Dilute versus concentrated vasopressin administration during laparoscopic myomectomy: a randomised controlled trial.

OBJECTIVE: To determine if higher-volume, fixed-dose administration of vasopressin further reduces blood loss at the time of minimally invasive myomectomy. DESIGN: Randomised multicentre clinical trial. SETTING: Tertiary-care academic centres in the USA. POPULATION: Women undergoing conventional laparoscopic or robot-assisted laparoscopic myomectomy. METHODS: All participants received the same 10-unit (U) dose of vasopressin, but were randomly assigned to one of two groups: (i) received 200 ml of diluted vasopressin solution (20 U in 400 ml normal saline), and (ii) received 30 ml of concentrated vasopressin solution (20 U in 60 ml normal saline). MAIN OUTCOME MEASURES: The primary study outcome was estimated blood loss; the study was powered to detect a 100-ml difference. RESULTS: A total of 152 women were randomised; 76 patients in each group. Baseline demographics were similar between groups. The primary outcome of intraoperative blood loss was not significantly different, as measured by three parameters: surgeon estimate (mean estimated blood loss 178 ± 265 ml and 198 ± 232 ml, dilute and concentrated groups respectively, P = 0.65), suction canister-calculated blood loss, or change in haematocrit levels. There were no vasopressin-related adverse events. CONCLUSION: Both dilute and concentrated vasopressin solutions that use the same drug dosing demonstrate comparable safety and tolerability when administered for minimally invasive myomectomy; however, higher volume administration of vasopressin does not reduce blood loss. TWEETABLE ABSTRACT: This randomised trial failed to show benefit of high-volume dilute vasopression.

Pregnancy outcomes in in vitro fertilization cycles with serum estradiol drop prior to human chorionic gonadotropin.

OBJECTIVE: To study the effect of an unpredictable drop in serum estradiol prior to hCG administration on pregnancy outcomes in in vitro fertilization cycles. METHODS: 3653 consecutive IVF cycles from January 1, 1998 to December 31, 2000 at Brigham and Women's Hospital were reviewed, and 65 cycles in which oocyte retrieval (ER) was performed following a drop in serum estradiol (E(2)) not associated with intentional withdrawal of gonadotropins were identified. Daily gonadotropin dose was decreased at some time in 25 of these cycles, while the remaining 40 cycles did not have a reduction in gonadotropin dose. A retrospective case-control study of the respective live birth rates and pregnancy loss rates of patients with unpredictable E(2) drops in the 65 study cycles were compared to 65 age matched controls. RESULTS: Live birth rates (32% vs. 35%, p=0.72) and pregnancy loss rates (28% vs. 30%, p=0.76) were similar for all study and control groups respectively. There were no differences in live birth and pregnancy loss rates in cycles undergoing gonadotropin dose reduction (40% vs. 44%, p=0.78 and 29% vs. 39%, p=0.70) and cycles without gonadotropin dose reduction (28% vs. 30%, p=0.81 and 27% vs. 20%, p=0.72). CONCLUSIONS: In the absence of coasting, a drop in serum estradiol levels during GnRH-agonist downregulated controlled ovarian hyperstimulation for IVF prior to hCG is not associated with a decrease in live birth rates or pregnancy loss rates.

Baboon corpus luteum: autonomous pulsatile progesterone secretion and evidence for an intraluteal oscillator demonstrated by in vitro microretrodialysis.

