A.F. Haney

Superovulation with intrauterine insemination in the treatment of infertility: a possible alternative to gamete intrafallopian transfer and in vitro fertilization

In vitro fertilization and embryo transfer (IVF-ET) and gamete intrafallopian transfer (GIFT) are used to treat intractable infertility in women with no distortion of the pelvic viscera, despite the lack of controlled trials demonstrating efficacy. The mechanism of any purportedly enhanced cycle fecundity in ovulatory women without significant distortion of the pelvic viscera is unclear, but both GIFT and IVF-ET increase the number of male and female gametes at the site of fertilization. Intrauterine insemination (IUI) during human menopausal gonadotropin (hMG)-stimulated superovulatory cycles has similar potential but does not require oocyte retrieval. To evaluate the possibility that simply increasing the number of gametes at the site of fertilization might account for pregnancies attributed to IVF-ET and GIFT, the authors retrospectively analyzed the outcome of couples undergoing IUI during hMG cycles between 1983 and 1986 in women with normal pelvic anatomy. IUI during hMG-stimulated cycles yielded a cycle fecundity (f) of 0.17 for endometriosis, 0.29 for cervical factor, and 0.19 for idiopathic infertility, which approaches the fecundity of normal women and equals or exceeds that reported for IVF-ET and GIFT. The authors conclude that treatment with IUI in hMG cycles, alleviating the need for invasive oocyte retrieval, should be considered for inclusion in a randomized, controlled trial in comparison with IVF-ET and GIFT.

Immunohistochemical analysis of estrogen and progesterone receptors in endometriosis: comparison with normal endometrium during the menstrual cycle and the effect of medical therapy *

Estrogen receptors (ER) and progesterone receptors (PgR) in 19 endometriotic implants from 16 normally cycling and hormonally treated women were measured using immunohistochemical techniques and compared with 34 samples of normal intrauterine endometrium. Endometriotic implants contained specific ER and PgR in both glandular epithelium and stroma. In contrast to intrauterine endometrium, receptor content among implants was noted to be more heterogeneous, and did not undergo predictable changes in response to endogenous hormones. In the endometriotic implants of patients treated with hormonal therapy, there were significant decreases in ER and PgR in both the glands and stroma relative to untreated patients. These data imply that endometriosis is unpredictable in its response to the cyclic hormonal milieu in terms of ER and PgR, but retains the ability to respond to hormonal suppression over a prolonged interval.

Expanded polytetrafluoroethylene (Gore-Tex Surgical Membrane) is superior to oxidized regenerated cellulose (Interceed TC7 ) in preventing adhesions

OBJECTIVE To compare the impact of expanded polytetrafluoroethylene (PTFE; Gore-Tex Surgical Membrane; W. L. Gore & Associates, Inc., Flagstaff, AZ) and oxidized regenerated cellulose (Interceed TC7, Johnson & Johnson Medical, Inc., Arlington, TX) on the development of postsurgical adhesions. DESIGN A multicenter, nonblinded, randomized clinical trial. SETTING University medical centers. INTERVENTIONS Each barrier was allocated randomly to the left or right sidewall of every patient. PATIENTS Thirty-two women with bilateral pelvic sidewall adhesions undergoing reconstructive surgery and second-look laparoscopy. MAIN OUTCOME MEASURES Adhesion score (on a 0- to 11-point scale), the area of adhesion (cm2), and the likelihood of no adhesions. RESULTS The use of both barriers was associated with a lower adhesion score and area of adhesion postoperatively. However, those sidewalls covered with PTFE had a significantly lower adhesion score (0.97 +/- 0.30 versus 4.76 +/- 0.61 points, mean +/- SEM) and area of adhesion (0.95 +/- 0.35 versus 3.25 +/- 0.62 cm2). Overall, more sidewalls covered with PTFE had no adhesions (21 versus 7) and, when adhesions were present on the contralateral sidewall, the number of sidewalls covered with PTFE without adhesions was greater than those covered with oxidized regenerated cellulose (16 versus 2). CONCLUSION Expanded polytetrafluoroethylene was associated with fewer postsurgical adhesions to the pelvic sidewall than oxidized regenerated cellulose.

