Zur Psychodynamik des Refertilisierungswunsches bei sterilisierten Frauen

From October 1979 to April 1982 forty two women with previous tubal ligations presented themselves at the Centre for Obstetrics and Gynaecology in Giessen with a high desire of restoration of their fertility. With questionaires and partly structured interviews these women were evaluated at the Centre for Psychosomatic Medicine in Giessen. The results largely confirm previous findings known in the literature regarding the background of tubal ligations in women with desire for restoration of fertility. Most of the patients (N = 37) had the sterilization performed under conditions which are known to have an adverse prognostic effect such as sterilization for medical indications in ten women, sterilization during a marital crisis in eighteen women, and sterilization in conjunction with a therapeutic abortion, confinement or a gynaecological operation in twenty eight women. The psychodynamics of women with a desire for restoration of fertility show two main groups. First: in twenty five women a sterilization and desire for restoration of fertility are an effort to resolve a specific conflict in their marital relationship inasmuch as a new infant should serve as a bonding function and documentation of the new partnership. Second: in sixteen patients sterilization and desire for refertilization are a symptom of an unresolved conflict of the role as woman and mother. The new infant or the restoration of fertility should eliminate the narcistic deficit suffered by the sterilization or restore the self esteem which suffered a female identity blow by the sterilization. Implications of these findings for the counselling practice are discussed.

Asymmetrical dimethylarginine, inflammatory and metabolic parameters in women with polycystic ovary syndrome before and after metformin treatment

CONTEXT

Insulin resistance plays a significant role in the pathogenesis of the polycystic ovary syndrome (PCOS) and represents a link to the unfavorable cardiovascular risk profile frequently found in affected patients. The endogenous nitric oxide synthase inhibitor asymmetrical dimethyl-L-arginine (ADMA) is associated with atherosclerosis and represents an independent marker for cardiovascular morbidity and mortality.

OBJECTIVE

We investigated ADMA levels among other cardiovascular, metabolic, and hormonal parameters in women with PCOS and the effects of metformin treatment on these parameters.

DESIGN

A cross-sectional study and clinical trial were performed.

PATIENTS AND PARTICIPANTS

Women with PCOS (n = 83) compared with a control group of healthy women (n = 39) were studied.

INTERVENTIONS

In a subgroup of patients with PCOS (n = 21), the effect of metformin was assessed after 6 months of treatment.

MAIN OUTCOME MEASURES

ADMA, intima media thickness (IMT), metabolic and hormonal parameters, and markers of inflammation were investigated.

RESULTS

ADMA levels were significantly higher in the PCOS group compared with controls (0.57 +/- 0.15 vs. 0.50 +/- 0.11; P = 0.024). Androgens, C-reactive protein, fasting C-peptide, area under the curve (AUC) insulin, AUC glucose, homeostatic assessment of insulin resistance, fasting insulin, glycosylated hemoglobin, cholesterol, low-density lipoprotein cholesterol, triglycerides, and IMT were significantly higher in women with PCOS compared with controls. In PCOS patients ADMA was found to be positively correlated with body mass index (BMI), waist to hip ratio, parameters of insulin sensitivity, hyperandrogenemia (free testosterone, free androgen index), and IMT. Treatment with metformin ameliorated hyperandrogenemia and decreased ADMA levels (0.53 +/- 0.06 vs. 0.46 +/- 0.09, P = 0.013). Decrease in ADMA levels subsequent to metformin treatment did not correlate with change in BMI or metabolic parameters.

CONCLUSIONS

ADMA amd parameters of insulin sensitivity are elevated in women with PCOS and the degree of insulin resistance confers the greatest influence on ADMA level. Metformin treatment led to improvement of hormonal and metabolic parameters and decreased ADMA levels possibly independent of BMI and metabolic changes.

