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Endocrinologist (diabetes, hormones), Obstetrician & Gynecologist (OB/GYN)
40 years of experience

Video profile

Credentials

Education ?

Medical School Score
Louisiana State University at New Orleans (1972)
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Awards & Distinctions ?

Awards  
One of America's Leading Experts on:
Female Infertility
Hysterectomy
Uterine Cancer (Uterine Neoplasm)
Uterine Diseases
Distinguished Surgeon Award, American Society for
Guide to America's Top Obstetricians and Gynecolog
America's Top Doctors 2001 - Present
Special Recognition Award, LSU Alumni Association
On-Time Doctor Award (2015)
Appointments
Florida International Univ. College Of Medicine
DEAN COLLEGE OF MEDICINE PROFESSOR OF OBSTETRICS AND GYNECO
Associations
Hormone Foundation
American Board of Obstetrics and Gynecology
American Society for Reproductive Medicine

Affiliations ?

Dr. Rock is affiliated with 11 hospitals.

Hospital Affiliations

Score

Rankings

  • South Miami Hospital Inc
    6200 SW 73rd St, South Miami, FL 33143
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    Top 25%
  • Healthsouth Doctors' Hospital
    5000 University Dr, Miami, FL 33146
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    Top 25%
  • Baptist Hospital Of Miami Inc
    8900 N Kendall Dr, Miami, FL 33176
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    Top 25%
  • Miami Children's Hospital
    Obstetrician & Gynecologist
    3100 SW 62nd Ave, Miami, FL 33155
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  • Mount Sinai Medical Center
    4300 Alton Rd, Miami Beach, FL 33140
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  • Childrens Hosp, New Orleans, La
  • Jackson North Medical Center
  • Doctors Hospital
    5000 University Dr, Miami, FL 33146
  • Jackson North
    160 NW 170th St, North Miami Beach, FL 33169
  • Baptist Health Care System
  • Jackson North Medical Center - N Miami Beach
  • Publications & Research

    Dr. Rock has contributed to 163 publications.
    Title Congenital Anomalies of the Uterine Cervix: Lessons from 30 Cases Managed Clinically by a Common Protocol.
    Date November 2010
    Journal Fertility and Sterility
    Excerpt

    To outline the anatomic variations of malformations of the uterine cervix and to discuss the clinical management of cervical agenesis and dysgenesis.

    Title 17beta-hydroxysteroid Dehydrogenase 3 Deficiency in a Male Pseudohermaphrodite.
    Date January 2008
    Journal Fertility and Sterility
    Excerpt

    OBJECTIVE: To present the clinical, biochemical, and genetic features of a male pseudohermaphrodite whose condition was caused by 17beta-hydroxysteroid dehydrogenase 3 (17beta-HSD3) deficiency. DESIGN: Case report. SETTING: Gynecology practice in a university teaching hospital. PATIENT(S): A 15-year-old black American male pseudohermaphrodite with 17beta-HSD3 deficiency. INTERVENTION(S): Laboratory evaluation, genetic mutation analysis, bilateral gonadectomy, and hormone replacement. MAIN OUTCOME MEASURE(S): Endocrinologic evaluation and genetic analysis. RESULT(S): A diagnosis of 17beta-HSD3 deficiency made on the basis of hormone evaluation was confirmed through genetic mutation analysis of the HSD17B3 gene. Female phenotype was attained after gonadectomy, passive vaginal dilatation, and hormone therapy. CONCLUSION(S): Deficiency of 17beta-HSD3 was diagnosed in this patient on the basis of endocrinologic evaluation and was confirmed with genetic mutation analysis. The patient was able to retain her female sexual identity after surgical and medical treatment.

    Title In Memoriam: Georgeanna Seegar Jones, M.d.: Her Legacy Lives On.
    Date December 2005
    Journal Fertility and Sterility
    Title An International Program for the Assessment of Tubal Anastomosis by Microsurgical Technique: a Preliminary Report.
    Date December 2005
    Journal Journal of Microsurgery
    Excerpt

    This report outlines a microsurgical training program that has established 16 centers around the world for the reversal of sterilization by microsurgical technique and for the evaluation of such procedures. An obstetrician-gynecologist was selected from each of several developing countries where an existing family planning program was responsible for a large number of sterilization procedures. Each course participant attended a 2-week course in microsurgical techniques for tubal anastomosis and then returned to his or her home country to establish a microsurgical center for sterilization reversal. Each of these centers has since been evaluated by the program director and is fully operational.

    Title Microsurgery for Tubal Reconstruction Following Falope-ring Sterilization in Swine.
    Date December 2005
    Journal Journal of Microsurgery
    Excerpt

    Thirteen domestic swine underwent laparotomy and sterilization using the Falope-Ring. The silastic band was applied to the isthmus in 6 swine, and to the isthmic-ampullary junction in 7 swine. Tubal reconstruction was performed using the OPMI-6 Zeiss operating microscope. Pregnancy was observed in 5 (83%) of 6 swine following isthmic-isthmic anastomosis, and in 5 (71%) of 7 swine following isthmic-ampullary anastomosis. Overall, 10 (77%) of 13 swine conceived following tubal anastomosis. An advantage to the placement of the Falope-Ring in the isthmus of the swine oviduct could not be demonstrated by chi-square analysis.

    Title Randomized, Double-blind Comparison of Immediate-release Omeprazole Oral Suspension Versus Intravenous Cimetidine for the Prevention of Upper Gastrointestinal Bleeding in Critically Ill Patients.
    Date May 2005
    Journal Critical Care Medicine
    Excerpt

    OBJECTIVE: To demonstrate that a new immediate-release omeprazole oral suspension is effective in preventing upper gastrointestinal bleeding in critically ill patients. DESIGN: A noninferiority analysis was used to compare rates of clinically significant upper gastrointestinal bleeding in a prospective, phase 3, double-blind trial with parallel omeprazole suspension and cimetidine treatment groups. SETTING: A total of 47 intensive care units in the United States. PATIENTS: A total of 359 critically ill patients who required mechanical ventilation for > or =48 hrs, had an Acute Physiology and Chronic Health Evaluation score of > or =11 at baseline, had an intact stomach with a nasogastric or orogastric tube in place, and had at least one additional risk factor for upper gastrointestinal bleeding. INTERVENTIONS: Patients were randomized to treatment with omeprazole suspension (two 40-mg doses on day 1, via orogastric or nasogastric tube, and 40 mg each day thereafter) or intravenous cimetidine (300-mg bolus and 50 mg/hr thereafter) for up to 14 days. Gastric aspirates were sampled for bleeding and pH. Medication doses were doubled for failure of pH control (two successive aspirates with pH < or = 4). MEASUREMENTS AND MAIN RESULTS: Clinically significant upper gastrointestinal bleeding (bright red blood not clearing after 5-10 mins of lavage or persistent Gastroccult-positive "coffee-grounds" material for 8 hrs on days 1-2 or for 2-4 hrs on days 3-14 and not clearing with > or =100 mL of lavage) was the primary end point of the trial. The rate of clinically significant bleeding in the per-protocol population was 4.5% with omeprazole suspension and 6.8% with cimetidine, meeting the criteria for the noninferiority of omeprazole suspension. Median gastric pH was > or =6 on all trial days with omeprazole suspension treatment and on 50% of days with cimetidine treatment (p < .001, all trial days). In the omeprazole suspension group, median gastric pH was >4 on each trial day in 95% of patients. CONCLUSIONS: Immediate-release omeprazole suspension is effective in preventing upper gastrointestinal bleeding and more effective than intravenous cimetidine in maintaining gastric pH of >4 in critically ill patients.

    Title The Current Staging System for Endometriosis: Does It Help?
    Date June 2003
    Journal Obstetrics and Gynecology Clinics of North America
    Excerpt

    A multicenter collaboration for data collection and statistical analysis may be necessary to establish and validate a classification system based on empirically derived scores for specific pathologic observations. The endometriosis pain instrument may be a tool for some of those variables with regard to pelvic pain. A similar strategy for uniform collection of data for analysis of important factors also is necessary for infertility. The challenge of creating a satisfactory classification of endometriosis remains. The ability of the current classification schemes to predict pregnancy outcome or aid in the management of pelvic pain is recognized to be inadequate. Further revisions of the current classification scheme are anticipated as the understanding of how endometriosis contributes to infertility and pelvic pain evolves. In any revision of the classification system, use of empirically derived weights and breakpoints to define disease stages based on outcome data in larger clinical trials should be attempted. It is also possible that additional factors, such as CA-125 level or lesion characteristics, may be shown to play an important role in prognosis. If so, these must be accounted for in the classification scheme. Careful and consistent use of the recommendations of the American Society for Reproductive Medicine classification of endometriosis subcommittee should allow for collection of data for use in further revisions. It is possible that a classification scheme that is designed to predict outcome with respect to pregnancy may be totally inadequate in assessing patients who have endometriosis and pelvic pain. Factors found to be important in the assessment of pelvic pain may be different from those involved with the pathophysiology of endometriosis and infertility. The AFS form suggested for use in the management of endometriosis in the presence of pelvic pain allows for recording of variables such as depth of invasion, histology, and documenting adjunct investigations and preoperative physical findings. Such prospective data collection and review in large centers may provide a large clinical base from which to derive empirical point scores and breakpoints in a classification scheme.

    Title Cox-2 Inhibitors and Their Role in Gynecology.
    Date March 2003
    Journal Obstetrical & Gynecological Survey
    Excerpt

    This review summarizes current knowledge about the roles of cyclooxygenases and prostaglandins in reproductive medicine. With the development of COX-2 specific inhibitors, new therapeutic options are available to obstetricians and gynecologists, offering better-tolerated alternatives to conventional NSAIDs. The analgesic effectiveness of COX-2 specific inhibitors is well established, and they are already in use in a range of painful conditions. Both celecoxib and valdecoxib are indicated for the treatment of primary dysmenorrhea, and may be effective in postoperative pain, including hysterectomy, and pain associated with endometriosis. There is also speculation that COX-2 specific inhibitors may be effective tocolytic agents without the risks to the fetus seen with conventional NSAIDs. The role of COX-2 in oncogenesis is also under investigation, and COX-2 specific inhibitors may eventually be used in the prevention and treatment of gynecologic malignancies. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be able to describe the two types of cylooxygenase enzymes (COX), to list the effects and side effects of NSAIDs and COX-2 medications, and to outline the various changes in COX expression during pregnancy.

    Title Treatment of Vaginal Agglutination Associated with Chronic Graft-versus-host Disease.
    Date December 2002
    Journal Fertility and Sterility
    Excerpt

    OBJECTIVE: To describe the presentation and clinical course of two patients after development of vaginal agglutination associated with chronic graft-versus-host disease. DESIGN: Case report. SETTING: Tertiary referral center for pelvic reconstructive surgery. PATIENT(S): Two patients with the diagnosis of chronic graft-versus-host disease who later developed vaginal agglutination requiring treatment. INTERVENTION(S): Surgical lysis of vaginal adhesions and postoperative use of vaginal dilators. MAIN OUTCOME MEASURE(S): Successful treatment of vaginal adhesions. RESULT(S): Both patients underwent successful surgical lysis of vaginal adhesions and maintained vaginal patency with postoperative use of vaginal dilators. CONCLUSION(S): Prompt diagnosis of vaginal agglutination in patients with chronic graft-versus-host disease and appropriate surgical correction of this complication rather than prophylaxis is the correct treatment course.

    Title Ambiguous Genitalia with Perineoscrotal Hypospadias in 46,xy Individuals: Long-term Medical, Surgical, and Psychosexual Outcome.
    Date October 2002
    Journal Pediatrics
    Excerpt

    OBJECTIVES: To identify and study adults (21 years or older) who have a 46,XY karyotype and presented as infants or children with genital ambiguity, including a small phallus and perineoscrotal hypospadias, reared male or female. METHODS: Participants were classified according to the cause underlying their intersex condition based on review of medical and surgical records. Long-term medical and surgical outcome was assessed with a written questionnaire and physical examination. Long-term psychosexual development was assessed with a written questionnaire and semistructured interview. RESULTS: Thirty-nine (72%) of 54 eligible patients participated. The cause underlying genital ambiguity of participants included partial androgen insensitivity syndrome (n = 14; 5 men and 9 women), partial gonadal dysgenesis (n = 11; 7 men and 4 women), and other intersex conditions. Men had significantly more genital surgeries (mean: 5.8) than women (mean: 2.1), and physician-rated cosmetic appearance of the genitalia was significantly worse for men than for women. The majority of participants were satisfied with their body image, and men and women did not differ on this measure. Most men (90%) and women (83%) had sexual experience with a partner. Men and women did not differ in their satisfaction with their sexual function. The majority of participants were exclusively heterosexual, and men considered themselves to be masculine and women considered themselves to be feminine. Finally, 23% of participants (5 men and 4 women) were dissatisfied with their sex of rearing determined by their parents and physicians. CONCLUSIONS: Either male or female sex of rearing can lead to successful long-term outcome for the majority of cases of severe genital ambiguity in 46,XY individuals. We discuss factors that should be considered by parents and physicians when deciding on a sex of rearing for such infants.

    Title 46,xy Intersex Individuals: Phenotypic and Etiologic Classification, Knowledge of Condition, and Satisfaction with Knowledge in Adulthood.
    Date October 2002
    Journal Pediatrics
    Excerpt

    OBJECTIVES: The objective of this study was to identify and study adults who have a 46,XY karyotype and presented as infants or children with variable degrees of undermasculinization of their genitalia (female genitalia, ambiguous genitalia, or micropenis). Participants' knowledge of their condition, satisfaction with their knowledge, and desire for additional education about their intersex condition were assessed. METHODS: Participants were classified according to the cause underlying their intersex condition based on review of medical and surgical records. Knowledge of medical condition, satisfaction with that knowledge, and desire for additional education were assessed with a written questionnaire and a semistructured interview. RESULTS: Patients were ineligible for recruitment because of death (9%), because of developmental delay (12%), or because they were not located (27%). Among the 96 eligible patients, 78% participated. Approximately half of the men (53%) and women (54%) exhibited a good understanding of their history. Fewer women who have a 46,XY chromosome complement and were born with female genitalia were informed about their intersex condition (36% with complete androgen insensitivity syndrome) than were women who were born with masculinized genitalia such as micropenis (80%) or ambiguous genitalia (72%). More women (66%) than men (38%) were satisfied with their knowledge of their medical and surgical history. CONCLUSIONS: Almost half of the patients, reared male or female, were neither well informed about their medical and surgical history nor satisfied with their knowledge.

    Title Congenital Micropenis: Long-term Medical, Surgical and Psychosexual Follow-up of Individuals Raised Male or Female.
    Date April 2002
    Journal Hormone Research
    Excerpt

    OBJECTIVES: To document long-term medical, surgical and psychosexual outcome of individuals with congenital micropenis (13 males, 5 females). METHODS: Physical measurements from childhood were collected retrospectively from medical records and at adulthood by physical examination. An adult psychosexual assessment was conducted with a written questionnaire and oral discussion. RESULTS: Adult penile length was below the normal mean in all men. Three women had vaginoplasty resulting in normal length. All men reported good or fair erections but 50% were dissatisfied with their genitalia. Dissatisfaction with body image resulted from having a small penis (66%), inadequate body hair (50%), gynecomastia (33%) and youthful appearance (33%). Ten men were heterosexual, 1 homosexual and 2 bisexual. Among women, 4 (80%) were dissatisfied with their genitalia. Three women reported average libido with orgasm and were also heterosexual. Two women had no sexual interest or experience. Finally, males were masculine and females feminine in their gender-role identity, and both groups were satisfied with their sex of rearing. CONCLUSIONS: Regarding choice of gender, male sex of rearing can result in satisfactory genito-sexual function. Female gender can also result in success, however it requires extensive feminizing surgery.

