Changes in volume, total protein and ovarian steroid concentrations of peritoneal fluid throughout the human menstrual cycle

Visualized peritoneal fluid variation in adolescents and young adults with endometriosis: is there more to it?

Background

Peritoneal fluid is a medium for endometriosis-associated biomarker discovery from which the local peritoneal environment and pathophysiologic pathways are often inferred. Therefore, we evaluated the associations between peritoneal fluid color and volume at time of endometriosis-related laparoscopic surgery with patient characteristics, endometriosis type and lesion location in adolescents and young adults with endometriosis.

Methods

We conducted a cross-sectional analysis among 545 patients undergoing surgery for endometriosis who enrolled in the Women's Health Study: from Adolescence to Adulthood cohort study. Patient characteristics, surgically visualized endometriosis phenotypes, and gross characteristics of peritoneal fluid were collected in compliance with World Endometriosis Research Foundation Endometriosis Phenome and Biobanking Harmonization Project (EPHect) tools. Chi-square or Fisher's exact tests were applied to test for differences across categories.

Results

Most of the patients were adolescents or young adults (86% age <25 years) of white race (89%), with only superficial peritoneal lesions and rASRM stage = I/II observed at surgery (both 95%). We observed variation in peritoneal fluid color across different menstrual cycle phases at time of surgery (p = 0.006). Among those who were cycling at time of surgery, endometriosis patients with red peritoneal fluid were most likely to be in the proliferative phase (49%) compared to the secretory phase (27%), while those with yellow or orange peritoneal fluid were most likely to be in the secretory phase (57% and 86% respectively). Yellow color was significantly less common in those taking combined oral contraceptives but much more common with progesterone only formulation exposure (p = 0.002). Peritoneal fluid volume did not differ by cycle phase but was more likely to be low (≤6 ml) for those exposed to hormones at time of surgery (p = 0.01). Those with acyclic pelvic pain were less likely to have red peritoneal fluid (p = 0.001) but had greater volume (p = 0.02) compared to those without.

Conclusion

Our findings highlight the importance of accounting for menstrual cycle phase and hormonal exposures when designing research using peritoneal fluid samples and inferring from biomarker results intended to advance our understanding of endometriosis and associated symptom pathophysiology.

Estrogen metabolites increase nociceptor hyperactivity in a mouse model of uterine pain

Pain emanating from the female reproductive tract is notoriously difficult to be treated and the prevalence of transient pelvic pain has been placed as high as 70-80% in women surveyed. Although sex hormones, especially estrogen, are thought to underlie enhanced pain perception in females, the underlying molecular and cellular mechanisms are not completely understood. Here we show that the pain-initiating TRPA1 channel is required for pain-related behaviors in a mouse model of estrogen-induced uterine pain in ovariectomized female mice. Surprisingly, 2- and 4-hydroxylated estrogen metabolites (HEMs) in the estrogen hydroxylation pathway, but not estrone, estradiol and 16-HEMs, directly increase nociceptor hyperactivity through TRPA1 and TRPV1 channels, and picomolar concentrations of 2- and 4-hydroxylation estrone (OHE1) can sensitize TRPA1 channel function. Moreover, both TRPA1 and TRPV1 are expressed in uterine-innervating primary nociceptors and their expressions are increased in the estrogen-induced uterine pain model. Importantly, pretreatment of 2- or 4-OHE1 recapitulates estrogen-induced uterine pain-like behaviors and intraplantar injections of 2- and 4-OHE1 directly produce a TRPA1-dependent mechanical hypersensitivity. Our findings demonstrate that TRPA1 is critically involved in estrogen-induced uterine pain-like behaviors, which may provide a potential drug target for treating female reproductive tract pain.

Progesterone Increases Mitochondria Membrane Potential in Non-human Primate Oocytes and Embryos

Mitochondrial activity is critical and correlates with embryo development. The identification of a novel human mitochondrial progesterone receptor (PR-M) that increases cellular respiration brings into question a role for progesterone in oocyte and preimplantation embryo development. Oocytes and embryos were generated from three Rhesus non-human primates (Macaca mulatta) undergoing in vitro fertilization. Immunohistochemical (IHC) staining for the progesterone receptor and mitochondria, RT-PCR with product sequencing for a mitochondrial progesterone receptor, and mitochondrial membrane determination with JC-1 staining were performed. IHC staining with selective antibodies to the progesterone receptor showed non-nuclear staining. Staining was absent in mouse control embryos. RT-PCR with product sequencing demonstrated PR-M transcript in Rhesus oocytes and embryos, which was absent in mouse embryos. Treatment of Rhesus oocytes and embryos with progesterone showed increased mitochondrial membrane potential, which was absent in mouse embryos. Our results support that progesterone increases mitochondrial membrane potential in oocytes and developing embryos. This is likely an in vivo mechanism to support preimplantation embryo development, and brings up the possibility of in vitro manipulation of culture media for optimization of growth.

Effect of sensor location on continuous intraperitoneal glucose sensing in an animal model

Background

In diabetes research, the development of the artificial pancreas has been a major topic since continuous glucose monitoring became available in the early 2000’s. A prerequisite for an artificial pancreas is fast and reliable glucose sensing. However, subcutaneous continuous glucose monitoring carries the disadvantage of slow dynamics. As an alternative, we explored continuous glucose sensing in the peritoneal space, and investigated potential spatial differences in glucose dynamics within the peritoneal cavity. As a secondary outcome, we compared the glucose dynamics in the peritoneal space to the subcutaneous tissue.

Material and methods

Eight-hour experiments were conducted on 12 anesthetised non-diabetic pigs. Four commercially available amperometric glucose sensors (FreeStyle Libre, Abbott Diabetes Care Ltd., Witney, UK) were inserted in four different locations of the peritoneal cavity and two sensors were inserted in the subcutaneous tissue. Meals were simulated by intravenous infusions of glucose, and frequent arterial blood and intraperitoneal fluid samples were collected for glucose reference.

Results

No significant differences were discovered in glucose dynamics between the four quadrants of the peritoneal cavity. The intraperitoneal sensors responded faster to the glucose excursions than the subcutaneous sensors, and the time delay was significantly smaller for the intraperitoneal sensors, but we did not find significant results when comparing the other dynamic parameters.

