The effect of norepinephrine and dibutyryl cyclic adenosine monophosphate on cation transport in duck erythrocytes.

Freshly prepared duck erythrocytes, incubated either in plasma or an isotonic synthetic medium containing norepinephrine ([K] of both media approximately 2.5 mM), maintain water and electrolyte composition in the steady state (upper steady state) for at least 90 min. If incubated in the synthetic medium without norepinephrine or in plasma to which a beta-adrenergic blocking agent (propranolol) is added, the cells lose both water and electrolyte (predominantly KCl) until a new steady state is reached (lower steady state). Reaccumulation of water and electrolyte from isotonic solutions toward the upper steady-state levels requires the addition of norepinephrine and KCl. Reaccumulation is maximal when the concentration of K and norepinephrine in the medium is 15 mM and 10(-7)M, respectively. Dibutyryl cyclic-AMP (10(-2)M) mimics norepinephrine in lower steady-state cells. Although an analogous effect in upper steady-state cells was not established with certainty, it is proposed that the catecholamine-induced net changes in water and electrolyte movement in duck erythrocytes are a consequence of stimulation of the activity of a membrane-bound adenyl cyclase system.

Long-term steroid therapy in patients with adrenogenital syndrome.

Fifteen years' experience with the adrenogenital syndrome at Duke University Medical Center is reviewed. Twenty-six patients were diagnosed before age 2. Of these, 20 had the salt-losing syndrome. The complications encountered and the results obtained in terms of growth, developemnt, and fertility are discussed. Delay in diagnosis and inappropriate gender assignment continue to be a problem.

Adrenal virilism due to 21-hydroxylase deficiency in the postmenarchial female.

Five new patients with postmenarchial onset of adrenal virilism related to 21-hydroxylase deficiency are presented. Diagnostic criteria are reviewed. Four pregnancies resulting in 3 term infants occurred after instigation of therapy. Eleven patients similar in clinical presentation are reviewed for comparison. Findings of value in distinguishing these two groups of patients are discussed.

Successful treatment of catamenial hemoptysis with danazol.

An unusual case is presented of pulmonary endometriosis characterized by cyclic hemoptysis. The literature associated with thoracic endometriosis is briefly reviewed. This case is the first reported cure of catamenial hemoptysis with the antigonadotropin danazol.

Hormonal function of a granulosa cell tumor.

Granulosa and theca cell tumors are rather common gonadal stromal tumors. A postmenopausal patient with a granulosa cell tumor, who complained chiefly of breast tenderness and enlarging, abdomen, is presented. Preoperative and postoperative studies including serum estrone, estradiol, prolactin, FSH, and LH,as well as urinary estrogens, 17-ketosteroids, and 17-hydroxysteroids are reported. A plan of treatment and followup is suggested. It is recommended that survival data on patients with such slow-growing tumors be adjusted to reflect the true incidence of death from the specific tumor in question.

Dynamic pituitary testing in a female with Kallman's syndrome and associated cardiac anomaly.

A patient with Kallman's syndrome and an anomalous right aortic arch is described. Dynamic pituitary testing was carried out revealing no significant response of prolactin to chlorpromazine stimulation or water loading suppression. A normal response of growth hormone to insulin induced hypoglycemia was observed. These data are interpreted as indicating a primary hypothalamic abnormality in Kallman's syndrome. In addition, this is the first report of the association of a cardiovascular abnormality with Kallman's syndrome.

Luteal phase defect as a marker of imminent ovarian failure.

A case of premature ovarian failure in a patient serendipitously studied with regard to clinical and histologic parameters during the 2 years preceding her diagnosis is presented. Progressively decreasing ovarian function was observed, beginning with a luteal phase defect and culminating in afollicular ovarian failure. Concepts concerning the etiologies and pathophysiology of premature ovarian failure are reviewed, and similarities to the natural climacteric are discussed.

Secondary amenorrhea associated with balanced X-autosome translocation.

This is the first reported instance of a patient with gonadal dysgenesis that involves translocation of part of the long arm of an X chromosome to the short arm of a number 7 autosome. The importance of considering gonadal dysgenesis early in the evaluation of patients with secondary amenorrhea considered for ovulation induction is stressed. The relation between chromosomal rearrangement, phenotypic expression, and clinical presentation is discussed.

A comparison of laparoscopy and laparotomy for the treatment of ectopic pregnancy.

A case-control method was used to examine differences in outcome between laparoscopy and laparotomy for the treatment of ectopic pregnancy. Cases and controls, 25 each, were matched by criteria selected to minimize differences in preoperative morbidity and technical difficulty. Patients treated laparoscopically had significantly shorter hospital stays (1.34 +/- 0.8 versus 3.92 +/- 1.1 days; mean +/- SD; P less than .01) and less operating time (77.5 +/- 26.1 versus 103.6 +/- 26.7 minutes; P less than .05). In addition, a laparoscopic approach resulted in a shorter convalescence (8.7 +/- 7.8 versus 25.7 +/- 16.2 days; P less than .01) and reduced postoperative analgesia requirements (0.84 +/- 2.3 versus 4.64 +/- 2.9 doses; P less than .01). We conclude that laparoscopic treatment of ectopic pregnancy is well tolerated by patients and, in comparison with laparotomy, requires fewer medical resources, thereby significantly reducing cost.

