Reproductive potential after methotrexate treatment of ectopic gestation in a community hospital.

OBJECTIVE: To compare the rates of ipsilateral tubal patency after methotrexate treatment versus conservative surgical treatment in a small community hospital lacking personnel dedicated to methotrexate management. STUDY DESIGN: From hospital and clinic records, cases of ectopic gestation within a six-year interval were identified. Method of treatment and location of the ectopic gestation were documented by review of records and confirmed by patient interviews. Women desiring fertility were offered hysterosalpingography (HSG) to evaluate tubal patency. HSG was performed under fluoroscopy with water-soluble contrast medium. RESULTS: HSG was completed in 11 cases of linear salpingostomy and 11 cases of ectopic gestations treated by methotrexate. Ipsilateral patency was documented in 8 of 11 (72%) tubes treated by linear salpingostomy and 9 of 11 (81%) methotrexate-treated tubes. One methotrexate case had a prior ipsilateral ectopic treated by salpingostomy, and two additional cases had a prior contralateral ectopic removed by salpingectomy. Each of these three cases had ipsilateral tubal patency after methotrexate for the most recent ectopic gestation. CONCLUSION: Data from this study suggest comparable tubal patency rates after methotrexate and conservative surgery. Comparable tubal patency outcomes were obtained in our community hospital despite a less-rigorous-than normal follow-up protocol.

Thrombosis, leiomyoma and GnRH-a therapy. A case report.

BACKGROUND: Diverse complications have been reported in association with the growth and medical treatment of uterine leiomyomata. Infarction and necrosis may be common and incite complications from parasitic vascular attachment, pain and thrombosis. The rarity of severe complications in this situation warrants presentation of the following unique association. CASE: A 33-year-old female, gravida 1, para 1, was treated with gonadotropin-releasing hormone agonist (GnRH-a) for three months prior to laparotomy and removal of a solitary, 5,190-g, pedunculated myoma. The mass had secured an additional vascular supply from the transverse colon and omentum. Although the immediate postoperative course was uncomplicated, delayed onset of abdominal pain and fever lead to the diagnosis of superior mesenteric and portal vein thrombosis. Portal vein thrombosis responded to thrombolytic infusion into the superior mesenteric artery. Superior mesenteric vein thrombosis persisted, with evidence of early vascular recanalization. After six weeks of additional anticoagulation, assessment by computed tomographic scan showed complete resolution of all thrombi. CONCLUSION: While thrombosis has been reported with GnRH-a therapy in men with prostate cancer, its association with treatment in this benign case may have been a consequence of the massive tumor size. Steroid hormone deprivation potentially contributed to neovascularization and bowel involvement.

Methods for enhancement of sperm function.

From a review of recent advances in human reproduction, it is apparent that therapeutic approaches to male infertility have been revolutionized. While our understanding of sperm function at the molecular level is steadily increasing, the realization of consistent oocyte fertilization by mechanically bypassing natural barriers has given new perspective for future investigation. This chapter reviews current knowledge of adjuvants that enhance sperm function and lend themselves to clinical application. Each compound is presented with recent publications supporting proposed mechanisms of action. Specifically, follicular fluid, progesterone, pentoxifylline, platelet activating factor and other cytokines have been studied for their impact on the in vitro fertilization capacity of spermatozoa. Intracytoplasmic sperm injection (ICSI) has provided infertile couples with hope for successful reproduction without sperm donation. The precise mechanism that allows subsequent pronuclear formation and syngamy is currently unknown and experimental models are few. Adjuvants that can be used in conjunction with controlled ovarian stimulation and intrauterine insemination are prominent areas for further research as this would provide an alternative to the expense and risks of in vitro fertilization and embryo transfer.

Platelet activating factor and conception.

PURPOSE: This review provides evidence for the involvement of platelet activating factor (PAF) in the several facets of pregnancy establishment. METHODS: A comprehensive literature review and new data. RESULTS: PAF has a role in spermatozoal function, fertilization, embryo development, and implantation. CONCLUSIONS: PAF is intimately involved in conception.

Platelet activating factor treatment of spermatozoa enhances rabbit oocyte fertilization following subzonal sperm insertion.

PURPOSE: The objective of this study was to evaluate the effects of spermatozoal platelet activating factor (PAF) treatment on fertilization rates employing subzonal sperm insertion in the rabbit. STUDY DESIGN: Oocytes (n = 130) with distinct first polar bodies were injected with three to seven motile spermatozoa. Half (n = 65) of the oocytes were injected with PAF-treated sperm, whereas the other half (n = 65) served as controls and were injected with nontreated sperm. Fertilization rates were assessed by the formation of two pronuclei followed by cleavage to the two-cell stage. RESULTS: In the group of oocytes injected with PAF-treated sperm, we noted a significant (P < 0.001) improvement in fertilization rates, 61.5% (40/65), vs. control nontreated sperm, 20.0% (13/65). Subsequent cleavage to the two-cell stage was noted for 95% (38/40) in the treated vs 92.3% (12/13) in the nontreated fertilized zygotes. CONCLUSION: We conclude that PAF treatment of rabbit spermatozoa prior to subzonal insertion improves fertilization rates and may be of clinical significance in assisted reproductive programs.