A healthy young woman with massive hemorrhagic ascites

Retrograde menstruation is the backward movement of menstrual fluids. The underlying mechanisms remain unknown. The converse current itself is benign, but the result can be abdominal pain caused by peritoneal irritation and, eventually, endometriosis. The case was of a 25-year-old woman with lower abdominal pain accompanied by significant hemoperitoneum. Physical examination and inspection using abdominal ultrasonography and computed tomography failed to reveal a differential diagnosis. Detailed history taking revealed sexual activities during her menstrual period, which allowed for a diagnosis of retrograde menstruation. These findings emphasize the importance of extensive history taking.

Control values of ovarian cancer tumor markers and standardisation of a protocol for sampling peritoneal fluid and performing washing during laparoscopy

BACKGROUND

Determination of the tumor marker concentration in peritoneal fluid (PF) may help to assess its potential to detect small concentration changes between benign ovarian pathology and early stage ovarian cancer. Peritoneal washing, which can also be obtained when PF is absent, is already included in the International Federation of Gynecology and Obstetrics (FIGO) staging classification for ovarian cancer but sampling has not yet been standardized. Since our aim was to evaluate the relationship between marker concentration in PF and washing, standardization of the sampling protocol was a prerequisite to ensure reliable results.

METHODS

Thirty-three women with non-malignant pathology of the reproductive organs were included in the study. We used three promising tumor markers for evaluation of the marker concentration in local fluid: osteopontin (sOPN), splice variant 6 of sCD44 (sCD44-v6) and vascular cell adhesion molecule-1 (sVCAM-1). After aspiration of PF, washing of the uterus, ovaries and pelvic peritoneum was performed with saline solution. Patients were divided into two groups based on the solution volume: A-20 ml and B-50 ml. To determine the efficiency of washing in relation to solution volume, washing was repeated three times. Concentrations of markers in samples were determined using flow cytometry.

RESULTS

Mean concentrations of markers were significantly higher (P <0.001) in PF than in the first washing. We demonstrated a significant positive correlation between marker concentrations in PF and first washing (sOPN: r = 0.447, P = 0.048; sCD44-v6: r = 0.660, P = 0.002; sVCAM-1: r = 0.526, P = 0.017). When using a smaller solution volume for washing, significantly higher (sVCAM-1: 2.5-fold, P = 0.021; sOPN: 3-fold, P = 0.024) or equal (sCD44-v6) mean concentrations of tumor markers were obtained.

CONCLUSIONS

Our work demonstrates for the first time that concentrations of sOPN, sCD44-v6 and sVCAM-1 in PF correlate with peritoneal washing in women with non-malignant pathology of the reproductive organs. This indicates that, for selected tumor markers, washing can replace PF when PF is absent. A standardized protocol for sampling PF and performing washing during laparoscopy was established.

Biochemical analysis of ascitic (peritoneal) fluid: what should we measure?

Ascitic fluid samples are frequently sent to the laboratory for analysis. Although the underlying cause of the ascites is often thought to be clinically obvious, it is important to establish a definitive diagnosis. The value of a cell count and bacterial culture of the ascitic fluid is not disputed, but the role of biochemical testing is less clear. The use of ascitic fluid total protein to try to classify ascitic fluids as either an exudate or a transudate has contributed to this. The use of the physiologically based serum ascites albumin gradient to differentiate ascites caused by portal hypertension from other causes provides a better diagnostic approach. We recommend that the serum ascites albumin gradient is performed by laboratories as the first-line test and that interpretative reports are provided. Additional testing should be restricted to specific diagnostic queries and requires close collaboration between the laboratory and the clinician.

Multiplexed quantitation of endogenous estrogens and estrogen metabolites in human peritoneal fluid

Endogenous estrogens and estrogen metabolites (EM) in human peritoneal fluid may play an important role in health and disease, yet little is known regarding their types and levels present in human peritoneal fluid, primarily due to the lack of an analytical method that is capable of directly quantifying their absolute abundances. In this report, we describe the application of a capillary LC-MS/MS method for identifying and quantifying biologically active and total endogenous EM in human peritoneal fluid. The method requires only 50 muL of peritoneal fluid, yet can quantify 13 distinct EM. Calibration curves for each EM were linear over a 10(3)-fold concentration range and the lower LOQ was 50 fg on-column. For a charcoal stripped human peritoneal fluid sample containing 10 pg/mL of each EM, accuracy ranged from 83 to 118%, and intrabatch precision ranged from 0.2 to 4.4% RSD and interbatch precision ranged from 5.5 to 15.5% RSD. The analyses of human female peritoneal fluid shows that at least 10 biologically active and 11 total endogenous EM can be positively identified and quantitatively measured. Many of the biologically active forms are present in high abundance and possess distinct biological activities which warrant further study. Although micellar EKC gave baseline separation of a standard mixture of 10 EM, the LOQs using UV detection were not suitable for the assay of the low level estrogens in biological samples.

Effect of ovarian involvement on peritoneal fluid cytokine concentrations in endometriosis patients

Peritoneal fluid cytokines are important for initiation and progression of endometriosis. The objective of this study was to compare a group of five cytokines (interleukins IL-1 beta, IL-6, IL-8, IL-13 and tumour necrosis factor alpha; TNFalpha) in peritoneal fluid of endometriosis patients with ovarian involvement (Group I, n = 17) to those in patients without ovarian involvement (Group II, n = 33) and to a reference group without endometriosis (Group III, n = 25). All three groups were comparable regarding age, parity and body mass index. IL-8 concentrations were significantly higher in groups I and II compared with the reference group (P = 0.01 and 0.02, respectively). Similarly, TNFalpha concentrations were significantly higher in groups I and II compared with the reference group (P < 0.0001 and 0.0004, respectively). All other cytokines were comparable in the three groups. No significant differences were found between groups I and II with respect to the cytokines measured. In conclusion, peritoneal fluid IL-8 and TNFalpha concentrations are significantly higher in endometriosis. Ovarian involvement does not alter the pattern of cytokines. It appears that the inflammatory mediators of endometriosis are similar with and without ovarian involvement.

Comparative concentrations of steroid hormones and proteins in human peri-ovulatory peritoneal and follicular fluids

Despite the fact that both peritoneal (PF) and follicular (FF) fluids have a common ovarian origin, FF is a natural inducer of sperm acrosome reaction (AR) while PF is not. To better understand these effects, concentrations of oestradiol, progesterone and proteins in peri-ovulatory PF and FF were determined and compared. PF was aspirated by laparoscopy at the peri-ovulatory stage from women with unexplained infertility. FF was collected from patients undergoing IVF and pooled. PF and FF were tested for the presence of antisperm antibodies. Oestradiol and progesterone were measured by enzyme immunoassay, and total protein concentration was determined and analysed. The AR was determined in spermatozoa that were exposed to PF alone, progesterone-supplemented PF, progesterone, control medium, or ethanol. No antisperm antibodies were found in any fluid tested. Oestradiol and progesterone and concentrations in PF were significantly lower than in FF. Protein concentration was also significantly lower in PF than in FF, but no differences were observed between the electrophoretic patterns. When capacitated spermatozoa were exposed to progesterone-supplemented PF there was a significant increase in the percentage of AR with respect to those in PF, control medium or ethanol. These results suggest that the lack of AR-stimulating activity of PF was related to its lower progesterone concentration compared with FF.

