Decreased pregnancy rate is linked to abnormal uterine peristalsis caused by intramural fibroids.

BACKGROUND: The relationship between fibroids and infertility remains an unsolved question, and management of intramural fibroids is controversial. During the implantation phase, uterine peristalsis is dramatically reduced, which is thought to facilitate embryo implantation. Our aims were to evaluate (i) the occurrence and frequency of uterine peristalsis in infertile women with intramural fibroids and (ii) whether the presence of uterine peristalsis decreases the pregnancy rate. METHODS: Ninety-five infertile patients with uterine fibroids were examined using magnetic resonance imaging (MRI). Inclusion criteria were as follows: (i) presence of intramural fibroids, excluding submucosal type; (ii) no other significant infertility factors (excluding endometriosis); and (iii) regular menstrual cycles, and MRI performed at the time of implantation (luteal phase day 5-9). The frequency of junctional zone movement was evaluated using cine-mode-display MRI. After MRI, patients underwent infertility treatment for up to 4 months, and the pregnancy rate was evaluated prospectively. RESULTS: Fifty-one patients fulfilled the inclusion criteria, and 29 (57%) and 22 (43%) patients were assigned to the low (0 or 1 time/3 min) or high frequency (≥ 2 times/3 min) uterine peristalsis group, respectively. Endometriosis incidence was the same in both groups. Ten out of the 29 patients (34%) in the low-frequency group achieved pregnancy, compared with none of the 22 patients (0%) in the high-frequency group (P< 0.005). Comparing pregnant and non-pregnant cases, 4 of 10 patients (40%) and 9 of 41 patients (22%), respectively, had endometriosis (not significant). CONCLUSIONS: A higher frequency of uterine peristalsis during the mid-luteal phase might be one of the causes of infertility associated with intramural-type fibroids.

Primary pulmonary hypertension in pregnancy.

Primary pulmonary hypertension (PPH) is an uncommon but serious disease. Most patients with PPH are young women and the disease is more serious and eventful in pregnant women. We have experienced a patient with PPH in pregnancy, who was delivered successfully but died suddenly on the 7th day after the delivery. We report the obstetric course and the clinical management for the delivery of the patient with PPH.

Free testosterone and abortion in early pregnancy.

OBJECTIVES: To investigate the relationship between percentage of free testosterone (% free T) and the abortion rate in early pregnancy. METHODS: Progesterone (P), estradiol (E2), total T, sex hormone binding globulin (SHBG), and % free T were measured in sera obtained from 60 pregnant women with normal pregnancy (n = 38) and missed abortion (n = 22) at between 4 and 12 weeks' gestation. RESULTS: P, E2, total T, and SHBG in 22 patients with missed abortion were significantly lower than those in normal group, whereas % free T was significantly higher. There was a significant negative correlation between % free T and SHBG concentration in the normal group, but not in the missed abortion group. All the subjects in whom % free T was 1.30% and higher subsequently miscarried, but no subject with % free T less than 0.70% had a miscarriage. CONCLUSIONS: The lower the % free T, the lower the rate of subsequent abortion. The value of % free T may be able to predict pregnancy outcome in early pregnancy.

Preventive effect of traditional herbal medicine, shosaiko-to, on danazol-induced hepatic damage.

The incidence of the hepatic damage during treatment with danazol (D), indicated by increased serum GOT, GPT and LDH levels, has been shown to be high especially in Japan. Thus, the preventive effect of the traditional herbal medicine, shosaiko-to (SS) was investigated in the administration of D and SS for 16 weeks (D + SS group, N = 9) and the pre-administration of SS for about 4 weeks followed by D and SS for 16 weeks (SS----D + SS group, N = 15). The incidence of serum GOT, GPT and LDH levels of more than normal range during the administration of danazol in the D + SS group was similar to that in the previous study of the administration of D alone. But it was significantly lower in the SS----D + SS group than the D + SS group. The mean levels of serum GOT and GPT were much lower in the SS----D + SS group than the D + SS group throughout the administration of danazol and the difference was significant at 8, 10 and 12 weeks in serum GOT levels and at 4 weeks in serum GPT levels. These results indicate that the pre-administration of SS has great efficacy in the prevention of danazol-induced hepatic damage.

Urinary surge of human luteinizing hormone in infertile women.

