Reproductive Outcomes following Laser Surgery for Twin-Twin Transfusion Syndrome.

BACKGROUND: There are limited studies describing future reproductive outcomes in women who have had selective fetoscopic laser photocoagulation (SFLP) for twin-twin transfusion syndrome (TTTS). OBJECTIVE: Our study aims to compare reproductive outcomes following monochorionic multiple gestational pregnancies complicated by TTTS requiring SFLP to those not requiring SFLP. METHODS: This is a retrospective cohort study that analyzed records of patients who were evaluated at the Cincinnati Fetal Center (2007-2014) for monochorionic multiple gestations. A questionnaire regarding reproductive, obstetric, gynecologic, and psychological outcomes following the index pregnancy was administered to consented participants by electronic distribution. The data was compared between pregnancies with prior SFLP versus no prior SFLP. RESULTS: There was a higher response rate in the SFLP group (219/474, 46.2%) versus the referent group (62/187, 33.2%). The median interval between the index pregnancy and survey completion was 74 months and 46 months in the SFLP and referent groups, respectively. Approximately 38 and 37% of the women in the SFLP and referent groups attempted conception after the index pregnancy with a >90% pregnancy success rate in both groups. Use of assisted reproductive technology was highly prevalent in both the index and subsequent pregnancies, with no significant difference between the groups. Over 60% of the women in each group did not attempt future pregnancy. Of those, approximately 1 in 3 cited the outcome of the index pregnancy as the primary reason for not pursuing future conception. There were no significant differences in selected maternal-fetal complications and new-onset gynecologic problems. More than 1 in 4 women in both groups were diagnosed with a mental health disorder following the index pregnancy. CONCLUSION: SFLP does not appear to be associated with adverse reproductive, obstetric, or gynecologic outcomes. The data may help facilitate evidence-based counseling for this patient population.

Evaluation of Total, Active, and Specific Myeloperoxidase Levels in Women with and without Endometriosis.

Myeloperoxidase (MPO) is a proinflammatory enzyme and a marker for neutrophil activation and oxidative stress. Since oxidative stress and inflammation are linked to the pathogenesis of endometriosis, we hypothesized that the total, active, and specific (active/total) MPO levels were significantly different in plasma of women with and without endometriosis. Samples were selected from our biobank from women with endometriosis (n = 212) and controls without endometriosis (n = 121) across the menstrual cycle. Total MPO plasma levels were measured by immunoassay and MPO activity by enzymatic assay. Total and active MPO levels did not differ significantly among endometriosis cases and controls, whereas the specific MPO activity was significantly lower in women with endometriosis than that in controls (p = 0.0159). After the subdivision of control patients into women with a normal pelvis and women with other benign gynecological disorders, a significant difference was observed only between women with endometriosis and women with other benign gynecological disorders (p = 0.0266). In conclusion, systemic MPO levels may not be suited as a single biomarker for endometriosis. Our data support the involvement of MPO in other gynecological disorders but do not provide any evidence for an association with endometriosis.

Antioxidant status in blood of gynaecological patients: influence of diagnosis and reproductive factors.

Cancer of the reproductive tract is an important cause of morbidity and mortality among women worldwide. In this study we evaluated the influence of diagnostic categories, age and reproductive factors on antioxidant enzymes and lipid hydroperoxides in the blood of gynaecological patients diagnosed with endometrial polyp, myoma, hyperplasia simplex, hyperplasia complex and endometrial adenocarcinoma. Multivariate regression analysis was used to assess the association of diagnosis, age, parity, abortions and abnormal uterine bleeding with the examined parameters. Diagnosis provided the best predictive model for superoxide dismutase, catalase and glutathione peroxidase activities, and also for the lipid hydroperoxide level. Abortions fitted the best predictive model for superoxide dismutase activity. A significant correlation was also found between the predictor variables themselves. This study showed that reproductive and other factors may be associated, at least partially, with antioxidant capacity and ability to defend against the oxidative damage in gynaecological patients with various diagnoses.

Recognition of 5α-reductase-2 deficiency in an adult female 46XY DSD clinic.