Laboratory testing for endometriosis

BACKGROUND

Typically, endometriosis is diagnosed surgically by laparoscopy. CA-125 is the principal serum marker used in the diagnosis and management of late-stage endometriosis. The search for a body fluid marker of early stage disease has included studies of serum, peritoneal fluid (PF), and/or tissue levels of secretory proteins, cell adhesion molecules, cytokines, tumor necrosis and vascular endothelial growth factors (VEGFs), chemokines, antiendometrial antibodies, autoantibodies to oxidized lipoproteins, aromatase P-450 expression, cytokeratins, and hormone receptors. We compared the diagnostic accuracy and clinical utility of these various types of substances in the non-surgical identification of patients with endometriosis.

METHOD

We reviewed the MEDLINE database for all publications on serum, peritoneal fluid and tissue markers of endometriosis.

RESULTS

Except for serum interleukin (IL)-6 and peritoneal fluid tumor necrosis factor (TNF)-alpha levels, the diagnostic accuracy of other markers of endometriosis was either similar or worse than that of CA-125 (sensitivity 24-94%; specificity 83-93%). The diagnostic accuracy of IL-6 and TNF-alpha was 90-100% (sensitivity) and 67-89% (specificity).

CONCLUSION

CA-125 has limited diagnostic accuracy in the identification of early stage endometriosis and none of the other markers we reviewed dramatically outperformed CA-125 in this regard with the possible exception of serum IL-6 and peritoneal fluid TNF-alpha levels.

Modulation of human sperm function by peritoneal fluid

OBJECTIVE

To examine the effect of peritoneal fluid on various parameters of sperm function in vitro.

DESIGN

Prospective study.

SETTING

Basic research laboratory.

PATIENT(S)

Semen samples were obtained from normozoospermic volunteers (n = 43). Peritoneal fluids were aspirated laparoscopically from women with unexplained infertility (n = 14). Follicular fluid and oocytes were collected from patients undergoing IVF-ET.

INTERVENTION(S)

Sperm incubated under capacitating conditions were exposed to peritoneal fluid, and functional variables were evaluated in vitro.

MAIN OUTCOME MEASURE(S)

Sperm viability and motility, follicular fluid and calcium ionophore-induced acrosome reactions, protein tyrosine phosphorylation, expression of D-mannose binding sites, and ability of sperm to interact with zona pellucida.

RESULT(S)

Exposure of sperm to peritoneal fluid for up to 6 hours did not affect sperm viability or motility. Unlike follicular fluid, peritoneal fluid did not induce the acrosome reaction. Moreover, incubation of sperm with > or =20% v/v peritoneal fluid for 1 hour prevented the follicular fluid and the ionophore-induced acrosome reaction. Although treatment with peritoneal fluid allowed protein tyrosine phosphorylation during capacitation, it resulted in a significant decrease in the expression of D-mannose binding sites and sperm-zona pellucida binding.

CONCLUSION(S)

Peritoneal fluid maintains sperm survival and decreases sperm ability to respond to inducers of the acrosome reaction and bind to the zona pellucida in vitro, indicating that this fluid might modulate sperm function in vivo.

Peritoneal secretion of ovarian hormones and its consequences

Secretion of ovarian hormones directly into the peritoneal cavity has been repeatedly demonstrated for 25 years, but the consequences of this pathway of secretion have not been fully considered. Circumstantial evidence suggests the following hypotheses: (1) Hormones enter the endometrial cavity through the tubes and influence the endometrial cycle. (2) Androgens are absorbed into the portal venous system and are inactivated in the liver. (3) In polycystic ovary syndrome, ovarian cortical fibrosis inhibits peritoneal secretion of androgens and contributes to hyperandrogenemia. (4) Bypass of the ovarian vein by peritoneal secretion leads to underestimation of ovarian hormone production rates. (5) Peritoneally secreted hormones are absorbed into the broad ligaments of the uterus and returned to the reproductive organs by veno-arterial countercurrent transfer. Some approaches to testing the hypotheses are outlined. If any of the hypotheses are supported by more direct evidence, some aspects of reproductive endocrinology will turn out be even more complicated than they have seemed.

Ascites as a predictor of ovarian malignancy

OBJECTIVE

To determine the utility of ascites as a predictor of ovarian malignancy and define its relationship with the histologic type of ovarian tumor (benign, borderline, or malignant) and stage of disease.

METHODS

This retrospective cohort study analyzed the clinical and pathological finding of 125 patients from two institutions treated for a pelvic mass. Preoperative data to include: physical examination, imaging studies (USD, CT, or MRI), and operative reports were reviewed for evidence of ascites. This was correlated with final pathologic findings and stage of disease. Collected data were summarized with descriptive statistics. Further statistical analysis was performed using Pearson's chi(2), cross tabulation, and the Median Test. Data were analyzed with SPSS 6.1 for Windows.

RESULTS

One-hundred twenty-five patients were evaluable for this study. The ovarian pathologic findings were as follows: 57 benign (45%), 12 borderline (10%), and 56 malignant (45%). Fifty-three patients (42%) had frank ascites at laparotomy. Seventy-two patients (58%) had no ascites. All patients with ascites diagnosed preoperatively (n = 41) on physical examination or imaging studies were confirmed intraoperatively. Absence of ascites was correctly diagnosed preoperatively in 72/84 patients (86%). Of the 57 benign tumors, only 5 patients (9%) had small amounts of peritoneal effusion. Of the 12 borderline tumors, 7 patients (58%) had ascites. Of the 56 malignant tumors, 41 (73%) had ascites. Using presence or absence of ascites on clinical assessment as the predictor variable and benign or malignant (borderline and invasive histopathology) tumors as the outcome variable, the positive predictive value (PPV) of ascites to detect ovarian malignancy was 95% and the negative predictive value (NPV) was 64%. When borderline tumors were excluded, the PPV and NPV of ascites to detect malignant invasive tumors were 95 and 73%, respectively. Furthermore, a progressive relationship between stage of ovarian malignancy and percentage of cases with ascites was identified. Ovarian malignancies in the early stages (I and II) produced ascites only in 17% of the cases. In advanced stages (III and IV), 89% produced ascites. In addition, for stage I and II disease, all patients possessed <0.5 liters of ascites at surgery, whereas the majority of patients (66%) with stage III and IV disease had >0.5 liters.

