Peritoneal fluid prostanoids in unexplained infertility.

Elevated peritoneal fluid thromboxane B2 and 6-keto-prostaglandin F1 alpha have been reported in patients with biopsy-proved endometriosis. In this paper these peritoneal fluid prostanoids were measured in patients with unexplained infertility and a fertile control group matched for age and day of the menstrual cycle. A subgroup of the women with unexplained infertility demonstrated a marked elevation of both prostanoids (p less than 0.01). These elevations may serve to identify women in whom undetected endometriosis or some other peritoneal irritant is associated with infertility.

Microsurgical reanastomosis of the fallopian tubes for reversal of sterilization.

Reversal of previous tubal ligation procedures for the restoration of fertility has become an increasingly frequent request. Microsurgical techniques are believed to offer a postoperative pregnancy rate superior to that obtained with macroscopic procedures. Of 63 women who requested reversal, microsurgical reanastomosis was performed in 40. With at least 6 months' follow-up, 22 women have become pregnant (55%), and there has been 1 ectopic pregnancy (2.5%). Comparison with previous studies using standard macroscopic techniques indicates that the use of meticulous surgical methods with precise reapproximation of the fallopian tubes results in a significant (P less than .005) improvement in pregnancy rates.

Peritoneal fluid thromboxane B2 and 6-keto-prostaglandin F1 alpha in endometriosis.

An anatomic basis for the infertility associated with endometriosis is often lacking. The present study measured peritoneal fluid levels of two of the stable products of prostaglandin endoperoxides (thromboxane B2 and 6-keto-prostaglandin F1 alpha) in patients with and without endometriosis. Both compounds were significantly elevated in the endometriosis group (n = 15, p less than 0.05). This suggests an increase in the peritoneal fluid levels of thromboxane A2 and prostacyclin, both of which could act on tubal smooth muscle and interfere with tubal function. Such altered tubal function might explain the phenomenon of endometriosis-induced infertility when there is no direct damage to the reproductive organs.

Pituitary response to LHRH in hypothyroid women.

This study was designed to characterize pituitary function in premenopausal women during hypothyroid and euthyroid periods. Six subjects with basal thyroid-stimulating hormone (TSH) levels above 10 microU/ml were studied. Estradiol (E2), prolactin (PRL), follicle-stimulating hormone (FSH), and luteinizing hormone (LH) levels were measured by radioimmunoassay at 30, 15, and 0 minutes before infusion. Pituitary function was evaluated by rapid infusion of 10 micrograms of luteinizing hormone-releasing hormone (LHRH) every 2 hours for a total of 6 hours. Samples were then obtained for FSH and LH every 30 minutes for the duration of the 6-hour study. A significant elevation in basal gonadotropins was observed during the hypothyroid period regardless of basal E2 levels in all 6 subjects (P < .01). Basal PRL levels were not significahtly different during the 2 periods (P > .05). In all 6 patients pituitary sensitivity and reserve correlated significantly with basal E2 levels (P < .05), but were not altered by the hypothyroid condition. It is concluded that pituitary responsiveness to LHRH is not altered in hypothyroid women, but that chronic elevation of basal gonadotropins may in part explain the anovulation that so often accompanies this disorder.

Ultrasonographic versus clinical evaluation of a pelvic mass.

Ultrasonography has become an essential tool in the practice of modern obstetrics. Its usefulness in the evaluation of a pelvic mass in gynecologic practice remains unclear. The present investigation is a comparison of pelvic examination findings and preoperative ultrasound findings in 72 patients who underwent exploratory laparotomy for a pelvic mass at the Nation Naval Medical Center. Of the 72 patients, 65 (90%) were correctly diagnosed as having a pelvic mass by both pelvic examination and ultrasonography. The ultrasound study had a 5.6% false-negative rate (4 patients), and 4.4% (3 patients) had false-positive pelvic examinations. There was no significant difference by chi 2 analysis in accuracy between ultrasonography and pelvic examination in detection, estimation of size, or determining the unilateral or bilateral position of the mass (P less than .05). Ultrasonography was significantly more accurate in determining the cystic or solid nature of the mass (P greater than .05). In no patient was the decision to perform exploratory laparotomy altered by the preoperative ultrasound study. It is concluded from this investigation that routine ultrasonography is not necessary in the preoperative evaluation of a pelvic mass unless the cystic or solid nature of the mass will modify the patient's treatment.

