Screening for hypothyroidism in infertile women.

OBJECTIVE: To determine the frequency of an elevated thyroid-stimulating hormone (TSH) level in 704 patients seeking treatment for infertility. STUDY DESIGN: Sera from 704 women evaluated for infertility were assayed for TSH levels using radioimmunoassay (normal, 0.45-4.09 mIU/mL). All women had at least one year of infertility. Women with a known history of thyroid disease were excluded from the review. RESULTS: Sixteen of 704 patients (2.3%) had elevated TSH levels and were treated with levothyroxine to normalize TSH. None of these women had overt clinical signs or symptoms of hypothyroidism. Of these women, 11 of 16, or 69%, had ovulatory dysfunction, and 7 (64%) later became pregnant while on thyroid replacement. Five of 704 (0.7%) women with infertility who presented without a history of ovulatory dysfunction had elevated TSH levels, and none became pregnant with treatment. CONCLUSION: The prevalence of elevated TSH in 704 women with at least one year of infertility was 2.3%. The majority of women diagnosed with hypothyroidism (11 of 16, or 69%) had ovulatory dysfunction. With treatment for hypothyroidism, successful pregnancies resulted in 7 of 11 (64%) of patients. Women with infertility and ovulatory dysfunction should be screened for hypothyroidism. Screening for hypothyroidism as part of a routine infertility workup in women with normal ovulatory function will yield few abnormal tests.

A randomized, double-blinded trial of preemptive analgesia in laparoscopy.

OBJECTIVE: We tested the hypothesis that local anesthetic administered before skin incision, an example of preemptive analgesia, reduces postoperative pain for women undergoing laparoscopy, as compared with postincisional local anesthetic or placebo. METHODS: Patients undergoing diagnostic laparoscopy were randomized to one of three blinded treatment groups. Treatment group A patients received local infiltration of 0.5% bupivacaine at the surgical site before incision and a saline placebo infiltration before incision closure. Treatment group B received the saline placebo before skin incision and bupivacaine after laparoscopy but before closure of the skin incisions. For treatment group C patients, saline was infiltrated as a placebo before and after laparoscopy. All patients underwent a standardized general anesthetic induction and maintenance. Postoperative pain was evaluated using the modified McGill Present Pain Intensity scale. Pain and supplementary analgesic use was compared among the three treatment groups. RESULTS: A total of 57 patients completed the study for analysis. Age, weight, height, race, indication, and operating time did not vary significantly between the three groups. By 24 hours after surgery, patients in treatment group A reported significantly lower pain scores (McGill Present Pain Intensity Scale: 0.5+/-0.9) than either treatment group B (1.6+/-1.3) or C (1.3+/-1.2). Group A patients also could tolerate a significantly longer time delay to their first analgesic medication than patients who received postincisional bupivacaine or than control patients who received no bupivacaine. CONCLUSION: The preemptive administration of bupivacaine before laparoscopy results in decreased postoperative pain and should allow a more rapid return to normal activities. The popular practice of infiltrating bupivacaine at time of incision closure does not offer any benefit in the control of pain after laparoscopy.

Flow cytometry provides rapid and highly accurate detection of antisperm antibodies.

OBJECTIVE: Immunobead testing (IBT), the current standard for antisperm antibody detection, is time consuming and somewhat subjective. To overcome these limitations and maintain accuracy, we studied an immunofluorescent assay using flow cytometry. DESIGN: A validation study comparing flow cytometry to IBT in the detection of serum antisperm antibodies. SETTING: Flow cytometry laboratory. PATIENTS: Sera from 37 men after vasectomy (test) and sera from 35 fertile men (control). MAIN OUTCOME MEASURE: Test serum with and without immunoglobulin (Ig)G, IgA, and IgM antisperm antibodies as defined by IBT were analyzed by flow cytometry. Sensitivity and specificity of flow cytometry was calculated by defining the IBT as the true result. RESULTS: Flow cytometry identified 22 of 22 sera that were IgG positive (100% sensitivity), 12 of 14 sera that were IgA positive (86% sensitivity), and 4 of 4 sera that were IgM positive (100% sensitivity). Overall, 22 of 37 men were positive for antisperm antibodies. The flow cytometry correctly identified 71 of 71 negative sera (100% specificity). Fluorescence intensity values from the 37 study patients significantly correlated with immunobead binding to the head region and to the entire (more than one) region. CONCLUSIONS: Detection of IgG, IgA, and IgM antisperm antibodies by flow cytometry is highly sensitive and specific. In addition, flow cytometry is able to assess thousands of sperm rapidly and accurately, reducing sampling error and technical time.

Hysteroscopic endometrial ablation using the rollerball electrode.

OBJECTIVE: To assess the efficacy of hysteroscopic endometrial ablation with the rollerball resectoscope. METHODS: From April 1989 to March 1991, 64 women underwent hysteroscopic endometrial ablation using electrosurgery. Telephone follow-up was obtained for 61 patients at least 6 months after the procedure. The majority of patients requested endometrial ablation because of irregular heavy menses, and two patients presented with postmenopausal bleeding. All patients had preoperative endometrial sampling that demonstrated benign endometrial histology. Five women had previous endometrial ablation with the Nd:YAG laser, with persistent bleeding. Eight patients had endometrial polyps and six had submucous fibroids that were resected at the time of hysteroscopic ablation. RESULTS: The average operative time was 31.6 minutes, and an average of 304 mL of distending medium was absorbed during the procedure. Complications included one uterine perforation in a patient who had a previous Nd:YAG ablation, and one epidural anesthetic complication. At follow-up, 18 women (29.5%) reported amenorrhea, 16 (26.2%) reported spotting, 21 (34.4%) reported decreased menstrual flow, four (6.6%) had no change, and two (3.3%) noted increased flow. Subjectively, 49 patients (80.3%) reported a satisfactory outcome. Of the 12 who were not satisfied, seven underwent a repeat ablation with satisfactory results, four chose hysterectomy, and one elected not to have further therapy. CONCLUSION: Endometrial ablation with the rollerball electrode is a safe, excellent method of management in women with excessive menstrual flow and provides a cost-effective, minimally invasive alternative to hysterectomy.

Endometrial ablation to control excessive uterine bleeding.

The use of surgical techniques is described for the management of dysfunctional uterine bleeding by endometrial ablation as alternatives to hysterectomy. Current approaches include the neodymium yttrium aluminium garnet (Nd:YAG) laser and resection by electrosurgery using a ball-end electrode. Of 484 patients treated since 1985, 361 (74%) became amenorrhoeic with only occasional spotting 68 (14%) reported satisfactory results with 55 (12%) reporting an unsatisfactory outcome.