CONCLUSIONS

Our findings indicate the presence of ascites on preoperative physical examination or imaging study is highly predictive of ovarian malignancy in women with a pelvic mass. The absence of ascites may not always predict benign disease since nearly half of borderline tumors and 83% of early stage malignant ovarian tumors do not produce ascites. A progressive relationship between stage of malignancy and incidence as well as volume of ascites was also observed.

Prolactin receptor in human endometriotic tissues

BACKGROUND

Augmented serum prolactin (PRL) levels have been implicated as a cause for infertility in patients with endometriosis. However, it has not been established whether this lactogenic hormone or its receptor (PRLR) have specific effects on the development of human endometriosis. In the present study we assessed PRLR expression in human endometriotic and normal tissue.

METHODS

Fourteen patients with laparoscopically proven endometriosis were recruited and the negative or positive expression of the PRLR in normal endometrial and endometriotic tissues obtained during the mid-late proliferative phase of the menstrual cycle was evaluated by RT-PCR. Evaluation of serum prolactin, and peritoneal fluid estradiol content were carried out by specific radioimmunoassays (RIA).

RESULTS

In endometriotic tissue samples the corresponding 1048 bp PRLR transcript was negative in 12/14 of the samples (86%) and positive in two samples (14%). The opposite was seen in normal tissue, since PRLR expression was positive in 11/14 samples (79%) and negative in the remaining three samples (21%). There was an association between serum prolactin concentrations and PRLR expression in normal tissue but not in endometriotic tissue.

CONCLUSIONS

The PRLR is expressed in normal endometrium, while cells of the endometriotic tissues did not express the PRLR, at least during the mid-late proliferative phase of the menstrual cycle. The absence of the PRLR in the endometriotic tissues could not be correlated with the serum prolactin levels. These results suggest the existence of differential regulation of PRLR expression between normal and endometriotic tissue.

Role of cytokines in endometriosis

OBJECTIVE

To review the literature on the role of cytokines in the pathogenesis of endometriosis and endometriosis-associated infertility.

DESIGN

Pertinent studies were identified by a computer search of MEDLINE. References of selected articles were hand-searched for additional citations.

RESULT(S)

Recent studies suggest that the peritoneal fluid of women with endometriosis contains an increased number of activated macrophages that secrete various local products, such as growth factors and cytokines. Levels of several cytokines were reported to be elevated in the peritoneal fluid of women with endometriosis. Because the peritoneal environment may be controlled by locally regulated factors, cytokines are believed to play a role in the development and progression of endometriosis and endometriosis-associated infertility. A possible pathogenic mechanism links cytokines with endometriosis.

CONCLUSION(S)

Cytokines, which are produced by many cell types including endometriotic tissues, play diverse roles in the pathogenesis of endometriosis and endometriosis-associated infertility. More studies about the specific role of these cells and soluble factors are needed to improve understanding of endometriosis and to develop novel therapies.

Pelvic inflammation induced by diagnostic laparoscopy in baboons

OBJECTIVE

To test the hypothesis that diagnostic laparoscopy can cause pelviperitoneal inflammation.

DESIGN

Retrospective analysis of data collected during a prospective controlled study in baboons.

SETTING

An academic research environment.

ANIMAL(S)

Samples were collected during laparoscopies in female baboons at the Institute of Primate Research, Kenya.

INTERVENTION(S)

In the first part of the study, 44 laparoscopies were performed in 16 baboons (5 with a normal pelvis, 11 with endometriosis) during the luteal phase, with a time interval of 1 month. In the second part of the study, 53 laparoscopies were performed in 15 baboons (6 with a normal pelvis, 9 with endometriosis) during the late follicular and luteal phases of one cycle, with a median time of 3-4 days between each laparoscopy.

MAIN OUTCOME MEASURE(S)

Peritoneal fluid (PF) was measured and analyzed for white blood cell (WBC) concentrations and, in the second part of the study, for the distribution of lymphocyte subsets (CD3, CD4, CD8, and CD20) and for the presence of cytokines transforming growth factor-beta1, interleukin (IL)-6, and IL-10.

RESULT(S)

In the first part of the study, PF volumes and WBC concentrations were comparable at the baseline and follow-up laparoscopies. In the second part of the study, PF obtained at the second laparoscopy showed a 10-fold increase in volume, a 3-fold increase in WBC concentration, a 10-fold increase in IL-6 concentration, and a 2-fold increase in transforming growth factor-beta1 concentration when compared with PF obtained at the first laparoscopy. The PF subset of granulocytes and CD3-positive cells was higher and the PF subset of macrophages was lower at follow-up laparoscopies than at the baseline laparoscopy.

CONCLUSION(S)

Diagnostic laparoscopy can cause peritoneal inflammation in baboons.

Lymphatic system of the mouse diaphragm: morphology and function of the lymphatic sieve

BACKGROUND

The diaphragm has a unique system that collects peritoneal fluid and carries it into the lymphatic system. However, our understanding of the morphology and function of this system is still incomplete.

METHODS

Twelve C57BL/6 mice of 13 to 25 weeks of age were used without regard to sex. In one series of experiments, the diaphragm was isolated and fixed 10-15 minutes after injection of india ink into the peritoneal cavity and then the peritoneal mesothelium was peeled off from the submesothelial connective tissue. The lymphatic vessels attached to the mesothelial strip were examined by scanning electron microscopy. The diaphragm was also observed in plastic-embedded semithin and ultrathin sections. In another series of experiments, the diaphragm was stained by 5'-nucleotidase histochemistry (Wachstein and Meizel, 1957a. Am. J. Clin. Pathol., 27:13-23), and several microdrops of india ink were placed on the peritoneal or pleural surface to reveal the profile of the lymphatic vessels.

