[Penetrating keratoplasty with long-term cryopreserved corneas]

Since March 1986, the authors studied the simplified corneal cryopreservation technique with their "QL Bio-Freezer". After successful animal experiments, 34 patients (35 eyes) were performed penetrating keratoplasty with human cadaver corneas cryopreserved 9 to 473 days, averaging 108 days. After following-ups of 1 1/2 to 28 months, 22 of the corneal grafts remained clear, 6 semitransparent, and 7 cloudy. A total of 25 eyes had their visual acuity improved significantly. The results show that the cornea cryopreservation technique with the simplified "two-step" method is a noteworthy clinical practice.

Maternal serum levels of estradiol, progesterone and human chorionic gonadotropin in ectopic pregnancy and their correlation with endometrial histologic findings

Plasma levels of estradiol 17-beta (E2), progesterone (P) and beta-human chorionic gonadotropin (b-HCG) were measured in 59 patients with ectopic pregnancy and in control patients made up of ten women with normal intrauterine pregnancies and five patients with threatened abortion. The gestational ages of the three groups were not statistically different, the means being 6.6, 6.5 and 6.7 weeks, respectively. The endometria in the patients with an ectopic pregnancy were examined histologically and the correlation with the hormonal levels was studied. Mean levels of b-HCG, E2 and P in patients with ectopic pregnancies (4,893 +/- 5,435 S.E.M. milli-international units per milliliter, 311 +/- 191 S.E.M. picograms per milliliter and 8.3 +/- 5.5 S.E.M. nanograms per milliliters, respectively) were significantly lower than those measured in normal pregnant control patients (b-HCG = 22,173 +/- 2,696 S.E.M. microunits per milliliter, p less than 0.00001; E2 = 769 +/- 81 S.E.M. picograms per milliliter, p less than 0.0001 and p = 37.8 +/- 6.1 S.E.M. nanograms per milliliter, p less than 0.0001), and in patients with threatened abortion (b-HCG = 20,310 +/- 1,688 S.E.M. milli-international units per milliliter, p less than 0.0001; E2 = 803 +/- 91 S.E.M. picograms per milliliter, p less than 0.001 and P = 29.7 +/- 2.9 S.E.M. nanograms per milliliter, p less than 0.001). Mean levels of P in ectopic pregnancies with secretory type endometria (10.4 +/- 6.0 S.E.M. nanograms per milliliter), were significantly higher than those with proliferative endometria (5.0 +/- 3.2 S.E.M. nanograms per milliliter, p less than 0.001). Data is provided not previously known, on the levels of E2 and P in ectopic pregnancy and correlation with endometrial histologic factors.

[Hemihepatectomy under hepato-portal interruption at normal temperature for liver malignancies--a report of 20 patients]

From July 1984 to December 1985, hemihepatectomy was done in 20 liver cancer patients under normothermic interruption of porta hepatis. There were 19 primary and 1 secondary liver carcinomas. Of the former, 17 (89%) were associated with mild or moderate cirrhosis. The peak age ranged 36-60 years. Right hemihepatectomy was performed in 18 and left hemihepatectomy in 2 with an operative mortality of 0%. Hepatic failure or secondary bleeding was not found. In the specimens resected, the largest weight was 2,500 gm. The normothermic interruption of porta hepatis usually lasted 15-25 minutes, a time long enough for hemihepatectomy. This procedure, being simple in manipulation and less detrimental to physiologic and biochemical balance in the human body, is relatively practical and beneficial to hepatectomy.

Ectopic pregnancy following treatment with human gonadotropins

After treatment with human gonadotropins, 289 anovulatory women with apparently normal fallopian tubes became pregnant 379 times. Ten ectopic pregnancies in nine women were diagnosed, for an incidence of 2.7% of all conceptions. All the ectopic pregnancies were found in the fallopian tubes. Four patients had also an intrauterine pregnancy. Five of the patients showed ovarian overstimulation, and hormonal modifications at the time of ovulation might explain the high incidence of tubal gestation.

Neocept: a simple, sensitive urine test of early pregnancy in women undergoing ovulation induction

Fifty-five anovulatory women undergoing hMG-hCG treatment in order to become pregnant had daily first morning urine specimens and blood samples drawn, starting from the 11th postovulatory day. The urine was tested with Neocept and the blood with a radioreceptor assay or a radioimmunoassay for beta-subunits of hCG. Twenty-two of the women became pregnant. The pregnancies were detected by Neocept within a span of 12 to 19 days after ovulation. On the day of the first positive urine test, the mean serum concentration of the beta-subunit of hCG in 17 women was 103 +/- 10.1 (S.D.) mIU/ml (range, 39 to 200), and the mean serum level of 5 women tested by the radioreceptor assay was 206.5 +/- 6.5 mIU/ml (range, 170 to 220). Of 8 women with a positive urine test on day 15 or sooner, only 1 aborted, whereas 7 of the 14 women who were found thereafter to be positive aborted. None of the treated women who ovulated but did not conceive had a positive urine test. Of these women there were nine with a prolonged luteal phase (18 to 22 days).