CONTEXT: The late presentation of steroid 5α-reductase-2 (SRD5A2) deficiency in females is poorly characterised. The ratios of 5α/5ß-reduced metabolites of adrenal steroids in a urine steroid profile (USP) can give an indication of SRD5A2 deficiency, although the diagnostic cut-off for 5α/5ß ratios are not clearly defined in genetically confirmed cases. OBJECTIVE: The aim of this study was to establish the frequency of SRD5A2 deficiency in an adult clinic for disorders of sexual development (DSD) focussing on 46XY partially virilised adult female subjects. We investigated the relationship between USP results and SRD5A2 genetic sequence and determined the cut-off for USP 5α/5ß-reduced steroid ratios compared with gene sequencing for the identification of SRD5A2 deficiency. METHODS: USP and SRD5A2 genetic analyses were performed in 23 adult females, aged 19-57 years, with 46XY DSD and in four males with confirmed SRD5A2 deficiency. 5α-Reductase activity was assessed using the USP ratio of androsterone to aetiocholanolone (A/Ae), 5α-tetrahydrocortisol (5α-THF)/tetrahydrocortisol (THF) and 5α-tetrahydrocorticosterone to tetrahydrocorticosterone (5α-THB/THB). RESULTS: The SRD5A2 gene mutations were found in 10/23 (43%) females and in all four males. Totally, four novel mutations were identified. All mutation-positive subjects had A/Ae and 5α-THB/THB ratios below the lower limit of normal (100% sensitivity) while the sensitivity of 5α-THF/THF ratio was 90%. CONCLUSION: SRD5A2 deficiency is more prevalent than expected in the adult female 46XY DSD population. The clinical spectrum of this disorder may extend to a more female phenotype than previously considered to include individuals with little or no virilisation.

[Matrix metalloproteinase 9 presence in adhesive intraperitoneal processes]. / Studiul prezentei metaloproteinazei 9 la nivelul proceselor aderentiale cronice intraperitoneale.

UNLABELLED: Matrix metalloproteinases (MMP) represents a zinc-dependent proteolytic enzyme multigenic family, directly involved in embryogenesis, some physiological and pathological processes, occurring in the adult organism. For physiological processes, MMP play roles in proliferation, tissue remodeling, wound healing, angiogenesis. AIM: The aim of the study was to analyze the MMP9 presence in chronic peritoneal adherences, following the correlation between the presence of this metalloproteinase and the evolution of the connective tissue remodeling process from intraperitoneal adherences. MATERIAL AND METHODS: 6 women formed the study group: 5 operated for gynecological pathologies (with harvested tissue fragments from the adherences) and one patient with harvested tissue from normal peritoneum. Fragments were fixed in 10% formalin and processed for the microscopic exam in routine staining and immunohistochemistry, using anti-MMP9 antibodies and a technique based on peroxidaze-antiperoxidase system. The immunohistochemical reaction was quantified by using image analysis software. RESULTS: The morphological structure of the adherences was mainly represented by fibrous tissue, sometimes associated with elements of muscle and adipose tissues. For the fibrous connective tissue, the collagen component was characterized by a fascicular organization with different orientations and with fibrillar aspect. Semiquantitative analysis showed increased levels for MMP9 in adherences by comparison with normal peritoneum (mean ration for the MMP9-positive area: 26.5% for the adherences versus 15.93% normal peritoneum). CONCLUSION: The intraperitoneal adherences with more than 1 year of evolution show an extension of the remodeling processes that can lead to the possible resolution.

Effect of experimental genital mycoplasmosis on production of matrix metalloproteinases in membranes and amniotic fluid of Sprague-Dawley rats.

PROBLEM: Preterm, premature rupture of membranes (PPROM) is a dire pregnancy outcome that is frequently associated with infection by the genital mycoplasmas, Mycoplasma hominis, Ureaplasma parvum, and U. urealyticum. One potential mechanism by which these microorganisms may cause PPROM is by increasing the concentration of matrix metalloproteinases (MMPs) in the membranes and amniotic fluid. We tested this hypothesis in a well-defined model system of genital infection with M. pulmonis, a natural reproductive pathogen of rats. METHOD OF STUDY: Timed-pregnant, specific pathogen-free, Sprague-Dawley rats were infected with 10(7) CFU M. pulmonis at gestation day (gd) 14. Controls received an equivalent volume (100 microL) of sterile medium. At gd 18, rats were euthanized, and membranes and amniotic fluids were harvested and stored at -70 degrees C until analysis. Proteinase activity of amniotic fluid and membranes was resolved on discontinuous 7.5% sodium dodecyl sulfate-polyacrylamide gel electrophoresis gelatin zymography gels. Band intensity was determined using a digital gel documentation system and the manufacturer's software (Kodak). RESULTS: Gelatinolytic activity associated with a band similar in molecular weight to ProMMP-9 (92 kDa, the inactive precursor of MMP-9) was significantly increased in amniotic fluids and membranes harvested from M. pulmonis-treated pups at gd 18 when compared with tissues harvested from control pups. Both ProMMP-9 and ProMMP-2 (72 kDa, the inactive precursor of MMP-2) were increased in infected animals at gd 21. CONCLUSION: Our study suggests that the genital mycoplasmas can increase MMP-9 production in vivo.

