Marvin A. Yussman

Endometriosis in association with uterine anomaly

Endometriosis is frequently a chronic process, which may begin soon after menarche. The process may be enhanced by mechanical obstruction. Theories of retrograde menstruation and metaplasia still remain in vogue. Endometriosis is a cause of both acute and chronic pelvic pain in the adolescent. We present case reports of müllerian lateral wall fusion defects with surgical correction and evidence for resorption of endometriosis. Clinicians must be aware that patients with uterine anomalies may develop extensive endometriosis, which upon creation of an unobstructed outflow tract results in complete resorption. Furthermore, the mechanism of formation of endometriosis in association with an outflow tract obstruction may be very different from that associated with infertility. We recommend consideration of endometriosis and/or a reproductive tract abnormality in the adolescent with persistent pelvic pain.

Induction of luteal phase defect with clomiphene citrate

The effect of clomiphene citrate and progesterone on luteal function in infertile women was studied. Endometrial biopsies were performed in 103 women immediately prior to menstruation. Group 1 (n = 62) had secretory endometrium with a histologic lag time of greater than or equal to 48 hours with respect to the subsequent menses, that is, luteal phase defect. Group 2 (n = 10) had normal histologic characteristics of the secretory phase. Group 3 (n = 31) had anovulatory endometrium. The last group was subdivided into those with polycystic ovary syndrome (n = 9) and those without the characteristic gonadotropin pattern of polycystic ovary syndrome (n = 22). Clomiphene citrate at doses of 50 to 250 mg daily for 5 days was administered for induction of ovulation, timing of ovulation, or treatment of luteal phase defect. An endometrial biopsy was obtained after three ovulatory treatment cycles. Only one fourth of the women with prior luteal phase defect had normalization of the biopsy specimen with clomiphene citrate, while one half of those treated with progesterone had normal specimens. Half of the normally ovulating women had induction of a luteal phase defect with clomiphene citrate. Only women with polycystic ovary syndrome had consistently well-timed endometrial histologic features with clomiphene citrate therapy. Despite successful induction of ovulation, 16 of the other 22 previously anovulatory women had endometrial histologic findings compatible with luteal phase defect. Increasing the clomiphene citrate dosage was unsuccessful in improving endometrial maturation. These results suggest that the use of clomiphene citrate may be associated with a high rate of luteal phase defect induction, except among women with polycystic ovary syndrome. Clomiphene citrate, even at high doses, appears to be ineffective therapy for luteal phase defect.

Plasma gonadotropin and sex steroid hormone levels during early, midfollicular, and midluteal phases of women with luteal phase defects

Thirteen women with luteal phase defects (LPD) confirmed by endometrial biopsies and 14 with histologically normal endometria were studied for early follicular and midfollicular phase follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels and for midluteal phase progesterone, estrogen, testosterone, and prolactin levels. The results showed that the women with LPD had significantly lower FSH levels and FSH/LH ratios in the early and midfollicular phases. LH levels, however, were similar in the LPD and normal women. During the midluteal phase, the LPD women showed significantly lower levels of progesterone and estrogen and normal levels of testosterone and prolactin. These findings reaffirm the prevailing concept that events surrounding follicular growth and development can indeed influence the quality of that cycles corpus luteum. Furthermore, LPD as a result of hyperprolactinemia appears to be a different entity from that due to inadequate follicular phase FSH.

Hysterosalpingography in the Evaluation of Infertility: A Six-Year Review

A series of 505 consecutive hysterosalpingograms (HSG) for the evaluation of infertility is reviewed. Two hundred and seventy-five (54.3%) were interpreted as normal. A tubal abnormality was found in 188 (37.2%) and a uterine abnormality in 42 (8.5%). The literature is reviewed. Hysterosalpingographic abnormalities in the present series are compared with those reported in studies previously published. Complications and advantages of the procedure are outlined. Analysis of the results shows a low morbidity and high return (45.7% abnormal), making HSG one of the most valuable tools in the initial evaluation of the infertile couple.

