Identification and Classification of Postpartum Psychiatric Disorders

1. Postpartum depression has been used as a catchall phase for many postpartum emotional symptoms. Categorizing a number of diverse disorders under one title has resulted in an inability to identify who is most at risk for developing postpartum problems. 2. The postpartum period is a particularly vulnerable period for depression, despite the fact that it is perceived as a time of joy and emotional well-being. 3. By increasing awareness among all health care professionals who care for women during the period following childbirth, postpartum psychiatric disorders can be identified early and treated correctly. 4. Limiting postpartum psychiatric disorders to postpartum depression may result in limited or inappropriate treatment options.

Sentinel lymph node detection and microstaging in vulvar carcinoma

OBJECTIVE

To determine the efficacy of using complementary techniques for detecting sentinel lymph nodes (SLNs) in vulvar carcinoma and to evaluate the utility of microstaging techniques.

STUDY DESIGN

Patients with invasive vulvar carcinoma underwent sentinel lymph node detection (SLND) using preoperative lymphoscintigraphy, intraoperative isosulfan blue dye injection and an intraoperative hand-held gamma-detecting probe. Eleven patients were included and a total of 16 groins evaluated. Sentinel nodes identified were excised, bisected and examined in surgical pathology using hematoxylin and eosin (H&E) staining. Pathologically negative SLNs were subjected to additional microstaging via serial sectioning and immunohistochemical staining for cytokeratin. Surgical management of the vulvar cancer and extent of inguinal-femoral lymphadenectomy were individualized based on clinicopathologic parameters, including depth of invasion, location of the tumor and patient performance status.

RESULTS

Lymphoscintigraphy, dye and gamma-detector methods led to the total detection of 16, 19 and 17 SLNs, respectively. In two cases the isosulfan blue dye assisted in the isolation of an additional sentinel node over that of the gamma probe. Each method individually identified SLNs in 10/11 patients (91%). A total of 19 sentinel nodes were isolated. One SLN (5%) was positive for metastatic disease using H&E staining. Of the 18 negative SLNs, 2 (11%) had micrometastases (< 0.2 mm) upon serial sectioning and immunohistochemical staining.

CONCLUSION

Combined-modality mapping enhances detection of SLNs in vulvar carcinoma. Histologic microstaging improves the detection of micrometastases within SLNs.

How to avoid multiple pregnancies in assistive reproductive technologies

Since 1980, there has been a worldwide dramatic increase in multiple births. This seems to be due to an increase in the age of reproduction, the use of ovulation induction, and the use of in vitro fertilization. Scarce data suggest that each of these causes is responsible for about one-third of the problem, although quintuplets and more are almost invariably due to ovulation induction. There has been little or no effort to issue guidelines or regulations with respect to ovulation induction, but there has been much advice as to how to control the problem in in vitro fertilization by limiting the number of embryos to be transferred. In sum, a good selection of high-quality embryos on day 3 would allow a high rate of pregnancy with the transfer of one or two blastocysts. Good results of cryopreservation must be part of an agreement in an in vitro fertilization program. If singleton live birthrates were considered to be the principal outcome of assisted reproductive technologies reported by centers and registry, twin and triplet rates should also be reported separately. And finally, if financial considerations would not limit the cost of reimbursement to in vitro fertilization procedures, the number of procedures could be increased with fewer embryos transferred.

Postoperative pelvic irradiation in early stage uterine mixed mullerian tumors

PURPOSE OF INVESTIGATION

To review our management experience with uterine mixed mullerian tumors (MMTs) in order to evaluate potential prognostic indicators, and assess the efficacy of various treatment modalities.

METHODS

A retrospective, clinicopathologic evaluation of 43 patients presenting for treatment of uterine MMTs between 1982 and 1992 was conducted. Diagnostic criteria for inclusion was the presence of both a malignant glandular or squamous epithelial component, and a homologous or heterologous stromal component.

