Martin D. Keltz

Sonohysterography for screening in recurrent pregnancy loss

OBJECTIVEnTo evaluate the role of sonohysterography for screening of the uterine cavity in patients with recurrent pregnancy loss.nnnDESIGNnProspective evaluation of sonohysterography, including comparison with available hysterosalpingography and hysteroscopy.nnnSETTINGnUniversity referral center.nnnPATIENT(S)nThirty-four reproductive-aged women with at least two consecutive pregnancy losses.nnnINTERVENTION(S)nSonohysterography was performed on all patients, using saline instilled through an endocervically placed balloon catheter with concurrent vaginal sonography.nnnRESULT(S)nSeventeen of 34 sonohysterograms (50.0%) demonstrated intrauterine abnormalities. Eighteen of 34 cases have undergone hysteroscopy or, in 1 case, laparoscopy. All confirmed the positive or negative sonohysterographic finding, resulting in a sensitivity and specificity of 100%. Additionally, 100% (12/12) of the defects were diagnosed accurately at sonohysterography when confirmed by surgery. Twenty-seven of 34 patients also had a hysterosalpingogram that demonstrated a 90.0% sensitivity and 20.0% specificity based on hysteroscopic findings, yet only 5 of 11 (45.5%) defects were diagnosed accurately at hysterosalpingography when compared with surgery.nnnCONCLUSION(S)nSonohysterography is a highly sensitive, specific, and accurate screening tool for the evaluation of uterine cavitary defects associated with recurrent pregnancy loss and offers several advantages over hysterosalpingography.

Modulation of leukemia inhibitory factor gene expression and protein biosynthesis in the human fallopian tube

OBJECTIVEnThe fallopian tube is the site of fertilization and early embryonic growth and a common site of ectopic implantation. Although the factors responsible for early embryogenesis and implantation are incompletely understood, leukemia inhibitory factor may have an important role in early embryonic development and implantation. We set out to evaluate the production and modulation of leukemia inhibitory factor in the fallopian tube.nnnSTUDY DESIGNnWe first investigated leukemia inhibitory factor messenger ribonucleic acid levels in fallopian tubes. We then investigated leukemia inhibitory factor messenger ribonucleic acid and protein production in tubal epithelial and stromal cell cultures.nnnRESULTSnLeukemia inhibitory factor messenger ribonucleic acid is expressed in the fallopian tube with only slight variation during the menstrual cycle; however, it is markedly elevated in association with ectopic pregnancy. The level is higher in the tubal mucosa than in the remaining layers and is higher in the more distal segments of the fallopian tube. Estradiol and progesterone did not modulate leukemia inhibitory factor expression in epithelial or stromal cell cultures. Interleukin-1 alpha, tumor necrosis factor-alpha, and transforming growth factor-beta enhanced leukemia inhibitory factor expression in epithelial and stromal cells, with transforming growth factor-beta 1 enhancing expression by fourfold in stromal cells. Epithelial cells secreted high levels of leukemia inhibitory factor compared with stromal cells (332 +/- 89 vs 25 +/- 42 pg/mg total protein). Yet stromal cells treated with transforming growth factor-beta alone or in combination with epidermal growth factor and platelet-derived growth factor, as well as TNF-alpha alone or in combination with interleukin-1 alpha enhanced secretion of leukemia inhibitory factor at or above the levels found with epithelial cells.nnnCONCLUSIONSnWe speculate that the high constitutive levels of leukemia inhibitory factor expressed in the ampullary portion of the fallopian tube may play a role in early embryonic development. Additionally, elevated expression with ectopic implantation and the marked induction of secretion in the tubal stroma by growth factors and cytokines suggest a link between inflammation, leukemia inhibitory factor, and tubal ectopic pregnancies.