Diethylstilbestrol-Induced Upper Genital Tract Abnormalities*

In utero diethylstilbestrol (DES) exposure has recently been associated with apparently unique abnormalities of the upper genital tract. Utilizing a standardized technique of hysterosalpingography (HSG) and a linear planimeter, the following measurements were made in a group of 13 DES-exposed women and compared with a control group of 22 women undergoing HSG during infertility investigations (mean +/- standard error: endometrial cavity area, 323.23 +/- 32.13 sq mm versus 626.56 +/- 52.75 sq mm; endometrial cavity circumference, 128.65 +/- 5.08 mm versus 140.52 +/- 5.56 mm; upper uterine segment length, 28.80 +/- 1.11 mm versus 38.03 +/- 1.81 mm; lower uterine sugment length, 36.03 +/- 4.77 mm versus 42.24 +/- 2.39 mm; intercornual distance, 36.40 +/- 2.56 mm versus 38.25 +/- 1.58 mm; internal os diameter, 3.90 +/- 0.44 mm versus 4.43 +/- 0.23 mm; widest diameter of the endocervical canal, 3.78 +/- 0.40 mm versus 9.39 +/- 0.60 mm; isthmic tubal diameter, 1.25 +/- 0.08 mm versus 1.20 +/- 0.01 mm; ampullary tubal diameter, 4.79 +/- 0.43 mm versus 4.65 +/- 0.22 mm. The endometrial cavity area, upper uterine segment, and endocervical canal measurements were significantly smaller in the DES-exposed group (P less than 0.01). The upper genital tract abnormalities observed appeared to be unlike spontaneously occurring Müllerian malformations and correlated with DES-induced cervicovaginal changes. Primary dysmenorrhea and menstrual irregularity occurred in 40% and 47%, respectively, of the DES-exposed patients.

Embolic microspheres within ovarian arterial vasculature after uterine artery embolization.

BACKGROUND Adverse events after uterine artery embolization, including hysterectomy and premature ovarian failure, are concerning for women who desire future fertility. CASE A 39‐year‐old woman underwent emergency hysterectomy after uterine artery embolization embolic microspheres found within the ovarian arterial vasculature. CONCLUSION Uterine artery embolization for the treatment of uterine fibroids has been associated with loss of ovarian function in up to 14% of patients. This case report demonstrates that embolic microspheres injected into the uterine artery can unintentionally migrate through anastomotic channels into the ovarian arterial vasculature and potentially compromise ovarian blood flow. Hypoxic tissue injury may be the mechanism of premature ovarian failure observed after uterine artery embolization. Understanding the etiology of premature ovarian failure after uterine artery embolization might allow better patient selection.

Murine peritoneal injury and de novo adhesion formation caused by oxidized-regenerated cellulose (Interceed [TC7]) but not expanded polytetrafluoroethylene (Gore-Tex Surgical Membrane).

STUDY OBJECTIVE To evaluate the impact of the materials contained in the available adhesion prevention barriers on the peritoneum. STUDY DESIGN, SETTING, PATIENTS: A murine paradigm was used, placing oxidized-regenerated cellulose (Interceed [TC7]) and expanded polytetrafluoroethylene (PTFE; Gore-Tex Surgical Membrane) in the peritoneal cavity for intervals up to 14 days. INTERVENTIONS AND MAIN OUTCOME MEASURES The appearance of the peritoneum on scanning and transmission electron microscopy and the presence of de novo adhesions were the end-points used. RESULTS Oxidized-regenerated cellulose caused localized sloughing of the mesothelial cell layer and leukocyte infiltration of the deeper tissue leading to the formation of adhesions to the bowel and liver in 58% of the animals. The surface of the oxidized-regenerated cellulose-injured peritoneum healed in 5 to 7 days. Neither peritoneal injury nor adhesions were noted in sham-operated animals or animals with PTFE. CONCLUSIONS Oxidized-regenerated cellulose but not PTFE has a localized injurious effect on the peritoneum of the mouse, resulting in de novo adhesions. The impact of the barrier material itself on normal peritoneum may be an important consideration in designing surgical barriers for the prevention of postoperative adhesions.

