Variant progesterone receptor mRNAs are co-expressed with the wild-type progesterone receptor mRNA in human endometrium during all phases of the menstrual cycle.

Progesterone receptor (PR) variant mRNAs in human endometrium could encode proteins with the potential to alter progesterone action in states of normal and abnormal endometrial development. We have assessed the expression levels of mRNA for the wild-type PR and splice variants of PR mRNA lacking exon 4 (del-4 PR), exon 6 (del-6 PR), exons 4 and 6 (del-4&6 PR), and part of exon 4 (del-p4 PR) or part of exon 6 (del-p6 PR) in the human endometrium throughout menstrual cycle development. Eighty-eight endometrial specimens (47 proliferative, 41 secretory) were collected from patients undergoing hysterectomy for benign gynaecologic causes. Measurements by RT-PCR indicated that mRNAs for wild-type PR, and splice variants del-4 PR, del-6 PR, del-4&6 PR, del-p6 PR, and a novel del-p4 PR were detected in all endometrial specimens throughout the menstrual cycle. Higher levels of wild-type PR and all PR variant mRNAs were found in the early and mid-proliferative endometrial phases than in secretory endometrium. The relative expression of mRNA for all PR variants compared to wild-type PR mRNA, however, did not change through all stages of endometrial development. We, therefore, found no evidence of differential co-expression of the PR variants compared with wild-type PR during normal menstrual development. Future studies will determine if the expression profile of PR variant mRNAs will be different in the endometrium of patients with infertility, recurrent pregnancy loss, or endometrial adenocarcinoma.

Hydrosalpinx treated with extended doxycycline does not compromise the success of in vitro fertilization.

OBJECTIVE: To determine if extended treatment with doxycycline before and after an in vitro fertilization (IVF) procedure can minimize the detrimental effect of a hydrosalpinx. DESIGN: Retrospective analysis. SETTING: University IVF program. PATIENT(S): Patients undergoing IVF, including 17 with a hydrosalpinx, 25 with adhesions or proximal tubal occlusion, and 22 with endometriosis or unexplained infertility. INTERVENTION(S): Women with a documented hydrosalpinx were prescribed doxycycline 100 mg twice daily starting 1 week before expected retrieval and continued until 6 days after retrieval. No antibiotics were prescribed in the other groups. MAIN OUTCOME MEASURE(S): Implantation rates and IVF outcomes. RESULT(S): Implantation rates were 30% for the doxycycline-treated group of patients with a hydrosalpinx, 27% for the group with tubal occlusion/adhesion, and 24% for the group with endometriosis or unexplained infertility. Eight (47%) of 17 patients with a hydrosalpinx had a live birth, compared with 11 (44%) of 25 for the group with tubal occlusion/adhesion and 12 (55%) of 22 for the group with endometriosis/unexplained infertility. There were no differences between the groups in patient age, number of oocytes retrieved, fertilization rate, or number of blastomeres of the transferred embryos. CONCLUSION(S): No detrimental effect of a hydrosalpinx was evident for patients treated with extended doxycycline. Tremendous cost savings can be realized if treatment with 2 weeks of an inexpensive antibiotic provides outcomes comparable to surgical correction of a hydrosalpinx before IVF.

Uterine artery embolization for symptomatic uterine myomas.

OBJECTIVE: To evaluate the role of uterine artery embolization as treatment for symptomatic uterine myomas. DESIGN: Medline literature review, cross-reference of published data, and review of selected meeting abstracts. RESULT(S): Results from clinical series have shown a consistent short-term reduction in uterine size, subjective improvement in uterine bleeding, and reduced pain following treatment. Posttreatment hospitalization and recovery tend to be shorter after uterine artery embolization compared with hysterectomy. Randomized controlled trials have not been conducted, and long-term efficacy has not been studied. A limited number of deliveries have been reported following uterine artery embolization for uterine myomas. CONCLUSION(S): Uterine artery embolization is a unique new treatment for symptomatic uterine myomas. Even without controlled studies, demand for this procedure has increased rapidly. Uterine artery embolization may be considered an alternative to hysterectomy, or perhaps myomectomy, in well-selected cases. At the present time, however, uterine artery embolization should not be routinely recommended for women who desire future fertility.

Delayed oral estradiol combined with leuprolide increases endometriosis-related pain.

