Theodore C. Nagel

Uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis: the University of Minnesota experience

OBJECTIVE To present the experience of a large referral center with patients with the rare but specific syndrome of uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis. DESIGN, PATIENTS Between 1953 and 1991, 15 patients with the syndrome were evaluated by the authors; each patients records were carefully reviewed. MAIN OUTCOME MEASURES For each patient, the clinical course, specific anatomic findings, treatment(s) offered, and obstetrical outcome are presented. RESULTS The specificity of the association of uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis was confirmed by our series, the largest in the literature to date. The findings suggest a specific development anomaly of the müllerian ductal system, probably secondary to a wolffian duct anomaly. The most common clinical presentation was that of the onset of pelvic pain and/or dysmenorrhea shortly after menarche, in association with the finding of a vaginal/pelvic mass. When a communication between the two sides existed, symptoms of abnormal vaginal discharge and bleeding were common. Optimal outcome appears to have occurred for patients initially managed using a conservative surgical approach, i.e., simple vaginal septum resection combined with conservative treatment of associated endometriosis. Obstetrical outcome in our patients was similar to that in patients with the more common combination of uterus didelphys and sagittal vaginal septum. CONCLUSION A greater awareness of the syndrome of uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis should lead to its prompt diagnosis, allowing for early and appropriate surgical intervention as well as decreased long-term morbidity.

Recommendations for Diagnosis, Treatment, and Management of Individuals with Turner Syndrome

The objective of this study was to establish the optimum treatment and overall care recommendations for individuals with Turner syndrome at all stages of life as an aid to medical professionals working with these individuals. The Turners Syndrome Society of the United States brought together 16 nat

Intrauterine insemination: the University of Minnesota experience

Forty-five patients initiated intrauterine insemination between October 1981 and August 1983. Indications for insemination included poor semen (count less than 20 X 10(6)/ml and/or motility less than 40%), poor cervical mucus, presence of sperm antibodies, unexplained poor postcoital tests, or various combinations of the above. During this time period, 374 inseminations were performed in 163 cycles and resulted in eight pregnancies in the 45 patients receiving artificial insemination by homologous donor, for an overall pregnancy rate of 17.4%. The fact that five of the pregnancies occurred in the first insemination cycle and two in the second cycle was felt to indicate a cause-and-effect relationship. A trial of intrauterine insemination in selected patients would appear to be warranted.

Hysteroscopic metroplasty in the diethylstilbestrol-exposed uterus and similar nonfusion anomalies: effects on subsequent reproductive performance; a preliminary report

OBJECTIVE To determine the feasibility of correcting the uterine abnormalities seen in diethylstilbestrol (DES)-exposed women and similar anomalies. DESIGN Patients served as their own controls. SETTING University based and private practice tertiary referral practice. PATIENTS Eight patients referred for infertility, recurrent pregnancy loss, or both with an abnormal uterine contour as seen by hysterosalpingogram. INTERVENTION Hysteroscopic metroplasty. OUTCOME MEASURES Ability to conceive and carry pregnancy to livebirth. RESULTS Three of five patients with secondary infertility and recurrent pregnancy losses had livebirths as did a patient with secondary infertility. Two patients with primary infertility failed to conceive. CONCLUSION Metroplasty may decrease pregnancy loss in these patients but may not enhance fertility.

Oophoropexy to prevent sequential or recurrent torsion.

Laparoscopic oophoropexy may prevent recurrent (repeat torsion of the same ovary) or sequential (subsequent torsion of the contralateral ovary) ovarian torsion. Two adolescent girls with sequential ovarian torsion underwent laparoscopic plication of utero-ovarian ligaments. Neither patient has had recurrence in the 6. 5 and 2 years, respectively, since surgery. Sequential ovarian torsion has been described,1-8 and in almost every instance the authors raised the question of whether or not oophoropexy should have been done at the time of the initial episode of torsion. In virtually every instance the second ovary was removed and the patient rendered menopausal. In two patients with sequential ovarian torsion the ovary was saved and oophoropexy performed laparoscopically in an effort to prevent recurrence.

