Properties of the estrogen receptor in the human oviduct and its interaction with ethinylestradiol and mestranol in vitro.

Biochemical properties of estrogen binding are investigated in the cytosol and nuclear fractions of the human Fallopian tube. Sucrose density ultracentrifugation and dextrancoated charcoal adsorption techniques are used for characterization of [3H]estradiol uptake in the human oviduct. There is indirect evidence for the presence of protease which can be inhibited by diisopropylfluorophosphate (DFP). When DFP is present in buffer of low ionic strength, the cytosol receptor sediments at 8S and 4S peaks. In the absence of DFP, the 4S peak alone is demonstrated. The proteolytic inhibitor does not alter the estrogen-binding capacity in the human oviduct. The dissociation constant (Kd) for [3H]estradiol in cytosol is 2 X 10(-10) M without DFP and 1.5 X 10(-10) M with DFP. The presence of protease in cytosol of human oviducts is confirmed by hydrolysis of benzoyl-arginine nitroanalide. The enzymatic activity is inhibited by DFP. Nuclear estrogen receptor sediments at 4S after extraction with 0.4 M KCL buffer. A rapid nuclear accumulation of [-3H]estradiol is seen at 25 C, with reciprocal depletion of cytoplasmic receptor in human oviduct tissue minces. The synthetic estrogens ethinylestradiol (17 alpha-ethynyl-1,3,5-estratriene-3,17 beta-diol) and mestranol [3-methoxy-17 alpha-ethinyl-1,3-5(10)-estratiene-17 beta-OL] are competitors for the estrogen receptor in the human Fallopian tube. Inhibition of oviductal estrogen binding is 500 times greater with ethinylestradiol than with mestranol (ki = 0.75 X 10(-9) M for ethinylestradiol; Ki = 3.74 X 10(-7) M for mestranol). The estrogen receptor in the human Fallopian tube shows properties similar to those of the estrogen receptor of the human uterus. However, the determination of the number of binding sites in the oviduct is not influenced by proteolytic enzyme activity.

PIP: The biochemical properties of estrogen binding are investigated in the cytosol and nuclear fractions of the human fallopian tube. Sucrose density ultracentrifugation and dextrancoated charcoal absorption techniques are used for characterization of estradiol uptake in the human oviduct. There is indirect evidence for the presence of protease which can be inhibited by (DFP) diisopropylfluorophosphate. When DFP is present in buffer of low ionic strength, the cytosol receptor sediments at 8S and 4S peak. In the absence of DFP, the 4S peak alone is demonstrated. The proteolytic inhibitor does not alter the estrogen-binding capacity in the human oviduct. The presence of protease in cytosol of human oviducts is confirmed by hydrolysis of benzoyl-arginine nitroanalide. The enzymatic activity is inhibited by DFP. Nuclear estrogen receptor sediments at 4S after extraction with 0.4M KCL buffer. A rapid nuclear accumulation of estradiol is seen at 25 C, with reciprocal depletion of cytoplasmic receptor in human oviduct tissue minces. The synthetic estrogens ethinyl estradiol (17alpha-ethynyl-1,3,5-estratriene-3,17 beta-diol) and mestranol (3-methoxy-17alpha-ethinyl-1,3,5(10)-3stratriene-17beta-OL) are competitors for the estrogen receptor in the human fallopian tube. Inhibition of oviductal estrogen binding is 500 times greater with ethinyl estradiol than with mestranol. The estrogen receptor in the human fallopian tube shows properties similar to those of the estrogen receptor of the human uterus. However, the determination of the number of binding sites in the oviduct is not influenced by proteolytic enzyme activity.

Blepharophimosis, ptosis, epicanthus inversus, and primary amenorrhea. A dominant trait.

The syndrome of blepharophimosis, ptosis, and epicanthus inversus is a rare but well-documented autosomal dominant disorder. Although autosomal dominant inheritance has been repeatedly confirmed, several observers have noted that transmission of the trait is predominantly through an affected male parent. To our knowledge, no published observations have accounted for this unusual differential transmission. Described here is a family with typical features of this disorder and in addition primary amenorrhea in the affected women. The primary amenorrhea, which has not been previously documented in this disorder, does account for differential transmission in this family and possibly in other families. Since affected individuals are treated by ophthalmologists, the possible occurrence of this extraocular manifestation should be recognized in the management of patients and their families.

