Jaroslav F. Hulka

Reproductive outcome after tubal reversal in women 40 years of age or older

OBJECTIVE To determine the reproductive outcome of women who received a microsurgical tubal anastomosis operation at age 40 years or older. DESIGN Multicenter retrospective cohort study. SETTING Four university teaching hospitals. PATIENTS Fifty-two women having undergone tubal sterilization reversal at age > or = 40 years. MAIN OUTCOME MEASURES Pregnancy and live birth rate. RESULTS Of the 52 women, 10 were lost to follow-up. Of those traced, 18 of 42 (42.8 percent) conceived. Of those 18, 6 patients had a live birth, 10 patients had a first trimester spontaneous abortion, 1 patient had an ectopic pregnancy, and 1 patient had an elective termination. Overall, the live birth rate was 14.3 percent, spontaneous abortion rate was 23.8 percent, and ectopic pregnancy rate was 2.4 percent. CONCLUSIONS Microsurgical tubal anastomosis is a justifiable alternative to IVF-ET in women age 40 years or older.

Outpatient laparoscopic sterilization with therapeutic abortion versus abortion alone.

Records of 108 patients undergoing combined vacuum aspiration and laparoscopic sterilization in an outpatient surgical program were reviewed and compared with those of 195 patients who underwent abortion only in the same outpatient program. Mean operating time for the combined procedure was 30 minutes; total mean hospitalization time was 5 hours and 7 minutes. Complication rates for the combined procedure and for abortion alone were 9.2 and 7.2 per cent, respectively. Subsequent hospitalization was necessary for 4.7 per cent of patients undergoing the combined procedure and 3.1 per cent of those having abortion only. Laparoscopic sterilization has been found to add no significant morbidity but has markedly reduced cost and hospitalization for the patient desiring permanent contraception following first trimester abortion.

COMBINED INTRA-ARTERIAL CHEMOTHERAPY AND RADIATION TREATMENT FOR ADVANCED CERVICAL CARCINOMA. THE MCCALL TECHNIQUE AND RESULTS.

Abstract A technique of hypogastric artery catheterization through a retroperitoneal approach followed by prolonged intermittent chemotherapy, devised by the late Dr. Milton L. McCall, is described. Results of 13 patients undergoing this surgery are presented. Very high total dosages of chemotherapeutic agents (up to 15.25 Gm. of 5-fluorouracil) infusing the pelvis were achieved. All four patients undergoing chemotherapy prior to radiation for Stages III and IV of cervical carcinoma have survived and are free of disease to date. Those treated after unsuccessful radiation therapy succumbed within a year. toxic reactions with these high doses were minimal, limited to skin erythema. Based on these data, that intra-arterial chemotherapy followed by radiation may improve survival rates of advanced pelvic malignancies, a controlled investigation of this possibility using this technique is being planned.

Ovarian transplantation: Graft-host interactions in corneal encapsulated homografts

Ovarian homografts encapsulated in corneal tissue may survive by the induction of specific immunologic tolerance in the host by the graft or the adaptation of the graft to the host. To test these hypotheses, these grafts were challenged in a series of experiments. Despite challenge grafts of ovarian tissue and skin from the original donor and of ovarian tissue from a “third party” donor, the ovarian tissue within the capsule remained viable for periods up to 30 weeks. A “backgraft” of encapsulated ovarian tissue removed from the recipient after 11 weeks and stripped of its capsule was not rejected after 6 weeks’ residence in the original donor. Rejection times for homografts of ear skin in animals with ovarian homografts were the same as controls. These data indicate that (a) survival was not due to immunologic tolerance and (b) the surviving ovarian tissue was nonantigenic in relation to the host but had not undergone adaptation. It is suggested that the less antigenic cells within the capsules had been “passively” selected for survival by prolonged incubation in an immunologically unfavorable environment.

Dyskaryosis in cervical cytology and its relationship to trichomoniasis therapy

One hundred and twenty women with a “Class IIR” report on routine screening in a Cervical Cancer Detection Program attended a dysplasia clinic where cytologic specimens, wet smears, and cultures were examined for the presence of trichomonads. All patients then received either metronidazole or a placebo and were re-evaluated after therapy. The prevalence of trichomonads was the same in the study group (21.7 per cent) as in the general population (17.6 per cent) as measured by Papanicolaou smear identification. Prevalence as measured by culture revealed trichomonads in 70.6 per cent of the study group; a false negative rate for the wet smear or Papanicolaou smear of about 60 per cent was observed. Metronidazole was anly 24 Per cent effective in eliminating trichomonads as measured by culture. About half of the study group reverted to Class I or II cytology regardless of the presence or absence of trichomonads, and regardless of metronidazole therapy. The conclusion drawn is that trichomonads are not a significant factor in the natural history of dyskaryotic cells in the uterine cervix.

Possible adrenal origin of estrogens in the testicular feminization syndrome

Abstract A patient with the testicular feminization syndrome underwent adrenal stimulation and suppression tests, as well as stimulation with purified human FSH prior to gonadectomy. Estrogen excretion was depressed by dexamethasone and clevated by ACTH. Purified FSH had no effect on estrogen excretion levels. After gonadectomy, preoperative urinary estrogen excretion levels were found, although the subject was not treated with exogenous steroids. Breast size, vaginal cornification, voice, and hair distribution did not change. Stimulation postoperatively with chorionic gonadotropin did not alter estrogen excretion. These data indicate that the estrogens formed in this patient are at least partly of adrenal origin.

Interference of cortisone-induced homograft survival by progestins

Abstract Because progestins have been observed to alter immune responses, they were administered in combination with cortisone to groups of rabbits undergoing skin homograft studies. The study was designed to see if some combination of progestin and cortisone would act synergistically and prolong skin graft survival while reducing the morbidity and mortality of corticosteroid therapy. Graft survival observed in animals receiving medroxyprogesterone or progesterone in combination with cortisone was shorter than in animals receiving cortisone alone in several different dose ranges; norethynodrel and norethindrone also interfered with the immunologic effect of cortisone to a lesser degree. Norethynodrel combined with cortisone led to weight loss far greater than that observed with cortisone alone. Similarly, medroxyprogesterone with cortisone resulted in greater mortality than that due to cortisone alone. Thus, the observed immunologic and metabolic effects of combining progestins with cortisone were opposite from those anticipated. Implications of these observations on transplantation surgery, trophoblast survival in pregnancy, and clinical therapeutics are discussed.

LAPAROSCOPIC TUBAL CLIP STERILIZATION UNDER LOCAL ANESTHESIA

Tubal anesthesia with lidocaine during laparoscopic tubal clip appli cation was evaluated in 149 women; 147 tubes received no lidocaine and 151 received 1 or 2 ml of 1% or 4% lidocaine. For unanesthetized tubes the mean pain rating depended on the dose of diazepam and fentanyl given to the patient (p less than .1); pain ratings were higher in women who received no drug. When any diazepam and/or fentanyl was given, the anesthetized tubes were given a significantly lower pain rating (p less than .01). 23.8% of unanesthetized tubes received a pain rating of 2, 12.9% a rating of 3 or 4, while no anesthetized tube received a 3 or 4 (on a scale of 0 to 4) and only 4% received a 2. 68.5% patients were their own control; 42% rated the pain equal in each tube (1 was anesthetized), while 58% rated the anesthetized tube less painful. 3.4% of the patients experienced vasovagal reflex stimulation. It is concluded that using a local anesthetic solution substantially reduces discomfort associated with fallopian tube manipulation during sterilization.