    Title Vaginal Creation for Müllerian Agenesis.
    Date January 2002
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The purpose of this study was to determine the effectiveness of passive vaginal dilation and McIndoe vaginoplasty in the creation of a neovagina for patients with müllerian agenesis. STUDY DESIGN: Fifty-one patients with Mayer-Rokitansky-Kuster-Hauser syndrome were treated for vaginal agenesis at either Johns Hopkins Hospital or Emory University. These historic prospective data were obtained by a review of medical records and a current office or telephone consultation. Initial office visits dated from November 18, 1983, through June 6, 1998. Their progress towards both anatomic and functional success was followed through August 1, 2000, which was a range of 2 to 16.8 years. One-way analysis of variance, Student t test, and logistic regression analysis were performed when appropriate. RESULTS: Four patients were lost to follow-up in various stages of the treatment. Ten patients refused vaginal dilation and proceeded to a successful modified McIndoe vaginoplasty. Of the 37 remaining patients, 91.9% anatomic and functional success was achieved from the Ingram method for vaginal dilation. Passive dilation failed in 8.1% of patients, who underwent a modified McIndoe vaginoplasty; all neovaginal creations were successful. All patients who underwent McIndoe vaginoplasty were compliant with postoperative vaginal form use. None of our patients lost vaginal space through contractions or loss of skin graft. Of those patients for whom dilation failed, only 1 patient discontinued the study because of bleeding and discomfort. In addition, only 1 patient from the 3 cases of failure had undergone a previous hymenotomy. Interestingly, 6 patients for whom dilation was successful (6/34 patients; 17.6%) had also undergone a previous hymenotomy. The mean follow-up time for all patients in this study was 111.1 +/- 7.2 months, with a range of 25 to 188 months. The mean follow-up time for those patients for whom dilation failed or who refused dilation was significantly lower at 64.5 +/- 9.5 and 65.3 +/- 18.5 months, respectively (P <.005). The mean time to successful dilation was 11.8 +/- 1.6 months with a range of 3 to 33 months. Although longer, no statistically significant difference was observed for dilation time in those patients for whom there was a failure to achieve anatomic or functional success (20.5 +/- 12.5 months; range, 8-33 months). CONCLUSION: These data reveal that passive dilation with the Ingram method is capable of creating an adequate vaginal canal in patients with vaginal agenesis, with respect to both function and anatomy even in those patients with a previous hymenotomy and resultant scar formation. Our modified McIndoe procedure has proved to be an excellent option for patients for whom conservative dilation techniques failed and who refuse to attempt any dilation. Interestingly, our data indicate that patients may now be trending toward immediate surgical correction rather than diligently using dilation techniques to create a vaginal space.

    Title Quality-of-life Assessment in Gynecologic Surgery.
    Date October 2001
    Journal The Journal of Reproductive Medicine
    Excerpt

    More than 90% of gynecologic surgery is performed for nonmalignant conditions, with a major objective of improving the patient's health-related quality of life (QOL). Clinical studies and patient surveys demonstrate that fatigue, diminished energy levels, increased need for rest, delayed time to return to work, difficulty performing daily routines, and difficulty caring for family and home persist for weeks to months or more following surgery. The social and economic implications of these outcomes provide a rationale for improving the QOL of gynecologic patients in the early weeks of recovery from surgery. Persistent and debilitating fatigue, which can lead to diminished QOL, is even more common than pain following hysterectomy. Global and specific subjective self-assessment instruments have been developed to measure fatigue as well as QOL parameters in postoperative gynecologic surgery patients. In addition, a QOL instrument combining both subjective self-assessment scales and objective measures of hemoglobin, hematocrit and muscle strength has been validated in postoperative orthopedic patients and may also have application in gynecologic surgery patients. Collectively, these various instruments may be useful in the assessment of recuperative power and vitality during early postoperative recovery in patients undergoing gynecologic surgery.

    Title Angiogenic Role for Glycodelin in Tumorigenesis.
    Date August 2001
    Journal Proceedings of the National Academy of Sciences of the United States of America
    Excerpt

    Angiogenesis plays an important role in neovascularization in tumors. Glycodelin, a hormone-responsive protein, has been detected in tumors of reproductive organs and is found in high levels in the plasma of subjects with gynecological malignancies. Glycodelin is also found in the endothelial cells of the umbilical cord and in the blood vessels of tumors. In this study, we tested whether glycodelin-rich amniotic fluid and a synthetic peptide derived from the sequence of glycodelin peptide (Gp) might promote angiogenic response by examining the migration and tube formation in human umbilical cord vein endothelial cells (HUVECs). Increased migration and tube formation of HUVECs were found in the presence of amniotic fluid and Gp, and this increase was blocked by antibody to Gp and by an anti-vascular endothelial growth factor (VEGF) antibody, suggesting that the angiogenic effects of glycodelin might be mediated by VEGF. The results also showed that Gp significantly increased the release of VEGF protein and mRNA expression in HUVECs, RL-95 (human endometrial carcinoma cells), OVCAR-3 (human ovarian adenocarcinoma cells), EM42 (human endometrial epithelial cells), THP-1 (human monocyte), and MCF-7 and MDA-MB-231 (human breast adenocarcinoma cells) cell lines. VEGF receptor Fit-1 mRNA expression in HUVECs was also increased in the presence of Gp. These findings, together with the suggestion from the literature that glycodelin may have immunosuppressive properties, suggest that glycodelin might play an important role in neovascularization during embryogenesis and tumor development.

    Title Retinoic Acid Suppresses Interleukin-6 Production in Human Endometrial Cells.
    Date June 2000
    Journal Fertility and Sterility
    Excerpt

    OBJECTIVE: To determine whether retinoic acid (RA) can regulate the expression of interleukin (IL)-6 in human endometrial cells in a manner that might be beneficial to women with endometriosis. DESIGN: In vitro study. SETTING: Academic medical center. PATIENT(s): Patients with endometriosis and controls. INTERVENTION(s): Endometrial cell cultures were treated with RA. MAIN OUTCOME MEASURE(s): Interleukin-6 protein secretion, messenger RNA expression, and IL-6-promoter activity. RESULT(s): Using a human endometrial cell line (EM42), as well as primary stromal and epithelial endometrial cells, we demonstrated that RA suppresses IL-6 protein and messenger RNA expression in a time- and dose-dependent fashion, showing maximal effects at pharmacologically achievable blood serum concentrations (micromoles per liter). Retinoic acid specifically inhibited the activity of IL-6-promoter reporter constructs that were transiently transfected into EM42 cells. Mutational analysis of reporter constructs indicated that RA suppression of IL-6 expression was mediated, at least in part, through the nuclear factor IL-6 binding site located in the IL-6 promoter. CONCLUSION: Retinoids may play a fundamental role in altering the pathophysiology of endometriosis related to aberrant production of IL-6.

    Title Implications in the Management of Pregnancy: Ii. Low Levels of Gene Expression but Enhanced Uptake and Accumulation of Umbilical Cord Glycodelin.
    Date April 2000
    Journal Fertility and Sterility
    Excerpt

    OBJECTIVE: We recently reported the presence of glycodelin in the endothelial cells of human umbilical cord. The objective of the current study is to determine whether human umbilical cord endothelial cells synthesize glycodelin. DESIGN: Controlled clinical study.Setting: Healthy women undergoing normal delivery at Grady Memorial Hospital, Atlanta, Georgia. PATIENT(s): Healthy women undergoing normal delivery. INTERVENTION(s): None. MAIN OUTCOME MEASURE(s): Human umbilical cord was collected after full-term delivery and total RNA from endothelial cells was isolated. Reverse-transcription polymerase chain reaction (RT-PCR) was performed by using primers from glycodelin sequence. Human umbilical cord endothelial cells at passage 3 were incubated with glycodelin-derived peptide or glycodelin-rich amniotic fluid. Immunocytochemical analysis was performed by using purified chicken anti-glycodelin peptide antibody to detect the accumulation of glycodelin in cells. RESULT(s): Little or no glycodelin message was detectable in the endothelial cells from human umbilical cord vein by RT-PCR and Southern blot analysis. However, these cells readily took up glycodelin protein and glycodelin-derived synthetic peptide from the medium. CONCLUSION(s): The presence and accumulation of glycodelin in the umbilical cord might indicate their potential role in the survival of fetal tissue in the maternal environment.

    Title Mentoring in Gynecology: Presidential Address.
    Date January 2000
    Journal American Journal of Obstetrics and Gynecology
    Title Hysteroscopic Metroplasty of the Class Va Uterus with Preservation of the Cervical Septum.
    Date December 1999
    Journal Fertility and Sterility
    Excerpt

    OBJECTIVE: To assess the safety and efficacy of hysteroscopic resection of the uterine septum in patients with a Class Va septate uterus. DESIGN: Retrospective clinical study. SETTING: University outpatient surgical center. PATIENT(S): Twenty-one patients with Class Va uterus treated between 1985-1998 in the senior author's academic practice. INTERVENTION(S): Hysteroscopic metroplasty with preservation of cervical septum. MAIN OUTCOME MEASURE(S): Intraoperative and postoperative complications; postoperative cumulative pregnancy and delivery rates. RESULT(S): No long-term complications were encountered. Fourteen of 15 women who attempted pregnancy postoperatively delivered viable neonates; the 15th is in an ongoing pregnancy. CONCLUSION(S): Surgical correction of the complete uterine septum with preservation of the cervical septum is associated with low morbidity and satisfactory postoperative obstetric outcome.

    Title The Effect of Regular Exercise on Women Receiving Danazol for Treatment of Endometriosis.
    Date December 1998
    Journal International Journal of Gynaecology and Obstetrics: the Official Organ of the International Federation of Gynaecology and Obstetrics
    Excerpt

    OBJECTIVE: To determine the effects of regular exercise on women receiving danazol for the treatment of endometriosis. METHODS: Thirty-nine patients were randomized to a danazol-only or a danazol/exercise regimen in a prospective clinical trial carried out at tertiary care institutions. Patients in the danazol/exercise group were instructed to exercise four times per week, for 40 min per session, at an intensity of 20 metabolic units. Side effect profiles, pelvic symptoms, aerobic fitness, strength and hormone levels were compared for all subjects. The number of side effects of danazol was analyzed by the method of generalized estimating equations. RESULTS: The number of side effects reported during a 4-week period was 1.09-2.17 times greater for the danazol-only than for the danazol/exercise group. All patients had improvement of symptoms during treatment. The danazol/exercise group had significantly lower testosterone levels during treatment. The time to recurrence of endometriosis was not different between groups. CONCLUSIONS: Exercise during danazol therapy reduces the number of androgenic side effects. Relief of pain and time to recurrence are unaffected.

    Title Treatment of Endometriosis.
    Date September 1998
    Journal Clinical Obstetrics and Gynecology
    Title Historical Prospective Cohort Study of the Recurrence of Pain After Discontinuation of Treatment with Danazol or a Gonadotropin-releasing Hormone Agonist.
    Date August 1998
    Journal Fertility and Sterility
    Excerpt

    OBJECTIVE: To determine the duration of time to the recurrence of pain attributable to endometriosis after the discontinuation of treatment with danazol or a GnRH agonist (GnRH-a) in patients who have had a satisfactory response to the treatment. DESIGN: Retrospective study. SETTING: Nine academic medical centers in three countries. PATIENT(S): Three hundred twenty-seven women with diagnosed and staged endometriosis who were treated with at least 6 months of danazol or a GnRH-a and who experienced significant pain relief with therapy. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Duration of pain relief after completion of treatment as determined by a patient-initiated report of pain recurrence or increase in pain severity requiring intervention. RESULT(S): The median time to the recurrence of pain was 6.1 months for patients treated with danazol and 5.2 months for patients treated with a GnRH-a. CONCLUSION(S): Although there was a lack of uniformity in treatment effects across sites, the analyses have taken into account major covariant effects. The time to the recurrence of endometriosis-associated pain after danazol treatment was slightly longer than that after GnRH-a treatment.

    Title Timing of Estrogen Replacement Therapy Following Hysterectomy with Oophorectomy for Endometriosis.
    Date May 1998
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To determine whether the immediate initiation of estrogen replacement therapy (ERT) in the postoperative period increases the incidence of symptom recurrence following total abdominal hysterectomy (TAH) with bilateral salpingo-oophorectomy (BSO) for the treatment of endometriosis. METHODS: In a retrospective cohort study, 95 women who underwent TAH with BSO for endometriosis at the Johns Hopkins Hospital during 1979-1991 and who subsequently received ERT were identified by computer search. Follow-up information was obtained from medical records, outpatient charts, and telephone surveys. Pain recurrence in patients who started ERT within 6 weeks after surgery and in those who delayed ERT for more than 6 weeks was compared and adjusted for length of patient follow-up and other covariates. RESULTS: Sixty women began ERT within the immediate postoperative period, and four (7%) of them had recurrent pain; 35 women began ERT more than 6 weeks after surgery, and seven (20%) of them had recurrent pain. The mean length of follow-up was 57 months. The difference in the crude rate of symptom recurrence following early and delayed initiation of ERT after TAH with BSO was not statistically significant (P = .09). Controlling for length of patient follow-up, no significant differences were observed between the two groups. Adjusting for covariates of stage, age, and postoperative adjunct medroxyprogesterone therapy, those who started ERT more than 6 weeks after surgery had a relative risk of 5.7 (95% confidence interval 1.3, 25.2) for pain recurrence. CONCLUSION: Although the number of patients in the study was too small to reach statistical significance in all analyses, these findings suggest that patients who begin ERT immediately after TAH with BSO are at no greater risk of recurrent pain than those who delay ERT for more than 6 weeks.

    Title Generation and Characterization of a Polyclonal Antipeptide Antibody to Human Glycodelin.
    Date April 1998
    Journal Fertility and Sterility
    Excerpt

    OBJECTIVE: To develop and characterize an antiglycodelin antibody using a 15-amino acid synthetic peptide as antigen, derived from the sequence of human glycodelin. DESIGN: We have developed a chicken antiglycodelin-derived peptide antibody and have characterized the antibody with the use of endometrial and ovarian cell lines. The antibody was also tested for its ability to detect glycodelin by ELISA assay, immunocytochemistry, and by Western blot. SETTING: Various cell lines, cell culture medium, and amniotic fluid were used in the experiments. PATIENT(S): Amniotic fluid was collected from pregnant patients in their first trimester of pregnancy. INTERVENTION(S): No intervention. MAIN OUTCOME MEASURE(S): Detection of glycodelin. RESULT(S): The cell lines RL95-2 (human endometrial carcinoma cells), OVCAR-3 (human ovarian adenocarcinoma cells), HeLa (human cervical epitheloid carcinoma cells), and EM42-D (human endometrial epithelial cells) reacted with the antibody, indicating the presence of glycodelin. A specific 45-kd protein representing glycodelin was detected by Western blot in the amniotic fluid. CONCLUSION(S): Antipeptide antibodies can be successfully used to detect and quantify the presence of glycodelin in cells and fluids.

    Title Interaction of Interceed Oxidized Regenerated Cellulose with Macrophages: a Potential Mechanism by Which Interceed May Prevent Adhesions.
    Date January 1998
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: The objective of the study was to determine whether Interceed oxidized regenerated cellulose (Johnson & Johnson Medical, Arlington, Tex.), because of its polyanionic nature, may compete for the macrophage scavenger receptor. STUDY DESIGN: RAW macrophages were incubated with Interceed oxidized regenerated cellulose and known scavenger receptor ligands. The production of interleukin-1beta by mouse peritoneal macrophages was measured in the presence of Interceed cellulose. RESULTS: When macrophages were incubated with Interceed cellulose, increasing concentrations inhibited the uptake of fluorescent acetyl low-density lipoprotein. In the presence of Interceed cellulose there was a decrease in the production of interleukin-1beta by mouse macrophages. CONCLUSION: These results suggest that the interaction of Interceed oxidized regenerated cellulose with macrophages with scavenger receptors may result in a decreased secretion of matrix components, inflammatory mediators, and cellular growth factors. Thus Interceed cellulose may function as a biologic barrier in preventing adhesions.

    Title Charge-based Interactions of Mammalian Sperm with Oocytes: Inhibition of Fertilization of Mouse Oocytes by Ligands of Macrophage Scavenger Receptor(s).
    Date January 1998
    Journal Fertility and Sterility
    Excerpt

    OBJECTIVE: To determine whether anionic ligands for the macrophage scavenger receptor inhibit the fertilization of mouse oocytes by mouse spermatozoa. DESIGN: In vitro study of sperm binding and two-cell embryo formation in the presence of scavenger receptor ligands. Sperm-oocyte interaction may be mediated by sulfated sugars. In this study, we tested other nonsulfated anionic ligands for the scavenger receptor for their ability to affect fertilization. The only common feature of these ligands is their anionic nature. SETTING: Oocytes and sperm from mice were used. MAIN OUTCOME MEASURE(S): Binding of sperm to oocytes and subsequent formation of two-cell embryos were determined. RESULT(S): Fucoidin, polyinosinic acid, oxidized low-density lipoprotein, acetyl low-density lipoprotein, and malondialdehyde-modified LDL inhibited the binding and fertilization of mouse sperm to mouse oocytes. Addition of fresh sperm to oocytes previously treated with sperm in the presence of these agents restored the binding and fertilization. CONCLUSION(S): These results show that charge-based interactions analogous to the interactions of the scavenger receptor with its ligands may play an important role in mammalian fertilization.

    Title Classification of Endometriosis.
    Date December 1997
    Journal Seminars in Reproductive Endocrinology
    Excerpt

    Classification systems for endometriosis continue to evolve. Past systems have been modeled primarily after those in use for grading malignant disease. Unfortunately, classification methods that attempted to quantitate the severity of disease have suffered from only modest predictability in determining outcome. The 1985 revised American Fertility Society classification system is limited by scoring arbitrariness, potential for observational error, limited reproductivity, failure to consider lesion morphologic type and a particularly poor correlation with pelvic pain. These shortcomings are being presently addressed.

