John A. Rock

Dating the Endometrial Biopsy

It is asserted that examination of the endometrium during the secretory phase yields more information about the time of ovulation degree of progestational change and normality of the endometrium than any other test used in sterility studies. Attention to qualitative changes in 8 morphological factors is most useful in dating the endometrial biopsy. During the 1st week of luteal activity attention should be focused on changes occurring in gland epithelium: gland mitosis pseudostratification of nuclei basal vacuolation and secretion. During the 2nd week stromal changes (including edema) predecidual reaction stromal mitosis and leukocytic infiltration are the key criteria. Tissue from the fundus of the uterus gives the most reliable information. These critera were used in 300 sterility biopsies taken from normally menstruating women over a 3-year period. Absence of organic endometrial disease and availability of accurate menstrual history were the only selection criteria. 12 observers dated the biopsies. 42 of the 300 patients (14%) menstruated on the day predicted 36 (12%) menstruated later and 222 (74%) menstruated earlier. When a +or- 1 day error was allowed 112 patients (38%) were found to menstruate at the time predicted. When these same slides were reviewed by a single observer and the date for the most advanced area of the biopsy was used 179 patients (60%) menstruated within 1 day of prediction. To test the validity of the dating criteria change in basal body temperature was used to correlate endometrial dating with ovulation rather than onset of menstruation. Of the 40 patients who had adequate temperature records 31 (78%) ovulated as predicted allowing a +or- 1 day error indicating that dating is a better gauge of duration of progesterone effect than predictor of onset of menses. To determine whether biopsy caused early menstruation the secretory phases of the 25 patients who had recorded temperatures in at least 2 cycles in addition to that in which the biopsy was taken were examined. The secretory phase was definitely shorter in the biopsied than control cycle suggesting that biopsy does accelerate the onset of flow. However further analysis showed that biopsy does not interfere with length of flow or succeeding menstrual rhythm.

Te Linde's operative gynecology

Te Lindes operative gynecology , Te Lindes operative gynecology , کتابخانه مرکزی دانشگاه علوم پزشکی تهران

Fertility Rates in Female Patients with Congenital Adrenal Hyperplasia Due to 21-Hydroxylase Deficiency

Among 80 women with congenital adrenal hyperplasia due to 21-hydroxylase deficiency (40 with the simple virilizing form and 40 with the salt-losing form), 40 reported having an adequate introitus and being heterosexually active. In 15 of 25 patients with the simple virilizing form, 25 pregnancies resulted in 20 normal children, whereas only 1 of 15 women with the salt-losing form became pregnant; this pregnancy was electively terminated. Several factors seem to be responsible for the low fertility rates: noncompliance with therapy was probably high, as suggested by hirsutism and poor endocrine follow-up in 25 percent of patients; whereas 49 patients had regular menstrual periods, 14 had irregular periods, 10 had amenorrhea, 5 had undergone hysterectomy, and 2 had entered menopause; 87 percent of patients with salt loss and 50 percent of those with simple virilization (P less than 0.001) had remained single; the vaginal introitus was reported to be inadequate for intercourse by 35 percent of patients (53 percent of those with salt loss and 18 percent of those with simple virilization; P less than 0.002); and heterosexual activity was reported less frequently among patients with an inadequate introitus. The status of the introitus seemed to have a more important role in the sexual activity reported than did the degree of prenatal exposure to androgen (which was higher among patients with salt loss than among those with simple virilization). However, our data did not rule out an effect of androgen exposure on female fetuses. Our experience indicates that improved surgical correction of the external genitalia and better compliance with therapy will be necessary to improve fertility rates among women with congenital adrenal hyperplasia due to 21-hydroxylase deficiency.

