Follicle Stimulating Hormone (FSH) as a Predictor of Decreased Oocyte Yield in Patients with Normal Anti-Müllerian Hormone (AMH) and Antral Follicle Count (AFC)

Background

The purpose of the current study was to determine the utility of early follicular phase follicle-stimulating hormone (FSH) testing in patients undergoing in vitro fertilization (IVF).

Methods

This was a retrospective review of patients from 2012 to 2015 at Mayo Clinic in Rochester, Minnesota, USA. Included subjects had a normal anti-Müllerian hormone (AMH) of 1 to 9 ng/ml and antral follicle count (AFC) of 10 to 29. Patients were stratified by FSH level when associated estradiol was less than 50 ng/ml. In total, 225 patients were categorized into three groups: high FSH (FSH ≥10 IU/L; n= 36), normal FSH (>5 IU/L and <10 IU/L; n=170), and low FSH (FSH ≤5 IU/L; n= 19). ANOVA and multiple logistic regression were used for statistical comparisons and for evaluation of the relationships between variables; significance level was set at <0.05.

Results

There were no significant differences in demographics, IVF cycle type, or peak estradiol level between the groups. Patients with a high basal FSH level had a similar clinical pregnancy rate and live birth rate compared to controls and patients with low FSH. High FSH level was associated with decreased follicular development (17 versus 22; p<0.01), oocyte yield (15 versus 18; p=0.02), and embryo yield (8 versus 10; p=0.04) despite higher total doses of gonadotropins.

Conclusion

Patients with normal AMH and AFC levels could be further stratified into lower responders and starting doses of medications can be adjusted based on high basal FSH levels. Therefore, it is suggested to counsel patients on pregnancy outcomes which seem to be quite similar regardless of the FSH level.

O-136 Once-daily relugolix combination therapy results in sustained reduction in symptoms and improved quality of life in women with uterine fibroids treated over 52 weeks

Study question

What is the effect of relugolix combination therapy (Relugolix-CT) on symptom burden and health-related quality-of-life (HR-QoL) in patients with uterine fibroids (UF) over 52 weeks?

Summary answer

Relugolix-CT demonstrated sustained, clinically meaningful improvement in patient-reported symptom severity and HR-QoL over 52 weeks in women with UF.

What is known already

In LIBERTY 1 and 2 randomized clinical trials, once-daily Relugolix-CT (40 mg relugolix, an oral gonadotropin-releasing hormone receptor antagonist, estradiol 1 mg, norethindrone acetate 0.5 mg) significantly reduced menstrual blood loss (MBL) and UF-associated pain versus placebo in women with UF and heavy menstrual bleeding (HMB), and was well tolerated, with bone mineral density (BMD) preservation through 24 weeks. In the LIBERTY long-term extension study, a sustained reduction in MBL was observed along with no new safety signals and BMD maintenance through 52 weeks. Relugolix-CT was previously shown to significantly improve patient-reported symptom severity and HR-QoL through 24 weeks.

Study design, size, duration

In the LIBERTY 1 and 2 studies, 770 premenopausal women with ultrasound-documented clinically significant UF and alkaline-hematin documented HMB were randomized 1:1:1 to Relugolix-CT for 24 weeks, relugolix 40 mg for 12 weeks followed by Relugolix-CT for 12 weeks, or placebo for 24 weeks. Women who completed the pivotal studies were eligible to enroll in the 28-week extension study (N = 477 enrolled). Patients included in the extension study received open-label once-daily Relugolix-CT.

Participants/materials, setting, methods

Changes from baseline to Weeks 24 and 52 in the Uterine Fibroid Symptom (UFS)-QoL symptom severity scale, Bleeding and Pelvic Discomfort scale (BPD; assessing distress due to HMB, passing blood clots, pelvic pressure/tightness); and HR-QoL (sub)scales were assessed. Higher symptom severity and BPD scores reflect higher severity and distress, respectively; higher HR-QoL scores indicate better outcomes. Least-squares mean changes were provided for the original pivotal-study randomized treatment groups Relugolix-CT and placebo.

Main results and the role of chance

A sustained improvement in symptom severity was observed for the Relugolix-CT group from baseline to Weeks 24 and 52, with LS mean changes of –36.9 and –37.3 points, respectively. In patients initially treated with placebo, small changes were observed at Week 24 (–10.8 points), whereas a greater reduction from baseline was demonstrated at Week 52 (–35.0 points) after transitioning to Relugolix-CT.

Considering the BPD, measuring distress from key UF symptoms, LS mean changes of –50.9 and –51.3 points were observed in the Relugolix-CT group from baseline to Week 24 and 52, respectively. In patients initially treated with placebo, small changes were observed at Week 24 (–15.9 points), whereas a greater reduction from baseline was demonstrated at Week 52 (–48.6 points) after transitioning to Relugolix-CT.

Treatment with Relugolix-CT also resulted in a sustained improvement in different aspects of HR-QoL. LS mean total HR-QoL score increased from baseline to Weeks 24 and 52 by 40.8 and 40.4 points, respectively. In patients initially treated with placebo, small changes were observed at Week 24 (11.4 points), whereas a greater increase from baseline was demonstrated at Week 52 (39.0 points) after transitioning to Relugolix-CT at Week 24.

Limitations, reasons for caution

The 28-week LIBERTY long-term extension study was non-comparative. Analyses were performed in a subset of patients who completed the LIBERTY pivotal studies and were eligible for the extension study. However, it is important to note that the demographic and baseline disease characteristics were similar between pivotal and long-term extension populations.

Wider implications of the findings

Relugolix-CT resulted in a sustained reduction in UF symptom burden, particularly in terms of distress from key UF symptoms, and a sustained improvement of HR-QoL over 52 weeks. Improvements observed after transitioning from placebo to Relugolix-CT at 24 weeks confirmed the positive effect of Relugolix-CT on UF-associated symptoms and HR-QoL.

Trial registration number

NCT03412890

Premature or early bilateral oophorectomy: a 2021 update

In this invited review, we discuss some unresolved and controversial issues concerning premature (<40 years) or early (40-45 years) bilateral oophorectomy. First, we clarify the terminology. Second, we summarize the long-term harmful consequences of bilateral oophorectomy. Third, we discuss the restrictive indications for bilateral oophorectomy in premenopausal women to prevent ovarian cancer that are justified by the current scientific evidence. Fourth, we explain the importance of estrogen replacement therapy when bilateral oophorectomy is performed. Hormone replacement therapy is indicated after bilateral oophorectomy until the age of expected natural menopause like in premature or early primary ovarian insufficiency. Fifth, we discuss the relationship between adverse childhood experiences, adverse adult experiences, mental health, gynecologic symptoms and bilateral oophorectomy. The acceptance and popularity of bilateral oophorectomy over several decades, and its persistence even in the absence of supporting scientific evidence, suggest that non-medical factors related to sex, gender, reproduction, cultural beliefs and socioeconomic structure are involved. We discuss some of these non-medical factors and the need for more research in this area.

