Ureteral displacement associated with pelvic peritoneal defects and endometriosis.

Ten women had endometriosis and pelvic peritoneal defects of the posterior leaf of the broad ligament, with the consistent finding of medial displacement of the ureter toward the uterosacral ligament. Ureterolysis at the time of surgery revealed the underlying course of the ureter and its proximity to the uterosacral ligament, making it susceptible to surgical injury. It is important for surgeons to be aware of this anatomic alteration associated with these specific peritoneal defects.

Nitric oxide (NO) and interleukin-1beta (IL-1beta) in follicular fluid and their correlation with fertilization and embryo cleavage.

PROBLEM: Using an IVF model, the goal of the study was to investigate the relationship between follicular fluid (ff) NO and IL-1beta levels, as well as their correlation with fertilization of mature oocytes and embryo cleavage rates. METHOD OF STUDY: Follicular fluid was collected from 17 patients at the time of transvaginal oocyte retrieval following controlled ovarian stimulation. Oocytes harvested from these follicles were followed through fertilization and embryo cleavage. The NO metabolites nitrate/nitrite (NO3/NO2) were measured using the Griess reaction as an indirect assessment of NO activity. IL-1beta was measured using a high sensitivity ELISA system (Amersham, UK). The Student's t-test was utilized for unpaired data with the means considered significantly different when P < or = 0.05. RESULTS: Follicular fluid NO3/NO2 levels were significantly lower in follicles containing mature oocytes that fertilized (n = 30; 9.7 +/- 1.0 microM), versus those that did not fertilize (n = 23; 15.4 +/- 2.4 microM; P < 0.05). Follicles that contained oocytes that fertilized and went on to divide beyond the 6 cell stage had significantly lower ff levels of NO3/NO2 (n = 18; 7.5 +/- 0.9 microM), as compared to ff that contained oocytes that did not fertilize or failed to develop beyond the 5 cell stage (n = 35; 14.6 +/- 1.7 microM; P < 0.01). No correlation was found between ff NO3/NO2 levels (n = 28; 13.8 +/- 2.0 microM) and ff IL-1beta levels (n = 28; 0.5 +/- 0.08 pg/mL). An analysis of ff IL-1beta levels in relation to fertilization and embryo cleavage rates revealed no correlation. CONCLUSIONS: Lower ff NO3/NO2 levels at the time of oocyte retrieval are associated with adequate fertilization and embryo cleavage rates. In our IVF model, no correlation was found between ff IL-1beta levels and ff NO3/NO2, fertilization, or embryo cleavage rates.

Ultrasound-guided injection of ectopic pregnancy.

Preliminary studies have demonstrated that salpingocentesis is a safe and effective treatment for unruptured ectopic pregnancies that are visible by transvaginal ultrasound. So far, experience with this technique has been confined to only a few centers around the world. The most promising results of these studies has been the virtual absence of side effects associated with local injection of either methotrexate or hyperosmolar glucose. Large prospective trials comparing efficacy, safety, and overall cost of salpingocentesis against systemic methotrexate will be necessary to better define the role of salpingocentesis in the management of ectopic pregnancy. Patient recruitment for this type of clinical trial would be feasible and acceptable to patients because both treatment arms would avoid surgery.

Gamete intrafallopian transfer. Comparison of epidural vs. general anesthesia.

OBJECTIVE: To investigate the reproductive outcome of laparoscopic gamete intrafallopian transfer (GIFT) performed under epidural vs. general anesthesia. STUDY DESIGN: Retrospective analysis of 110 consecutive laparoscopic GIFT procedures performed under general or epidural anesthesia. All patients underwent controlled ovarian hyperstimulation employing human menopausal gonadotropin and gonadotropin releasing hormone agonist, given either in the midluteal or early follicular phase. Data were retrieved concerning age, diagnosis, estradiol levels and maximum follicular diameter at the time of human chorionic gonadotropin injection, percentage of mature oocytes retrieved and number of oocytes transferred. These variables were compared using the independent means t test. Pregnancy rates and outcome between the general and epidural anesthesia groups were compared with the chi 2 test. RESULTS: Of the 110 procedures, 84 were performed under general anesthesia, whereas 22 were done using epidural anesthesia. Four procedures started with epidural anesthesia and were converted to general anesthesia because of upper abdominal discomfort. The success rate of epidural anesthesia, therefore, was 85% (22/26). There were no significant differences in the confounding variables between the general and epidural anesthesia groups. However, patients receiving epidural anesthesia had a significantly higher pregnancy rate, 59.1%, and a live birth rate of 40.9% as compared to 31.0% and 21.4%, respectively, for the general anesthesia group. CONCLUSION: Laparoscopic GIFT can be performed safely under epidural anesthesia. Because of the higher pregnancy and live birth rates, epidural is the anesthetic of choice for GIFT. However, a prospective, randomized study is needed to confirm the above observation.