Multi-locus (ML)-FISH is a reliable tool for nondisjunction studies in human oocytes

In the present study, we developed a fluorescence in situ hybridization (FISH) strategy, which allows a reliable determination of the chromatid number of specific chromosomes in mature human oocytes. 168 unfertilized oocytes were analyzed by dual-color FISH with two direct-labeled locus-specific DNA probes for chromosome 13 and 21. To exclude FISH failures, metaphases with abnormal signal patterns were reanalyzed by multi-locus-FISH (ML-FISH) for chromosome 13 and 21. Following dual-color FISH, abnormal signal patterns were detected in 21 out of 108 metaphases (19.4%). 17 of these metaphases were reanalyzed by ML-FISH. In contrast to the first FISH, seven metaphases showed normal signal patterns after rehybridization, whereas ten metaphases remained abnormal. Out of these real aneuploid metaphases, five showed gain or loss of a single signal (= chromatid), two showed missing double signals (= chromosome) and three showed both. In conclusion, locus-specific FISH probes facilitate differentiation between first meiotic nondisjunction of whole chromosomes and prematurely divided chromatids. Moreover, simultaneous hybridization with a second locus-specific probe on the same chromatid (ML-FISH) helps to differentiate between FISH failures and real meiotic division errors and therefore, allows a more reliable analysis of aneuploidies in human oocytes.

Matrix metalloproteinases and TACE play a role in the pathogenesis of endometriosis

Endometriosis, a benign gynecologic disorder, occurs in about 10% of women in reproductive age and in up to 50% of women with infertility. The basic etiologic factors causing this disease are unknown as yet. Matrix metalloproteinases (MMP) are involved in degradation of the extracellular matrix (ECM). Their proteolytic activity is regulated by tissue inhibitors of metalloproteinases (TIMPs). Tumor necrosis factor-alpha converting enzyme (TACE) is a membrane-bound disintegrin metalloproteinase that processes the membrane-associated cytokine proTNF-alpha to its mature soluble form. TNF-alpha induces the secretion of several MMPs. In order to study the expression of MMP-1, -2, -3 and -9, TIMP-1 and -2, TACE and TNF-alpha in endometrium and endometriotic tissue, we investigated formalin-fixed paraffin sections of endometriotic tissues and normal endometrium with immunohistochemical techniques and in situ hybridisation. Furthermore, quantitative PCR was used for quantification of TACE-mRNA in fresh tissue. We found in this study significant higher protein expression of MMP-1 and TACE and significant lower protein expression of TMP-1 and -2 in endometriotic tissue compared to endometrium. This data may suggest that high TACE expression causes the increased conversion of membrane-bound proTNF-alpha into its soluble form, which stimulates the increased secretion of MMP-1. The simultaneous deficiency of TIMP-1 and -2 in endometriotic tissue suppose an additional proteinase inhibitor imbalance in endometriosis.

Long-term GnRH analogue treatment is equivalent to laparoscopic laser diathermy in polycystic ovarian syndrome patients with severe ovarian dysfunction

This prospective, randomized study included 18 polycystic ovarian syndrome (PCOS) patients with severe ovarian dysfunction, who were evaluated by standard clomiphene and FSH stimulation. In this group of patients, a 6 month down-regulation with gonadotrophin-releasing hormone (GnRH) analogues gave outcomes similar to laparoscopic ovarian laser diathermy with respect to stimulatory outcome and pregnancy rate. Clomiphene stimulation with 50 mg of clomiphene/day and FSH stimulation in a low-dose, step-up protocol with purified FSH did not result in oligofollicular development; thus patients were divided into two subgroups: one subgroup received laparoscopic laser drilling and the other received 6 months of therapy with GnRH analogues plus add-back therapy after diagnostic laparoscopy. Subsequently, three cycles of low-dose, step-up stimulation with recombinant FSH were started. In both groups, approximately 30% of cycles still remained anovulatory. In the down-regulated subgroup, this mainly happened in the first cycle. In each group, ovulation was achieved in 14 cycles, intrauterine insemination was performed, and five pregnancies were obtained. This resulted in a pregnancy rate of 36% per ovulatory cycle in both groups. Overall, 50% of the formerly unreactive patients in both groups overcame childlessness. In achieving this, long-term treatment with GnRH analogues was as successful as laparoscopic laser diathermy.