Safety and efficacy of the selective progesterone receptor modulator asoprisnil for heavy menstrual bleeding with uterine fibroids: pooled analysis of two 12-month, placebo-controlled, randomized trials

STUDY QUESTION

Can asoprisnil, a selective progesterone receptor modulator, provide clinically meaningful improvements in heavy menstrual bleeding (HMB) associated with uterine fibroids with an acceptable safety profile?

SUMMARY ANSWER

Uninterrupted treatment with asoprisnil for 12 months effectively controlled HMB and reduced fibroid and uterine volume with few adverse events.

WHAT IS KNOWN ALREADY

In a 3-month study, asoprisnil (5, 10 and 25 mg) suppressed uterine bleeding, reduced fibroid and uterine volume, and improved hematological parameters in a dose-dependent manner.

STUDY DESIGN, SIZE, DURATION

In two Phase 3, double-blind, randomized, placebo-controlled, multicentre studies, women received oral asoprisnil 10 mg, asoprisnil 25 mg or placebo (2:2:1) once daily for up to 12 months.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Premenopausal women ≥18 years of age in North America with HMB associated with uterine fibroids were included (N = 907). The primary efficacy endpoint was the percentage of women who met all three predefined criteria at 12 months or the final month for patients who prematurely discontinued: (1) ≥50% reduction in monthly blood loss (MBL) by menstrual pictogram, (2) hemoglobin concentration ≥11 g/dL or an increase of ≥1 g/dL, and (3) no interventional therapy for uterine fibroids. Secondary efficacy endpoints included changes in other menstrual bleeding parameters, volume of the largest fibroids, uterine volume and health-related quality of life (HRQL).

MAIN RESULTS AND THE ROLE OF CHANCE

In all, 90% and 93% of women in the asoprisnil 10-mg and 25-mg groups, respectively, and 35% of women in the placebo group met the primary endpoint (P < 0.001). Similar results were observed at month 6 (P < 0.001). The percentage of women who achieved amenorrhea in any specified month ranged from 66-78% in the asoprisnil 10-mg group and 83-93% in the asoprisnil 25-mg group, significantly higher than with placebo (3-12%, P < 0.001). Hemoglobin increased rapidly (by month 2) with asoprisnil treatment and was significantly higher versus placebo throughout treatment. The primary fibroid and uterine volumes were significantly reduced from baseline through month 12 with asoprisnil 10 mg (median changes up to -48% and -28%, respectively) and 25 mg (median changes up to -63% and -39%, respectively) versus placebo (median changes up to +16% and +13%, respectively; all P < 0.001). Dose-dependent, significant improvements in HRQL (Uterine Fibroid Symptom and Quality of Life instrument) were observed with asoprisnil treatment. Asoprisnil was generally well tolerated. Endometrial biopsies indicated dose- and time-dependent decreases in proliferative patterns and increases in quiescent or minimally stimulated endometrium at month 12 of treatment. Although not statistically significantly different at month 6, mean endometrial thickness at month 12 increased by ~2 mm in both asoprisnil groups compared with placebo (P < 0.01). This effect was associated with cystic changes in the endometrium on MRI and ultrasonography, which led to invasive diagnostic and therapeutic procedures in some asoprisnil-treated women.

LIMITATIONS, REASONS FOR CAUTION

Most study participants were black; few Asian and Hispanic women participated. The study duration may have been insufficient to fully characterize the endometrial effects.

WIDER IMPLICATIONS OF THE FINDINGS

Daily uninterrupted treatment with asoprisnil was highly effective in controlling menstrual bleeding, improving anemia, reducing fibroid and uterine volume, and increasing HRQL in women with HMB associated with uterine fibroids. However, this treatment led to an increase in endometrial thickness and invasive diagnostic and therapeutic procedures, with potential unknown consequences.

STUDY FUNDING/COMPETING INTEREST(S)

This trial was funded by AbbVie Inc. (prior sponsors: TAP Pharmaceutical Products Inc., Abbott Laboratories). E.A. Stewart was a site investigator in the Phase 2 study of asoprisnil and consulted for TAP during the design and conduct of these studies while at Harvard Medical School and Brigham and Women's Hospital. She received support from National Institutes of Health grants HD063312, HS023418 and HD074711 and research funding, paid to Mayo Clinic for patient care costs related to an NIH-funded trial from InSightec Ltd. She consulted for AbbVie, Allergan, Bayer HealthCare AG, Gynesonics, and Welltwigs. She received royalties from UpToDate and the Med Learning Group. M.P. Diamond received research funding for the conduct of the studies paid to the institution and consulted for AbbVie. He is a stockholder and board and director member of Advanced Reproductive Care. He has also received funding for study conduct paid to the institution from Bayer and ObsEva. A.R.W. Williams consulted for TAP and Repros Therapeutics Inc. He has current consultancies with PregLem SA, Gedeon Richter, HRA Pharma and Bayer. B.R. Carr consulted for and received research funding from AbbVie. E.R. Myers consulted for AbbVie, Allergan and Bayer. R.A. Feldman received compensation for serving as a principal investigator and participating in the conduct of the trial. W. Elger was co-inventor of several patents related to asoprisnil. C. Mattia-Goldberg is a former employee of AbbVie and may own AbbVie stock or stock options. B.M. Schwefel and K. Chwalisz are employees of AbbVie and may own AbbVie stock or stock options.

TRIAL REGISTRATION NUMBER

NCT00152269, NCT00160381 (clinicaltrials.gov).

TRIAL REGISTRATION DATE

7 September 2005; 8 September 2005.

DATE OF FIRST PATIENT’S ENROLMENT

12 September 2002; 6 September 2002.

A 12-month extension study to evaluate the safety and efficacy of asoprisnil in women with heavy menstrual bleeding and uterine fibroids

STUDY QUESTION

What is the safety and efficacy profile during long-term (12–24 months) uninterrupted treatment with the selective progesterone receptor modulator asoprisnil, 10 and 25 mg in women with heavy menstrual bleeding (HMB) associated with uterine fibroids?

SUMMARY ANSWER

Uninterrupted treatment with asoprisnil should be avoided due to endometrial safety concerns and unknown potential long-term consequences.

WHAT IS KNOWN ALREADY

Asoprisnil was well tolerated in shorter-term studies and effectively suppressed HMB and reduced fibroid volume.

