Anthony A. Luciano

Denovo synthesis of prolactin by human decidua

Abstract Relatively large amounts of immunoreactive prolactin were measured in homogenates of human decidual tissue obtained immediately after delivery of normal term pregnancies. In order to study the release and possible synthesis of prolactin by this tissue, explants of decidua were incubated for 24 hours at 37°C in oxygenated Geys buffer containing 20% fetal calf serum. When cycloheximide was added to the medium in concentrations sufficient to prevent in vitro protein synthesis, 85–90% of the prolactin present in the tissue was released into the medium during the first 3 hours of incubation. No additional prolactin accumulated in either the medium or the tissue during the remainder of the incubation period. In the absence of cycloheximide, the prolactin concentration in the medium increased progressively during incubation, so that after 24 hours the total amount of hormone present in the tissue and medium was significantly greater than that in the tissue and medium prior to incubation (37.6 ± 9.6 ng/ml at 0 time vs 82.2 ± 7.7 ng/ml at 24 hours). When 3H-1-leucine (100 u Ci) was supplied during incubation, radioactive proteins were detected in the medium at 24 hr, 14–20% of which were specifically precipitated by antiserum to human pituitary prolactin. When aliquots of this medium were chromatographed on Sephadex G-100, 80–95% of the 3H-proteins precipitated by antiserum to pituitary prolactin eluted in the same position as did purified, iodinated pituitary prolactin. These data indicate that a species of prolactin which is identical to pituitary prolactin by the criteria of immunoprecipitation and gel chromatography is synthesized by human decidual tissue in vitro .

Adhesion reformation after reproductive surgery by videolaseroscopy.

After initial videolaseroscopy for the treatment of endometriosis-associated infertility, 157 patients underwent a second-look laparoscopy to evaluate and treat recurrence of disease and/or adhesions. The patients were divided into two groups. Group 1 consisted of 135 patients who underwent second-look laparoscopy for persistent infertility and/or recurrence of pain. Group 2 consisted of 22 patients who achieved pregnancy after initial surgery and underwent second-look laparoscopy for evaluation of ectopic pregnancy or in association with uterine evacuation for first trimester spontaneous abortion. Both groups of patients demonstrated a significant reduction in adhesion scores involving the ovaries, tubes, posterior cul-de-sac, anterior cul-de-sac, and omentum/bowel. Although the initial mean adhesion scores were similar for both groups, at second-look laparoscopy the mean adhesion scores were significantly lower for group 2, particularly for ovarian and tubal adhesions. None of the patients formed de novo adhesions. From these results we may conclude that videolaseroscopy: (1) is effective in reducing peritoneal adhesions; (2) is associated with a low frequency of postoperative adhesion recurrence; and (3) appears to completely avoid de novo adhesion formation.

Can hysterosalpingo-contrast sonography replace hysterosalpingography in confirming tubal blockage after hysteroscopic sterilization and in the evaluation of the uterus and tubes in infertile patients?

OBJECTIVE The objective of the study was to assess the accuracy of hysterosalpingo-contrast sonography (HyCoSy) in establishing tubal patency or blockage and evaluating the uterine cavity by comparing it with hysteroscopy laparoscopy (HLC) or hysterosalpingography (HSG). STUDY DESIGN This study was a chart review evaluating infertility patients and patients who had undergone hysteroscopic sterilization who underwent both HyCoSy and HLC or HyCoSy and HSG at private offices associated with university hospitals. Sensitivity, specificity, positive predictive value, and negative predictive value of HyCoSy were calculated. RESULTS HyCoSy compared with HLC had a sensitivity of 97% and specificity of 82%, and HyCoSy compared with HSG was 100% concordant. Uterine cavities evaluated by sonohysterography and hysteroscopy were 100% concordant. CONCLUSION HyCoSy is accurate in determining tubal patency and evaluating the uterine cavity, suggesting it could supplant HSG not only as the first-line diagnostic test in an infertility workup but also in confirming tubal blockage after hysteroscopic sterilization.

Three-Dimensional Ultrasound in Diagnosis of Adenomyosis: Histologic Correlation With Ultrasound Targeted Biopsies of the Uterus

