William W. Hurd

Size of the urogenital hiatus in the levator ani muscles in normal women and women with pelvic organ prolapse.

Objective Compare urogenital hiatus size in normal women and women with pelvic organ prolapse. Methods The sagittal and transverse urogenital hiatus diameters were measured and hiatus area calculated in 300 women whose support was scored using a modified Baden system. Results In women with normal support and without prior surgery, hiatus area was 5.4 cm2 (± 1.71 standard deviation [SD], n = 197). In women with uncorrected clinical prolapse (grade 2–3), the area of the hiatus was enlarged (9.6 cm2 ± 3.97, n = 34, P < .05) and became larger with progressive prolapse (grade 0, 5.4 cm2 ± 1.71, n = 197; grade 1, 7.3 cm2 ± 1.91, n = 27; grade 2, 8.3 cm2 ± 2.45, n = 18; grade 3,11.0 cm2 ± 4.90, n = 16). When matched for age and parity, prolapse patients had a larger hiatus than normal women. Women with recurrent prolapse had a larger hiatus than cured women (13.3 cm2 ± 3.86 n = 8 compared with 8.1 cm2 ± 2.44 n = 16 P < .05) or women with recurrence after one operation (8.9 cm2 ± 1.77 n = 18 P < .05). Hiatus size in patients surgically cured (8.3 cm2 ± 2.44. n = 16) did not return to normal (5.4 cm2 ± 1.71, n = 197, P < .05). Increasing area of the hiatus was correlated with an increase in anteriorposterior diameter (r2 = 0.9, P < .05), was less attributable to increased transverse diameter (r2 = 0.6, P < .05), and was not related to thickness of the perineal body (r2 = 0.0, P > .05). Conclusion Increasing pelvic organ prolapse is associated with increasing urogenital hiatus size; the hiatus is larger after several failed operations than after successful surgery or single failure.

Gonadotropin-releasing hormone analog cotreatment for preservation of ovarian function during gonadotoxic chemotherapy: a systematic review and meta-analysis.

OBJECTIVE To determine whether gonadotropin-releasing hormone (GnRH) analog cotreatment with chemotherapy provides better reproductive outcomes for women at risk of premature ovarian failure (POF) as a side-effect of gonadotoxic chemotherapy. DESIGN Systematic review and meta-analysis. SETTING University-affiliated research centers. PATIENT(S) None. INTERVENTION(S) Electronic and manual searches (e.g., MEDLINE, EMBASE, CENTRAL) up to January 2010 were performed to identify randomized controlled trials (RCTs) comparing GnRH cotreatment with chemotherapy alone in premenopausal women. MAIN OUTCOME MEASURE(S) Incidence of POF after treatment, incidence of women with resumption of ovulation, POF after an initial normal cycle, normal cycles but abnormal markers of ovarian reserve, spontaneous occurrence of pregnancy after treatment, and time to reestablishment of menstruation; data also extracted to allow for an intention-to-treat analysis. RESULT(S) Twenty-eight RCTs were identified, but only six met the inclusion criteria. Data were only available for the incidence of women with new onset of POF, resumption of ovulation, and occurrence of pregnancy. The incidence of POF or resumption of ovulation both demonstrated a statistically significant difference in favor of the GnRH cotreatment. The occurrence of spontaneous pregnancy showed no statistically significant difference between GnRH cotreatment and the control groups. CONCLUSION(S) Evidence from RCTs suggests a potential benefit of GnRH cotreatment with chemotherapy in premenopausal women, with higher rates of spontaneous resumption of menses and ovulation but not improvement in pregnancy rates. Data relating to study quality and possible bias for the majority of the outcomes in this review were not available, denoting possible selective reporting of trial data.

Progesterone Receptor-A and -B Have Opposite Effects on Proinflammatory Gene Expression in Human Myometrial Cells: Implications for Progesterone Actions in Human Pregnancy and Parturition