STUDY DESIGN, SIZE, DURATION

Women with uterine fibroids who had previously received placebo (n = 87) or asoprisnil 10 mg (n = 221) or 25 mg (n = 215) for 12 months in two double-blind studies entered this randomized uncontrolled extension study and received up to 12 additional months of treatment followed by 6 months of post-treatment follow-up. Women who previously received placebo were re-randomized to either asoprisnil 10 or 25 mg for the extension study. This report focuses on the 436 women who received asoprisnil in the double-blind studies and this extension study. Results for women who previously received placebo in the double-blind studies are not described.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women ≥18 years of age who completed a 12-month, double-blind, placebo-controlled study, had estradiol levels indicating that they were not menopausal and had no endometrial hyperplasia or other significant endometrial pathology were eligible. The safety endpoints were focused on endometrial assessments. The composite primary efficacy endpoint was the proportion of women who demonstrated a response to treatment by meeting all three of the following criteria at the final month for participants who prematurely discontinued or at month 12 for those who completed the study: a reduction from initial baseline to final visit of ≥50% in the menstrual pictogram score, hemoglobin concentration ≥11 g/dl or an increase of ≥1 g/dl from initial baseline at the final visit, and no surgical or invasive intervention for uterine fibroids. Other efficacy endpoints included rates for amenorrhea and suppression of bleeding, changes in fibroid and uterine volume and changes in hematologic parameters. No statistical tests were planned or performed for this uncontrolled study.

MAIN RESULTS AND ROLE OF CHANCE

Imaging studies revealed a progressive increase in endometrial thickness and cystic changes that frequently prompted invasive diagnostic procedures. Endometrial biopsy results were consistent with antiproliferative effects of asoprisnil. Two cases of endometrial cancer were diagnosed. At the final month of this extension study (total duration of uninterrupted treatment up to 24 months), the primary efficacy endpoint was achieved in 86 and 92% of women in the asoprisnil 10- and 25-mg groups, respectively. During each month of treatment, amenorrhea was observed in the majority of women (up to 77 and 94% at 10 and 25 mg, respectively). There was a progressive, dose-dependent decrease in the volume of the primary fibroid with asoprisnil 10 and 25 mg (−55.7 and −75.2% median decrease, respectively, from baseline [i.e. the beginning of the placebo-controlled study] to month 12 [cumulative months 12–24] of this extension study). These effects were associated with improvements in quality of life measures.

LIMITATIONS, REASONS FOR CAUTION

This study was uncontrolled, which limits the interpretation of safety and efficacy findings. The study also had multiple protocol amendments with the addition of diagnostic procedures and, because no active comparator was included, the potential place of asoprisnil in comparison to therapies such as GnRH agonists and surgery cannot be determined.

WIDER IMPLICATIONS OF THE FINDINGS

Long-term, uninterrupted treatment with asoprisnil leads to prominent cystic endometrial changes that are consistent with the ‘late progesterone receptor modulator’ effects, which prompted invasive diagnostic procedures, although treatment efficacy is maintained. Although endometrial cancers were uncommon during both treatment and follow-up, these findings raise concerns regarding endometrial safety during uninterrupted long-term treatment with asoprisnil. This study shows that uninterrupted treatment with asoprisnil should be avoided due to safety concerns and unknown potential long-term consequences.

STUDY FUNDING/COMPETING INTEREST(S)

AbbVie Inc. (prior sponsor, TAP Pharmaceutical Products Inc.) sponsored the study and contributed to the design and conduct of the study, data management, data analysis, interpretation of the data and the preparation and approval of the manuscript. Financial support for medical writing and editorial assistance was provided by AbbVie Inc. M. P. Diamond received research funding for the conduct of the study paid to the institution and is a consultant to AbbVie. He is a stockholder and board and director member of Advanced Reproductive Care. He has also received funding for study conduct paid to the institution for Bayer and ObsEva. E. A. Stewart participated as a site investigator in the phase 2 study of asoprisnil and served as a consultant to TAP Pharmaceuticals during the time of design and conduct of the studies while on the faculty of Harvard Medical School and Brigham and Women’s Hospital, Boston, MA. In the last 3 years, she has received support from National Institutes of Health grants HD063312, HS023418 and HD074711. She has served as a consultant for AbbVie Inc., Allergan, Bayer HealthCare AG and Myovant for consulting related to uterine leiomyoma and to Welltwigs for consulting related to infertility. She has received royalties from UpToDate and the Med Learning Group. A.R.W. Williams has acted as a consultant for TAP Pharmaceutical Products Inc. and Repros Therapeutics Inc. He has current consultancies with PregLem SA, Gedeon Richter, HRA Pharma and Bayer. B.R. Carr has served as consultant and received research funding from AbbVie Inc. and Synteract (Medicines360). E.R. Myers has served as consultant for AbbVie Inc., Allergan and Bayer. R.A. Feldman received compensation for serving as a principal investigator and participating in the conduct of the trial. W. Elger was a co-inventor of several patents related to asoprisnil.

C. Mattia-Goldberg is a former employee of AbbVie Inc. and owns AbbVie stock or stock options. B.M. Schwefel and K. Chwalisz are employees of AbbVie Inc. and own AbbVie stock or stock options.

TRIAL REGISTRATION NUMBER

NCT00156195 at clinicaltrials.gov.

Limited impact of awareness-raising campaigns on hepatitis C testing practices among general practitioners

The global hepatitis strategy calls for increased effort to diagnose those infected, with a target of 90% diagnosed by 2030. Scotland's Action Plan on Hepatitis C included awareness-raising campaigns, undertaken during 2008-2011, to promote testing by general practitioners. We examined hepatitis C virus (HCV) testing practice among general practitioners before and following these campaigns. Scottish general practitioners were surveyed, using Dillman's method, in 2007 and 2013; response rates were 69% and 60%, respectively. Most respondents offer testing when presented with a risk history (86% in 2007, 88% in 2013) but only one-fifth actively sought out risk factors (19% in 2007, 21% in 2013). Testing was reportedly always/almost always/usually offered to people who inject drugs (84% in 2007, 87% in 2013). Significant improvements in the offer of testing were reported in patients with abnormal LFTs (41% in 2007, 65% in 2013, P<.001) and who had received medical/dental treatment in high prevalence countries (14% in 2007, 24% in 2013, P=.001). In 2013, 25% of respondents had undertaken HCV-related continued professional development. This group was significantly more likely to actively seek out risk factors (P=.009) but only significantly more likely to offer a test to patients who had received medical/dental treatment in high prevalence countries (P=.001). Our findings suggest that government-led awareness raising campaigns have limited impact on general practitioners' testing practices. If the majority of the HCV-infected population are to be diagnosed, practitioner-based or physician-centred interventions should be considered alongside educational initiatives targeted at professionals.

Academic advocacy in public health: Disciplinary 'duty' or political 'propaganda'?

The role of 'advocacy' within public health attracts considerable debate but is rarely the subject of empirical research. This paper reviews the available literature and presents data from qualitative research (interviews and focus groups conducted in the UK in 2011-2013) involving 147 professionals (working in academia, the public sector, the third sector and policy settings) concerned with public health in the UK. It seeks to address the following questions: (i) What is public health advocacy and how does it relate to research?; (ii) What role (if any) do professionals concerned with public health feel researchers ought to play in advocacy?; and (iii) For those researchers who do engage in advocacy, what are the risks and challenges and to what extent can these be managed/mitigated? In answering these questions, we argue that two deeply contrasting conceptualisations of 'advocacy' exist within public health, the most dominant of which ('representational') centres on strategies for 'selling' public health goals to decision-makers and the wider public. This contrasts with an alternative (less widely employed) conceptualisation of advocacy as 'facilitational'. This approach focuses on working with communities whose voices are often unheard/ignored in policy to enable their views to contribute to debates. We argue that these divergent ways of thinking about advocacy speak to a more fundamental challenge regarding the role of the public in research, policy and practice and the activities that connect these various strands of public health research.