Cryothermic and Hyperthermic Treatments of Human Leiomyomata and Adjacent Myometrium and Their Implications for Laparoscopic Surgery

STUDY OBJECTIVE To evaluate the effects and feasibility of direct cryothermic and hyperthermic therapy on leiomyomata and adjacent myometrium, and to contribute to evidence-based treatment thresholds based on measurements of direct cell injury. DESIGN Experimental study (Canadian Task Force classification II-2). SETTING University hospital. SUBJECTS Leiomyoma and myometrium tissue from 10 women undergoing total abdominal hysterectomy with or without bilateral salpingo-oophorectomy. INTERVENTION In vitro cryothermic or hyperthermic therapy was performed with representative leiomyoma and myometrium tissue samples. Using a directional solidification stage to simulate cryothermic therapy, 10 leiomyoma and 6 myometrium specimens were cooled in vitro at a rate of -5 degrees C/minute to end temperatures of -20 degrees, -40 degrees, -60 degrees, and -80 degrees C with a 15-minute hold period and then rapidly thawed to 21 degrees C. Hyperthermic therapy was simulated using a preheated 45 degrees, 55 degrees, 60 degrees, 65 degrees, 70 degrees, 75 degrees, and 80 degrees C constant temperature copper heating block with a 10-minute treatment period. In conjunction with tissue culturing and control tissues, cell death was assessed with routine histology and viability dyes (ethidium homodimer/Hoechst). MEASUREMENTS AND MAIN RESULTS In cryothermic results, leiomyomata cell death (LCD) increased from 12% to 27% by histology and 26% to 38% by viability dye assay over the thermal range from -20 degrees to -80 degrees C, respectively. Myometrial cell death (MCD) increased from 10% to 12% and 4% to 20% for the same measurements, respectively. Whereas MCD appeared relatively stable from -40 degrees to -80 degrees C, it was significantly less than LCD over this range (p <0.05). For hyperthermic results, LCD increased from 17% to 88% by histology with progressive temperature increase from 45 degrees to 80 degrees C, respectively. The MCD showed a similar increase from 16% to 91% by histology over this temperature range. Hyperthermic histology and dye assay results were similar for LCD and MCD. CONCLUSIONS In comparison with myometrium, leiomyomata showed greater direct cryothermic and equal hyperthermic cell injury. Whereas cell death increased up to 70 degrees C and down to -80 degrees C, the interval increases in cell injury diminished with more extreme temperatures. In vivo studies of combined direct and ischemic vascular injury thresholds have yet to be performed, but direct LCD matrixes determined in this study will help provide guidelines for minimally invasive surgical techniques for the treatment of leiomyomata.

Hysteroscopic cannulation for proximal tubal obstruction: a change for the better? *

OBJECTIVE To compare overall the results of hysteroscopic tubal cannulations and resection anastomosis for proximal tubal occlusion. DESIGN Nonrandomized retrospective analysis of patients operated on by two surgeons. SETTING University and large tertiary referral private practice. PATIENTS Seventy-four patients over a 10-year period, with bilateral or unilateral proximal occlusion of a single tube. INTERVENTIONS Hysteroscopic cannulation, resection anastomosis, or both. MAIN OUTCOME MEASURES Intrauterine and ectopic pregnancy rates, long-term tubal patency, and pathology of tubal segments. RESULTS In patients with normal distal tubes, intrauterine pregnancy rates were similar (12/21, 57% versus 12/24, 50%) and ectopic pregnancy rates were lower (0/21, 0% versus 7/24, 29.1%) in the cannulation group. One-year patency rates in nonpregnant patients was higher in the anastomosis group (12/15, 80% versus 3/8, 33%). CONCLUSIONS Hysteroscopic cannulation should be first choice in the management of proximal tubal obstructions in selected patients. It may be a treatment option for delayed occlusion after successful cannulation or resection anastomosis.

Duration of progesterone-in-oil support after in vitro fertilization and embryo transfer: A randomized, controlled trial

OBJECTIVE To determine the efficacy of a short P-in-oil protocol (11 days) in comparison with a traditional P-in-oil protocol (6 weeks) after IVF and embryo transfer. DESIGN Prospective randomized, controlled trial. SETTING Tertiary referral reproductive medicine unit. PATIENT(S) The first IVF-embryo transfer cycle of women<or=37 years old. INTERVENTION(S) Either the standard protocol, 50 mg of IM P-in-oil daily for 6 weeks (group 1) or the study protocol, 50 mg of IM P-in-oil daily for 11 days (group 2). MAIN OUTCOME MEASURE(S) Clinical pregnancy, ongoing pregnancy, and live birth rates. RESULT(S) One hundred one patients were enrolled (48 in group 1, 53 in group 2). Mean age (31.8 years vs. 32.7 years) and reasons for infertility were not different between the groups. Despite higher embryo quality in group 1 than in group 2 (60.3 vs. 51.6), clinical (63.0% vs. 62.7%) and ongoing (58.7% vs. 51.0%) pregnancy rates (PR) were not significantly different. Live birth rates (52.2% vs. 49.0%) were not significantly different. CONCLUSION(S) Pregnancy and live birth rates were not different between the two groups, suggesting that the common practice of lengthy (>or=6 weeks) P support of IVF pregnancies may be unnecessary.