Postpartum hypokalemic paralysis.

An attack of hypokalemic paralysis occurring in a 23-year-old woman during the immediate postpartum period of her fourth pregnancy is described. A flaccid paralysis of her extremities and markedly diminished deep tendon reflexes developed 3 hours after delivery, at which time her serum potassium level was found to be 1.7 mEq/liter. Hypokalemic paralysis has not been previously reported as an immediate postpartum complication. The pathophysiology and management of this condition are discussed, as are the treatment and follow-up of this specific patient.

The physiologic hyperparathyroidism of pregnancy. Is it primary or secondary?

Controversy exists over whether the increase in maternal serum parathyroid hormone levels observed during the second half of pregnancy is due to autonomous parathyroid function or is secondary to changes in maternal serum ionized calcium levels. In order to study this problem further, 9 subjects were followed serially throughout normal pregnancy. Total serum calcium, ionized calcium, parathyroid hormone (PTH), calcitonin, and albumin levels were measured monthly. Six of these subjects had the studies repeated 6 weeks postpartum. Serum ionized calcium levels were found to decrease from 3.81 +/- 0.12 mg/dl to 3.63 +/- 0.18 mg/dl between 21 and 25 weeks' gestation. This decrease was significant at P less than 0.01. The ionized calcium remained in this lower range until term. A significant return to 3.77 +/- 0.1 mg/dl was observed 6 weeks postpartum. Serum PTH levels showed a significant rise after 21 weeks' gestation (P less than 0.05). No serial change in serum calcitonin was observed during pregnancy, although the mean level of the group was significantly higher than in nonpregnant controls (P less than 0.01). The increase in maternal serum PTH observed during pregnancy appears to be due in part to a decrease in maternal serum ionized calcium.

A reassessment of the fractional postcoital test.

The present investigation was designed to reassess the fractional postcoital test (PCT). Specifically, the study addressed the question of whether the internal cervical mucus sperm count is significantly different from the sperm counts at other cervical levels. By means of standardized methodology, 25 normal postcoital tests were perfoemed on 22 couples. Cervical mucus from three different levels within the endocervical canal was examined for total count, motility, and sperm morphology. No significant difference could be found in these three parameters among any of the cervical levels (p greater than 0.05). Significantly fewer abnormal sperm were found in the cervical mucus when compared to the total abnormal forms in the semen (p less than 0.001). Therefore, while the fractional PCT is a reflection of cervical sperm, this study indicates that the three different cervical levels in the fractional PCT (internal-mid-external) are equally effective in the interpretation of the postcoital test.

Continued clinical experience with an increasing dosage regimen of clomiphene citrate administration.

Between August 1, 1975, and July 31, 1977, 60 patients with infertility and ovulatory dysfunction were evaluated at the Naval Regional Medical Center, Oakland. Of these, 15 had incomplete work-ups or were lost to follow-up. Of the remaining 45 patients, 2 (4.5%) failed to ovulate at a maximal dose of 250 mg of clomiphene for 5 days with 10,000 units of human chorionic gonadotropin. Of the 43 (95.5%) who did ovulate, 33 conceived. Of these 33 patients, 9 (27%) required greater than 100 mg of clomiphene and/or longer than three ovulatory cycles to conceive. Of the 10 patients who did not become pregnant, additional infertility factors were present in 5. When these 5 were eliminated, the corrected pregnancy rate was 87% (33 of 38). The spontaneous abortion rate was 12.2% and there were no multiple gestations. These results would further emphasize that clomiphene can be used safely and effectively at doses greater than 100 mg or for longer than three ovulatory cycles.

Spontaneous pregnancy during the infertility evaluation.

Of 299 patients evaluated for infertility between July 1, 1974, and December 31, 1976, 21 (7.2%) became pregnant during the initial evaluation prior to any recognized therapy. A comparative analysis was made between these 21 couples and the 223 completely evaluated infertility couples. No significant difference in sexual, psychiatric, or menstrual history was found. There was a significantly increased incidence of low coital frequency in the pregnancy group (P less than 0.01). The mean duration of infertility was also significantly less (1.6 years versus 2.9 years) in the pregnancy group. It is concluded that the majority of patients who become pregnant during an evaluation for infertility do so because of prior low coital exposure. There was no evidence in this study to support the concept that psychophysiologic factors were altered in these 21 couples during the initial clinical visits.