Management of fertility issues in cancer survivors.

BACKGROUND: With improved survival of cancer patients, the issue of fertility after treatment assumes greater importance. Consideration of fertility preserving measures before treatment needs to be considered. OBJECTIVE: To discuss an approach to management of fertility issues in survivors of cancer. DISCUSSION: Sensitive early counselling on fertility options is important to cancer survivors hoping to achieve a pregnancy. Assessment of fertility, the safety of a possible pregnancy and the impact of cancer treatments on future fertility treatments all need to be considered.

Congenital bilateral absence of the vas deferens, cystic fibrosis mutation analysis and intracytoplasmic sperm injection.

The aim of this study was to assess the outcome of intracytoplasmic sperm injection (ICSI) with fresh and frozen-thawed surgically retrieved spermatozoa from men diagnosed with congenital bilateral absence of the vas deferens (CBAVD). Twenty-seven azoospermic men with their partners were treated [25 with CBAVD and two with clinical cystic fibrosis (CF)]. CF gene mutation analysis and genetic counselling was provided. Spermatozoa were aspirated by microsurgical epididymal sperm aspiration (MESA), percutaneous epididymal sperm aspiration (PESA) or open testis biopsy. Of the men with CBAVD, 60% carried a single mutation, 20% were compound heterozygotes, and 20% had no CF mutation identified. Of the 28 sperm aspiration procedures, 86% had supplementary spermatozoa for cryopreservation with 83% of those samples assessed as satisfactory when thawed. Of 29 cycles with fresh spermatozoa a fertilization rate of 76% of oocytes injected and 17% embryo implantation rate occurred. Twenty-four cycles in which cryopreserved spermatozoa were used resulted in an oocyte fertilization rate of 69% and embryo implantation rate of 20%. Eighteen clinical pregnancies occurred with 14 live births without congenital anomaly. Two pregnancies were achieved following pre-implantation genetic diagnosis. It is concluded that the presence of CF mutations in the male partner does not compromise in-vitro fertilization treatment outcomes or the opportunity for healthy live births.

Microlaparoscopy for suspected pelvic pathology--a comparison of 2mm versus 10mm laparoscope.

This study presents an independently-assessed comparison of the laparoscopic view obtained using a 2mm versus 10mm laparoscope in women with suspected pelvic pathology. Fifteen female volunteers booked for laparoscopy with clinical evidence of pelvic abnormality according to clinical findings and/or pelvic ultrasound were recruited for this study. Sequential observations were carried out by independent observers for clinically significant differences. Although discrepancies were noted in 3 patients the view obtained with the 2mm microendoscope was considered to be comparable to that obtained with the 10mm telescope. The cases with discordant findings included mild or minimal endometriosis and distal tubal disease. The results of this study suggest that microendoscopy is likely to be entirely adequate for many routine laparoscopic procedures and sterilization.

Transarterial embolization of the uterine arteries: patient reactions and effects on uterine vasculature.

BACKGROUND: Therapeutic embolization of the uterine arteries has been successfully used to manage profuse gynecological hemorrhage. In the present study we aimed to investigate whether embolization of uterine arteries may serve as a safe and effective alternative treatment in cases of menorrhagia in fertile and perimenopausal women. As a first step, we have evaluated the methodology, patient reactions and effects on the uterine vasculature. METHODS: The distal part of the uterine artery was embolized with polyvinyl alcohol particles via catheterization of the right femoral artery. Total abdominal hysterectomy was performed the next day. RESULTS: Bilateral embolization in two patients resulted in considerable pain that required morphine analgesic medication and epidural analgesia. One patient was embolized unilaterally and experienced only slight discomfort with no need for analgesic medication at all, indicating that unilateral embolization is a well-tolerated method. After embolization, angiography showed stagnant flow in embolized vessels without contrast filling of distal branches. Angiography of the specimen showed normal vascular architecture in non-treated vessels. In treated vessels the main arterial trunks were patent but all smaller branches were occluded. Histology showed that most of the particles lodged in small arteries and that arterioles never showed injected material. CONCLUSION: The study indicates that the procedure involves an efficient occlusion of uterine vessels and that unilateral embolization of uterine arteries is well tolerated.

Is the male involved in the aetiology of ectopic pregnancy?

