Combined electroejaculation and in vitro fertilization in the evaluation and treatment of anejaculatory infertility.

Seven couples underwent combined electroejaculation and in vitro fertilization for anejaculatory infertility after a failed regimen of electroejaculation and intrauterine insemination. Two pregnancies resulted, one proceeding to a term vaginal delivery and one ending in a 6-week spontaneous abortion. Poor sperm binding and no fertilization were seen in two of the couples. Fertilization of the oocytes but no subsequent pregnancy were seen in the other three couples. Combined in vitro fertilization and gamete intrafallopian transfer was performed in four of the couples. The combination of electroejaculation and in vitro fertilization offers the opportunity to evaluate the female pelvis, observe the sperm-oocyte interaction, and achieve a pregnancy in couples with anejaculatory infertility.

Scintigraphic localization of ovarian dysfunction.

To assess the potential role of scintigraphy in the evaluation of clinically and biochemically suspect ovarian hyperandrogenism (HA), dexamethasone suppression 131I-6 beta-iodomethyl-19-norcholesterol (NP-59) scans were performed to characterize ovarian function in nine patients. Pelvic ultrasound and/or computed tomography (CT) identified anatomic abnormalities in the adnexal region in six women in whom there was discernible pelvic accumulation(s) of NP-59. In the remaining three patients testosterone levels were normal or only slightly elevated and the NP-59 scan did not demonstrate abnormal adrenal or pelvic uptake. CT and/or ultrasound studies failed to demonstrate an abnormality in the pelvis suggesting excessive peripheral conversion or abnormal end organ sensitivity of androgen precursors as potential etiologies of their HA. In three women with androgen secreting lipoid tumors of the ovary, unilateral, pelvic NP-59 activity was noted; these tumors were subsequently resected. Two women with bilateral pelvic NP-59 uptake were later shown to have hyperthecosis with markedly asymmetric and enlarged ovaries. In one woman the extent of asymmetric NP-59 uptake was anticipated by the asymmetry of ovarian vein androgen levels at selective venous catheterization. In another woman with markedly asymmetric polycystic ovary disease, intense focal uptake of NP-59 localized to the side of the anatomically abnormal, enlarged ovary. Thus, our preliminary study reviews our experience to date and suggests that NP-59 scintigraphy may be used to localize both tumorous and nontumorous ovarian dysfunction in states of HA and virilization.

Comparison of peripheral, uterine and cord estrogen and progesterone levels in laboring and nonlaboring women at term.

Although a direct effect of steroid hormones on the initiation of labor has been shown in animals, conclusive data on human parturition are lacking. To elucidate steroid changes associated with human labor, venous serum samples were obtained at cesarean section from the maternal peripheral and uterine veins and umbilical cord vein of seven laboring and seven nonlaboring women at term. Assays of estradiol (E2), estriol (E3) and progesterone (P) revealed that: (1) there is a major concentration difference in all the steroids between peripheral and local values, (2) labor is associated with a significant rise in systemic and local E2 but no change in P, and (3) the increased production of E2 does not appear to be from a fetoplacental source. These data strongly support a modulating role for alterations in steroid hormones at the onset of human labor. The results demonstrate an increase in estrogen, rather than the classic "withdrawal", as the prime factor in E2:P ratio changes associated with labor and suggest that the source of the estrogen increase may be maternal rather than fetal.

Sonographic evaluation of cervical length in pregnancy: diagnosis and management of preterm cervical effacement in patients at risk for premature delivery.

Sonographic measurement of cervical length during pregnancy can provide an objective, noninvasive assessment of anatomical shortening associated with premature labor and delivery. One hundred fifty normal women underwent serial sonographic cervical length measurements during uncomplicated pregnancy. The mean cervical length was 52 +/- 12 mm until 34 weeks' gestation, when gradual effacement and cervical length shortening began. Using these data, we managed 88 pregnant women with previous second-trimester pregnancy losses by a combination of cerclage placement for cervical length less than 40 mm and aggressive therapy for premature uterine contractions. The results showed the following: 1) 97% of women with diethylstilbestrol exposure and 80% of women with müllerian abnormalities exhibited cervical length shortening; 2) only 60% of women with a normal uterine cavity showed cervical lengths of less than 40 mm; and 3) all three groups of high-risk patients, independent of cervical length, showed significant premature uterine activity. These observations suggest that sonographic cervical length measurement may be a useful adjunct in the assessment of anatomical cervical integrity and the decision for cerclage placement. Furthermore, the presence of both premature cervical length shortening and preterm uterine activity in 65% of high-risk patients suggests that "cervical incompetence" and premature labor may not be distinct entities, but common symptoms associated with an increased risk of preterm delivery.

