Transdermal hormone replacement therapy and Doppler findings in normal and overweight postmenopausal patients.

The aim of this study was to evaluate the effects of transdermal hormone replacement therapy on some biological cardiovascular risk factors, specifically the thromboxane B2 levels, plasma viscosity and the lipid profile. Furthermore, we investigated the Doppler flow modifications at the level of the uterine artery, the internal carotid, the ophthalmic and the bladder wall arteries, and we finally evaluated whether there were significant differences in the examined parameters between normal and overweight postmenopausal women. Forty-five postmenopausal women (mean age+/-standard deviation, 53.5+/-3.8 years) participated in the study and were divided into two groups (27 with a body mass index of < 25 kg/m2 and 18 with a body mass index of > 25 kg/m2). Patients were treated with a continous estradiol transdermal supplement and a 12-day course of medroxyprogesterone acetate every 2 months, and were studied at baseline and after 6 months (in the estrogen-only phase of the second cycle). Our results showed a beneficial effect of hormone substitution on plasma viscosity, thromboxane B2 levels and lipid profile after 6 months of therapy and significant improvements of Doppler flow parameters in the examined vessels. Furthermore, we observed a lower impact of the treatment in overweight women. In conclusion, obesity represents an additional cardiovascular risk condition and it can only partially be modified by the administration of hormone replacement therapy.

Pelvic ultrasound and color Doppler findings in different isosexual precocities.

OBJECTIVE: To evaluate the role of ultrasound and color Doppler analyses in improving the differential diagnosis of pubertal precocities. METHODS: Sixty-nine girls with premature (<8 years old) breast development and/or pubic hair growth underwent: auxological (height, weight, body mass index, skeletal maturation), hormonal (basal, gonadotropin releasing hormone (GnRH)-test, adrenocorticotropic hormone test), and sonographic (uterine and ovarian volume and endometrial echo) including color Doppler (uterine arteries) evaluations. RESULTS: The uterine size was greater in girls with a pubertal response to the GnRH test (Group II, n = 16; 7.48 +/- 4.18 mL) than in those with a prepubertal response to the GnRH test (Group I, n = 17; 3.02 +/- 1.36 mL; P = 0.006), an isolated pubarche (Group III; n = 20; 2.58 +/- 1.32 mL; P < 0.001) or an isolated thelarche (Group IV, n = 16; 1.82 +/- 1.07 mL; P < 0.001). Endometrial echo was observed in 87.5%, 29.4% and 5% of girls, respectively, in Groups II, I and III. The Doppler analysis of the uterine arteries showed the lowest impedance to be in patients with a pubertal response to the GnRH test (Group II). CONCLUSIONS: Sonographic and color Doppler parameters may improve the diagnosis of GnRH-dependent precocious puberty and may be useful to determine which girls need treatment.

Pelvic sonography and uterine artery color Doppler analysis in the diagnosis of female precocious puberty.

OBJECTIVES: To evaluate the role of ultrasound and color Doppler analyses in the diagnosis of precocious puberty. METHODS: Gray-scale sonographic uterine and ovarian evaluation together with color Doppler analysis of the uterine artery were prospectively performed in 29 girls presenting with premature breast development and pubic hair growth. The values were compared with results obtained from the gonodotrophin releasing hormone stimulation test. Excluded from the study were patients with isolated thelarche or isolated pubarche and those patients with gonodotrophin releasing hormone-independent puberty and with polycystic ovaries. RESULTS: According to the Tanner scale, all the girls presented a breast stage of 2-3 and pubic hair stage 2-3. The uterine size was greater in those girls who presented a pubertal response to the gonodotrophin releasing hormone test (Group II; n = 20) (8.07 +/- 4.47 mL) than in those who did not (Group I; n = 9) (3.07 +/- 1.18 mL; P = 0.001). The ovarian volume and the number of small follicles was not significantly different between the groups. On Doppler analysis, more elevated impedances were observed in Group I (pulsatility index = 3.28 +/- 0.37) than in Group II (pulsatility index = 2.29 +/- 0.19; P = 0.001) girls. The presence of a low pulsatility index (< 2.5) at the level of the uterine arteries had a high diagnostic value for precocious puberty (sensitivity 86%, specificity 100%). CONCLUSIONS: Uterine artery Doppler analysis may assist the diagnosis of gonodotrophin releasing hormone-dependent precocious puberty, may be useful for the selection of those girls needing treatment, and may simplify the follow-up of girls treated for precocities.