We have previously observed a low incidence of ectopic pregnancies in couples having gamete intra-Fallopian transfer (GIFT) with donated spermatozoa. Based on findings in both animal and human models, we proposed the hypothesis that sperm defects may be associated with the expression of paternal genes which cause abnormal early embryo development and predispose the embryos to interact inappropriately with the genital tract epithelium, and so increase the risk of an ectopic implantation. To both confirm and extend the initial observation, GIFT and in-vitro fertilization (IVF) pregnancies entered on the Australian and New Zealand national database between 1979 and 1993 were analysed with regard to the incidence of ectopic pregnancy. There was an increased risk of ectopic pregnancy for IVF relative to GIFT and when spermatozoa from the male partner were used rather than donor spermatozoa. However, when couples were categorized with respect to the aetiology of their infertility, we were unable to show a significant association between ectopic pregnancy and whether spermatozoa from the male partner or a donor were used. We have therefore been unable to confirm a direct association between the source of spermatozoa and ectopic pregnancy.

Granulocyte-macrophage colony-stimulating factor: presence in human follicular fluid, protein secretion and mRNA expression by ovarian cells.

In recent years it has become evident that a leukocyte-cytokine network contributes to the paracrine regulation of ovarian function. The objectives of this study were to examine the presence of a potent lympho-haemopoietic cytokine, granulocyte-macrophage colony-stimulating factor (GM-CSF), in tissues and fluids from human ovaries. In a prospective study, follicular fluid and plasma were collected from naturally cycling women and women undergoing hyperstimulation for in-vitro fertilization (IVF). Granulosa-lutein cells were collected at the time of oocyte recovery for IVF and corpora lutea were collected at the time of hysterectomy for non-ovarian reasons. Culture supernatants from ovarian cell and tissue cultures were harvested on completion of a 48 h incubation. Immunoactive GM-CSF was measured by enzyme-linked immunosorbent assay, and was found to be present at statistically significantly higher levels in follicular fluid (8.9 +/- 0.7 pg/ml) and plasma (11.3 +/- 0.8 pg/ml) of women undergoing hyperstimulation compared to follicular fluid (5.3 +/- 0.3 pg/ml) and plasma (7.1 +/- 0.5 pg/ml) from naturally cycling women. Immunoactive GM-CSF was also detected in culture supernatants of granulosa-lutein cells (47.6 pg/10(5) cells), early luteal phase corpora lutea (0.52 pg/microgram DNA) and mid-luteal phase corpora lutea (0.98 pg/microgram DNA). Furthermore, transcripts for GM-CSF, and both the alpha and beta subunits of the GM-CSF receptor, were detected by reverse transcription polymerase chain reaction (RT-PCR) in granulosa-lutein cell culture preparations and corpora lutea collected during the early, mid- and late luteal phase of the menstrual cycle. These results show that GM-CSF is expressed and secreted by cells within the human ovary, and, together with the finding of expression of mRNA for GM-CSF receptor, suggest a role for GM-CSF in the local regulation of ovarian events.

Distribution of leukocyte subpopulations in the human corpus luteum.

Cytokines, as secreted products of leukocytes, have roles in many organs of the body via paracrine or autocrine mechanisms. In the present study, we demonstrate by immunocytochemistry the leukocytes present in the human corpus luteum in order to investigate further the relationship between leukocytes, cytokines and corpus luteum function. Ten intact corpora lutea were collected from female patients who had no apparent ovarian disease. The mean age of these patients was 37 years (range 23-55 years). Frozen and paraffin sections were subjected to analysis using monoclonal antibodies which were specific to leukocyte marker antigens. The results showed that there are macrophages, cells positive for leukocyte common antigen (LCA), T lymphocytes including T helper/inducer (T4) cells, T cytotoxic/suppressor (T8) cells and activated T (Ta) cells (interleukin-2 receptor-positive cells), monocytes and natural killer (NK) cells but not B lymphocytes present in the human corpus luteum. The distribution of the leukocytes present in the different parts of the corpus luteum was found to be in the order: theca-luteal area greater than loose connective tissue area greater than granulosa-luteal area. Macrophages and T lymphocyte subsets comprised the main components of the total leukocytes in the human corpus luteum. Ta cells were only localized in the loose connective tissue of the corpus luteum. In most cases, macrophages, LCA cells and T4 cells tended to be situated in a single cell layer on the edge of the theca-luteal area and surrounding the granulosa-luteal area. These results suggest that the leukocytes may act to a greater extent in the theca-luteal area than in the granulosa-luteal area.(ABSTRACT TRUNCATED AT 250 WORDS)

The neodymium:YAG laser and the resectoscope for the treatment of menorrhagia.