Prevention of postoperative adhesions in rabbits with ibuprofen, a nonsteroidal anti-inflammatory agent

Twenty-six New Zealand White rabbits were randomly assigned to control or treated groups. In the treated group, the rabbits were medicated with either dexamethasone or ibuprofen. The injuries were made as standard as possible for each animal. The animals were killed 2 to 3 weeks postoperatively and the extent of adhesions was evaluated. Ibuprofen appeared to inhibit the formation of significant adhesions as compared with adhesion formation in untreated control animals, and the results seemed as effective as in the dexamethasone-treated animals. Further studies should be performed to substantiate these initial observations and to determine the most effective dosage. Ibuprofen may have a potential place in tubal surgery.

The use of human gonadotropins for the induction of ovulation in women with polycystic ovarian disease

During the years 1974 to 1977, a total of 77 treatment cycles of human menopausal gonadotropin (hMG)-human chorionic gonadotropin (hCG) were administered to 41 infertile patients with polycystic ovarian disease who failed to conceive on clomiphene. Twenty-seven patients (65.9%) conceived, two of them twice, making twenty-nine pregnancies. The abortion rate was 24.1% and the multiple pregnancy rate was 36.3%. Of the 77 treatment cycles, 7.8% were complicated by mild hyperstimulation and 3.9% by severe hyperstimulation. In six treatment cycles (7.8%), ovulation occurred spontaneously prior to the hCG injection. hMG-hCG is an additional safe and effective, nonsurgical treatment for women with polycystic ovarian disease who have failed to respond to clomiphene therapy. The reaction to exogenous gonadotropins is unpredictable and probably depends on the stage of follicular development prior to the stimulation. Therefore, daily estrogen determinations from the 1st day of treatment are mandatory in order to avoid hyperstimulation and/or multiple births.

Pregnancy following treatment with human gonadotropins in primary unexplained infertility

Six patients with primary unexplained infertility of 2 to 9 years duration, and who failed to conceive after repeated trials of clomiphene treatment, were treated with human gonadotropins; 3 of them became pregnant following one or two courses of treatment. Three patients failed to conceive in spite of 3 courses of human gonadotropins, 2 of them had high titers of sperm-agglutinating antibodies found in their sera, which may explain their infertility. None of the 13 treatments resulted in hyperstimulation syndrome or multiple births. This preliminary result seems encouraging but awaits further study.

Fetal contribution to oxytocin in human labor

Fetal oxytocin contribution to the mother during spontaneous labor was investigated using a specific and sensitive radioimmunoassay to measure oxytocin in blood, amniotic fluid, and urine. In 26 subjects with spontaneous labor and vaginal delivery (Group I) and 18 subjects with cesarean section after labor (Group II), umbilical arterial plasma (UA) oxytocin concentrations were significantly higher than umbilical venous plasma (UV) ocytocin concentrations. With elective cesarean section (Group III), UA oxytocin concentration was 29.8 +/- 7.5 pg/ml and UV oxytocin concentration was 16.1 +/- 5.9 pg/ml (n = 14). In contrast, the mean UV oxytocin concentration was higher than the mean UA oxytocin concentration, when oxytocin was given to the mothen concentration in Groups I and II was significantly higher than in Group III. Amniotic fluid oxytocin concentrations in Group I and II patients were higher than in Group III. Oxytocin was also present in fetal urine. The findings indicate that during spontaneous labor, oxytocin is produced by the fetus and flows toward the maternal circulation.

