45,X/46,XX mosaicism in patients with idiopathic premature ovarian failure.

OBJECTIVE: To determine whether low-level 45,X/46,XX mosaicism may be present in some women with premature ovarian failure (POF). DESIGN: Slide preparations were made from lymphocyte cultures stimulated with phytohemagglutinin, and fluorescence in situ hybridization (FISH) was then performed using a biotin-labeled X-chromosome probe. SETTING: Cytogenetics laboratory. PATIENT(S): Fifteen women with idiopathic POF, 20 age-matched controls, and an additional 10 older control women with normal reproductive histories. INTERVENTION(S): Blood samples were collected. MAIN OUTCOME MEASURE(S): The number of X chromosomes present in each cell. RESULT(S): In patients with POF, the percentage of cells with a single X chromosome (mean, 5.50) was significantly greater than in the controls of similar age (mean, 2.42). For control subjects, there appeared to be a linear correlation between the number of cells with a single X chromosome and age. CONCLUSION(S): Some cases of POF may be attributable to low-level 45,X/46,XX mosaicism, which can be detected using FISH. In the lymphocytes from normal women, the rate of accumulation of cells with a single X chromosome was approximately 700 per 10(6) cells per year.

Identification of a meiotically expressed carbohydrate antigen in ovarian carcinoma: II. Association with proteins in tumors and peritoneal fluid.

A monoclonal antibody developed against a meiotically expressed porcine oocyte carbohydrate antigen has been shown to recognize an antigen in ovarian surface epithelial cells (OSE) of numerous mammalian species, including the non-human primate and the human (1). Although most of the ovarian surface epithelial cells are lost during aging in the human, a few cells may remain in ovarian crypts. Because the majority of ovarian carcinomas are thought to be derived from the OSE cells in aging women the PS1 antibody has been used to evaluate ovarian tumors. The secretory origin of this carbohydrate antigen in meiotic cells prompted further analyses of peritoneal fluid collected from gynecological surgery patients including those diagnosed with ovarian cancer. The present study demonstrates that ovarian tumor proteins separated on SDS PAGE include an antigen having a heterogeneous molecular weight (> 100 kDa) typical of glycosylated proteins. Additional studies show that peritoneal fluid from 19 patients not having cancer contain PS1 associated glycoproteins. However, of 14 cancer patients, only one had detectable levels of the carbohydrate antigen. These observations suggest that either the secretion of this glycoprotein is altered in ovarian carcinoma or that glycosidases or other proteolytic enzymes are involved in the degradation of these glycoproteins.

Treating endometriosis pain: a multidisciplinary approach.

Endometriosis is a painful recurring disease for which there are several treatments but little or no clinical guides for optimal application. In order to more appropriately treat these patients, we need to take a more holistic long-term approach to disease management.

Use of medroxyprogesterone acetate in the prevention of postoperative adhesions.

OBJECTIVES: To evaluate the efficacy of a commonly used progestogen, medroxyprogesterone acetate (MPA), in the prevention of postoperative adhesion formation. DESIGN: A double-blind, controlled study evaluated the efficacy of MPA to reduce postoperative adhesion formation and compared it with other adjuvants and controls in a rat model. SETTING: Animal Care Facility of an academic research setting. SUBJECTS: Seventy-five Sprague-Dawley female rats randomly divided into five groups. INTERVENTIONS: Three weeks before surgery, the animals from each group were administered an IM injection of one of the following regimens: [1] 15 mg MPA; [2] both 15 mg MPA and 0.75 mg leuprolide acetate (LA); [3] 0.75 LA; or [4] and [5] comparable volumes of sterile saline. A standardized surgical trauma was inflicted in all animals. Before abdominal closure, 2 mL of Ringer's Lactate was instilled in the abdominal cavity of all groups except group 5 (controls). Three weeks after surgery, the rats were killed and the adhesions were scored on a scale of 0 to 3 according to their size, thickness, and vascularity. MAIN OUTCOME MEASURE: Postoperative adhesions. RESULTS: The preoperative administration of MPA resulted in the least number and the least severe adhesions. The combination of LA and MPA did not reduce postoperative adhesion formation. Both Ringer's Lactate and LA reduced postoperative adhesions but not to the same extent as MPA. CONCLUSION: The preoperative administration of MPA in our laboratory animal model results in the most significant reduction of postoperative adhesion formation. This action of MPA may be mediated by the induction of both a progestational and a hypoestrogenemic milieu. However, the ultimate role of MPA in a clinical situation requires further investigation.