OBJECTIVES: To determine if low-dose estrogen replacement can be added to GnRH agonist therapy after three months to reduce hypoestrogenic symptoms while allowing continued relief of pain in patients with endometriosis. MATERIALS AND METHODS: Thirteen women with endometriosis and pain were treated with six months of leuprolide acetate in a prospective, randomized double-blind placebo controlled study. After three months of therapy, six subjects initiated oral estradiol 1 mg daily, and seven received an identical placebo. RESULTS: Dysmenorrhea improved in both groups, and dyspareunia significantly improved in the GnRH agonist plus placebo group. The mean pain scores of the oral estrogen group tended to be higher than the placebo group, and hot flushes tended to be less severe with estrogen treatment. However, differences observed between the study and placebo groups did not reach statistical significance. CONCLUSION: In a prospective, randomized study, low-dose estrogen replacement increases endometriosis-related pain during GnRH agonist therapy. The study was terminated after the first 13 subjects due to the concerning trend toward recurrent symptoms in women who received oral estradiol during GnRH agonist therapy for endometriosis-related pain. With the trend toward increasing pain with estrogen add-back therapy, a larger study would not seem to be justifiable.

Permanent implantation of expanded polytetrafluoroethylene is safe for pelvic surgery. United States Expanded Polytetrafluoroethylene Reproductive Surgery Study Group.

Clinical trials have shown the expanded polytetrafluoroethylene (ePTFE) membrane to be a highly effective adhesion barrier in gynaecological reconstructive surgery, but the material has not gained wide acceptance because of uncertainty about long-term safety. We conducted a prospective, observational multicentre study to determine if permanent implantation of the ePTFE membrane in the pelvis caused any adverse effects. The subjects were 146 women in whom the membrane was implanted permanently during peritoneal reconstruction in 1991-1996. Postoperatively, patients were examined at regular intervals. The mean postoperative observation time was 3.5 years. No long-term complications occurred. There were 10 births by Caesarean section and 12 by vaginal delivery. All of the pregnancies before these 22 births were uneventful, including 10 in which the women had uterine implantation sites. There were two ectopic pregnancies and three spontaneous abortions. Since the primary purpose of the study was to evaluate the long-term safety of ePTFE, early second-look laparoscopy was not performed routinely. Nevertheless, 24 women had a subsequent operation. Adhesions were present at 8/21 of the membrane sites in these women, a significant decrease compared with adhesions at 17/21 sites during the initial procedure (P = 0.005). This large, multicentre study confirmed the long-term safety of the ePTFE membrane in pelvic reconstruction. Removal of the barrier is not necessary.

Computer-controlled bipolar endotubal sterilization is successful in a rabbit model.

OBJECTIVE: To determine the efficacy of a computer-controlled bipolar endotubal catheter system designed to accomplish safe, effective, and inexpensive female sterilization in preventing pregnancy in a rabbit model. DESIGN: Prospective controlled study. SETTING: University animal care facility. ANIMAL(S): Sixty healthy virginal female New Zealand white rabbits. INTERVENTION(S): Rabbits were assigned to the following groups: [1] endotubal radiofrequency minimal energy (95 degrees C) treatment; [2] endotubal radiofrequency maximal energy (105 degrees C) treatment; [3] endouterine radiofrequency (105 degrees C) treatment; [4] nonsurgical control; [5] laparotomy-only control; [6] endotubal radio-frequency sham control; and [7] external Kleppinger forceps bipolar cautery control. Rabbits were mated at 4 or 12 weeks after treatment. MAIN OUTCOME MEASURE(S): Pregnancy outcomes in treated animals and nontreated controls. RESULT(S): No pregnancies were observed in any of the uterine horns in which minimal or maximal energy was delivered to the fallopian tubes or uterus, although pregnancy occurred in one horn as a result of the delivery of energy below the radiofrequency minimum of 95 degrees C. The outcomes of the treatment groups were significantly different from those of the nonsurgical and sham surgical control groups. CONCLUSION(S): With adequate tissue heating, 100% sterilization efficacy was achieved with a new, computer-controlled bipolar catheter, whereas pregnancies occurred in all untreated control groups. If human studies support these results, the goal of a safe, effective means of transcervical sterilization may be realized.

Controlled radiofrequency endotubal sterilization.