Frequency of CFTR gene mutations in males participating in an ICSI programme

A higher prevalence of cystic fibrosis transmembrane regulator (CFTR) gene mutations has been suggested both in men affected by congenital aplasia of the vas deferens, and in individuals presenting with reduced sperm quality. In this case, an increased risk for offspring being affected by cystic fibrosis (CF) can be expected in couples who are planning to undergo intracytoplasmic sperm injection (ICSI), since most of the male partners suffer from infertility. In order to determine the risk for these couples more precisely, we offered them a test for the most frequent CF mutations prevalent in the German population. The frequency of mutations within the CFTR gene in the female group was in the same range as expected for the general population (six out of 150). In 10 out of 207 males tested, infertility could be explained by exogenous factors not related to CFTR. Among the remaining 197 males with idiopathic infertility, we detected 13 heterozygotes for a mutation within the CFTR gene. This slightly, but significantly (P = 0.014), elevated rate could indicate that infertile males have, compared with the general population, an increased risk of being a carrier of a CFTR gene mutation.

Chlororganic pesticides and polychlorinated biphenyls in breast tissue of women with benign and malignant breast disease

Persistent chlorinated hydrocarbons assimilated through the diet may, as a result of their carcinogenic, immunotoxic, and, at least in regard to certain of these substances, estrogenic properties, play a role in the etiology of human breast cancer. As a consequence, increased concentrations of these ubiquitous environmental contaminants may be found in breast tissue of women suffering from malignant breast disease. To examine this possibility, surgically removed breast tissue samples from 65 women in Hesse, Germany were examined by capillary gas chromatography for p, p'-dichloro(diphenyl)trichloroethane (p,p'-DDT), p, p'-dichloro(diphenyl)-dichloroethane (p,p'-DDD), p, p'-dichloro(diphenyl)dichloroethene (p,p'-DDE), hexachlorobenzine (HCB), alpha-, beta-, and gamma-hexachlorocyclohexane (HCH) as well as the polychlorinated biphenyls (PCB) no. 28, 31, 49, 52, 101, 105, 118, 138, 153, 156, 170, and 180. Of the 65 patients, 45 were diagnosed with breast cancer. The control group of 20 women suffered from benign breast disease such as mastopathy. After statistical adjustment for age differences, higher concentrations of p,p'-DDT, p, p'-DDE, HCB as well as PCB-congeners no. 118, 138, 153, and 180 were detected in tissue from women with breast cancer than in tissue from control persons. These differences were weakly significant for p, p'-DDE (p = 0.017), for PCB 118 (p = 0.042) and for PCB no. 153 barely not significant (p = 0.083). On an average, a 62% higher concentration of p,p'-DDE was found in cancer tissue (cancer patients: 805 microg/kg fat; controls: 496 microg/kg fat) and 25% higher concentration of PCB no. 118 (81 microg/kg fat; 65 microg/kg fat). The concentrations of beta-HCH, PCB no. 156 and 170 were lower (not significant) in cancer tissue than in tissue from women with benign disease. PCB-congeners no. 105 and 149 as well as gamma-HCH could only be detected in individual tissue samples; congeners no. 28, 31, 49, 52, and 101 as well as alpha-HCH and p,p'-DDD were not detected in any of the samples. To rule out the possibility that the concentrations of chlorinated hydrocarbons measured were influenced by the surgical procedure, 20 samples of tissue that were at a distance (minimum 1 cm and maximum 3 cm) from the tumor, tissue that was in direct proximity to the tumor (no more than 5 mm from the tumor), and tumor tissue itself (center of tumor) were separately prepared and analyzed. The average concentrations of chlorinated hydrocarbons varied to differing degrees and only minimally in tumor and surrounding breast tissue, indicating that the surgical procedure did not influence the results.

Pregnancy and birth after intracytoplasmic sperm injection with spermatozoa from a patient with tail stump syndrome

Tail stump syndrome, which may be associated with primary ciliary dyskinesia, is also associated with morphological defects of the flagellum resulting in severe asthenozoospermia. Until recently, these morphological anomalies caused definite male infertility. Today, however, new methods such as micromanipulation techniques provide a rational therapy for this patient group. A pregnancy followed by living offspring was achieved following the intracytoplasmic injection of immotile spermatozoa from a patient with tail stump syndrome.

[Laparoscopic ante-fixation of the uterus--modification of the Menge operation]

Surgical antefixation of the retroflected uterus is today for several reasons a rare event. We report on a forty-year old patient with dyspareunia, dysmenorrhoea and lumbalgia. Elevation of the uterus by means of a Hodge pessary relieved her symptoms. This prompted laparoscopical suspension of the diagnosed retroflexio uteri mobilis. We used a modification of Menge's technique stitching the rotund ligament to the anterior surface of the uterus. This modified technique is especially useful because it can be performed easily by laparoscopy. In addition shortening of the round ligaments achieves a physiological position of the uterus in the pelvis without major changes in the pelvic anatomy.