Pulsatility of serum progesterone (P) is usually ascribed to stimulation of the corpus luteum (CL) by pulsatile release of pituitary LH. We investigated P secretion by the primate CL by performing microretrodialysis on 6 fresh CL obtained at laparotomy from baboons (Papio anubis) with well defined menstrual cycles. Individually microdialyzed for 24-26 h with Dulbecco's Modified Eagle's Medium and Ham's F-12 enriched with HEPES buffer in a perifusion chamber, the retrodialyzed fluid was collected every 10 min and measured for P, estradiol, and 17 alpha-hydroxyprogesterone by specific and sensitive RIAs. The chronodynamics of hormone secretion were analyzed for pulse detection by PC-Pulsar 3.0. All 6 CL (2 each from early, LH +1 to +5; mid, LH +6 to +10; and late luteal phases, LH +11 to +15) demonstrated pulsatile secretion of P in vitro, with distinct and detectable peaks over the 24-26 h studied. The CL secreted 23-27 pulses of P in 24 h in early luteal, 8-20 pulses in midluteal, and 6-19 pulses in late luteal phases. Peak lengths were 23.8 +/- 18.5 to 35.7 +/- 17.1 min. Four CL gave interpeak intervals of 46-55 min, whereas two gave intervals of 136-137 min. Analysis of distribution of pulses against different interpulse intervals in individual CL and all CL together revealed a bell-shaped distribution, with the largest number of pulses seen at an interpulse interval of 21-40 min. Because of the low concentrations of estradiol and 17 alpha-hydroxyprogesterone retrodialyzed, a similar analysis of these data was not possible. Histological examination of the tissue at the termination of the experiment using hematoxylin and eosin and localization of 3 beta-hydroxysteroid dehydrogenase activity indicates that the steroidogenic potential of the tissue is minimally affected, although some morphological changes do occur. Our findings suggest autonomous pulsatile P secretion by the primate CL, indicating local control by and the presence of an intraluteal oscillator or pulse generator for P secretion.

Epidermal growth factor receptors in uteroplacental tissues in term pregnancy before and after the onset of labor.

Using saturation binding assays and Scatchard analyses, we determined the concentrations and binding affinities of epidermal growth factor (EGF) receptors in human myometrium (n = 13) and decidua (n = 10) before and during labor and in placenta (n = 15), chorion (n = 17), and amnion (n = 17) before labor, during labor, and after vaginal delivery. Each tissue was individually assayed. In myometrium and chorion, EGF receptors increased significantly from 5.6 +/- 0.8 and 13.5 +/- 1.7 fmol/mg protein (mean +/- SEM) before labor to 11.1 +/- 2.8 and 26.7 +/- 3.0 fmol/mg protein, respectively, after the onset of labor (P < 0.05). In amnion, EGF receptors increased from 12.8 +/- 2.7 fmol/mg protein before labor to 33.0 +/- 2.3 fmol/mg protein during labor, but decreased significantly (5.9 +/- 1.2 fmol/mg protein) with vaginal delivery (P < 0.05). Decidual and placental concentrations of EGF receptors did not change significantly with labor. The binding affinity of EGF receptors in all tissues studied did not change significantly with labor, as reflected by their respective association and dissociation constants. Up-regulation of EGF receptors in myometrium, chorion, and amnion with spontaneous labor may enhance stimulation of prostanoid production and stimulate uterine activity.

The Amount of MUC5B mucin in cervical mucus peaks at midcycle.

The physical character and amount of mucus secreted by the endocervix changes dramatically during the menstrual cycle to facilitate sperm migration at the time of midcycle ovulation. Mucins are highly glycosylated, high-molecular-weight proteins, which are the major structural components of the protective mucus gel covering all wet-surfaced epithelia, including that of the endocervix. We have previously demonstrated that the endocervical epithelium expresses messenger RNA (mRNA) of three of the large gel-forming mucins, designated MUC5AC, MUC5B, and MUC6, with mRNA of MUC5B predominating. Because mucin protein levels may be regulated posttranscriptionally, measurement of MUC5B protein levels with cycle are needed for correlation to mRNA levels. Measurement of specific mucin gene products within mucus secretions has been limited by availability of specific, well-characterized antibodies and by volume requirements of the isolation protocols for mucins, which include CsCl density centrifugation and fraction isolation. To measure MUC5B protein within the cervical mucus through the hormone cycle, we developed a polyclonal antibody specific to the mucin. The antibody, designated no. 799, is to a synthetic peptide mimicking a 19-amino-acid segment of an intercysteine-rich region within the D4 domain in the 3' region of the MUC5B protein. It recognizes native as well as denatured MUC5B on immunoblot, is preadsorbable with its peptide, and binds to apical secretory vesicles of epithelia expressing MUC5B. We used the MUC5B antibody along with a cervical mucin standard cervical mucin isolate in enzyme-linked immunosorbent assay to determine the relative amount of MUC5B mucin in samples of human cervical mucus taken through the menstrual cycle. We demonstrate a peak of MUC5B mucin in human cervical mucus collected at midcycle, compared with mucus from early or late in the cycle. This peak in MUC5B content coincides with the change in mucus character that occurs at midcycle, suggesting that this large mucin species may be important to sperm transit to the uterus.

Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium.