OBJECTIVE: To assess the efficacy of destruction of the endometrium by ablation with a neodymium:YAG laser or resection with electrocautery in the management of menorrhagia. DESIGN: The efficacy of the treatment was assessed subjectively by each patient comparing the duration and amount of her menstrual bleeding before and after the operative procedure. Randomisation of treatments or patients was not undertaken. SETTING: The study was carried out in tertiary centres. Most of the procedures were undertaken in the Day Surgery Units of those centres. PATIENTS: A total of 64 patients underwent one or more procedures. One had continuous bleeding per vagina on hormone replacement therapy, all others had menorrhagia which they considered incapacitating. INTERVENTIONS: Of the patients 40 had removal of endometrium via a resectoscope and 24 had endometrial vaporisation with the neodymium:YAG laser. MAIN OUTCOME MEASURE: The outcome was assessed by each patient as amenorrhoea, hypomenorrhoea, attainment of normal menstrual amount or no change in menstrual loss. RESULTS: Both operative procedures were satisfactory in that amenorrhoea, hypomenorrhoea or normal menstruation was achieved in 87% of cases. Uterine perforation occurred on two occasions with thermal bowel injury in one patient. CONCLUSION: Destruction of the endometrium by the neodymium:YAG laser or the resectoscope is a successful way of managing menorrhagia in the absence of demonstrable pathological cause in nearly 90% of cases. The performance of the procedures as day cases with minimal discomfort makes them attractive alternatives to hysterectomy in the management of menorrhagia.

Ablation of endometriotic implants in rabbits by hematoporphyrin derivative photoradiation therapy using the gold vapor laser.

In a rabbit model, endometriotic lesions were utilized to study hematoporphyrin derivative (HPD) uptake and the effect of photoradiation using the gold vapor laser. Morphological studies confirmed successful induction of ectopic endometrial growth and the lesions displayed preferential HPD uptake compared to normal intraperitoneal structures. Gold vapor laser irradiation of the lesions in HPD pretreated animals produced necrosis of the endometriotic lesions leaving surrounding tissues healthy. Results from this study suggest that HPD-mediated photodynamic therapy may be a suitable means of treating endometriosis in the human.

Adjuvant leuprolide in normal, abnormal, and poor responders to controlled ovarian hyperstimulation for in vitro fertilization/gamete intrafallopian transfer.

Fifty patients (normal responders) received either human menopausal gonadotropin (hMG) alone (control group) or leuprolide + hMG (leuprolide group). The use of leuprolide was associated with a reduction of hMG requirements (14.8 versus 17.8 ampules, P = 0.02) and the abolition of spontaneous luteinizing hormone surges (nil versus 3, P = 0.006). The rate of fertilization (87% versus 65%, P = 0.003) was higher in the leuprolide group. Pituitary and ovarian suppression was effected for 16 subjects who had previously shown a poor follicular response and a further 19 subjects who had previously responded abnormally. The poor responders required more hMG (43.9 versus 27.1 ampules, P less than 0.001), achieved a lower estradiol maximum (5.1 versus 12.1 nmol/l, P less than 0.001), and had fewer oocytes recovered (4.1 versus 11.5, P less than 0.001), than the abnormal responders.

Muscle cell potassium, RNA and hydration in pregnancy and pre-eclampsia.