Medical therapies for heavy menstrual bleeding in women with uterine fibroids: a retrospective analysis of a large commercially insured population in the USA

OBJECTIVES

To report patterns and patient characteristics associated with initiation of and persistence with medical therapies for uterine fibroid-related heavy menstrual bleeding.

DESIGN

Retrospective cohort study.

SETTING

US commercial insurance claims database.

POPULATION

41 561 women aged 18-54 years with uterine fibroids and heavy menstrual bleeding who initiated medical therapies from January 2000 through December 2013.

METHOD

Multinomial logistic regression was used to assess patient characteristics associated with initiation and persistence. Cox proportional hazards regression was used on propensity score-matched cohorts to examine change from index medication.

MAIN OUTCOMES MEASURES

Initiation of and persistence with four first-line medical therapies: short- and long-acting reversible contraceptive steroids, leuprolide acetate, and tranexamic acid.

RESULTS

Most women (79.4%) took short-acting reversible contraceptive steroids as first-line therapy (index medication), whereas 9.5%, 8.5%, and 2.7% used long-acting reversible contraceptive steroids, leuprolide acetate, and tranexamic acid, respectively. During follow-up, 16 594 women (39.9%) switched to nonindex medication (18.4%) or procedural treatment (81.6%). In comparison with women taking short-acting steroids, those receiving long-acting steroids were less likely to switch [hazard ratio (HR) 0.84, 95% CI 0.79-0.91], whereas women taking leuprolide acetate (HR 2.44, 95% CI 2.27-2.62) or tranexamic acid (HR 1.44, 95% CI 1.26-1.65) were more likely to switch. Older age, emergency department visits, anaemia, and inflammatory disease diagnoses at baseline were associated with increased probability of discontinuing the index medication or switching to another therapy.

CONCLUSIONS

Women with uterine fibroid-related heavy menstrual bleeding were more likely to persist with their initial therapy of long-acting reversible contraceptive steroid compared with other medical options.

TWEETABLE ABSTRACT

80% women with fibroid-related heavy menstrual bleeding use SARC, but LARC users are more persistent.

Magnetic resonance-guided focused ultrasound (MRgFUS) compared with abdominal hysterectomy for treatment of uterine leiomyomas

OBJECTIVES

To compare women undergoing magnetic resonance-guided focused ultrasound (MRgFUS) to a group of contemporaneously recruited women undergoing total abdominal hysterectomy. Patient demographics, safety parameters, quality of life outcomes and disability measures are reported.

METHODS

One hundred and nine women were recruited in seven centers for MRgFUS treatment and 83 women who underwent abdominal hysterectomy were recruited in seven separate centers to provide contemporaneous assessment of safety. The adverse-event profile and disability parameters were prospectively assessed. Patients were also screened at baseline and at 1, 3 and 6 months using the SF-36 health survey questionnaire.

RESULTS

There were no life-threatening adverse events in either group. Overall, the number of significant clinical complications and adverse events was lower in women in the MRgFUS group compared to women undergoing hysterectomy. MRgFUS was associated with significantly faster recovery, including resumption of usual activities. At 6 months of follow-up, there were four (4%) treatment failures in the MRgFUS arm. Regarding SF-36 subscale scores, at 6 months there was improvement in all SF-36 subscales for both treatment groups. However, most of the SF-36 subscale scores were significantly better at this stage in the hysterectomy group than in the MRgFUS group. Women undergoing MRgFUS had steady improvement in all parameters throughout the 6-month follow-up period, despite the fact that they continued to have myomatous uteri and menstruation, which at baseline had given them significant symptomatology.

CONCLUSIONS

The results of this study show that MRgFUS treatment of uterine leiomyomas leads to clinical improvement with fewer significant clinical complications and adverse events compared to hysterectomy at 6 months' follow-up.

Gonadotropins and the uterus: is there a gonad-independent pathway?

In the gonads, LH and hCG act via the same receptor to stimulate the production of progesterone in the luteal phase of the menstrual cycle and in early pregnancy. There are numerous reports that these two hormones can have direct actions on the uterus in addition to their indirect actions via stimulation of ovarian steroid hormones. However, unlike the situation in the gonads, various uterine tissues have been shown to respond to the related hormones FSH and TSH or the alpha-subunit common to these hormones. These additional actions cannot be mediated by the gonadal LH/hCG receptor. There have also been a series of reports that the uterus contains LH/hCG receptors. Attempts to characterize the molecular structure of these receptors have been difficult; thus, the possibility of a variant receptor cannot be excluded. The possibility also exists of a nonhomologous receptor, which would explain the differences in ligand specificity in uterine tissues. I will review the evidence regarding gonadotropin action in nongonadal tissues, primarily the uterus. In addition, the data regarding receptors will be reviewed. Finally, the clinical areas informed by this information will be explored.

Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium

OBJECTIVES

Basic fibroblast growth factor (bFGF) is an angiogenic growth factor present in human endometrium and myometrium. Women with leiomyoma-related abnormal uterine bleeding have local dysregulation of bFGF and its type 1 receptor (FGF-R). This study was designed to evaluate if adenomyosis expresses bFGF and FGF-R, and if present, to compare bFGF and FGF-R expression in adenomyosis and autologous endometrium.

DESIGN

Menopausal uteri containing endometrium and adenomyosis were analyzed using immunohistochemistry with monoclonal antibodies specific for bFGF, FGF-R, and proliferating cell nuclear antigen (PCNA), a marker of cellular proliferation. The expression and intensity of staining for bFGF, FGF-R, and PCNA were evaluated in the glandular epithelium and stroma of adenomyosis and endometrium.

RESULTS

Glandular epithelial staining was significantly greater in adenomyosis compared with autologous endometrium for bFGF and FGF-R. Stromal staining for bFGF and PCNA was significantly increased in adenomyosis compared with autologous endometrium.

CONCLUSIONS

Upregulation of the bFGF receptor/ligand system and increased cellular proliferation in adenomyosis may contribute to the pathogenesis of abnormal uterine bleeding associated with adenomyosis.

A high-resolution radiation hybrid map of the human genome draft sequence

We have constructed a physical map of the human genome by using a panel of 90 whole-genome radiation hybrids (the TNG panel) in conjunction with 40,322 sequence-tagged sites (STSs) derived from random genomic sequences as well as expressed sequences. Of 36,678 STSs on the TNG radiation hybrid map, only 3604 (9.8%) were absent from the unassembled draft sequence of the human genome. Of 20,030 STSs ordered on the TNG map as well as the assembled human genome draft sequence and the Celera assembled human genome sequence, 36% of the STSs had a discrepant order between the working draft sequence and the Celera sequence. The TNG map order was identical to one of the two sequence orders in 60% of these discrepant cases.