RESULTS

The lymphatic vessels on the peritoneal side of the diaphragm were flattened. They usually ranged from several to 100 microns in width and from close to zero to a few micrometers in thickness. In other words, they formed extremely flat lumina, differing from the more usual tubular lymphatic vessels. Several lymphatic vessels extended radially and parallel to one another from the central tendon to the thoracic wall, with numerous connecting branches, forming an area of lymphatic vessels. The india ink that had been injected intraperitoneally and the staining with 5'-nucleotidase revealed that there were seven to nine such lymphatic areas in one hemisphere of the diaphragm. The lymphatic areas spread in parallel with the peritoneal surface of the diaphragm and all the areas together appeared to occupy more than half the surface area of the sternocostal part of the diaphragm. Each area was a relatively distinct functional unit with respect to the draining of india ink. Microdrops of india ink placed on the pleural surface did not enter the lymphatic vessels, while those placed on the peritoneal surface immediately entered the peritoneal lymphatic vessels and migrated to the pleural lymphatic vessels via the transmuscular lymphatic branches.

CONCLUSIONS

The peritoneal lymphatic vessels of the diaphragm have extremely flat lumina that spread in parallel with the peritoneal surface of the diaphragm and form a lymphatic sieve that covers approximately half or more of the surface area of the sternocostal region for drainage of fluid and particulate matter from the peritoneal cavity. The lymphatic system has been characterized by the presence of openings (= stomata) to the peritoneal cavity and the amplitude of the lumina (= lacunae). However, the fundamental characteristic of the system is the extremely flat lumen (= vadum), which facilitates the formation of the lymphatic sieve.

Increased angiotensin II in ascites during severe ovarian hyperstimulation syndrome: role of early pregnancy and ovarian gonadotropin stimulation

OBJECTIVE

To investigate the implications of the ovarian renin-angiotensin system (RAS) in the pathophysiology of the ovarian hyperstimulation syndrome (OHSS) in relation to gonadotropin stimulation and early pregnancy.

DESIGN

A controlled clinical study comparing blood and simultaneously sampled peritoneal fluid (PF) from patients with severe OHSS and from controls without OHSS.

SETTING

University Hospitals.

PATIENT(S)

Eleven patients with severe OHSS, 8 patients with ascites of other origin, 9 patients with a first-trimester pregnancy, and 15 patients stimulated with gonadotropins for IVF.

MAIN OUTCOME MEASURE(S)

Angiotensin II immunoreactivity was measured in blood and PF and analyzed by high-performance liquid chromatography (HPLC) in ascites from OHSS.

RESULT(S)

Angiotensin II immunoreactivity (pg/mL; mean +/- SE) was highest in the ascites from pregnant OHSS (1,669 +/- 418), reaching levels 5 times higher than in the plasma (331 +/- 61) and 100 times higher than in control ascites (17 +/- 6.7). Angiotensin II immunoreactivity was elevated in the PF during early pregnancy (211 +/- 68) and after gonadotropin stimulation (244 +/- 41) and was higher than in the plasma in both groups. Analysis by HPLC showed that the majority of Ang II immunoreactivity in the ascites of OHSS was because of true Ang II.

CONCLUSION(S)

Severe forms of OHSS, especially those associated with pregnancy, are consistently characterized by huge concentrations of Ang II immunoreactivity in the ascites, proved to be true Ang II by HPLC analysis. This may be due to the synergistic effects of exogenous and endogenous hCG on the ovarian RAS.

Low intraovarian vascular resistance: a marker for severe ovarian hyperstimulation syndrome

OBJECTIVE

To assess intraovarian blood flow in relation to the severity of ovarian hyperstimulation syndrome (OHSS) after controlled ovarian hyperstimulation.

DESIGN

A prospective study.

SETTING

Monash IVF, Clayton, Victoria, Australia.

PATIENT(S)

Thirty patients with OHSS after embryo or gamete transfer who also had sonographic evidence of ascites.

MAIN OUTCOME MEASURE(S)

The resistance to blood flow within the ovaries of 11 patients with severe OHSS and 19 patients with mild OHSS was measured by using transabdominal ultrasonography with color flow and pulsed Doppler imaging.

RESULT(S)

The pulsatility index (PI), resistance index (RI), and the S-D ratio, all measures of downstream vascular impedance, were significantly lower in those patients with severe OHSS. In cases with RI < 0.48, more than two thirds of the patients had a pleural effusion, whereas patients with either PI < 0.75 or S-D < 1.92 had pleural effusion in over one half of the cases. It was notable that blood flow velocity did not differ significantly between the two groups despite the changes in vascular impedance.

CONCLUSION(S)

There appears to be a close correlation between the severity of OHSS and the resistance to blood flow within the stimulated ovaries. Measurement of intraovarian vascular resistance before gamete transfer or ET in patients undergoing controlled ovarian hyperstimulation may help in predicting those patients at particular risk of developing severe OHSS.

A unique case of massive ascites before ovulation associated with gonadotropin therapy

OBJECTIVE

To describe a unique case of massive ascites associated with gonadotropin therapy.

DESIGN

Case report.

SETTING

Patient in a hospital-based private IVF center.

INTERVENTION(S)

Ovulation induction with gonadotropins for subsequent IVF.

RESULT(S)

Ovulation induction with gonadotropins resulted in the accumulation, before ovulation, of 1,200 and 2,000 mL of peritoneal fluid in two consecutive cycles. The stimulation yielded four and six oocytes, respectively.

CONCLUSION(S)

Gonadotropin therapy can result in ascites before ovulation without an exaggerated ovarian response and without interfering with follicular development.

Human intraperitoneal fibrinolytic response to elective surgery

Intra-abdominal adhesions develop in over 90 per cent of patients undergoing laparotomy. Peritoneal fibrinolysis is believed to be important in the pathophysiology of adhesion formation. This study investigated the fibrinolytic response of postoperative peritoneal fluid in 12 patients undergoing elective laparotomy. There was a significant reduction in the plasminogen activating activity to undetectable levels at 24 h, which was sustained at 48 h (P < 0.05). While there was an early reduction in the concentration of tissue plasminogen activator (median 40.0, 28.2, 16.3 and 31.9 ng/ml at 2, 6, 24 and 48 h respectively; P < 0.05), the abolition of functional fibrinolytic activity appeared to be secondary to a marked increase in the concentration of plasminogen activator inhibitor (PAI) 1 (median 86, 196, 800 and 730 ng/ml at 2, 6, 24 and 48 h respectively; P < 0.05) and PAI-2 (median less than 6, 12, 155 and 245 ng/ml at 2, 6, 24 and 48 h respectively; P < 0.05). This reduction in the plasminogen activating activity of peritoneal fluid may favour the formation of permanent fibrous adhesions following surgery.

