Gerard S. Letterie

Histology of proximal tubal occlusion

From 1979 to 1985, 18 patients who were found to have proximal tubal obstruction by hysterosalpingography and laparoscopic chromopertubation underwent resection of the obstructed tubal segment and reimplantation or microanastomosis. Resected tubal segments were studied histologically, and in 11 of the 18 cases no tubal occlusion could be demonstrated. A variety of histologic abnormalities were noted, however, including six cases in which the tubal lumen contained an amorphous material of unknown etiology, often appearing to form a cast of the tube. Such plugs, which the authors believe to be previously unreported, have no clearly established clinical significance at present. However, if they cause tubal occlusion, this would explain several previously published findings, and would also have implications for therapy.

Efficacy of a gonadotropin-releasing hormone agonist in the treatment of uterine leiomyomata: long-term follow-up *

The authors employed a gonadotropin-releasing hormone agonist (GnRH-a) (D-His6-pro9-NET-GnRH) to treat 19 patients with symptomatic uterine leiomyomata, by daily subcutaneous injections (4 micrograms/kg) for 6 months. After therapy, patients were followed for 6 months without any therapy. Uterine volumes were measured by serial pelvic examinations and pelvic sonography. Measurements of serum estradiol, luteinizing hormone, and follicle-stimulating hormone were used to assess treatment response. Pituitary desensitization and hypoestrogenemia were achieved in all within 8 weeks, and in 18 of 19, hypoestrogenemia was maintained for the duration. Uterine volume at the conclusion of therapy (207.5 +/- 152.7 ml) was significantly reduced in all patients when compared with pretreatment sizes (420.8 +/- 276.4, P less than 0.05). Side effects included hot flashes (78%), vaginal dryness (32%), and transient frontal headaches (55%). All patients reported partial or complete relief from their symptomatic leiomyomata. Uterine volume at the conclusion of follow-up (345.4 +/- 195.7 ml) was greater than at the conclusion of therapy. Menses resumed in all patients within 4 to 8 weeks. In conclusion, GnRH-a therapy does not provide definitive therapy for symptomatic uterine leiomyomata but is effective in reducing the size of leiomyomata as a temporary measure. Gonadotropin-releasing hormone agonist therapy may be useful as an adjunct before myomectomy or hysterectomy and deserves further investigation.

Hysteroscopic cannulation and lavage in the treatment of proximal tubal occlusion

In two patients with apparent PTO, as diagnosed by HSG and laparoscopy, tubal patency was restored by hysteroscopic cannulation of the tubal ostia, followed by direct lavage. Tubal resection and reanastomosis/reimplantation may not be necessary for all patients with apparent PTO.

Histology of proximal tubal obstruction in cases of unsuccessful tubal canalization

OBJECTIVEnTo determine possible etiologies of unsuccessful fluoroscopically guided tubal canalization, we studied the histology of tubal segments in cases of failed canalization for proximal tubal obstruction. Factors contributing to cases of unsuccessful fluoroscopically guided tubal canalization remain unclear.nnnDESIGNnProspective.nnnSETTINGnReproductive Endocrinology Clinic.nnnMATERIALSnTwenty-seven cornual and/or isthmic tubal segments from 15 patients who underwent proximal tubal surgery after fluoroscopically guided tubal canalization were studied. Specimens were prepared with hemotoxylin-eosin and Masson trichrome stains.nnnRESULTSnHistologic examination of excised cornual and isthmic tubal segments revealed abnormalities in 93% of specimens. Obliterative fibrosis (61%), chronic salpingitis (57%), and salpingitis isthmica nodosa (42%) were the most commonly found histologic tubal abnormalities. One case of complete tubal occlusion and tubal schistosomiasis was also detected.nnnCONCLUSIONSnThese data suggest that cases of failed fluoroscopically guided tubal canalization may be secondary to severe intrinsic tubal disease and tubal occlusion and not to the technique. Fluoroscopically guided tubal canalization may provide a means of differentiating a functional obstruction amenable to conservative management from true occlusion requiring management by microsurgical techniques or in vitro fertilization.

Magnetic Resonance Imaging of Intrauterine Synechiae

Magnetic resonance imaging (MRI) is a sensitive method to diagnose a variety of gynecologic conditions. Uterine anatomy may be accurately imaged with MRI providing a noninvasive method to assess both myometrial and endometrial architecture. MRI was used in 2 patients with amenorrhea and intrauterine synechiae to determine the possible role of this technique in assessing the endometrial cavity. MRI signal features in both patients provided an assessment of the endometrium complementary to the anatomy demonstrated on hysterosalpingography and suggested markedly different etiologies for similar clinical presentations. MRI may have a role supplementary to conventional studies in the evaluation of intrauterine synechiae.

Endometrial histology after electrocoagulation using different power settings.