An improved semiquantitative immunoassay method allows human luteinizing hormone (hLH) in urine to be detected from 2.5 to 640 mIU/ml has developed. With this method, the hLH surges in every 3 h urine samples while awake were measured in 8 normal and 12 infertile women. The result was that the urinary hLH surge in infertility was insufficient regardless of the high urinary E2 value. This result may play, at least in part, an etiologic role in infertility.

Effect of traditional herbal medicine, shakuyaku-kanzo-to on total and free serum testosterone levels.

The effect of the traditional herbal medicine, Shakuyaku-Kanzo-To (SK), which contains Shakuyaku (S) and Kanzo (K) in equal amounts, on serum testosterone levels was investigated in androgen-sterilized rats. They were given orally SK [0, 22.5, 45, 90 and 180 mg/kg body weight (b.w.)] and S or K (0, 11.25, 22.5, 40 and 90 mg/kg b.w.) in 2 ml of water daily for 2 weeks. Dose-dependent decreases in free serum testosterone (T) levels were found in the administration of SK. Total serum T levels in the administration of SK and S decreased in a dose-dependent manner. K decreased total serum T levels slightly in 11.5 and 22.5 mg/kg doses but showed the dose-dependent increase in much higher doses, the extent of which was much less than that of the decrease in S. Serum estradiol/T (E2/T) ratios were significantly elevated in 45 to 180 mg/kg doses of SK, 90 mg/kg dose of S and 11.25 to 90 mg/kg doses of K. Serum LH and FSH levels were not changed by SK, S and K. Oophorectomized rats were similarly given SK (0, 90 and 180 mg/kg b.w.) and S or K (the half doses of SK). There were no changes in serum T, LH and FSH levels in all given doses. Thus, one of the mechanisms for SK to lower serum T levels is the direct action on the ovary to stimulate the aromatase activity, resulting in decreasing the T secretion and this is the additive effects of S and K.

Effect of paeoniflorin, glycyrrhizin and glycyrrhetic acid on ovarian androgen production.

We have shown that traditional herbal medicine, Shakuyaku-Kanzo-To consisted of Shakuyaku and Kanzo decreased serum testosterone levels in woman and rat. Therefore, paeoniflorin and glycyrrhizin, a main component of Shakuyaku and Kanzo, respectively, and glycyrrhetic acid, a metabolite of glycyrrhizin in vivo, were investigated for the steroid production in the rat ovary on the morning of proestrus. The homogenized tissues of one ovary were incubated in the Dulbecco's modified Eagle medium (pH 7.5) with 100 micrograms/ml of paeoniflorin, glycyrrhetic acid and glycyrrhizin and the medium only (the control) at 37 degrees C for 270 min. After the centrifugation, the concentrations of delta 4-androstenedione, testosterone and estradiol in the supernatants were determined by RIA. The production of the hormones expressed by [concentration x supernatant volume/weight of the ovary] was compared to the control. Paeoniflorin, glycyrrhetic acid and glycyrrhizin decreased significantly the testosterone production but did not change that of delta 4-androstenedione and estradiol. Testosterone/delta 4-androstenedione production ratio was lowered significantly by paeoniflorin, glycyrrhetic acid and glycyrrhizin. Estradiol/testosterone production ratio was increased significantly by glycyrrhetic acid and not changed by paeoniflorin and glycyrrhizin. These results suggest that paeoniflorin, glycyrrhetic acid and glycyrrhizin affect the conversion between delta 4-androstenedione and testosterone to inhibit testosterone synthesis and stimulate the aromatase activity to promote estradiol synthesis by the direct action on the rat proestrous ovary.

[Establishment of an optimum bowel preparation method before gynecologic laparoscopic surgery].