Steroid hormones in ovarian vein and cyst fluid of a virilizing stromal tumor.

A 23-year-old female with clinical signs of excessive androgen and estrogen production was found to have a gonadal stromal tumor. The clinical symptoms correlated well with steroid hormone values in ovarian vein blood and ovarian cyst fluid of the ovarian tumor. Ovarian vein blood draining the ovarian tumor measured as follows: estrone, 162 pg/ml; estradiol, 1688 pg/ml; progesterone, 9.6 ng/ml; testosterone, 9775 ng/100 ml; and dihydrotestosterone, 2905 ng/100 ml. The ovarian cyst fluid produced higher estrogen and lower androgen values compared with ipsilateral ovarian vein blood. Peripheral levels of immunoreactive testosterone ranged from 210 to 244 ng/100 ml. It is concluded that excessive androgen and estrogen production may arise from a gonadal stromal tumor that has been previously classified as a purely virilizing ovarian tumor.

Simplified sperm washing techniques and intrauterine insemination.

Sperm washing followed by intrauterine insemination of the husband's semen has emerged as a useful therapy. Several drawbacks restrict wider availability of this technique. The present study compared the pregnancy rate of a more complicated laboratory protocol with that of a simplified washing protocol in 42 patients. Eighteen pregnancies resulted, for an overall rate of 43%; eight occurred with the complicated protocol in 93 attempts and ten with the simplified protocol in 108 attempts, rates that do not differ significantly. We conclude that sperm washing protocols can be simplified without affecting efficacy, making the technique suitable for office settings.

Transient hyperprolactinemia in infertile women with luteal phase deficiency.

This study was conducted to evaluate the prevalence of transient hyperprolactinemia in infertile women with luteal phase deficiency. One hundred fifty-one luteal phase deficiency patients and 11 controls had serum prolactin (PRL) measured daily for 3-4 days near ovulation. Thirty-three subjects (21.9%) had transient hyperprolactinemia, with PRL above 20 ng/mL for 1 or 2 days, and were studied further. The blood samples of these 33 subjects and of the controls were also analyzed for LH and FSH. Plasma progesterone was measured on the fourth, seventh, and tenth days after ovulation in both groups. The mean (+/- SD) of the mid-cycle integrated LH surge (125.0 +/- 23.0 mIU/mL; N = 26) and the sum of three plasma progesterone levels (23.8 +/- 4.5 ng/mL; N = 21) in the luteal phase deficiency women were significantly (P less than .001) lower than those of the controls (LH 158.7 +/- 13.8 mIU/mL; progesterone 33.8 +/- 6.5 ng/mL). All 33 luteal phase deficiency subjects with transient hyperprolactinemia were treated with bromocriptine at a dose ranging from 1.25-5 mg/day to maintain mid-cycle PRL levels between 5-15 ng/mL. Both the integrated LH surge and the sum of three progesterone levels increased significantly (P less than .05) during bromocriptine treatment, to 142.6 +/- 22.4 mIU/mL (N = 20) and 28.2 +/- 6.2 ng/mL (N = 18), respectively. Fourteen of the 33 patients conceived. The cumulative probability of conception was 31% for six cycles and 45% for 12 cycles of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Follicular phase treatment of luteal phase defect with follicle-stimulating hormone in infertile women.

Fifteen infertile women diagnosed by endometrial dating to have a luteal phase defect were treated with human pituitary follicle-stimulating hormone (hFSH) for 45 cycles. Human follicle-stimulating hormone was administered intramuscularly in a dose of 50 IU/day (group 1) for 35 cycles and 100 IU/day (group 2) for ten cycles from either the third or fifth day of the cycle for five days. Plasma estrogen was measured daily during drug injection. Plasma progesterone was measured on the fourth, seventh, and tenth days after ovulation by basal body temperature during 11 pretreatment control cycles and 39 treatment cycles. Endometrial biopsies were performed on the seventh day after ovulation. The daily estrogen levels increased gradually during hFSH treatment. There was no significant difference between the two dosage groups. The mean progesterone levels were: 1) significantly (P less than .02) greater in the treatment cycles than in the control cycles, 2) significantly (P less than .05) greater in the pregnancy cycles than in the nonpregnancy cycles, 3) significantly (P less than .01) greater in the cycles with normal endometrial dating than in the cycles with abnormal endometrial dating after treatment, and 4) significantly (P less than .05) greater in group 1 than in group 2. After treatment, the endometrial biopsy specimens were improved to normal in 20 of 38 cycles. Five patients became pregnant during the treatment. The authors have concluded that hFSH may be useful in treatment of luteal phase defect.

