Michael W. Vernon

Studies on the surgical induction of endometriosis in the rat.

As a model to examine the pathophysiologic attributes of endometriosis, attempts were made to surgically induce the disease in the rat by autotransplanting endometrial or uterine tissue to the peritoneum. Rats (n = 46) were randomly assigned to one of four surgical techniques: (1) four uterine squares sutured to the peritoneal cavity; (2) uterine luminal lavages instilled into the peritoneal cavity; (3) endometrial scrapings flushed into the peritoneal cavity; and (4) sham-operated controls. Rats were examined at various days after surgery for the presence of endometrial implants. The autotransplantation of uterine squares to the peritoneal cavity was the only treatment that yielded healthy endometriotic implants. These implants grew into ellipsoidal cystic structures that were composed of both endometrial glands and stroma and were found to contain prostaglandin F (202 ng/mg) at concentrations similar to those measured in uterine tissue (205 ng/mg). To examine the effect of surgically induced endometriosis upon fecundity, rats (n = 40) were autotransplanted with uterine squares or were sham operated and mated. The presence of ectopic endometrial tissue reduced the number of pups at term by 48% and the number of day 14 embryos by 28% (P less than 0.05). Peritoneal adhesions were greater in rats with induced endometriosis than in sham-operated controls (P less than 0.05); however, in rats with induced endometriosis, no differences were noted in the severity of adhesions between pregnant and nonpregnant rats. Endometriotic implants underwent complete regression in the day 14 pregnant rat but had doubled in size in the nonpregnant rat. At term, the endometriotic implants were larger than in the day 14 pregnant rat (P less than 0.05) and similar to their original size. The successful growth and development of surgically transplanted endometrial tissue in the rat offers a research model that can be used to study those aspects of endometriosis that cannot be adequately investigated in women.

Classification of endometriotic implants by morphologic appearance and capacity to synthesize prostaglandin F

The severity of the symptoms of endometriosis has not always correlated well with the anatomic severity of the disease. This lack of correlation may be due to variations in the metabolic activity of the endometriotic implants present at different stages of the disease. Because prostaglandin F (PGF) has been implicated as a hormonal mediator of the clinical symptoms of endometriosis, PGF synthesis and content was measured in implants from 14 patients with mild, moderate, severe, or extensive disease. To assess whether PGF production was related to the status of implants, the authors classified implants, based on gross and histologic criteria, as petechial or reddish; intermediate or brown; or powder-burn or black. PGF production of implants from patients with mild or moderate disease was greater than that of implants from patients with severe or extensive disease (P less than 0.05), and PGF content was similar for all stages of endometriosis. Petechial implants produced twice the amount of PGF than intermediate implants (P less than 0.05), which in turn produced more PGF than powder-burn implants (P less than 0.05). Powder-burn implants did not have the in vitro capacity to produce PGF, and the amount of PGF contained in implants of all classes was similar. Therefore, endometriotic implant PGF production and possibly other biochemical activities are dependent on the physical status of the implant. The classification of implants by morphologic appearance may afford additional assistance in determining the prognosis of the disease and in the examination of the subtle effects of the disease on symptoms.

Immunomodulation of Rat Endometriotic Implant Growth and Protein Production

PROBLEM: The immune system has been implicated in the pathophysiology of endometriosis. To determine if modulation of the immune system influences endometriotic implant growth and protein production, the following experiment was conducted.

The clinical relevance of luteal phase deficiency: A committee opinion

Luteal phase deficiency (LPD) has been described in healthy normally menstruating women and in association with other medical conditions. While progesterone is important for the process of implantation and early embryonic development, LPD, as an independent entity causing infertility, has not been proven.

Concurrent ganirelix and follitropin beta therapy is an effective and safe regimen for ovulation induction in women with polycystic ovary syndrome

OBJECTIVE To evaluate controlled ovarian stimulation cycles using the GnRH antagonist ganirelix in combination with the recombinant FSH, follitropin-beta, in women with polycystic ovary syndrome (PCOS). DESIGN Prospective, nonrandomized clinical study. SETTING Hospital-based infertility practice. PATIENT(S) Twenty women with PCOS planning to undergo ovarian stimulation. INTERVENTION(S) Fasting glucose and insulin levels were used to calculate insulin resistance ratios (FG/I). After pretreatment with oral contraceptives, serum LH levels were determined, and 250 microg ganirelix was administered on cycle day 2. Upon suppression of LH, concurrent ganirelix and follitropin-beta therapy (morning ganirelix and evening follitropin-beta) was started and continued until the day of hCG. MAIN OUTCOME MEASURES Days of stimulation, dose of follitropin-beta, pregnancy, and ongoing pregnancy were compared based on FG/I ratios. RESULTS One dose of ganirelix effectively suppressed LH levels in all patients. All patients ovulated as documented by a rise in progesterone. Significant differences were observed between the insulin-resistant and non-insulin-resistant groups for both days of stimulation and dose of follitropin-beta. The overall clinical pregnancy rate was 44.4%, with an ongoing pregnancy rate of 27.8%. CONCLUSIONS In this preliminary study, we demonstrate the effectiveness of a concurrent ganirelix and follitropin-beta therapy for ovarian stimulation in women with PCOS.