Luteal phase defect and premenstrual syndrome in an infertile population.

To test the hypothesis that an abnormal luteal phase is associated with significant symptoms of premenstrual syndrome, psychologic and somatic premenstrual syndrome symptoms were evaluated in a group of 83 infertile patients undergoing timed endometrial biopsy for the assessment of luteal phase adequacy. The severity of psychologic and somatic symptoms was evaluated separately. It was found that luteal phase defect, defined by endometrial biopsy, was associated with less severe psychologic and no more severe somatic symptoms of premenstrual syndrome in comparison with normal luteal phase controls. The data suggest that the hormonal milieu associated with luteal phase defects does not correlate with premenstrual syndrome symptoms and do not support the hypothesis that suboptimal ovarian function causes premenstrual syndrome.

The luteal phase defect: the relative frequency of, and encouraging response to, treatment with vaginal progesterone.

Three hundred and ninety-six patients were evaluated for primary and secondary infertility between December 1976 and May 1979 at a large referral center. Timed late luteal endometrial biopsies were routinely obtained as part of the work-up and were repeated for confirmation if subsequent menses did not occur within 2 days of the expected date. If both biopsies were abnormal, a diagnosis of luteal phase defect (LPD) was made and patients were treated with vaginal progesterone suppositories for a minimum of 6 months. LPD was discovered in 32 of 396 patients (8.1%); among those patients whose infertility was not complicated by other abnormalities, 9 of 13 conceived (70%) and 7 of 13 carried to term (54%). These data suggest an incidence higher than generally recognized and a very encouraging response to replacement therapy.

Gel chromatographic properities of human prolactin released from decidua tissue in vitro.

Human decidua tissue releases immunoactive prolactin into the medium upon incubation in vitro. The prolactin secreted is indistinguishable from pituitary prolactin in its binding and displacement characteristics, using two different antisera. By gel chromatographic criteria more than 90% of the prolactin is monomeric.

Comparison of polyglactic and polyglycolic acid sutures in reproductive tissue.

Polyglactic acid and polyglycolic acid suture materials were compared in rat uterine and abdominal wall tissues for inflammatory response and tissue fibrosis. By 90 days after surgery, the tissue inflammatory reaction and fibrosis were significantly less in response to polyglactic acid suture (Vicryl) in both uterus and skin as compared with the response to polyglycolic acid (Dexon). In addition, the over-all tissue response in skin was significantly greater than that in uterus for both suture materials. The potential importance of tissue fibrosis--particularly in oviductal surgery, over and above the formation of adhesions between one organ and another--is emphasized. It is concluded that (1) the magnitude of tissue response to suture material varies for different tissues, (2) the degree of tissue wall fibrosis does not necessarily correspond to external tissue adhesions, (3) adhesions are maximal at the surgical knots regardless of the suture material used, and (4) polyglactic acid suture material may be preferable to polyglycolic acid suture material for infertility surgery, in which a minimum of tissue reaction is imperative.

Postoperative adhesion formation after ovarian wedge resection with and without ovarian reconstruction in the rabbit.

A rabbit model was used to examine adhesion formation after ovarian wedge resection with and without reapproximation of the ovarian cortex. A wedge resection was completed on one ovary with a scalpel, and the ovarian cortex was reapproximated using microsurgical technique. In the contralateral ovary, a wedge resection was performed using the Nd:YAG laser and the cortex was left to heal by secondary intention. A second laparotomy was performed and the adhesion scores were compared between the two adnexa. In 17 of 19 rabbits, the adhesion score was greater on the side where ovarian reconstruction had been performed. No difference was noted in adhesion scores when, in our preliminary studies presented herein, laser and scalpel wedge resections were both followed by reapproximation of the cortex. These data have ramifications for conservative ovarian surgery performed both at laparotomy and laparoscopy.

Diagnosis and treatment of cornual obstruction using a flexible tip guidewire.

Proximal tubal obstruction, either unilateral or bilateral, is a frequent finding on hysterosalpingogram (HSG). Approximately two-thirds of the fallopian tubes resected for proximal tubal obstruction reveal an absence of luminal occlusion. The distinction between true pathologic occlusion and either spasm or plugging is crucial in determining therapy. We combined hysteroscopic cannulation of the proximal fallopian tube with laparoscopy in 11 patients with proximal tubal obstruction diagnosed by HSG and confirmed at laparoscopy. Hysteroscopic cannulation was able to be performed in 72% of the fallopian tubes attempted, and there was a postcannulation patency rate by HSG of 73%. Six of the 11 patients became pregnant after tubal cannulation and adjunctive distal tubal surgery. Hysteroscopic cannulation of the fallopian tube is a safe diagnostic procedure that can be used to identify those patients with true proximal occlusion, and may also serve as a therapeutic procedure in some of these patients.

