An evaluation of the inter-observer and intra-observer variability of the ultrasound diagnosis of polycystic ovaries.

BACKGROUND: This prospective observational study was undertaken to evaluate the reliability and consistency of ultrasound diagnosis of polycystic ovarian syndrome (PCOS). METHODS: Eighteen women with clinical and biochemical features suggestive of PCOS and nine normal control women underwent transvaginal ultrasound scan by a single ultrasonographer. The 27 ovarian scans were video-recorded and the recordings were later edited and arranged randomly so that each record appeared twice at random on the tape producing a total of 54 ovarian scans. Four experienced observers independently reviewed the recordings. The observers scored each case as follows: normal, possible polycystic ovary (PCO) and definite PCO. RESULTS: The mean intra-observer agreement was 69.4% (kappa = 0.54) and the mean inter-observer agreement was 51% (kappa = 0.28). CONCLUSION: The results suggest that the currently used ultrasonographic criteria for the diagnosis of polycystic ovaries do have significant intra-observer and inter-observer variability and as such must be considered subjective. Transvaginal ultrasonography alone may not therefore be a reliable method of diagnosing or excluding PCOS.

Factor V Leiden and prothrombin G20210A mutations in pregnancies with adverse outcome.

BACKGROUND: Inherited thrombophilia has been associated with obstetric complications through mechanisms that are not yet fully elucidated. The aim of this study was to investigate the relationship between specific obstetric adverse outcomes and factor V Leiden and prothrombin G20210A mutations. METHODS: Forty-five women with adverse pregnancy outcome defined as severe pre-eclampsia, abruptio placentae, intrauterine growth restriction and stillbirth, were tested for factor V Leiden and prothrombin G20210A mutations. The control group comprised 100 women with at least one normal pregnancy and no history of thrombosis. RESULTS: Overall, 13 women with one or more of the above-mentioned pregnancy complications (28%) had either thrombophilic mutation, as compared with six in the control group (6%) (p < 0.001, odds ratio (OR) 6.1; 95% confidence interval (CI) 1.9-20). The factor V Leiden mutation was detected in ten of the women with complicated pregnancies (22%) and in four of the controls (4%) (p < 0.001, OR 6.6; 95% CI 1.7-27.2). The prothrombin G20210A mutation was detected in three women in the group with complications (6%) and in two of the controls (2%) (p = 0.17, OR 3.4; 95% CI 0.4-30.5). Compared to controls, the prevalence of the factor V Leiden mutation was significantly higher in the subgroups of severe pre-eclampsia, abruptio placentae and fetal growth restriction. The prevalence of the prothrombin G20210A mutation does not appear to be significantly different from that in the controls in any of the groups studied. CONCLUSIONS: Our data suggest that inherited thrombophilia, and specifically the factor V Leiden mutation, may be associated with adverse pregnancy outcome. The role of the prothrombin G20210A mutation remains to be elucidated.

Factor V leiden and prothrombin G20210A mutations, but not methylenetetrahydrofolate reductase C677T, are associated with recurrent miscarriages.

The aim of this study was to investigate the relationship between recurrent miscarriages and factor V Leiden, prothrombin G20210A and C677T methylenetetrahydrofolate reductase (MTHFR) mutations. In this case-control study the prevalence of factor V Leiden, prothrombin G20210A and C677T methylenetetrahydrofolate reductase mutations was determined in a consecutive series of 80 recurrent miscarriage patients and 100 controls. Fifteen of 80 recurrent miscarriage patients and four out of 100 controls carried the factor V Leiden mutation (19 versus 4%, P = 0.003, odds ratio 5.5, 95% confidence interval (CI): 1.7-17). Seven of 80 recurrent miscarriage patients and two of 100 controls were carriers of the prothrombin G20210A mutation (9 versus 2%, P = 0.038, odds ratio 4.6, 95% CI: 0.9-23.2). Six of 80 recurrent miscarriage women and 15 of 100 controls were homozygotes for the C677T MTHFR mutation (8 versus 15%, P = 0.134, odds ratio: 0.4, 95% CI: 0.1-1.2). Our results suggest that the presence of factor V Leiden and prothrombin G20210A polymorphism, but not MTHFR C677T homozygosity, could be additional risk factors for recurrent miscarriages. Furthermore, it was suggested that the prevalence of factor V Leiden and prothrombin G20210A mutations is more prominent in second trimester, primary fetal losses and it is independent of the existence of additional pathology predisposing to recurrent fetal losses.