Further characterization of estrogen receptors in the human oviduct.

Estrogen binding in human oviducts was studied in vitro by the dextran-coated charcoal assay and sucrose density ultracentrifugation. Estrogen binds with high affinity and limited capacity to cytosol of the human oviduct. The concentration of competitive inhibitors to produce 50% reduction in estrogen binding was 8 x 10(-8) M for the antiestrogen CI-628, 8 x 10(-7) M for the progestogen norethynodrel, and 3 x 10(-6) M for the testosterone derivative danazol at the ligand concentration of 1 nM estradiol. Nuclear estrogen binding was not inhibited by a 100-fold excess of progesterone or by a 10-fold excess of norethynodrel. Estrogen-binding protein with a sedimentation coefficient of 4S was seen in oviductal cytosol of all three anatomic segments. The nuclear 4S peak of estrogen binding was demonstrated in the ampullary tubal segment.

Paradoxical pituitary hormone responses in a case of primary hypothyroidism and Hashimoto's thyroiditis.

A 24-year-old woman is described with irregular menstruation, anovulation, and infertility due to primary hypothyroidism and Hashimoto's thyroiditis. Her baseline gonadotropins and thyroid-stimulating hormone (TSH) were increased. Microsomal and thyroglobulin antibodies were present. Stimulation of pituitary hormone release with thyrotropin-releasing hormone (TRH) resulted in appropriate responses of TSH and prolactin (PRL) as well as a substantial rise in the level of luteinizing hormone (LH). Luteinizing hormone releasing factor (LRF) markedly inhibited LH release. Bromoergocryptine led to inhibition of TSH and PRL. These results suggest that specific and nonspecific responses of pituitary glycoproteins to provocative stimuli reflect a profound disturbance of the hypothalamic-pituitary axis in this case of hypothyroidism.

Pregnancy induced with menotropins in a woman with polycystic ovaries, endometrial hyperplasia, and adenocarcinoma.

A 31-year-old woman is described with PCOD associated with endometrial hyperplasia and well-differentiated adenocarcinoma. Conservative treatment with ovulation induction was pursued for a total of 3 1/2 years. After CC treatment failed to achieve conception, treatment with menotropins resulted in a twin pregnancy that aborted spontaneously and a singleton term pregnancy. Hysterectomy was performed 4 1/2 years after the initial diagnosis of well-differentiated endometrial adenocarcinoma was made. Histologic examination of the endometrium showed no progression of the disease. Ovulation induction of patients with polycystic ovaries and well-differentiated and noninvasive endometrial adenocarcinoma may be justified in properly selected cases.

Serum progesterone levels in women treated with human menopausal gonadotropin and human chorionic gonadotropin for in vitro fertilization.

For evaluation of the adequacy of luteal function after in vitro fertilization-embryo transfer (IVF-ET), serum progesterone (P) levels were measured on days 3, 7, and 10 after laparoscopic follicle aspiration. Fifty-six infertile patients were treated during 86 cycles with human menopausal gonadotropin-human chorionic gonadotropin (hMG-hCG) for stimulation of follicular development. Serum estradiol (E2) levels were measured daily during hMG-hCG treatment. P levels were determined in 67 cycles. The mean (+/- standard deviation [SD]) of the sums of 3 P levels was 55.63 +/- 24.13 ng/ml. There were 11 pregnancies. The mean of the sums of 3 P levels of pregnant patients was 64.45 +/- 26.23 ng/ml and of 56 nonpregnant cycles was 53.90 +/- 23.35 ng/ml. The duration of luteal phase varied from 9 days to 15 days. The mean of the sums of 3 P values of patients with different luteal phase lengths ranged from 28.8 ng/ml to 60.51 +/- 25.68 ng/ml. The mean of the sums of 3 P levels of women with normal luteal phase and that of women with luteal phase defect by endometrial biopsy study were used as controls for comparison. There was poor correlation (r = 0.3441) between E2 peak levels and P levels; the sum of 3 P levels did not indicate luteal phase inadequacy in IVF-ET patients; and the majority of the nonpregnant cycles (32/56) showed a luteal phase of 11 days or less, in spite of adequate P levels.(ABSTRACT TRUNCATED AT 250 WORDS)

The outcome of continued treatment of luteinizing hormone-surged cycles in in vitro fertilization with the use of human menopausal gonadotropin.