Spontaneous and steroid-induced recurrence of endometriosis after suppression by a gonadotropin-releasing hormone antagonist in the rat*†

Recurrent endometriosis in women is difficult to study because of the ethical consideration of performing repeated surgeries. Previously in the rat model we described therapeutic regression of endometriosis with the gonadotropin-releasing hormone antagonist antide. Presently we report the spontaneous and steroid-induced recurrence of endometriosis after withdrawal from antide therapy. Rats with endometriosis received antide or vehicle on days 0 (proestrus), 3, 6, and 9 and were killed on days 0, 6, 12, 18, 24, 30, and 42 (n = 4 antide-treated and 4 vehicle-treated rats killed per day). Additional antide-treated rats (n = 4 per treatment) received estrogen, progesterone, both estrogen and progesterone, cholesterol, and no steroid on day 9 and were killed on day 12. Antide significantly suppressed endometriotic implant size on days 12, 18, and 24. However, implant size spontaneously returned to pretreatment values by day 30. Administration of steroids on day 9 elicited regrowth of antide-suppressed endometriosis (estrogen plus progesterone greater than estrogen, progesterone, or cholesterol greater than no steroid) by day 12. This resilience of endometriosis offers an explanation for treatment failure and recurrence of the disease in women.

Characterization of a computerized semen analysis system

In the present studies we have evaluated the optimal operating conditions for the Hamilton-Thorn HTM-2000 computerized semen analyzer (Hamilton-Thorn, Danvers, MA). The best reproducibility in measurement of sperm concentration was obtained using 20 frames acquired at 19 frames/s. The measurement of sperm concentration was not adversely affected by the number of fields analyzed. The intrasample and intersample coefficients of variation for sperm concentration were 9.5% and 25.5%; sperm motility, 18.4% and 28.9%; lateral head displacement, 16.5% and 19.9%; path velocity, 6.8% and 13.9%; progressive velocity, 4.5% and 9.9%; and linear index, 2.5% and 4.2%; respectively. These differences suggest that sampling error has a significant influence on the reliability of sperm evaluation. The precision and rapidity of the HTM-2000 compares favorably with data previously reported from other systems available for clinical semen analysis.

Successful pregnancies from men with retrograde ejaculation with the use of washed sperm and gamete intrafallopian tube transfer (GIFT)

Viable sperm were collected from men suffering from retrograde ejaculation by the technique of rapid washing of semen/urine in a buffered collection solution. The utilization of washed semen/urine from two men with retrograde ejaculation in the GIFT procedure lead to successful conceptions and the birth of two healthy female babies. Thus, the technique of rapid washing of sperm from retrograde ejaculating men coupled with GIFT represents a viable alternative for the attainment of pregnancy.

Uterine septum: a guideline

The purpose of this guideline is to review the literature regarding septate uterus and determine optimal indications and methods of treatment for it. Septate uterus has been associated with an increase in the risk of miscarriage, premature delivery, and malpresentation; however, there is insufficient evidence that a uterine septum is associated with infertility. Several studies indicate that treating a uterine septum is associated with an improvement in live-birth rates in women with a history of prior pregnancy loss, recurrent pregnancy loss, or infertility. In a patient without infertility or prior pregnancy loss, it may be reasonable to consider septum incision following counseling regarding potential risks and benefits of the procedure. Many techniques are available to surgically treat a uterine septum, but there is insufficient evidence to recommend one specific method over another.

Detection of a progesterone-induced secretory protein synthesized by the uteri but not the endometriotic implants of rats with induced endometriosis

Steroids modulate the secretory activity of the uterus, but little is known of their effect on ectopic endometrium protein synthesis and secretion. We utilized two-dimensional electrophoresis to visualize proteins produced by the uteri and endometriotic implants of both steroid-treated and reproductively cyclic rats with and without surgically induced endometriosis. Of the greater than 300 proteins visualized, only the uterine cultures from progesterone (P)-stimulated, estrogen-suppressed rats contained a distinctive glycoprotein (P-induced uterine protein-1; molecular weight [Mr] 70,000; isoelectric point [pI] 5.7). This protein was not detected in any of the endometriotic implant cultures. Progesterone-induced uterine protein-1 could play a role in luteal or endometrial physiology and may be valuable in assessing endometrial function. The aberrant secretory behavior of the ectopic endometrium suggests a possible involvement in the reproductive dysfunction associated with endometriosis.