    Title Surgical Management of Complete Obliteration of the Endometrial Cavity.
    Date January 1997
    Journal Fertility and Sterility
    Excerpt

    OBJECTIVE: To describe a technique for surgical management of complete obliteration of the endometrial cavity. DESIGN: A report of a series of three patients. SETTING: A university-based hospital. PATIENT(S): Three patients with complete obliteration of the endometrial cavity. INTERVENTION(S): Transfundal scar removal using stents in the fallopian tubes to serve as landmarks. MAIN OUTCOME MEASURE(S): Regular withdrawal bleeding. RESULT(S): Regular menses in all three patients. CONCLUSION(S): The technique described here show promise for establishing uterine cavity integrity in cases of complete endometrial obliteration where there are no landmarks in the uterine cavity.

    Title Inhibition of Oxidative Modification of Proteins by Ru486.
    Date November 1996
    Journal Fertility and Sterility
    Excerpt

    OBJECTIVES: To elucidate further the antioxidant properties of RU486. We determined whether it can protect biologic molecules such as proteins (albumin, low-density lipoprotein [LDL] and oxidized LDL) from damage by pre-existing lipid peroxides. DESIGN: In vitro study. INTERVENTIONS: We tested the effects of RU486 on the formation of fluorescent oxidatively modified proteins by pre-existing lipid peroxides. We used two model systems, the incubation of oxidized linoleic acid with serum albumin and the incubation of human LDL with copper. MAIN OUTCOME MEASURES: The formation of modified protein was established by determining fluorescence at excitation wavelength of 330 nm and emission wavelength between 390 and 500 nm. Modified protein has a characteristic emission between 425 and 430 nm. RESULTS: The addition of increasing amounts of RU486 inhibited the formation of fluorescent oxidatively modified protein products in both model systems. CONCLUSION: These results provide evidence that RU486 not only can prevent the formation of lipid peroxide, but also can block the formation of fluorescent protein adducts in the presence of pre-existing lipid peroxides.

    Title Endometriosis in an Adolescent Population: the Emory Experience.
    Date October 1996
    Journal Journal of Pediatric and Adolescent Gynecology
    Excerpt

    OBJECTIVE: To determine the incidence, clinical stage, and lesion type of endometriosis in adolescent girls. DESIGN: Retrospective review of patient records of adolescent girls (11-19) admitted to Emory University Affiliated Hospitals. SETTING: Patients from a private practice institutional setting. PATIENTS: 67 adolescent girls who had not responded to analgesia or oral contraceptives for pelvic pain. INFORMATION: Laparoscopy or exploratory laparotomy to determine the etiology of pelvic pain. MAIN OUTCOME MEASURE: Stage of endometriosis by the American Fertility Society classification system and description of lesion type. RESULTS: Endometriosis was diagnosed in 49 (73%) patients. The majority of patients had stage I disease. Superficial red lesions were most commonly observed. CONCLUSIONS: Adolescent girls with pelvic pain have a high incidence of endometriosis. Minimal disease is most often encountered. Meticulous inspection of the pelvic peritoneal surfaces will often reveal superficial or atypical lesions.

    Title Pain Recurrence: a Quality of Life Issue in Endometriosis.
    Date January 1996
    Journal International Journal of Gynaecology and Obstetrics: the Official Organ of the International Federation of Gynaecology and Obstetrics
    Excerpt

    Studies reveal endometriosis to be present in 38-51% of women undergoing laparoscopy for chronic pelvic pain. Symptoms attributable to endometriosis include dysmenorrhea, dyspareunia, generalized pelvic pain, dyschezia, and radiation of pain to the back or leg. Psychological factors may also contribute to a more intense pain experience. Medical therapy provides symptom relief in 72-93% of patients, although recurrence is common following treatment discontinuation. Surgical therapy has had varying results for long-term pain relief; adequacy of the initial surgical treatment appears to be a critical factor. Important adjunctive measures include presacral neurectomy and excisional techniques to remove deep, fibrotic, retroperitoneal lesions. The quality of life of women with endometriosis will improve with greater focus on achieving the long-term relief of pelvic pain. Limitation of pain recurrence would benefit the patient greatly, by providing symptom relief and preventing the cycle of its probably adverse effects on physical activity, work productivity, sexual fulfilment, and mood.

    Title Incidence of Symptom Recurrence After Hysterectomy for Endometriosis.
    Date December 1995
    Journal Fertility and Sterility
    Excerpt

    OBJECTIVES: To determine the relative risk of symptom recurrence and/or reoperation after hysterectomy with ovarian preservation for the treatment of endometriosis. DESIGN: Historical prospective study of patients with endometriosis who underwent hysterectomy with or without ovarian preservation. PATIENTS: One hundred thirty-eight women who underwent hysterectomy with the diagnosis of endometriosis. METHODS: A computer search identified 138 women who underwent hysterectomy with the diagnosis of endometriosis at Johns Hopkins Hospital from 1979 to 1991. Follow-up information was obtained from medical records, outpatient charts, and telephone surveys. RESULTS: Twenty-nine women had hysterectomy with some ovarian tissue preserved; 109 had all ovarian tissue removed. Of those with ovarian preservation, 18 of 29 (62%) had recurrent pain and 9 of 29 (31%) required reoperation. Of those who had no ovarian preservation, 11 of 109 (10%) had recurrent symptoms and 4 of 109 (3.7%) required reoperation. Ovarian conservation was associated with a relative risk for pain recurrence of 6.1 (95% confidence interval [CI] 2.5 to 14.6) compared with patients with oophorectomy in a Cox proportional hazards model. The relative risk for reoperation in patients with ovarian conservation was 8.1 (95% CI 2.1 to 31.3). CONCLUSION: Compared with women who had oophorectomy for endometriosis, patients who underwent hysterectomy with ovarian conservation had 6.1 times greater risk of developing recurrent pain and 8.1 times greater risk of reoperation.

    Title Expanded Polytetrafluoroethylene (gore-tex Surgical Membrane) is Superior to Oxidized Regenerated Cellulose (interceed Tc7+) in Preventing Adhesions.
    Date May 1995
    Journal Fertility and Sterility
    Excerpt

    OBJECTIVE: To compare the impact of expanded polytetrafluoroethylene (PTFE; Gore-Tex Surgical Membrane; W. L. Gore & Associates, Inc., Flagstaff, AZ) and oxidized regenerated cellulose (Interceed TC7, Johnson & Johnson Medical, Inc., Arlington, TX) on the development of postsurgical adhesions. DESIGN: A multicenter, nonblinded, randomized clinical trial. SETTING: University medical centers. INTERVENTIONS: Each barrier was allocated randomly to the left or right sidewall of every patient. PATIENTS: Thirty-two women with bilateral pelvic sidewall adhesions undergoing reconstructive surgery and second-look laparoscopy. MAIN OUTCOME MEASURES: Adhesion score (on a 0- to 11-point scale), the area of adhesion (cm2), and the likelihood of no adhesions. RESULTS: The use of both barriers was associated with a lower adhesion score and area of adhesion postoperatively. However, those sidewalls covered with PTFE had a significantly lower adhesion score (0.97 +/- 0.30 versus 4.76 +/- 0.61 points, mean +/- SEM) and area of adhesion (0.95 +/- 0.35 versus 3.25 +/- 0.62 cm2). Overall, more sidewalls covered with PTFE had no adhesions (21 versus 7) and, when adhesions were present on the contralateral sidewall, the number of sidewalls covered with PTFE without adhesions was greater than those covered with oxidized regenerated cellulose (16 versus 2). CONCLUSION: Expanded polytetrafluoroethylene was associated with fewer postsurgical adhesions to the pelvic sidewall than oxidized regenerated cellulose.

    Title The Revised American Fertility Society Classification of Endometriosis: Reproducibility of Scoring. Zoladex Endometriosis Study Group.
    Date May 1995
    Journal Fertility and Sterility
    Excerpt

    OBJECTIVE: To assess the reproducibility in staging endometriosis using the revised American Fertility Society (AFS) classification of endometriosis. DESIGN: Visual documentation of laparoscopies of 315 women with endometriosis was scored by the investigators and a blinded reviewer. SETTING: Patients from private practice institutional setting. PARTICIPANTS: Patients who participated in a multicenter trial to study the efficacy and safety of a GnRH agonist (GnRH-a). INTERVENTIONS: Laparascopic visual documentation of the extent of endometriosis before and after 6 months of GnRH-a therapy. MAIN OUTCOME MEASURE: The reproducibility of the AFS classification system comparing scoring during laparoscopy and by a blinded reviewer. RESULTS: Good to fair agreement scoring endometriosis between the investigator and the blinded reviewer was noted. CONCLUSIONS: Visual documentation may be used to determine the stage of endometriosis using the revised AFS classification guidelines.

    Title Goserelin (zoladex) Versus Danazol for Endometriosis: the North American Experience.
    Date July 1994
    Journal British Journal of Obstetrics and Gynaecology
    Title Reconstruction of the External Genitalia in Females with Bladder Exstrophy.
    Date June 1994
    Journal International Journal of Gynaecology and Obstetrics: the Official Organ of the International Federation of Gynaecology and Obstetrics
    Excerpt

    OBJECTIVES: A very characteristic genital anomaly accompanies bladder exstrophy in females. This includes anterior displacement and narrowing of the vagina and separation of the clitoris into two distinct bodies. The authors have had a relatively large experience with correction of this rare genital anomaly. From this experience, it began to appear that certain procedural details were associated with improved outcomes. The objective of this article was to review this experience and detail the reconstruction of the external genitalia in these patients. METHODS: All cases of bladder exstrophy in females presenting from January 1, 1970 to December 31, 1992 were reviewed. A total of eight patients who underwent surgical correction of the external genitalia were included. Data was obtained regarding urologic treatment, associated anomalies, corrective gynecologic procedures, complications and subsequent course. RESULTS: Corrective gynecologic surgery included enlargement of the vaginal orifice in all eight patients. Five patients had reapproximation of the bifid clitoris. Three patients performed postoperative dilatation therapy. Postoperatively, one patient experienced dyspareunia requiring a repeat procedure to enlarge the vaginal orifice. No patient had complications related to pelvic organ prolapse. CONCLUSIONS: Care should be taken not to extend the perineal incision too far posteriorly in reconstruction of the external genitalia in females with bladder exstrophy. Failure to do so may further predispose the patient to uterine prolapse. Post-operative dilator therapy may be an important adjunctive technique.

    Title Analysis for Steroid Production of a Sertoli-leydig Cell Tumor.
    Date March 1994
    Journal Gynecologic Oncology
    Excerpt

    Sex cord stromal tumors of the ovary can be characterized by the production of virilizing steroid hormones. The authors present a case of a poorly differentiated Sertoli-Leydig cell tumor in which ascitic fluid was found to have a high concentration of androgenic hormones and precursors from the delta steroid pathway (17-OH progesterone, testosterone, and androstenedione). These values correlated with samples taken from the right ovarian vein, draining the ovarian neoplasm, but not with those taken from the left ovarian vein or the peripheral blood sample. Selective peritoneal fluid sampling may aid in the diagnosis of hormonally active tumors.

    Title The History and Future of Operative Laparoscopy.
    Date February 1994
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    Laparoscopic sterilization was first performed in the United States in 1941. During the 1950s and 1960s hospitals procured the relatively inexpensive basic laparoscopic instrumentation, and education for physicians learning the techniques was provided mostly by academic centers during residency training. Interest in expansion of laparoscopic procedures was slight until the mid-1980s when operative laparoscopic management of ectopic pregnancies began to spread from academic centers to the private sector. Major technologic developments in instrumentation greatly simplified the endoscopic procedures and provided the first impetus for an explosive growth of operative laparoscopic applications in surgery. The great financial resources of private hospitals enabled them to adapt and retool quickly for operative endoscopy. Lacking these resources, academic institutions lagged behind; thus a growing divergence began between academic and private institutions in their influence on the development, use, and acceptance of the new technology. The development of expensive disposable instruments, with costs passed on to patients by private hospitals, further priced academic institutions out of the market. Two concerns today are paramount regarding operative laparoscopy: (1) The majority of laparoscopic techniques and procedures being performed by surgeons in this country have not been taught in the controlled setting of a residency or fellowship training program; (2) the legitimacy of the procedures themselves is questionable because of lack of sufficient data in the literature to support them. Academic institutions, working in tandem with the private sector, must assume the responsibility for answering these concerns.

    Title Delayed Birth Intervals of Immature Fraternal Triplets in Preterm Labor. A Case Report.
    Date January 1994
    Journal The Journal of Reproductive Medicine
    Excerpt

    The preterm birth of immature triplets before 28 weeks is associated with excess morbidity and mortality risks attributable to extreme immaturity. We report a case of fraternal triplets in preterm labor in which the second and third triplet births were delayed 11 days after the first birth, at 26 4/7 weeks' gestation. The later-born sibs were heavier at birth and throughout their neonatal course in the hospital and suffered less severe complications as compared to the first-born triplet. Delayed birth intervals of triplets in preterm labor should be considered to improve perinatal salvage of immature triplets, although a successful outcome is rare and unexpected.

    Title Endometriosis and Pelvic Pain.
    Date January 1994
    Journal Fertility and Sterility
    Title Zoladex (goserelin Acetate Implant) in the Treatment of Endometriosis: a Randomized Comparison with Danazol. The Zoladex Endometriosis Study Group.
    Date August 1993
    Journal Obstetrics and Gynecology
    Excerpt

    OBJECTIVE: To compare the efficacy, endocrine effects, and safety of Zoladex (goserelin acetate) and danazol in the treatment of premenopausal women with endometriosis in a multicenter, randomized, open study. METHODS: Three hundred fifteen patients with stages I-IV endometriosis (revised American Fertility Society [AFS] classification) were treated with Zoladex, 3.6 mg every 28 days by subcutaneous injection, or danazol, 400 mg orally twice daily for 24 weeks. Efficacy was assessed by determination of pelvic signs and symptoms scores and revised AFS endometriosis scores. Endocrine effects were determined by measurements of hormone levels. Safety was evaluated by physical examination, laboratory indices, occurrence of adverse events, and bone mineral density changes. RESULTS: Both treatments significantly (P < .0001) reduced mean subjective signs and symptoms scores both during and after therapy. The mean percent reduction in the revised AFS endometriosis score after 24 weeks of treatment was 53% for Zoladex and 33% for danazol, and reduction in the endometrial implants score was 56% for Zoladex and 46% for danazol. Serum estradiol levels decreased to the postmenopausal range in the Zoladex group and to the early follicular phase range in the danazol group. Hypoestrogenic effects occurred more frequently with Zoladex, whereas androgenic side effects were more common with danazol. There was a higher percentage of withdrawals due to adverse events with danazol than with Zoladex. Mean bone mineral density decreased from baseline by 5.4% in the Zoladex group and increased by 1.0% in the danazol group at the end of treatment. CONCLUSION: Zoladex is as well tolerated and as effective as danazol in the treatment of premenopausal women with endometriosis.

    Title Prevention of Adhesion Formation/reformation with the Gore-tex Surgical Membrane.
    Date July 1993
    Journal Progress in Clinical and Biological Research
    Excerpt

    Eighteen patients with extensive adhesions and 10 undergoing myomectomy had GORE-TEX Surgical Membranes placed in order to prevent adhesion formation/reformation. At the time of second-look laparoscopy the membranes were removed easily and the extent of adhesion was minimal. Preliminary data from 10 additional patients undergoing adhesiolysis demonstrated that the GSM resulted in significantly fewer adhesions than did oxidized regenerated cellulose. The number of patients in this group will be expanded to insure that this difference is maintained.

    Title New Considerations for the Classification of Endometriosis.
    Date June 1993
    Journal International Journal of Gynaecology and Obstetrics: the Official Organ of the International Federation of Gynaecology and Obstetrics
    Excerpt

    The historical background to the classification of endometriosis is presented and modern classification systems are reviewed. The effectiveness of the currently used revised American Fertility Society classification system is limited and improved systems are required. Factors that should be incorporated into such systems include the documentation of endometriotic implants, classification of disease, prediction of pregnancy rates and prediction of prognosis for relief of pain.

    Title Abdominal Myomectomy in the Treatment of Infertility.
    Date March 1993
    Journal International Journal of Gynaecology and Obstetrics: the Official Organ of the International Federation of Gynaecology and Obstetrics
    Excerpt

    OBJECTIVE: To determine the effect of abdominal myomectomy as a treatment for infertility in women with uterine leiomyoma. METHODS: Records were reviewed for 37 women at Johns Hopkins Hospital who underwent myomectomy as a primary procedure for infertility between 1975 and 1990. RESULTS: Kaplan-Meier life-table analysis demonstrated a cumulative pregnancy rate of 57% and live birth rate of 48%. The size or number of myomas did not affect either the pregnancy rate or the myoma recurrence rate. The presence of pelvic adhesions at the time of myomectomy significantly reduced the chance of conception (P < 0.05). Adhesions were documented in 13 (68%) of 19 patients who underwent abdominal surgery at a later date. CONCLUSIONS: Nearly half of the infertile women with uterine leiomyoma were able to bear children following abdominal myomectomy. Adhesion formation appears to be a common occurrence following myomectomy and reduces its effectiveness when present before surgery.