Interference in the measurement of CA-125 in peritoneal fluid *

CA-125 has been found to be mildly elevated in the serum of patients with advanced stages of endometriosis, but not with minimal endometriosis. Peritoneal fluid levels were measured in conjunction with serum levels in 12 consecutive patients with endometriosis and 12 consecutive normal controls. Apparent peritoneal fluid values were found to be 10-fold higher than serum levels, with no difference between the study groups (130 versus 106 U/ml, respectively). However, when peritoneal fluid was diluted to validate the assay system in peritoneal fluid, no sample of peritoneal fluid showed decreased binding with serial dilutions of 1:2, 1:5, and 1:10. At a dilution of 1:100, there was some decreased binding, but the level was 17-fold higher than expected. The source of this interference is unknown.

Follicular fluid Lidocaine levels during transvaginal oocyte retrieval

Lidocaine has been shown to have adverse effects on mouse oocyte fertilization and embryo development. We have demonstrated the presence of pharmacologic levels of lidocaine in human serum and follicular fluid obtained during ultrasound guided transvaginal oocyte retrieval. The significance of this finding is unclear, as four of the eight patients studied became pregnant, including the patient with the highest follicular fluid lidocaine levels. Further evaluation of the effect of lidocaine on human embryos is warranted.

Radiation exposure of ovaries during hysterosalpingography

Radiation exposure to an area approximating the location of the ovaries was measured in 29 patients undergoing hysterosalpingography. A thermoluminescent crystal technique was used for some patients; a pocket dosimeter placed into the upper vagina was used for additional patients. Radiation dosage varied from 75 to 550 millirads. The weight of the patient did not affect the amount of radiation delivered to the gonads. The duration of fluroscopic time was the major factor increasing dosage. A discussion of hysterodalpingographic technique and suggestions for decreasing gonadal irradiation during hysterosalpingography are included.

Comparison of Avitene, Topical Thrombin, and Gelfoam as Sole Hemostatic Agent in Tuboplasties*

Forty-eight virgin guinea pigs were subjected to bilateral sectioning of the uterine horn and cuff type salpingostomy. Avitene, Topical Thrombin, or Gelfoam was used as the sole hemostatic agent in each of three study groups. Bipolar cauterization was used in a control series. These agents were compared with regard to ease of application, degree of adhesion formation, net surface area, and microscopic evaluation of degree of fibrosis and inflammatory reaction. The results revealed no statistically significant differences among the various methods of hemostasis. Data were evaluated by uni- and multivariate analyses. Several trends in the data were noted: the greatest amount of fibrosis was associated with Topical Thrombin and Avitene, and the greatest inflammatory response was associated with Avitene. These agents show no superiority to currently used cautery methods of obtaining hemostasis.

Stability of human chorionic gonadotropin and its alpha subunit in human blood

The stability of human chorionic gonadotropin (hCG) and its alpha-subunit in whole blood, plasma, and serum under a variety of sample handling conditions commonly encountered in clinics, hospital wards, physicians offices, and clinical service laboratories was investigated with the use of radioreceptor assay, radioimmunoassays, as well as hormone integrity determinations. The results clearly demonstrate that hCG and its alpha-subunit are stable in unfrozen whole blood, plasma, and serum for at least 6 days and in frozen plasma and serum samples for at least 6 months. Repeated freezing and thawing of the samples during this period had no effect. Separation of plasma or serum from erythrocytes is not needed for at least 12 hours. Hemolysis in samples resulted in a 20% to 30% decrease in hCG and its alpha-subunit levels, which may be attributable to sample dilution.

Light and electron microscope immunocytochemical localization of 5- and 12-lipoxygenases and cyclooxygenase enzymes in human granulosa cells from preovulatory follicles

Cellular and subcellular distribution of 5- and 12-lipoxygenases and cyclooxygenase enzymes were investigated in human granulosa cells from preovulatory follicles using light and electron microscope immunocytochemistry. The results demonstrated that all three enzymes are present in granulosa cells but not in minor contaminating red blood cells. While the distribution of cyclooxygenase and 12-lipoxygenase was relatively uniform among the granulosa cells, 5-lipoxygenase was not uniformly distributed among these cells. All three enzymes are present in microvillus plasma membranes, rough endoplasmic reticulum, cytoplasm, nuclear membranes and chromatin. In summary, 5- and 12-lipoxygenases and cyclooxygenase enzymes, which catalyze the transformation of arachidonic acid into different eicosanoids, are present in several subcellular organelles including nuclei of granulosa cells from preovulatory follicles.