Serious complications of uterine artery embolization for conservative treatment of fibroids

OBJECTIVE Document major complications following treatment of fibroids by uterine artery embolization (UAE). DESIGN Two case reports. SETTING University medical center. PATIENTS Two women with symptomatic fibroid uteri. INTERVENTION(S) Selective bilateral uterine artery embolization. MAIN OUTCOME MEASURE(S) Complications attributable to UAE. RESULT(S) Two patients experienced significant morbidity requiring hysterectomy due to infection and/or partial bowel obstruction resulting from UAE. CONCLUSION(S) Reports of the management of symptoms related to fibroids with UAE infrequently include adverse outcomes and/or complications. The two cases we managed reinforce that UAE is not free of the risk of life-threatening complications that require emergency hysterectomy. Increasing surveillance for complications may help define the selection criteria that decrease the risks of UAE.

Limited hormonal responsiveness of ectopic endometrium: Histologic correlation with intrauterine endometrium*

In order to assess the hormonal responsiveness of ectopic endometrium, 438 unselected endometrial implants and corresponding intrauterine endometrium from 196 patients were evaluated and classified by standard endometrial dating criteria. Only 13% of the endometrial implants were histologically synchronous with the corresponding intrauterine endometrium. Both proliferative and secretory implants were present in relatively constant proportions throughout the menstrual cycle, demonstrating a lack of correlation with cyclic endogenous hormones. A significant percentage (range, 25% to 49%) of endometrial implants displayed some form of local hemorrhage irrespective of the menstrual cycle timing. Sixty percent of the patients had evidence of hemorrhage in at least one implant. In women receiving hormonal therapy at the time of surgery, the proportion of endometrial implants that were histologically in concert with the corresponding endometrium ranged from 0% to 33%. In early pregnancy and menopause, 50% and 31% of endometrial implants were histologically similar, respectively. These data indicate that the hormonal responsiveness of endometrial implants is unpredictable and inconsistent.

Expanded-polytetrafluoroethylene but not oxidized regenerated cellulose prevents adhesion formation and reformation in a mouse uterine horn model of surgical injury *

OBJECTIVE To evaluate the ability of the two currently available surgical barriers, oxidized regenerated cellulose and expanded-polytetrafluoroethylene (PTFE), to prevent postsurgical adhesions. DESIGN Murine uterine horns were approximated in the midline and the contacting uterine surfaces injured by electrocautery, cutting, and scratching, with and without barriers interposed. Sham-operated and experimental animals had adhesions assessed visually and histologically 7 days postoperatively. In another group, adhesions were created and then lysed 7 days later with barriers interposed. Readhesion formation was assessed 14 days after lysis with the PTFE being removed 7 days after lysis. SETTING Research laboratory RESULTS Adhesions occurred at 58.5% of the electrocautery sites without barriers, 100% of the readhesion sites with recautery for hemostasis, and 92% of the recautery sites without hemostasis. None of the sham-operated sites developed adhesions. When oxidized regenerated cellulose was interposed, adhesions were observed at 36% of uninjured uterine horn sites, 62% with single and 92% with double electrocautery injuries and 90% of the reformation sites. The PTFE did not cause adhesions in uninjured controls and completely prevented adhesion formation and reformation, regardless of the type of injury or whether hemostasis was achieved. A thin cellular membrane, continuous with the uterine serosa, enveloped the PTFE. CONCLUSIONS Expanded-polytetrafluoroethylene, but not oxidized regenerated cellulose, prevents adhesion formation and reformation in this murine uterine horn model. Additionally, oxidized regenerated cellulose was adhesiogenic even without surgical injury.

Recurrent first trimester pregnancy loss is associated with uterine septum but not with bicornuate uterus

OBJECTIVE Determine the relative frequency of having a uterine septum or bicornuate uterus in women presenting with first trimester recurrent pregnancy loss and a divided uterine cavity by hysterosalpingography (HSG) or hysteroscopy. DESIGN Retrospective analysis of the frequency of a uterine septum or a bicornuate uterus in all patients undergoing surgery (laparoscopy and hysteroscopy) with the clinical presentation of recurrent pregnancy loss and a divided uterine cavity between January 1995 and October 2002. SETTING An academic medical center. PATIENT(S) Thirty-five consecutive, premenopausal women with a divided uterine cavity on preoperative HSG or hysteroscopy. INTERVENTION(S) Diagnostic laparoscopy and diagnostic hysteroscopy. MAIN OUTCOME MEASURE (S): A fused uterine fundus at laparoscopy indicating a uterine septum. RESULT(S) All 35 patients had a uterine septum. CONCLUSION(S) When presenting with recurrent first trimester pregnancy loss and a divided uterine cavity by HSG or hysteroscopy, virtually all the women have a uterine septum.