    Title Time-related Effects of Ru486 Treatment in Experimentally Induced Endometriosis in the Rat.
    Date March 1993
    Journal Fertility and Sterility
    Excerpt

    OBJECTIVE: To evaluate the time-dependent effect of the progesterone antagonist RU486 on experimentally induced endometriosis in the rat. DESIGN: Endometriosis was induced by implanting endometrium onto the peritoneal side wall. Size of the implants was measured before and after treatment. PARTICIPANTS: Fifty-two adult female Sprague-Dawley female rats weighing 200 to 225 g. SETTING: Departmental research laboratory of university hospital. INTERVENTION: Animals treated with RU486 or vehicle only for 2, 4, 6, or 8 weeks. MAIN OUTCOME MEASURES: Size of the implant was measured before and after treatment; relative change in size of the implants was calculated. RESULTS: There was not a statistically significant difference between the treatment groups and the control groups. There was no regression of endometriosis in any of the treatment groups. CONCLUSIONS: RU486 administered for 8 weeks in the rat model was not effective therapy for endometriosis.

    Title Intraocular Endometrium in the Rabbit As a Model for Endometriosis.
    Date February 1993
    Journal Fertility and Sterility
    Excerpt

    The model described suggests that endometrium can be successfully transplanted to the rabbit eye and observed through a slit lamp for morphological changes such as vascularization. Sampling of aqueous humor in volumes adequate for biochemical measurements have been demonstrated. Autografts of rabbit endometrium survived for up to 181 days. Although xenografts of human endometrial and endometriotic tissue demonstrate some adherence and vascularization, there is indication of immune rejection by day 7. Other treatment regimens will be explored with the objective of prolonging the graft survival time.

    Title Pathogenesis of Endometriosis.
    Date December 1992
    Journal Lancet
    Title A Comparison of the Reproductive Outcome Between Women with a Unicornuate Uterus and Women with a Didelphic Uterus.
    Date August 1992
    Journal Fertility and Sterility
    Excerpt

    OBJECTIVE: To compare the reproductive performance of women with a unicornuate uterus with the reproductive performance of women with a didelphic uterus. DESIGN: Retrospective. SETTING: Reproductive endocrinology service of a tertiary referral hospital. MAIN OUTCOME MEASURES: The proportion of pregnancies resulting in spontaneous abortion, preterm delivery, term delivery, and living children was determined for each group. RESULTS: Twenty-nine women with a unicornuate uterus and 25 women with a didelphic uterus were identified. Twenty women with a unicornuate uterus produced a total of 40 pregnancies, whereas 13 women with a didelphic uterus produced a total of 28 pregnancies. The 33% spontaneous abortion rate in the unicornuate group was not significantly different from the 23% rate in the didelphic group. The proportion of pregnancies resulting in preterm delivery, term delivery, and living children was similar in both groups. CONCLUSIONS: The reproductive performance of women with a unicornuate uterus is similar to the performance of women with a didelphic uterus.

    Title Preoperative Dilatation to Facilitate Repair of the High Transverse Vaginal Septum.
    Date July 1992
    Journal Fertility and Sterility
    Excerpt

    A difficult resection and anastomosis of the high transverse vaginal septum at puberty may result in long-term vaginal stenosis. In this report, we describe an alternative approach to the patient with a transverse vaginal septum to include the following: (1) US-directed needle aspiration with broad spectrum antibiotic prophylaxis to decompress the hematocolpos and relieve the acute pain; (2) continuous suppression of ovulation to prevent acute recurrence of the hematocolpos; and, most importantly, (3) vaginal dilatation before resection of the obstructing membrane to lengthen the lower vagina and ensure postoperative compliance with dilatation before vaginal anastomosis is attempted. Using this approach, we have obtained excellent results in three patients. Further study is necessary to validate this surgical modification.

    Title Endometriosis.
    Date June 1992
    Journal Current Opinion in Obstetrics & Gynecology
    Excerpt

    Recent advances in endometriosis research are reviewed. Factors relating to the increasing frequency of laparoscopic diagnosis as well as potential diagnostic tests utilizing endometrial antibody and CA 125 assays of both serum and peritoneal fluids are discussed. A new classification is proposed that takes into consideration depth of endometriotic lesions. The pathophysiology of endometriosis is an area of increased research activity with attention directed toward autoimmune theories of impaired surveillance. A variety of autoantibodies have been found to be increased in patients with endometriosis, and peritoneal macrophage activation is also thought to play a role. Laparoscopic treatment options are reviewed, including investigations of various laser methods as well as electrocautery. Medical therapy comparing various gonadotropin-releasing hormone agonists and danazol and the effects of these treatment options on bone density are presented. New directions in immunomodulatory drug therapy are discussed.

    Title Superovulation with or Without Intrauterine Insemination for the Treatment of Infertility.
    Date May 1992
    Journal The Journal of Reproductive Medicine
    Excerpt

    Patients undergoing human menopausal gonadotropin (hMG) superovulation were reviewed retrospectively to determine whether fecundity was greater for intrauterine insemination (IUI) than timed intercourse. Forty patients with unexplained infertility, American Fertility Society I or II endometriosis, luteal phase defect and/or cervical factor were treated with hMG alone or hMG plus IUI. Twenty-eight underwent 52 cycles of hMG/IUI, and 19 underwent 31 cycles of hMG. The probability of pregnancy after four cycles was significantly better in the hMG/IUI group (.90) than the hMG group (.37, P = .049). There was a 54.5% multiple pregnancy rate, and one patient was admitted to the hospital for hyperstimulation. When traditional therapy fails, hMG/IUI significantly increases the pregnancy rates as compared to hMG with timed intercourse in a "good prognosis" group of patients.

    Title Endometriosis: the Present and the Future--an Overview of Treatment Options.
    Date May 1992
    Journal British Journal of Obstetrics and Gynaecology
    Title The Effect of the Menstrual Cycle and of Decompression Stress on Arachidonic Acid-induced Platelet Aggregation and on Intrinsic Platelet Thromboxane Production in Women Compared with Men.
    Date January 1992
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    Menstrual cycle variations in platelet aggregation and thromboxane production in association with sex steroids have been reported. External stimuli such as decompression sickness have been associated with clotting activity changes, specifically, increased platelet aggregation. Differences in response of platelets from women and men, when subjected to such a stress, have been observed. This study evaluated the ability of washed platelets from women in the proliferative and secretory phases of the menstrual cycle to aggregate in response to arachidonic acid and the aggregation difference between washed platelets from women and men in response to decompression stress and arachidonic acid. Additionally, platelet thromboxane production differences between the assessed platelet populations were compared. Our results indicate no difference in platelet aggregability between phases of the menstrual cycle. A significant aggregation difference between platelets from women and men was noted. Platelets from women were more sensitive to arachidonic acid aggregation. These differences were not affected by decompression stress. No difference in thromboxane B2 production was noted between the platelet populations evaluated.

    Title Clinical and Pathologic Spectrum of 46,xy Gonadal Dysgenesis: Its Relevance to the Understanding of Sex Differentiation.
    Date December 1991
    Journal Medicine
    Excerpt

    The condition termed "46,XY gonadal dysgenesis" is characterized by a 46,XY karyotype and incomplete testicular determination. It is likely the result of a mutation in the gene for the testicular determination factor or in another gene involved in the early stages of testicular differentiation. In view of the present interest in the identification of gene(s) initiating the differentiation of the embryonic gonads into testes, we have reviewed the phenotype of 15 patients with 46,XY gonadal dysgenesis to use this information for future molecular studies. Seven patients presented a complete form, 46,XY pure gonadal dysgenesis, including streak gonads, normal Müllerian structures, and normal female external genitalia. The structure of the streak gonads in these patients presented some variation. Eight patients presented an incomplete form, 46,XY partial gonadal dysgenesis, with ambiguous external genitalia and partial development of Müllerian and Wolffian structures. Among them, 3 had bilateral dysgenetic testes, and 4 had a streak gonad on one side with a contralateral dysgenetic testis. The streak gonads showed ovarian stroma with occasional primitive sex cords devoid of germ cells. However, a primordial follicle was observed in 1 streak gonad. The dysgenetic testes showed disorganized seminiferous tubules and ovarian stroma. In some patients, the ovarian stroma was intermixed with testicular tissue, while in others, distinct ovarian and testicular portions were present. In 1 patient, the dysgenetic testis contained a focus of well-differentiated ovarian tissue with primordial follicles. Our observations support the hypothesis that streak gonads in 46,XY pure gonadal dysgenesis arise from fetal ovaries and that dysgenetic testes in the partial form in 46,XY partial gonadal dysgenesis develop from ovotestis.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Microgravity Testing a Surgical Isolation Containment System for Space Station Use.
    Date October 1991
    Journal Aviation, Space, and Environmental Medicine
    Excerpt

    Anticipated hazards for crewmembers in future long term space flights may result in a variety of injuries including trauma and burns. Management of these injuries will require special techniques because of the lack of gravity, limitations of space and environmental restrictions. A small surgical isolation containment system was developed and tested in microgravity. The chamber provided both protection of the injury and of the cabin environment and is felt to be the most effective means of trauma and burn care in future Health Maintenance Facilities planned for prolonged space exposure.

    Title The Role of Laparoscopy in the Treatment of Endometriosis.
    Date May 1991
    Journal Fertility and Sterility
    Title The Incidence of Human Immunodeficiency Virus (hiv) in Fetal Cord Samples Utilized As Serum Supplements for in Vitro Fertilization.
    Date April 1991
    Journal Journal of in Vitro Fertilization and Embryo Transfer : Ivf
    Excerpt

    Prior to initiating routine fetal cord serum (FCS) supplementation in our in vitro laboratory, the incidence of HIV in 306 random fetal cord samples obtained at the Labor and Delivery Unit of the Johns Hopkins Hospital from July 1985 to January 1988 was determined from a cross-sectional patient sample. Of 306 samples, 3 (0.98%) were positive for HIV, and confirmed by Western blot analysis, enzyme immunoassay (ELISA), a prevalence significantly higher than a national sample (0.012%). The use of FCS in this setting was determined to be an unacceptable risk to patients undergoing in vitro fertilization. The 90-day quarantine period for verification of HIV seronegativity applied to semen donors may not be applicable to FCS sampling. Patient risk may also increase with pooling of FCS samples prior to HIV testing.

    Title Obstructed Uterovaginal Anomalies: Demonstration with Sonography. Part Ii. Teenagers.
    Date April 1991
    Journal Radiology
    Excerpt

    The sonograms of 13 patients with obstructed uterovaginal anomalies were reviewed to determine the role of sonography in diagnosis and management. In a retrospective analysis, the authors were able to define the cause of the obstruction and the upper level and length of the obstruction by combining the sonographic findings with those from the physical examination (ie, bulging hymen, blind vaginal pouch, no vaginal depth, normal vagina) or by combining transabdominal sonography with simultaneous digital insertion into the vaginal orifice. When the sonogram demonstrated hematometrocolpos or hematocolpos, the lesion was due to an imperforate hymen (n = 1) or high, middle, or low transverse vaginal septum (n = 7). When the sonogram demonstrated a hematometra, the lesion was due to Mayer-Rokitansky-Küster-Hauser syndrome with functioning uterine anlage(n) (n = 2), cervical dysgenesis (n = 1), and an obstructed uterine horn (n = 2). The presence and patency or absence of the cervix was established. Since the differentiation between a transverse vaginal septum, Mayer-Rokitansky-Küster-Hauser syndrome with active anlagen, and cervical dysgenesis with absent vagina cannot be made clinically, sonography provides important presurgical information.

    Title Laparoscopic Cautery in the Treatment of Endometriosis-related Infertility.
    Date March 1991
    Journal Fertility and Sterility
    Excerpt

    Life table analysis and the two-parameter exponential method have been applied to pregnancy rates in 72 patients undergoing laparoscopic cautery exclusively. Patients with male factor infertility were excluded. Estimated cure rates for patients with stage I and II disease were 98.2% and 76.6%, respectively (not significantly different). No significant difference was seen when anovulation complicated the endometriosis (68.6%). When greater than one infertility factor was present, a significant difference was observed (50.6%). Patients with stage I disease had an average fecundity of 10.30% with decreasing values observed in stage II (7.59%), anovulation (6.67%), and more than one infertility factor (3.33%). We conclude that laparoscopic cauterization is an effective mode of therapy for the treatment of stage I and II endometriosis associated with infertility.

    Title Time-related Effects of Gonadotropin-releasing Hormone Analog Treatment in Experimentally Induced Endometriosis in the Rat.
    Date March 1991
    Journal Fertility and Sterility
    Excerpt

    The purpose of our study was to characterize the time-dependent effect of gonadotropin-releasing hormone analog (GnRH-a) therapy on endometriosis explant using the rat model. Endometriosis was induced in 60 mature female rats. One group of treated animals as well as controls were killed at 2, 4, 6 and 8 weeks of treatment at which time the explant was evaluated. Explant volume was significantly reduced in all treatment groups, an effect that was more significant in animals treated for greater than or equal to 4 weeks compared with those treated for only 2 weeks. We conclude that GnRH-a treatment caused gradual regression of endometrial explant that was effectively complete by 4 weeks of treatment. We further conclude that this experimental model may be useful in the evaluation of other modes of endometriosis therapy.

    Title Neosalpingostomy for Distal Tubal Obstruction: Prognostic Factors and Impact of Surgical Technique.
    Date January 1991
    Journal Fertility and Sterility
    Excerpt

    We reviewed the clinical records of all women who underwent microsurgical terminal neosalpingostomy for distal tubal obstruction between January 1983 and June 1988. We identified 95 women whose preoperative evaluation revealed no other contributory factors for infertility and analyzed their pregnancy outcome after this procedure. Pregnancy success was inversely related to the extent of tubal distortion (dilation, rugal integrity, and status of the fimbria) and degree of adnexal adhesions. Using our classification system for distal tubal obstruction, patients with mild disease had an 80% pregnancy rate, whereas patients with moderate and severe disease had a 31% and 16% success rate, respectively. We found no statistically significant difference in pregnancy outcome when we compared this series with our previous group, reported in 1978, where contemporary microsurgical technique was not used. Although we feel that optimal surgical technique is important to maximize success, we conclude that the most important prognostic factor in pregnancy outcome after neosalpingostomy for distal tubal disease is the anatomical and functional integrity of the tube.

    Title Effect of Serum from Patients with Minimal to Mild Endometriosis on Mouse Embryo Development in Vitro.
    Date December 1990
    Journal Fertility and Sterility
    Excerpt

    Two-cell mouse embryos were cultured at 37 degrees C in 5% CO2, 95% air with a 7.5% serum supplement from patients with minimal to mild endometriosis, (group I, n = 31), tubal factor (group II, n = 33), male factor (group III, n = 17), fetal cord samples (group IV, n = 37), and Ham's F-10 medium (Gibco, Grand Island, NY) without a serum supplement (group V, n = 30). The progression to blastocyst stage (mean percent +/- SE) at 96 hours in groups I, II, III, IV, and V was 29.9% +/- 3.7%, 60.6% +/- 4.9%, 56.2% +/- 5.2%, 61.7% +/- 5.8%, and 63.2% +/- 6.9%, respectively. Serum factors appear to be associated with an inhibition of early embryogenesis, which may explain the decreased fertility rates observed in patients with minimal to mild endometriosis.

    Title Antinuclear Antibodies in Sera of Patients with Recurrent Pregnancy Wastage.
    Date December 1990
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    Four groups of women were studied to determine whether low-level antinuclear antibody titers are associated with a higher risk for pregnancy loss. Group A consisted of 30 patients with a history of unexplained fetal losses. Group B consisted of 30 women with "explained" fetal losses (e.g., uterine septum or luteal phase defect). Ages and number of losses were comparable between the women in groups A and B. Group C consisted of 61 healthy pregnant women. Group D involved 61 healthy nonpregnant women of reproductive age. In groups A and B, 40% and 53.3% of the respective patients had antinuclear antibody titers greater than or equal to 1:40. In groups C and D the frequencies of positive antinuclear antibody titers were 8.2% and 5.6%, respectively. This study demonstrates a high prevalence of low-titer antinuclear antibody-positive serum in patients with explained and unexplained pregnancy losses.

    Title The Efficacy of Presacral Neurectomy for the Relief of Midline Dysmenorrhea.
    Date July 1990
    Journal Obstetrics and Gynecology
    Excerpt

    The present study was undertaken to evaluate prospectively the efficacy of presacral neurectomy for the treatment of midline dysmenorrhea. All patients had moderate to severe dysmenorrhea and stage III-IV endometriosis. Of the patients undergoing presacral neurectomy (N = 17), only two had a recurrence of pain. The remainder of the patients undergoing presacral neurectomy remain pain-free at 42 months of follow-up. Of the patients undergoing resection of endometriosis but not presacral neurectomy (N = 9), none received relief of midline pain. Relief of lateral pain, back pain, and dyspareunia was variable in both groups. Our findings corroborate previous retrospective studies showing that presacral neurectomy is highly effective in the treatment of dysmenorrhea. We speculate that the most common reasons for failure of presacral neurectomy are inappropriate selection of patients and incomplete resection of the presacral nerve plexus.