Incidence of symptom recurrence after hysterectomy for endometriosis

OBJECTIVES To determine the relative risk of symptom recurrence and/or reoperation after hysterectomy with ovarian preservation for the treatment of endometriosis. DESIGN Historical prospective study of patients with endometriosis who underwent hysterectomy with or without ovarian preservation. PATIENTS One hundred thirty-eight women who underwent hysterectomy with the diagnosis of endometriosis. METHODS A computer search identified 138 women who underwent hysterectomy with the diagnosis of endometriosis at Johns Hopkins Hospital from 1979 to 1991. Follow-up information was obtained from medical records, outpatient charts, and telephone surveys. RESULTS Twenty-nine women had hysterectomy with some ovarian tissue preserved; 109 had all ovarian tissue removed. Of those with ovarian preservation, 18 of 29 (62%) had recurrent pain and 9 of 29 (31%) required reoperation. Of those who had no ovarian preservation, 11 of 109 (10%) had recurrent symptoms and 4 of 109 (3.7%) required reoperation. Ovarian conservation was associated with a relative risk for pain recurrence of 6.1 (95% confidence interval [CI] 2.5 to 14.6) compared with patients with oophorectomy in a Cox proportional hazards model. The relative risk for reoperation in patients with ovarian conservation was 8.1 (95% CI 2.1 to 31.3). CONCLUSION Compared with women who had oophorectomy for endometriosis, patients who underwent hysterectomy with ovarian conservation had 6.1 times greater risk of developing recurrent pain and 8.1 times greater risk of reoperation.

Endometriosis: pathophysiology, diagnosis, and treatment.

Endometriosis remains a poorly understood disease. Multiple factors are likely to be responsible for the relative infertility in patients with endometriosis. All therapeutic options should be presented to the patient. Treatment of a patient with endometriosis should be individualized based on symptoms (i.e., pain and/or infertility), extent of disease, age and associated pelvic pathology. Diagnosis continues to require visual documentation with histologic confirmation if possible.

The obstetric consequences of uterovaginal anomalies

Congenital uterovaginal anomalies can have adverse effects on pregnancy outcome. Early diagnosis and an aggressive evaluation of any patient presenting with mid-trimester abortion, premature labor, malpresentation, or retained placenta may prevent additional pregnancy wastage and maternal morbidity. With more timely and accurate diagnosis, appropriate management is likely to provide the best possible outcome for all such patients.

Disappearance of exogenously administered human chorionic gonadotropin

Concentrations of human chorionic gonadotropin (hCG) were measured after intramuscular hCG administration in 34 patients undergoing ovarian stimulation in an in vitro fertilization program. Serum hCG levels were detectable by an immunoenzymetric assay up to 14 days after injection. Individual variation in hCG concentration after injection could be minimized by expressing the daily hCG level as a fractional distribution of the value observed 36 hours after hCG administration (hCG0). In nonpregnant patients, less than 10% of the hCG0 value was found on day 10. The disappearance rate measured 36 hours after injection of hCG was exponential with a mean half-life of 2.32 days. These findings are significant for ovarian stimulation protocols, including exogenous hCG, with respect to timing and accuracy of quantitative pregnancy testing.

Fertility Following Bilateral Ovarian Wedge Resection: A Critical Analysis of 90 Consecutive Cases of the Polycystic Ovary Syndrome

Fertility following bilateral ovarian wedge resection (BOWR) was evaluated in a retrospective cohort study of 90 consecutive cases of the polycystic ovary syndrome. Post-BOWR follow-up was available for varying time spans of up to 10 years. BOWR resulted in the resumption of menstrual cyclicity in 91.1% (82/90) of the cases. However, within this ovulatory group, 26 patients were characterized by oligo-ovulation and a significantly reduced conception rate (29.2%), as compared with that of 56 normo-ovulatory counterparts (60.3%). Although the crude overall conception rate for this series was 47.8%, the overall cumulative probability of conception at the end of follow-up as determined by life table analysis was 73%. The likelihood of conception at any given point in time was estimated by a monthly fecundability rate of 1.34%. Our findings also indicate that the probability of post-BOWR conception was unaffected by age, race, ward status, or duration of infertility. In contrast, persistent post-BOWR oligo- or anovulation and the presence of concurrent tuboperitoneal disease were reaffirmed as the most important determinants of the likelihood of post-BOWR conception. A minimum incidence of 7.8% was documented for acquired post-BOWR pelvic disease.

The double uterus associated with an obstructed hemivagina and ipsilateral renal agenesis.

Twelve patients with a double uterus, unilateral vaginal obstruction, and ipsilateral renal agenesis are described. The clinical presentation varies, depending on whether the obstruction was partial or complete. In rare instances a communication existed between the obstructed vaginal pouch and the opposite patent vagina through a defect in the septum of the double uterus. Early accurate diagnosis followed by the excision of the obstructing vaginal septum offers complete relief of symptoms while preserving reproductive capacity.

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.