Sonohysterographic Screening Before In Vitro Fertilization

OBJECTIVEnTo evaluate the use of sonohysterography for uterine screening before IVF.nnnDESIGNnProspective screening with sonohysterography and comparison with available hysterosalpingographic and hysteroscopic evaluations.nnnSETTINGnPrivate practice.nnnPATIENT(S)nSeventy-two women undergoing IVF-ET using their own or donor eggs.nnnINTERVENTION(S)nSonohysterography was performed by instilling saline into the uterine cavity through an intracervical balloon catheter; there was concurrent vaginal sonographic visualization in all cases.nnnMAIN OUTCOME MEASURE(S)nSonohysterographic findings and pregnancy rates.nnnRESULT(S)nCavitary lesions were detected in 8 (11.1%) of 72 sonohysterographic examinations. Six of 8 cases were confirmed and treated by hysteroscopy. After sonohysterographic evaluation, 35 (48.6%) of 72 patients conceived, resulting in 25 ongoing or delivered pregnancies, 5 chemical pregnancies, and 5 spontaneous abortions. No statistically significant difference was observed in the pregnancy outcome for patients undergoing IVF who had sonohysterography compared with that for patients undergoing IVF during the same period who previously had a uterine evaluation by a different method. The estimated cost savings per patient undergoing sonohysterography instead of in-office hysteroscopy was

Baseline cyst formation after luteal phase gonadotropin-releasing hormone agonist administration is linked to poor in vitro fertilization outcome*

275.nnnCONCLUSION(S)nSonohysterography offers advantages over in-office hysteroscopy and hysterosalpingography for evaluation of the uterus before IVF.

Dilutional hyponatremia during hysteroscopic myomectomy with sorbitol-mannitol distention medium

OBJECTIVEnTo investigate the prognostic significance of baseline ovarian cysts after luteal phase GnRH agonist (GnRH-a) administration for IVF-ET.nnnDESIGNnAll nondonor IVF-ET cycles in one program in which luteal phase GnRH-a was administered between July 1993 and January 1994 were assessed for the formation of baseline ovarian cysts defined as a mean diameter > or = 15 mm. Outcome data from the IVF cycles were compared between patients with and without baseline ovarian cysts.nnnRESULTSnOf 78 IVF cycles, baseline cysts > or = 15 mm were noted in 26 cycles. Cycles in which cysts were formed were associated with significantly older patients with significantly higher baseline FSH values. Cycles in which cysts were present demonstrated fewer follicles, retrieved oocytes, and embryos. Cyst cycles also demonstrated a lower peak E2 level, implantation rate, and clinical pregnancy rate (PR) per initiated cycle (7.7% versus 32.7%). Cyst cycles also demonstrated a higher cancellation rate. Logistic regression modeling, accounting for age, confirmed significantly lower clinical PRs in cycles with a baseline cyst.nnnCONCLUSIONSnBaseline cyst formation after luteal phase GnRH-a administration is both a marker for poor responders and a reliable predictor of poor stimulation and low PRs in a given IVF-ET cycle.

Endosalpingiosis found at laparoscopy for chronic pelvic pain

To determine the frequency of hyponatremic complications during hysteroscopic myoma resections using sorbitol-mannitol distending medium and its relationship to operative time, fluid balance, and myoma size, we reviewed all operative hysteroscopic procedures performed by the Section of Reproductive Endocrinology and Fertility at Yale-New Haven Hospital over a 1-year period during which that medium was used. Twenty-six cases were identified of which seven involved hysteroscopic myoma resections. Hyponatremia occurred in four of the seven patients, and in one it was associated with severe posttransurethral prostatic resection (post-TURP) syndrome. The degree of hyponatremia varied roughly in direct proportion to fibroid volume and fibroid volume as a percentage of uterine volume. No relationship was found between the degree of hyponatremia and operating time, estimated submucosal volume, and uterine volume. We conclude that dilutional hyponatremia and the post-TURP syndrome may occur with the use of sorbitol-mannitol distension medium during hysteroscopy. They occur more frequently during operative hysteroscopy to resect myomata, with myoma size and myoma volume expressed as a percentage of uterine volume possibly influencing the degree of hyponatremia.