    Title Megestrol Acetate for Treatment of Endometriosis.
    Date April 1990
    Journal Obstetrics and Gynecology
    Excerpt

    Between 1977-1989, 29 women with symptomatic endometriosis were treated with megestrol acetate by the Johns Hopkins Division of Reproductive Endocrinology. All had previously received one or more alternative medical treatments for endometriosis, in each case discontinued because of poor response or development of unacceptable side effects. Treatment consisted of a daily dose of 40 mg megestrol acetate orally for up to 24 months. Disease-related symptoms (dysmenorrhea, noncyclic pelvic pain, and dyspareunia) were relieved in 86% of the subjects treated with an adequate course of therapy. Side effects were fairly well tolerated, although eight women discontinued treatment within 2 months and two others stopped the drug by 4 months. These preliminary findings suggest that megestrol acetate may be an effective treatment for patients with endometriosis, even those who have been unresponsive to other modes of therapy.

    Title Clinical Significance of Prostanoid Concentration in Women with Endometriosis.
    Date March 1990
    Journal Progress in Clinical and Biological Research
    Title Vulvar Congenital Dysplastic Angiopathy.
    Date March 1990
    Journal Obstetrics and Gynecology
    Excerpt

    Congenital dysplastic angiopathy is a syndrome consisting of vascular angiomata, congenital varicosities, and trophic changes of the soft tissue and the skeleton. Frequently referred to as Klippel-Trenaunay or Klippel-Trenaunay-Weber syndrome, it rarely affects the female genitalia. An 18-year-old woman underwent evaluation and treatment for Klippel-Trenaunay syndrome with vulvar involvement. Preoperative evaluation included consultation with pediatric surgeons, gynecologic surgeons, and an interventional radiologist as well as individual and family psychological counseling. Attention to intraoperative detail resulted in minimal operative blood loss and preservation of normal anatomy. A postoperative hematoma was treated aggressively with surgical evacuation and drainage. Six-month follow-up revealed functionally and cosmetically normal vulvar anatomy.

    Title Prospective Study of Vulvar Nevi.
    Date February 1990
    Journal Journal of the American Academy of Dermatology
    Excerpt

    We report the results of a year-long prospective study to approximate the prevalence of pigmented lesions of the vulva in a gynecology practice. A total of 301 new patients were screened during their routine gynecologic examination. Thirty-one (10.3%) had pigmented lesions in the vulvar region, and an additional six (2%) had diffuse hyperpigmentation. Only seven patients (2.3%) had vulvar nevocytic nevi.

    Title Endometriosis. Overview and Future Directions.
    Date February 1990
    Journal The Journal of Reproductive Medicine
    Excerpt

    Several modalities can be employed in managing the patient with endometriosis, and ultimate selection hinges on a number of criteria, including age, extent of disease, severity of symptoms and pain. The current scoring system may underestimate the severity of the disease in some women. For instance, the system does not consider the presence of subtypes of endometriosis in individual patients. Endometriotic implants differ from uterine endometrium in terms of their response to the hormonal milieu and demonstrate a wide range of morphologic development, from poorly to highly differentiated glands. The number of estrogen, progestin and/or androgen receptors in endometriotic lesions may differ markedly from that in normal endometrium. These developments suggest not only problems with current scoring but the possibility of using such innovations as receptor studies to individualize therapy in the future. Danocrine (danazol), an isoxazol derivative of 17-alpha ethinyl-testosterone, when used at appropriate dosages, is an excellent drug for the treatment of endometriosis. Exercise has been demonstrated to markedly reduce the incidence of androgenic side effects that occur with danazol. Gonadotropin releasing hormone agonists also appear to be promising for this indication. Further research is needed with these drugs, especially in the area of combination therapy with danazol.

    Title A Placebo-controlled Trial of a Depot Gonadotropin-releasing Hormone Analogue (leuprolide) in the Treatment of Uterine Leiomyomata.
    Date December 1989
    Journal Obstetrics and Gynecology
    Excerpt

    Several studies have shown that treatment with a gonadotropin-releasing hormone (GnRH) analogue can reduce uterine volume in women with leiomyomata. However, no study to date has used a controlled population for comparison, nor has any study delineated the physiologic mechanism of volume reduction. We performed a double-blind, placebo-controlled study of a depot form of a GnRH analogue (leuprolide) given monthly for 24 weeks in 11 patients with symptomatic uterine leiomyomata. Patients initially treated with placebo were subsequently treated with active drug for 24 weeks. Magnetic resonance imaging was used to identify specifically the total uterine volume, total myoma volume, and total non-myoma volume. Treated patients had a significant reduction in total uterine and non-myoma volumes as compared with placebo patients (P less than .02). Total myoma volume was also reduced, but only to a P = .06 level. Pre- versus post-therapy values for all 11 patients showed significant reduction in all three volumes (P less than .02). Most symptoms were markedly improved. By 24 weeks post-therapy, all volumes had returned to baseline levels, although symptomatic improvement commonly persisted. The non-myoma volume was proportionally reduced to a greater extent than the myoma volume (42.7 versus 30.4%), and we therefore could explain the reenlargement seen when treatment was discontinued. Side effects were well tolerated and there were no study dropouts. We conclude that temporary hypoestrogenism induced by GnRH analogues can produce significant though temporary reduction in uterine volumes, and that the non-myoma volume is responsible for much of the reduction and reenlargement.(ABSTRACT TRUNCATED AT 250 WORDS)

    Title Interval Bone Mineral Density with Long-term Gonadotropin-releasing Hormone Agonist Suppression.
    Date November 1989
    Journal Fertility and Sterility
    Excerpt

    Twenty-six patients of mean age 37 +/- 4.8 (SD) years, who received a 6-month course of gonadotropin-releasing hormone (GnRH) analogue, were selected for study. Bone mineral density (BMD) was measured by dual-photon absorptiometry before initiation and after completion of agonist therapy. Mean BMD (g/cm2) by dual-photon absorptiometry at L2 to L4, femoral neck, Ward's triangle, and the trochanteric area did not change significantly (P = not significant [NS]) after 6 months of GnRH analogue suppression. Mean percent (%) expected density as standardized for age, weight, and sex remained in the range of 89.3% to 94.2% (P = NS). The interval detectable change in BMD after therapy was 0.05 +/- 0.06 g/cm2. These findings are reassuring with respect to the use of long-term GnRH analogue regimens to induce a hypoestrogenic state in the treatment of hormone-dependent conditions.

    Title Exogenous Estrogen Effect on Lipid/lipoprotein Cholesterol in Transsexual Males.
    Date November 1989
    Journal Journal of Endocrinological Investigation
    Excerpt

    Lipid/lipoprotein cholesterol values and sex-hormone-binding globulin levels were determined in 40 transsexual males aged 20-38, 20 castrated and 20 non-castrated, taking conjugated estrogens to induce female characteristics. Variables controlled included dose of estrogen, age, weight, smoking, alcohol intake, exercise and diet history. Transsexual males on estrogens had significantly higher mean (+/- SE) HDL cholesterol levels (69.0 +/- 7.1 mg/dl) respectively, for castrated males and (53.8 +/- 6.2 mg/dl) for non-castrated males, respectively compared to normal control males not on hormonal therapy (41.5 +/- 5.4) (p less than 0.001), regardless of dose of estrogen received. The total cholesterol/HDL ratio was 3.31-4.05 in transsexual males on estrogens compared to 5.03 for normal males (p less than 0.001). Transsexual males had mean SHBG levels in the female range (63.4 to 71.8 nmol/ml), significantly higher than controls (26.7 nmol/ml) (p less than 0.001). SHBG levels were correlated with estrogen use, dose and HDL cholesterol levels. We conclude that exogenous estrogens administered to transsexual males results in a female pattern of lipid/lipoprotein cholesterol and SHBG concentration. The decreased total cholesterol/HDL ratio may imply a lower atherogenic potential and a lessened cardiovascular risk in males who take estrogens.

    Title Disappearance of Exogenously Administered Human Chorionic Gonadotropin.
    Date October 1989
    Journal Fertility and Sterility
    Excerpt

    Concentrations of human chorionic gonadotropin (hCG) were measured after intramuscular hCG administration in 34 patients undergoing ovarian stimulation in an in vitro fertilization program. Serum hCG levels were detectable by an immunoenzymetric assay up to 14 days after injection. Individual variation in hCG concentration after injection could be minimized by expressing the daily hCG level as a fractional distribution of the value observed 36 hours after hCG administration (hCG0). In nonpregnant patients, less than 10% of the hCG0 value was found on day 10. The disappearance rate measured 36 hours after injection of hCG was exponential with a mean half-life of 2.32 days. These findings are significant for ovarian stimulation protocols, including exogenous hCG, with respect to timing and accuracy of quantitative pregnancy testing.

    Title Total Ablation of the Penis After Circumcision with Electrocautery: a Method of Management and Long-term Followup.
    Date October 1989
    Journal The Journal of Urology
    Excerpt

    Four patients who had traumatic loss of the penis were managed after the initial injury with a feminizing genitoplasty. Patient reconstruction ranged from 6 months to 3 years. The technique of feminizing genitoplasty is described. There were no instances of flap necrosis, urinary tract infection or urinary incontinence. Immediate results were considered to be cosmetically satisfactory in all patients. Followup ranged from 8 months to 23 years, with a median of 10.5 years. The long-term results have been particularly gratifying in 2 individuals who have been observed for more than 18 years. Early feminizing genitoplasty offers an excellent method of reconstruction of the external genitalia in the child with traumatic loss of the penis who is assigned a female sex of rearing.

    Title Extrapelvic Endometriosis.
    Date August 1989
    Journal Obstetrics and Gynecology Clinics of North America
    Excerpt

    Extrapelvic endometriosis has been reported in nearly every organ system of the human female body. The etiology of this disease may well be due to one or more factors. Though less common than pelvic disease, extrapelvic endometriosis is often difficult to diagnose and more difficult to treat. Our experience combined with a review of world literature is presented focusing on diagnosis and management.

    Title Microscopic Peritoneal Endometriosis.
    Date July 1989
    Journal Fertility and Sterility
    Title Endometriosis: Pathophysiology, Diagnosis, and Treatment.
    Date June 1989
    Journal Obstetrical & Gynecological Survey
    Excerpt

    Endometriosis remains a poorly understood disease. Multiple factors are likely to be responsible for the relative infertility in patients with endometriosis. All therapeutic options should be presented to the patient. Treatment of a patient with endometriosis should be individualized based on symptoms (i.e., pain and/or infertility), extent of disease, age and associated pelvic pathology. Diagnosis continues to require visual documentation with histologic confirmation if possible.

    Title Construction of a Neovagina for Patients with a Flat Perineum.
    Date May 1989
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    Vaginal dilatation affords an acceptable functional success rate for women with vaginal agenesis, provided there is an introitus with a pouch or dimple. In contrast, women with a flat perineum who lack labia majora, labia minora, and vaginal introitus have no alternative to development of a vagina-like orifice other than surgical vaginoplasty. This study addresses the anatomic and functional success rate of these women after undergoing modified McIndoe technique. Thirty-four patients with microphallus were assigned the female gender as the sex of rearing at the Johns Hopkins Hospital between 1951 and 1987. A majority of patients underwent surgical revision of the external genitalia and gonadectomy before 2 years of age. Family counseling was begun at birth. Of these patients, 15 (17 to 25 years old) who requested the ability to have sexual relations underwent modified McIndoe vaginoplasty. All 15 of these women have experienced satisfactory coitus. All but one patient have an adequate size vagina. Results of this group indicate that patients with ambiguous genitalia as a result of male hermaphroditism or microphallus can achieve functional success after vaginal creation with a modified McIndoe technique despite the presence of a flat perineum.

    Title Deploying and Testing an Expandable Surgical Chamber in Microgravity.
    Date April 1989
    Journal Aviation, Space, and Environmental Medicine
    Excerpt

    Prolonged spaceflights will increase the possibility of injury to flight crews and mission personnel. These injuries are anticipated to include foreign body injury, mechanical injury, and burns. Surgical repair of these injuries must take into consideration problems of contamination of the injury as well as contamination of the Space Station or transport vehicle environment. Use of a portable expandable surgical chamber is felt to be the most efficient and effective means of providing necessary surgical care in a Space Station environment. A first prototype expandable surgical chamber has been developed and tested in zero gravity. A second prototype has now been developed and will be tested.

    Title Changes in Plasma Volume During Bed Rest: Effects of Menstrual Cycle and Estrogen Administration.
    Date November 1988
    Journal Journal of Applied Physiology (bethesda, Md. : 1985)
    Excerpt

    Bed rest (BR) is associated with a decrease in plasma volume (PV), which may contribute to the impaired orthostatic and exercise tolerances seen immediately after BR. The purpose of this study was to determine whether increases in blood estrogen concentration, either during normal menstrual cycles or during exogenous estrogen administration, would attenuate this loss of PV. Nineteen healthy women (21-39 yr of age) completed the study. Twelve women underwent duplicate 11-day BR without estrogen supplementation. PV decreased significantly (P less than or equal to 0.01) during both BR's, from 2,531 +/- 113 to 2,027 +/- 102 ml during BR1 and from 2,445 +/- 115 to 2,244 +/- 96 ml during BR2. The women who began BR in the periovulatory stage of the menstrual cycle (n = 3), a time of elevated endogenous estrogens, had a transient delay in loss of PV during the first 5 days of BR. Women who began BR during other stages of the menstrual cycle (n = 17) showed the established trend to decrease PV primarily during the first few days of BR. Seven additional women underwent a single 12-day BR while taking estrogen supplementation (1.25 mg/day premarin). PV decreased during the first 4-5 days of BR, then returned toward the pre-BR level during the remainder of the BR (pre-BR PV, 2,525 +/- 149 ml; post-BR PV, 2,519 +/- 162 ml). Thus menstrual fluctuations in endogenous estrogens appear to have only small transient effects on the loss of PV during BR, whereas exogenous estrogen supplementation significantly attenuates PV loss.

    Title Treatment Independent Pregnancy with Operative Laparoscopy for Endometriosis in an in Vitro Fertilization Program.
    Date October 1988
    Journal Fertility and Sterility
    Excerpt

    Thirty-nine patients with Stage I to IV endometriosis and at least 5 years of primary infertility were enrolled in the Johns Hopkins In Vitro Fertilization Program. At the time of laparoscopic oocyte retrieval, operative endoscopy with lysis of adhesions, fulguration or resection of pelvic endometriosis, or enucleation of ovarian endometriomas was performed. Although the in vitro fertilization-embryo transfer cycle did not result in pregnancy, 12 patients (28%) conceived within 10 months of the operative laparoscopic procedure. Nine of the pregnancies occurred in patients with Stage I to II endometriosis.

    Title Reproductive Uterine Surgery.
    Date May 1988
    Journal Obstetrics and Gynecology Clinics of North America
    Excerpt

    Uterine reconstructive surgery may be accomplished through both the abdomen and the hysteroscope. It is important to obtain a complete evaluation of infertility or repeated pregnancy wastage prior to surgery. Newer approaches include the hysteroscopic resection of the uterine septum and medical therapy with GnRH analogues for reduction of fibroid size, volume, and symptoms. In some instances, larger fibroids may be approached through the hysteroscope or resectoscope after medical therapy.

    Title Insensitive Ovary Syndrome with a Unique Process of Follicular Degeneration.
    Date March 1988
    Journal Fertility and Sterility
    Title The Glycosphingolipid Composition of the Placenta of a Blood Group P Fetus Delivered by a Blood Group Pk1 Woman and Analysis of the Anti-globoside Antibodies Found in Maternal Serum.
    Date March 1988
    Journal Archives of Biochemistry and Biophysics
    Excerpt

    To further define the molecules that may mediate spontaneous abortion due to maternal-fetal blood group incompatibility within the P blood group system, we have examined the fine specificities of maternal antibodies and the glycolipid antigens from the placenta of a P infant born to a Pk1 mother. Maternal antibodies obtained during therapeutic plasmapheresis were analyzed to determine their reactivities with placental glycolipid extracts on thin-layer plates. Second antibodies specific for IgM, IgG, and IgA revealed immunoglobulins of all of these classes strongly reactive with one major placental glycolipid that comigrates with globoside. GC/MS analysis confirmed that the major P-active pentaglycosylceramide of placenta has the same structure as that previously shown for the P antigen of red blood cells: GalNAc beta 1-3Gal alpha 1-4Gal beta 1-4Glc-Cer. Serum antibodies partially purified by affinity chromatography on globoside-octyl-Sepharose specifically recognize glycolipids that contain terminal GalNAc beta 1-3Gal . . . residues and also recognize the same sequence as an internal determinant in some, but not all, glycolipids with extended globoside core regions. Thus, in the blood group P incompatible fetus, the major P antigen present in placenta has the same carbohydrate structure as the P antigen present in fetal and adult erythrocytes and might be a target for the maternal immune system.