Thirty four pregnant women from 26 to 38 weeks gestation and 24 pregnant women with pre-eclampsia gave samples of muscle (rectus abdominis) at caesarean section. Muscle samples were analysed for H2O, K+, Mg2+ and Na+. Cell extracellular H2O was partitioned by the use of the Cl- space. Also protein, nucleic acids and Zn2+ were determined. From 26 to 38 weeks gestation the concentration of K+ per litre of cell water ([Ki]) slowly declined. The slope was significant. Points for patients with pre-eclampsia fell below the line and analysis of covariance showed that the two populations were different (P less than 0.001). Patients A-J were regarded clinically as severe pre-eclamptics. Points for these patients, in general, fell between 1 and 2 SDs below the normal line. Since other cations per litre of muscle cell water did not change, questions are raised. is the cation gap filled by amino acids or does vascular spasm cause a leakage of K+ from muscle cells? Does hypotonicity eventually develop leading to water intoxication? The low oncotic pressure in pre-eclampsia (shown here), the negative free water clearance could all favour increased cell hydration (some evidence for this is presented here towards term). Assessment of available information concerning creatinine excretion during normal pregnancy and K40, K42 studies together with our own rodent studies leads us to believe that a significant increase in muscle mass occurs, but such may not be the case in pre-eclampsia since the reduction in RNA and Zn2+ concentrations in muscle would suggest excessive protein degradation.(ABSTRACT TRUNCATED AT 250 WORDS)

Concentrations of steroid hormones, and of prolactin, in washings of the human uterus during the menstrual cycle.

Levels of steroid hormones, prolactin and protein were determined in trans-cervical flushings of uteri of 73 consenting women presenting for reversal of sterilization. Median total levels of steroids (pmol), prolactin (mu i.u.) and protein (mg) in the washings were: pregnenolone, 4.22; pregnenolone sulphate, 15.1; progesterone, 1.01; dehydroepiandrosterone (DHEA), 8.92; DHEA sulphate, 368; androstenedione, 2.23; testosterone, 1.04; oestrone, less than 0.7; oestrone sulphate, 0.49; oestradiol, 0.08; prolactin, 23.8; and protein, 5.75. Levels of these components of uterine flushings did not vary significantly between Days 6-10, 11-14, 15-20 and 21-28 after the onset of the previous menstrual period (P greater than 0.05). Uniform levels of free steroids in uterine washings throughout the menstrual cycle, and low free steroid/total protein ratios (all less than 3 pmol/mg), support other evidence for a paucity of steroid-binding proteins in human histotroph. The predominance of DHEA sulphate and of pregnenolone sulphate in human uterine washings is in accord with their abundance in plasma, and may provide an important precursor pool for de-novo steroidogenesis by human embryos before implantation. Our results support the view that human histotroph is a filtrate of plasma.

Current investigation and therapy of secondary amenorrhoea.

The advent of radioimmunoassays enabling measurement of pituitary gonadotrophins, ovarian and adrenal steroids and prolactin has allowed precise investigation of patients with secondary amenorrhoea. The most frequently encountered causes of this disorder are associated with hypothalamic-pituitary failure or dysfunction. Clinical and radiographic investigations must be utilised to look for the presence of a pituitary fossa space occupying lesions, particularly when hyperprolactinaemia is found. The presence of hirsutism should alert to the possibility of an adrenal or ovarian tumour or more commonly the presence of the polycystic ovary syndrome. When fertility is required, recommencement of menstrual cycles will often be possible with ovulation-inducing drugs. Patients not wishing to be fertile will often require oestrogen therapy while amenorrhoea persists, as low endogenous oestrogen levels may otherwise lead to menopausal degenerative changes.

Muscle cell growth and the distribution of water and electrolyte in human pregnancy.

Ten normal pregnant women had muscle composition analyses (rectus abdominis) carried out at 39-40 weeks of pregnancy. Water, chloride (Cl), chloride space (ECV), non-chloride space (ICW), potassium (K), sodium (Na), magnesium (Mg) and zinc (Zn) determinations were carried out. Analyses for DNA (cell number), protein: DNA ratio (cell size), RNA and collagen were also performed. Similar analyses were performed on uterine muscle and placentae before and after perfusion with Earle's solution. Data from pregnant patients were compared with similar estimations carried out on rectus abdominis samples from 13 non-pregnant subjects undergoing gynaecological procedures. Muscle tissue and predicted muscle mass (MM) (which constitutes 40% of body weight) demonstrated that the gain in body K was due to the products of conception, that ICW decreased per unit weight in muscle (8%), ECV increased (41%) without a radical change in muscle water content (2%). Overall a 6 l gain in ECV and a 2 l gain in ICW can be accounted for during pregnancy. The results of this study indicate that added hydration excluding the products of conception (placenta, infant, uterus) is mainly extracellular. Intracellular Na concentration decreases (50%) and it is speculated that the cation gap is made up by H+ in the presence of extracellular alkalosis. Muscle cells diminish in size but cell number per gram is constant. Zinc content (Zn/DNA) decreases. Previous experimental work suggests that MM increases by about 10% during pregnancy and this information has been included in considerations but it remains to be shown to what extent total muscle cell numbers increase and as to whether such increased muscle growth remains following pregnancy.