Intratesticular Doppler flow, seminal plasma nitrites/nitrates, and nonobstructive sperm extraction from patients with obstructive and nonobstructive azoospermia.

OBJECTIVE: To prospectively evaluate the role of intratesticular vascular flow in modulating sperm function in men with obstructive and nonobstructive azoospermia. The correlation of testicular Doppler values with nitric oxide and testicular sperm extraction was further evaluated. DESIGN: Prospective study. SETTING: Assisted reproduction unit at a university center. PATIENT(S): Twenty-eight men with azoospermia undergoing sperm extraction for intracytoplasmic sperm injection. INTERVENTION(S): Ultrasound and color Doppler scanning of the testes. Testicular sperm retrieval and nitrite/nitrate assay. MAIN OUTCOME MEASURE(S): Doppler analysis of testicular transmediastinal artery, plasma and seminal plasma nitrite/nitrate values, and sperm extraction histopathology. RESULT(S): The pulsatility index (PI) of the transmediastinal artery was higher in patients with nonobstructive azoospermia (PI = 1.40 +/- 0.13) than in those with obstructive azoospermia (PI = 1.09 +/- 0.15; P=.011). Seminal plasma nitrite/nitrate concentrations were more elevated in cases of obstructive azoospermia than in gonadal failure. Unsuccessful sperm recovery was observed in four patients who showed the worst indices of gonadal failure. In this subgroup, a transmediastinal PI value >1.50 was always observed. CONCLUSION(S): Doppler analysis of the transmediastinal artery and nitrite/nitrate seminal plasma concentrations are useful for distinguishing between obstructive and nonobstructive azoospermia and allow the identification of the presence of spermatozoa within the testes.

The use of a starting dose of recombinant follicle stimulating hormone for controlled ovarian hyperstimulation: a randomized pilot study.

The aim of this study was to compare the costs and effects of two different controlled ovarian hyperstimulation treatments: a starting dose of recombinant follicle stimulating hormone (FSH) followed by highly purified urinary FSH; or highly purified urinary FSH alone. Forty-six infertile patients, after being given luteal gonadotropin-releasing hormone (GnRH) agonist, were randomly assigned to the two stimulation protocols. During the ovarian stimulation regimen the patients underwent transvaginal ultrasonographic evaluation of follicular number and size. The retrieved oocytes were classified on the basis of the criteria of Acosta and colleagues. To study the impact of embryo quality on implantation, the embryos were graded morphologically before replacement. Pregnancy rates were ascertained and the costs of the two different protocols were analyzed. The number of days of FSH stimulation and the cost of gonadotropin treatment were similar in both groups. The number of follicles > 17 mm in size, the number of collected oocytes, and pregnancy rate per cycle were significantly higher in the group partially treated with recombinant gonadotropin. We conclude from these results that the use of recombinant FSH in the early phase of controlled ovarian hyperstimulation leads to significant improvements in pregnancy rate per cycle without increasing the costs of treatment.

Seminal plasma nitrite/nitrate and intratesticular Doppler flow in fertile and infertile subjects.

The objective of the present study was prospectively to evaluate the role of nitric oxide (NO) in modulating intratesticular blood flow and sperm function. A total of 56 males, undergoing assisted reproduction, were divided into three groups according to semen analysis: (i) normozoospermic (n = 16); (ii) oligozoospermic (n = 21); and (iii) azoospermic (n = 19). All the subjects were submitted to hormone analysis [luteinizing hormone, follicle stimulating hormone (FSH), growth hormone, testosterone, androstenedione, insulin], and to ultrasonographic (testicular volume) and Doppler (transmediastinal artery) evaluations. Plasma and seminal plasma nitrite/nitrate concentrations, and plasma insulin-like growth factor-I were assayed. All 56 patients completed the study. In normozoospermic patients, significantly greater testicular volume, lower transmediastinal resistances, and higher seminal plasma nitrite/nitrate concentrations were observed in comparison with both oligo- and azoospermic subjects. Testicular volume was inversely correlated with plasma FSH (r = -0.589; P = 0.005) and pulsatility index of transmediastinal artery (r = -0.402; P = 0.049). Furthermore, the seminal plasma nitrite/nitrate concentrations were inversely correlated with pulsatility index of transmediastinal artery (r = -0.511; P = 0.015). It was concluded that NO is involved in vascular modulation of testicular vessels and ultimately in sperm output.