    Title Fluid Volume and Prostanoid Concentration During the Proliferative and Periovulatory Phase of the Menstrual Cycle.
    Date February 1988
    Journal Contributions to Gynecology and Obstetrics
    Title Failure of Tubal Closure Following Laser Salpingostomy for Ampullary Tubal Ectopic Pregnancy.
    Date December 1987
    Journal Fertility and Sterility
    Excerpt

    A patient with recurrent ectopic pregnancy is described. The first ectopic gestation was treated by laparoscopic linear laser salpingostomy of the right fallopian tube. Her hCG became negative and a hysterosalpingogram demonstrated right tubal patency. She conceived again after Pergonal ovulation induction, but had a recurrent right ectopic pregnancy. At laparotomy, the pregnancy was extruding through the unhealed incision of her prior linear salpingostomy. This complication of conservative management of ectopic pregnancy has important potential clinical significance.

    Title Are We Exploiting the Infertile Couple?
    Date December 1987
    Journal Fertility and Sterility
    Excerpt

    We hope that this article brings into focus some problems that merit consideration and debate. These thoughts come from a group of individuals who are actively engaged in reproductive endocrine/infertility practices with special interests ranging from ovulation induction to IVF to laser surgery. As a group, we practice in all parts of the country, and the problems mentioned are not restricted to any individual or region. We urge that all of us be candid with ourselves and our colleagues about what we can and cannot do for the infertile couple. We suggest that gynecologists ask themselves this question and proceed when the answer is affirmative: "Is this procedure really in the patient's best interest?"

    Title A Rat Uterine Horn Model of Genital Tract Wound Healing.
    Date December 1987
    Journal Fertility and Sterility
    Excerpt

    A rat uterine horn model of genital tract wound healing is described. Healing was reflected by acquisition of strength and elasticity, measured by burst strength (BS) and extensibility (EX), respectively. A tensiometer (Instron Corp., Canton, MA) was used to assess these characteristics in castrated and estrogen-supplemented or nonsupplemented animals. While the horn weights (HW), BS, and EX of contralateral horns were not significantly different, the intra-animal variation of HW was 7.2%, BS was 17.7% and EX was 38.2%. In a second experiment, one uterine horn was divided and anastomosed, and the animal given estrogen supplementation or a placebo pellet. Estrogen administration was found to increase BS and EX of anastomosed horns prior to 14 days, but had no beneficial effect at 21 or 42 days. The data suggest that estrogen may be required for optimal early healing of genital tract wounds.

    Title Genital Anomalies in Childhood.
    Date November 1987
    Journal Clinical Obstetrics and Gynecology
    Title Bilateral Functioning Uterine Anlagen with the Rokitansky-mayer-kuster-hauser Syndrome.
    Date October 1987
    Journal International Journal of Fertility
    Excerpt

    This report describes an adolescent female with a shallow vaginal pouch and bilateral functioning uterine anlagen, who presented with cyclic pelvic pain and a pelvic mass. Removal of both functioning uterine anlagen afforded complete relief of symptoms.

    Title Resectoscopic Techniques for the Lysis of a Class V: Complete Uterine Septum.
    Date October 1987
    Journal Fertility and Sterility
    Title Tubal Anastomosis: Pregnancy Success Following Reversal of Falope Ring or Monopolar Cautery Sterilization.
    Date August 1987
    Journal Fertility and Sterility
    Excerpt

    The present study reviews pregnancy outcome following tubal anastomosis in 80 previously sterilized women. Thirty of 58 women (52%) sterilized by monopolar cautery techniques delivered a living child as compared to 19 of 22 women (86%) sterilized using the Falope ring method. Cumulative pregnancy curves were calculated for the Falope ring and cautery groups using life-table methods. Following reversal of Falope ring sterilization, the estimated cumulative probability of pregnancy 6, 12, 24, and 36 months after surgery was 28.4%, 48.8%, 69.3%, and 87.2% respectively. The corresponding estimates following reversal of cautery sterilization were lower at 6, 12, 24, and 36 months following surgery: 22.7%, 37.8%, 52.4%, and 57.9%, respectively. The ectopic tubal pregnancy and spontaneous abortion rate were higher among women sterilized with monopolar cautery. A decreased pregnancy rate was associated with ampullary-isthmic anastomosis in the cautery group; however, pregnancy was least likely to occur in women with shortened oviducts of less than 4 cm.

    Title Cervical Agenesis Combined with Vaginal Agenesis Diagnosed by Magnetic Resonance Imaging.
    Date August 1987
    Journal Fertility and Sterility
    Title Cul-de-sac Fluid in Women with Endometriosis: Fluid Volume, Protein and Prostanoid Concentration During the Periovulatory Period--days 13 to 18.
    Date August 1987
    Journal Fertility and Sterility
    Excerpt

    Cul-de-sac fluid from women with histologically confirmed endometriosis (n = 45) or from infertile women without evidence of endometriosis (n = 28) was collected at the time of laparoscopy during the periovulatory period (days 13 to 18). This fluid was analyzed for prostaglandin E2 (PGE2), prostaglandin F2a (PGF2a), 13,14-dihydro-15 keto-PGF2a (PGFM), and thromboxane B2 (TXB2) by radioimmunoassay (RIA). Protein content of the fluid also was determined. No difference (P greater than 0.05) in cul-de-sac fluid volume was found between women with and without endometriosis, nor were differences detected in the level of any of the prostanoids measured in fluid from infertile control patients compared with those with endometriosis. This was true regardless of whether the prostanoids were expressed as a concentration, total amount in fluid, or as a ratio of prostanoid to protein content. The present study does not support the theory that cul-de-sac fluid prostanoids provide a useful diagnostic index of endometriosis.

    Title Procidentia in the Newborn.
    Date June 1987
    Journal International Journal of Gynaecology and Obstetrics: the Official Organ of the International Federation of Gynaecology and Obstetrics
    Excerpt

    Complete uterine prolapse was noted shortly after birth in a female infant with a meningomyelocele at the level of the iliac crest with a palpable dimpled defect caudal to the primary lesion. The vagina and uterus were restored to their normal position with a rubber nipple placed into the vagina. The prolapse resolved on the sixth day of life after a repair of the meningomyelocele. Thus, conservative therapy with temporary support provides a satisfactory solution for newborn procidentia.

    Title The Association of Anti-p and Early Abortion.
    Date April 1987
    Journal Transfusion
    Excerpt

    The current report details the serologic findings in a case reported previously of a P1k woman, para 0 gravida 13, who was treated during her fourteenth pregnancy with plasmapheresis to reduce the anti-P titer. These studies suggest that anti-P can induce early abortion in Pk women and that the abortions are immunologically mediated. Further, this case supports the disputed proposal that the anti-P component of anti-PP1Pk is responsible for pregnancy loss in p women.

    Title Anatomic Abnormalities.
    Date April 1987
    Journal Clinical Obstetrics and Gynecology
    Title Fertility Rates in Female Patients with Congenital Adrenal Hyperplasia Due to 21-hydroxylase Deficiency.
    Date February 1987
    Journal The New England Journal of Medicine
    Excerpt

    Among 80 women with congenital adrenal hyperplasia due to 21-hydroxylase deficiency (40 with the simple virilizing form and 40 with the salt-losing form), 40 reported having an adequate introitus and being heterosexually active. In 15 of 25 patients with the simple virilizing form, 25 pregnancies resulted in 20 normal children, whereas only 1 of 15 women with the salt-losing form became pregnant; this pregnancy was electively terminated. Several factors seem to be responsible for the low fertility rates: noncompliance with therapy was probably high, as suggested by hirsutism and poor endocrine follow-up in 25 percent of patients; whereas 49 patients had regular menstrual periods, 14 had irregular periods, 10 had amenorrhea, 5 had undergone hysterectomy, and 2 had entered menopause; 87 percent of patients with salt loss and 50 percent of those with simple virilization (P less than 0.001) had remained single; the vaginal introitus was reported to be inadequate for intercourse by 35 percent of patients (53 percent of those with salt loss and 18 percent of those with simple virilization; P less than 0.002); and heterosexual activity was reported less frequently among patients with an inadequate introitus. The status of the introitus seemed to have a more important role in the sexual activity reported than did the degree of prenatal exposure to androgen (which was higher among patients with salt loss than among those with simple virilization). However, our data did not rule out an effect of androgen exposure on female fetuses. Our experience indicates that improved surgical correction of the external genitalia and better compliance with therapy will be necessary to improve fertility rates among women with congenital adrenal hyperplasia due to 21-hydroxylase deficiency.

    Title Congenital Adrenal Hyperplasia: Long-term Results Following Vaginal Reconstruction.
    Date January 1987
    Journal Fertility and Sterility
    Excerpt

    Forty-two women with virilizing congenital adrenal hyperplasia who had attempted coitus were studied retrospectively a mean of 23.6 years after vaginal repair. Satisfactory intercourse, as defined by the patient, was observed in 62% of the subjects. The functional success rate was higher if repeat operations were performed after the age of 16 years (61% versus 12%, P less than 0.05) or if the patient suffered from the non-salt-losing variety of the disorder (87% versus 46%, P less than 0.05). The outcome of the initial attempt to exteriorize the vagina did not differ significantly by age at surgery. In cases of moderate virilization, vaginal repair may be delayed until the patient's menarche, maturity, and desires for sexual activity are well established. Clitoroplasty should be performed as soon as possible.

    Title Circulating Antiovarian Antibodies in Premature Ovarian Failure.
    Date December 1986
    Journal Obstetrics and Gynecology
    Excerpt

    The presence of antiovarian antibodies in sera of women with premature ovarian failure was determined by an indirect fluorescent antibody assay using human ovarian tissue. Of 27 patients, 14 had positive ovarian fluorescence, compared with zero of 24 normal cycling controls (P less than .001) and one of 22 postmenopausal controls (P less than .01). In patients with autoimmune diseases, five of 17 demonstrated positive fluorescence compared with zero of 24 premenopausal controls (P less than .01). Immunoperoxidase staining revealed antigen concentrated at the granulosa cells and oocyte in nine of the 14 ovarian failure cases. The finding that a significant proportion of patients with premature ovarian failure have circulating antiovarian antibodies confirms previous studies, but localization of peroxidase staining to granulosa cells and/or oocytes represents a new finding in this study.

    Title Sexual Functioning and Psychologic Evaluation of in Vitro Fertilization Couples.
    Date November 1986
    Journal Fertility and Sterility
    Excerpt

    Couples requesting in vitro fertilization (IVF) may be sexually dysfunctional either as an etiologic factor in their infertility or because they experience decreased sexual satisfaction as a reaction to previous infertility treatment. The present study assessed the sexual functioning and psychologic status of 45 married couples who had requested IVF. The couples were given complete psychosexual evaluation by senior staff members of the Sexual Behaviors Consultation Unit and each participant completed the Derogatis Sexual Functioning Inventory (DSFI). Seven couples (15.5%) were experiencing a sexual dysfunction and 13 individuals (14.4%) were given Diagnostic and Statistical Manual of Mental Disorders III diagnoses. In total, 19 individuals (21%) of the sample were found to have either a sexual dysfunction or psychologic disorder. Couples with a sexual dysfunction were more likely (P = 0.05) to have unexplained infertility. Norms for psychologic evaluation as part of IVF are suggested and the role of such evaluation discussed.

    Title Unsuspected Endometriosis Documented by Scanning Electron Microscopy in Visually Normal Peritoneum.
    Date October 1986
    Journal Fertility and Sterility
    Title Malposition of the Ovary Associated with Uterine Anomalies.
    Date May 1986
    Journal Fertility and Sterility
    Title A Computer-based System for Patient Care and Research Management in Reproductive Endocrinology.
    Date April 1986
    Journal Fertility and Sterility
    Excerpt

    We describe a medical information system tailored to the operational needs of the Gynecologic and Infertility Clinic at The Johns Hopkins Hospital. It is used for patient registration and scheduling, medical and surgical record keeping, and research investigation. Data entered include a complete medical history, diagnoses, procedures performed and their outcomes, surgical pathologic study, follow-up notes, phone consultations, and laboratory findings. Data are coded individually and can be retrieved and presented in a standard or user-specific report format. The Reproductive Endocrinology Medical Information System (REMIS) was implemented over 6 months from January to June 1984. To date, 8000 new patient registrations and 3600 outpatient visits have been entered. There are approximately 100 new patient entries and 240 return visit entries per month. Preliminary evaluation of the system based on the effect on quality care, use by each user group, and research applicability demonstrates that the REMIS provides clinicians with more complete, organized, and accessible patient records to serve as an effective adjunct to clinical operations.

    Title Surgical Correction of Genital Prolapse in Three Rhesus Monkeys.
    Date November 1985
    Journal Laboratory Animal Science
    Excerpt

    Three adult female rhesus monkeys (Macaca mulatta) in a breeding colony of approximately 75 adult females developed a clinical condition characterized by protrusion of the cervix through the vulva during pregnancy and/or following parturition. The Gilliam round-ligament uterine ventro-suspension procedure (hereafter called the Gilliam uterine suspension or uterine suspension procedure) was used to return the cervix to a normal anatomical position. Following the procedure, one female delivered a normal live infant, but reprolapsed. After a second suspension procedure, she again became pregnant and delivered a normal live infant without a reoccurrence of the prolapse. A second animal never became pregnant despite repeated breedings to different males for two years. The third animal became pregnant twice following the procedure. The first pregnancy terminated in abortion at two months of gestation, while the second pregnancy ended in an apparent dystocia, necessitating a cesarean section and delivery of a dead fetus. The animal died post-operatively. This surgical procedure successfully salvaged one of these animals which otherwise had no reproductive future.

    Title Thyrotropin-releasing Hormone-induced Contraction of Urethral and Vaginal Muscle.
    Date October 1985
    Journal The Journal of Clinical Endocrinology and Metabolism
    Excerpt

    Pressure studies were carried out in 10 women to determine whether TRH stimulates muscular contractions in the genitourinary system. TRH (500 micrograms) or saline was administered iv as a bolus injection. Whereas saline had no effect, TRH increased intraurethral pressures in all women, vaginal pressure in 7, and bladder pressure in none. These findings suggest that TRH, acting centrally, peripherally, or both, may play a role in initiating muscular contractions in the female genitourinary tract.

    Title In Vitro Fertilization and Embryo Transfer: the Johns Hopkins Hospital, Baltimore, Maryland.
    Date September 1985
    Journal Journal of in Vitro Fertilization and Embryo Transfer : Ivf
    Title Plasmapheresis for the Treatment of Repeated Early Pregnancy Wastage Associated with Anti-p.
    Date September 1985
    Journal Obstetrics and Gynecology
    Excerpt

    It has been proposed that the blood group antibody, anti-P, produced by p or Pk individuals may cause abortion early in pregnancy. The authors have studied and successfully treated a Pk woman with anti-P who had 13 consecutive first-trimester miscarriages. Anti-P was implicated as the cause of repeated pregnancy loss after extensive clinical, endocrinologic, immunologic, and chromosomal evaluations. To remove P blood group antibodies, plasmapheresis was begun at five weeks' gestation during the 14th pregnancy with one plasma volume exchange two to three times per week. This therapy resulted in a reduction in the titer of anti-P, and the patient was delivered of a viable female infant after 33 weeks' gestation. The management and outcome indicate that habitual abortion presumably due to anti-P can be successfully treated with plasmapheresis. This case provides additional evidence that anti-P is responsible for abortions in p or Pk women, and that these abortions are immunologically mediated.

    Title Fetal Malformations Following Progesterone Therapy During Pregnancy: a Preliminary Report.
    Date August 1985
    Journal Fertility and Sterility
    Excerpt

    This report presents the outcome of pregnancies of 93 women who conceived while taking progesterone (P) suppositories (n = 42) or P in oil intramuscularly (n = 51). The dosage and duration of treatment varied according to the indication. The total dose (in milligrams) increased with the duration of treatment and ranged from 75 to 13,500 mg. Two of 75 term pregnancies (2.6%) were noted to have congenital anomalies. Both women had been treated with P in oil. No patient treated with P suppositories gave birth to a malformed infant. An increased spontaneous abortion rate (28.6%) was noted among women treated with P suppositories. The authors recommend that a national registry be created to document fetal outcome after P therapy.

    Title The Obstetric Consequences of Uterovaginal Anomalies.
    Date June 1985
    Journal Fertility and Sterility
    Excerpt

    Congenital uterovaginal anomalies can have adverse effects on pregnancy outcome. Early diagnosis and an aggressive evaluation of any patient presenting with mid-trimester abortion, premature labor, malpresentation, or retained placenta may prevent additional pregnancy wastage and maternal morbidity. With more timely and accurate diagnosis, appropriate management is likely to provide the best possible outcome for all such patients.