RESULTS

Overall 2- and 5-year cancer related Kaplan-Meier survival estimates with 95% confidence intervals were 44 (.28, .59) and 26% [.12, .39], respectively. Survivals were 83 [.62, .99] and 58% [.31, .85] when disease was confined to the uterus, and 22 [.03, .41] and 7% [.01, .20] when disease extended beyond the uterus. Clinical staging was often inaccurate, with 29% of clinical stage I or II disease being upstaged at laparotomy. A significant survival advantage was found in patients with stage I or II disease treated with surgery plus pelvic irradiation (p = 0.001), as compared to those treated with surgery alone. The prognosis after disease recurrence was poor, irrespective of secondary therapy, with a median survival of 11 months.

CONCLUSIONS

A therapeutic advantage may be gained from postoperative pelvic irradiation in the treatment of surgical stage I or II uterine MMT.

Impact of a cryopreservation program on the multiple pregnancy rate associated with assisted reproductive technologies

OBJECTIVE

To determine the impact of a cryopreservation program on pregnancy rates and multiple-pregnancy rates in ART cycles.

DESIGN

Retrospective study.

SETTING

University teaching hospital.

PATIENT(S)

Women who underwent stimulation for in vitro fertilization at the Jones Institute for Reproductive Medicine between October 1987 and June 1999.

INTERVENTION(S)

Analysis of pregnancy and multiple-pregnancy rates based on the number of embryos transferred.

MAIN OUTCOME MEASURE(S)

Implantation; pregnancy and multiple-pregnancy rates.

RESULT(S)

Pregnancy rates per transfer increased from 9% when one embryo was transferred to 20% with two embryos, 35% with three embryos, 40% with four embryos, and 41% with five embryos. The rate of twin pregnancies increased to 21% with two embryos, 23% with three embryos, 21% with four embryos, and 22% with five embryos. The triplet pregnancy rates were 8% with three embryos, 9% with four embryos, and 2% with five embryos. A theoretical model limiting the number of embryos transferred to two with cryopreservation and subsequent transfer yields a cumulative pregnancy rate of 77%, a twin rate of less than 20%, and no triplet or higher-order pregnancies.

CONCLUSION(S)

The use of a cryopreservation program can help maximize pregnancy rates while minimizing multiple-pregnancy rates. Cryopreservation should be considered in all assisted reproductive technology cycles.

Evaluation of the clinical efficacy of embryo cryopreservation

To fully evaluate the advantages of a cryopreservation program a method needs to be established to express the additional patients pregnant from cryopreservation. The patient specific method considers cryopreservation as augmentation only among patients without a pregnancy from the fresh transfer, or from previously transferred frozen material from the same harvest. In an analysis of the pregnancy rate at the Jones Institute between January 1996 and December 1998 we found a fresh pregnancy rate of 40.8% in the good responders and 28.8% in poor responders. The patient specific pregnancy rate in the same cycles was 53.4% in good responders and 32.3% in poor responders. Good responders less than 35 years of age with ten or more mature eggs at retrieval had a fresh pregnancy rate of 40.2% and a patient specific pregnancy rate of 57.9%. It is exceedingly important for the physician and patient to understand and comprehend the potential in cryopreserved material.

Detection of endometrial pinopodes by light microscopy

OBJECTIVE

To study the value of light microscopy (LM) in the assessment of endometrial pinopodes.

DESIGN

Comparative histologic study.

SETTING

Outpatient infertility clinic in an academic teaching institution.

PATIENT(S)

Eighteen oocyte donors undergoing controlled ovarian hyperstimulation.

INTERVENTION(S)

Endometrial biopsies on days 14-24 of the cycle.

MAIN OUTCOME MEASURE(S)

Assessment of pinopodes by scanning electron microscopy (SEM) and of endometrial surface projections by LM.

RESULT(S)

The luminal surface was identified by LM in 36 of 38 endometrial specimens obtained. Although apical projections could be recognized in all, they were few, moderate, and abundant in 20, 12, and 4 cases, respectively. Pinopodes were detected by SEM in all 4 samples with abundant projections, but in only 14 of 32 samples with lesser quantities of these surface features. No predictive value could be ascribed to apical projections viewed by LM for the developmental stage of pinopodes as defined by SEM.

CONCLUSION(S)

The LM of routine endometrial specimens can serve as a preliminary tool in the evaluation of surface morphology. Although abundant apical projections by LM are compatible with the presence of pinopodes by SEM, the latter modality remains as the definitive method in cases with few or moderate projections and for the evaluation of the stage of pinopode development.

