Thomas A. Klein

The value of serum antimicrosomal antibody testing in screening for symptomatic postpartum thyroid dysfunction

We investigated the value of a screening program for postpartum thyroiditis in a heterogeneous American population and used serum antithyroid antibodies to identify postpartum women at risk. Blood was drawn from 1034 consecutive women on their second postpartum day and tested for antimicrosomal and antithyroglobulin antibodies by hemagglutination. Seventy-two women (7.0%) were seropositive for antimicrosomal antibodies, but only seven (0.7%) had antithyroglobulin antibodies. There was a significant difference in the racial prevalence of antimicrosomal antibodies, with seropositivity in 52 of 588 white women (8.8%) versus nine of 367 black women (2.5%; p less than 0.001). Thirty-four of 51 (67%) antimicrosomal seropositive women followed at least 6 months post partum developed biochemical thyroid dysfunction and 20 of these patients required treatment for hypothyroidism. The mean (+/- SEM) serum thyroxine and thyrotropin levels in these patients before treatment were 3.0 +/- 0.3 micrograms/dl (normal 6.1 to 12.3 micrograms/dl) and 77 +/- 17 mU/L (normal 0.3 to 4.0 mU/L), respectively. Psychologic interviews revealed a significant increase in impaired concentration, carelessness, depression, and total complaints when patients with postpartum hypothyroidism were compared with postpartum euthyroid women. Medical evidence now suggests that postpartum thyroiditis is a common event and causes significant symptoms in women who develop hypothyroidism. Therefore, we propose that serum antimicrosomal antibody testing of postpartum women provides a feasible cost-effective screening method of identifying women likely to suffer from this disease.

The predictive value of hysterosalpingography for tubal and peritoneal infertility factors

OBJECTIVE To investigate a practical classification system of hysterosalpingogram (HSG) results that accurately identifies patients with severe pelvic disease or a normal pelvis to allow appropriate patient counseling of therapeutic options. DESIGN Retrospective chart review from university teaching hospital. Hysterosalpingography results were classified as normal, abnormal (bilateral distal tubal obstruction), or suspicious (all others). At surgery, chromopertubation was performed, and pelvic disease was documented. RESULTS From a total of 756 patients, HSGs were confirmed surgically in 96.6% of normals, 63.1% of suspicious, and 95.7% of abnormal. Associated moderate-severe pelvic disease was found in 16.2% of normals, 53.9% of suspicious, and 81.7% of abnormal. CONCLUSION Abnormal HSGs are highly predictive of severe pelvic disease, and counseling of treatment options does not require diagnostic laparoscopy. Patients with suspicious HSGs frequently have normal tubes but also have a significant likelihood of tubal or associated pelvic disease, and they are responsible for the poor predictive value of the HSG. This group of patients requires confirmatory laparoscopy preferably by a physician qualified in pelviscopic surgery. Normal HSGs have a high negative predictive value. Nevertheless, the incidence of associated pelvic disease in the normal HSG group is high enough to warrant diagnostic laparoscopy if nonsurgical treatment is unsuccessful.

Hysteroscopic cannulation and lavage in the treatment of proximal tubal occlusion

In two patients with apparent PTO, as diagnosed by HSG and laparoscopy, tubal patency was restored by hysteroscopic cannulation of the tubal ostia, followed by direct lavage. Tubal resection and reanastomosis/reimplantation may not be necessary for all patients with apparent PTO.

Natural killer cell activity from pregnant subjects is modulated by RU 486

Natural killer cells form an integral component of the bodys innate immune system. Natural killer cell activity is reduced during pregnancy, especially in the latter half. To investigate the role progesterone may play in immunomodulating natural killer cell activity during pregnancy, we evaluated the effect of RU 486 on natural killer cells isolated from pregnant subjects. Natural killer cell activity was measured with an 18-hour, Chromium 51 release, microcytotoxicity assay with K-562 cells as target cells. We demonstrated that RU 486, in a concentration range from 5 to 40 mumol/L, augmented natural killer activity threefold to fivefold over baseline. This augmentation of activity was suppressed to baseline by the addition of excess progesterone. The addition of hydrocortisone resulted in an insignificant reduction in this augmented activity. This study suggests that progesterone may play a role as an immunomodulating factor in maternal acceptance of the fetal allograft.