Alpha-2,3-sialyltransferase enhances Neisseria gonorrhoeae survival during experimental murine genital tract infection.

The addition of host-derived sialic acid to Neisseria gonorrhoeae lipooligosaccharide is hypothesized to be an important mechanism by which gonococci evade host innate defenses. This hypothesis is based primarily on in vitro assays of complement-mediated and phagocytic killing. Here we report that a nonpolar alpha-2,3-sialyltransferase (lst) mutant of N. gonorrhoeae was significantly attenuated in its capacity to colonize the lower genital tract of 17-beta estradiol-treated female BALB/c mice during competitive infection with the wild-type strain. Genetic complementation of the lst mutation restored recovery of the mutant to wild-type levels. Studies with B10.D2-HC(o)H2(d)H(2)-T18c/OSN (C5-deficient) mice showed that attenuation of the lst mutant was not due to increased sensitivity to complement-mediated bacteriolysis, a result that is consistent with recently reported host restrictions in the complement cascade. However, Lst-deficient gonococci were killed more rapidly than sialylated wild-type gonococci following intraperitoneal injection into normal mice, which is consistent with sialylation conferring protection against killing by polymorphonuclear leukocytes (PMNs). As reported for human PMNs, sialylated gonococci were more resistant to killing by murine PMNs, and sialylation led to reduced association with and induction of a weaker respiratory burst in PMNs from estradiol-treated mice. In summary, these studies suggest sialylation confers a survival advantage to N. gonorrhoeae in mice by increasing resistance to PMN killing. This report is the first direct demonstration that alpha-2,3-sialyltransferase contributes to N. gonorrhoeae pathogenesis in an in vivo model. This study also validates the use of experimental murine infection to study certain aspects of gonococcal pathogenesis.

Role of matrix metalloproteinase-7 in the modulation of a Chlamydia trachomatis infection.

To determine the role of matrix metalloproteinase-7 (MMP-7) in the pathogenesis of chlamydial infection, C57BL/6 wild-type (WT) and MMP-7 knockout (KO) mice were infected intravaginally with Chlamydia trachomatis mouse pneumonitis (MoPn). Over a period of 6 weeks postinfection, various organs were cultured for C. trachomatis. Other infected animals were mated to assess their fertility status. No significant differences were observed between WT and KO mice in the number of animals with positive vaginal cultures, length of time of C. trachomatis shedding, or the number of C. trachomatis inclusion-forming units (IFU) recovered from their genital tracts. Likewise, the number of animals with hydrosalpinx, and the fertility rates and the number of embryos per mouse, were similar in WT and KO mice. Cultures from the spleen, lungs, kidneys and large intestine yielded similar numbers of IFU from WT and KO mice. However, the number of C. trachomatis IFU recovered from the small intestine of KO mice was significantly higher than that recovered from the small intestine of WT mice at 2 weeks postinfection. Because MMP-7 KO mice are deficient in active intestinal alpha-defensins, the results suggest that these components play a role in regulating colonization of the gastrointestinal tract by Chlamydia. By contrast, MMP-7 is dispensable in the progression and resolution of the genital tract infection.

COX-2 inhibitors and their role in gynecology.

UNLABELLED: This review summarizes current knowledge about the roles of cyclooxygenases and prostaglandins in reproductive medicine. With the development of COX-2 specific inhibitors, new therapeutic options are available to obstetricians and gynecologists, offering better-tolerated alternatives to conventional NSAIDs. The analgesic effectiveness of COX-2 specific inhibitors is well established, and they are already in use in a range of painful conditions. Both celecoxib and valdecoxib are indicated for the treatment of primary dysmenorrhea, and may be effective in postoperative pain, including hysterectomy, and pain associated with endometriosis. There is also speculation that COX-2 specific inhibitors may be effective tocolytic agents without the risks to the fetus seen with conventional NSAIDs. The role of COX-2 in oncogenesis is also under investigation, and COX-2 specific inhibitors may eventually be used in the prevention and treatment of gynecologic malignancies. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be able to describe the two types of cylooxygenase enzymes (COX), to list the effects and side effects of NSAIDs and COX-2 medications, and to outline the various changes in COX expression during pregnancy.

Mucinases and sialidases: their role in the pathogenesis of sexually transmitted infections in the female genital tract.