Histochemical localization of endometrial insulin-like growth factor binding protein-1 and -3 during the luteal phase in controlled ovarian hyperstimulation cycles: a controlled study

OBJECTIVE

To determine if controlled ovarian hyperstimulation (COH) affects the endometrial expression of IGFBP-1 and IGFBP-3.

DESIGN

Prospective, controlled study.

SETTING

Tertiary infertility clinic.

PATIENT(S)

Eighteen oocyte donors undergoing COH cycles and 17 natural cycle controls.

INTERVENTION(S)

Controlled ovarian hyperstimulation, endometrial biopsies.

MAIN OUTCOME MEASURE(S)

Immunohistochemical scoring of endometrial IGFBP-1 and -3 expression, morphological endometrial dating, and serum estradiol (E(2)), LH, and progesterone (P(4)) concentrations.

RESULT(S)

No statistically significant difference was observed between natural and stimulated cycles in change in IGFBP-1 or -3 over standardized cycle days throughout the window of embryo implantation (days 17-24). The IGFBP-1 and -3 expression was zero or near zero for both the natural and COH cycles until day 12-13. Both IGFBPs showed increased production throughout the secretory phase. Advanced endometrial histology (>/=1 day) in glands and stroma was noted in COH cycles. Significant positive correlations of E(2) and P(4) were noted with IGFBP-1 and -3 but not with advanced endometrial morphology in the COH cycles.

CONCLUSION(S)

The COH cycles have no significantly increased endometrial IGFBP-1 or -3 expression throughout the implantation phase of the luteal cycle compared with normal menstrual cycles. Both IGFBPs were absent in the proliferative phase and increased throughout the secretory portion of the embryo implantation window.

Endometrial glycodelin-A expression in the luteal phase of stimulated ovarian cycles

OBJECTIVE

To determine if controlled ovarian hyperstimulation (COH) affects the endometrial expression of glycodelin-A (GdA).

DESIGN

Prospective, controlled study.

SETTING

Tertiary infertility clinic.

PATIENT(S)

Fifteen oocyte donors undergoing COH cycles and 19 natural-cycle control patients.

INTERVENTION(S)

COH, endometrial biopsies.

MAIN OUTCOME MEASURE(S)

Immunohistochemical scoring of endometrial GdA expression, morphologic endometrial dating, and serum E2, LH, and P4 concentrations.

RESULT(S)

GdA was detected in all subjects throughout the implantation window period. Immunolocalization was demonstrated in the endometrial glands and not in the stroma or on the surface. A significantly increased proportion of GdA-staining endometrial cells were noted in COH cycle patients as compared with natural-cycling control patients throughout the window of embryo implantation. Both cycle types demonstrated increasing GdA expression throughout the late luteal phase. A significant positive correlation was noted between GdA expression and serum E2 levels (r = 0.5, P<.001) in natural cycles and advanced histology in COH cycles (r = 0.63, P=.01). Neither LH nor P4 were correlated with endometrial GdA expression.

CONCLUSION(S)

COH cycles have a significantly increased endometrial GdA expression throughout the implantation phase of the luteal cycle when compared with normal menstrual cycles. The increased expression may affect implantation during COH cycles.

Surface morphology of the human endometrium. Basic and clinical aspects

The human endometrium is an extremely sensitive target for steroid hormones. During the menstrual cycle, this tissue undergoes dynamic changes that are reflected on the surface morphology of the epithelium and that can be followed by scanning electron microscopy. The morphologic changes peak at the midsecretory phase, with the formation of the so-called pinopodes. Increasing evidence suggests that these pinopodes are accurate markers for endometrial receptivity, and their detection may be of high clinical utility in the preparation of endometrium before embryo transfer. This article recapitulates published figures of endometrial ultrastructure and presents some unpublished data from ongoing studies.

Evidence for oxidised low density lipoprotein in synovial fluid from rheumatoid arthritis patients

The oxidative modification of human LDL has been implicated in atherosclerosis, but the mechanisms by which such modification occurs in vivo are not fully understood. In the present study, we have isolated LDL from knee-joint synovial fluid of patients with rheumatoid arthritis. We demonstrate that such LDL is oxidatively modified as evidenced by an increased negative charge, distorted particulate nature and more rapid degradation by cultured macrophages. These results indicate that formation of oxidised LDL is associated with the local inflammatory response. Because the cellular interactions in rheumatoid arthritis have analogies with those in atherogenesis, we suggest that the rheumatoid joint is a useful model of atherosclerosis in which the in vivo process of LDL oxidation may be readily studied.