The two pools of pituitary gonadotropin: regulation during the menstrual cycle

Information on the relative activity and on the functional relationships between the acutely releasable (1st) and reserve (2nd) pools of pituitary LH during the course of the normal menstrual cycle was obtained via a 4 h LRF infusion (0.2 mug/min X 4 h). This was immediately followed by 3 pulses of LRF (10 mug at 2 h intervals) to assess further the size of the acutely releasable pool after activation of the reserve pool by the infusion. Our observations indicate that two functional pools of LH are present in all phases of the menstrual cycle and that comparative pool size or activity is influenced profoundly by ovarian steroid feedback as well as by the pattern of input of hypothalamic LRF. From the early to the late follicular phase, in synchrony with the rising levels of E2, the size of the 2nd pool is preferentially augmented. A small increase in the 1st pool activity is not apparent until the late follicular phase when a 5-fold increase in the size of the 2nd pool is also attained. During the mid-luteal phase and in association with relatively high progesterone (P) and E2, th large 2nd pool is maintained as in the late follicular phase but the 1st pool is strikingly smaller. Activation of the 2nd pool of LH by the LRF infusion (priming) increases the acutely releasable LH (1st pool) in all three phases of the cycle, as evidenced by an enhanced response to the 1st but not subsequent pulses of LRF at the end of the infusion as compared with non-infused controls. This priming effect is likely a reflection of activation or "shifting" of LH from the larger 2nd pool to the smaller 1st pool. It is found that this priming effect is greatest during the mid-luteal phase as compared to other phases of the cycle. During the days of mid-cycle LH surge, a dramatic reversal of the relative activity of the two pools in observed and this is manifested by an enormous increase in the activity of the 1st relative to the 2nd pool. In contrast to other phases of the cycle, the release of LH from the 2nd pool is not sustained and this premature decline in LH release despite continuous LRF infusion appears to be due to pituitary depletion of LH as evidenced by the failure of the pituitary response to pulses of LRF immediately following the infusion...

Assessments of the functional capacity of the gonadotrophs in men: effects of estrogen and clomiphene

Serum LH and FSH responses to serial injections of LRF with small (10 mug x 5), large (150 mug x 5), decremental (300 to 10 mug), and incremental (10 to 300 mug) doses at 2-hour intervals were assessed in eugonadal men. At constant doses, pulses of LRF induced pulsatile LH release which was qualitatively similar but quantitatively greater for the large than for the small dose of LRF. There were no periods of refractoriness or augmentation of subsequent responses from prior exposure to LRF when administered at 2-hour intervals. LH responses to incremental and decremental doses of LRF resulted in corresponding measurable changes in the magnitude of pituitary LH release. The FSH responses to pulses of LRF at all doses tested were uniformly small. These data suggest that analyses of the initial and integrated release (10 h experiment) to pulses of LRF may disclose the functional capacity of the gonadotrophs and that small variations in the endogenous LRF delivered may represent a significant factor in the control of LH release. The small dose (10 mug x 5) of pulses of LRF was utilized in the assessment of estrogen and clomiphene treatments on the functional capacity of the gonadotrophs in normal men. Compared with the pretreatment results, both constant doses of ethinyl estradiol (50 mug/day x 7 days) and incremental doses of estradiol benzoate (100 to 400 mug, twice daily injections x 4 d) induced an attenuation of the initial release as well as of the integrated response 10 h) to pulses of LRF. Clomiphene treatment (100 mg/day x 5 d), likewise, resulted in a reduction of gonadotropin release to all pulses of LRF. These data suggest that circulating estrogen in intact men may have both a negative and a positive feedback effect on the gonadotrophs and that the testicular estrogen secretion as well as the extraglandular sources of estrogen, may play a critical role in the regulations of gonadotropin secretion in man.

The functional changes of the pituitary gonadotrophs during the menstrual cycle

Submaximal doses of LRF, administered over a period of several hours, either by repeated pulses (10 mug at 2 h intervals X 5) or by constant infusion (0.2 mug/min X 4 h), have permitted the assessment of changes in the releasable gonadotropin during the menstrual cycle. Quantitations in the acute releasable and ultimately releasable gonadotropins were made which represent, respectively, the sensitivity and reserve of the gonadotrophs. The functional expression of these two components of gonadotropin release exhibited profound changes during the menstrual cycle and were in synchrony with the cyclicity of ovarian steroid levels; during the early follicular phase, both sensitivity and reserve were at a minimum, but with increasing levels of E2, a preferential increase in reserve over sensitivity (P less than 0.005) was found. Although both sensitivity and reserve increased dramatically near the midcycle, the relative change in these two components was reversed from the late follicular phase to the midcycle surge. The presence of this phenomenon may be causally related to the development of a self-priming effect of LRF at this time, as evidenced by an augmentation of gonadotropin release to the 2nd pulse of LRF. Thus, a build-up in pituitary store consequent to the greater increase in reserve than in sensitivity, together with the appearance of the self-priming effect of LRF induced by progressively rising levels of E2, may constitute the essential dynamics required for the development of the midcycle gonadotropin surge. Pituitary sensitivity and reserve continued to be high during the early luteal phase but reduced progressively thereafter. In all studied, FSH responses were less obvious but showed remarkable parallelism to the pattern of LH responses. We have concluded that the functional capacity of the gonadotrophs exhibits a remarkable cyclic change and that the adenohypophysis represents a critical feedback site in the development of pre-ovulatory gonadotropin surge.