Peritoneal fluid volume and steroid hormone concentrations in baboons with and without either spontaneous minimal/mild endometriosis or the luteinized unruptured follicle syndrome

This study was performed to document for the first time peritoneal fluid volumes and steroid hormone levels in baboons with and without endometriosis. A laparoscopy was carried out in 19 female baboons (11 with a normal pelvis and 8 with histologically proven spontaneous minimal/mild endometriosis) during 64 cycles in the early luteal phase. Peritoneal fluid was measured and aspirated. The pelvis was examined for evidence of recent ovulation and endometriosis. Peritoneal fluid and serum were assayed for 17 beta-estradiol and progesterone. The mean volume of peritoneal fluid and its concentration of 17 beta-estradiol and progesterone were 2.6 ml, 679 pmol/l and 64 nmol/l, respectively. No differences were observed between animals with or without either endometriosis or luteinized unruptured follicle syndrome. The peritoneal fluid and serum steroid levels were comparable to those found in women. The results presented are similar to those obtained in women with endometriosis and this suggests that the baboon can be used for the study of this disease.

Fertility and sexual and gynecologic function after ileal pouch-anal anastomosis

PURPOSE

This study was designed to determine the incidence of infertility, gynecologic problems, and sexual dysfunction after ileal pouch-anal anastomosis (IPAA).

METHODS

A questionnaire was sent to 206 females who underwent pouch surgery at a single institution from 1980 through 1991. Response rate was 53 percent (110/206). The computerized registry of the 206 females undergoing IPAA at this institution was reviewed to add additional data.

RESULTS

Mean age at pouch construction was 32 (range, 14-61) years. Mean time from pouch surgery to survey was 49 (range, 1-132) months. Fifty-seven females had 119 children before pouch surgery, and 23 children were born to 19 females after IPAA (5 vaginal deliveries, 18 Cesarean sections). Eighteen females experienced infertility after IPAA. Thirty patients had persistent dyspareunia. Pelvic cysts developed in 15 patients; 11 patients required surgery.

CONCLUSIONS

Although childbirth appears safe, gynecologic problems, such as dyspareunia and formation of pelvic cysts, may be underestimated after IPAA. The effects of IPAA on fertility are still unknown.

Mid to late luteal phase steroids in minimal stage endometriosis and unexplained infertility

Serum and peritoneal fluid concentrations of progesterone and 17 beta-oestradiol were measured during days 20-27 of the luteal phase in 33 women with minimal stage endometriosis and 21 with unexplained infertility. The results were analysed using Student's t-test and straight line regression analysis. In both groups, 17 beta-oestradiol and progesterone values were several-fold higher than the corresponding serum values and there were significant correlations between the peritoneal fluid and the serum steroid values. In the peritoneal fluid there was a significant reduction in both progesterone and its ratio with 17 beta-oestradiol in women with minimal stage endometriosis (P < 0.03, P < 0.04, respectively). The peritoneal fluid levels of 17 beta-oestradiol in women with minimal stage endometriosis were, however, not significantly altered. Despite the correlations between peritoneal fluid and serum steroid levels, there were no significant changes in the serum concentrations of progesterone, 17 beta-oestradiol or the ratio of progesterone to 17 beta-oestradiol in women with minimal stage endometriosis. It is concluded that luteal phase progesterone and its relationship to 17 beta-oestradiol are subtly altered in infertile women with minimal stage endometriosis compared with women with unexplained infertility. These alterations may be more clearly demonstrated in peritoneal fluid rather than in peripheral blood, possibly because the latter contains steroids which are of non-ovarian origin and are also constantly affected by the liver enzyme activity and enterohepatic circulation of individual subjects.

A mid-luteal phase comparison of peritoneal fluid volume and its content of PGF2 alpha and PGE2 in women with minimal stage endometriosis and a normal pelvis

The study was carried out following the approval of our Hospital Ethics Committee and an informed patient consent. Samples of peritoneal fluid were collected from the Pouch of Douglas at laparoscopy from 32 subjects with minimal stage endometriosis (MSE) and 16 without any visible signs of endometriosis (normal group). All the subjects were in 20 to 23 day period of their menstrual cycle which was histologically confirmed. The endometriosis score was estimated according to the American Fertility Score, 1985 and the fluid samples were collected in tubes containing heparin/indomethacin and standing in ice. The samples were estimated for volume, erythrocyte count, prostaglandin(PG) F2 alpha, and PGE2. Radioimmunoassay techniques were used for the estimation of PGs. Prostaglandin F2 alpha, was measured in its parent form while PGE2 was converted into bicyclic-PGE2 before estimation. The results indicate that the peritoneal fluid in women with MSE has higher than normal levels of PGF2 alpha and lower than normal levels of PGE2 and its PGE2: PGF2 alpha ratio is also below normal. There is no difference in the volume of peritoneal fluid in the two groups. Provided the fluid sample is not contaminated with abdominal blood its erythrocyte count is not related to its prostaglandin content.

The ascites in the ovarian hyperstimulation syndrome does not originate from the ovary

OBJECTIVE

To evaluate the direct ovarian contribution to ascites formation in the ovarian hyperstimulation syndrome (OHSS) in a rabbit model.

DESIGN

Prospective experimental study.

SETTING

Research center of a university teaching hospital.

PARTICIPANTS

New Zealand White rabbits.

INTERVENTIONS

Both ovaries of the rabbits in the experimental group were enclosed within a pouch developed from the surrounding peritoneum and mesosalpinx by microsurgery. Animals in the control group did not undergo any surgical intervention. Ovarian hyperstimulation was induced by alternate day equine chorionic gonadotropin and intermittent human chorionic gonadotropin (hCG).

MAIN OUTCOME MEASURES

Degree of ascites formation and the morphological and endocrinologic signs of ovarian hyperstimulation.

RESULTS

The serial plasma estradiol and progesterone levels, ovarian weights, and ascites response were not statistically different between the two groups.

CONCLUSIONS

Isolation of both ovaries from the peritoneal cavity does not prevent ascites formation in the OHSS. Increased transudation across extraovarian serosal surfaces contributes to ascites formation in OHSS.

Influence of peritoneal fluid from spontaneous and stimulated cycles on sperm motility in vitro

Peritoneal fluids (PFs) from spontaneous (n = 14) and gonadotrophin-stimulated cycles (n = 20) were obtained during diagnostic laparoscopy and gamete intrafallopian transfer (GIFT) procedures, respectively. The effects of these fluids on the linear component of sperm motility and on the percentage of motile spermatozoa were studied in vitro by objective motility assessments and compared to a control medium (B2-Ménézo). Overall, the two types of PFs were found to have rather similar effects on the motility parameters studied. However, the fluids from hormonally-stimulated cycles sustained motility better (i.e., sperm velocity and percentage of motile sperm) and in a rather constant manner as a function of time (narrower range distributions of the motility measurements). Furthermore, it was observed that under identical experimental conditions motility measurements depended not only on the type of PF used but also on the sperm sample. These results suggest that assisted reproduction procedures in which PF is the medium where the gametes eventually meet and interact, such as direct peritoneal insemination (DIPI) or peritoneal oocyte and sperm transfer (POST), could have different success rates if performed in spontaneous rather than in stimulated cycles. At the same time, our results may help to explain why different pregnancy rates were reported in different studies using DIP or POST.