Growth hormone response to oral glucose tolerance and insulin tolerance tests in patients with PCOS.

Polycystic ovary syndrome (PCOS) is characterized by its heterogeneity. This is the reason for the diversity in the clinical manifestations and laboratory findings. In this study we examined the serum levels of growth hormone (GH) in 15 women with PCOS and 5 healthy volunteers following oral administration of 75 gr glucose (OGTT) and intravenous administration of insulin (ITT). The OGTT produced no significant difference between the two groups of women, in the ITT there was a difference between the GH response of the women with PCOS and that of the healthy women. The group with PCOS showed a later, more prolonged, higher response, indicating that the hypothalamus is probably involved in PCOS.

Endometrial protein PP14 and CA-125 in recurrent miscarriage patients; correlation with pregnancy outcome.

The concentrations of endometrial proteins PP14 and CA-125 were measured in uterine flushings taken on days LH+10 and LH+12 (10 and 12 days after luteinizing hormone surge) of the menstrual cycle from 15 normal, fertile women and 49 women who suffered recurrent miscarriage. The concentration of PP14 was significantly lower in the flushings from the recurrent miscarriage patients than in those from fertile controls on both day LH+10 (median: 1300, range: 3-10 300 ng/ml versus median: 13 933, range: 2174-40 404 ng/ml; P < 0.01) and LH+12 (median: 1560, range: 820-12 100 ng/ml versus median: 14 047, range 1402-62 108 ng/ml; P < 0.05). Similarly concentrations of CA-125 were significantly lower in flushings from recurrent miscarriage women compared to controls on both day LH + 10 (median: 1555, range: 47-6710 U/ml versus median: 6385.5, range 2884-27 731 U/ml, P < 0.01) and LH+12 (median: 2892, range: 956-9974 U/ml versus median: 7127.5, range: 1591-21 343 U/ml; P < 0.05). In contrast there was no significant difference in the concentration of PP14 in plasma samples taken on the same days as the flushings from recurrent miscarriage patients and fertile controls. The concentrations of PP14 in uterine flushings obtained on day LH + 10 or LH + 12 from recurrent miscarriage women during a pre-pregnancy investigative cycle were significantly lower (P < 0.05) in patients who went on to miscarry (median: 1000, range: 9-2900 ng/ml) than those who went on to have a live birth (median: 1440, range: 4-12 100 ng/ml) during a subsequent pregnancy. In contrast there was no significant difference in uterine CA-125 or plasma PP14 concentrations between these two groups of recurrent miscarriage patients. The results suggest that measurements of uterine PP14 and CA-125 may be useful in the assessment of endometrial development in recurrent miscarriage patients and suggest the importance of PP14 in preparing the endometrium for embryo implantation. In addition pre-pregnancy uterine PP14 measurements may be useful in predicting subsequent pregnancy outcome.

Factors affecting the outcome of laparoscopic ovarian drilling for polycystic ovarian syndrome in women with anovulatory infertility.