CONTEXT Progesterone promotes uterine relaxation during pregnancy and its withdrawal induces labor. Progesterone withdrawal in human parturition is mediated in part by changes in the relative levels of the nuclear progesterone receptor isoforms, PR-A and PR-B, in myometrial cells. Parturition also involves myometrial inflammation; however, the functional link between nuclear PR-mediated progesterone actions and inflammation in human myometrial cells is unclear. OBJECTIVE Our objective was to determine how PR-A and PR-B regulate progesterone action in human myometrial cells and specifically the expression of genes encoding contraction-associated proteins and proinflammatory mediators. DESIGN Effects of PR-A and PR-B on the capacity for progesterone to modulate gene expression was determined using an immortalized human myometrial cell line stably transfected with inducible PR-A and PR-B expression transgenes and conditioned to express various PR-A and PR-B levels. Gene expression was assessed by genome wide transcriptome analysis, quantitative RT-PCR and immunoblotting. RESULTS PR-A and PR-B were each transcriptionally active in response to progesterone and affected the expression of distinct gene cohorts. The capacity for progesterone to affect gene expression was dependent on the PR-A to PR-B ratio. This was especially apparent for the expression of proinflammatory genes. Progesterone decreased proinflammatory gene expression when the PR-A to PR-B ratio favored PR-B and increased proinflammatory gene expression when the ratio favored PR-A. Progesterone via PR-B increased expression of inhibitor-κBα, a repressor of the nuclear factor-κB transcription factor, and inhibited basal and lipopolysaccharide-induced proinflammatory gene expression. Both of those PR-B-mediated effects were inhibited by PR-A. CONCLUSIONS Our data suggest that during most of human pregnancy, when myometrial cells are PR-B dominant, progesterone promotes myometrial quiescence through PR-B-mediated antiinflammatory actions. At parturition, the rise in PR-A expression promotes labor by inhibiting the antiinflammatory actions of PR-B and stimulating proinflammatory gene expression in response to progesterone.

Electroejaculation and assisted reproductive technologies in the treatment of anejaculatory infertility

OBJECTIVE To determine the efficacy of electroejaculation in combination with assisted reproductive technology (ART). DESIGN Case series. SETTING University fertility program. PATIENT(S) One hundred twenty-one consecutive couples seeking treatment of anejaculatory infertility. INTERVENTION(S) Electroejaculation with IUI, or gamete intrafallopian transfer or IVF. MAIN OUTCOME MEASURE(S) Pregnancy and pregnancy outcome. RESULT(S) Fifty-two couples became pregnant (43%), 39 by IUI alone (32.2%). Cycle fecundity for IUI was 8.7%. No difference in cycle fecundity was seen among ovarian stimulation protocols (clomiphene citrate, 7.6%, hMG, 13.2%, and natural cycle, 11.2%). Pregnancy was unlikely when the inseminated motile sperm count was <4 million. Female management protocol and etiology of anejaculation did not affect results. Patients undergoing IVF had higher cycle fecundity (37.2%) than did those undergoing IUI. The rates of spontaneous abortion and multiple gestations were 23% and 12%, respectively. CONCLUSION(S) Electroejaculation with stepwise application of ART is effective in treating anejaculatory infertility. Intrauterine insemination with the least expensive monitoring protocol should be used for most couples, because use of more expensive monitoring did not improve results. It is cost-effective to bypass IUI and proceed directly to IVF in men who require anesthesia for electroejaculation and in those with a total inseminated motile sperm count < 4 million.

Laparoscopic injury of abdominal wall blood vessels: A report of three cases

Background:Operative laparoscopy is being used for an increasing number of applications. Many of these innovative techniques require the insertion of large trocars through the anterior abdominal wall at points lateral to the midline. Because of the rich vascular supply of the anterior abdominal wall

Complications associated with optical-access laparoscopic trocars

OBJECTIVE To investigate the number and type of serious complications associated with optical‐access trocars reported by sources other than the medical literature. METHODS Optical‐access trocars, first introduced in 1994, were designed to decrease the risk of injury to intra‐abdominal structures by allowing the surgeon to visualize abdominal wall layers during placement. To date, very few complications with their use have been reported in the medical literature. MEDLINE, the Food and Drug Administrations Medical Device Reporting, and the Manufacturer and User Facility Device Experience databases were searched for reports of complications occurring during the use of optical‐access trocars for laparoscopic access. RESULTS Only two serious complications resulting from the use of optical‐access trocars (vena cava injuries) have been reported in the medical literature. However, 79 serious complications using these techniques have been cited in the Medical Device Reporting and Manufacturer and User Facility Device Experience databases since 1994. These include 37 major vascular injuries involving aorta, vena cava, or iliac vessels, 18 bowel perforations, 20 cases of significant bleeding from other sites, three liver lacerations, and one stomach perforation. Four of these complications resulted in patient deaths. CONCLUSION Optical‐access trocars may be associated with significant injuries despite having the ability to visualize tissue layers during insertion.