OBJECTIVES: Basic fibroblast growth factor (bFGF) is an angiogenic growth factor present in human endometrium and myometrium. Women with leiomyoma-related abnormal uterine bleeding have local dysregulation of bFGF and its type 1 receptor (FGF-R). This study was designed to evaluate if adenomyosis expresses bFGF and FGF-R, and if present, to compare bFGF and FGF-R expression in adenomyosis and autologous endometrium. DESIGN: Menopausal uteri containing endometrium and adenomyosis were analyzed using immunohistochemistry with monoclonal antibodies specific for bFGF, FGF-R, and proliferating cell nuclear antigen (PCNA), a marker of cellular proliferation. The expression and intensity of staining for bFGF, FGF-R, and PCNA were evaluated in the glandular epithelium and stroma of adenomyosis and endometrium. RESULTS: Glandular epithelial staining was significantly greater in adenomyosis compared with autologous endometrium for bFGF and FGF-R. Stromal staining for bFGF and PCNA was significantly increased in adenomyosis compared with autologous endometrium. CONCLUSIONS: Upregulation of the bFGF receptor/ligand system and increased cellular proliferation in adenomyosis may contribute to the pathogenesis of abnormal uterine bleeding associated with adenomyosis.

Metformin for the treatment of the polycystic ovary syndrome.

The polycystic ovary syndrome (PCOS) is characterized by increased secretion of LH, insulin and androgens. The main clinical complaints of women with PCOS include: oligo- or amenorrhea, dysfunctional uterine bleeding, hirsutism, obesity and/or anovulatory infertility. The first line treatment for these problems include: 1) estrogen-progestin therapy for oligomenorrhea and dysfunctional uterine bleeding; 2) estrogen-progestin therapy and/or antiandrogens for hirsutism; 3) lifestyle changes such as diet and exercise for obesity and 4) weight loss or clomiphene for anovulatory infertility. However, clinical trials have indicated that metformin is effective second line therapy when first line therapy has not been effective, is not acceptable to the patient or is medically contraindicated. The addition of metformin to the armamentarium of the gynecological endocrinologist represents an important advance.

Computer-assisted reproductive surgery: microsurgery for the digital age.

Although considerable progress has been made in the field of medically assisted reproduction, minimally invasive surgery remains of vital importance in optimizing and preserving fertility, as well as treating infertility. By definition, reproductive surgery employs microsurgical techniques with the objective of restoring natural fertility or enhancing assisted reproductive technologies. The avant-garde minimalist philosophy of this branch of gynecology has made it the natural trailblazer of laparoscopic surgery. Minimally invasive conservative treatment of uterine, tubal, ovarian and peritoneal pathology has long been the gold standard for women of reproductive age and those seeking fertility preservation. Robust surgical outcome data acknowledge clear advantages of advanced laparoscopic surgery over laparotomy. However, this comes at the cost of significant technical challenges. Computer-assisted laparoscopy, also known as robotic surgery, is posed to address the practical limitations of conventional laparoscopic surgery and bridge this technical gap. This enabling technology is a conceptual fusion of the practicality of conventional open surgery and the minimally invasive nature of laparoscopic surgery. With this comes the promise of simplifying complex minimally invasive fertility-sparing procedures so that they can be performed in a safe and reproducible manner by reproductive specialists.

The role of GnRH agonists plus add-back therapy in the treatment of endometriosis.

Agonistic analogs of GnRH have emerged as effective drugs in the treatment of pelvic pain associated with endometriosis. Iatrogenic hypoestrogenism is the fundamental mechanism through which GnRH agonists induce regression of the exquisitely estrogen-dependent endometriotic lesions. The decrease in bone mass consistently observed in women on long-term GnRH agonist treatment has prompted regulatory agencies such as the FDA to approve the use of these drugs for a maximum of six months in the treatment of endometriosis. The very high recurrence rate of pelvic symptomatology after the interruption of medical therapy underlines the importance of strategies aiming at improving the safety of effective long-term treatments. Data has recently become available suggesting the existence of an ideal range of circulating estradiol levels which would maintain a normal bone metabolism and still cause atrophy of endometriotic lesions. Add-back regimens including estrogen preparations have been therefore studied with variable results. In strict analogy, as oral progestins have been shown to improve bone mass in postmenopausal women, regimens employing progestin add-back have been proposed. Our review describes most of the currently published studies employing these and other substances in association with the commonly used GnRH agonists in patients with symptomatic endometriosis.

