Histologic evaluation of the luteal phase in women following follicle aspiration for oocyte retrieval.

The luteal phase was evaluated by endometrial biopsy (EMB) 11 to 13 days after administration of human chorionic gonadotropin (hCG) or initiation of the luteinizing hormone (LH) surge (hCG/LH) in 25 stimulated patients not undergoing embryo transfer (ET). Luteal phase defect (LPD) was defined as an EMB greater than 2 days out-of-phase when compared with the onset of subsequent menses. Nineteen women (76%) had LPDs ranging from 3 to 7 days. Mean estradiol (E2) on day of hCG/LH was significantly (P less than 0.01) higher (1709 +/- 997) in patients with in-phase EMBs than mean E2 levels in two groups of patients with out-of-phase EMBs (687 +/- 251, 941 +/- 366, respectively). These findings are further evidence of the importance of optimal follicular development to subsequent endometrial maturation.

Microsurgical laser technique for abdominal myomectomy.

This study was designed to evaluate the applicability of a hand-held CO2 laser combined with microsurgical principles to the abdominal myomectomy in women with menorrhagia and infertility. Seventeen patients with submucous and intracavitary myomata diagnosed by hysterosalpingography were included in this study. The myomectomy technique described was rapid, allowed for excellent intraoperative hemostasis, and resulted in a short, uneventful postoperative hospital stay. In all patients, menstrual pattern returned to normal. Seven out of ten patients who attempted pregnancy succeeded.

Conservative microsurgical management of ectopic gestation.

The current management of ectopic gestation has been greatly affected by two apparent trends: a world-wide dramatic increase in its incidence; and a tendency for women to delay childbearing into later life. In the past, the objective of surgery for ectopic pregnancy was saving lives, and salpingectomy was the procedure of choice. At present, with improved methods of an early diagnosis, namely quantitative beta-HCG, ultrasonography, and laparoscopy, preservation of maximal reproductive potential of the affected women becomes a primary surgical goal. Conservative microsurgical approach with the reconstruction of the affected oviduct may be the procedure of choice. Following standard salpingectomy for ectopic gestation, two-thirds of such patients will not subsequently reproduce successfully. On the other hand, statistics indicate that microsurgical repair of the affected oviduct at the time of operation for an ectopic pregnancy will be followed by term pregnancy in 50 to 72% of patients. In this presentation, a variety of conservative surgical approaches are described and discussed. They represent a spectrum from operative laparoscopy to laparotomy with linear salpingotomy, segmental excision with or without an immediate anastomosis, to the management of tubal abortion. General principles of microsurgical techniques applicable to the management of unruptured ectopic gestation are outlined. The analysis of available data indicate that conservative approach is advantageous for preservation and enhancement of future reproductive potential of the affected patient. Since ectopic tubal gestation is an unqualified human reproductive disaster, preservation and restoration of normal pelvic architecture appears logical and applicable, especially in cases of chronologically older women whose first pregnancy is an ectopic location.

The polycystic ovary syndrome.

Much is known about the pathophysiology and pathogenesis of the polycystic ovary syndrome (PCO). The key clinical features are inappropriate gonadotropin secretion, altered production rates, binding and metabolism of steroids and androgen excess, all resulting in defeminization, anovulatory infertility, obesity and endometrial hyperplasia. Management should be based on the patient's reproductive goals. Adjunct measures can control hirsutism.

Modern management of prolactinoma.

Hyperprolactinemia can cause amenorrhea, oligomenorrhea, galactorrhea and infertility. Prolactin (PRL) increase can have pharmacologic, neoplastic and nonneoplastic causes. The clinical approach to such patients should include both static and dynamic evaluation of PRL levels and radiographic imaging of the sella turcica and pituitary gland.

Effect of danazol on gonadal steroidogenesis in patients with a complete form of testicular feminization.