Over a 2-year period 75 patients were treated for 109 cycles with human menopausal gonadotropin for in vitro fertilization. The occurrence of endogenous luteinizing hormone (LH) surges was monitored by daily blood sampling. Forty-six cycles (42%) showed an endogenous LH surge. Instead of canceling the treatment cycle as other programs do, we proceeded to oocyte collection when the surge was detected. Human chorionic gonadotropin was administered routinely to the "surge" patients as soon as the LH surge was determined. The oocyte collection was carried out around 24 hours after the "surge" blood had been drawn, although the beginning of the endogenous LH surge was unable to be pinpointed. Significantly more immature oocytes, lower fertilization rate, and lower cleavage rate were seen in the "surge" patients than in the "nonsurge" patients. In five "surge" cycles laparoscopy for oocyte collection was canceled, but none was canceled because of premature ovulation detected by the immediately preoperative ultrasonography. In four "surge" cycles no potentially fertilizable egg was recovered. This was not significantly different from that of the "nonsurge" group. The pregnancy rate of the "surge" group (4/41 or 9.8% per laparoscopy and 4/34 of 11.8% per embryo transfer) was not statistically different from that of the "nonsurge" group (7/61 or 11.5% per laparoscopy and 7/56 or 12.5% per embryo transfer). This study presents the possibility of proceeding to oocyte collection, fertilization, embryo transfer, and pregnancy in patients with endogenous LH surge in in vitro fertilization procedures with the use of human menopausal gonadotropin treatment.

Hormonal and cytogenetic studies in phenotypically female patients with gonadal dysgenesis.

In 4 cases of gonadal dysgenesis the clinical, hormonal, cytogenetic, and histological findings were correlated. There were 2 patients with 46,XY karyotype, one patient with 45,X Turner's syndrome and one patient with a 46,XX chromosome complement. All patients had streak gonads with ovarian stroma. In one phenotypically female 46,XY individual an involuted gonadoblastoma was found. Her testosterone was four-fold higher in gonadal vein blood compared to peripheral blood. Cytogenetic analysis of multiple tissues in both cases with the 46,XY karyotype greatly reduced the probability of mosaicism. In the patient with 45,X Turner's syndrome and in the one with 46,XX gonadal dysgenesis only peripheral blood cells were karyotyped and mosaicism was not further excluded by analysis of other tissues. The concentrations of steroid hormones in gonadal vein blood were low. The levels ranged as follows: estrone 41-98 pg/ml, estradiol 18-90 pg/ml, testosterone 37-294 ng/100 ml, dihydrotestosterone 13-22 ng/100 ml, and progesterone 0.3-1.5 ng/ml. It was concluded that gonadal streaks were similarly deficient in biosynthesis of steroid hormones despite different chromosomal complements.

The androgen receptor of the human endometrium.

Available androgen binding to soluble proteins from the cytosol of human endometrium was studied using the dextran coated charcoal adsorption method and sucrose density centrifugation analysis. Specific binding of [3H]-5 alpha-dihydrotestosterone ([3H]-DHT) was observed with both methods. The apparent dissociation constant (Kd), for DHT binding is 1.3 +/- 0.2 (SEM) nM and the binding capacity 177 +/- 42 (SEM) fmol/mg protein. Sucrose density ultracentrifugation identifies specific [3H]-DHT binding that sediments at 4S and 8S. The stability of the androgen receptor in human endometrium is increased by the addition of 10% glycerol to the homogenization buffer. The addition of trypsin or pronase and heating at 60 degrees C reduces specific binding which demonstrates that the specific [3H]-DHT binder is a protein. The uptake of [3H] DHT in endometrial tissue minces indicated that 20% of the bound radioactivity was nuclear. Steroid specificity suggests that the binding protein from the uterus is specific for androgens. These observations indicate that androgen binding protein in the human uterus has the characteristics of the androgen receptor.

Heuristic determination of relevant diagnostic procedures in a medical expert system for gynecology.