The role of laparoscopy in management of nonpalpable testes.

Laparoscopy is the ideal first operative step in management of boys with nonpalpable testes. No other investigation is as reliable in locating a nonpalpable testis or in confirming its absence. Whatever the laparoscopic findings, further operative intervention is generally necessary and the laparoscopic findings determine the subsequent operative steps. Laparoscopy also permits endoscopic manipulation such as application of a spermatic vessel clip for staged Fowler-Stephens orchidopexy. Herein we report our experiences with laparoscopy in 30 patients with nonpalpable testes.

Electroejaculation of paraplegic males followed by pregnancies.

Semen obtained by electroejaculation was used to achieve pregnancies in the spouses of T5-6 and T4-5 paraplegics. Viable semen was recovered in both an antegrade and retrograde fashion. In both cases, the SPA test was positive. Semen recovered for AIH IUI was washed and swum up prior to insemination.

The effect of insulin on aromatase activity in isolated human endometrial glands and stroma.

Hyperinsulinemic states have been associated with an increased incidence of estrogen-dependent endometrial neoplasia. To study the effect of insulin on the ability of endometrium to aromatize androgens to estrogens, late proliferative endometrium was obtained from normally cycling women at the time of indicated surgery, separated into component glands and stroma, and grown to confluence. Separated gland and stromal cultures were incubated in triplicate with increasing insulin concentrations and epidermal growth factor. Aromatase activity was assayed by the production of tritiated water from tritium-labeled androstenedione. The activity was noted to increase proportionally with increasing concentrations of insulin greater than 10 U/ml, and the effect was specific. These data suggest the following conclusions: (1) Insulin stimulates aromatase activity in both endometrial glands and stroma; (2) hyperinsulinemia may predispose to endometrial neoplasia by enhancing endogenous endometrial estrogen production.

Surgical incision for cesarean section.

Ninety-seven women undergoing cesarean section were delivered through a muscle-cutting Maylard or a Pfannenstiel abdominal incision. In these two similar groups of women, the mean Maylard incision length was significantly greater (18.3 +/- 4.5 cm) than that of the Pfannenstiel incision (14.0 +/- 2.1 cm), with no difference in operative morbidity. Difficulty with infant delivery was significantly less frequent with both the Maylard and Pfannenstiel when the incision was at least 15 cm in length. These results suggest that cesarean delivery is performed optimally with an adequate surgical incision, and that the Maylard incision is a safe option which should be strongly considered when risk factors (eg, macrosomia, twins) demand maximal surgical exposure for nontraumatic abdominal delivery.

Luteal phase dysfunction in endometriosis: elevated progesterone levels in peripheral and ovarian veins during the follicular phase.

Endometriosis has been associated with corpus luteum inadequacy and abnormalities of luteal phase progesterone (P) secretion. In this study, abnormal luteolysis, as a second factor of luteal dysfunction, was assessed in 13 women with endometriosis and 25 control patients by measurement of ovarian vein estradiol (E2) and P during the follicular phase. The results reveal that women with endometriosis have (1) significantly lower ovarian vein E2, (2) significantly higher both peripheral and ovarian vein P, and (3) threefold higher P/E2 ratios than controls during the follicular phase. These data support the concept of continued P production from an active corpus luteum well into the follicular phase of the following cycle in women with endometriosis. Failure of adequate luteolysis is a second aspect of luteal dysfunction in endometriosis and strongly supports the growing body of data confirming ovulatory asynchrony in the minimal; endometriosis infertility syndrome.

Diagnostic considerations in virilization: iodomethyl-norcholesterol scanning in the localization of androgen secreting tumors.

Accurate localization of the source of androgen hypersecretion is critical to the appropriate surgical or medical management of women with virilization. Seven patients with virilization and hyperandrogenism of various causes were evaluated with the use of sequential studies: testosterone stimulation and suppression tests; computerized tomography (CT); selective venous catheterization; and 131I-iodomethyl-norcholesterol (NP-59) scintigraphy. Comparison of the diagnostic accuracies of these localization studies with the ultimate diagnoses in this group of virilized women showed that: endocrinologic suppression/stimulation studies are of limited value in tumor localization and helpful only in patients with steroidogenic enzyme deficiencies; both selective catheterization and CT scanning may provide spurious localization data; and NP-59 scintigraphy, by depicting both the anatomic localization and functional androgen hypersecretion, may provide the most significant localization data in the evaluation of patients with virilizing syndromes.