Gonadotropin secretion in response to low and high doses of LRF in normal and hypogonadal women (functional disparity of the gonadotrophs)

A comparison was made of gonadotropin release after an iv bolus of large (150 mug) and small (10 mug) doses of LRF during various phases of the menstrual cycle and in primary hypogonadal women. Gonadotropin release was quantitatively similar to small and large doses of LRF in hypogonadal women with low estradiol levels. In contrast, normal women from the early to late follicular phase of the cycle, the gonadotropin response to a small dose of LRF (10 mug) was not as great as that observed with a large dose of LRF (150 mug) and did not elicit the augmented gonadotropin response of the late follicular phase. During the mid-luteal phase, a significant enhancement of responses to small doses of LRF was observed. The sustained gonadotropin release induced by the large dose of LRF in the late follicular phase was no longer apparent during the mid-luteal phase, although the dose-related discrimination of LH release was maintained. These dose-related disparities in the gonadotropin release to LRF might represent functional expressions of the two-pool dynamics of the gonadotrophs induced by ovarian steroids.

The effects of estrogen and progesterone on the functional capacity of the gonadotrophs

The functional capacity of the gonadotrophs under the influence of exogenous estrogen and progesterone was assessed by repeated stimulation with submaximal doses of LH-releasing factor (LRF) (10 mug at 2-h intervals) of subjects during the early follicular phase of the cycle and of hypogonadal women. The initial increment of peak serum LH and FSH concentrations after the first administration of LRF, was used to describe the pituitary sensitivity, and the integrated release during the 10 hours of LRF-stimulated pulses was utilized to approximate the pituitary gonadotropin reserve. During the early follicular phase, response to LRF stimulations was relatively stable with corresponding release of LH and FSH. An augmentation of sensitivity, as well as the reserve, for both LH and FSH was elicited by an incremental change in circulating estradiol levels, a change imposed by daily administration of estradiol benzoate for 4 days during the early follicular phase. Under the same conditions, the addition of progesterone (10 mg, im) at the end of the estradiol benzoate treatment induced a marked amplification of the estrogen-augmented pituitary gonadotropin sensitivity and reserve. The pituitary sensitivity, relatively higher than the reserve in hypogonadal subjects, was reversed by the administration of ethinyl estradiol (20-50 mug/day) for 7 days. These data indicate that the functional capacity of the gondotrophs is profoundly modulated by estrogen through relative changes in pituitary sensitivity and reserve, and that progesterone in low doses exhibited an amplifying effect on estrogen-primed gonadotrophs in both the pituitary sensitivity and the reserve.

The role of estrogen in the modulation of pituitary sensitivity of LRF (luteinizing hormone-releasing factor) in men

The role of estradiol in modulating pituitary gonadotropin release in the human male was studied by evaluating the effects of clomiphene on the pituitary gonadotropin response to synthetic LRF (150 mug) in 6 eugonadal men. Administration of clomiphene (100 mg single daily dose time 5 days) induced a significant elevation of the basal levels of LH, FSH, estradiol and testosterone. However, the pituitary release of LH and FSH in response to LRF was markedly diminished by the clomiphene treatment. This finding suggests that in men, as in women, endogenous estradiol provides feedback regulation of gonadotropin output by the pituitary.

Direct evidence of estrogen modulation of pituitary sensitivity to luteinizing hormone-releasing factor during the menstrual cycle

To delineate the role of estradiol in the augmented pituitary gonadotropin responsiveness to synthetic luteinizing hormone releasing factor (LRF) seen during high-estrogen phases of the ovulatory cycles (late follicular and midluteal phases), the anti-estrogenic effect of clomiphene citrate (Clomid) on pituitary response to LRF was evaluated during different phases of the ovulatory cycle. Clomid administration (100 mg/day times 5 days) completely negates the augmented gonadotropin responses to LRF (150 mug) during late follicular and midluteal phases observed during the control studies. Thus, a quantitatively and qualitatively similar pituitary sensitivity to LRF during three distinct phases of the menstrual cycle was induced by Clomid treatment that resembles the LRF responsiveness of themale pituitary. The present study demonstrates the pituitary component of the estrogen-induced changes in the sensitivity to LRF. From this and previous data, we conclude that the increases of estradiol secretion associated with the follicular maturation and corpus luteum formation represent a major component of the feedback signal in the modulation of cyclic gonadotropin release occasioned in a large measure by the augmented pituitary sensitivity to LRF.