Uterine fibroids

Uterine leiomyomas (fibroids or myomas), benign tumours of the human uterus, are the single most common indication for hysterectomy. They are clinically apparent in up to 25% of women and cause significant morbidity, including prolonged or heavy menstrual bleeding, pelvic pressure or pain, and, in rare cases, reproductive dysfunction. Thus, both the economic cost and the effect on quality of life are substantial. Surgery has been the mainstay of fibroid treatment, and various minimally invasive procedures have been developed in addition to hysterectomy and abdominal myomectomy. Formation of new leiomyomas after these conservative therapies remains a substantial problem. Although medications that manipulate concentrations of steroid hormones are effective, side-effects limit long-term use. A better approach may be manipulation of the steroid-hormone environment with specific hormone antagonists. There has been little evidence-based evaluation of therapy. New research into the basic biology of these neoplasms may add new treatment options for the future as the role of growth factors and genetic mutations in these tumours are better understood.

Towards the social analysis of twinship

The article examines the proposition that twinship is an irreducibly social phenomenon. Gender, age, birth order, socio-economic status and other variables are considered, along with the role of different patterns of socialization as these affect twinship. It is argued that, to a very large extent, from conception. through gestation, childbirth and subsequently childhood and adolescence, the social processing and regulation of social members take place in unitary terms and that therefore twins (and higher multiples) are an anomaly in relation to such processes. Twins' reactions to stigma, stereotyping and labelling are explored as an integral aspect of the social structuring of twinship. The role of the twin, as distinct from the role of the non-twin, is examined in the context of cultural expectations of twinship regarding similarity of identity and similarity of behaviour. Subsequent or concurrent processes of differentiation between twins are also examined. The article concludes with suggestions for further analyses of twinship.

The comparative constitution of twinship: strategies and paradoxes

In both traditional and modern societies, twinship, as an unusual mode of reproduction, involves difficulties for social systems in maintaining consistent classification systems. It is proposed that the most prevalent response to twinship involves various 'strategies of normalisation' to defuse and contain the potential disruption. This proposition is illustrated and analysed in relation to ethnographic maternal drawn mainly (but not exclusively) from African communities in the twentieth century. Following a discussion of twin infanticide as the most extreme of the normalising strategies, the article concludes by identifying a number of paradoxes in the social construction of twinship.

Transcervical placement of a Malecot catheter after hysteroscopic evaluation provides for easier entry into the endometrial cavity for women with histories of difficult intrauterine inseminations and/or embryo transfers: a prospective case series

OBJECTIVE

To evaluate a new technique designed to improve access to the endometrial cavity through tortuous and/or stenotic endocervical canals in women with histories of difficult IUIs, ETs, or endometrial biopsies.

DESIGN

Prospective case series.

SETTING

Tertiary care center.

PATIENT(S)

Women with histories of difficult intrauterine procedures because of tortuous and/or stenotic endocervical canals who continued to undergo treatment.

INTERVENTION(S)

Hysteroscopic evaluation and/or correction of the endocervix, followed by transcervical placement of a Malecot catheter (CR Bard Inc., Covington, GA) for an average of 10 days.

MAIN OUTCOME MEASURE(S)

Improvement in the ease of access to the endometrial cavity during IUIs or ETs.

RESULT(S)

Thirty-two of 36 patients had significantly easier procedures after the placement and removal of a Malecot catheter.

CONCLUSION(S)

Hysteroscopic evaluation and placement of a Malecot catheter is a useful technique that allows easier entry through the cervical canal in patients in whom previous IUIs, ETs, and endometrial biopsies have been difficult. This procedure may lead to improved pregnancy rates, particularly with IVF-ET, as the ease of ET has been correlated with improved implantation rates.

Prolactin is an autocrine or paracrine growth factor for human myometrial and leiomyoma cells

OBJECTIVE

To test the hypothesis that prolactin (PRL) acts as a mitogenic growth factor for human leiomyoma and myometrial cells.

METHODS

To test this hypothesis, we performed three different types of experiments. First, we assessed whether exogenous PRL acted as a mitogen for cultured uterine smooth muscle cells. Second, we examined the role of endogenous PRL by assessing the cell number after exposure of the cultures to a neutralizing antibody to PRL. Finally, we examined both fresh tissues and cultured cells for expression of the PRL receptor messenger ribonucleic acid using the techniques of reverse-transcriptase polymerase chain reaction and Southern blotting.

RESULTS

A significant suppression in cell number was seen after 5 days of culture for leiomyoma cells but not for myometrial cells after treatment with exogenous PRL. Both cell types showed a significant decrease in cell number after treatment with anti-PRL antibody. A 893-bp segment consistent with the cytoplasmic domain of the long form of the PRL receptor was amplified from both fresh and cultured tissues and confirmed by Southern blotting and sequencing.

CONCLUSIONS

PRL appears to be an autocrine or paracrine growth factor for both leiomyoma and myometrial cells. However, there are some differences between tissues in their sensitivity to this growth factor.

Onapristone suppresses prolactin production in explant cultures of leiomyoma

OBJECTIVE

To assess the action of onapristone, a type I antiprogestin, on prolactin (PRL) production by explant cultures of leiomyoma and myometrium.

DESIGN

Explant cultures of myometrium and leiomyomas from 3 premenopausal women undergoing hysterectomy in the proliferative phase of the menstrual cycle.

MAIN OUTCOME MEASURES

PRL secretion measured by radioimmunoassay.

RESULTS

PRL secretion was decreased in leiomyomas by onapristone. There was no effect in the myometrium. There was no additional effect with the addition of the type II antiprogestin mifepristone (RU 486).

CONCLUSION

PRL production is suppressed in leiomyomas but not in myometrium after treatment with onapristone in vitro. This suppression may serve as a marker for the clinical effectiveness of agents used in the treatment of leiomyomas.

Messenger ribonucleic acid for the gonadal luteinizing hormone/human chorionic gonadotropin receptor is not present in human endometrium

OBJECTIVE

To determine whether messenger RNA for the gonadal LH/hCG receptor is present in human endometrium with the use of reverse-transcriptase polymerase chain reaction.

DESIGN

In vitro experiment.

SETTING

Academic medical center.

PATIENT(S)

Premenopausal women who were not receiving hormonally active medications and who were undergoing hysterectomy for uterine leiomyomas, menorrhagia, pelvic pain, or uterine prolapse.

INTERVENTION(S)

Tissue from hysterectomy specimens was processed for RNA and treated with deoxyribonuclease where appropriate, and RNA was reverse-transcribed to complementary DNA.

MAIN OUTCOME MEASURE(S)

An appropriately sized band after reverse-transcriptase polymerase chain reaction, followed by sequencing to confirm the results.

RESULT(S)

A primer pair that spanned the extracellular domain was unable to amplify receptor complementary DNA from human endometrial tissue. For a primer pair that spanned transmembrane regions 2-6 of the receptor and was contained wholly in exon 11, a 552-base pair fragment was amplified successfully in 19 of 25 human endometrial samples.