Detection of free peritoneal fluid by transvaginal sonography

The recognition of peritoneal fluid is of considerable clinical importance; however, the sensitivity of modern techniques for the detection of this finding has not been determined. The purpose of this study was to assess the utility of transvaginal sonography for the detection of free peritoneal fluid. Nineteen infertile women scheduled to undergo diagnostic laparoscopy were scanned with a 5-MHz transvaginal probe just before the surgical procedure. Peritoneal fluid was then aspirated laparoscopically, and the volume and location was compared to the sonographic findings. The volume of fluid obtained at laparoscopy ranged from 0 mL to 45 mL (median 8 mL). All patients with fluid volumes > or = 0.8 mL had free fluid identified sonographically. The location of fluid observed sonographically corresponded to that noted at laparoscopy in all cases. Free peritoneal fluid was visualized in 8 (73%) of 11 patients with regular menstrual cycles who were in the follicular phase at the time of the study. We conclude that transvaginal sonography is a sensitive and reliable method for the detection of free peritoneal fluid in anatomically normal women. This finding should not necessarily be considered abnormal, at least in women of reproductive age, nor should it be considered diagnostic of oocyte release.

Expression of interleukin-1 (IL-1) beta messenger ribonucleic acid (mRNA) and IL-1 receptor antagonist mRNA in peritoneal macrophages from patients with endometriosis

OBJECTIVE

To investigate the expression of interleukin-1 (IL-1) beta messenger ribonucleic acid (mRNA) and IL-1 receptor antagonist (IL-1ra) mRNA in peritoneal macrophages.

DESIGN, SETTING

Peritoneal fluid (PF) samples were collected from patients who underwent laparoscopy or laparotomy. Northern blot analysis was performed at the reproductive research laboratory.

PATIENTS

Twenty-six patients with endometriosis, 10 patients with postinflammatory pelvic adhesion, and 12 control women with normal pelvis.

MAIN OUTCOME MEASURE

Polyadenylated RNA isolated from peritoneal macrophages was analyzed on Northern blots by using synthetic oligonucleotide probes.

RESULTS

The level of IL-1 beta mRNA expression was elevated in the group with stage I endometriosis, whereas the increased expression of IL-1ra mRNA was observed in the group with stages III and IV endometriosis. The level of IL-1 beta mRNA showed a positive correlation with that of IL-1 beta in PF and a negative correlation with the level of IL-1ra mRNA.

CONCLUSIONS

Our results suggest that peritoneal macrophages express IL-1ra mRNA rather than IL-1 beta mRNA with the progress of endometriosis and that peritoneal macrophages may secrete IL-1ra protein that modulates the effects of IL-1.

High CA-125 concentrations in peritoneal fluid of normal cyclic women with various infertility-related factors as demonstrated with two-step immunoradiometric assay

OBJECTIVE

To determine CA-125 concentrations and total amounts in peritoneal fluid (PF) of women with various infertility-related factors throughout the menstrual cycle.

DESIGN

Peritoneal fluid was obtained at laparoscopy. CA-125 was determined using the assessed two-step immunoradiometric assay (IRMA) which, in contrast to the one-step IRMA, gives valid results.

SETTING

University Hospital Nijmegen, Nijmegen, The Netherlands.

PATIENTS

One hundred six infertile women with a regular and ovulatory cycle were included.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

The mean PF CA-125 concentration and total amount were significantly lower during the luteal phase as compared with other phases of the menstrual cycle. No correlation was found with the presence or absence of endometriosis, adhesions, a male and/or cervical mucus infertility factor, and with patent or closed fallopian tubes.

RESULTS

Peritoneal fluid CA-125 concentrations varied from 630 to 12,000 arbitrary units/mL (mean +/- SD = 3,437 +/- 2,286). Total PF CA-125 amounts (concentration x PF volume) varied from 1,760 to 13,300 arbitrary units (mean +/- SD = 30,219 +/- 26,841).

CONCLUSIONS

CA-125 secretion into the abdominal cavity varies during the menstrual cycle. Retrograde menstruation is not the main source of CA-125 in PF.

Peritoneal fluid interleukin-1 beta and tumor necrosis factor in patients with benign gynecologic disease

The levels of interleukin 1 beta (IL-1 beta) and tumor necrosis factor (TNF) in peritoneal fluid (PF-IL-1 beta and PF-TNF) and production of IL-1 beta and TNF by peritoneal macrophages were determined in patients with benign gynecologic disease. The level of PF-IL-1 beta was elevated in the acute pelvic inflammatory disease (PID) and stages I and II endometriosis (E I/II) groups compared with the normal pelvis group, but not in the myoma of the uterus, ovarian cyst, and postinflammatory pelvic adhesion groups. The level of PF-TNF was elevated in the PID, EI/II and stages III and IV endometriosis (EIII/IV) groups. There was no correlation between the levels of PF-IL-1 beta and PF-TNF. Neither the level of PF-IL-1 beta nor that of PF-TNF was correlated with the concentration of peritoneal macrophages. Peritoneal macrophages produced IL-1 beta and TNF in vitro in the absence of stimulants. The levels of PF-IL-1 beta and PF-TNF are presumably linked to the activation of peritoneal macrophages.

Retrograde seeding of endometrial epithelial cells by uterine-tubal flushing

OBJECTIVE

To estimate the amount of endometrial epithelial cells in peritoneal fluid (PF) after uterine-tubal flushing (40 mL) throughout the menstrual cycle.

DESIGN

We cultured the cell pellet of flush medium present in the peritoneal cavity.

SETTING

University Hospital Nijmegen, The Netherlands.

PATIENTS

Ninety-two women with various infertility-related factors.

INCLUSION CRITERIA

(1) ovulatory cycle, (2) patent tubes, and (3) no adhesions.

INTERVENTIONS

None

MAIN OUTCOME MEASURE(S)

The number of developing epithelial cell colonies were counted after 7 days. We started to record the amount of flush medium recovered during the study.