The clinical applicability of danazol has been postulated to depend upon its antigonadotropic and androgenic properties. However, the true mechanism of action of danazol has not been fully elucidated, and experimental evidence indicates that the major pharmacologic action of this drug may be related to the direct inhibition of multiple enzymes of gonadal steroidogenesis. In the present study, the hypothesis that danazol directly inhibits gonadal steroidogenesis was tested during the course of endocrine studies on three sisters with a complete form of testicular feminization. Serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), and testosterone (T) levels were determined following short-term administration of varying doses of danazol. In these patients, the absence of androgen receptors and the expected inability of danazol to serve as a metabolic precursor of estrogens would minimize possible antigonadotropic effects of this drug and allow the evaluation of its direct action on the secretion of steroids by the gonads in vivo. During the experiments, there was a highly significant and dose-related suppression of serum T levels in all patients. E2 levels decreased slightly. Both LH and FSH levels showed no consistent decline and remained within the range of normal. In one patient, LH and FSH levels declined significantly during treatment, but in the other two patients serum concentrations of LH remained stable or even increased while T levels fell. In spite of the fall in steroid levels, a compensatory increase in gonadotropins did not always occur. In conclusion, danazol effectively suppresses peripheral T levels in patients with a complete form of testicular feminization. Such suppression is dose related and can occur in the absence of a decline in LH serum concentrations, possibly as a result of a direct action on gonadal steroidogenesis.l

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.

Transverse vaginal septum.

Transverse vaginal septum, perhaps the most common congenital anomaly of the vagina, is nonetheless an unusual finding. A case report and its management and theories concerning the embryology of the vagina are presented. The varying presentations of imperforate versus perforate transverse septa are reviewed, as well as diagnostic tools and treatment modalities. Surgical excision of the septum is advocated.

Endocrine physiology of the breast.

Endocrine physiology of the breast is discussed in regard to both the development and functional aspects. The interaction of hormones at the mammary gland level is presented from the fetal stage through the reproductive era. The mechanisms of galactopoiesis and lactation are discussed. Finally, physiology of prolactin and the influence of this hormone upon the breast in physiologic and pathologic states is presented.

Serum prolactin levels in short-term and long-term use of inert plastic and copper intrauterine devices.

Serum prolactin values were assessed in 59 normally menstruating parous women; groups were divided with respect to short-term (6 weeks) and long-term (4-60 months) use of either the inert plastic IUD (Saf-T-Coil or Lippes Loop) or copper IUD (Cu-7). Preinsertion values served as controls in the short-term study while a separate control group using barrier contraception was used in the long-term study. Prospective analysis of short-term IUD use and retrospective analysis of long-term IUD use revealed no significant differences in mean hPRL compared to control values. Both short- and long-term mean values were within the normal range for serum hPRL. In addition, duration of use had no significant effect on hPRL values.

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.

Immune infertility and new approaches to treatment.

A number of patients who have involuntary infertility show sperm antibodies in the blood serum, as detected by two quite different methods of spermagglutination. These techniques are the Kibrick method (gelatin agglutination test) and the F-D method (tube-slide agglutination test). By the former technique, the sera of 18% of women and 9% of men from infertile couples were found to be positive; by the latter technique, the sera of 15% of women and 5% of men were positive. Such cases are termed "immunologic infertility." In an effort to develop new methods for the treatment of infertility, two procedures were explored. One is a sperm washing insemination method in which fresh semen from a man with the antibody is centrifuged, resuspended in an albumin solution, and then used for insemination. The second is an immunosuppression method, using methylprednisolone at a dose of 96 mg/day for 7 days. A striking decrease in antibody level was seen in some cases, with ensuing pregnancy. The success rates for these methods have been of the order of 14% to 22%.

Antibodies to spermatozoa. VIII. Correlation of sperm antibody activity with postcoital tests in infertile couples.

A study of the correlation between results of postcoital tests (PCTs) and presence of sperm antibodies in sera of either male or female partners or in the cervical mucus of seminal plasma, was made in 127 infertile couples. The percentage of positive antibody tests increased progressively as PCT results deteriorated from excellent to poor. Thus, the percentage of positive serum tests, by either method used, was 7% in the excellent group as compared to 52% in the poor group. This progressive increase was evident only in the females; the antibody tests in the males did not correlate directly with the PCT results. Nonetheless, even with excellent PCT results, 7% of women and 21% of men showed presence of antibodies. On the other hand, in the group showing poor PCTs, 48% of women had an absence of antibodies.