Absence of progestational activity of oral spironolactone.

Menstrual irregularity is a recognized side effect of spironolactone when used as a treatment for hirsutism in women. This effect has been attributed to the progestational activity of spironolactone observed in animal models. However, when oral spironolactone was given to women with appropriately estrogen-primed endometrium, secretory transformation of the endometrium was absent in comparison with control cycles. When control cycles were repeated with the addition of spironolactone, a decidualized endometrial response was seen. These findings suggest that spironolactone at clinically used dosages does not act as a progestin or an antiprogestin on the human endometrium.

Hysteroscopy versus hysterectomy for the treatment of abnormal uterine bleeding: a comparison of cost.

OBJECTIVE: To compare the costs of hysteroscopic treatment of abnormal uterine bleeding with the costs associated with abdominal and vaginal hysterectomy. DESIGN: Retrospective review. SETTING: Academic medical center and outpatient gynecology practice. PATIENTS: A list of all women undergoing an endometrial ablation (n = 60), hysteroscopic myomectomy (n = 14), abdominal (n = 192), or vaginal (n = 37) hysterectomy between June 1, 1987 and June 1, 1992 for the treatment of abnormal uterine bleeding was generated by a computer search of billing records using the appropriate ICD-9-CM codes. MAIN OUTCOME MEASURE: The direct cost per case for each patient were defined as the sum of the surgeon's fee, all related hospital and operating room charges, the anesthesiologist's fee, and the cost of preoperative medications. When the initial procedure failed, the cost associated with any additional surgery was accounted for in the determination of the direct cost per case. Indirect costs per case were calculated based on known demographic data, recovery time, and the cost in lost productivity during recuperation. Mean direct and indirect costs per case were determined for each procedure and compared. RESULTS: The mean direct cost per case for endometrial ablation was $5,159 and for myomectomy and ablation was $5,525. The direct cost per case was not different between the hysteroscopic procedures but both were significantly less expensive than either vaginal ($8,132) or abdominal ($8,833) hysterectomy. Total hospital cost also was significantly less for the hysteroscopic procedures than for hysterectomy by either technique. The indirect costs associated with the hysteroscopic procedures were significantly less than those incurred by abdominal and vaginal hysterectomy. CONCLUSIONS: The total direct and indirect cost per case of an hysteroscopic approach to the treatment of abnormal uterine bleeding is significantly less than that associated with vaginal or abdominal hysterectomy. This difference persists when the cost of failure of an hysteroscopic procedure is accounted for.

Ultrasonographic assessment of luteinized unruptured follicle syndrome in unexplained infertility.

Ultrasound can be used to monitor the growth and rupture of the dominant follicle. Thirty-three patients with unexplained infertility underwent serial sonography (mean, 3.2 scans/cycle) for luteinized unruptured follicle syndrome (LUFS). The incidence of LUFS was 9% (three patients) in the initial scan cycle. Three patients (9%) demonstrated rupture of a follicle significantly smaller than the mean (22.1 mm) (z less than 0.01) in the initial scan cycle. At standard radiology fees ($7000 +/ diagnosed LUFS) the cost/benefit ratio of this method of diagnosis will be controversial. It is suggested that scanning at reduced fees in the gynecologist's office, particularly in conjunction with postcoital tests, would decrease cost and increase the potential benefit.

Hysteroscopic metroplasty: surgical technique and obstetric outcome.

Congenital Müllerian abnormalities, particularly the septate uterus, may result in recurrent abortion or premature labor. Twenty-five patients found to have a septate uterus during evaluation for infertility or recurrent abortion were treated by hysteroscopic metroplasty with laparoscopic visualization. Surgical outcome was excellent, intraoperative and postoperative morbidity was negligible, and the postoperative course was similar to that following laparoscopy alone. Preoperative fetal wastage in 17 previously fertile patients was 90%. Of 11 patients, 6 or more months postoperatively, 10 had conceived: 5 delivered vaginally at term, 2 delivered by cesarean section, and 2 pregnancies are in progress. One pregnancy miscarried at 21 weeks secondary to an incompetent cervix. With hysteroscopic metroplasty, septa can be incised successfully with lower morbidity and as good a surgical outcome as with abdominal procedures. If further studies confirm the pregnancy outcome reported, then hysteroscopic metroplasty should become the treatment of choice for the septate uterus.

Titrating the dose of bromocriptine when treating hyperprolactinemic infertile women.

We have shown that a smaller dose of bromocriptine is effective in lowering the PRL level to the normal range in some hyperprolactinemic women. Based on these findings, we recommend that when treating hyperprolactinemic women who desire conception, the dose of bromocriptine should be titrated according to the response of circulating PRL levels. This will minimize the dose, reduce cost, probably reduce side effects, and possibly avoid undesirable functional effects such as corpus luteum dysfunction.