The normal menstrual cycle has no effect on gastric emptying.

Recent studies have demonstrated that orocaecal transit time is prolonged both in the luteal phase of the ovulatory cycle in normal women and during pregnancy, but have made no attempt to differentiate between the individual effects of gastric emptying and small intestinal transit. We have assessed the effect of the normal menstrual cycle on gastric emptying of solids and liquids in 10 women, using a dual isotope scintigraphic technique. In each subject gastric emptying was measured on 2 days: first during the follicular phase (day 8-10) and then during the luteal phase (day 18-20) of one ovulatory menstrual cycle (where day 1 was the first day of menstrual bleeding). Measures of solid and liquid gastric emptying did not change significantly between the follicular and luteal phases indicating that the normal menstrual cycle has no effect on gastric emptying.

A factor present in human milk, but not colostrum, which is cytotoxic for human lymphocytes.

This study reports the presence of a factor in human milk which is cytotoxic to both autologous and heterologous human peripheral blood mononuclear cells (PBMC). The cytotoxic effect was measured by the release of 51Cr from labelled cells or by the inability of PBMC to exclude trypan blue following exposure to milk. The cytotoxic factor was not dialysable or sensitive to heating at 56 degrees C for 30 min, and could not be adsorbed from milk by PBMC. It lysed lymphocytes harvested from colostrum and from autologous or heterologous milk. The cytotoxic factor in the milk was different from the factor found in colostrum which inhibits the proliferation of mitogen stimulated PBMC, but which is not cytotoxic. Testing of serial samples of milk from the same mother indicated that the factor could be detected in the milk after 3-4 days post partum. We conclude that factors cytotoxic for human PBMC appear in human milk early in lactation.

Inhibition by colostrum of the responses of peripheral blood mononuclear cells to mitogens.

This study investigated the inhibition by colostrum of the uptake of tritiated thymidine by both autologous and heterologous peripheral blood mononuclear cells (PBMC) stimulated with the mitogens phytohaemagglutinin (PHA), pokeweed mitogen (PWM) or Concanavalin A (Con A). This inhibition was not the result of an alteration in the dose response or kinetics of mitogenesis by the colostrum. The inhibitory factor in the colostrum was neither dialysable nor lymphocytotoxic. Lymphocytes which were briefly pre-treated with colostrum, then washed and cultured, also incorporated much less labelled thymidine than control cells. The inhibitory factor was not adsorbed from colostrum by mononuclear cells. We conclude that colostrum contains a cytostatic factor which inhibits mitogenesis in PBMC.

Blood flow in the ovary and adjacent structures of the non-pregnant sheep.

Blood flow of the ovary, vascular pedicle and oviduct was measured in anaesthetized non-cycling and cycling ewes by timed collection of ovarian venous blood. The degree of arterio-venous shunting across the ovary and pedicle was estimated both in vivo and in vitro by perfusing the tissues with 15 +/- 5 micrometers radioactive microspheres. The mean ovarian blood flow in non-cycling animals was 1.9 ml/min, which was 51% of blood flow in the ovarian vein. In cycling animals ovarian blood flow at midcycle was 2.9 ml/min (66% of ovarian venous flow) in non-luteal ovaries and 4.3 ml/min (79% of venous flow) in luteal ovaries. The degree of arterio-venous shunting was low in all stages of the cycle (1.0-2.6% across ovary + pedicle). The degree of shunting was also found to be very small in vitro (0.007-1.38%) in both non-luteal and luteal ovaries. A considerable number of microspheres was entrapped in the vascular pedicle of the ovary indicating the presence of an extensive capillary bed. There was an inverse relationship between blood flow in the ovary and flow in the vascular pedicle. Alterations in distribution of blood flow between the ovary and adjacent structures supplied by the ovarian artery may be of functional significance in allowing rapid changes in ovarian blood flow. The results of the present study indicate that changes in ovarian blood flow during the oestrus cycle are not caused by an action on arterio-venous shunt vessels.