Acrosin activity of human spermatozoa by means of a simple gelatinolytic technique: a method useful for IVF

Acrosin activity was determined using a gelatinolysis technique in 100-microliter semen aliquots of 114 patients (normozoospermia, n = 90; asthenozoospermia, n = 12; oligozoospermia, n = 10; polyzoospermia, n = 2) attending an in vitro fertilization (IVF) program. Halo diameter, halo formation rate, and a calculated acrosin activity index correlated significantly with the IVF rates (P = 0.0054, r = 0.396; P = 0.0009, r = 0.401; and P = 0.0003, r = 0.428, respectively). In cases where the halo diameter was < 10 microns and halo formation rate was < 60%, all patients were subfertile or infertile, that is, they showed poor or no fertilization in vitro, respectively. The assay demonstrated a relatively low sensitivity: 25.7% for halo diameter, 37.1% for halo formation rate, and 25.7% for acrosin activity index, respectively. This might be attributed to other sperm functional aspects, such as disturbed acrosome reaction or impaired zona binding.

Effect of anesthesia on sperm motility in gamete intrafallopian transfer

The existence of a motility-inhibiting substance in human peritoneal fluid (hPF) has been demonstrated. The results of this study indicate that this factor from hPF is a heat-resistant, volatile molecule with a very small molecular mass (e.g., halothane, which is used for general anesthesia in laparoscopic GIFT). This may be the reason for the conflicting results concerning pregnancy rates in gamete intrafallopian transfer.

Estrogen induces expression of endometrial epidermal growth factor receptors before implantation

PROBLEM

Pharmacological doses of 17 beta-estradiol increase epidermal growth factor binding to uterine membranes.

METHODS

To determine whether physiological elevated E2 concentrations in the preimplantation phase of rabbits and preovulatory phase of women cause epidermal growth factor (EGF) receptor expression, we performed radioligand binding studies of endometrial membranes with [125I]-EGF.

RESULTS

Unmated rabbits revealed a binding maximum (Bmax) of 514 +/- 197 fmol/mg protein for [125I]-EGF. The Bmax values increased significantly to 1424 +/- 430 fmol/mg on day 1 and to 2244 +/- 224 fmol/mg on day 2 after mating. On day 3 the Bmax values decreased to 1409 +/- 238 fmol/mg and on days 4 to 8 the binding maxima were not significantly different from the Bmax values of unmated rabbits. In ovariectomized rabbits a significant increase of [125I]-EGF-binding could be mimicked 12 and 18 h after the intramuscular injection of estradiol (40 micrograms/kg). The estradiol-induced increase of [125I]-EGF Bmax values was blocked by the parallel application of the antiestrogen tamoxifen. Progesterone (2 mg/kg) did not influence [125I]-EGF-binding to endometrial membranes. Membrane preparations of the human endometrium from the periovulatory phase bound significantly more [125I]-EGF compared to endometrium of the early proliferative phase. The expression of EGF receptor mRNA was localized in the epithelial cells of the human endometrium by in situ hybridization technique.

CONCLUSIONS

These results provide insight into the regulation of the autocrine and paracrine factor EGF in the endometrium during the preimplantation period.