Perifollicular Doppler flow and follicular fluid vascular endothelial growth factor concentrations in poor responders.

OBJECTIVE: To prospectively evaluate follicular fluid levels of vascular endothelial growth factor in women undergoing IVF cycles and to investigate the correlation of these levels with ovarian response to gonadotropins and with uterine or ovarian Doppler findings. DESIGN: Prospective study. SETTING: University hospital. PATIENT(S): 41 patients undergoing ART were divided into two groups according to response to ovarian stimulation protocols: poor responders (n = 18) and normoresponders (n = 23). INTERVENTION(S): Doppler analysis of perifollicular arteries and assay of follicular fluid vascular endothelial growth factor. MAIN OUTCOME MEASURE(S): During ovarian stimulation, patients underwent hormonal (E2), ultrasonographic (follicular number and diameter, endometrial thickness) and Doppler (uterine and perifollicular arteries) evaluation. Serum and follicular fluid concentrations of vascular endothelial growth factor were assayed in each female patient. RESULT(S): Compared with poor responders, more oocytes were collected and more embryos were transferred but follicular fluid levels of vascular endothelial growth factor levels were lower in normoresponders. Follicular fluid levels of vascular endothelial growth factor were inversely correlated with number of oocytes retrieved. Poor responders had significantly higher uterine and perifollicular Doppler flow resistances. The pregnancy rate per cycle was significantly higher in normoresponders (26%) than poor responders (6%). CONCLUSION(S): Elevated follicular fluid levels of vascular endothelial growth factor concentrations are associated with poor ovarian response and a very low pregnancy rate.

Allergic reaction to a highly purified urinary follicle stimulating hormone preparation in controlled ovarian hyperstimulation for in vitro fertilization.

We report a case of general hypersensitivity-like allergic reactions to intramuscular injections of highly purified urinary follicle stimulating hormone (uFSH-HP) successfully managed by using intramuscular recombinant FSH (rFSH). The patient underwent a first cycle of in vitro fertilization (IVF) and controlled ovarian hyperstimulation (COH) was achieved with a combination of gonadotropin releasing hormone against (GnRH-a) and uFSH-HP. Because, after oocyte recovery, no fertilization occurred, the couple subsequently entered an intracytoplasmic sperm injection (ICSI) program. During the COH, the woman developed general hypersensitivity-like allergic reactions with itching, redness and swelling. Although there was regular follicular growth, the allergic symptoms worsened and, on day 8 of COH, the stimulation cycle was suspended. A few months later, the patient entered a new ICSI cycle. COH was achieved by using a combination of GnRH-a and rFSH. The cycle was completed and the patient did not report any allergic reaction. To avoid allergic reaction to the protein components of the urine-derived FSH preparations, the use of rFSH is suggested in those patients who present local and/or general hypersensitivity-like allergic reactions.

Successful induction of ovulation using highly purified follicle-stimulating hormone in a woman with Kallmann's syndrome.

OBJECTIVE: To describe a woman with Kallmann's syndrome who was treated successfully with highly purified FSH to achieve ovulation induction and pregnancy. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 32-year-old woman with Kallmann's syndrome who had been treated with oral contraceptives to prime secondary sex characteristics and genital organs since the age of 16 years. INTERVENTION(S): Highly purified FSH was administered intramuscularly for a total dose of 3,825 IU. MAIN OUTCOME MEASURE(S): Follicle number and diameter. RESULT(S): Three follicles with a diameter of > 1.7 cm and an endometrial thickness of 8 mm were observed. A clinical pregnancy, which subsequently was spontaneously aborted, was obtained. CONCLUSION(S): In primed patients with Kallmann's syndrome, highly purified FSH may be a useful alternative to pulsatile GnRH or menopausal gonadotropins to achieve ovulation induction and pregnancy.

Polycystic ovary syndrome: a new ultrasonographic and color Doppler pattern.