Criteria that indicate endometriosis is the cause of chronic pelvic pain

Chronic pelvic pain and endometriosis remain two of the most perplexing problems in gynecology. In some women with both conditions, endometriosis might not be the cause of their pain. The problem is determining when the pain is caused by endometriosis. On the basis of clinical studies, I suggest three criteria that should be met before attributing chronic pelvic pain to endometriosis. First, the pelvic pain should be cyclic because endometriosis is a hormonally responsive disease. Second, endometriosis should be diagnosed surgically to avoid overdiagnosing this condition. Finally, medical or surgical treatment of endometriosis should result in prolonged pain relief. Application of these evidence-based criteria reminds us that endometriosis often can be asymptomatic, even in some women with chronic pelvic pain. These criteria might help gynecologists determine the women for whom surgical therapy will resolve the pain; however, only prospective evaluation can determine their ultimate usefulness.

The location of abdominal wall blood vessels in relationship to abdominal landmarks apparent at laparoscopy

OBJECTIVE Our purpose was to evaluate the location of the major blood vessels of the abdominal wall relative to landmarks apparent at laparoscopy. STUDY DESIGN Abdominal computed tomographic images of 21 reproductive-aged women at an academic center were retrospectively reviewed to determine the location of the inferior epigastric, superficial epigastric, and superficial circumflex iliac arteries and the lateral rectus muscle margins in relation to the symphysis pubis, the umbilicus, and the abdominal midline. These locations were correlated with each other and with body mass index using Pearsons correlation coefficient. RESULTS Above the symphysis the inferior and superficial epigastric arteries were 5.6 +/- 1.0 cm (mean +/- SD) and 5.5 +/- 2.0 cm from the midline, respectively. Although the location of these two vessels correlated (r = 0.6, p = 0.02), the mean difference in their location was 1.4 +/- 1.1 cm. Near the level of the umbilicus the superficial epigastric and circumflex iliac arteries and the lateral rectus muscle margin were 4.6 +/- 1.4 cm, 10.7 +/- 1.7 cm, and 7.6 +/- 1.5 from the midline, respectively. Only the lateral rectus muscle margin correlated with body mass index (r = 0.65, p = 0.004). CONCLUSION When laparoscopic landmarks are not visible to guide placement, lateral trocars should be placed approximately 8 cm from the midline and at least 5 cm above the symphysis to minimize the risk of vessel injury.

Comparison of intracervical, intrauterine, and intratubal techniques for donor insemination *

OBJECTIVE To compare the efficacy of intracervical insemination (ICI), intrauterine insemination (IUI), and a combination of intratubal and intrauterine insemination (ITI/IUI) for donor insemination. DESIGN Prospective randomized clinical trial. SETTING The University of Michigan donor insemination program. PATIENTS, PARTICIPANTS Forty-one women undergoing donor insemination with cryopreserved sperm for either isolated male factor or male factor plus ovulatory dysfunction corrected by clomiphene citrate. INTERVENTION Each patient was randomly assigned to receive each of the three insemination techniques in consecutive cycles until pregnancy occurred or the patient dropped from the study. MAIN OUTCOME MEASURES Cycle fecundity rates were compared using the chi 2 test, and cumulative pregnancy rates (PRs) determined by life table analysis were compared using a log-rank test. RESULTS Cycle fecundity rate was significantly higher for IUI (18.3%) than for ICI (3.9%) or ITI/IUI (7.3%). By life table analysis, the cumulative PR for IUI was significantly higher than for ICI, but the PR for ITI/IUI was not. CONCLUSION For donor insemination with cryopreserved sperm, IUI increases cycle fecundity compared with ICI. The addition of ITI to IUI, however, interferes with the apparent beneficial effect of IUI alone.

The role of irrigation in the development of hypothermia during laparoscopic surgery

OBJECTIVES Our purpose was to determine the incidence and etiology of hypothermia during laparoscopic surgery and to evaluate the role of irrigation fluid temperature. STUDY DESIGN A prospective randomized study was performed of 35 women undergoing operative laparoscopy under general anesthesia who received surgical irrigation fluid either at ambient temperature or warmed to 39 degrees C. The core body temperature was determined with use of both an esophageal sensor and a tympanic membrane sensor and was expressed as the change from baseline. Additional data collected included age, height, weight, amount of irrigation fluid and intravenous fluid used, room temperature, length of anesthesia, and amount of carbon dioxide used for pneumoperitoneum. RESULTS Hypothermia occurred in 94% of all patients, with no difference in incidence between the groups. The minimal core temperature was lower in the ambient temperature group (-1.7 degrees +/- 0.2 degrees C) than in the warmed fluid group (-1.0 degrees +/- 0.2 degrees C). Of the variables measured, length of anesthesia and the amount of ambient temperature fluid alone explained the drop in core temperature. CONCLUSION Hypothermia is extremely common in laparoscopic surgery and is related to the length of anesthesia and the use of ambient temperature irrigation fluid. The use of warmed irrigation fluid can decrease, but not eliminate, this drop in core temperature.