STUDY OBJECTIVE: A safe, effective, inexpensive method of transcervical tubal sterilization could have a major impact on women's health. In this study, we evaluated the efficacy of a new radiofrequency catheter prototype designed for endotubal sterilization using animal models. SETTING: Animal research laboratory. DESIGN: Prospective observational study. METHOD: The optimal energy delivery to create a complete circumferential transmural thermal lesion in the tube was determined in 114 in vitro acute studies using porcine and bovine fallopian tubes. A study was then initiated with eight mini-pigs. Thirty-four lesions were made in the fallopian tubes using computer-controlled power delivery. Three weeks later the animals were euthanized and evaluated. MEASUREMENTS AND MAIN RESULTS: A hydrosalpinx was evident in 8/11 of the tubes with separate proximal and distal cautery, implying occlusion at each of these sites. Complete occlusion of the tubes was seen at 12/22 sites evaluated by histology. Narrowing was seen in 9/22, and 1/22 was open. CONCLUSION: The endotubal cautery prototype creates a reproducible lesion, but did not always cause complete closure of the tube in this preliminary study. However, based on our results, we hypothesize that a radiofrequency catheter can be developed for minimally invasive transcervical sterilization.

Reproductive sequelae in female rats after in utero and neonatal exposure to the phytoestrogen genistein.

OBJECTIVE: To determine reproductive sequelae in female rats after in utero and lactational dietary exposure to genistein. DESIGN: Experimental animal study. SETTING: University laboratory. ANIMAL(S): Sprague Dawley rats. INTERVENTION(S): Pregnant rats were fed control rat chow or rat chow incorporated with genistein (approximately 50 microg/d) beginning on day 17 of gestation and continuing until the end of lactation (postpartum day 21). Genistein-exposed female pups were divided into two groups on day 21. One group continued to receive a genistein-added diet (G70); the other group was changed to a control diet (Ex-G). At necropsy (days 21 and 70), blood and reproductive tissues were collected. MAIN OUTCOME MEASURE(S): Serum levels of gonadotropins and gonadal steroids and histopathologic examination of the ovaries. RESULT(S): The weight of the ovaries and uterus and serum levels of E2 and progesterone in genistein-exposed rats on day 21 (G21) were significantly reduced compared with control rats. On day 70, serum levels of E2, progesterone, LH, and FSH were similar in all groups. Atretic follicles and secondary interstitial glands were more common in G70 and Ex-G rats compared with control rats. Cystic rete ovarii was observed in some G70 and Ex-G rats. CONCLUSION(S): Our data indicate that in utero and lactational exposure to dietary genistein adversely affects reproductive processes in the adult female rat.

Diagnosing ovarian torsion with computed tomography. A case report.

BACKGROUND: The diagnosis of adnexal torsion is difficult to make on the basis of symptoms, physical findings or radiologic techniques. Unfortunately, delayed intervention can lead to irreversible damage and loss of the adnexa. This report describes a finding seen on computed tomography (CT) that may increase suspicion of the diagnosis of ovarian torsion. CASE: A 21-year-old woman was admitted with constant abdominal pain and a tender retrouterine mass. Ultrasound failed to provide a definitive diagnosis. CT showed a central, hypodense area consistent with fat and surrounded by a shell of intermediate density. At laparotomy the patient was found to have a necrotic left adnexa due to torsion. Bisection of the adnexal mass confirmed a dermoid cyst with overlying edematous ovarian cortex. CONCLUSION: The observation of a round, hypodense central lesion (dermoid cyst) surrounded by thickened, edematous ovarian cortex on CT is a finding that may aid in the diagnosis of adnexal torsion. The finding is a thickened shell of ovarian cortex surrounding a central mass that has caused the torsion; in this case it was a dermoid cyst.

Assisted hatching does not enhance IVF success in good-prognosis patients.

PURPOSE: The role of assisted hatching in good-prognosis IVF patients was evaluated in a prospective, randomized, controlled pilot study, which was followed by a retrospective observational series. METHODS: After assisted hatching was proved successful in a mouse embryo study, 20 good-prognosis IVF patients were randomly assigned to either assisted hatching (13) or no assisted hatching (7; the controls). Following this series, 27 good-prognosis IVF patients were retrospectively evaluated to determine the outcome with assisted hatching. RESULTS: In the prospective study, clinical pregnancies resulted from 3 (23%) of 13 patients in the hatching group, compared to 3 (43%) of 7 in the control group. Implantation rates were similar: 9.6% in the hatching group and 10.7% in the controls. In the retrospective series, the 11.1% implantation rate with assisted hatching was significantly less than the 42.9% implantation rate seen with traditional IVF. CONCLUSIONS: Implantation and pregnancy rates are high in young women undergoing traditional IVF. Assisted hatching is not beneficial in these patients.

Preprogrammed, unmonitored ovarian stimulation reduces expense without compromising the outcome of assisted reproduction.