Gamete intrafallopian transfer. Does smoking play a role?

OBJECTIVE: To investigate the effects of active and passive cigarette smoking on the outcome of gamete intrafallopian transfer (GIFT). STUDY DESIGN: A retrospective analysis of 98 patients who had laparoscopic GIFT was performed. Data were retrieved concerning age, diagnosis, amount of human menopausal gonadotropins (hMG) used for controlled ovarian hyperstimulation (COH), and number of oocytes retrieved and transferred. A detailed smoking history, if any, of patients and household members was obtained from chart review and an additional telephone survey. Pregnancy rates and outcome in active and passive smokers were compared to those of non-smokers. RESULTS: No difference was observed among active smokers (n = 19), passive smokers (n = 13) or nonsmokers (n = 66) regarding diagnosis, age percentage of mature oocytes retrieved or number of oocytes transferred during GIFT. However, active, but nor passive, smokers consumed a higher amount of hMG for COH as compared to nonsmokers. More important, pregnancy and live birth rates for active smokers (15.8% and 10.5%, respectively) were significantly lower than those for passive smokers (46.2% and 23.1%) and nonsmokers (45.5% and 33.3%). No difference, however, was noted between the latter two groups. CONCLUSION: Our results show that active, but not passive, smoking has a negative impact on GIFT pregnancy rates and outcomes. It is important to counsel patients against cigarette smoking prior to GIFT, but whether smoking cessation will improve the outcome needs further study.

Human corpus luteum function in normal and abnormal pregnancy states.

Investigators have shed new light on the precise manner by which human chorionic gonadotropin rescues and regulates corpus luteum function in normal and abnormal pregnancy states. It has also been shown using ultrasound that both an undetectable or shrinking corpus luteum volume are predictive of poor pregnancy outcomes. Ultrasound and transvaginal color Doppler sonographic findings do not, however, correlate with either progesterone or 17-hydroxyprogesterone serum levels and, therefore, these imaging modalities alone are not reflective of corpus luteum function in early pregnancy.

Recurrent miscarriage: causes and management.

The workup is a challenge, as genetic, anatomic, endocrine, or immunologic factors may be involved. Although 60% of patients will have a successful pregnancy even without intervention, correctable causes should be sought.

Atrial natriuretic peptide, oestradiol and progesterone in women undergoing spontaneous and gonadotrophin-stimulated ovulatory cycles.

The objective of this study was to examine the relationship between the concentrations of oestradiol and progesterone on the one hand and atrial natriuretic peptide (ANP) concentrations on the other, during the follicular and luteal phases of spontaneous and gonadotrophin-stimulated ovulatory menstrual cycles. A total of 27 ovulatory women undergoing either a spontaneous (n = 9) or a gonadotrophin-stimulated (n = 18) cycle were selected for inclusion in this study. In comparison with spontaneous cycles, gonadotrophin-stimulated cycles had increased peak follicular oestradiol (mean +/- SE; 937 +/- 150 versus 195 +/- 18 pg/ml; P < 0.05) and midluteal progesterone (mean +/- SE; 44.0 +/- 7.4 versus 14.1 +/- 2.4 ng/ml; P < 0.05) concentrations. There were no differences in the circulating ANP concentrations between the follicular and luteal phases of the menstrual cycle. Despite the increased oestradiol and progesterone concentrations following gonadotrophin stimulation, no difference in ANP concentrations was seen between stimulated and spontaneous cycles. There was no correlation between circulating concentrations of oestradiol, progesterone (at physiological and supraphysiological concentrations) and ANP throughout the menstrual cycle.

Human peritoneal macrophage and T lymphocyte populations in mild and severe endometriosis.

PROBLEM: The aim of this study was to characterize the phenotype of peritoneal lymphocyte and macrophage populations in mild versus severe endometriosis. METHOD: Using dual staining, antigen expression on peritoneal leukocytes from 24 women with endometriosis and 21 control patients was analyzed by flow cytometry. RESULTS: All groups had CD4:CD8 ratios of 0.6, with subpopulations of CD8+ cells expressing cytotoxic marker S6F1. Mild and severe endometriosis patients had increased CD3/DR+ cells, relative to controls. Two populations of macrophages were identified by size in all groups. Mild endometriosis patients had increased percentages of small macrophages expressing CD14 and HLA DQ, compared to controls and severe disease patients. In severe disease patients, antigen expression on small macrophages did not differ from controls, but decreased percentages of large macrophages expressed CD14 relative to controls and mild disease patients. CONCLUSION: All women with endometriosis exhibit activated peritoneal lymphocytes, whereas macrophage expression of CD14 is differentially expressed as a function of disease stage. Alterations in the functional capacity of these cells may contribute to the pathophysiology of this disease.