Superovulation with human menopausal gonadotropins is associated with endometrial gland-stroma dyssynchrony.

OBJECTIVE: To investigate the prevalence of endometrial inadequacy in endometrial biopsies from women undergoing superovulation with hMG and to correlate these findings with the hormonal milieu. DESIGN: Controlled, retrospective analysis. SETTING: University-based, tertiary referral, outpatient infertility clinic. SUBJECTS: Endometrial biopsies were performed during the late luteal phase in 89 women undergoing hMG superovulation combined with IUI. Results were compared with the initial biopsies obtained as part of their routine infertility evaluation. MAIN OUTCOME MEASURES: Biopsies were dated by two different observers using standard dating criteria. Serum samples obtained during the midluteal phase were assayed in duplicate for E2 and P levels using commercially available RIAs. RESULTS: Fifty-seven percent of the endometrial biopsies showed differences in the dating of the glandular epithelium that differed by > 2 days when compared with the stroma. In contrast, only 13% of endometrial biopsies obtained during a nonstimulated cycle showed gland-stroma dyssynchrony. When cycles associated with gland-stroma dyssynchrony were compared with cycles associated with coordinated development of the glands and stroma, no significant differences were observed in E2 level on the day of hCG administration, midluteal serum P, midluteal E2 level, or P:E2 ratios. CONCLUSIONS: This study demonstrates that when endometrial biopsies are obtained during the late luteal phase in patients undergoing ovarian hyperstimulation there is a significant dyssynchrony in the maturation of the glandular epithelium and the stroma. This may reflect the degree of responsiveness of an individual woman's endometrium rather than a result of the hormonal milieu.

A randomized and longitudinal study of human menopausal gonadotropin with intrauterine insemination in the treatment of infertility.

OBJECTIVE: To study in a randomized and longitudinal manner the efficacy of human menopausal gonadotropin (hMG) superovulation combined with intrauterine insemination (IUI) versus IUI alone in the treatment of various causes of infertility in the presence of normal ovulation. METHODS: An initially randomized and subsequently longitudinal study of infertile couples was performed at a university-based clinical research center. One hundred nineteen couples with longstanding infertility (average duration 3.7 years) associated with male factor infertility, unexplained infertility, and/or endometriosis were enrolled. All patients were randomized in the initial cycle to treatment with either hMG/IUI or urine LH-timed IUI alone. They were then followed longitudinally as they alternated subsequent cycles between the two modalities. Outcome indices measured were cycle fecundity, pregnancy outcome, and cumulative pregnancy rates evaluated by life-table analysis. RESULTS: Human menopausal gonadotropin/IUI therapy was consistently more effective than IUI alone in the treatment of endometriosis, male factor infertility, and unexplained infertility, with cycle fecundities ranging from 7.1-19.0% versus 0-6.7%, respectively, during the first seven cycles. CONCLUSION: Human menopausal gonadotropin/IUI is a more effective therapy for enhancing fertility than is IUI alone for the treatment of endometriosis, male factor infertility, and unexplained infertility.

Conservative management of interstitial pregnancy.

Earlier detection of ectopic pregnancies allows the patient and physician the option of conservative management. Conservative surgical management of ampullary ectopic pregnancies has been well described. Traditional management of interstitial or cornual gestation has been by salpingectomy with or without cornual resection or by hysterectomy. In this paper we present a case report of alternative, less radical surgical management and review the literature on conservative surgical and medical management of interstitial pregnancies.

Histologic features associated with hormonal responsiveness of ectopic endometrium.

OBJECTIVE: To correlate histologic parameters of endometriosis with hormonal responsiveness. DESIGN: Seven hundred sixty-eight unselected endometriotic implants and the corresponding intrauterine endometrium from 196 patients were classified by standard endometrial dating criteria. In addition, other histologic characteristics of endometriotic implants such as the amount of stroma, amount of fibrosis, the presence of surface epithelium, presence of focal hemorrhage, and gland characteristics were also noted. SETTING: Academic tertiary referral center. MAIN OUTCOME MEASURES: Comparison of histologic dating between endometriotic implants and the corresponding endometrium as a function of histologic parameters. RESULTS: Implants that were synchronous with the corresponding eutopic endometrium had more stroma than those that were out of phase. The amount of fibrosis was inversely related to hormonal responsiveness. The presence of surface epithelium in implants was also associated with an impaired response (28.0% versus 48.0% in phase). Endometriomas were found to be in phase with the corresponding endometrium less often than other types of implants (21.7% versus 43.3%). Although endometriomas had similar amounts of stroma when compared with other implants, they had significantly more fibrosis (850.2 microns versus 195.0 microns). CONCLUSIONS: These results suggest that the unpredictable response of endometriotic implants to cyclic endogenous hormones and hormonal therapy may be related to the architectural relationships between the cellular elements found in normal endometrium.