OBJECTIVE: To determine if a novel, preprogrammed, unmonitored stimulation protocol could reduce the cost of assisted reproductive technology (ART) without compromising outcome or safety. DESIGN: Prospective, nonrandomized study of unmonitored ART versus traditional monitoring. SETTING: University ART program. PATIENT(S): Infertile women aged < 39 years, with a basal FSH level < 15 mIU/mL (conversion factor to SI unit, 1.00) and regular menstrual cycles, undergoing ART. INTERVENTION(S): Oocyte retrieval was performed at a predetermined time in 72 unmonitored cycles based on age and basal FSH level. No monitoring of any type was performed before retrieval. There were 86 monitored control cycles. MAIN OUTCOME MEASURE(S): The number of oocytes, and embryos; complications including ovarian hyperstimulation. RESULT(S): The total cost for unmonitored ART was significantly less than for monitored cycles. There was no difference between groups for patient age, number of oocytes obtained, or number of metaphase II oocytes. For non-male-factor patients, the number of oocytes fertilized, number of embryos transferred, and the clinical pregnancy rates were comparable. There was one case of severe hyperstimulation requiring hospitalization in the unmonitored group. CONCLUSION(S): This novel, unmonitored ovarian stimulation protocol provides ART at a significantly lower cost than is incurred with traditional monitoring, with no apparent compromise in outcome.

The role of oestrogen in follicular development.

Most of our knowledge of ovarian physiology is based upon studies that have demonstrated functional oestrogen receptors in the ovaries of lower animal species. The presence of oestrogen receptors in primate granulosa cells has been questioned by some investigators. However, we have found oestrogen receptor messenger RNA in human granulosa cells by reverse transcriptase-PCR assay. Furthermore, using immortalized granulosa cell lines transfected with a plasmid containing an oestrogen response element, a functional oestrogen receptor was confirmed. These experiments strongly support the hypothesis that human granulosa cells express biologically active oestrogen receptor.

Neonatal exposure to coumestrol, a phytoestrogen, does not alter spermatogenic potential in rats.

The objective of this study was to determine the effects of neonatal exposure to phytoestrogens on male reproductive function as adults. Male rats were injected either with 100 micrograms coumestrol or DMSO (controls) daily during their first 5 d of life. Pituitary gland, testes, sex accessory organs, and blood were collected on d 60 of life. Serum testosterone, LH, and FSH levels were determined by RIA. Levels of steady-state mRNA for gonadotrophin subunits (LH beta and FSH beta were determined by Northern blot analysis and quantified by a scanning densitometer. Coumestrol had no effect on weights of testes and sex accessory organs, or sperm count. Similarly, there were no significant differences among serum concentrations of testosterone, LH beta and FSH of coumestrol-treated rats and those of controls. Whereas steady state levels of LH beta mRNA in coumestrol-treated rats did not differ from those of controls, steady state levels of FSH beta mRNA increased (37%) in treated animals. However, the augmented FSH beta mRNA expression in coumestrol-treated rats did not negatively affect reproductive potential in male rats. We conclude that neonatal exposure to coumestrol does not alter reproductive organ structure or spermatogenic potential in male rats.

Transcervical gamete and zygote intrafallopian transfer. Does it enhance pregnancy rates in an assisted reproduction program?

OBJECTIVE: To evaluate the role of early tubal transfer procedures, we compared outcomes of transcervical gamete intrafallopian transfer (TC-GIFT) and transcervical zygote intrafallopian transfer (TC-ZIFT) versus in vitro fertilization/embryo transfer during the first two years of our assisted reproduction (AR) program. STUDY DESIGN: Prospective, nonrandomized, concurrent, controlled comparison of TC-GIFT and TC-ZIFT pregnancy outcomes versus those after IVF-ET. All cycles for patients less than age 39 undergoing transfer of at least three viable oocytes, zygotes or embryos in the first two years of our program were included. Patients with normal fallopian tubes underwent TC-GIFT (n = 9) or TC-ZIFT (n = 12), whereas those with tubal compromise underwent IVF-ET (n = 28). RESULTS: Implantation rates were 4.2% for TC-ZIFT, 2.8% for TC-GIFT and 3.7% for combined TC procedures as compared to 7.4% for IVF-ET. Delivery rates were no different for the TC procedures than the IVF-ET procedures (14%). Patients ages, number of oocytes retrieved and number transferred were comparable between the TC and IVF-ET groups. CONCLUSION: TC-GIFT and TC-ZIFT did not enhance the pregnancy outcome as compared to IVF-ET in the first two years of our AR program. Ultrasound-directed tubal catheterization is harder to learn and more difficult and expensive to perform than simple uterine embryo transfer. Since we could not demonstrate an improved outcome for TC transfers even in a new AR program, IVF-ET and laparoscopic GIFT are now our procedures of choice.

