L. Russell Malinak

Recurrent endometriosis: Incidence, management, and prognosis☆

The rate of recurrence of endometriosis after treatment has varied from 2% to 47% in published reports. In order to determine whether a meaningful prognosis for recurrence can be rendered, 423 patients treated with conservative surgical procedures from 1967 to 1982 were followed as outpatients. From among these, 62 patients underwent reoperation. Annual rates of recurrence based on findings at reoperation ranged from 0.9% in the first postoperative year to 13.6% in the eighth postoperative year. The cumulative 3- and 5-year recurrence rates were 13.5% and 40.3%, respectively. Severity of disease was not predictive of recurrence. Pregnancy did not preclude, but did delay, recurrence. Forty-seven percent of infertile patients with recurrent endometriosis conceived after a second conservative operation. Of 20 patients who had a second conservative operation for endometriosis, 20% required a third laparotomy. This is the first study of postoperative recurrent endometriosis to utilize a control group and the first to report annual rates of recurrence and reoperation.

Conservative surgery versus expectant management for the infertile patient with mild endometriosis

During an 8-year period, the records of 90 patients with mild pelvic endometriosis diagnosed by endoscopy were reviewed to determine whether conservative surgical treatment resulted in higher pregnancy rates than expectant management. Forty-five patients were found to have mild endometriosis as the only abnormality in a complete fertility workup. Sixteen patients were managed expectantly, and 75% became pregnant in 1 year. Twenty-nine patients had conservative surgery, and 72.4% conceived in 1 year. This surgery-to-pregnancy interval was similar in both groups. Sixty patients had mild endometriosis only or mild endometriosis and anovulation corrected by clomiphene citrate. The pregnancy rate in 1 year was 72.2% in 18 patients managed expectantly and 76.2% in 42 patients treated with conservative surgery. The surgery-to-pregnancy interval was 5 and 6 months, respectively. These results suggest that expectant management should be considered prior to medical or surgical treatment of infertile patients with mild endometriosis.

Endometriosis and anovulation: a coexisting problem in the infertile female.

Over an 8 year period, 350 cases of endometriosis (77 per cent confirmed histologically) from the Department of Obstetrics and Gynecology, Baylor College of Medicine, were reviewed. Of these cases, 58 (17 per cent) exhibited significant anovulation as measured by a scoring system. Endometriosis and anovulation can coexist contrary to classic concepts of these diseases. Both infertility factors required treatment to achieve pregnancy. A 43 per cent pregnancy rate reflects the dual infertility problem.

Insulin resistance improves in hyperandrogenic women treated with Lupron

OBJECTIVE To examine if changes in insulin sensitivity and glucose effectiveness in women with polycystic ovarian disease (PCOD) occurred after ovarian androgen suppression with a GnRH agonist, leuprolide acetate (LA, Lupron; TAP Pharmaceuticals, Deerfield, IL) using the minimal model method. DESIGN Twelve patients with PCOD were tested in the untreated state (baseline) and after 6 weeks of LA treatment. Subjects were divided into two groups based on the degree of impairment of their baseline insulin sensitivity index (SI; (min-1) (microU/mL-1): mild insulin resistance (SI > 1) or severe insulin resistance (SI < 1). RESULTS In all patients, serum T was significantly decreased from elevated baseline levels to normal female concentrations after 6 weeks of LA therapy. Insulin sensitivity in PCOD patients with mild insulin resistance significantly improved from baseline after 6 weeks of LA therapy, whereas no change in SI on LA therapy was seen in PCOD women with severe insulin resistance. Glucose utilization independent of increased insulin secretion did not change as a function of LA treatment in either group. CONCLUSION These findings indicate a significant improvement in SI in mildly insulin-resistant women with PCOD after suppression of ovarian function with LA treatment.

Reoperation after initial treatment of endometriosis with conservative surgery

One hundred and fifty-three patients with pelvic endometriosis met the study criteria of inferility, tissue diagnosis, treatment with conservative surgery, and adequate follow-up. The extent of disease was classified according to Acosta and and associates. Pregnancy rates were 10 to 100% in various subclassifications of patients; these pregnancy rates were related to the extent of disease and the existence of concurrent inferitility factors. One hundred and seventeen patients were followed up for three years. Reoperation in this group was carried out in 28 patients for recurrent pain and/or persistent infertility. Each patient had diagnostic laparoscopy preceding relaparotomy. The reoperation rate was 40.6% in those patients who remained infertile, whereas this rate was only 3.7% in those patients who conceived following initial operation. The incidence of conception after a second conservative procedure was 12%. However, an equal number of patients in this group required total abdominal hysterectomy as a third procedure for control of recurrent pain. Thus, repeat conservative surgery should play a secondary role in the treatment of patients with infertility and recurrent endometriosis.