Sperm electron microscopy for the evaluation of in vitro fertilization failures.

When performing IVF, the clinician is frequently confronted with the failure of fertilization. When the standard parameters to evaluate the male factor are "within normal limits," the conclusion is often made that the lack of fertilization is most likely due to "poor egg quality." These two cases demonstrate the fallacy of this approach and support a more rigorous evaluation of the male factor. Ultrastructural analysis of sperm is underutilized and, as demonstrated by these two cases, can play an essential role in this evaluation process.

Clinical and histologic classification of endometriomas. Implications for a mechanism of pathogenesis.

One hundred eighty-seven consecutive patients with persistent ovarian cysts and endometriosis underwent laparoscopic evaluation and ovarian cystectomy. All patients had been followed for a minimum of 6 weeks prior to surgery. The cysts were identified initially to be endometriomas based on their gross appearance and the presence of endometriosis at other pelvic sites. Presumed endometriomas were classified into three types based on size, cyst contents, ease of removal of the capsule, adhesions of the cyst to other structures and location of superficial endometrial implants relative to the cyst wall. After clinical laparoscopic classification, the cysts were evaluated histologically without knowledge of the clinical assessment. Histologically small (< 2 cm), superficial ovarian cysts were always endometriomas, and the cyst wall was very difficult to remove (type I). Large cysts with easily removed walls were usually luteal cysts (type II). Large cysts with walls adherent in multiple areas adjacent to superficial endometriosis were generally endometriomas but some also had histologic characteristics of functional (luteal or follicular) cysts (types IIIa and IIIb). These findings led to the conclusion that superficial ovarian endometriosis is similar to endometriosis in extra-ovarian sites in that the formation of superficial cysts is limited in size by fibrosis and scarring. In contrast, large endometriomas may develop as a result of secondary involvement of functional ovarian cysts by the endometriotic process.

Hormone-resistant endometriosis following total abdominal hysterectomy and bilateral salpingo-oophorectomy: correlation with histology and steroid receptor content.

Endometriosis is rare after hysterectomy and oophorectomy for conditions unrelated to endometriosis. We present a case of delayed development of aggressive, hormone-resistant endometriosis temporally remote from hysterectomy and oophorectomy performed for chronic pelvic inflammatory disease. Treatment with depo-medroxyprogesterone acetate resulted in continued growth of the retroperitoneal endometrioma and necessitated posterior exenteration because of the endometrioma's location. Estrogen and progesterone receptor levels were measured to clarify why this woman's endometriosis was resistant to hormone therapy. Despite administration of large amounts of depo-medroxyprogesterone acetate, the progesterone receptor content was elevated while the estrogen receptor content was undetectable. Why this patient developed this particular type of aggressive endometriosis is unclear, but the lack of down-regulation of progesterone receptors in response to high-dose progestin therapy may indicate an alteration in basic regulatory and cellular processes within the endometriotic implant.

Slow excretion of exogenous human chorionic gonadotropin simulating repeated pregnancies and pregnancy losses.

We report a patient undergoing hMG-induced superovulation who demonstrated delayed excretion of hCG, originally believed to be because of successive biochemical pregnancies. However, sequential hCG titers after administration of exogenous hCG demonstrated a longer than normal half-life for the excretion of hCG in this patient. To what extent delayed excretion of hCG contributes to the diagnosis of biochemical pregnancy in assisted reproductive technology programs has yet to be determined.

Reproductive dysfunction in amenorrheic athletes and anorexic patients: a review.

Strenuous athletic training and anorexia are associated with a high incidence of amenorrhea. While the physiological and/or psychological stressors that contribute to the development of menstrual dysfunction in these individuals appear to differ, they both involve disorders of the reproductive system that originate in the hypothalamus. The available data suggest that both groups experience alterations in the pulsatile release of GnRH, which in turn produces perturbations in pituitary and ovarian function ultimately leading to menstrual dysfunction. In this review, the reproductive and "stress" hormone profiles in amenorrheic athletes and anorexic patients are compared, and the interaction of these hormonal axes in the occurrence of menstrual dysfunction is discussed.