BACKGROUND: Mucinases and sialidases contribute to the process of invasion and colonisation in many conditions and infections of the female reproductive tract by degrading the protective cervical mucus. The role of hydrolytic enzymes in the pathogenesis of sexually transmitted diseases and their effect on cervical mucus are discussed in this review. METHODS: Articles were searched for using the keywords "sialidase," "mucinase," "protease," and "sexually transmitted infections." As well as review and other articles held by our group, searches were conducted using PubMed, Grateful Med, and the University of Bath search engine, BIDS. RESULTS: Numerous publications were found describing the production of hydrolytic enzymes in sexually transmitted diseases. Because the number of publications exceeded the restrictions imposed on the size of the review, the authors selected and discussed those which they considered of the most relevance to sexually transmitted infections.

Hyaluronan and myeloperoxidase in human peritoneal fluid during genital inflammation.

The changes in concentration of hyaluronan (HYA) and myeloperoxidase in the peritoneal fluid (PF) were studied during genital intraperitoneal inflammation. PF were collected from 111 women undergoing laparotomy for adhesiolysis and reconstructive surgery of the fallopian tubes or laparoscopy in search of causes of infertility or low abdominal pain. When the number of leukocytes in the PF had been counted, the fluid samples were centrifuged and the supernatants analyzed for the concentrations of HYA and myeloperoxidase. During genital inflammation, whether postoperative or postinfectious, leukocytosis and elevated levels of HYA and myeloperoxidase were found in the PF. Concentrations of these substances in the PF may be usable as clinical markers for genital inflammation.

Cytochrome P-450 activity in human leiomyoma and normal myometrium.

Variations in cytochrome P-450 levels may influence the responsiveness of uterine and breast tissue as well as carcinomas to endocrine therapy and may be of particular importance with agents such as tamoxifen (Nolvadex) where hydroxylation is known to alter therapeutic activities. Therefore, a sensitive spectrophotometric assay of cytochrome P-450 levels in reproductive tissue microsomes was developed to measure cyclohexane hydroxylase activity. Cyclohexane served as a substrate for several forms of cytochrome P-450. Human uterine leiomyomas (uterine fibroid tumor) contained significantly higher (p less than 0.01) cytochrome P-450 activity than adjacent normal myometrium. Specific activities for both leiomyomas (2.87 +/- 0.26 nmol/min/mg) and normal myometrium (1.60 +/- 0.11 nmol/min/mg) were in the range of those observed for untreated rabbit liver microsomes (1 to 3 nmol/min/mg). The contribution of smooth muscle in the specimen, the phase of the menstrual cycle, and the clinical diagnosis did not influence the level of cytochrome P-450 activity.

Increased activity in serum of an alkaline phosphatase isoenzyme in cancer: analytical method and preliminary clinical studies.

Serum of cancer patients often contains high activities of a homoarginine-sensitive isoenzyme of alkaline phosphatase with high electrophoretic mobility, which is present in relatively low activities in sera from most normal persons and persons with benign disease. In earlier studies of this isoenzyme, in a semi-quantitative assay, electrophoresis was used in the separation step. This report describes a column separation procedure, which provides quantitative data. We tested the revised procedure by assaying a mixed panel of 192 sera (cancer, benign disease, and normal). The organ sites of cancer and benign disease in this study were: lung, pancreas, uterus, and ovaries. The isoenzyme showed moderate sensitivity for lung (0.6) and pancreas (0.8) cancer and high specificity for all cancers tested. Thus the assay may be useful for discriminating between cancer sera and non-cancer sera for these cancer types.

Markers for ovarian cancer: regan isoenzyme and other glycoproteins.

Since embryonic genes are not generally active in normal adult subjects and because certain of these genes are activated in cancer leading to ectopic synthesis, it is the difference between the ectopic level and the normal adult concentrations of embryonic gene products which we seek in developing "markers" for ovarian cancer. The carcinoplacental alkaline phosphatases corresponding to the term gestational phenotypes correlate positively with ovarian cancer as does hCG. Other fetal and placental glycoproteins whose presence is noted in ovarian cancer include CEA, alpha-FP, and Björklund's antigen. Antigens of mucinous cystadenocarcinoma have not yet been examined for their possible fetal or placental origins. The degree of concordance of expression of Regan isoenzyme and hCG is variable. Profiles of glycoproteins would appear to offer an opportunity to inquire more deeply into the nature of ovarian cancer and from this inquiry, one can expect to develop a system of markers which can be of clinical use.