Evaluation and management of chronic pelvic pain

OBJECTIVEnTo assess a correlation between endosalpingiosis and pelvic pain.nnnDESIGNnA retrospective analysis of every patient undergoing laparoscopy for chronic pelvic pain at Yale-New Haven Hospital by one surgeon from August 1992 through October 1993 was performed, focusing on those cases with endosalpingiosis.nnnRESULTSnOf 51 laparoscopies performed for chronic pelvic pain, 37 demonstrated visual evidence of implants and pathology specimens were read as either endometriosis or endosalpingiosis in 23 cases. Of those 23 cases, 6 demonstrated endosalpingiosis, and 4 of those 6 demonstrated both endosalpingiosis and endometriosis. In all six cases endosalpingiosis was found in locations consistent with the patients pelvic pain symptoms, and all six patients experienced relief from their pain symptoms after surgery.nnnCONCLUSIONSnEndosalpingiosis may be found in association with chronic pelvic pain. The pelvic distribution of endosalpingiosis in patients with chronic pain is consistent with that generally found in endometriosis.

Large Bowel-to-Pelvic Sidewall Adhesions Associated With Chronic Pelvic Pain

Evaluating patients with chronic pelvic pain is complex. A detailed medical history should be ideally supplemented by psychologic evaluation and assessment of the womans social background. At the time of physical examination, the location and intensity of the pain should be mapped. Assessment of pain relief with the administration of a local anesthetic to trigger points or selected nerves may be useful in predicting the potential efficacy of surgical interventions such as uterosacral nerve ablation. Appropriate tests include pelvic ultrasound and magnetic resonance imaging. Ultimately, laparoscopy may provide the final diagnosis. Management should address the underlying cause(s) of pain; when this cannot be done, it should focus on treating the pain itself. When appropriate, empiric administration of antidepressants may be considered. In selected women, therapeutic goals may be achieved by electrical stimulation of nerves.

Hysterosalpingography Versus Sonohysterography for Intrauterine Abnormalities

STUDY OBJECTIVESnTo assess retrospectively the prevalence of colon-to-pelvic sidewall adhesions associated with pelvic pain or pelvic endometriosis, and to evaluate prospectively their prevalence compared with controls.nnnDESIGNnA retrospective review of all patients undergoing laparoscopy for chronic pelvic pain between August 1992 and September 1993; and abased on a power analysis, a prospective comparison of women undergoing laparoscopy for chronic pelvic pain with those undergoing laparoscopy for tubal sterilization between October 1994 and December 1995.nnnSETTINGnA university-associated teaching hospital.nnnPATIENTSnFifty women in the retrospective portion, and 30 women (15 in each group) in the prospective portion.nnnMEASUREMENTS AND MAIN RESULTSnOf the 50 women undergoing laparoscopy for pelvic pain, 47 (94%) had either right- or left-sided colon-to-sidewall adhesions, and these adhesions were more common than any other type of intraabdominal adhesion, 94% versus 58%. Thirty-eight (76%) of these women had visual and 25 (50%) histologic evidence of endometriosis. The prospective study revealed that women with pelvic pain had a higher rate of colon-to-sidewall adhesions than controls (93.3% vs 13.3%) and a correspondingly higher rate of visualized endometriosis (73.3% vs 6. 7%). Right-sided paracolic adhesions were both more common than left-sided adhesions (87.7% vs. 46.7%) and were more often extensive than minimal (46.7% vs 6.7%).nnnCONCLUSIONSnColon-to-sidewall adhesions occur in the majority of patients with chronic pain, whereas they are an uncommon finding in the general population. The lateral gutters are dependent regions of the abdominal cavity that are susceptible to the spread of peritoneal endometriosis or other inflammatory processes, and should be evaluated at diagnostic laparoscopy for chronic pelvic pain.

In vitro maturation and its role in clinical assisted reproductive technology.

Sonohysterography was found to be more sensitive, specific, and accurate in the evaluation of specific intrauterine defects than hysterosalpingography.