RESULTS

The amount of flush medium recovered was positively correlated with the presence of endometriosis (P = 0.017). Endometrial epithelial cells were identified in 85 flush media (92%). The number of epithelial cell colonies varied from 0 to 100 or more and was higher when flushing was performed during the early follicular phase (P less than 0.01). High estradiol-17 beta and progesterone levels in culture medium did not change the number of developing cell colonies. Methylene blue significantly reduced the number of cell colonies (P = 0.002).

CONCLUSIONS

Uterine-tubal flushing results in varying numbers of endometrial epithelial cells in PF. Methylene blue adversely affects the growth potential of these cells.

The origin of estrogens, progesterone, androgens and sex hormone binding globulin in peritoneal fluid in the immediate postovulatory period in normal ovulating women

In 20 women with proven fertility, one menstrual cycle was monitored by ovarian ultrasonography, laparoscopy and estimation of 17 beta-estradiol (E2), estrone (E1), progesterone, testosterone, androstenedione (Adion), dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), and sex hormone binding globulin (SHBG) in serum and peritoneal fluid. Three groups were studied, in which the peritoneal fluid was collected within 1, 3 and 5 days after ovulation. E1, E2 and progesterone levels in peritoneal fluid were highest shortly after ovulation and decreased with time. Testosterone and Adion in peritoneal fluid showed no changes, but peritoneal fluid levels were always higher than serum levels. No differences were found between the peritoneal fluid and serum levels of DHEA and DHEAS. SHBG in serum was always higher than in peritoneal fluid. The results are compared with reported steroid levels in follicular fluid from the literature and factors complicating the interpretation of steroid levels in peritoneal fluid are discussed.

Peritoneal fluid volume and sex steroids in the pre-ovulatory period in mild endometriosis

Twenty infertile women with laparoscopically confirmed mild endometriosis and ten women with tubal infertility underwent diagnostic laparoscopy 32 h after the onset of the endogenous luteinizing hormone (LH) surge during a spontaneous menstrual cycle. All visible peritoneal fluid was aspirated for assessment of volume and sex steroid content. There was no significant difference in peritoneal fluid volume or concentrations of oestradiol, progesterone and androstenedione between the two groups. Furthermore, in the endometriosis group there was no significant difference in peritoneal fluid volume and concentrations of sex steroids between those women who had been treated previously with danazol and those who were left untreated.

The pathogenesis of the ovarian hyperstimulation syndrome (OHS): a possible role for ovarian renin

Two patients with severe ovarian hyperstimulation syndrome are described. Increased plasma concentrations of immunoradiometrically determined total renin are shown, together with greatly increased plasma levels of active renin and aldosterone. These very high values for total renin, renin activity and aldosterone were not suppressed when extracellular compartments were greatly expanded; the values subsequently declined to normal levels, despite the use of diuretics. This suggested that the renin was of non-renal origin since its production was apparently unaffected by influences which control juxtaglomerular secretion. The high concentrations of the renin-angiotensin-aldosterone system suggest that it contributes to the genesis of the ovarian hyperstimulation syndrome.

Elevated peritoneal fluid luteinizing hormone and prolactin concentrations in infertile women with endometriosis

In this study, we compared (Mann-Whitney U-test) the peritoneal fluid FSH, LH and PRL levels, measured by RIA, at the follicular and luteal phases of the menstrual cycle in women with (n = 43; age 25-44 years) and with no evidence of endometriosis (n = 35; age 25-39 years) who were considered as controls. Both follicular and luteal phase FSH concentrations of women with endometriosis were not statistically different (n = 22 vs 18; 0.32-5.8 vs 0.50-8.2 IU/l, P = 0.247; n = 13 vs 14; 0.6-6.5 vs 0.66-6.7 IU/l, P = 0.604) compared to their respective controls. In contrast to FSH, the concentrations of LH at follicular (n = 19 vs 17; 3.1-34.2 vs 2.3-12.2 IU/l, P = 0.01) and luteal (n = 17 vs 15; 2.1-95.4 vs 1.3-17.9 IU/l, P = 0.02) phases of the test group was significantly elevated at both phases of the cycle. With respect to differences in PRL concentrations at follicular phase no significant change (n = 21 vs 16; 1030-5800 vs 1305-4650 mIU/l; P = 0.255) was observed. The greatest difference in luteal PRL concentrations (P = 0.007) was obtained between the women with endometriosis and controls (n = 17 vs 17; 1895-8600 vs 1041-5000 mIU/l). The results suggest that disordered synchronization of neuroendocrine mechanisms controlling LH and PRL may be the underlying abnormality causing infertility in our group of patients with endometriosis.

Diagnostic paracentesis. A potent clinical tool

Diagnostic paracentesis is a potent diagnostic tool capable of rapidly detecting portal hypertension and peritonitis. Gram's stain and chemical analysis of ascitic fluid add additional information by determining the predisposition to SBP, the presence of organisms, and the severity of peritonitis. In patients with a narrow A-GRAD, the chemical analysis, cell count and differential, and cytology will add direction for the work-up if the etiology is not apparent and confirmation if it is. This information should be available within a few hours of admission if the paracentesis and blood are obtained immediately. The results should optimize patient care and minimize costs.

Reduction of the intraperitoneal inflammation associated with endometriosis by treatment with medroxyprogesterone acetate

An intraperitoneal inflammatory exudate has been repeatedly observed in infertile women without mechanical compromise of the pelvic viscera, particularly with endometriosis. This is manifested by increases in the peritoneal fluid volume, leukocyte number, and proteolytic enzyme concentrations. We tested the hypothesis that the stimulus responsible for eliciting this intraperitoneal inflammation is retrograde menstruation by measuring the peritoneal fluid volume and leukocyte count in 16 infertile women with endometriosis before and after ovulation suppression with medroxyprogesterone acetate, 30 mg/day for 4 months. Medroxyprogesterone acetate therapy significantly reduced the peritoneal fluid volume (22.5 +/- 4.1 versus 6.8 +/- 0.9 ml mean +/- SE, p less than 0.0001), the peritoneal fluid leukocyte count (30.7 +/- 6.5 versus 7.1 +/- 0.7 x 10(6) cells per patient, p less than 0.0001), and American Fertility Society score (23.2 +/- 5.1 versus 15.4 +/- 4.1, p less than 0.0002). We conclude that medroxyprogesterone acetate treatment reduces the intraperitoneal exudate associated with endometriosis. These results support the contention that the stimulus eliciting the intraperitoneal inflammation in infertile women with endometriosis is retrograde menstruation.