Lisa A. Kolp

Complications of laparoscopy—operative and diagnostic *

OBJECTIVE To assess the characteristics and rates of complications for operative laparoscopy and diagnostic laparoscopy. DESIGN Retrospective review. SETTING Tertiary-care university hospital. PATIENTS Two thousand three hundred twenty-four patients undergoing operative laparoscopy or diagnostic laparoscopy. INTERVENTIONS Operative laparoscopy including lysis of adhesions, tubal surgery, ovarian surgery, uterine surgery, or destruction of endometriosis. MAIN OUTCOME MEASURES Complication rates for operative and diagnostic laparoscopies were tabulated and compared. RESULTS The overall major complication rate for this series of 2,324 laparoscopies was 0.22%. There were five major and 15 minor complications. In the operative laparoscopy group, there were more complications from Veress needle and trocar insertion (n = 15) than from the actual operative procedures (n = 3). There were more total complications in the operative laparoscopy group (n = 18) than in the diagnostic laparoscopy group (n = 3). CONCLUSION Operative laparoscopy is efficacious for a variety of gynecologic surgical procedures.

Endoscopic versus laparotomy management of endometriomas

OBJECTIVE To compare the surgical management and follow-up of patients with endometriomas managed by endoscopic surgery versus laparotomy using a retrospective case control format. DESIGN Endoscopic oophorocystectomies were performed on 36 patients. Chart review of laparotomy oophorocystectomies from 21 patients was conducted. Six-week and 12-month follow-up for evaluation of symptoms, evidence of recurrence, and fertility was available on all subjects. RESULTS In the endoscopy group, 39 patients had screening laparoscopy for possible endoscopic surgery. Three of this group required laparotomy and 36 patients underwent endoscopic surgery. Chart review identified 21 patients who had undergone primary laparotomy for endometriomas. Patient groups were matched for age, severity of disease, presence of other infertility factors, and absence of perioperative medical suppression. Outcome parameters for each group were: operating time--endoscopy 2.8 hours (+/- 1.2), laparotomy 3.1 hours (+/- 1.8); estimated blood loss--endoscopy 40 cc (+/- 45); laparotomy, 240 cc (+/- 107); recovery time--endoscopy, 6.2 days (+/- 2.5), laparotomy 30 days (+/- 6.8); endometrioma recurrence rate--endoscopy 11.1%, laparotomy 19%; and pregnancy rate--endoscopy 42.8%, laparotomy 46.6%. CONCLUSION A high percentage of patients with endometriomas associated with advanced endometriosis can be managed effectively by endoscopic surgery.

Mechanisms subserving the trophic actions of insulin on ovarian cells. In vitro studies using swine granulosa cells

Direct actions of insulin on gonadal tissues have been difficult to demonstrate in vivo. We have developed an in vitro system in which swine ovarian cells remain highly responsive to trophic actions of insulin. Purified porcine insulin significantly augmented the biosynthesis and secretion of progesterone by cultured granulosa cells. These stimulatory actions of insulin were dose- and time-dependent and saturable. Under serum-restricted conditions, insulin also significantly amplified the capacity of estradiol and 8-bromo cyclic AMP to stimulate progesterone production. Inhibitors of protein and RNA synthesis (cycloheximide, actinomycin D, and alpha-amanatin) inhibited insulin action. The stimulation of progesterone production by insulin was attributable to increased biosynthesis of pregnenolone, rather than diminished catabolism of progesterone to its principal metabolite, 20alpha-hydroxypregn-4-en-3-one. Insulin also enhanced progesterone production in the presence of a soluble sterol substrate, 5-cholesten-3beta,25-diol, which readily gains access to the mitochondrial cholesterol side-chain cleavage system. Moreover, exposure of granulosa cells to insulin produced a three- to sevenfold increase in mitochondrial content of cytochrome P-450 measured by difference spectroscopy, with a corresponding increase in mitochondrial cholesterol side-chain cleavage activity. The capacity of insulin to facilitate progesterone biosynthesis by ovarian cells was mimicked by the insulinlike somatomedin, multiplication stimulating activity, but not by epidermal growth factor, fibroblast growth factor, or porcine relaxin. Insulins augmentation of progesterone production reflected a selective action on progestin biosynthesis, since insulin significantly suppressed estrogen biosynthesis by granulosa cells.Thus, our investigations indicate that insulin acts on ovarian cells selectively to stimulate pregnenolone (but not estrogen) biosynthesis. The actions of insulin are exerted by processes that require protein and RNA synthesis, and by mechanisms that augment mitochondrial cytochrome P-450 content and facilitate the utilization of cholesterol in the side-chain cleavage reaction. The striking mimicry of insulin effect by multiplication stimulating activity suggests that insulin action may be mediated through somatomedin receptors. Moreover, in view of the high concentrations of somatomedin in ovarian follicles in vivo, our in vitro observations suggest that specific trophic actions of insulin or insulinlike growth factors are likely to significantly regulate the differentiated function of the Graafian follicle in vivo.