OBJECTIVE: To establish a new method for preoperative bowel preparation that facilitates nursing care and minimizes the patient's discomfort during the clinical pathway of laparoscopic surgery. METHOD: A randomized controlled trial was conducted for the following two preparation methods. Twenty cases were assessed with Method 1 and 18 cases with Method 2. Method 1 (the conventional procedure): oral magnesium citrate is given in the afternoon of the day before surgery, followed by a glycerin enema in the night of the day before surgery and in the morning of the day of surgery. Method 2 (a new procedure): oral magnesium citrate is given in the afternoon of the day before surgery, followed by oral picosulfate in the night before the day of surgery and a bisacodyl suppository in the morning of the day of surgery. To evaluate the two methods we sent questionnaires to the surgeons (blinded to the method used), nurses, and patients. RESULTS: No statistical difference existed between the two methods in their effectiveness as a preoperative treatment. Facilitation of nursing care was significantly better in Method 2, and patients had considerably reduced discomfort with Method 2. DISCUSSION: Patients who received oral picosulfate and a bisacodyl suppository experienced much less discomfort and nursing care was easier when compared with the conventional method of administering a glycerin enema. Since an enema is disliked by young women and an effect comes out with discomfort very shortly after the administration, the degree of discomfort of patients would have become high. Picosulfate is an oral medicine and thereby the effect comes out mildly. That would be the reason why the degree of discomfort of patients was low. In the nursing care, an enema requires time for preparation and administration, while picosulfate is easy to administer, making the nursing care easier. Therefore, Method 2 was chosen as a preoperative bowel treatment for the clinical pathway. Thus, we could establish a new evidence-based method useful for the preoperative bowel preparation in the clinical pathway of laparoscopic surgery.

The participation of pharmacists in a team to introduce a clinical pathway to laparoscopic cystectomy in obstetrics and gynecology.

In the Department of Obstetrics and Gynecology at our hospital, a team of doctors, pharmacists, nurses, and other medical staff was established to prepare a clinical pathway for laparoscopic cystectomy. Various data on clinical charts including the use of drugs were collected from 57 patients by pharmacists and nurses. Based on the analysis of these data, hospitalization period, method of preoperative bowel preparation, time to initiation of food intake, duration of antibiotic administration, and time and content of pharmaceutical instructions to patients of dosage and administration were determined. Criteria for variances requiring the doctor's directions were determined for fever, wound pain, and vomiting. The clinical pathway established here allows of not only the efficient and uniform care of patients, but also the active exchange of opinions among members of the medical team. Moreover, most patients who replied to a questionnaire said that they were at ease during hospitalization because they had received detailed information about the clinical pathway including the use of drugs before surgery. Thus, the participation of pharmacists on a medical team that is introducing a clinical pathway is particularly important because the use of drugs and pharmaceutical care are an important part of good patient care.

[Centrifugal ultrafiltration method for determining the percent of free testosterone in serum].

Serum free testosterone (T) % in the follicular phase of 11 normal women, 11 normal men and 30 pregnant women of 5 to 39 weeks of gestation were determined by the centrifugal ultrafiltration method (CUF), which was performed at the centrifugation of 5 minutes, 1000 g and 37 degrees C, using the Amicon MPS-3 and YMT membrane. These conditions were shown to be appropriate for measuring the free T. There was a significant correlation between the percentage of free T due to the CUF and the equilibrium dialysis method (ED) (r = 0.88, p less than 0.01). Serum free T % and free T concentrations by the CUF method were, respectively, 2.89 +/- 0.09 (SE) % and 166.3 +/- 9.8 pg/ml in normal men, 1.76 +/- 0.09% and 9.4 +/- 0.7 pg/ml in non-pregnant women and 1.14 +/- 0.03%, 22.4 +/- 1.4 pg/ml in pregnant women. Serum free T % in non-pregnant women was significantly lower than in men (p less than 0.001) and higher than in pregnant women (p less than 0.001). In the CUF method the intra-assay CV was 4.9% in women, 6.0% in men and the inter-assay CV was 5.1% in women, 6.2% in men. The CUF method was more simple, rapid and accurate on the determination of the free T in serum than the ED method.

[Effect of danazol on serum prolactin and cortisol levels].