In vitro microdialysis of the ovine corpus luteum of pregnancy: effects of insulin-like growth factor on progesterone secretion.

The effects of insulin-like growth factor-1 (IGF-1) and cAMP on progesterone (P) secretion by CL of streptozotocin-induced-diabetic pregnant ewes were compared with the effects on normal pregnant animals. Two types of CL were identified in the ovaries removed on Days 126.6 +/- 2 of pregnancy. They were either large, reddish in color, and vascular (type A) or small and pale yellow (type B). Both types were found in diabetic and normal sheep. Each CL was divided in two and perfused in parallel for 14 h in an in vitro microdialysis-perifusion system. One half was used to evaluate basal P secretion and the effect of cAMP. The effect of IGF-1 and cAMP infusion was studied in the other half. During microdialysis, fractions were collected every 15 min, and P was determined by RIA. IGF-1 stimulated secretion of P in the large type A, normal and diabetic sheep CL in discrete pulses. The smaller CL (type B) from normal sheep produced comparatively higher levels of P in discrete pulses in the presence of IGF-1. However, the small CL from diabetic sheep showed no response to IGF-1 or cAMP, and P secretion was lower. Thus, it is probable that the large CL may be the "active" CL producing P and that IGF-1 stimulates pulsatile P secretion in such CL from both normal and diabetic pregnant sheep.

Observations on the use of purified follicle-stimulating hormone in the treatment of luteal phase defects.

We treated 18 infertile patients affected by histologically confirmed luteal phase deficiency with 75 IU of purified follicle-stimulating hormone (FSH) daily during the first 5 days of the cycle. Patients who were not pregnant after the first cycle of treatment underwent a second cycle. In the second cycle the daily doses of purified FSH were doubled if luteal phase deficiency had persisted during the first cycle. During the two cycles before treatment and during treatment, patients underwent an endometrial biopsy 1-3 days before the expected onset of menses. An assessment of progesterone serum concentrations was also performed on days 8, 6 and 4 before the expected onset of menses. Treatment was administered in a total of 33 cycles resulting in 30 ovulatory cycles. Six pregnancies were achieved. Among non-conception ovulatory cycles, 13 presented delayed endometrial dating and 11 normal endometrium. The mean +/- SD of the sum of the three progesterone determinations was 14.7 +/- 1.4 ng/ml in pretreatment cycles, 14.6 +/- 1.6 ng/ml in cycles with normalization of endometrial dating, 14.8 +/- 1.7 ng/ml in cycles with persistence of luteal phase deficiency and 30.4 +/- 3.0 ng/ml in conception cycles (P < 0.05 versus other groups). We conclude that purified FSH, if effective in the treatment of luteal phase deficiency, does not act through an increase in progesterone concentrations.

MUC4 and MUC5B transcripts are the prevalent mucin messenger ribonucleic acids of the human endocervix.

Mucins secreted by the endocervical epithelium protect the surfaces of the reproductive tract epithelium from pathogen penetrance and modulate sperm entry into the uterus. Three large gel-forming mucins, MUCs 5AC, 5B, and 6, are expressed by the endocervical epithelium, as is MUC4, a relatively uncharacterized mucin for which only tandem repeat sequence has been reported. We sought to determine the relative abundance of each of these mucin gene transcripts and to relate their expression to blood progesterone and estradiol. Samples were obtained from six subjects at successive stages in the menstrual cycle. Primers to nontandem repeat sequences of MUCs 4, 5AC, 5B, and 6 were used in semiquantitative reverse transcription-polymerase chain reaction to determine relative abundance of each mucin gene in relation to beta2-microglobulin message control. In order to design primers from a nontandem repeat region of MUC4 so that MUC4 message levels could be quantitated, we obtained approximately 2.7-kilobase nontandem repeat sequence 5' to the tandem repeat sequence of a MUC4 genomic clone. The sequence showed lack of cysteine-rich D-domains and was rich in serine and threonine. Semiquantitative polymerase chain reaction analyses indicated that the principal mucin transcripts of human endocervix are MUC4 and MUC5B, with MUC4 predominant in 15 of 21 samples. When correlated with plasma steroid levels, message levels of both MUC4 and MUC5B were inversely related to progesterone levels.