STUDY OBJECTIVE To evaluate the accuracy of 3-dimensional transvaginal sonography (3D TVS) in the diagnosis of adenomyosis by correlating adenomyosis-induced morphologic alterations in the myometrium and the junctional zone (JZ) with histopathologic features of targeted biopsy specimens of the uterus. DESIGN Prospective study (Canadian Task force classification II-2). SETTING Private practice associated with a university program. PATIENTS Symptomatic premenopausal women scheduled to undergo hysterectomy because of benign conditions. INTERVENTIONS Patients underwent preoperative 3D TVS of the uterus to evaluate alterations to the JZ, to measure the smallest (JZ(min)) and largest (JZ(max)) JZ thickness, and to assess for the presence of myometrial heterogeneous and cystic areas, hyperechoic striations, and asymmetry of the myometrial wall. Localization and position of the lesions in the myometrial wall were accurately recorded. Results of the sonographic features were correlated with the histopathologic findings of the ultrasound-based targeted biopsy specimens of the uterus. MEASUREMENTS AND MAIN RESULTS The study included 54 symptomatic premenopausal women with a mean age of 42.1 years. Of these, 12 had previously undergone endometrial ablation and 10 were receiving medical therapy, and these patients were considered separately for the statistical analysis. The prevalence of adenomyosis at histology was 66.6% (36/54). Of 32 patients who had received no previous treatment, 26 had adenomyosis on the targeted biopsy specimens of the myometrium. 3D TVS features of adenomyosis with the best specificity (83%) and positive predictive values were JZ(max) ≥8 mm, myometrial asymmetry, and hypoechoic striation. When we considered the presence of at least 2 of the described ultrasound features for the diagnosis of adenomyosis, accuracy was 90% (sensitivity, 92%; specificity, 83%; positive predictive value, 99%; and negative predictive value, 71%). Diagnostic accuracy was decreased to 50% in patients who had previously undergone endometrial ablation, and to 60% in patients receiving medical therapy. CONCLUSION 3D TVS demonstrates high diagnostic accuracy in detection of site and position of adenomyosis in the uterine walls. Endometrial ablation and medical therapy alter the appearance of the JZ, compromising the accuracy of 3D US in enabling the diagnosis of adenomyosis.

The uterine junctional zone: a 3-dimensional ultrasound study of patients with endometriosis

OBJECTIVE The uterine junctional zone (JZ) alterations are correlated with adenomyosis. An accurate evaluation of the JZ may be obtained by 3-dimensional transvaginal sonography (TVS). The aim of the present prospective study was to assess the value of detectable alterations by 3-dimensional TVS of the JZ in patients with pelvic endometriosis (diagnosed by laparoscopy and histologic condition) and to compare these findings with those of women without pelvic endometriosis. STUDY DESIGN Eighty-two patients who were scheduled for laparoscopy had undergone previous surgery and 2- and 3-dimensional TVS. Uterine multiplanar sections that were obtained by 3-dimensional TVS were used to evaluate JZ features. During laparoscopy, an accurate staging of pelvic endometriosis was performed. JZ thickness and JZ alterations were correlated with stage of endometriosis. RESULTS Of the 82 patients, 59 patients had endometriosis at laparoscopy and histology. The maximum thickness of JZ in patients with endometriosis was significantly greater than in patients without endometriosis (6.5 ± 1.9 mm vs 4.8 ± 1.0 mm; P < .001). The features of JZ appeared similar at different stages, whereas they are statistically different if correlated with patients without endometriosis. CONCLUSION JZ thickness and its alterations are different in patients with endometriosis compared with those women without endometriosis and are not correlated with American Society of Reproductive Medicine staging methods. Because these JZ ultrasound features are associated mostly with adenomyosis, a correlation between endometriosis and JZ hyperplasia and adenomyosis could be hypothesized. Noninvasive evaluation of the JZ may be useful in the identification of those women who are affected by endometriosis also in early stage of the disease when there are no other sonographic signs of pelvic endometriosis.

Reduction of postoperative adhesions by N,O-carboxymethylchitosan: a pilot study

OBJECTIVE To examine the logistics, safety, and efficacy of N,O-carboxymethylchitosan (NOCC) in reducing adhesions in women. DESIGN Multicenter, prospective, randomized, reviewer-blinded clinical trial. SETTING Gynecologic practices. PATIENT(S) Thirty-four patients were enrolled; 17 in each group were available for the safety analysis and 16 for the efficacy analysis. INTERVENTION(S) Adhesion reduction by administration of NOCC vs. Ringers lactate at the conclusion of the initial surgical procedure, as assessed at second-look laparoscopy. The NOCC was applied as 200 mL of a 1% NOCC gel that was tamped in place, followed by 100 mL of 2% NOCC solution. Efficacy was assessed by covariate analysis. MAIN OUTCOME MEASURE(S) Safety and postoperative adhesion formation. RESULT(S) Groups did not differ in age, ethnicity distribution, height, weight, or body mass index. No deaths or serious adverse events were attributable to NOCC, and no adverse events were definitively or probably related to NOCC administration. Adhesions recurred at 61% of sites in controls and 38% of sites in NOCC recipients. De novo grade 1a and 1b adhesions tended to occur more commonly in controls than NOCC recipients. Adhesion extent and severity at second look were also less in NOCC recipients. CONCLUSION(S) Intraperitoneal use of NOCC gel and solution appears to be safe. Despite the small sample, strong trends were identified for reduction of occurrence, extent, and severity of adhesion recurrence and de novo adhesion formation.