OBJECTIVE: To describe and analyse the factors affecting the pregnancy rate of laparoscopic ovarian drilling for polycystic ovarian syndrome in women with anovulatory infertility. DESIGN: A retrospective study. SETTING: A specialist infertility clinic based at a teaching hospital in England. POPULATION: One hundred and eighteen women, for whom hospital records and follow up data were available, with polycystic ovarian syndrome who underwent laparoscopic ovarian surgery for anovulatory infertility over a five year period, between January 1991 and December 1995. MAIN OUTCOME MEASURES: Ovulation and pregnancy rate. RESULTS: The cumulative conception rate 12 months after the treatment was 54%. Women who conceived following the surgery had a shorter duration of infertility, were treated with diathermy (rather than laser), had higher pre-operative luteinising hormone levels, were younger and were more likely to have ultrasonographic evidence of polycystic ovarian disease. Logistic multiple regression analysis showed that the duration of infertility, modality used in treatment (laser or diathermy) and the pre-operative levels were the main determinants of the outcome. CONCLUSION: Women with polycystic ovarian syndrome respond favourably to laparoscopic ovarian drilling. The success rate in women with infertility duration of less than three years, treated with diathermy, in whom the pre-operative level was more than 10 IU/L reached 79%.

Complications of laparoscopic pelvic surgery: recognition, management and prevention.

Laparoscopic surgery has many advantages but it is not without complications. The complexity of the surgery significantly influences the complication rate. Laparoscopic surgeons ought to be aware of the possible complications and how they could be prevented, recognized without delay, and managed safely and efficiently. Important complications include injuries to the vessels, bowel and urinary tract. Incisional hernia ought to be reduced by careful closure of the fascia whenever a trocar > or =10 mm is used at the extraumbilical site. Gas embolism is a rare but potentially life threatening complication. Shoulder pain is a minor complication but is exceedingly common; it is less likely to occur if as much gas as possible is removed at the end of the operation while the patient is still in head down Trendelenburg position. Rare complications include pneumothorax, subcutaneous and pre-peritoneal emphysema, cardiac arrhythmia, nerve injury and venous thrombosis. Laparoscopic surgeons should also understand the principles of electrosurgery and how to avoid complications arising from the use of electrical energy including capacitative coupling, direct coupling and insulation failure.

The production of tumour necrosis factor alpha (TNF-alpha) by human endometrial cells in culture.

The production of tumour necrosis factor alpha (TNF-alpha) by cultured human endometrial epithelial and stromal cells prepared from endometrium obtained at different stages in the menstrual cycle has been investigated. TNF-alpha was not detectable in the supernatants of stromal cell cultures prepared from endometrial tissue obtained at any time in the menstrual cycle. TNF-alpha production by endometrial epithelial cells in culture varied depending on the time in the cycle at which the endometrial tissue was taken. Cells prepared from tissue obtained during the late proliferative phase of the cycle produced more TNF-alpha than those prepared from tissue obtained at other times in the cycle. In addition, a small increase in TNF-alpha production was seen by cells prepared from tissue obtained during the mid-secretory phase of the cycle. Interleukin 1 (IL-1) (1.4-140 pmol/l) caused a dose-dependent increase in TNF-alpha production by cells prepared from both proliferative and secretory endometrium. Maximum IL-1-stimulated increases in TNF-alpha production were similar in cells from both proliferative and secretory endometrium and typically reached from four to 10 times basal values. High doses of progesterone, either alone or in the presence of oestradiol, also affected TNF-alpha production by epithelial cells. TNF-alpha production by cells prepared from proliferative endometrium was increased by progesterone. In contrast, TNF-alpha production by cells prepared from secretory endometrium was decreased in the presence of progesterone. The effects of steroids on TNF-alpha production were less marked than that of IL-1, with values increasing or decreasing to a maximum of three times the basal value. Placental protein 14 (PP14) (0.18 and 1.8 nmol/l) also increased TNF-alpha production by cells prepared from proliferative tissue, but had no effect on its production by cells prepared from secretory endometrium. PP14-stimulated TNF-alpha levels typically only reached a maximum of two times basal values.

Post-operative adhesions after laparoscopic electrosurgical treatment for polycystic ovarian syndrome with the application of Interceed to one ovary: a prospective randomized controlled study.