Assisted fertility using electroejaculation in men with spinal cord injury--a review of literature.

OBJECTIVE: To review the effectiveness of rectal probe electroejaculation in terms of pregnancy in treatment of anejaculatory males due to spinal cord injury. The characteristics of electroejaculates also are examined. DATA IDENTIFICATION: All English language studies reporting pregnancies as a result of electroejaculation from men with spinal cord injury and related publications on electroejaculation were identified through MEDLINE search and manual scanning of recent relevant journals. RESULTS: Electroejaculation has become an accepted mode of semen procurement in anejaculatory individuals, with a success rate of approximately 60% to 90% varying among different centers. In general these electroejaculates exhibit high sperm counts but low motility and poor sperm function. Retrograde ejaculation is also common. Pregnancies using electroejaculates have been documented since 1975 in the form of case reports and small series. Assisted reproductive technology recently has been used in conjunction with electroejaculation. Although results are encouraging, pregnancy rates, however, cannot be accurately estimated because of the lack of large series in the literature. CONCLUSIONS: An increasing number of spinal cord-injured patients desiring fertility can achieve pregnancy through combined use of electroejaculation and assisted reproductive techniques. Larger series are needed to establish an accurate pregnancy rate. Elucidation by further studies on etiology of sperm dysfunction of these individuals may improve their prognosis.

Sciatic nerve endometriosis treated with a gonadotropin releasing hormone agonist. A case report.

Sciatic nerve endometriosis was previously treated primarily with surgery. Most commonly hysterectomy and bilateral salpingo-oophorectomy have been used; however, two reports also describe successful conservative surgery with resection of the endometriosis from the sciatic nerve. Only one case of sciatic nerve endometriosis has been reported to have responded to medical management. This report details the rapid and complete resolution of sciatica secondary to endometriosis after medical treatment with the gonadotropin releasing hormone analog leuprolide acetate for depot suspension.

A prospective series of unruptured ectopic pregnancies treated by tubal injection with hyperosmolar glucose.

OBJECTIVE: To evaluate the safety and efficacy of hyperosmolar glucose injection in select unruptured tubal gestations with hCG levels less than 2500 mIU/mL. METHODS: In this prospective series, 16 patients with an hCG titer less than 2500 mIU/mL and an unruptured ectopic pregnancy were treated by tubal injection with hyperosmolar (50%) glucose. Hyperosmolar glucose was injected transabdominally into the antimesenteric site of the tubal pregnancy, using a 20-gauge spinal needle. The main outcome measures evaluated were duration of surgery, success rate, time to resolution, and follow-up tubal patency rates. RESULTS: Ninety-four percent (15) of the subjects were treated successfully with a median time to resolution of 24 days (range 5-78). The one treatment failure required methotrexate because of rising hCG titers and worsening pain 4 days after the patient was treated with hyperosmolar glucose. The mean (+/- standard error) duration of surgery was 45 +/- 6 minutes. So far, all ten patients undergoing postoperative hysterosalpingograms have demonstrated tubal patency in the treated tube. CONCLUSION: Laparoscopic injection with hyperosmolar glucose is an effective, systemically nontoxic alternative treatment for select unruptured ectopic pregnancies (hCG less than 2500 mIU/mL) that achieves tubal patency rates comparable to other conservative medical and surgical treatments.

Laparoscopic treatment of ectopic pregnancy. Residents' learning experience.

Although operative laparoscopy is a safe and effective method of treating ectopic pregnancy, its widespread acceptance requires appropriate operator training and experience. This retrospective study correlated operative results with experience of the resident performing surgery. Thirteen postgraduate year 3 and 4 gynecology residents treated 60 ectopic pregnancies by laparoscopy. There were four complications: two cases of atelectasis and two of persistent human chorionic gonadotropin titers. There were no blood transfusions. We found that the duration of surgery decreased as operator experience increased, and residents who had experience with five or more cases required a mean operative time of 74 minutes. We conclude from our results that the minimal amount of supervised training necessary for gynecology residents to safety and expeditiously treat ectopic pregnancy laparoscopically is five cases. Furthermore, the minimal morbidity in this study supports our continued recommendation that each resident have prior training experience of at least 10 laparoscopic sterilizations before attempting his or her first case of ectopic pregnancy.

Hydrogynecography: a new technique enables vaginal sonography to visualize pelvic adhesions and other pelvic structures.

Vaginal ultrasonography, done after the transcervical injection of isotonic saline into the cul-de-sac, is a new technique we named hydrogynecography. This was prospectively used in patients suffering from infertility and pelvic pain. In 84% of patients we were able to identify pelvic adhesions confirmed by laparoscopy. In 16% the procedure provided false-negative results.