The aim of this study was to evaluate whether patients with partial bilateral polycystic ovaries show different ovarian and uterine blood flow to those with complete bilateral polycystic ovaries, and to investigate whether there is a correlation between ultrasonographic and hormonal parameters. Fifteen patients with partial polycystic ovaries and eighteen patients with complete bilateral polycystic ovaries underwent clinical, biochemical, gray-scale and color Doppler ultrasonographic evaluation. Hormonal (luteinizing hormone (LH), follicle-stimulating hormone (FSH), LH/FSH concentration ratio, estradiol, prolactin, androstenedione, testosterone), clinical (body mass index, Ferriman-Gallwey score), ultrasonographic (ovarian volume, number and distribution of subcapsular follicles, stromal score) and Doppler (uterine artery and intraparenchymal vessels pulsatility index, ovarian stromal vascularization) parameters were evaluated, in the early follicular phase (cycle day 3-5) in oligomenorrheic patients, or at random in amenorrheic patients. Significantly higher androstenedione plasma levels and LH/FSH concentration ratios were observed in complete bilateral polycystic ovaries. In partial polycystic ovaries, gray-scale and color Doppler ultrasonography showed different features in affected and unaffected areas of the ovary, similar to polycystic and normal ovary appearance respectively. In conclusion, PCOS does not predetermine a single ultrasonographic or Doppler pattern.

Polycystic ovary syndrome: it is always bilateral?

OBJECTIVE: To evaluate whether patients with unilateral polycystic ovary showed different ovarian and uterine blood flow from those with bilateral polycystic ovaries, and to investigate whether there was a correlation between the ultrasonographic aspect and different hormonal parameters. DESIGN: An observational study. SUBJECTS: Sixteen patients with unilateral polycystic ovary and twenty patients with bilateral polycystic ovaries underwent clinical, biochemical, gray-scale and color Doppler ultrasonographic evaluation. METHODS: The following parameters were evaluated: hormonal (luteinizing hormone (LH), follicle stimulating hormone (FSH), LH/FSH concentration ratio, estradiol, prolactin, androstenedione, testosterone), clinical (body mass index, Ferriman-Gallwey score), ultrasonographic (ovarian volume, number and distribution of subcapsular follicles, stromal score) and Doppler (uterine artery and intraparenchymal vessel pulsatility index, ovarian stromal vascularization), in oligomenorrheic patients in the early follicular phase (cycle days 3-5) or in amenorrheic patients at random. RESULTS: Significantly higher androstenedione plasma levels and LH/FSH concentration ratios were observed in bilateral polycystic ovaries. In unilateral polycystic ovaries, gray-scale and color Doppler ultrasonography showed different features in the affected and the unaffected ovary, similar to the appearance of a polycystic and normal ovary, respectively. CONCLUSION: Polycystic ovary syndrome does not predetermine a single ultrasonographic and Doppler pattern.

Uterine and cerebral vascularization in postmenopausal women treated with hormone-replacement therapy.

The effects of hormone-replacement therapy on the Doppler flow parameters of the ophthalmic artery in postmenopausal women were studied and compared with those registered at the level of the internal carotid and uterine arteries. Fifty-seven postmenopausal patients were submitted to continuous estradiol transdermal supplementation and 12-day courses of medroxyprogesterone acetate. During the estrogen phase of hormone-replacement therapy all patients underwent (at 1, 3 and 6 months after the beginning of hormone-replacement therapy) transvaginal ultrasonographic evaluation of the pelvic organs and of endometrial thickness. On the same day, they underwent color Doppler analysis of the blood flow impedance of the uterine, internal carotid and ophthalmic arteries. Estradiol plasma concentrations were assayed on the day that ultrasonographic and Doppler examinations took place. The pulsatility index of all the arteries improved, from baseline values, during the therapy and attained stable values compared to those after the first month of treatment. Furthermore, at the level of the internal carotid and ophthalmic arteries, a significant increase of the peak systolic blood flow velocity (Vmax) was observed over the 6 months of therapy. Doppler studies of the ophthalmic artery are capable of affording specific and precise pathophysiologic information to assess peripheral intracranial blood flow variations. Furthermore, such studies may be useful in monitoring hormone-replacement therapy effects on cerebral perfusion.