In order to investigate the effect of Danazol (D) on serum prolactin (PRL) and cortisol levels, D was given orally in a daily dose of 400 mg for 2 weeks to 4 women (400 mg group) and 600 mg to 5 women (600 mg group) at one month and more after menopause and oophorectomy. The blood samples were taken through an indwelling catheter into the cubital vein every 20 minutes for 2 hours before and after the administration of D. Serum hormone levels were determined by each specific RIA. In a comparison in each individual of mean hormone levels of 7 serum samples before and after D, (1) serum PRL levels were significantly lowered in 2 women after D of 400 mg (p less than 0.001) and in one woman after D of 600 mg (p less than 0.001), but increased in one woman after D of 600 mg (p less than 0.001), (2) serum cortisol levels were significantly lowered in one woman after D of 400 mg (p less than 0.01) and in 4 women after D of 600 mg (p less than 0.001). When the mean hormone levels in the 400 and 600 mg group (an average of the mean hormone levels of 7 samples in each group) were compared before and after D, (1) the mean serum PRL levels were not significantly affected by D in either group, (2) the mean serum cortisol levels were significantly lowered by D in the 600 mg group, but not in the 400 mg group. The present study demonstrated that serum PRL levels were not consistently affected by D in the condition without ovarian hormones, and serum cortisol levels were lowered after a relatively larger dose of D.

Effects of low-caloric diet in puerperium on prolactin, TSH estradiol and milk secretion.

Ten puerperal women were put on a 1,200 kcal diet per day for 3 days followed by an ordinary 1,800 kcal diet per day for 3 days [Low-Caloric (LC) group]. Fifteen puerperal women were put on an ordinary 1,800 kcal diet per day for 6 days[Ordinary-Caloric (OC) group]. All of the women took breakfast at 7:30 am, blood was drawn at 9:30 am and then the breasts were milked for 2 minutes with an electric breast pump starting on the day of delivery (Day 0) and continuing to Day 5. Four women in the LC and OC groups underwent a thyrotropin-releasing hormone (TRH) stimulation test on Days 1 and 3. Serum prolactin (PRL) and TSH levels in the LC group tended to be much lower than those of the OC group during the test period. Serum PRL and TSH release response to TRH in the OC group were much higher than in the LC group on Days 1 and 3. No significant difference was noted between the OC and LC groups in serum estradiol (E2) and cortisol levels from Day 0 to Day 5. The milk volume in the LC group was significantly less than in the OC group on Day 1. Analysis of milk specimen components revealed little difference between the OC and LC groups. These results suggested that a low-caloric diet may suppress PRL, TSH and milk secretion and may not be useful for breast-feeding.

[Evaluation of the dopaminergic neuroendocrine control of prolactin release during labor in humans].

Eight women with normal term pregnancy were i.v. administered 10 mg Metoclopramide (M), dopamine antagonist, before and during labor. Serum prolactin (PRL), TSH, GH and cortisol levels were measured at -30, 0, 30 and 60 minutes after M administration by specific radioimmunoassay. Basal serum PRL levels before labor, 287.5 +/- 28.6 ng/ml (mean +/- S.E.), significantly declined during labor to 237.0 +/- 22.4 and 216.4 +/- 22.9 ng/ml (p less than 0.05 at both) at 0 and 30 minutes before M administration, respectively. The increments in serum PRL at 30 and 60 minutes after M administration during labor (209.5 +/- 33.9 and 120.0 +/- 27.1 ng/ml, respectively) were not significantly different from those before labor (202.1 +/- 48.7 and 89.9 +/- 30.1 ng/ml, respectively), suggesting that the decline in serum PRL levels during labor is not due to the dopaminergic control. Basal serum TSH and GH levels were not significantly changed by labor and M administration either before or during labor. Serum cortisol levels tended to increase during labor, but these changes were not significant. The data suggest that the PRL releases from the pituitary during labor are not controlled by the dopaminergic mechanism.

[Changes in urinary adrenaline and noradrenaline and plasma cortisol concentrations during labor and delivery].

Urinary adrenaline and noradrenaline concentrations were determined at 38-41 wks of gestation, admission for the onset of labor, 4 hrs after admission and at the cervical dilatation of 8-10 cm, immediately after delivery and on the next morning. Both catecholamine concentrations rose remarkably at the dilatation of 8-10 cm and were found to be still high immediately after delivery. The rise in adrenaline concentrations was much greater than noradrenaline. On the morning after delivery, the adrenaline concentrations fell significantly but noradrenaline remained high. The time-course of urinary catecholamines was similar to that of plasma reported by others. Serum cortisol concentrations rose significantly during labor and delivery but returned to the concentrations of 38-41 wks of gestation by the next morning. The present time course of adrenaline, noradrenaline and cortisol levels in urine or serum during labor, delivery and puerperium suggests that these hypersecretion may be due to emotional, physical and painful stress, respectively, considering literatures.