OBJECTIVEnTo study endometrial histology after electrocoagulation in an in vitro model using 50 watts (W) and 100 W of coagulation current and determine the depth of endometrial destruction and survival, if any, of glands beneath this zone.nnnDESIGNnTwenty fresh uteri of similar weights and dimensions were obtained from patients undergoing hysterectomy for benign disease. Specimens were bivalved into anterior and posterior walls and each wall divided in half. Endometrial electrocoagulation was carried out with a 5-mm probe at 50 W and 100 W applied to anterior and posterior quarters of the specimen, respectively. The adjacent untreated endometrial surfaces served as controls. Specimens were formalin-fixed, embedded in paraffin, and sections stained with hematoxylin and eosin.nnnMAIN OUTCOME MEASURESnThe number and morphology of the endometrial glands were counted and classified manually for each section and compared between each power setting and controls.nnnRESULTSnHistologic examination revealed morphologically normal glands in all specimens beneath the zone of destruction regardless of power setting. Both power settings produced significant focal and diffuse glandular and stromal destruction when compared with controls. Significant differences were noted in the number of normal glands after treatment with 50 W (71.33 glands +/- 76.44 [mean +/- SD]), 100 W (21.11 +/- 35.71) and untreated controls (240.16 +/- 110.81). Tissue destruction increased with increasing power, and there were significant differences in the percentage of morphologically normal, surviving glands between 50 W (11.7% +/- 11.4% [mean +/- SD]) and 100 W (4.9% +/- 10.9%).nnnCONCLUSIONnThese data suggest that electrocoagulation may result in a variable degree of endometrial destruction dependent on power. Viable glands and stroma may survive beneath the zone of destruction regardless of power. Such variations in endometrial insult in an in vitro model may explain, in part, the variable clinical results of endometrial electrocoagulation. The survival of glands beneath the zone of destruction in this model raises the theoretical concern for occult malignant changes and leaves open to question the exact role and mode of hormonal therapy during the menopause after endometrial ablation.

Expectant management of abnormal concentrations of human chorionic gonadotropin during the first trimester of pregnancy.

Abnormal serum human chorionic gonadotropin (hCG) levels during the first trimester may be associated with a nonviable intrauterine pregnancy or ectopic pregnancy. With the availability of sensitive hCG assays, expectant management of these patients may provide a viable alternative to surgery. To evaluate this approach, we managed 20 patients with low levels of serum hCG expectantly using serial hCG monitoring and clinical examination only. Serum hCG concentrations were followed to levels of less than 10 mIU/ml. Peak levels of serum hCG ranged from 72 to 5,685 mIU/ml. Duration of expectant management ranged from 7 to 97 days. No patient required intervention due to acute symptoms. These data suggest that a select group of patients with decreasing hCG concentrations may be managed expectantly without undue morbidity thereby avoiding surgical intervention.

Modulation of hepatic cholesterol metabolsim by ethinyl estradiol and norgestrel

Previous investigators reported that certain combination oral contraceptives are associated with significant alterations in serum lipid concentrations, namely a decrease in high density lipoprotein and increase in low density lipoprotein fractions. The mechanism(s) responsible for these changes remain unclear. In the present study we sought to determine the effect of the oral contraceptive components, ethinyl estradiol (EE) and norgestrel (N) on hepatic cholesterol metabolism, specifically on 3-hydroxy-3-methylglutaryl coenzyme A (HMG) reductase. Forty-eight cycling female Sprague-Dawley rats were divided into six groups and treated daily with either 0.1 mg or 1.0 mg EE daily, 1.0 mg or 10.0 mg N daily, or 0.1/1.0 mg or 1.0/10.0 mg EE/N in combination daily. Twelve age- and weight-matched animals served as controls. No significant changes in hepatic HMG reductase activity were observed between those groups treated with either EE or N alone and the control group. However, hepatic HMG reductase activity was increased significantly in both EE/N combination-treated groups when compared to controls, the EE-treated groups and the N-treated groups. These results are suggestive that the changes in serum lipids noted clinically in association with oral contraceptive use may be related to the induction specifically of hepatic HMG reductase activity and subsequent changes in cellular cholesterol synthesis or metabolism.

A Combination of Gonadotropin-Releasing Hormone Analog and Human Menopausal Gonadotropins for Ovulation Induction in Premature Ovarian Failure

A combination of gonadotropin‐releasing hormone agonist and human menopausal gonadotropins was used for ovulation induction in a patient with premature ovarian failure. A paradoxical suppression of any ovarian response was noted despite increasing doses of human menopausal gonadotropins.

Strategies to Minimize Multiple Births in Recipients of Egg Donation

Multiple gestation is increasingly considered a complication of in vitro fertilization (IVF). No longer held is the view that pregnancy should be pursued at all costs and that multiples are simply another inevitable consequence of infertility treatment. Improved techniques for embryo culture and selection, a better understanding of the substantial risks of multiple embryo transfer, and increased regulatory scrutiny have led to a reconsideration of the definition of success in assisted reproductive technology (ART). The well-documented hazards of multiple embryo transfer together with a broader definition of adverse outcomes that include harm to the potential child(ren), mothers, families, health-care systems, and society are force vectors that encourage a revision in ART practice.