Exogenous estrogen therapy for treatment of clomiphene citrate-induced cervical mucus abnormalities: is it effective?

Clomiphene citrate (CC) may have an adverse effect on cervical mucus (CM) quality and quantity. A placebo-controlled study was performed to assess the effect of exogenous follicular phase estrogen (E) on CM. Subjects qualified for inclusion by repeated demonstration of poor CM while on CC therapy as judged by spinnbarkeit, quantity, and viscosity. Subjects were treated by a randomized, placebo-controlled format using: (1) oral micronized estradiol (E2), 2 mg; (2) conjugated Es, 5 mg, or (3) placebo administered on cycle days 9 to 14. Cervical mucus was scored blindly during therapy within 48 hours before ovulation. Twelve subjects were observed through 36 treatment cycles with mean (+/- SD) CM scores: micronized E2, 4.2 +/- 1.8; conjugated Es, 4.3 +/- 1.7; and placebo, 4.7 +/- 2.9. There was no significant difference in mean values (P = 0.96, analysis of variance) or frequency of CM score greater than 4 (P = 0.85, Fisher exact test). We conclude that therapy with the E preparations tested did not improve the quality or quantity of CM in CC-treated patients.

Endocrine impact of pure estradiol replacement in postmenopausal women: Alterations in anterior pituitary hormone release and circulating sex steroid hormone concentrations

Thirteen healthy postmenopausal volunteers were studied under basal conditions and at intervals (days 1, 5, 10, and 30) after intravaginal placement of a polysiloxane ring impregnated with 400 mg of estradiol. Mean serum estradiol concentrations rose 26-fold with a twofold increase in serum estrone concentrations. Serum delta 4-androstenedione, dehydroepiandrosterone sulfate, and total testosterone did not change, but absolute and percent free testosterone concentrations declined significantly by day 5. Concurrently, serum concentrations of immunoactive follicle-stimulating hormone declined progressively, while serum luteinizing hormone and free alpha-subunit concentrations exhibited a biphasic pattern of suppression. Serum levels of prolactin increased monophasically and those of growth hormone, somatomedin C, and thyroid-stimulating hormone did not change.

Pituitary self-priming actions of gonadotropin-releasing hormone. Kinetics of estradiol's potentiating effects on gonadotropin-releasing hormone-facilitated luteinizing hormone and follicle-stimulating hormone release in healthy postmenopausal women.

We examined the kinetically distinct characteristics of estradiols effects upon pituitary luteinizing hormone (LH) and follicle-stimulating hormone (FSH) release in response to pulses of exogenous gonadotropin-releasing hormone (GnRH) in healthy postmenopausal individuals. The putative self-priming actions of GnRH on LH and FSH release were tested by intravenous injections of equal paired doses of GnRH (10 micrograms) before and after 1, 5, 10, and 30 d of pure estradiol-17 beta delivery via an intravaginal silastic ring. Self-priming actions of GnRH, as defined by heightened gonadotropin release in response to the second pulse of GnRH compared with the first, were completely absent in the hypoestrogenemic state. However, estradiol administration unmasked GnRH self-priming in a time-dependent fashion, with maximal expression after 5 and 10 d of steroid replacement, followed by attenuation by 30 d. Since estradiols modulation of GnRH action was expressed differentially on LH and FSH release, we suggest that such facilitation of GnRH-stimulated pituitary LH and FSH release may provide an additional mechanism for dissociated secretion of gonadotropic hormones in health or disease.

Oocyte retention after follicle luteinization

Indirect evidence supports the existence of the luteinized unruptured follicle syndrome in infertile women. To seek direct evidence of oocyte retention, infertile and normal women were studied in the early and midluteal phase by visual documentation of ovulation stigma, needle aspiration of ovarian follicles, and peritoneal fluid collection for estradiol and progesterone assay. Luteal phase was confirmed by endometrial biopsy (postovulation day 2 to 8). In normal control subjects (n = 16), 25% of test cycles were stigma-negative and no oocytes were recovered. In infertile group (n = 23), 43% of test cycles were stigma-negative. Five oocytes were recovered including one from a stigma-bearing follicle. Peritoneal fluid steroid levels failed to discriminate stigma-positive from stigma-negative cycles in either group. Oocyte retention after luteinization occurs in infertile women.