CONCLUSION(S)

The traditional gonadal LH/hCG receptor does not appear to be present in human endometrial tissue. The presence of a portion of the transmembrane part of the molecule suggests that human endometrium may express a truncated or variant form of the receptor.

A physical map of 30,000 human genes

A map of 30,181 human gene-based markers was assembled and integrated with the current genetic map by radiation hybrid mapping. The new gene map contains nearly twice as many genes as the previous release, includes most genes that encode proteins of known function, and is twofold to threefold more accurate than the previous version. A redesigned, more informative and functional World Wide Web site (www.ncbi.nlm.nih.gov/genemap) provides the mapping information and associated data and annotations. This resource constitutes an important infrastructure and tool for the study of complex genetic traits, the positional cloning of disease genes, the cross-referencing of mammalian genomes, and validated human transcribed sequences for large-scale studies of gene expression.

New concepts in the treatment of uterine leiomyomas

Uterine leiomyomas are a common clinical occurrence for gynecologists. The current approach to treating these neoplasms is shaped by classic surgical principles and the knowledge that these tumors are responsive to the gonadal steroids estrogen and progesterone. As knowledge of leiomyomas advances through the techniques of molecular biology and molecular genetics, new concepts are developed that go beyond just myomas as steroid-responsive tumors. Understanding the molecular events involved in the transformation of a normal myometrial cell into a neoplastic cell and the subsequent growth of these leiomyoma cells will be important in determining the pathogenesis of these tumors and providing new targets for treatment. Knowing the role of peptide growth factors, including basic fibroblast growth factor and transforming growth factor-beta, in the pathogenesis of leiomyoma-related symptoms might lead to new treatments targeting these molecules or their receptors. As the effects of genes, including HMGIC and HMGI(Y), are determined; new treatments to prevent leiomyoma formation or growth may be developed. As we gain understanding of the molecular events that cause benign gynecologic conditions such as leiomyomas, safer and more effective treatments might be found as we enter the 21st century.

Interferon-alpha is a potent inhibitor of basic fibroblast growth factor-stimulated cell proliferation in human uterine cells

PROBLEM

Abnormal uterine bleeding is a significant health problem for many women and is the number-one reason for performing hysterectomy in the United States. Leiomyomas (uterine fibroids) are benign neoplasms that are a frequent cause of abnormal uterine bleeding. The goal of this study was to assess the effects of the anti-angiogenic cytokine, interferon (INF)-alpha, on the proliferation of both leiomyoma and normal uterine cells.

METHOD OF STUDY

Primary cultures of leiomyoma, myometrial, and endometrial stromal cells were established for in vitro study. The effects of INF-alpha (10, 100, and 1000 U/ml) were tested on serum-stimulated and basic fibroblast growth factor-stimulated cell proliferation using the [3H]thymidine incorporation assay.

RESULTS

INF-alpha was a potent inhibitor of cell proliferation for all three cell types, with endometrial stromal cells showing the greatest sensitivity. The antiproliferative effect did not appear to result from toxic effects on the cells.

CONCLUSION

INFs may prove to be useful therapeutic agents for the treatment of leiomyoma-related abnormal uterine bleeding.

Leuprolide acetate-treated leiomyomas retain their relative overexpression of collagen type I and collagen type III messenger ribonucleic acid

OBJECTIVE

To evaluate the levels of mRNA for the extracellular matrix proteins collagen type I, collagen type III, and fibronectin in leiomyomas and myometrium obtained from women treated with GnRH-agonist (GnRH-a) and to examine steroid hormone regulation of these proteins using an in vitro explant culture system.

METHODS

Northern blot analysis of mRNA was obtained from hysterectomy specimens at the time of surgery or after 48 hours of in vitro steroid treatment. A portion of the tissue was processed for RNA, and the remaining tissue was used to establish explant cultures. Extracellular matrix/alpha-tubulin ratio was computed for each band, and within each experiment the lowest ratio was standardized to a value of one densitometry unit to allow for comparison among experiments.

RESULTS

There is a relative overexpression of both collagen type I and collagen type III mRNAs but not fibronectin in leiomyomas compared to myometrium from the same uteri of women treated with GnRH-a.

CONCLUSION

Leiomyomas obtained from women treated with GnRH-a show an up-regulation of collagens type I and type III similar to that seen in leiomyomas obtained from women in the proliferative phase of their menstrual cycles.

Expression of the fibroblast growth factor receptor in women with leiomyomas and abnormal uterine bleeding

Basic fibroblast growth factor (bFGF) is a regulator of angiogenesis which is overexpressed in leiomyomas compared with matched myometrium. To understand the physiological significance of this finding we characterized the expression of the type 1 receptor for this ligand (FGFR1). Utilizing reverse transcription-polymerase chain reaction (RT-PCR) we identified the complete and alternatively spliced transmembrane forms and two secreted forms of the FGFR1 in endometrium, myometrium and leiomyomas from all patients. This is the first report of secreted forms in uterine tissue. Proteins consistent with each of these isoforms were identified by Western blot analysis in all three tissues. Immunohistochemistry revealed menstrual cycle-specific regulation of FGFR1 protein in the endometrial stroma of normal women but not in women with leiomyomas and abnormal uterine bleeding. Stromal FGFR1 expression is suppressed in the early luteal phase in normal women, but not in women with leiomyoma-related bleeding. These findings support the role of the bFGF ligand-receptor system in the pathogenesis of leiomyoma-related bleeding and may have implications for fertility and contraception since the differential FGFR1 expression occurs in the peri-implantation period of the early luteal phase.

An STS-based radiation hybrid map of the human genome

We have constructed a physical map of the human genome by using a panel of 83 whole genome radiation hybrids (the Stanford G3 panel) in conjunction with 10,478 sequence-tagged sites (STSs) derived from random genomic DNA sequences, previously mapped genetic markers, and expressed sequences. Of these STSs, 5049 are framework markers that fall into 1766 high-confidence bins. An additional 945 STSs are indistinguishable in their map location from one or more of the framework markers. These 5994 mapped STSs have an average spacing of 500 kb. An additional 4484 STSs are positioned with respect to the framework markers. Comparison of the orders of markers on this map with orders derived from independent meiotic and YAC STS-content maps indicates that the error rate in defining high-confidence bins is < 5%. Analysis of 322 random cDNAs indicates that the map covers the vast majority of the human genome. This STS-based radiation hybrid map of the human genome brings us one step closer to the goal of a physical map containing 30,000 unique ordered landmarks with an average marker spacing of 100 kb.

A gene map of the human genome

The human genome is thought to harbor 50,000 to 100,000 genes, of which about half have been sampled to date in the form of expressed sequence tags. An international consortium was organized to develop and map gene-based sequence tagged site markers on a set of two radiation hybrid panels and a yeast artificial chromosome library. More than 16,000 human genes have been mapped relative to a framework map that contains about 1000 polymorphic genetic markers. The gene map unifies the existing genetic and physical maps with the nucleotide and protein sequence databases in a fashion that should speed the discovery of genes underlying inherited human disease. The integrated resource is available through a site on the World Wide Web at http://www.ncbi.nlm.nih.gov/SCIENCE96/.