Safe Technique for Laparoscopic Entry into the Abdominal Cavity

Abstract Study Objective To evaluate and compare the safety and efficacy of a new method to enter the abdominal cavity at laparoscopy. Design (Canadian Task Force classification II-2). Setting Referral center for reproductive surgery in a teaching hospital affiliated with a university-based residency program. Patients Twenty representative women of variable body habitus (body mass index 16.5–39 kg/m2). Intervention Laparoscopy and laparotomy. Measurements and Main Results We measured the thickness of the abdominal wall at the base of the umbilicus and just below its inferior border. We also measured distances traversed by the Veress needle or cannula from skin to peritoneal cavity at both sites when the piercing instrument was directed at 45- or 90-degree angle from the horizontal plane of the abdominal wall. Finally, we measured distances created between parietal peritoneum and underlying viscera when the abdominal wall was lifted manually or with towel clips placed laterally, 2 cm from the umbilicus and at the edges of the intraumbilical incision. Distances created between parietal peritoneum and underlying viscera while lifting the abdominal wall by each of these three techniques were measured with a calibrated probe inserted through the intraumbilical port and observed with a 5-mm laparoscope from the suprapubic port. These distances were measured before and after carbon dioxide insufflation at 15 mm Hg, as well as before and while inserting the cannula through the abdominal wall. Mean ± SD thickness of the abdominal wall at the base of the umbilicus and lower border of the umbilicus were 1.4 ± 0.5 and 3.0 ± 1.1 cm, respectively (p Conclusion Our technique of inserting the cannula perpendicularly through the base of the umbilicus traverses the shortest distance to the abdominal cavity through the least vascular area of the abdominal wall. Lifting the abdominal wall with towel clips placed at the edges of the intraumbilical incision achieves the greatest distance between parietal peritoneum of the abdominal wall and underlying viscera, thus maximizing the margin of safety in protecting peritoneal organs and retroperitoneal vessels from injury.

Ectopic pregnancy from surgical emergency to medical management.

During the past 25 years, the incidence of ectopic pregnancy has progressively increased while the morbidity and mortality have substantially decreased, and the treatment has progressed from salpingectomy by laparotomy to conservative surgery by laparoscopy and more recently to medical therapy. This therapeutic transition from surgical emergency to medical management has been attributed to early diagnosis through the use of sensitive assays for hCG and the high definition of vaginal ultrasound. By using these sensitive diagnostic tools, we are now able to select those patients who are most likely to respond to medical management versus those who are at high risk of rupture and require surgery. Besides being less invasive and associated with significantly lower risks, medical therapy with methotrexate results in significant cost savings, which have been calculated to be approximately

Management of benign ovarian cystic teratomas: laparoscopy compared with laparotomy.

3,000 per treated patient. Our goal is to identify those patients with ectopic pregnancy who are most likely to respond to methotrexate therapy and least likely to develop significant side effects. Recent studies have helped us define the predictors of success with methotrexate treatment in women with ectopic pregnancy. The reported success rates of treating ectopic pregnancy with methotrexate vary from 71% to 100%. The highest success rates have been reported from institutions that have detailed diagnostic and therapeutic protocols, readily available assays for serum hCG levels, high‐resolution vaginal probe ultrasound, and support staff that can closely monitor clinical response. The importance of developing specific protocols to create a clinical environment that supports the effective use of medical therapy for ectopic pregnancy is confirmed by the associated cost savings, decreased morbidity, and patient preference. Modern diagnostic advances and minimally invasive treatments coupled with improved success rates for assisted reproductive technologies should reduce the morbidity and mortality associated with ectopic pregnancy and offer the affected couple a much more optimistic outlook for subsequent reproductive potential.

Surgical Management of Interstitial Pregnancy

STUDY OBJECTIVE To determine the outcomes of laparoscopic management of benign ovarian cystic teratomas (dermoids) compared with traditional laparotomy and excision. DESIGN A retrospective analysis of patients treated from October 1988 to May 1993. SETTING University of Connecticut Health Center-affiliated hospitals. PATIENTS Thirty-eight women with dermoid cysts that were managed either by laparotomy or laparoscopy, 19 matched patients in each group. The majority of lesions in both groups were diagnosed at routine pelvic examination. INTERVENTIONS The two groups were assessed with respect to age, gravidy, parity, size of lesions, and estimated blood loss at surgery. MEASUREMENTS AND MAIN RESULTS Two values were significantly different in the group treated by laparoscopy: more dermoids ruptured intraoperatively, and the mean hospital stay was significantly shorter (p</=0.01). In most cases cystectomy was performed with preservation of the involved ovary. After a mean follow-up of 11 months no complications such as severe chemical granulomatous peritonitis or persistent pelvic pain have been encountered in the laparoscopy group. CONCLUSIONS Laparoscopic management of dermoids is safe and cost effective, and provides patients the benefit of a shorter hospital stay and recovery time.