Comparison of amniotic fluid disaturated phosphatidylcholine and the lecithin-sphingomyelin ratio in the prediction of fetal lung maturity.

Although use of the lecithin-sphingomyelin (L/S) ratio has contributed to a reduction in the frequency of respiratory distress syndrome (RDS), its accuracy in pregnancies complicated by fetomaternal disease has been questioned. Disaturated phosphatidylcholine is the major active component of surfactant and has been advocated as being a more specific indicator of fetal lung maturity. A study of 105 pregnancies in which a L/S ratio and disaturated phosphatidylcholine assay were performed on amniotic fluid was carried out to ascertain if amniotic fluid disaturated phosphatidylcholine is indeed a more accurate predictor of RDS. The results of this investigation reveal no significant difference in the reliability of these two tests in predicting neonatal RDS. Five infants developed RDS with a mature L/S ratio ranging from 2.0 to 3.36, suggesting that the disaturated phosphatidylcholine assay may be a helpful adjunctive test in instances in which the L/S ratio is less than 3.5.

Scintigraphic evidence of adrenal cortical dysfunction in the polycystic ovary syndrome.

The polycystic ovary syndrome (PCO) is frequently associated with elevated plasma levels of adrenal androgens and/or abnormal adrenal androgen responses to hormonal stimulation and suppression. Because of the overlap in the output of hormones between the adrenal glands and the ovaries, we measured adrenal iodocholesterol accumulation as an index of adrenocortical function in 11 women with PCO confirmed by laparoscopy or culdoscopy. All patients had normal dexamethasone suppression of plasma cortisol or urinary 17-hydroxycorticosteroid excretion. 6 beta-[131I]Iodomethylnorcholesterol (NP-59) adrenal scintiscans showed bilateral and excessive adrenal cortical uptake in PCO patients [0.46 +/- 0.08% (+/- SE) of the administered dose compared to 0.21 +/- 0.01% in a group of normal women; P less than 0.05]. The elevation of adrenal cortical NP-59 uptake in PCO was quantitatively similar to that in women with ACTH-dependent Cushing's syndrome (0.64 +/- 0.11%; P greater than 0.1). These data support the presence of abnormal adrenal cortical function in patients with PCO. The adrenal dysfunction of PCO most likely represents abnormal control of adrenal androgen production/secretion.

Hypothalamic osteopenia--body weight and skeletal mass in the premenopausal woman.

Clearly, changes in skeletal bone mass are one of the major issues of potential clinical concern in the health care of the thin premenopausal woman. Each of the three parameters of skeletal mass--1) initial pubertal growth, 2) rate of bone loss, and 3) superimposed estrogen-deficient osteoporosis--may be negatively influenced by syndromes associated with low body weight and weight loss. Inherent in constitutional thinness and nutritional patterns of thin women are alterations in bone growth and rates of bone loss which may predispose to osteopenia and fracture in later adulthood. When these negative factors are compounded by hypothalamic/pituitary-mediated hypoestrogenism, decreased initial bone mass and true osteoporosis may result. We now possess excellent radiographic tools for monitoring bone mass but do not have the capability to predict fracture or diagnose osteoporosis. Urgently needed are longitudinal prospective studies of the dynamics of both trabecular and cortical bone growth and epidemiologic correlation as to the clinical impact (fractures) of decreased BMD in thin women. For the present, a physiologically oriented program directed toward prophylaxis--maximizing initial bone mass, decreasing rates of adult bone loss, and minimizing active osteoporosis--embracing early dietary calcium supplementation and hormonal therapy on an individually assessed basis seems most prudent. Indeed, this bodily "disease" of osteopenia may not be a pathologic process of bone metabolism at all, but truly an "ailment of the spiritual part"--secondary manifestations of sociologic and endocrinologic alterations inherent in the struggles of the mind and body to maintain low body weight.

Anthropomorphic, hormonal, and psychologic correlates of semen quality in endurance-trained male athletes.

Twenty male marathon athletes were evaluated by hormonal profiles, psychologic testing, anthropomorphic indices, and semen evaluations. Although total testosterone (T) was significantly decreased in 14 of 20 subjects, free testosterone (FT) was within the normal range in the majority. Ninety percent of subjects (18 of 20) had normal semen analyses. Running mileage, body fat, T, and FT values did not correlate with semen quality. Two athletes with severe oligospermia were found to have the lowest values of T and FT and significant differences in psychologic stress scores. From these data we conclude that (1) vigorous endurance training may be associated with significantly decreased T values but not sperm production; (2) a subgroup of severely oligospermic athletes may be characterized by an "anorectic" symptom complex including higher stress, increased body leanness, and significantly decreased T levels; (3) male endocrine evaluation should be interpreted within the context of physical activity; and (4) factors other than T levels need to be evaluated when one is formulating a therapy plan in oligospermic male athletes.