Treatment of cornual obstruction by transvaginal cannulation without hysteroscopy or fluoroscopy.

A new method for relief of cornual obstruction performed totally in the office is presented. We used the Jansen-Anderson catheter with 0.007-cm guide-wire for relief of the obstruction. Ultrasonography is used for demonstrating the position of the catheter and for tubal patency. Subsequent HSG is used for confirmation of tubal patency.

Laparoscopic removal of mullerian remnants in a woman with congenital absence of the vagina.

Most women with mullerian agenesis do not have cyclic pain and therefore do not require surgery. When surgery is necessary, we recommend a laparoscopic approach as described in this report because of the decreased morbidity and cost compared with laparotomy. Results from this case suggest that outpatient laparoscopic treatment of this condition is safe and effective. Regardless of the surgical approach used, a preoperative IVP is essential to limit the risk of damage to the urinary tract.

Histology of midluteal corpus luteum and endometrium from clomiphene citrate-induced cycles.

OBJECTIVE: To determine the histologic development of midluteal corpus luteum (CL) and endometrium in normal fertile women after induction of ovulation with clomiphene citrate (CC). DESIGN, PATIENTS, INTERVENTIONS: Twelve normally cycling women planning to undergo an elective tubal ligation were treated with 50 to 150 mg of CC daily on days 5 through 9 of the cycle. Luteectomy and endometrial biopsy were performed simultaneously 7 days after the urinary luteinizing hormone surge. RESULTS: Because polyovulation occurred in 10 of the 12 women, 22 CL and 12 endometrial biopsies were studied. Ten women had luteal and endometrial histology that were within 2 days of the ovulation to biopsy interval. The 2 remaining women had endometrial histology that lagged 3 days behind the chronological postovulatory date. In these women, out-of-phase endometrium occurred despite polyovulatory cycles in which two and three histologically normal CL lutea were present and associated with elevated progesterone concentrations. CONCLUSIONS: In CC-induced ovulatory cycles: (1) midluteal CL histology is normal and (2) apparently out-of-phase preimplantation endometrium occurs in midluteal phase.

Laparoscopic treatment of painful perihepatic adhesions in Fitz-Hugh-Curtis syndrome.

This report illustrates a case of Fitz-Hugh-Curtis syndrome associated with pelvic inflammatory disease in which the clinical symptom of right upper quadrant pain was severe and persistent despite appropriate antibiotic therapy. Because of the atypical course, an extensive work-up was performed to rule out other possible etiologies for the pain. In this context, a laparoscopy was performed and identified dense adhesions between the liver and the anterior abdominal wall. These adhesions were safely and successfully lysed using a KTP/532 laser through a second puncture site. After surgery the pain was completely resolved, with no further recurrence after 6 months of follow-up.

Effect of clomiphene citrate on the synthesis and release of the human beta-lactoglobulin homologue, pregnancy associated endometrial alpha 2-globulin, by the uterine endometrium.

As an extension to a previous study to examine the effects of clomiphene citrate (CC) on human chorionic gonadotrophin/luteinizing hormone (LH) receptors in human corpora lutea, we sought to determine the effect of CC on the synthesis of the beta-lactoglobulin homologue, pregnancy associated endometrial alpha 2-globulin (alpha 2-PEG) by the luteal phase human endometrium. Seventeen normally-cycling women aged 25.9 +/- 2.1 years (mean +/- SE), undergoing elective tubal ligation, were divided into four groups consisting of controls (n = 2) and three treatment groups. Each of the treatment groups (n = 5/group) was treated with either 50 mg (group 1), 100 mg (group 2) or 150 mg (group 3) of CC daily on days 5 to 9 of the cycle. Portions of endometrial tissue were obtained by curettage 7 to 9 days following the urinary LH surge and were either fixed for histological analyses or cultured in vitro in the presence of [35S]methionine. Tissue media (TCM) that were analysed by two-dimensional gel electrophoresis followed by fluorography indicated that the synthesis of alpha 2-PEG was most markedly reduced in groups 2 and 3. Densitometric scans of TCM Western blots and radioimmunoassay (RIA) of TCM showed that the overall synthesis of alpha 2-PEG decreased from 5.8 +/- 1.9 arbitrary units (AU) and 371.2 +/- 239.3 ng/ml in group 1 to 3.1 +/- 0.8 AU and 69.4 +/- 24.9 ng/ml, and 2.7 +/- 1.1 AU and 52.4 +/- 19.8 ng/ml in groups 2 and 3 respectively. On cycle days 20-22, control values were 5.8 AU and 498.1 ng/ml respectively.(ABSTRACT TRUNCATED AT 250 WORDS)