Variations in plasma levels of substance P and effects of a specific substance P antagonist of the NK(1) receptor on preovulatory LH and FSH surges and progesterone secretion in the cycling cynomolgus monkey

These studies investigated the role of substance P (SP) in the regulation of the hypothalamic-pituitary-ovarian axis in cynomolgus monkeys with normal menstrual cycles. Plasma concentrations of SP were determined in blood samples taken every morning in normally menstruating cynomolgus monkeys throughout the menstrual cycle. There was a significant decreasing linear trend of SP during the follicular phase (cycle day -13 to day 0) and a significant inverse relationship between SP plasma values and plasma 17beta-estradiol (E(2)) values from day -13 to day 0 of the adjusted cycle. Correspondingly, SP area under the curve was significantly greater during the follicular phase than the luteal phase. In a second experiment, plasma concentrations of E(2), luteinizing hormone (LH), follicle-stimulating hormone (FSH) and progesterone and length of cycles were measured after five daily intragastric administrations (10 mg/kg) of an NK(1) receptor (SP receptor) antagonist (RPR 100893; 10 mg/kg) initiated after serum E(2) concentrations had exceeded 125 pg/ml. There was a statistically significant reduction in the amplitude (41% of control) and the area under the curve (37% of control) of the preovulatory LH surge. In addition, there was a reduction of the duration of the LH surge (3 +/- 0.1 days in controls vs. 2.1 +/- 0.2 days in treated animals). The present results show for the first time that there are significant variations in plasma levels of SP, with a strong negative correlation with serum levels of E(2) during the follicular phase of the cynomolgus monkey, and that endogenous SP has a potentiating role in the interactive hypothalamo-anterior-pituitary mechanisms which lead to the preovulatory LH and FSH surges during the menstrual cycle in the monkey.

Public perception on infertility and its treatment: an international survey. The Bertarelli Foundation Scientific Board

The first large survey on the public perception of infertility and its treatment was conducted in six European countries, the USA and Australia. A representative sample of 8194 adults was polled, using standard validated methodology. The results obtained highlighted the following major aspects: (i) infertility is perceived as a disease by less than half of the people surveyed (38%), in contrast to the accepted medical opinion; (ii) awareness about the definition and incidence of infertility is relatively low, despite the fact that half of the people polled claimed to know someone affected by infertility; (iii) close to 90% of the adults surveyed knew about in-vitro fertilization (IVF), but less than one-quarter of them knew about the chances of success of this assisted reproductive technology; and (iv) when confronted with the knowledge that the cost of three IVF cycles is roughly equivalent to the cost of a hip replacement (a commonly reimbursed procedure), a large majority (70%) of the individuals interviewed agreed that IVF should be reimbursable.

New reproductive technologies

The ethical calculus is described. There are four entities that have a stake in all ethical decisions. These are the individual, family, community and society at large. Values assigned to these entities can be modified by experience, cultural background, religious authority and the law. In the simple case of in vitro fertilization (IVF), there seems to be general international acceptance, except for the official position of the Roman Catholic Church, the origin of which dissent is extensively discussed. There is concern about the number of pre-zygotes/pre-embryos to be transferred, the disposition of any unfertilized egg and the reporting of results. Clear ethical considerations arise as IVF is applied in more complex situations, such as unmarried couples, the use of donor gametes and donor pre-embryos, the use of cryopreservation, intracytoplasmic sperm injection (ICSI), prenatal genetic diagnosis, surrogate gestational motherhood and research on the pre-embryo. The ethical, religious and legal acceptance of these depends on the weight given to elements of the ethical calculus as described in the chapter.