Sterilization failures with bipolar tubal cautery.

From a consecutive series of 105 patients undergoing bipolar tubal sterilization (BPS), ten pregnancies were reported, and a tubal patency rate of 16% was found at hysterosalpingography. There were no significant clinical variables separating the BPS failure patients from those with successful sterilization. Ninety percent of the BPS failures were intrauterine, and 90% occurred within three cycles of BPS. The results of this investigation suggest that (1) BPS tubal occlusion may be associated with an increased failure (pregnancy and tubal patency) rate; (2) the majority of BPS failures are intrauterine gestations; (3) delayed fibrosis, rather than immediate tubal destruction, may be the mechanism of BPS tubal occlusion; (4) for maximum effectiveness, patients undergoing BPS should use alternative contraception for two to three cycles; and (5) surgeons employing BPS require precise training in the application of this modality of female sterilization.

PIP: From a consecutive series of 105 patients undergoing bipolar tubal sterilization (BPS), 10 pregnancies were reported, and a tubal patency rate of 16% was found at hysterosalpingography. There were no significant clinical variables separating BPS failure patients from those successfully sterilized. 90% of the BPS failures were intrauterine, and 90% occurred within 3 cycles of BPS. The results suggest that 1) BPS tubal occlusion may be associated with an increased failure rate (pregnancy and tubal patency); 2) the majority of BPS failures are intrauterine gestations; 3) delayed fibrosis, rather than immediate tubal destruction, may be the mechanism of BPS tubal occlusion; 4) for maximum effectiveness, patients undergoing BPS should use alternative contraception for 2-3 cycles; and 5) surgeons employing BPS need precise training in the application of this modality of female sterilization.

Osteopenia in hypoestrogenic young women with anorexia nervosa.

Replacement estrogen therapy for premenopausal women with secondary hypogonadism (exercise/weight loss amenorrheas) remains controversial. In a group of 14 women with anorexia nervosa, amenorrhea, and no evidence of other endocrinopathy or protein-calorie malnutrition, significant osteopenia was demonstrated as assessed by cortical thickness of carpal bones. The degree of bone thinning was related to the duration and age at onset of amenorrhea as well as abnormalities of pubertal milestone progression. In the young women with "constitutionally delayed" menarche, or with secondary amenorrhea and hypogonadism, significant osteopenia may also be present. For those women with (1) hypoestrogenism and amenorrhea of over 36 months' duration, (2) pubertal delay, and (3) early onset of secondary amenorrhea, evaluation of osteopenia radiographically, and serious consideration for estrogen replacement, is important.

Neuroendocrine indices of depression in pseudocyesis. A case report.

Depressive illness has been associated with reversible abnormalities in the pituitary response of growth hormone, prolactin, and ACTH-cortisol. We saw similar neuroendocrine abnormalities in a patient with pseudocyesis. Normalization of the hormonal responses occurred with resolution of the pseudocyesis. Ovarian responsiveness to HCG suggests pseudocyesis to be of central hypothalamic-pituitary origin similar to polycystic ovarian disease, with neuroendocrine data consistent with reversible depression. In patients with affective illness, ovulatory disturbances may be the presenting symptom. Thorough psychosocial evaluation may be an important tool in the diagnosis of and therapy for anovulation.

The "luteal breast": hormonal and sonographic investigation of benign breast disease in patients with cyclic mastalgia.

The pathophysiology, malignant potential, and hormonal therapy for benign breast disease remain controversial. This report investigates the anatomic and endocrinologic correlates of luteal phase mastodynia patients, compared with asymptomatic control subjects. Objective sonographic evidence of fibrocystic disease (FCD) was found in one-half of both mastodynia and control groups. Endocrine abnormalities observed in the mastodynia group included (1) significantly lower luteal phase progesterone and (2) prolactin hyperresponsiveness to thyroid-releasing factor. The presence or absence of anatomic FCD was not correlated with endocrine abnormalities. These data suggest that (1) cyclic mastalgia may be the end result of a dyshormonal milieu resembling the inadequate luteal phase; (2) FCD may be hormonally independent; and (3) cyclic mastalgia and FCD are different, if often coexistent, factors in benign breast disease syndromes.