compared with controls. It is concluded that Nb2 lymphoma bioassay does not provide additional diagnostic value to RIA in defining the cause of euprolactinemic galactorrhea and/or reproductive disorders.

Correlation and comparison of Nb2 lymphoma cell bioassay with radioimmunoassay for human prolactin.

Serum samples from groups of men and women with normal and elevated prolactin (PRL) levels were assayed by radioimmunoassay (RIA) and by Nb2 lymphoma cell bioassay (BA) for the presence of PRL. Because the Nb2 lymphoma cells respond to both PRL and growth hormone, BA for PRL activity was carried out before and after neutralization of growth hormone in the serum samples. There were excellent correlations between RIA and BA both in euprolactinemic (r = 0.7587; P less than 0.002) and hyperprolactinemic (r = 0.9558; P less than 0.001) subjects. On an absolute basis, RIA and BA values were similar in the euprolactinemic group (6.6 +/- 0.8 versus 6.2 +/- 1.0), whereas in the hyperprolactinemic group, RIA values were significantly higher than the BA results (89.41 +/- 22.4 versus 62.1 +/- 21.2). The two assay systems also appeared to correlate better in women who were hyperprolactinemic, with obvious menstrual cycle disturbances, than in hyperprolactinemic women without menstrual cycle disturbances.

A combined radioimmunoassay for the measurement of unconjugated and sulfoconjugated pregnenolone, 17 hydroxypregnenolone, dehydroepiandrosterone, and estrone applied to fetal and maternal ovine plasma.

This report describes a radioimmunoassay (RIA) method for the combined measurement of four steroid sulfoconjugates and their four unconjugated counterparts in maternal and fetal ovine plasma: pregnenolone (delta 5P), 17-hydroxypregnenolone (17 delta 5P), dehydroepiandrosterone (DHEA), and estrone (E1). In the procedure a preliminary ether extraction is utilized to isolate the unconjugated steroids followed by salting out, ethyl acetate extraction, and mineral acid solvolysis of the remaining sulfated steroids. The hydrolyzed sulfoconjugates are then separated chromatographically and measured in a manner identical to their unconjugated counterparts. The combined measurement of these eight steroids in single samples of fetal and maternal ovine plasma has not been reported previously and plasma concentrations of these steroids were heretofore unknown. Since no previous data was available for comparison, rigorous specificity evaluation of this RIA system was required prior to its use for physiologic studies and the reporting of concentrations in this species.

Comparison of two rapid cortisol radioimmunoassays for use in the fetal sheep.

Cortisol radioimmunoassays (RIA's) utilizing highly specific antisera combined with a simple ethanol protein precipitation procedure (ETOH-PPT) are widely utilized to measure cortisol in human plasma. This same type of RIA has been assumed specific for measurement of cortisol in the plasma of several different species of experimental animals. In order to test this assumption as applied to fetal ovine plasma, we compared an ETOH-PPT cortisol RIA with another rapid cortisol assay which utilizes a dichloromethane extraction (DM-E) step. The DM-E assay in turn was compared with a chromatographic assay previously shown to be highly specific for measurement of fetal plasma cortisol in this species. Fetal ovine plasma cortisol concentrations determined by the DM-E method were nearly identical to the concentrations obtained by the specific chromatographic RIA procedure. On the other hand, the ETOH-PPT RIA grossly overestimated cortisol concentrations when compared with the DM-E RIA. While the rapid DM-E RIA appears to be suitable for use in fetal ovine plasma, the widely used ETOH-PPT RIA yields spuriously high and unpredictable values and must be considered unreliable. These comparisons demonstrate the need for careful reassessment of steroid assays prior to their application in experimental animals even though they have been previously documented as specific in human plasma.

Validation of a specific radioimmunoassay to measure plasma cortisol in the fetal sheep.

A procedure utilizing co-chromatography and complementary antiserum comparisons was employed to assess the specificity of a cortisol radioimmunoassay for use in the chronically catheterized fetal sheep preparation. Complementary antiserum comparisons is a technique by which two different cortisol antisera, prepared from conjugates attached at opposite ends of the cortisol molecule, were used to determine cortisol concentrations in the same ovine fetal plasma specimens. Results were not significantly different between the two groups, each measured by a different antiserum. This procedure may be used to assess assay specificity in any species in which steroid radioimmunoassays are being adapted.

Pituitary tumors and pregnancy.

This paper contains a review of the natural history of pituitary tumors in nonpregnant and pregnant patients. Data were drawn from previously published reports and from responses to a questionnaire and were analyzed by life-table techniques. Follow-up of 62 nonpregnant patients with untreated pituitary tumors with and without visual field changes revealed a median time to treatment of 15 1/2 years and similar, relatively constant hazard functions. In 91 pregnancies occurring in 73 women with previously untreated pituitary tumors, ovulation had occurred spontaneously in 9 per cent, headache occurred in 23 per cent, and visual disturbances in 25 per cent with 61 per cent remaining asymptomatic. In those patients who developed symptoms, median time to headache was 10 weeks and to visual disturbance, 14 weeks. The hazard functions were relatively constant and similar. The relative risk of developing symptoms is independent of whether or not the first or second pregnancy occurred in the presence of the pituitary tumor. Of the pregnant patients with previously untreated pituitary tumors, 30 per cent required surgery or radiation therapy. Median time to treatment was 19 weeks. None of the 69 pregnant women without pituitary therapy had permanent sequelae. Only four patients who underwent surgery or received radiation treatment developed permanent symptoms and none was serious. In 78 pregnancies occurring in 73 women with previously treated pituitary tumors, headache occurred in 4 per cent and visual disturbances in 5 per cent. Only one patient required therapy. Treatment during pregnancy results in significantly increased prematurity rates but unchanged abortion and perinatal mortality rates. Small pituitary tumors do not constitute a contraindication to either induction of ovulation or pregnancy.

Hematologic characteristics in IUD users.

Increased uterine bleeding has often been cited as a frequent side effect of IUD usage. Previous reports have consistently linked IUD usage to increased menstrual blood loss; however, the role of the IUD as an etiologic agent in the development of iron deficiency with or without anemia is still unclear. This study examines hematologic and menstrual parameters in 52 IUD subjects and 40 control subjects. 90% of subjects with an IUD reported an increase in the amount and duration of menstrual flow and 35% noted intermenstrual bleeding. However, in a group of healthy women, the use of an IUD was not associated with significant or detrimental changes in common hematologic parameters.

The reproductive performance of women before and after metroplasty.

Nineteen women with congenital uterine anomalies underwent metroplasty. Prior to surgical correction of the uterine malformation, 44 of their 45 (98%) pregnancies had ended with a spontaneous abortion, and no woman had a living child. Following metroplasty, only 4 of 18 (22%) pregnancies aborted, and 12 of the 14 (86%) women attempting pregnancy had a living child. There were no unusual intraoperative or postoperative complications. Metroplasty procedures can be performed safely, and are associated with excellent reproductive outcomes.