Diethylstilbestrol metabolites and analogs: differential ligand effects on estrogen receptor interactions with nuclear matrix sites.

Estradiol (E), diethylstilbestrol (DES), and three structurally similar DES derivatives and analogs, consisting of racemic mixtures of indenestrol-A (IA; rac), indenestrol-B (IB; rac), and the Z-isomer of pseudo-DES (PD) were used as probes to determine the effect of ligand on receptor-nuclear acceptor site interactions. IA (rac), IB (rac), and Z-PD have been previously shown to interact with the mouse uterine estrogen receptor with high affinity (Kd, approximately 1.5-2.2 x 10(-10) M), occupy similar levels of receptor in the nucleus in vivo, and have nuclear retention times similar to those of E and DES. However, in spite of these similarities, they differentially stimulate estrogenic responses that were previously thought to be interrelated and obligatory for full estrogenic action. In an attempt to elucidate the mechanism of differential stimulation of estrogen-regulated responses, the temporal pattern of KCl-resistant receptor sites was examined after a single injection of E, DES, IA (rac), IB (rac), Z-PD, or saline. Z-PD displayed lower levels of KCl-resistant receptor than the other compounds, whereas IA (rac) and IB (rac) had patterns similar to those of E and DES. In cell-free binding assays, all of the different receptor-ligand complexes were equally effective at competitively inhibiting the binding of receptor-[3H]E complexes to mouse uterine nuclear matrix with a Ki of 1.1 x 10(-10) M. Direct binding analysis showed no difference in the number of nuclear binding sites (range, 40.4-63.9 fmol/100 micrograms DNA) or Kd (range, 1.3-1.8 x 10(-10) M) among the different receptor-ligand complexes. Dissociation studies performed at 4 C showed no differences among the different complexes. In contrast, Z-PD-receptor complexes dissociated much faster from matrix sites at 22 C than any of the other complexes. Significant differences were noted in the proportion of complexes that were resistant to extraction with 0.6 M KCl. Forty-three percent of receptor-E complexes and 44% of receptor-DES complexes were resistant to KCl extraction, while 61% of receptor-IA and 29% of receptor-PD complexes were resistant to extraction, paralleling their activity in eliciting some estrogenic responses. In contrast, no difference was seen by gel shift assays in the ability of the ligand-receptor complexes to bind to a specific PS2 estrogen-responsive DNA sequence. These results demonstrate that the ligand may significantly affect the interaction of the estrogen receptor with nuclear acceptor sites.

Chelex 100 as a medium for simple extraction of DNA for PCR-based typing from forensic material.

Procedures utilizing Chelex 100 chelating resin have been developed for extracting DNA from forensic-type samples for use with the PCR. The procedures are simple, rapid, involve no organic solvents and do not require multiple tube transfers for most types of samples. The extraction of DNA from semen and very small bloodstains using Chelex 100 is as efficient or more efficient than using proteinase K and phenol-chloroform extraction. DNA extracted from bloodstains seems less prone to contain PCR inhibitors when prepared by this method. The Chelex method has been used with amplification and typing at the HLA DQ alpha locus to obtain the DQ alpha genotypes of many different types of samples, including whole blood, bloodstains, seminal stains, buccal swabs, hair and post-coital samples. The results of a concordance study are presented in which the DQ alpha genotypes of 84 samples prepared using Chelex or using conventional phenol-chloroform extraction are compared. The genotypes obtained using the two different extraction methods were identical for all samples tested.

A comparative analysis of the cycle fecundity rates associated with combined human menopausal gonadotropin (hMG) and intrauterine insemination (IUI) versus either hMG or IUI alone.