Changes in maternal serum total and free androgen levels in early pregnancy: Lack of correlation with fetal sex

The fetal testis actively produces androgens during early gestation. To determine whether this fetal production of androgens might be reflected by levels of androgens in maternal serum, which might then be a useful test for antenatal fetal sex determination, we measured serum testosterone (total and free) and serum dihydrotestosterone in 83 pregnant women whose fetuses ranged from 4 to 20 weeks in age. For no maternal serum androgen measured was there a significant difference between women carrying a male fetus and those carrying a female fetus, even when this comparison was limited to various 4-week subintervals or fetal age. Total serum testosterone correlated directly with fetal age (r = 0.341, p less than 0.005), but serum dihydrotestosterone did not (r = 0.146, p = NS). Inverse correlations with fetal age were observed for percentage free testosterone (r = -0.531, p less than 0.001) as well as absolute serum free testosterone (r = -0.349, p less than 0.005). We conclude that maternal serum androgen levels are not useful for antenatal fetal sex determination in early pregnancy. The reason for the progressive fall in serum free testosterone, and presumably androgen production, during early gestation remains obscure.

Androgen metabolism by human peritoneal macrophages

Peritoneal macrophages (PM) were obtained by peritoneal dialysis from a regularly menstruating woman with renal failure. Macrophages (10(6) cells) were incubated at 37 degrees C for various periods of time (0-4 hr) in the presence of 14C-androstenedione or 3H-androstenedione and various concentrations (0.06-5.06 microM) of nonradiolabeled androstenedione (A). Testosterone (T) formed was purified by column chromatography, thin layer chromatography, acetylation, and recrystalization to constant 3H:14C ratios. The rate of formation of T from A was linear for nearly 2 hr. Conversion of A to T was linear at cell numbers in the incubation up to 1 x 10(6). The formation of T from A followed Michaelis-Menten kinetics at concentrations of A between 0.06 and 5.06 microM. The apparent Km of the enzyme for A was 0.75 microM and the Vmax for T formation from A in these cells was 33.9 pmol x hr-1 x 10(6) cells-1. PM were obtained also from normal patients (n = 6) and patients with endometriosis (n = 5). The rate of T synthesis from A in PM obtained from patients with endometriosis [527 +/- 263 pmol x hr-1 x 10(6) cells-1 (mean +/- SEM, n = 5)] was similar to that observed in PM obtained from normal patients [518 +/- 226 pmol x hr-1 x 10(6) cells-1 (mean +/- SEM, n = 6)]. We observed a near 30-fold variation in the rate of formation of T from A by PM obtained from different individuals (range 54 to 1580 pmol x hr-1 x 10(6) cells-1). Further study is needed to elucidate the physiologic significance of PM androgen metabolism and its relationship to reproductive function.

The effect of a surgical lubricant on in vivo sperm penetration of cervical mucus

The implications of these data is that coital lubricants may impair fertility of some couples. Unfortunately, conception was not an end point on this study, and our conclusions must be considered inferential. Nevertheless, the results from this study lead us to recommend avoidance of surgical lubricants by couples attempting pregnancy.

Natural Killer Cell Activity in Early Human Pregnancy

Natural killer (NK) cell activity was determined in 41 women during the first trimester of pregnancy. NK cytotoxicity was similar between the study subjects and nonpregnant controls and was not a reflection of a change in the circulating number of cells or density in culture. Although NK cells may play a role in maternal immune status in advanced pregnancy, NK cells do not appear to be crucially involved in the first trimester, when reproductive wastage usually occurs.

Tubal and peritoneal factors in the infertile woman: use of patient history in selection of diagnostic and therapeutic surgical procedures

For facilities with both ambulatory and inpatient surgical capabilities, we have attempted to develop an efficient strategy for the evaluation of infertile women. The strategy was intended to (1) avoid inpatient laparoscopy, (2) minimize the number of patients having laparoscopy who subsequently required laparotomy, and (3) minimize hysterosalpingography (HSG). Patients were selected for ambulatory laparoscopy or inpatient laparotomy by means of an algorithm based on their history and the selective use of HSG. Laparoscopy was avoided in 18.1% of patients and HSG in 41.6% of patients. We conclude that, when both inpatient and outpatient surgical facilities are available, the evaluation of female infertility may not always require HSG or laparoscopy.

The role of laparoscopy in the evaluation of candidates for sterilization reversait

An algorithm that avoids preliminary laparoscopy for sterilization reversal (SR) candidates with previous Pomeroy, loop, Hulka clip, Irving, and single-burn cautery tubal ligation techniques was used. Anastomosis was attempted only when it could be anticipated that the final length of at least one tube would be 3 cm or more. Of 259 SR candidates evaluated according to the algorithm, 235 had SR procedures. Seven of 185 patients (3.8%) who did not undergo laparoscopy were found to have inoperable tubes at laparotomy. Four of these patients had histories of a prior unilateral salpingectomy. The authors conclude that, given their criteria for proceeding with tubal anastomosis, laparoscopy can be avoided in properly selected SR candidates. The results also indicate that patients with a history of unilateral salpingectomy should undergo preliminary laparoscopy.