    Title Hot Flashes in Postmenopausal Women Ameliorated by Danazol.
    Date April 1985
    Journal Fertility and Sterility
    Excerpt

    Six postmenopausal women with hot flashes were studed for two 8-week periods during which they received low-dose danazol (100 mg/24 hours) for one time interval and placebo for the other in a randomized double-blind manner. The patients recorded the number and severity of their hot flashes daily. On the last day of each period the patients were admitted to the research center overnight for an 8-hour monitoring of forehead skin temperatures and for continuous withdrawal of blood to determine 20-minute integrated levels of luteinizing hormone. Three of the six patients responded to danazol with a mean reduction of 88% in the number of hot flashes and a 53% decrease in the severity of hot flashes. Responders differed from nonresponders in that on treatment the frequency of nocturnal pulses of luteinizing hormone was reduced more (36.1% versus 14.4%), the increase in amplitude of the pulses was greater (+30.7% versus -11.8%), and the fall in the mean level of luteinizing hormone was more marked (19.0% versus 10.5%). The findings suggest that danazol may be a reasonable alternative to estrogen in the treatment of postmenopausal women with severe vasomotor symptoms.

    Title The Clinical Management of Congenital Absence of the Uterine Cervix.
    Date November 1984
    Journal International Journal of Gynaecology and Obstetrics: the Official Organ of the International Federation of Gynaecology and Obstetrics
    Excerpt

    Eight women with cervical atresia were evaluated and treated for symptoms of pelvic pain. Two distinct anatomic variations of cervical atresia were observed among these patients. A fibrous cord, with islands of endocervical glands, was noted in two patients surgically treated with the creation of a cervicovaginal fistula through the fibrous cord. Alternatively, a complete absence of the cervical stroma required a uterovaginal anastomosis in two women. One of the two women with the cervicovaginal fistula continues to menstruate. Both women, after the anastomosis, required additional surgery to maintain menstrual flow and ultimately received hysterectomy. Subsequently, four women with complete congenital absence of the cervical stroma were treated primarily with the removal of the uterine fundus. Although menstrual function may be maintained in patients with some cervical stroma, no pregnancies have occurred. Thus, removal of the uterine fundus remains the treatment of choice, relieving symptoms and avoiding additional surgery to maintain uterovaginal patency.

    Title The Efficacy of Postoperative Hydrotubation: a Randomized Prospective Multicenter Clinical Trial.
    Date September 1984
    Journal Fertility and Sterility
    Excerpt

    Term pregnancies following surgery on patients with distal tubal obstruction have been disappointingly few. There has been continuing interest in whether postoperative hydrotubation increases the rate of pregnancy following salpingoneostomy and fimbrioplasty. This hypothesis was tested in a prospective, randomized, multicenter clinical trial. Patients with no infertility factors other than distal fimbrial disease were randomly assigned to either a control group (no hydrotubation, n = 86) or one of two treatment groups (hydrotubation with lactated Ringer's solution, n = 60, or lactated Ringer's solution containing hydrocortisone, n = 60). The statistical evaluation of differences among treatment groups was based on the Cox Proportional Hazards Model, which allows for covariable adjustment and for the inclusion of all patients regardless of the length of follow-up. A significant difference in the live birth rate could not be demonstrated among the groups studied (P = 0.36). The probability of a successful live birth among women treated by hydrotubation with hydrocortisone was about one-half that of the other groups (P = 0.12). Patients with moderate and severe disease had a substantially lower probability of pregnancy than those with mild disease (P = 0.013 and P = 0.0016, respectively). The probability of pregnancy increased somewhat as the number of previous pregnancies increased (P = 0.12). In this clinical trial, a beneficial effect following postoperative hydrotubation could not be demonstrated.

    Title Medical and Surgical Considerations for Women in Spaceflight.
    Date September 1984
    Journal Obstetrical & Gynecological Survey
    Title Vaginal Forms for Dilatation And/or to Maintain Vaginal Patency.
    Date September 1984
    Journal Fertility and Sterility
    Title Microsurgical Tubal Anastomosis: a Controlled Trial in Four Asian Centers.
    Date September 1984
    Journal Microsurgery
    Excerpt

    An international program to determine the reversibility of female sterilization in Asia using microsurgical technique was established in 1980. One hundred eleven of 219 patients (51%) conceived following tubal anastomosis; of these, 79 delivered living children. The overall cumulative probability of conception at the end of follow-up, as determined by life-table analysis, was 63%. A decreased pregnancy rate was associated with anastomosis of tubes sterilized by electrocautery methods.

    Title An Expandable Surgical Chamber for Use in Conditions of Weightlessness.
    Date July 1984
    Journal Aviation, Space, and Environmental Medicine
    Excerpt

    An expandable surgical chamber of transparent polyvinyl has been designed to provide a sterile environment for minor surgical procedures performed in conditions of weightlessness. Contamination of the cabin with blood and other debris is prevented while performing surgery. The patient's extremity is inserted through a cuff into the surgical chamber. The cuff may be inflated for rapid hemostasis. All instruments and suture material are stored within the chamber.

    Title A Management Engineering Study of Our Lab.
    Date May 1984
    Journal Mlo: Medical Laboratory Observer
    Title A Community Hospital Develops an Integrated, Comprehensive Toxicology Laboratory.
    Date May 1984
    Journal Pathologist
    Excerpt

    A model system was developed at the author's institution for providing toxicology and therapeutic drugs monitoring services. These services were expanded with chromatography instrumentation and the Syva EMIT-st Drug Detection System. An emergency screen for various drugs in urine takes about one hour. The drugs or drug families detected are opiates, barbiturates, benzodiazepines, amphetamines, phenothiazines, cocaine metabolite, acetaminophen, and ethyl alcohol. Confirmation and quantitation of drugs in serum can be done by either higher performance liquid chromatography, gas chromatography, or radioimmunoassay. Sample preparation takes from five to 15 minutes and chromatography requires about 15 minutes in most cases. While more than 60 drugs can be quantitated using these procedures, rarely are more than one or two drugs present in patient samples.

    Title Comparison of the Operating Microscope and Loupe for Microsurgical Tubal Anastomosis: a Randomized Clinical Trial.
    Date April 1984
    Journal Fertility and Sterility
    Excerpt

    Reversal of sterilization was performed by microsurgical tubal anastomosis in 72 women using either loupe (n = 36) or microscope (n = 36). The study design called for the randomization of patients within pairs, which were matched for method of sterilization and site of anastomosis. A significant difference between methods could not be demonstrated at 12 months (P = 0.39) or 24 months (P = 0.37) after the procedure.

    Title A Comparison of Danazol and Conservative Surgery for the Treatment of Infertility Due to Mild or Moderate Endometriosis.
    Date December 1983
    Journal Fertility and Sterility
    Excerpt

    Although both medical and surgical therapy have been widely used in the treatment of infertility due to endometriosis, there is little information on the comparative success of these treatment modalities. In a group of 313 infertile women who presented to The Johns Hopkins Hospital with mild or moderate endometriosis in whom there had been no previous therapy, the results of danazol (91 patients) and conservative surgery (133 patients) were compared. It was found that the cumulative pregnancy curves of the two groups virtually coincided. There was no significant difference in the estimated proportion of patients who were "cured," i.e., who would ultimately conceive if followed for a long enough period (68.3% for surgery versus 74.0% for danazol), nor in the monthly rate of pregnancy among those cured (5.7% versus 4.0%), respectively.

    Title Autoimmunity in a Patient with 47,xxx Karyotype.
    Date November 1983
    Journal Obstetrics and Gynecology
    Excerpt

    Premature ovarian failure in women with a 47,XXX karyotype have been described, but an explanation for this gonadal disorder has not been forthcoming. The present case identifies a 47 triple X woman with premature ovarian failure associated with an autoimmune disorder. A possible association between the 47,XXX karyotype, autoimmune disorders, and premature ovarian failure is proposed.

    Title A Paracentric Chromosomal Inversion Associated with Repeated Early Pregnancy Wastage.
    Date August 1983
    Journal Fertility and Sterility
    Title Success Following Vaginal Creation for Müllerian Agenesis.
    Date July 1983
    Journal Fertility and Sterility
    Excerpt

    Eighty-eight women with Müllerian agenesis underwent vaginal dilatation (n = 21) and/or vaginal creation using a modified McIndoe technique (n = 79). Patient and family counseling was considered an essential component of the therapy regimen. An initial trial of vaginal dilatation was successful in 9 of 21 patients (43%). Failure was associated with a prior vaginal exploration in eight women. All of the 79 women experienced satisfactory sexual activity and were satisfied with vaginal depth following vaginal creation using a split thickness graft technique. However, anatomic success, as judged by the surgeon, was noted in 72 patients (91%). Our experience suggests an initial trial of vaginal dilatation coupled with careful instruction and family counseling is appropriate in the motivated patient. However, vaginoplasty using a split thickness graft technique is highly successful and should be offered to those patients unwilling or unable to obtain an adequate neovagina with dilatation.

    Title The Clinical Management of Repeated Early Pregnancy Wastage.
    Date March 1983
    Journal Fertility and Sterility
    Excerpt

    A rational systematic evaluation is essential to the management of a couple with repeated early pregnancy wastage. Psychologic support in the form of frequent discussions and sympathetic counseling are crucial to the successful evaluation and treatment of the anxious couple. A prompt and orderly evaluation will relieve anxiety. When no etiologic factor is identified, a 60% to 80% fetal salvage rate may be expected. Once a patient conceives, serial ultrasonography, beta-hCG determination, and estradiol determination may be useful in detecting the stage of the embryonic death if subsequent abortion occurs. A karyotypic analysis of the products of conception should be performed if fetal loss occurs.

    Title Artificial Insemination with Fresh Donor Semen Using the Cervical Cap Technique: a Review of 278 Cases.
    Date March 1983
    Journal Obstetrics and Gynecology
    Excerpt

    Two hundred twenty-six patients received artificial insemination with fresh donor semen (AID) using the cervical cap technique; 52 patients underwent the procedure for 2 conceptions. Using life-table analysis to adjust for uneven patient follow-up, the cumulative pregnancy rate was 62.5% after 6 months of AID, and 82.4% after 10 months. Moreover, using a mathematical model of cumulative pregnancy following AID, the estimated cure rate was not significantly different from 100%, and the estimated monthly probability of pregnancy among those cured was 15.5%. Age was found to be inversely related to pregnancy success, while parity had no effect. For those who continued to undergo AID beyond 6 months, the monthly probability of pregnancy did not decline. Patients can be advised that their chance of conception with AID should approach that of normal fertile couples.

    Title True Hermaphroditism.
    Date February 1983
    Journal The Johns Hopkins Medical Journal
    Excerpt

    Eleven cases of true hermaphroditism (eight previously reported) studied at The Johns Hopkins Hospital are presented. The two most recently observed patients had what is to be considered an appropriate endocrine evaluation. This includes karyotyping, and measurement of 24-hour urinary 17-ketosteroids, gonadotropins, plasma testosterone, dihydrotestosterone, and all their precursors before and following a human chorionic gonadotropin stimulation test, and a sexual skin biopsy for androgen receptor binding and 5 alpha-reductase activity. The differential diagnosis of true hermaphroditism is discussed and an approach to gender assignment is presented.

    Title Surgical Correction of a Rectovaginal Fistula.
    Date January 1983
    Journal International Journal of Gynaecology and Obstetrics: the Official Organ of the International Federation of Gynaecology and Obstetrics
    Title Testicular Morphology in the 47xxy Fetus at 16 Weeks Gestation.
    Date December 1982
    Journal International Journal of Gynaecology and Obstetrics: the Official Organ of the International Federation of Gynaecology and Obstetrics
    Title Assessing the Efficacy of The American Fertility Society's Classification of Endometriosis: Application of a Dose-response Methodology.
    Date October 1982
    Journal Fertility and Sterility
    Excerpt

    In order to promote uniform reporting of endometriosis. The Americal Fertility Society (AFS) recently proposed a classification in which severity was categorized on the basis of both location and extent of disease. The results of this study indicate that the AFS scale poorly specifies the relation between severity of disease and pregnancy outcome after therapy, because of the arbitrary point scores assigned to each classification category, and the arbitrary cutoff points chosen to divide patients into severity groupings. A nonparametric monotonic estimator, which generates a dose-response relationship between AFS score (dose) and pregnancy following treatment (response) is shown to improve the discriminatory power of the AFS scale; however, in order to obtain the full benefit of the detail provided by the AFS classification, it is recommended that the current arbitrary individual-category weights be replaced by empirically derived weights.

    Title Nurse Specialization in Reproductive Endocrinology.
    Date September 1982
    Journal Jogn Nursing; Journal of Obstetric, Gynecologic, and Neonatal Nursing
    Title Cul-de-sac Fluid in Women with Endometriosis: Fluid Volume and Prostanoid Concentration During the Proliferative Phase of the Cycle--days 8 to 12.
    Date August 1982
    Journal Fertility and Sterility
    Excerpt

    Cul-de-sac fluid from women with histologically confirmed endometriosis (n = 45) or with no evidence of endometriosis (n = 17) was removed during the proliferative phase of the menstrual cycle (days 8 to 12) and analyzed for prostaglandin E2 (PGE2), prostaglandin F2 alpha (PGF2 alpha), 15-keto-13,14-dihydroprostaglandin F2 alpha (PGFM), and thromboxane B2 (TXB2). The fluid volume was recorded. Peripheral blood was also obtained to determine the concentration of PGFM. Prostanoid concentrations (PGE2, PGF2 alpha, PGFM, TXB2) in women with endometriosis were not significantly different from a comparable group of disease-free women. Furthermore, a meaningful elevation of prostanoid with increasing severity of disease could not be demonstrated. Plasma PGFM was not significantly different from controls. There was, however, an elevation of PGFM with severity of disease, although this increase was not statistically significant (P = 0.11). An increase in fluid volume was not demonstrated in women with endometriosis, as compared with controls.

    Title Leydig Cell Hypofunction Resulting in Male Pseudohermaphroditism.
    Date July 1982
    Journal Fertility and Sterility
    Excerpt

    An 11-year-old patient with male pseudohermaphroditism presented with essentially normal-appearing female external genitalia. When examined, inguinal gonads, redundant foreskin, and some posterior labial fusion were found. Evaluation revealed basal testosterone (T) levels ranging from 65 to 107 ng/dl with slightly elevated serum gonadotropin levels (luteinizing hormone [LH]: 76 ng/ml, and follicle-stimulating hormone [FSH]: 568 ng/ml). Neither T nor its precursors increased with human chorionic gonadotropin (hCG) stimulation. However, progesterone (P), 17-hydroxyprogesterone (17-OHP), and cortisol (F) responses to adrenocorticotropic hormone (ACTH) were normal. Androgen binding and 5 alpha-reductase activity in cultured genital skin fibroblasts were normal. These data, plus the microscopic finding of a markedly reduced number of Leydig cells, strongly suggest that the male pseudohermaphroditism in this patient was due to inadequate Leydig cell function unrelated to LH receptors.

    Title A Genetic Male Patient with 17 Alpha-hydroxylase Deficiency.
    Date July 1982
    Journal Obstetrics and Gynecology
    Excerpt

    A patient with 46,XY karyotype and 17 alpha-hydroxylase deficiency is reported who illustrates marked virilization of the external genitalia. Marked phallic development and almost complete labioscrotal fusion with no development of a utriculovaginal pouch were noted. Because the perineum was essentially similar to that seen in male-to-female transsexuals, vaginal construction required the McIndoe procedure. Hence, although some patients with 17 alpha-hydroxylase deficiency have minimal virilization of the external genitalia, this patient's history indicates the operative management necessary in the opposite extreme, when patients show complete masculinization. Hormonal evaluation after gonadectomy revealed the enzyme deficiency based on abnormalities of steroid secretion by the adrenal cortex.

    Title Tubal Anastomosis Following Unipolar Cautery.
    Date July 1982
    Journal Fertility and Sterility
    Excerpt

    Twenty-five of 48 women (52%) sterilized by unipolar cautery techniques conceived following tubal anastomosis, of whom 17 (36%) had a living child. The overall cumulative probability of conception at the end of follow-up as determined by life-table analysis was 76%. Increasing age, parity, and the duration of the interval from sterilization to reversal did not influence pregnancy success. A decreased pregnancy rate was associated with ampullary-isthmic anastomosis; however, a pregnancy was least likely to occur in women with shortened oviducts of less than or equal to 4 cm (P less than 0.01). A decreased pregnancy rate in cautery-sterilized patients undergoing reversal may be related to the destruction of a larger segment of the fallopian tube. Interestingly, 71% of the cautery-sterilized patients were noted to have associated tubal disease such as endometriosis and/or proximal hydrosalpinx. The influence of these findings on subsequent pregnancy success remains to be established.

    Title Pregnancy Success Following Surgical Correction of Imperforate Hymen and Complete Transverse Vaginal Septum.
    Date July 1982
    Journal Obstetrics and Gynecology
    Excerpt

    Pregnancy success was evaluated in 48 women following surgical correction of a vaginal obstruction due to imperforate hymen (N = 22) or to a complete transverse vaginal septum (N = 26). Pregnancy success was more likely to occur following surgical correction of imperforate hymen (P less than .05). Patients with a complete transverse septum in the middle or upper vagina were less likely to conceive than were patients with a septum in the lower vagina. Prompt diagnosis and surgical correction to drain accumulated blood may preserve preserve fertility possibly through the prevention of endometriosis.