Subclinical pregnancy loss in clomiphene citrate-treated women

OBJECTIVE To ascertain the subclinical pregnancy loss rate in clomiphene citrate (CC)-treated infertile women compared with women of normal fertility. DESIGN Following a prospective format, serum samples were taken during the luteal phase of 92 menstrual cycles associated with CC treatment and 47 cycles in normal women. Human chorionic gonadotropin (hCG) assay sensitivity was 0.25 IU/L. Human chorionic gonadotropin assay was validated against 95 nonpregnant cycles. Criterion for pregnancy was a single serum sample greater than or equal to 0.5 IU/L. SETTING All subjects were under clinical management at the University of Virginia Health Sciences Center. PATIENTS AND PARTICIPANTS Patients undergoing CC induction of ovulation with satisfactory ovulatory response were candidates for the study group (n = 34). Control subjects of proven normal fertility were recruited (n = 22). Nonpregnant control subjects were sexually abstinent or had been surgically sterilized (n = 89). INTERVENTION A serum sample was taken during the late luteal phase of all subjects. RESULTS Thirteen percent of CC-treated cycles and 4.3% of normal control cycles were subclinical losses (P = 0.09). Fifty percent of CC-induced pregnancies were subclinical losses compared with 16.6% of normal control pregnancies (P = 0.05). Of CC patients who had at least one subclinical loss 47.6% later conceived a term pregnancy compared with 15.3% who did not have a subclinical loss (P = 0.06). CONCLUSION Subclinical pregnancy loss is more common in CC-treated women than normal women and may be a predictor of subsequent normal conception.

Evaluation of LH secretory dynamics during the rat proestrous LH surge

The preovulatory luteinizing hormone (LH) surge results from the integration of complex interactions among gonadal steroids and hypothalamic and pituitary hormones. To evaluate changes in LH secretory dynamics that occur during the rat LH surge, we have 1) obtained frequently sampled serum LH concentration time series, 2) used both waveform-dependent and waveform-independent convolution analyses, and 3) independently assessed proestrous LH half-life and basal non-gonadotropin-releasing hormone (GnRH)-dependent LH secretion during the LH surge. Waveform-independent pulse analysis revealed a 24-fold increase in the maximal pulsatile LH secretory rate attained during late proestrus compared with early proestrus. A 15-fold increase was quantified for the mean LH secretory rate. In complementary analyses, we applied a measured LH half-life of 17 ± 2.7 min and a median basal LH secretion rate of 0.0046 μg ⋅ l-1 ⋅ min-1 for convolution analysis, revealing a 16-fold increase in the mass of LH released/burst and more than sixfold rise in the amplitude of the secretory peaks. Evaluation of the approximate entropy of the LH surge profiles was performed, showing an increase in the orderliness of the LH release process during the surge. We conclude that both quantitative (mass/burst) and qualitative (approximate entropy) features of LH release are regulated during the proestrous LH surge.

Forskolin-Associated Luteinizing Hormone Release by Rat Anterior Pituitary Glands: Effects of Castration and Estradiol Replacement

We have previously shown that the diterpene forskolin, a compound which increases intracellular cyclic AMP (cAMP), causes a concentration-dependent release of luteinizing hormone (LH) by continuously perifused anterior pituitary cells from female rats. To test the hypothesis that cAMP-associated LH release is an estrogen-dependent process, we first compared concentration-response relationships between forskolin and both cAMP production and LH secretion by tissue obtained from intact female, intact male and ovariectomized (OVX) rats. Anterior pituitary fragments were perifused with medium alone or medium plus several concentrations of forskolin for 4 h. All three groups demonstrated concentration-dependent cAMP production in response to forskolin. However, while a concentration-dependent release of LH by forskolin was confirmed in pituitary fragments from intact female rats, no such relationship could be identified for tissue from OVX or male rats. Pituitary fragments from OVX rats administered estradiol via silastic capsule for 48 h were next challenged with 3 microM forskolin. In response to this submaximal concentration of the diterpene, a brisk increase in LH secretion was observed. These results demonstrate that, although forskolin stimulates the production of cAMP in intact male, intact female and OVX animals, an associated release of LH can be documented only in the intact female group. These findings, together with the observation that administration of estrogen appears to restore forskolin-associated LH secretion in OVX animals, suggest that estrogen may play a key role in the stimulation of LH release by cAMP.