Leiomyoma-related bleeding: a classic hypothesis updated for the molecular era

Leiomyomas are an important cause of menorrhagia and other forms of abnormal uterine bleeding. The pathogenesis of this process is largely unknown, however. A classic theory, first suggested by Sampson's work in 1912 (Surg. Gynecol. Obstet., 14, 215-230), states that local dysregulation of the vascular structures in the uterus is responsible for this abnormal bleeding. Recent work demonstrates dysregulation of a number of growth factors in the myomatous uterus. As many of these factors regulate the process of angiogenesis or have other effects on vascular structures, we hypothesize that this dysregulation of growth factors or their receptors provides the molecular mechanism underlying these vascular abnormalities. In turn, these abnormal vessels lead women with leiomyomas to experience menorrhagia. Factors that may prove to be important in this process include basic fibroblast growth factor, vascular endothelial growth factor, heparin-binding epidermal growth factor, platelet-derived growth factor, transforming growth factor-beta, parathyroid hormone-related protein and prolactin. Current treatment regimens for women with leiomyoma-related bleeding depend on manipulation of the steroid hormone environment. By better understanding the pathogenesis of this disease process, therapies directed against growth factor abnormalities may result in better treatment with less harmful side-effects.

RU486 suppresses prolactin production in explant cultures of leiomyoma and myometrium

OBJECTIVE

To assess the action of RU486 (mifepristone), in the presence and absence of P, on PRL production by explant cultures of leiomyoma and myometrium.

DESIGN

Explant cultures using tissue from nine premenopausal women undergoing hysterectomy in the proliferative phase of the menstrual cycle; immunohistochemical staining of tissue sections from five patients for P receptor (PR) subtype.

MAIN OUTCOME MEASURES

Prolactin secretion (measured by RIA), lactate dehydrogenase secretion (measured by quantitative colorimetric assay), and immunohistochemistry for PR subtype.

RESULTS

Prolactin secretion was decreased in leiomyomas by RU486 at concentrations of 10(-7) M and 10(-5)M when normal serum-containing medium was used. In experiments with all detectable P removed from serum, PRL secretion was suppressed in both leiomyomas and myometrium at an RU486 concentration of 10(-7)M. Immunohistochemistry results suggest that the A form of the PR is the dominant form in both leiomyomas and myometrium.

CONCLUSIONS

Prolactin production is suppressed in both leiomyomas and myometrium after treatment with RU486 in vitro, and this suppression may serve as a marker for the clinical effectiveness of agents used in the treatment of leiomyomas.

Transthoracic needle biopsy with a coaxially placed 20-gauge automated cutting needle: results in 122 patients

PURPOSE

To determine the utility of coaxial transthoracic needle biopsy (TNB) with use of a 20-gauge automated cutting biopsy needle in the diagnosis of thoracic lesions.

MATERIALS AND METHODS

A retrospective review was performed in 122 patients. Computed tomography was used to guide coaxial TNB, which was performed with aspirating (n = 87) and automated cutting (n = 99) needles. The sensitivities for malignant and benign lesions were determined, with a comparison of the relative yields from the two techniques.

RESULTS

The overall diagnostic yield for coaxial TNB was 88%. For malignancy the sensitivity was 95%, whereas a specific benign diagnosis was obtained in 91%. Although no difference was found for fine-needle aspiration versus core biopsy of malignant lesions (92% vs 86%), a statistically significant difference was found for benign lesions (44% vs 100%, P<.05). Pneumothorax occurred in 54%.

CONCLUSION

Coaxial TNB performed with an automated cutting needle helps provide a diagnosis in the majority of patients with focal chest disease and is particularly useful in the diagnosis of benign lesions.

The myometrium of postmenopausal women produces prolactin in response to human chorionic gonadotropin and alpha-subunit in vitro

OBJECTIVES

To examine the effect of equimolar concentrations of hCG and dissociated alpha-subunit on PRL production by leiomyoma and myometrial tissue obtained from different hormonal states and to examine changes in PRL messenger RNA levels as PRL protein levels increased.

DESIGN

Explant cultures of leiomyomas and myometrium were established and cultured for 96 hours. Tissue was studied from normal cycling women, postmenopausal women, pregnant women, and women undergoing GnRH agonist (GnRH-a) therapy. Cultured medium was collected at 24, 48, and 96 hours and assayed for PRL. In selected experiments, tissue was processed at 0 and 96 hours to analyze messenger RNA (mRNA) levels.

RESULTS

Human chorionic gonadotropin and alpha-subunit stimulated PRL secretion in [1] explant cultures of leiomyoma and myometrium from premenopausal women, [2] cultures of tissue treated in vivo with leuprolide acetate for both leiomyoma and myometrium, and [3] myometrium obtained from postmenopausal women. Postmenopausal myometrium was significantly more responsive to stimulation. Prolactin mRNA levels were documented to increase after hormone treatment in postmenopausal myometrium.

CONCLUSION

Myometrium from postmenopausal women is very responsive to hCG and alpha-subunit. There is a difference in response between tissue obtained from menopausal women and that from women undergoing GnRH-a therapy to achieve a "medical menopause" and reproductive age women. The level of endogenous gonadotropins as well as the steroid milieu may modulate myometrial PRL secretion.

Increased expression of messenger RNA for collagen type I, collagen type III, and fibronectin in myometrium of pregnancy

OBJECTIVE

To determine the expression of the extracellular matrix proteins collagen type I, collagen type III, and fibronectin by immunohistochemistry, and the messenger RNA (mRNA) for these proteins by Northern blot analysis in the myometrium of pregnancy compared with myometrium from normal premenopausal women.

METHODS

Myometrial tissue was obtained from seven pregnant women undergoing elective cesarean delivery and eight nonpregnant premenopausal women undergoing hysterectomy. Tissue was paraffin embedded and processed for RNA. Antibodies to collagen type I, collagen type III, and fibronectin were used to examine protein expression by immunohistochemistry. Complimentary DNA probes for the same proteins were used to examine mRNA expression by Northern blot analysis.

RESULTS

Increased staining was seen for all three proteins in the myometrium of pregnancy. Densitometric analysis of Northern blots showed increased levels of collagen type I mRNA (P < .003), collagen type III mRNA (P < .005), and fibronectin mRNA (P < .04) in the myometrium of pregnancy compared with myometrium from nonpregnant premenopausal women.

CONCLUSION

There is increased expression of both protein and mRNA for collagen type I, collagen type III, and fibronectin in the myometrium of pregnancy.