The psychological status at school age of children conceived by in-vitro fertilization

This study assessed the behavioural and psychological profiles of children conceived by in-vitro fertilization (IVF) who are now at school age. A total of 743 IVF children born at one institution and now of school age, over 4 years old, were surveyed with Achenbach questionnaires. Follow-up telephone interviews were conducted with non-responders. The results from the study group were compared to the questionnaire control group using one-tailed t-test with statistical significance set less than 0.05. There was an 84% overall response rate. Sixty-seven per cent returned questionnaires. An additional 17% completed a telephone interview. The study group had no statistically significant increase in the rate of behavioural or psychological problems compared with the control group. There were no statistically significant differences within the study group related to sex or to multiple gestation IVF births. This large group of school-age IVF children has normal psychological development with no identified adverse effect of their status as IVF children. Determining the role, if any, of IVF in the very small number of children with behavioural and psychological problems will require additional study.

Endometrial estrogen and progesterone receptor and pinopode expression in stimulated cycles of oocyte donors

OBJECTIVE

To study the effect of controlled ovarian hyperstimulation and the ovarian response on several features of endometrial morphology simultaneously.

DESIGN

Prospective controlled study.

SETTING

Academic infertility center.

PATIENT(S)

Twenty-five oocyte donors undergoing COH and 10 ovulatory controls.

INTERVENTION(S)

Endometrial biopsies during the luteal phase and measurement of serum E2 and progesterone levels on days 12, 13, and 18-20.

MAIN OUTCOME MEASURE(S)

Endometrial morphology as judged by histologic dating, pinopode expression, and estrogen and progesterone receptor content.

RESULT(S)

Controlled ovarian hyperstimulation caused the early expression of endometrial features as judged by histologic dating criteria, estrogen and progesterone receptor expression, and the timing of pinopode expression in many of the subjects. A significant correlation within subjects with regard to their particular result on any one measure (e.g., histologic examination) and the others (e.g., estrogen and progesterone receptors, pinopodes) was observed. Those with higher levels of progesterone the day after hCG administration exhibited the most prematurity of morphologic features.

CONCLUSION(S)

Many controlled ovarian hyperstimulation cycles are associated with synchronous early expression of the expected pattern of histologic features, estrogen and progesterone receptors, and pinopodes. The most predictive feature of this premature expression was the level of progesterone the day after hCG administration.

The detection of DNA from a range of bacterial species in the joints of patients with a variety of arthritides using a nested, broad-range polymerase chain reaction

OBJECTIVE

Bacteria have been implicated in the pathogenesis of many types of inflammatory arthritides. The aim of this study was to identify any bacterial DNA in synovial fluid (SF) from patients with a range of inflammatory arthritides.

METHODS

A highly sensitive, broad-range, nested polymerase chain reaction (PCR) protocol targeting the bacterial 16S rRNA gene was designed and applied to SF from 65 patients with a range of rheumatic diseases.

RESULTS

Bacterial DNA was detected in 26 SF samples, including eight from patients with rheumatoid arthritis and five with juvenile arthritides. PCR products were identified by sequencing and searching of bacterial genomic databases; 'best fits' included Haemophilus influenzae, Bordetella and Yersinia.

CONCLUSIONS

These finding suggest an association between bacterial infection and inflammatory arthritides in some patients. Further research is required to determine the role of these organisms in the pathogenesis and whether such patients might respond to prolonged antibiotic therapy.

Endometrial pinopodes indicate a shift in the window of receptivity in IVF cycles

The formation of endometrial pinopodes detected by scanning electron microscopy may be a specific marker for uterine receptivity. Aiming to assess the effects of ovarian stimulation on pinopode formation, we examined sequential endometrial biopsies from 17 oocyte donors. Seven normally menstruating women served as controls. Up to four samples were taken from each woman at 24-72 h intervals between days 14 and 24, giving a total of 69 samples. The day of oocyte retrieval was designated day 14 in ovarian stimulation cycles and the day of luteinizing hormone surge was designated day 13 in natural cycles. Endometrial morphology and pinopode numbers were similar in both groups. Fully developed pinopodes appeared in only one sample per cycle, indicating their short life span. However, the cycle day these structures appeared varied up to 5 days between women and the distribution was as follows: day 18 (n = 2), day 19 (n = 7), day 20 (n = 4), day 21 (n = 3), day 22 (n = 1) in ovarian stimulation cycles, and day 20 (n = 2), day 21 (n = 2), day 22 (n = 3) in natural cycles. Furthermore, accelerated pinopode formation in ovarian stimulation cycles was positively correlated with day 13 progesterone. Our findings show that ovarian stimulation does not affect endometrial pinopode formation in terms of quantity and life span. The cycle days when pinopodes form are specific to the individual, being on average 1-2 days earlier in ovarian stimulation than in natural cycles. These changes in pinopode expression may reflect shifts in the window of receptivity, resulting in ovo-endometrial asynchrony and limiting implantation success in in-vitro fertilization.

