Aspiration cytology of ovarian cysts in in vitro fertilization patients.

Transvaginal ultrasonography is routinely performed in the course of egg retrieval in patients presenting for in vitro fertilization (IVF) and results in the discovery of occult, subclinical ovarian cysts that would otherwise have gone undetected. This study (1) evaluated the cellular composition of the cyst fluids based on a comparison with cells obtained from cysts of known and documented histologic type, and (2) attempted to determine if the cytologic evaluation of cyst fluid was necessary to exclude occult ovarian cancer. During the 1.8 years of our study, 931 patients underwent 1,544 ultrasound-guided ovum retrievals; during this same period, 90 specimens of ovarian cyst fluid were examined. Of them, none contained cancer cells. A single case of cystic ovarian cancer was detected by ultrasound but was not aspirated. The cytologic diagnosis of endometriosis was established in 12 specimens from 10 patients, 5 of whom did not have a previously documented clinical diagnosis of endometriosis. The role of routine ovarian cyst fluid cytology as part of an IVF protocol may be of limited value in cancer diagnosis. However, until the incidence of ovarian cancer in the subset of women with both infertility and ovarian cysts is known, it would seem prudent to continue to examine any voluminous or discolored ovarian cyst fluid obtained from IVF patients. The presence of ovarian cysts did not affect the clinical pregnancy rate per retrieval.

Conservative surgical procedures for tubal pregnancy.

The early diagnosis of tubal pregnancy has become easier with recent diagnostic techniques. Early diagnosis provides a greater opportunity for conservative surgery in women who wish to maintain fertility. The procedure chosen will depend on the location of the pregnancy. One must differentiate between a pregnancy in the ampullary portion of the fallopian tube and one in the isthmic portion, and one must also determine whether a rupture has occurred.

Recent techniques for the conservative management of tubal pregnancy. Surgery, laparoscopy and medicine.

Differentiation between radical and conservative surgery for the management of tubal pregnancies depended, in the past, upon whether an effort was made to preserve all or part of the affected fallopian tube. Recent techniques for conservative management include laparoscopic salpingotomy with either an electrical current or the carbon dioxide laser and the use of methotrexate. The latter method does not require surgery. In the near future any laparotomy approach for tubal pregnancy may well be considered nonconservative.

Formation and prevention of postoperative abdominal adhesions.

Postoperative abdominal adhesion formation can undo the reconstructive work of the infertility surgeon. Adhesions can form in as little as three hours after surgery. Most adhesions are transient and lyse spontaneously within 72 hours of surgery. Such factors as tissue trauma, anoxia and ischemia cause a reduction in plasminogen activator activity that is strongly correlated with the persistence and progression of postoperative adhesions. Adhesions can be prevented by a proper and meticulous surgical technique emphasizing preservation of tissue without abrasion, anoxia or ischemia. Dextran, antiprostaglandins, antibiotics, steroids, antihistamines, anticoagulants and enzymes have various roles. Our current regimen involves Hyskon, Motrin and deoxycycline.

Microsurgical transplantation of nonvascularized segments of the fallopian tube in the rabbit.

Microsurgical nonvascularized transplantation of a 1-cm segment of fallopian tube was performed using the rabbit as a model. Autograft experiments showed survival of a 1-cm tubal segment for as long as 10 months postoperatively. Allografts survived equally as well, and one rabbit became pregnant.

Incidence of hyperprolactinemia during oral contraceptive therapy.

A study was undertaken to determine the incidence of increased serum levels of human prolactin (hPRL) in women during oral contraceptive therapy, and to correlate this with both the dose of oral contraceptive medication and the duration of its use. The 123 patients in this study were divided into 3 groups according to the dosage of estrogenic component of the combined oral contraceptives. Thirty percent of these women had hyperprolactinemia of varying degree. Neither the dosage of steroids within our range nor the duration of therapy correlated with the presence or degree of hyperprolactinemia. The actions of estrogen-progestin compounds on hPRL are discussed.

The MURCS association: Müllerian duct aplasia, renal aplasia, and cervicothoracic somite dysplasia.

Two patients and 28 others in the literature were ascertained because of congenital vaginal agenesis associated with clinical and/or radiographic evidence of malformations derived from the cervicothoracic somites. In these patients, there was a high incidence of Müllerian duct aplasia/hypoplasia (96%), renal agenesis and/or ectopy (80%), and abnormalities related to cervicothoracic somite dysplasia, particularly 2 to 4 anomalous vertebrae located between C5-T1 (80%). These consistent findings suggest a distinctive non-random association of malformations: Müllerian duct (MU) aplasia, renal (R) aplasia, and cervicothoracic somite (CS) dysplasia (MURCS). Identification of one component of the MURCS association suggests the presence of the other associated anomalies. A hypothesis for the embryogenic pathogenesis of the MURCS association is proposed which attributes the malformations to an alteration of the blastemas of the lower cervical-upper thoracic somites, arm buds, and pronephric ducts, all of which have an intimate spatial relationship at the end of the fourth week of fetal life. A presently unidentified teratogen may be one of the possible causes of the MURCS association on the basis of a lack of familial transmission, normal chromosomal studies, and the similar effects of a known teratogen (thalidomide) on the developing genitourinary tract.

Microsurgical anastomosis of the rabbit oviduct using 9-0 monofilament polyglycolic acid suture.

As part of a larger study to determine which factors are important in fallopian tube reconstruction, 9-0 monofilament polyglycolic acid suture on a 145 micron-needle was used for rabbit oviduct microsurgical anastomosis. A 100% pregnancy rate in five rabbits with no disruption of the endosalpingial or muscular layers was noted. Of special note, the suture was totally resorbed, and no suture residuum or surrounging reaction was noted. The suture material appears to fulfill the criteria for an ideal suture described at the beginning of the paper. This is the first report of the use of a 9-0 monofilament polyglycolic acid suture.

The effect of conjugated estrogens on coagulability in menopausal women.

To investigate the effect of conjugated equine estrogens on the coagulability in menopausal women, blood samples were drawn from 69 menopausal females--35 receiving estrogens and 34 receiving no replacement therapy. Using tests for antithrombin and heparin-antithrombin activities, 14.7% of the control patients were found to be hypercoagulable. This is a 289% increase in the incidence of hypercoagulability in the group treated with estrogens. The particular relevance of this finding to menopausal women and the importance of the use of the coagulation profile in managing such patients is discussed.

Conservative surgical management of tubal pregnancy.

In an attempt to maintain optimal fertility in the patient treated for midtubal pregnancy, an investigation of conservative surgical procedure was made. The technic developed utilizes tubal excision, reanastomosis, and a single hydrotubation with Dextran. Tubal patency was maintained without the use of stents that may damage the fimbria. The procedure is compared to other conservative technics and its advantages discused. Thus far 2 patients have undergone this excision and reanastomosis, and both patients successfully established intrauterine gestations within 2 months of returning to normal active coital frequency. Both were in the midtrimester of pregnancy at the time of this report.