Oxygen tension in follicular fluid falls with follicle maturation

The increase in follicular diameter during maturation is accompanied by an increase in vascular supply. The oxygen tension (PO2) in the follicular fluid of the growing follicle should therefore give an insight whether the oxygen delivery during this pertinent process is sufficient. Follicular fluid of 20 patients subjected to in vitro fertilization and embryo transfer were sampled in heparinized glass capillaries which were placed between the puncturing needle and the collecting reservoir. All patients were treated with human menopausal gonadotropin (HMG) and follicle-stimulating hormone (FSH). The PO2, PCO2 and pH of the follicular fluid were measured with an automatic gas analyser (Ciba Corning). Simultaneously, the same parameters were estimated in maternal capillary blood taken from the arterialized well perfused earlobe. Follicular size was measured by ultrasound. With growing follicular size (FS), the oxygen partial pressure (PO2) fell from 80 to 50-60 mmHg (PO2 = 114.4-3.3.FS; r = 0.79) while the carbondioxide partial pressure (PCO2) in the follicle increased from 35 to 50 mmHg (PCO2 = 15.1 +/- 1.9.FS; r = 0.71). In correlation to these results, the pH in follicular fluid fell from 7.40 to 7.30 (pH = 7.6-0.019.FS; r = 0.62). The correlation between the PCO2 and the pH demonstrates a deviation from the regression line if no metabolic alterations take place (delta log PCO2/delta pH = -0.69). The increase in ovarian blood flow during follicular maturation is obviously not sufficient to bridge the growing diffusion distance between the capillary network surrounding the follicle and its center.(ABSTRACT TRUNCATED AT 250 WORDS)

[Salpingoscopy--an aid in the diagnosis of sterility]

The condition of the fallopian tubes was assessed in 100 fertile women on whom a caesarean section had been performed and in 100 infertile women who had undergone a diagnostic laparascopy. The 100 infertile women revealed both peritubal adhesions (20% vs 2%) and fimbrial agglutinations (4% vs 0%) in a significantly higher number of cases. When the diagnostic procedure was extended to include the salpingoscopy of 20 women with periampullary and peritubal adhesions, 10% of them were found to be suffering from damage of the endosalphinx. In patients with fimbrial agglutination, the same diagnostic procedure revealed mucosal damage in 40% of the cases. The rate of damage to the endosalpinx may help to explain the relatively high rate of ectopic pregnancies (15%) following microsurgical fimbrioplasty. Thus, in cases where the patient is suffering from peritubal adhesions and fimbrial agglutinations, salpinogoscopy can be of use in deciding whether microsurgery is indicated. In those cases, where there is evidence of damage to the endosalpinx, in-vitro fertilization with intrauterine embryo transfer must be considered as the preferential method.

[Neurologic complication following spinal anesthesia for manual detachment of the placenta]

Long-term paralysis of the lower extremities was observed in a 31-year-old fourth-gravida patient, undergoing a curettage under spinal anaesthesia because of placenta accreta. The patient recovered within three days from her neurological signs and symptoms, consisting of complete paresis of the hip and knee flectors and severe headache. Clinical investigations including a neurological examination, spinal puncture, x-ray pictures of the lumbosacral area and haemograms revealed no evidence for an infection, abscess or haematoma. With regard to the fact, that neurological deficiency disappeared completely within three days, it seems probable, that the symptoms were caused by the longer lasting gynaecological position (Steinschnitt-position) during the period of delivery and curettage thereafter.

Nuclear magnetic resonance imaging of a patient with an ectopic pregnancy

We attempted to demonstrate the morphological changes of an extrauterine pregnancy by nuclear magnetic resonance imaging. Spin echo mode was used to take images in all three space directions. An enlargement of the uterus with an empty cavity and a hyperplasia of the supporting vasculature were demonstrated as alterations correlating with an extrauterine pregnancy.

The binding sites of the calcium antagonist [3H] PN 200,110 in the human myometrium and myosalpinx

Calcium antagonists of the dihydropyridine type may prove to be an important adjunct to the therapy of premature labor due to their proven ability to inhibit uterine contractility. Specific binding sites for calcium blockers were concentrated in 45,000 X g membrane preparations of human myometrium and myosalpinx. Scatchard plot analysis of the binding of [3H] PN 200,110, a benzoxadiazole-substituted dihydropyridine derivate, revealed that the binding sites of myometrial membranes numbered between 500 and 700 fmoles/mg protein (Bmax) and had an affinity (KD) of 0.3 +/- 0.1 nmol/l. In myosalpingeal membrane preparations Bmax was between 250 and 300 fmoles/mg protein, with KD values of 0.9 +/- 0.1 nmol/l. Unlabelled calcium antagonists displaced [3H] PN 200,110 binding in the following order of potency ranking: nitrendipine greater than or equal to nifedipine greater than d-cis-diltiazem greater than D-600 greater than or equal to tiapamil. The calcium channels were especially dense (796 +/- 186 fmoles/mg protein) in the myometrium of the dorsal uterine wall. The number of binding sites in the myosalpinx was greatest in the isthmus (242 +/- 23 fmoles/mg protein).