Human menopausal gonadotropin (hMG) superovulation combined with washed intrauterine insemination (IUI) has been advocated for the treatment of various forms of infertility when more traditional therapy has failed. To assess the relative efficacy of combined treatment with hMG and IUI compared with either hMG or IUI alone, pregnancy outcomes of the three treatment groups were compared in couples having infertility because of male factor, cervical factor, endometriosis, or unexplained. A total of 751 cycles were analyzed from 322 couples. The mean cycle fecundity rate associated with hMG/IUI therapy was significantly higher than either hMG or IUI therapy alone for all patients (hMG/IUI = 19.6%, hMG = 6.3%, IUI = 3.4%). The improvement in cycle fecundity rates with hMG/IUI therapy was also observed when the couples were separated by infertility diagnostic groups: male factor (hMG/IUI = 15.3%, hMG = 4.4%, IUI = 3.0%), cervical factor (hMG/IUI = 26.3%, hMG = 7.9%, IUI = 5.1%), endometriosis (hMG/IUI = 12.85%, hMG = 6.6%), and unexplained infertility (hMG/IUI = 32.6%, hMG = 5.5%, IUI = 0%). Moreover, in patients who had failed to conceive with hMG or IUI alone, the cycle fecundity rate when they were switched to hMG/IUI therapy equaled that of patients who received combined therapy from the onset. We conclude that cycle fecundity rates and cumulative pregnancy rates are significantly greater using a combination of hMG and IUI compared with either modality alone in the treatment of male factor, cervical factor, endometriosis, or unexplained infertility. Indeed, in couples with nontubal related infertility, cycle fecundity rates with hMG/IUI approach the rates seen with in vitro fertilization and gamete intrafallopian tube transfer.

Endometriosis--what can medical therapy offer?

Endometriosis is often debilitating and can adversely affect fertility. Medical management has largely consisted of hormonal therapy, employing the entire spectrum of sex steroids, singly or in combination, and has primarily aimed to relieve pain and increase conception rates. Recently the efficacy of such treatment has been called into question. The current status of the hormonal therapy of endometriosis is critically reviewed, with sufficient historical background and summaries of clinical trials to allow interpretation of the available data. The impact of hormonal therapy on the cause and the natural history of disease is also assessed. Finally, recommendations regarding therapy, along with necessary directions for future clinical studies, are presented.

Effect of age on response to human menopausal gonadotropin stimulation.

Conception rates decline in the latter part of the reproductive years. To examine which ovarian parameters are altered with aging, 486 cycles from 225 ovulatory infertile women undergoing human menopausal gonadotropin (hMG) superovulation and washed intrauterine insemination were analyzed. Infertility factors included endometriosis (68%), unexplained infertility (8.4%), male factor (12.9%), and ovulatory dysfunction (10.7%). Parameters that demonstrated a linear relationship with increasing age included numbers of ampules of hMG required per cycle (r = 0.79; P less than 0.05), days of stimulation (r = 0.73; P less than 0.01), estradiol level at the time of hCG (r = -0.92; P less than 0.0001), number of follicles larger than 15 mm (r = -0.61; P less than 0.05), and rate of rise of estradiol (r = -0.92; P less than 0.0001). These same age-dependent changes were observed in women receiving a standard stimulation protocol (3 ampules hMG beginning on cycle day 2). When standard cycles were limited to the first cycle only, the preovulatory estradiol (r = -0.92; P less than 0.005), slope of estradiol rise (r = -0.92; P less than 0.005), and number of preovulatory follicles (r = -0.92; P less than 0.005) still showed a significant decrease with age. Although the mean estradiol level per preovulatory follicle showed a slight decrease with maternal age, no statistically significant trend was noted. In addition, the cycle day of hCG administration was unaffected by age. With advancing age, there appears to be a decreased ovarian response to an increased amount of stimulation, as measured by steroidogenesis and follicular recruitment; yet the estradiol/follicle remains unaltered, indicating continued health of the follicle. These observations may explain in part the observed decrease in fecundity in older women.

Adhesion reformation after reproductive surgery by videolaseroscopy.

After initial videolaseroscopy for the treatment of endometriosis-associated infertility, 157 patients underwent a second-look laparoscopy to evaluate and treat recurrence of disease and/or adhesions. The patients were divided into two groups. Group 1 consisted of 135 patients who underwent second-look laparoscopy for persistent infertility and/or recurrence of pain. Group 2 consisted of 22 patients who achieved pregnancy after initial surgery and underwent second-look laparoscopy for evaluation of ectopic pregnancy or in association with uterine evacuation for first trimester spontaneous abortion. Both groups of patients demonstrated a significant reduction in adhesion scores involving the ovaries, tubes, posterior cul-de-sac, anterior cul-de-sac, and omentum/bowel. Although the initial mean adhesion scores were similar for both groups, at second-look laparoscopy the mean adhesion scores were significantly lower for group 2, particularly for ovarian and tubal adhesions. None of the patients formed de novo adhesions. From these results we may conclude that videolaseroscopy: (1) is effective in reducing peritoneal adhesions; (2) is associated with a low frequency of postoperative adhesion recurrence; and (3) appears to completely avoid de novo adhesion formation.