Relative overexpression of collagen type I and collagen type III messenger ribonucleic acids by uterine leiomyomas during the proliferative phase of the menstrual cycle

Uterine leiomyomas contain abundant quantities of extracellular matrix (ECM). We characterized the localization of three ECM proteins, collagen type I, collagen type III, and fibronectin, in leiomyomas and adjacent normal myometrium. We further examined the expression of messenger ribonucleic acid (mRNA) levels for these proteins from 1) women who were in various stages of the menstrual cycle and 2) multiple leiomyomas from the same patient. Immunohistochemical staining showed that fibronectin was localized primarily around individual smooth muscle cells (SMC). Collagen type I was distributed across the ECM and also in the cytoplasm of SMC. Collagen type III was found primarily in the ECM. Leiomyomas showed more intense staining for collagen types I and III than corresponding normal myometrium. Northern blot and densitometric analysis showed that both collagen type I and III mRNAs were consistently elevated in leiomyomas relative to the adjacent myometrium in patients who were in the proliferative phase of the menstrual cycle (P < 0.02 for both). These differences were not evident in the secretory phase. Fibronectin mRNA levels were quite variable, and there were no significant differences between the two tissues at any stage of the menstrual cycle. We conclude that leiomyomas show increased levels of mRNA for collagen types I and III relative to the normal myometrium. However, this difference is only manifested during the proliferative phase of the menstrual cycle. These findings suggest that leiomyomas may be more sensitive to the hormonal changes that occur during the menstrual cycle than is normal myometrium.

Glycoprotein hormones and their common alpha-subunit stimulate prolactin production by explant cultures of human leiomyoma and myometrium

OBJECTIVE

The purpose of this study was to examine the effect of the gonadotropins luteinizing hormone, follicle-stimulating hormone, and human chorionic gonadotropin on prolactin production by human leiomyomas and myometrium. A secondary goal was to explore the effect of thyroid-stimulating hormone and the alpha-subunit common to all these glycoproteins in the same system.

STUDY DESIGN

Explant cultures were established, and harvested medium was assayed for total protein and prolactin. Dose-response studies were performed with follicle-stimulating hormone, luteinizing hormone, and human chorionic gonadotropin. A second set of studies was conducted with a single dose of human chorionic gonadotropin, thyroid-stimulating hormone, and alpha-subunit.

RESULTS

Gonadotropins, thyroid-stimulating hormone, and alpha-subunit all stimulated prolactin production in both leiomyoma and myometrium. Prolactin production was significantly higher in leiomyoma than in myometrium. A positive effect of time, dose, and gonadotropin treatment on prolactin production was seen in each tissue. There was no treatment effect on total protein secretion.

CONCLUSIONS

All four glycoprotein hormones and their common alpha-subunit stimulate prolactin production. This appears to be a specific effect.

Polymorphic microsatellites and Wilson disease (WD)

Wilson disease (WD), an autosomal recessive disorder of copper metabolism, has been previously mapped to chromosome 13q. Highly informative PCR-based polymorphic microsatellites closely linked to the WD locus (WND) at 13q14.3, as well as sequence-tagged sites for closely linked loci, are described. Two polymorphic microsatellite markers at D13S118 and D13S119 lie within 3 cM of WND. Two others (D13S227 and D13S228) were derived from a yeast artificial chromosome containing D13S31. These were placed on a genetic linkage map of chromosome 13 and were typed in 74 multiplex WD families from a variety of geographic origins (166 affected members). Multipoint analysis provides very high odds that the location of WND is between D13S31/D13S227/D13S228 and D13S59. Previous odds with RFLP-based markers were only 7:1 more likely than any other location. Current odds are 5,000:1. Preclinical testing of three cases of WD by using the highly informative polymorphic microsatellite markers is described. The markers described here ensure that 95% of predictive tests using DNA from both parents and from at least one affected sib will have an accuracy > 99%.

The effect of baseline complex ovarian cysts on in vitro fertilization outcome

STUDY OBJECTIVE

To determine the effect of baseline complex ovarian cysts on controlled ovarian hyperstimulation and in vitro fertilization (IVF) outcome.

DESIGN

Retrospective analysis with stratification by stimulation regimen and the presence or absence of surgically documented endometriosis.

PATIENTS

Two hundred sixty-one women undergoing IVF from May 1, 1989 to December 31, 1990.

MAIN OUTCOME MEASURES

The outcome measures assessed were the maximum estradiol (E2) concentration on day of human chorionic gonadotropin (hCG) administration, number of follicles with maximum diameter greater than or equal to 15 mm, number of follicles with maximum diameter greater than or equal to 12 mm, number of days to hCG administration, number of ampules of human menopausal gonadotropin (hMG) used, number of oocytes retrieved and fertilized, number of embryos transferred, and pregnancy and cycle cancellation rates.

RESULTS

There were no statistical differences between cyst and noncyst groups in any of the above parameters of IVF performance. In a single subgroup, patients with endometriosis stimulated with hMG and patients with cysts had significantly lower E2 concentrations than patients without cysts.

CONCLUSION

The presence of a complex cyst on a baseline ultrasound does not appear to adversely affect IVF cycle outcomes.

Operative laparoscopy followed by colpotomy for resecting a colonic leiomyosarcoma. A case report

Operative laparoscopy was followed by colpotomy for the excision of an unsuspected, 7 x 7.5-cm, colonic leiomyosarcoma intact. That surgical approach was quick and had all the benefits of operative laparoscopy without potentially increasing the risk of tumor spread by cutting through malignant tissue.

Human carboxypeptidase A identifies a BglII RFLP and maps to 7q31-qter

A genomic clone for human carboxypeptidase has been isolated with a probe for rat CPA1 cDNA. A 1.7-kb HindIII/EcoRI fragment from the 3' flanking region of human carboxypeptidase detects a DNA polymorphism with BglIII. Multipoint linkage analysis with an established map of chromosome 7 markers shows that the most likely location of carboxypeptidase is at 7q31-qter, between D7S87 and D7S93. All other placements can be excluded with odds greater than 100:1. These and other markers confirm that carboxypeptidase lies distal to the locus for cystic fibrosis, at a distance of approximately 12 centimorgans. The regions containing identity to the rat gene were sequenced and shown to be 82% identical to exons 9 and 10 of the rat gene. The presence of a codon for isoleucine at the residues corresponding to codon 255 of rat CPA1 cDNA strongly suggests that the A form of human carboxypeptidase has been isolated.

A PstI polymorphism for the human erythrocyte surface protein band 3 (EPB3) demonstrates close linkage of EPB3 to the nerve growth factor receptor

Erythrocyte surface protein band 3 (EPB3) plays an important role in CO2 transport in the blood. We have isolated a recombinant lambda bacteriophage that contains coding sequence for the human gene. Sequence analysis demonstrated that the human insert contains a portion of exon 13. A 1.1-kb BamHI fragment revealed a two-allele polymorphism with PstI. Alleles of 1.4 and 0.9/0.5 kb were present in Caucasoids at frequencies of 0.74 and 0.26, respectively. EPB3 has previously been mapped to 17q21-qter by in situ hybridization, and linkage analysis showed that EPB3 is tightly linked to the gene for the nerve growth factor receptor (NGFR). The maximum likelihood estimate of recombination (theta) is 0.00, with a lod score of 11.40 and confidence interval of 0.00 to 0.04.