Binding properties of beta-adrenergic receptors in oviductal smooth muscle membranes

In particular membrane fractions of human and rabbit oviductal smooth muscle specific binding sites for the radiolabelled beta-adrenergic antagonist [125I]- cyanopindolol (I- CYP ) were detectable utilizing the radioligand technique. The binding was saturable, relative to the concentration of protein as well as ligand in the assay. The analysis of the binding kinetics by Scatchard plots revealed a number of beta-adrenergic receptor sites of 30 fmol I- CYP bound per milligram protein with a dissociation constant (KD) of 20 pM. In competition binding studies with beta 2-adrenergic agonists and antagonists the receptors in their pharmacological range corresponded to the beta 2-subtype of beta-adrenergic receptors. Within the oviduct the ampulla possessed 70% of all traceable beta-adrenergic receptor sites.

Mechanically induced tube damage in the artificial hydrosalpinx

One-sided artificial hydrosalpinx was caused in mature New Zealand rabbits by proximal and distal ligature. After 2 weeks the average secretion accumulation was 2.1 ml, after 8 weeks 6.3 ml. A fold relief could no longer be detected after 8 weeks. The light-microscopical study of the epithelium showed signs of cell degeneration with cell dedifferentiation, pyknosis of the nucleus, and perinuclear aerolae. The ciliation of 66% ciliated cells for the normal oviduct (pars ampullaris) was reduced to 15% after 8 weeks of artificial hydrosalpinx. Based on the hypertrophy of the muscularis the percentage loss of E2 receptors within 4 weeks was smaller in comparison with the percentage reduction of the ciliation during the same time. Finally, after 8 weeks an amount of 15% for the estrogen receptors as well as for the ciliation was achieved--both compared to the untreated oviduct. It is possible that the oviduct damage, caused only by the mechanical influence of the secretion congestion, is the reason for the unfavorable pregnancy rate after salpingoneostomy of a chronic atrophied hydrosalpinx.

Failure of oxytocin and lysine-vasopressin to stimulate prolactin release in humans

In order to test a possible stimulatory effect of oxytocin and lysine-vasopressin on prolactin (PRL) release six female volunteers received either saline or 1 IU oxytocin (Syntocinon) i.v.. Blood sampling was performed at intervals over 90 minutes. Nine puerperae were treated with oral oxytocin (Sandopart) 50 IU t.i.d. for seven days. Nine other untreated postpartum women served as controls. Blood was collected before delivery and on subsequent postpartum days, and the milk volumes produced were estimated by increases in the babies' weight. In addition, seven volunteers received 5 or IU lysine-vasopressin (Vasopressin) i.m. Blood was withdrawn at regular intervals for 180 minutes, the urine volumes excreted in 30-minute intervals were measured and the clearance of free water calculated. Oxytocin failed to modify basal plasma PRL in the acute trial and in the post-partum women, and milk amounts produced were not influenced by treatment. Vasopressin did not change the PRL plasma profile despite a significant (p less than 0.05) reduction in the excretion of free water. Results indicate that neuropeptides are not implicated in the control of PRL release.

Solubilization of a mammalian beta-adrenergic receptor

Binding sites for iodohydroxybenzylpindolol with characteristics of a beta2-adrenergic receptor have been identified in a crude membrane fraction from guinea-pig lung. The binding sites could be solubilized by treatment of the membrane fraction with digitonin. Upon solubilization receptors retain their beta2-adrenergic type as indicated by the rank order of potencies of agonists in binding-inhibition experiments. The solubilized receptors demonstrate a marked increase in affinity for agonists compared with particulate receptors whereas antagonist affinity remains unchanged. Solubilized receptors are insensitive to divalent cations (Mg2+, Mn2+, Ca 2+) which increase the potency of agonists for particulate receptors. The effects of Mg2+ can be reversed by Gpp(NH)p in particulate preparations; Gpp(NH)p is ineffective for the solubilized preparation. These experiments establish that beta-adrenergic receptors can be solubilized even from crude mammalian membrane preparations. They also show that the mammalian beta-adrenergic receptor in situ is under constraints with respect to agonist affinity and is modulated by divalent cations and guanyl nucleotides in the intact membrane.