Many professions including medicine have standard operating procedures for the performance of their tasks. In the construction of expert systems, knowledge engineers have exploited this fact in devising heuristic rules that mimic the standard practice among such personnel (i.e., experts). This article suggests that the expert system designer should not stop at the level of the standard operating procedure heuristic but should instead investigate the reasons that the standard procedures have become standard. Because the experts in a field often do not understand the reasons for the standard operating procedures of their profession, this effort not only rewards the system designer but the expert as well. Because medical training does not always emphasize the logical reasoning underlying certain standard operating procedures, the ability to perform this reasoning is especially important in medicine. Further, a medical expert system for consultation or education would make a valuable impact by incorporating such knowledge and inference rules. This article investigates the development of a computerized medical expert system that applies the principles of artificial intelligence by limiting the number of questions and tests to find the solution for an ill-defined complex problem. Finally, we describe a logic program that tests the basic ideas.

Monitoring of ovulation induction with HMG-HCG therapy by plasma estrogen and progesterone.

Seventeen patients with anovulation or luteal deficiency were tested with HMG-HCG for 40 cycles. Follicular development was monitored daily by measurement of immunoreactive plasma estrogen. Ovulation was evaluated by determination of plasma progesterone. Ovulation was induced in 16 patients and 37 of 40 cycles (93%). Fourteen pregnancies occurred in 13 patients. Plasma estrogen measurements in ovulatory cycles at the time of HCG injection ranged from 315 to 1,482 pg/ml (mean 764 pg/ml). Mild hyperstimulation occurred in two cycles with preovulatory estrogen values of 720 pg/ml and 784 pg/ml. The highest preovulatory estrogen level which was followed by anovulation was 493 pg/ml. The preovulatory estrogen peak in one triplet pregnancy measured 1,356 pg/ml. Determinants of treatment failure included inadequate follicular stimulation, interruption of HMG therapy for more than 1 day, previous ovarian wedge resection, and congenital anomaly of the uterus. Increase in body weight required higher doses of drug therapy in one case. We conclude that optimal estrogen levels prior to HCG injection range from 500 to 700 pg/ml. The risks for ovarian hyperstimulation and multiple pregnancy may be reduced and ovulation accomplished by daily administration of HMG until the defined estrogen level is reached.

Human chorionic gonadotropin, estriol, and testosterone changes in two pregnancies with hyperreactio luteinalis.

A case of hyperreactio luteinalis is presented with measurements of human chorionic gonadotropin, total and free testosterone, and estriol throughout two term pregnancies. Ovulation induction with menotropins resulted in one spontaneous first-trimester abortion, one singleton term pregnancy, and 1 triplet pregnancy that converted to a singleton term pregnancy after spontaneous degeneration of two fetuses in the first trimester. During the first term pregnancy, levels of human chorionic gonadotropin peaked at 34 weeks of gestation (169,000 mIU/ml) and levels of total testosterone peaked at the same time (1777 ng/dl). Free testosterone (16.6 ng/dl) and estriol (10.8 ng/ml) reached their peak at 36 weeks of gestation. During the second term pregnancy, peak values of human chorionic gonadotropin (150,900 mIU/ml) and total testosterone (870 ng/dl) occurred at 10 and 5 weeks of gestation, respectively, before two fetuses of a triplet pregnancy degenerated.

Autoimmunity in premature ovarian failure.

We performed laparoscopic ovarian biopsies in 17 of 19 cases with premature ovarian failure. Primordial follicles were found in three cases, corpora albicanti in two, and epithelial-lined cysts in two cases. Chromosome analysis revealed a normal 46XX karyotype in 15 patients, 46XY in two, 45XO in one, and 46XO/46XX mosaicism in one patient. Immunofluorescence studies were performed on ovarian tissue obtained by laparoscopic biopsy in 12 cases with premature ovarian failure. Blood serum was analyzed for circulating anti-ovary and other autoantibodies in all 12 cases. Circulating autoantibodies were found in the serum of six patients, but not in healthy controls. Direct immunofluorescence was positive in 5 of 12 ovarian tissue samples with predominantly vascular wall staining. Indirect immunofluorescence was positive in 10 of 12 cases; antibodies reacting with ovarian stromal components were present in eight cases, antibody reacting with follicular epithelium was present in one case, and antibodies reacting with nuclear antigens were present in five cases. Two of the patients had anti-thyroid microsomal antibodies, and one had antitesticular antibody. We conclude that a significant number of patients with ovarian failure have serologic and biopsy findings suggestive of and consistent with autoimmunity, even though there are no overt clinical manifestations of autoimmune disease.