Ovulation induction in the nonestrogenized patient.

Women with nonestrogenized amenorrhea comprise a wide array of clinical problems. Identification and correction of the underlying pathologic process is the most appropriate approach to ovulation induction. Patients with central nervous system (CNS) or hypothalamic amenorrhea are treated with pulsatile gonadotropin-releasing hormone (GnRH) when it is not possible to correct the underlying causes of these disorders. Gonadotropin therapy is needed for pituitary-related amenorrhea after conservative therapy is unsuccessful. However, ovarian hyperstimulation and multiple pregnancies are risks of gonadotropin therapy. The outcome is poor for ovarian failure or gonadotropin-resistant ovaries. An occasional pregnancy is established, but oocyte donation or adoption should be an early consideration. Women with nonestrogenized amenorrhea and a low or normal follicle-stimulating hormone (FSH) level can expect high ovulation and pregnancy rates with gonadotropin therapy when more conservative means are unsuccessful: Treatment is not likely to benefit those with elevated FSH levels.

Endoscopic ultrasound. A new instrument for laparoscopic surgery.

OBJECTIVE: Although laparoscopy is an important tool for evaluating pelvic pathology, visualization is limited to the surface of structures. A method of seeing below the surface during laparoscopy could be useful. We report on our early experience with new laparoscopic ultrasound. STUDY DESIGN: Following diagnostic laparoscopy the pelvis is filled with fluid to obtain optimal imaging. A 10-mm ultrasound probe is introduced through the umbilical trocar and the uterus and adnexa examined. RESULTS: High-resolution images can be obtained to delineate such abnormalities as suspected ovarian cysts and uterine myomata. CONCLUSION: Endoscopic ultrasound is a new instrument that allows the surgeon to evaluate and define pelvic pathology suspected at the time of laparoscopy. Endoscopic ultrasound may augment the diagnosis of subtle pathologic findings during laparoscopy.

Evaluation of synthetic serum substitute versus serum as protein supplementation for mouse and human embryo culture.

PURPOSE: Our purpose was to determine the effect of Synthetic Serum Substitute (SSS) versus serum supplementation on fertilization rates and subsequent development of embryos from patients undergoing IVF. PROCEDURE: Experiment I compared the effects of SSS to human serum on mouse embryo development. Two hundred one-cell B6D2F1 mouse embryos were cultured in 100-microliter droplets of human tubal fluid (HTF) containing either (1) no protein (control; n = 37), (2) 15% serum from women with tubal infertility (n = 44), (3) 15% serum from women with endometriosis (n = 49), (4) 15% fertile donor serum (n = 33), or (5) 15% SSS (n = 37). Experiment II compared the effects of SSS to human serum on the development of embryos from patients undergoing IVF. Thirty-three women were included in this study. A total of 371 oocytes was cultured in HTF containing either (1) maternal or donor serum (n = 140) or (2) 15% SSS (n = 231). Embryo development was evaluated 48 hr after fertilization. RESULTS: In Experiment I, the rate of blastocyst development was evaluated at 48, 72, and 96 hr of culture. Sixty-four and nine-tenths percent of embryos cultured in SSS were morulae at 48 hr of culture (versus 5.4, 0, 8.2, and 6.1 in Groups 1, 2, 3, and 4, respectively). By 72 hr, 29.7% of these embryos had developed into blastocysts (versus 0, 0, 8.2, and 3.0, for Groups 1, 2, 3, and 4, respectively). This percentage increased to a total of 83.7 after 96 hr (versus 27.0, 20.4, 38.8, and 39.4 for Groups 1, 2, 3, and 4, respectively). Forty-three and two-tenths percent of the blastocysts cultured in SSS had hatched from their zonae by 96 hr. With the exception of Group 5, which had a rate of 9.1%, embryo hatching was not observed in any of the groups at the termination of culture (96 hr). In Experiment II there were no differences in cell stage or quality of human embryos cultured in SSS or serum, but fertilization rates tended to be better (P = 0.07) for oocytes inseminated in media containing SSS (70.0%, vs 55.0% for serum). CONCLUSIONS: SSS appears to be a superior protein source for mouse embryo growth and is as good as serum from fertile donors in promoting in vitro human embryo development.