In this prospective, randomized, controlled clinical study, 21 women underwent a second-look laparoscopy 2-11 weeks after standardized laparoscopic electrosurgical treatment for polycystic ovarian syndrome (PCOS). Following bilateral ovarian treatment, one ovary was randomly chosen to have Interceed applied to its surface using a specially designed applicator, with the other ovary serving as a control. Peri-adnexal adhesions of significant extent and severity developed in 57% of the women and 38% of the adnexa. The incidence of adhesions on the Interceed-treated side was 43%, while on the control side it was 33%. In addition, the extent and severity of the adhesions appeared to be similar on the Interceed-treated and control side. However, larger numbers would be required to determine statistically the effects of Interceed on de-novo adhesion formation after laparoscopic electrosurgical treatment of PCOS, as described here.

Physical barriers in adhesion prevention.

OBJECTIVE: To evaluate physical barriers in adhesion prevention. STUDY DESIGN: Literature search. RESULTS: Although numerous adjuvants have been used to prevent or reduce postoperative adhesions, they are by no means a panacea, and research on new synthetic adhesion barriers continues. CONCLUSION: Preliminary data from animal studies indicate that biocompatible, absorbable gel barriers are safe and effective. These agents are easy to apply and readily conform to irregular tissue shapes without fixation. We await the results of future clinical studies.

An analysis of the outcome of microsurgical and laparoscopic adhesiolysis for infertility.

We evaluated 81 women with adnexal adhesions and no male factor who underwent microsurgical (n = 59) and laparoscopic (n = 22) adhesiolysis for infertility. The cumulative conception rates for all 81 patients at 12 and 24 months were 41 and 44% respectively. The impact of the following variables on cumulative conception rates for all patients was examined: age, duration of infertility, type of infertility, ovulatory status, presence and stage of endometriosis, adhesion grade, adnexal status (bilateral or unilateral disease, unilateral tubal absence), history of previous surgery, history of pelvic inflammatory disease and treatment modality (microsurgical versus laparoscopic). The results of independent comparisons of subgroups within each of these variables may be biased because of the interrelationships between the variables. To overcome this problem, a stepwise Cox's proportional hazards regression analysis was employed. Our analysis showed that the single most significant variable influencing the cumulative conception rates was the duration of infertility (P < 0.005). For every additional year of infertility, the probability of pregnancy after adhesiolysis (microsurgical or laparoscopic) was reduced by approximately 20%. Cumulative conception rates at 12 and 24 months after microsurgical adhesiolysis were 36 and 40% respectively, while after laparoscopic adhesiolysis they were 57% at 12 and 24 months. When imbalances were adjusted between the two treatment groups, there was no statistically significant difference between the cumulative conception rates for microsurgical and laparoscopic adhesiolysis.

An analysis of the outcome of microsurgical and laparoscopic adhesiolysis for chronic pelvic pain.

We evaluated the outcome of microsurgical (n = 72) and laparoscopic (n = 51) adhesiolysis in women who complained of chronic pelvic pain. Adhesion severity was not significantly different between the two treatment groups. The influences of the following variables on the outcome of all 123 cases of adhesiolysis were examined: (i) surgical modality (microsurgical or laparoscopic), (ii) history of infertility, (iii) associated dyspareunia and (iv) aetiological factors of adhesive disease (endometriosis, pelvic inflammatory disease and previous laparotomy). To adjust for differences in follow-up intervals, overall and subgroup cumulative rates of pain persistence/recurrence were calculated and compared. To adjust for interrelationships between variables and to correct fo differences between the treatment groups, a proportional hazards regression analysis was employed. This analysis showed that the cumulative rate of pain persistance/recurrence at 24 months was not significantly different after microsurgical (44%) and laparoscopic (53%) adhesiolysis. From all the variables which were examined, the only one which appeared to influence the impact of surgical adhesiolysis for chronic pelvic pain was a history of previous laparotomy. A history of previous laparotomy was associated with approximately three times higher rates of pain persistence or recurrence. This effect did not depend on whether previous laparotomy was carried out for pain or for other indications. The most likely explanation for the failure of these patients who had a previous laparotomy to respond to surgery is that they intrinsically have a higher rate of adhesion formation and reformation. This can only be confirmed with a prospective study where all patients will undergo a second-look laparoscopy.