Sex Hormones Regulate ABR Latency

In an effort to characterize more completely the influence of sex hormones on auditory brainstem response (ABR) latency, we evaluated the ABRs of normal male and female subjects and women with previously diagnosed endocrinologic syndromes. We describe ABR latency results from the following subjects: five normal males, nine normally cycling females on no hormonal therapy, nine females using oral contraceptive pills, five females with premature ovarian failure (POF) undergoing cyclic estrogen-progesterone replacement therapy, and five hyperandrogenized females with polycystic ovarian disease (PCOD) treated with the gonadotropin-releasing hormone agonist, Lupron depot, to suppress ovarian steroid production. All subjects were between 23 and 40 years of age. Serum levels of estradiol, progesterone, testosterone, prolactic, and gonadotropins (lutienizing hormone and follicle stimulating hormone) were measured to document the hormonal status of each of the subjects at the time of the ABR evaluation. Normal cycling females and females with POF underwent ABR testing during different phases of the same cycle. Male subjects and females using birth control pills were studied four times in the same month at 1-week intervals. Females with PCOD were also studied four times; baseline and then at 2-week intervals after the initiation of Lupron depot therapy. Increased ABR wave V peak latencies were found to be associated with elevated levels of estrogen or testosterone. We have previously reported a lengthening of ABR wave V peak latencies coincident with peak estrogen levels during the female cycle. Because testosterone is converted to estrogen by central neuroendocrine tissue to exert its effect on brain function, we postulated that increased latency in males is a result of the effect of aromatization of testosterone to estrogen in the central auditory pathway. This hypothesis would account for the slightly increased wave V peak latencies found in the PCOD females with elevated testosterone before treatment with Lupron to suppress ovarian androgen secretion. These findings suggest that neural conduction time is modified by changes in estrogen concentrations in the brainstem auditory pathway of both sexes.

Ultrasound evaluation of female genital tract anomalies: a review of 64 cases

Sixty-four patients with an ultrasound diagnosis of an anomaly of the female genital tract were studied retrospectively to determine the accuracy and usefulness of sonographic examination of these anomalies in the pregnant (64%) and the nonpregnant (36%) patient. Ultrasound diagnoses in 46 patients with follow-up included: (1) bicornuate/septate uterus in 21 cases, (2) uterus didelphys in 18 cases, (3) cervical and vaginal atresia in three cases, (4) obstructed lower but normal upper genital tract in two cases, and (5) abnormal-appearing uterus in two cases. Ultrasound diagnosis was compared with hysterosalpingographic and/or surgical findings in 43 patients and with physical examination in three patients. Scan results were classified as diagnostic in 26%, confirmatory in 63%, and incorrect in 11%. Ultrasound is a reliable clinically useful method of studying genital tract anomalies in gynecologic patients.

Postoperative danazol therapy in infertility patients with severe endometriosis

The value of perioperative medical therapy in the management of infertility patients with severe endometriosis is uncertain. Previous reports of pre- or postlaparatomy danazol provide no clear direction regarding efficacy. Of 200 consecutive cases of severe endometriosis, 138 infertility patients were selected for study. One hundred nineteen patients, the control group, had laparotomy alone; 19 had laparotomy followed immediately by danazol therapy. The pregnancy rate in the control group was 30% (36/119) versus 79% (15/19) in the study group, (P less than 0.001). The results of this preliminary report indicate that danazol treatment in the immediate postlaparotomy period of patients with severe endometriosis significantly improves the pregnancy rate over comparable patients treated with surgery alone. It is hoped that these results will encourage other surgeons to implement a prospective surgical-medical approach, so that the most efficacious treatment for infertile patients with severe endometriosis can be determined.

ANDROGEN RESPONSES TO ACUTELY INCREASED ENDOGENOUS INSULIN LEVELS IN HYPERANDROGENIC AND NORMAL CYCLING WOMEN

We examined androgen responses in hyperandrogenic (polycystic ovarian disease [PCOD]) and normal women after an acute endogenous insulin elevation. Standard intravenous glucose tolerance tests (IVGTTs), modified to include a tolbutamide injection 20 minutes after IVGTTs, were performed. Polycystic ovarian disease patients were studied in the untreated state, after 6 weeks of ovarian androgen suppression with leuprolide acetate, after a 6-week rest period, and after 6 weeks of antiandrogen therapy with spironolactone. Normal menstruating women were studied during the early follicular, midcycle, and luteal phases of a single cycle. An acute rise in insulin did not alter serum testosterone or androstenedione levels in PCOD or normal women. A significant rise in dehydroepiandrosterone sulfate after modified IVGTTs was found in both hyperandrogenic and normal cycling women. Although these results are not supportive of the theory that insulin acts on the ovary to stimulate androgen production, they may be because of the short time course of insulin elevation that occurs during an IVGTT.

Adolescent Mothers and Fetal Loss, What is Learned from Experience?

73 gravida I adolescent mothers and 93 gravida III adolescent mothers of low socio-economic status were compared to verify that a higher rate of fetal loss exists with parity. Gravida III adolescent mothers had only a 45 % chance of having all three children living compared to the 95% of gravida I adolescent mothers. Moreover, gravida III adolescent mothers used prenatal care and preventive health programs less frequently than their gravida I counterparts. Most problems with babies also occurred more frequently with gravida III young women.