Intrauterine insemination in fertile women delivers larger number of sperm to the peritoneal fluid than intracervical insemination.

Randomized IUI or intracervical insemination of eight fertile women with 50 x 10(6) sperm was performed to determine whether IUI delivers more spermatozoa to the peritoneal cavity. After IUI (n = 4), 2,053 to 29,450 sperm were recovered in the PF at laparoscopy. No sperm were found in the PF after intracervical insemination (n = 4). After IUI, CM contained 1.0 x 10(6) to 57.0 x 10(6) sperm/mL; after intracervical insemination, 0 to 1.2 x 10(3) sperm/mL were seen. One therapeutic mechanism for IUI is delivery of larger sperm numbers to the fertilization site by rapid (4 hours) transport. In addition, there is greater retrograde colonization of CM that may result in sustained release of sperm.

Endometriosis and chronic pelvic pain.

Although epidemiology can suggest populations at risk for endometriosis, a single form of therapy with consistent results for all patients is lacking. It is without question that the advancement of conservative therapy for endometriosis-associated pain will depend on the results of well-controlled and randomized studies. Laparoscopic treatment with standardized procedures and instruments should be evaluated in recognition of the requirement of surgery for diagnosis. New approaches may be developed as our understanding of the disease itself expands and its relationship to pain is better defined.

Platelet-activating factor production from in vitro and in vivo fertilized murine embryos is similar.

PROBLEM: This study measured platelet-activating factor (PAF) production of in vitro and in vivo fertilized murine embryos to ascertain whether site of fertilization impacted subsequent embryonic PAF production. METHOD: Oocytes and embryo were collected from stimulated B6D2F1 mice. PAF production throughout the preimplantation phase from the two-celled stage through expanded blastocysts was measured and compared among normally developing embryos with the only difference being site of fertilization. RESULTS: A striking increase in PAF production was noted for both in vivo and in vitro fertilized embryos over the four days of culture. Significantly higher (P < .001) levels of PAF production were noted with development from the two-celled stage (47.22 +/- 4.13; 44.30 +/- 2.43) to expanded blastocysts (254.31 +/- 24.01; 255.11 +/- 5.35 ng/embryo/24 h) for both in vitro and in vivo fertilized embryos, respectively. There was no significant difference (P > .05) in PAF production between the two groups of embryos. CONCLUSIONS: Embryonic PAF production in the mouse increases in a stage-specific manner, and specifically the site of fertilization in vitro versus in vivo does not affect PAF production in normally developing embryos.

Embryonic platelet activating factor production in the rabbit increases during the preimplantation phase.

OBJECTIVE: This study measured platelet activating factor (PAF) production by rabbit embryos in vitro and ascertained if there is increased PAF production associated with advancing embryonic development. STUDY DESIGN: Two-cell rabbit embryos were recovered from superovulated New Zealand White does and cultured in vitro for 96 hr. Every 24 hr embryos were scored for developmental stage and PAF activity from the corresponding culture medium was measured by platelet aggregation and organic phosphate analyses. RESULTS: PAF was detected in culture medium at all stages from two cells to blastocysts and rose significantly (P < 0.001) at each 24-hr interval, reaching maximal levels at the expanded blastocyst stage. CONCLUSION: Maximal PAF production by expanded blastocysts may be an embryonic paracrine signal that facilitates implantation.

Correlation of focal pelvic tenderness with implant dimension and stage of endometriosis.

Reported symptoms in patients with endometriosis have shown poor correlation with the extent of disease at surgery. Recent data have suggested that signs and symptoms may correlate with depth and volume of individual implants. In this study preoperative focal tenderness was correlated with the presence or absence of endometriosis, depth and volume of the endometrial implants and the presence of other pathology. The findings suggest that focal tenderness has limited value in predicting the stage of endometriosis, but is strongly associated with the presence of disease in the cul de sac and uterosacral ligaments. There was also significant association of tenderness with deeper and larger volumes of implants, a finding that may be of clinical significance in the surgical management of endometriosis-associated symptoms and tenderness.

Focal pelvic tenderness, pelvic pain and dysmenorrhea in endometriosis.

A study was conducted to determine if the increased recognition of various forms of endometriosis might have increased the ability to correlate focal tenderness with lesions. The prospective study of 82 patients revealed a strong correlation between focal tenderness on examination with the presence of deep fibrotic endometriosis and other fibrotic pathology. The data suggested that focal tenderness and depth of infiltration may direct further study in women with endometriosis.