MUC1 in secretory phase endometrium: expression in precisely dated biopsies and flushings from normal and recurrent miscarriage patients.

MUC1 is a cell-surface and secretory product of endometrial epithelium. Immunohistochemical studies carried out using two different antibodies to the mucin-type tandem repeat region of MUC1 indicate a cell-surface location in proliferative phase glands, with intracellular deposits accumulating in the early secretory phase. Commencing 3-4 days after the luteinizing hormone (LH) peak and continuing into the late secretory phase, secretory MUC1 appears in gland lumens. Uterine flushings were collected as a function of time after the LH peak and were analysed using a two-site enzyme-linked immunosorbent assay for MUC1. Low but measurable concentrations were observed up to day 7, while on days 7-13 much higher values were obtained. In women suffering from recurrent spontaneous miscarriage, the concentration of MUC1 in flushings was significantly lower than in the controls on day LH + 10. Lower values were observed on days 7 and 13. Reduced epithelial secretory function and a resultant change in uterine fluid composition are features of endometrium from recurrent miscarriage patients.

The measurement of CA 125 and placental protein 14 in uterine flushings in women with recurrent miscarriage; relation to endometrial morphology.

The concentrations of CA 125 and placental protein 14 (PP14) were measured in uterine flushings obtained throughout the luteal phase of the cycle from eight normal fertile women. The concentrations of both proteins increased in a similar pattern throughout the luteal phase of the cycle, with the most dramatic increase occurring 6 days after their luteinizing hormone surge (day LH +6). However, a greater variation in CA 125 concentrations was seen compared to that seen for PP14. The concentrations were compared to those obtained on day LH +7 of the cycle from a group (n = 35) of women with recurrent miscarriage. The ranges in concentration of PP14 and CA 125 in the flushings of fertile and recurrent miscarriage patients were very similar. However, a greater proportion of women with recurrent miscarriage (55%) had low concentrations (< 5 ng/ml) of PP14 than in the control group (12.5%) and the concentrations of PP14 in the uterine flushings were significantly less (P < 0.05) in women with recurrent miscarriage compared to the normal fertile group. There was no significant difference in the concentration of CA 125 in the uterine flushings between the two groups. Histological observation of the endometrial biopsy samples from recurrent miscarriage patients gave menstrual cycle datings that ranged from day LH +2.5 to LH +6.5 with retarded endometrium (< day LH +5) in 12 of 35 (34%) patients. Of these 12 patients, 10 (83%) had low PP14 concentrations and six (50%) had low CA 125 concentrations in their uterine flushings. In the recurrent miscarriage patients with histologically normal (> or = day LH +5) endometrial development, 10 out of 23 (43%) also had low PP14 concentrations and 8 out of 23 (35%) had low CA 125 in their uterine flushings. The results suggest that PP14 is better than CA 125 as a marker for endometrial function in this group of women. In some cases (52%) the low concentrations of PP14 in the uterine flushings could be explained by retarded endometrial development but for the others the reduction in PP14 concentration in the uterine flushing was not associated with retardation of endometrial development.

Morphology of the human endometrium in the peri-implantation period.

Although the histology and ultrastructure of the human endometrium are well documented, it is clear that morphometry can reveal subtle changes in cellular biology, especially when combined with suitable sampling and dating of the specimen. These changes reflect functional events, such as protein secretion, which may be studied using the endometrial flushing technique. Although it is likely that further insights into the basic cell physiology of the reproductive tract will result from the use of appropriate in vitro models, the role of endometrial biopsy for clinical monitoring remains essential.