Plasma substance-P and substance-K and gonadal steroids in relation to the gonadotropin surge in normal human reproductive cycles

PURPOSE

This study was designed to examine changes in peripheral plasma substance-P and -K levels, their association with follicle-stimulating hormone and luteinizing hormone release in normal reproductive cycles in humans, and their correlation with plasma estradiol and progesterone.

METHODS

Fourteen healthy, normally menstruating women underwent daily blood sampling (cycle day 4, 4-14 days) for measurement of estradiol, progesterone, luteinizing hormone, and follicle-stimulating hormone, substances-P and -K, and daily transvaginal ultrasounds assessing follicular growth and documentation of ovulation.

RESULTS

Estradiol peaked on day 13, luteinizing hormone and follicle-stimulating hormone peaked on day 14, and progesterone began an exponential increase on about day 13.

CONCLUSIONS

In contrast to other experimental designs using in vitro or in vivo rat or monkey tissue, peripheral levels of substances-P (P = 0.8391) and -K (P = 0.3205) reflected no modulation related to midcycle gonadotropin release in cycling woman.

An analysis of discharge drug prescribing amongst elderly patients with renal impairment

Renal impairment is common amongst elderly patients and increases the risk of drug toxicity. Analysis of the discharge summaries of patients discharged from the geratology wards of an Oxfordshire hospital, showed that renal impairment was not referred to in 42% of patients with calculated creatinine clearances of 10-20 ml/min. A fifth of these patients, and 67% of patients with calculated creatinine clearances < 10 ml/min, had discharge drug prescriptions that contradicted the British National Formulary guidelines for prescribing in the presence of renal impairment. There should be increased awareness that, in elderly patients, normal serum creatinine concentrations do not exclude renal impairment and that several commonly prescribed drugs require dose adjustments or should be avoided in the presence of renal insufficiency.

Inactivation of antithrombin III in synovial fluid from patients with rheumatoid arthritis

OBJECTIVE

To investigate the thrombin inhibitory capacity of antithrombin III in the inflamed human joint.

METHODS

Thrombin inhibitory capacity was measured, using a kinetic spectophotometric method, in matched plasma and synovial fluid samples of patients with rheumatoid arthritis (n = 22) and osteoarthritis (n = 16), together with normal control plasma samples (n = 13). In the same samples, the concentration of antithrombin III was also determined by the method of radial immunodiffusion. The combination of these measurements allowed the calculation of the specific thrombin inhibitory capacity of these samples.

RESULTS

An increased concentration of antithrombin III in rheumatoid compared with osteoarthritic synovial fluid was noted (p < 0.05). However, there was a significant depression in the specific activity of antithrombin III in rheumatoid synovial fluid when compared with matched plasma samples (p < 0.001) or with osteoarthritic synovial fluid (p < 0.05).

CONCLUSION

In rheumatoid synovial fluid the thrombin inhibitory capacity of antithrombin III is disproportionately depressed relative to the concentration of antithrombin III, indicating the inactivation of antithrombin III in the rheumatoid joint.

Cryopreservation: the practicalities of evaluation

An attempt was made to integrate data from cryopreserved embryos with those from fresh embryos to obtain a realistic assessment of the role of cryopreservation in assisted reproductive treatment. Principles were applied to previously published data from a large prospective randomized multicentre study comprising recombinant and urinary follicle stimulating hormone in in-vitro fertilization.

Cryopreservation: a simplified method of evaluation

A theoretical model is presented by which a true expression of pregnancy rate resulting from stimulated cycles can be calculated. This includes the transfer of both fresh and cryopreserved embryos. It is concluded that the total reproductive potential of a single cycle of stimulation can only be evaluated by including pregnancies arising from all fresh and frozen embryo transfers resulting from that cycle.