    Title A Parametric Method for Comparing Cumulative Pregnancy Curves Following Infertility Therapy.
    Date June 1982
    Journal Fertility and Sterility
    Excerpt

    When evaluating the results of infertility therapy, it is often of interest to know whether differences exist between a new form of therapy and the established one, between medical and surgical therapy, or between patient groups that differ in severity of disease, age, parity, and so on. In this paper, a likelihood-ratio test is developed to evaluate differences between cumulative pregnancy curves of different patient groups. The test takes into account variation in patient follow-up and can be applied to any type of infertility therapy. It is illustrated by consideration of a group of patients who underwent artificial insemination by donor (AID) and determination of whether pregnancy outcome differed according to parity. It was found that the cure rate for both nulliparous and parous patients was virtually 100% and that the monthly probability of pregnancy was not significantly different between the two groups.

    Title Pleural and Parenchymal Pulmonary Endometriosis.
    Date January 1982
    Journal Obstetrics and Gynecology
    Title Fertility Following Bilateral Ovarian Wedge Resection: a Critical Analysis of 90 Consecutive Cases of the Polycystic Ovary Syndrome.
    Date December 1981
    Journal Fertility and Sterility
    Excerpt

    Fertility following bilateral ovarian wedge resection (BOWR) was evaluated in a retrospective cohort study of 90 consecutive cases of the polycystic ovary syndrome. Post-BOWR follow-up was available for varying time spans of up to 10 years. BOWR resulted in the resumption of menstrual cyclicity in 91.1% (82/90) of the cases. However, within this ovulatory group, 26 patients were characterized by oligo-ovulation and a significantly reduced conception rate (29.2%), as compared with that of 56 normo-ovulatory counterparts (60.3%). Although the crude overall conception rate for this series was 47.8%, the overall cumulative probability of conception at the end of follow-up as determined by life table analysis was 73%. The likelihood of conception at any given point in time was estimated by a monthly fecundability rate of 1.34%. Our findings also indicate that the probability of post-BOWR conception was unaffected by age, race, ward status, or duration of infertility. In contrast, persistent post-BOWR oligo- or anovulation and the presence of concurrent tuboperitoneal disease were reaffirmed as the most important determinants of the likelihood of post-BOWR conception. A minimum incidence of 7.8% was documented for acquired post-BOWR pelvic disease.

    Title Microsurgery for Treatment of Adnexal Disease.
    Date October 1981
    Journal Fertility and Sterility
    Title Management of Pelvic Endometriosis with Low-dose Danazol.
    Date September 1981
    Journal Fertility and Sterility
    Excerpt

    Thirty-eight women with pelvic endometriosis diagnosed by laparotomy or laparoscopy were enrolled in a double-blind study utilizing danazol. Danazol was administered for 6 months in four doses schedules: 600, 400, 200, and 100 mg/day. At the completion of 6 months of therapy, repeat laparoscopy was performed and 71% of the women were found to have improvement of pelvic endometriosis. Minimal and moderate pelvic endometriosis appeared to respond well to doses of danazol of less than 400 mg/day, whereas severe endometriosis appeared to be best treated with danazol doses of greater than 400 mg/day. Symptomatic relief of pain, dysmenorrhea, and dyspareunia occurred in 89% of the women. The over-all pregnancy rate in women attempting conception was 28% (8 of 28). Fifty-four per cent of the women had recurrence of symptoms within 1 year of discontinuation of danazol.

    Title Pregnancy Outcome Following Treatment of Intrauterine Adhesions.
    Date September 1981
    Journal International Journal of Fertility
    Excerpt

    Twenty-five patients were evaluated for reproductive failure and menstrual dysfunction before and after therapy of intrauterine adhesions. The patients were classified according to the extent of adhesion formation by means of a classification proposed by Toaff and Ballas. A pretherapy successful pregnancy rate of 32% was increased to 52% posttherapy. The spontaneous abortion rate of 78% was improved to 20% posttherapy. Altered menstrual function was noted in six of 25 patients. A correlation between the extent of intrauterine adhesion formation and pregnancy outcome following therapy could not be demonstrated. The authors recommend the adoption of a classification system based on hysteroscopic findings which may serve as a standard method of reporting to allow for comparison of treatment regimens and ultimately for prediction of pregnancy outcome.

    Title Estimation of a Model of Cumulative Pregnancy Following Infertility Therapy.
    Date August 1981
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    Life-table estimation of cumulative pregnancy curves following infertility therapy is an important tool for evaluating the effectiveness of therapy. However, a satisfactory method for summarizing an entire cumulative pregnancy curve in terms of a small number of clinically useful parameters is currently lacking. In the present paper, a model is developed in which cumulative pregnancy is expressed as a function of two parameters: the cure rate and the instantaneous probability of pregnancy among those cured. This model is applied to data on endometriosis and polycystic ovary syndrome, and the resulting predicted cumulative pregnancy curves almost perfectly follow the observed data.

    Title The Conservative Surgical Treatment of Endometriosis: Evaluation of Pregnancy Success with Respect to the Extent of Disease As Categorized Using Contemporary Classification Systems.
    Date May 1981
    Journal Fertility and Sterility
    Excerpt

    A homogeneous group of 214 infertile women with endometriosis treated at the Johns Hopkins Hospital from 1960 to 1979 received conservative surgery as the sole therapeutic modality. Among this group, 115 patients (54%) conceived following surgery; of these conceptions, 109 resulted in a living child. Among 49 patients with secondary infertility, the spontaneous abortion rate was reduced from 49% to 20% after conservative surgery (P less than or equal to 0.01). Three contemporary classification systems were utilized to categorize patients according to the sites and amount of endometriosis at the time of conservative surgery. Those systems suggested by Buttram (Fertil Steril 30:240, 1978) and by Kistner and coauthors (Fertil Steril 28:108, 1977) revealed differences among fecundability rates among the different categories (P less than or equal to 0.01); however, the system suggested by The American Fertility Society (AFS) (Fertil Steril 32:633, 1979) revealed significant differences only if categories were combined (mild plus moderate versus severe plus extensive, P less than or equal to 0.05). Nevertheless, the AFS system revealed that pregnancy success was significantly reduced if an ovarian endometrioma was greater than 3 cm or had ruptured (P less than or equal to 0.01).

    Title Endometriosis and the Development of Tuboperitoneal Fistulas After Tubal Ligation.
    Date April 1981
    Journal Fertility and Sterility
    Excerpt

    The present study details gross and histologic findings of 79 previously ligated fallopian tubes from 3 groups of patients. Of 20 oviducts removed after documented sterilization failure (group I), 6 revealed a process compatible with endometriosis. Four of nine previously ligated fallopian tubes removed at the Johns Hopkins Hospital (group II) were successfully injected with India ink. In two patients histologic examination demonstrated the India ink in epithelium-lined spaces that lay beyond the muscle of the tubal wall extending from the tubal lumen to the serosal surface. Fifty oviducts were studied in twenty-five patients requesting reversal of their sterilizations (group III). A higher percentage of fistulas was demonstrated in patients with less than 4 cm of remaining proximal tubal segment. Furthermore, most of these fistulas were demonstrated in patients for whom 3 years had elapsed since the original sterilization procedure. Patients sterilzed by laparoscopic cautery methods were observed to have a higher percentage of fistula formation and histologic documentation of endometriosis at the sterilization site as compared with patients sterilized by other methods. Our observations suggest that ligation of the oviduct within 4 cm of the uterine cornu may predispose to the development of endometriosis and subsequent fistula formation in the tip of the ligated oviduct.

    Title A Unilateral Functioning Uterine Anlage with Müllerian Duct Agenesis.
    Date February 1981
    Journal International Journal of Gynaecology and Obstetrics: the Official Organ of the International Federation of Gynaecology and Obstetrics
    Excerpt

    The case reports of two female adolescents with congenital absence of the Müllerian ducts and a unilaterally enlarged uterine anlage containing functioning endometrial tissue are presented. The clinical manifestations may vary depending upon the delay in diagnosis after the onset of endometrial shedding within the anlage. A high index of suspicion and proper diagnostic evaluation may prevent unnecessary hospitalization. In our experience, prompt removal of the functioning uterine anlage affords complete relief of the symptoms.

    Title The Double Uterus Associated with an Obstructed Hemivagina and Ipsilateral Renal Agenesis.
    Date November 1980
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    Twelve patients with a double uterus, unilateral vaginal obstruction, and ipsilateral renal agenesis are described. The clinical presentation varies, depending on whether the obstruction was partial or complete. In rare instances a communication existed between the obstructed vaginal pouch and the opposite patent vagina through a defect in the septum of the double uterus. Early accurate diagnosis followed by the excision of the obstructing vaginal septum offers complete relief of symptoms while preserving reproductive capacity.

    Title Assignment of the H-y Antigen Gene to the Short Arm of Chromosome Y.
    Date October 1979
    Journal The Journal of Heredity
    Excerpt

    We have presented two cases strongly suporting a Y chromosome short-arm location for the H-Y antigen gene. The first case was HY antigen-positive with an isochromosome for the short arm of the Y with no long arm of the Y being present. The other case was H-Y antigen-negative in fibroblasts from an individual with a 46,X,i(Yq) karyotype with no short arm of the Y present. The two cases presented also confirmed previous reports that the testicular forming gene is also located on the short arm of chromosome Y.

    Title The Role of the H-y Antigen in Human Sexual Development.
    Date September 1979
    Journal The Johns Hopkins Medical Journal
    Title Gestational Outcome of Clomiphene-related Conceptions.
    Date August 1979
    Journal Fertility and Sterility
    Excerpt

    The experience of the gynecologic endocrinology and infertility clinic at The Johns Hopkins Hospital has been subjected to a nonconcurrent prospective analysis in an attempt to evaluate the gestational fate of clomiphene-related conceptions (study series, n = 86). This latter series was contrasted with a series of pregnancies following bilateral ovarian wedge resection (BOWR) (n = 51) in a comparative analysis of gestational outcome event rates. Post-therapy follow-up was available for varying time spans of up to 15 years. A 12.8% twinning rate constituted the single most important complication of clomiphene therapy, resulting in measurable increments in perinatal morbidity and mortality rates. The observation of a 26.5% spontaneous abortion rate would seem to suggest that clomiphene-related conceptions are at little or more risk for spontaneous abortion than would have been expected from the infertile population under discussion. A 3.1% incidence of post-clomiphene birth defects was not increased as compared with commonly quoted rates for the population at large. The corresponding incidence rates of twinning, spontaneous abortion, and birth defects for the BOWR series were 0%, 21.6%, and 0%, respectively.

    Title Pregnancy Outcome Following Uterotubal Implantation: a Comparison of the Reamer and Sharp Cornual Wedge Excision Techniques.
    Date August 1979
    Journal Fertility and Sterility
    Title Cytogenetic and Clinical Notes on a Girl with a 46,x,i(yq) Karyotype, H-y Antigen-negative, and a Gonadoblastoma.
    Date March 1979
    Journal Birth Defects Original Article Series
    Title Technique of Surgical Sex Reassignment for Micropenis and Allied Conditions.
    Date March 1979
    Journal American Journal of Obstetrics and Gynecology
    Excerpt

    Although the etiology of micropenis is diverse, individuals who have in common a penile length of 2 cm. or less at birth do not function well as men. For this reason, during the last 18 years, 10 individuals with this problem were selected for surgical sex reassignment. The technique of the surgical procedure is described. The immediate results are considered to be cosmetically satisfactory, and the long-term results, as judged by two individuals who have been observed for 18 plus years seem to indicate that surgical sex reassignment is a useful procedure in selected patients with this disorder.

    Title Pregnancy Success Following Abdominal Myomectomy for Infertility.
    Date March 1979
    Journal Fertility and Sterility
    Excerpt

    There were 46 patients with primary infertility (34 patients) or secondary infertility (12 patients) with no other detectable cause except myomas. After myomectomy, 38% of the patients with primary infertility had full-term pregnancies and 50% of those with secondary infertility. Preoperative distortion of the endometrial cavity was not impressively correlated with the postoperative prognosis.

    Title Factors Influencing the Success of Salpingostomy Techniques for Distal Fimbrial Obstruction.
    Date February 1979
    Journal Obstetrics and Gynecology
    Excerpt

    The present study reviews the pregnancy outcome of 99 patients treated with salpingostomy techniques for distal fimbrial obstruction. Eighty-seven patients were treated with terminal salpingostomy, 10 with medioampullary salpingostomy, and 2 with isthmic salpingostomy. The pregnancy rates were 28%, 20%, and 0%, respectively. Within the terminal salpingostomy group, 5 of 18 patients treated with a prosthesis conceived, for a pregnancy rate of 28%. Nineteen of the 69 patients treated with an eversion technique conceived, for a pregnancy rate of 28%. No advantage with the use of a terminal prosthesis could be demonstrated. Tubal disease treated with techniques of salpingostomy was categorized according to a classification incorporating the several prognostic factors thought to influence subsequent conception. The pregnancy rate was found to be in direct relationship to the extent of tubal disease and pelvic adhesion formation. The tubal patency rate decreased in direct relationship to the extent of disease. The use of postoperative hydrotubation did not appear to improve the conception rate after salpingostomy for distal fimbrial obstruction.

    Title On the Reanastomosis of Fallopian Tubes After Surgical Sterilization.
    Date August 1978
    Journal Fertility and Sterility
    Title Normal Range for Serum Thyroxine in Neonates.
    Date December 1977
    Journal Clinical Chemistry
    Title The Clinical Management of the Double Uterus.
    Date September 1977
    Journal Fertility and Sterility
    Title Choice of Analgesia or Anesthesia for Pain Relief in Suction Curettage.
    Date July 1977
    Journal Obstetrics and Gynecology
    Excerpt

    One hundred and fifteen patients admitted to Duke University Medical Center from January 1, 1973, to December 31, 1974 inclusive, with the diagnosis of uncomplicated spontaneous incomplete or inevitable abortion were included in a randomized prospective study. All patients underwent suction curettage under either analgesia or general inhalation anesthesia. Patient response was adjudged regarding comfort and cooperativeness in the group receiving analgesia and postprocedure rehabilitation and discharge times in both groups. Fifteen of 59 patients receiving analgesia only were recorded unanimously as failures. Post-operative ambulation was no more rapid in patients receiving analgesia. Procedure-to-discharge intervals were unrelated to medication modality. There appears to be no advantage to analgesia as far as rehabilitation time, procedure-to-discharge time, and medical complications are concerned.

    Title Endometriosis.
    Date April 1977
    Journal Obstetrics and Gynecology
    Title Conservative Treatment of Endometriosis: the Effects of Limited Surgery and Hormonal Pseudopregnancy.
    Date October 1976
    Journal Fertility and Sterility
    Excerpt

    This study compares the effects of limited surgery or hormonal pseudopregnancy, or a combination of these two, upon fertility and the need for subsequent surgery with respect to the extent of the disease at the time of initial diagnosis in patients with endometriosis externa. Of the 61 patients who desired to enhance or preserve reproductive capacity, 20 patients became pregnant, for a pregnancy rate of 33%. The pregnancy rate in all categories, that is, those patients treated with pseudopregnancy, conservative surgery, and combined pseudopregnancy and surgery, was found to be in direct relationship to the initial extent of disease. In such patients, conservative surgery alone seemed to give the best results in the achievement of pregnancy. There seemed to be little difference between pseudopregnancy alone and conservative surgery in regard to the need for subsequent surgery after initial therapy, although there seemed to be a significantly greater chance for the need for subsequent surgery in patients receiving a combination of the two forms of therapy. The need for subsequent surgery after initial therapy in 80 patients increased in direct relationship to the initial extent of disease present, despite the form of therapy used. Fifty-nine other patients with endometriosis, who did not desire to preserve fertility and presented for relief of other symptoms, underwent initial "radical" therapy. Forty-six patients underwent complete operation, including removal of uterus, tubes and ovaries, and none required subsequent reoperation. Of the 13 remaining patients, who underwent incomplete surgical removal, leaving one or both ovaries in situ, 11 required subsequent reoperation for recurrent pelvic endometriosis.

    Title Genital Cytologic Abnormalities in Patients Having Therapeutic Abortion.
    Date April 1976
    Journal Southern Medical Journal
    Excerpt

    In the three years 1971-1973, 1,032 patients had therapeutic abortions at the Duke University Medical Center. Of these 99 (9.59%) had abnormal cervical cells on routine preabortion Papanicolaou smears. The patient who presents for therapeutic abortion appears to be at high risk for early cervical neoplasia. Therefore, it is mandatory that evaluation of the preabortion patient include adequate genital cytologic studies with means for proper follow-up.

    Title Dextrostix Method for Determination of Blood Glucose Levels. A Statistical Evaluation.
    Date November 1966
    Journal Jama : the Journal of the American Medical Association

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