metroplasty of the class va uterus italian style

1
objective was to determine if peritoneal TGFb1/b2 mRNA ratios are locally elevated in adhesive as compared to normal peritoneal tissue in the rat. Design: A prospective, randomized, double-blinded study. Materials/Methods: Cecal abrasion using a previously validated, stan- dardized method was performed on five Sprague-Dawley rats. Seven days later necropsy was performed with adhesion and adjacent normal peritoneal tissues collected from the cecal abrasion sites from all the operated rats; and, normal cecal tissue was also harvested from a previously non-operated rat (baseline). Total RNA was extracted from all tissues. Multiplex reverse transcriptase / polymerase chain reaction (RT-PCR) using rat-specific TGF-b1 and b2 primers, with b-actin as the normalizing control, was utilized to quantitate the relative changes in TGF-b1 and b2 mRNA levels in the tissues. Results: In the four cecal adhesion tissue specimens the normalized ratios ranged as follows: b1, 0.845 to 5.77, and b2, 0.292 to 2.87. In the postoperative normal cecum the ratios were: b1, 0.291, and b2, 0.301. In the baseline rat the ratios were: b1, 0.684, and b2, 0.659. Comparing respective sample TGF-b1/b2 isoform ratios yielded these Results: adhesion tissue, 2.09, 2.34, 2.01, 4.10; normal peritoneal tissue, 0.97; and baseline, 1.04. There was at a minimum a doubling in the TGF-b1/b2 ratio in adhesion tissue specimens over that observed in the adjacent normal tissue and non-operated baseline specimens. Conclusions: The TGF-b1/b2 ratio is increased in adhesion as compared to normal peritoneal cecal tissue in the rat. Normally healing postoperative tissue, maintains the same TGF-b1/b2 ratio seen in fresh, non-operated tissue. The rat peritoneum demonstrates an increase in the TGF-b1/b2 ratio after wounding and adhesion formation as seen in other animal models and tissues. Manipulation of TGF-b1 and b2 to achieve ratios associated with less adhesions and scarring is a potential avenue to decrease postoperative adhesion formation. Wednesday, October 24, 2001 4:30 P.M. O-283 A 5 MHz finger grip ultrasound probe for real-time intraoperative guidance during complex reproductive surgical procedures. G. S. Let- terie. Virginia Mason Medical Ctr, Seattle, WA. Objective: To investigate the usefulness of a 5 MHz finger grip probe for intraoperative guidance of complex intra-abdominal reproductive surgical procedures. Design: Case series. Materials/Methods: A 5 MHz finger grip probe was used to monitor intra-abdominal reproductive surgery in 2 sets of patients. The first set underwent uterine reconstruction and excision of obstructive uterine horn (n 5 3) and a second group underwent transabdominal myomectomy for multiple uterine leiomyomata (n 5 3). Intraoperative real-time imaging was accomplished by direct application of the finger grip probe to the uterine serosa using saline solution as a transmission media. Ultrasound imaging and surgical dissection were carried out both sequentially and simulta- neously. Images were taken with an Aloka unit, model SSD-1700. Results: Monitoring surgery with the finger grip probe provided an additional dimension in planning surgical incisions and assessing the extent of dissection. In the first group of patients, use of the finger probe delineated intrauterine anatomy in 1 patient who had a normally sized and shaped uterus with an obstructed intracavitary horn and hematometra. In 2 other patients, the obstructed uterine horn extended deep into the pelvis lateral to the vagina. Real-time imaging provided intraoperative monitoring of depth of dissection into the paravaginal space. In those patients undergoing a myomectomy, finger grip probe provided precise location of the leiomyo- mata and intraoperative guidance for dissection. Conclusions: The finger grip probe demonstrated intrauterine anatomy and enabled a more directed surgical approach, both in placement of uterine incisions for surgical reconstruction and excision of obstructed horns for mullerian abnormalities and in identification and dissection for leiomyo- mata. It may have a role in complex reproductive surgical procedures to monitor both the location of uterine incisions and depth of dissection. Wednesday, October 24, 2001 4:45 P.M. O-284 Metroplasty of the class Va uterus Italian style. T. C. Nagel. Repro- ductive Medicine Ctr, Univ of Minnesota, Minneapolis, MN. Objective: To present a series of ten patients treated with an alternative, simpler and safer method of surgical correction of the Class Va uterine anomaly by which method the cervix is transected, and subsequent course in those patients who conceived. Design: Case studies of ten patients with Class Va class uterus. Materials/Methods: In 1996 Vercellini (1) et al described a technique for metroplasty in patients the Va uterus in which the cervix was divided hysteroscopically with laparoscopic monitoring. They described ten women who underwent the procedure. Six subsequently conceived. Four delivered vaginally at term, one by C-section at another hospital, and one aborted in the second trimester. Transection of the cervix did not result in cervical incompetence. We report nine additional cases done between April 1997 and June 2000 using a similar procedure. Our procedures were done with ultrasound monitoring to obviate the need for laparoscopy. Three of the patients have conceived, in two instances with twins. The twins were dichorionic, diamniotic in one instance and monochorionic, diamniotic in the other. Results: The pertinent data regarding the patients is presented in the table below. The operative technique was essentially that of Vercellini et al except that laparoscopy was done only if indicated for other reasons. The metroplasty was done with ultrasonic monitoring. Nine cases studies of patients with class VA uterus. Patient Age- Surg Date Diag/Treat Parity Post-op preg. Weeks gest’n 1 40–5/97 Sec Inf: prior loss at 9 week with subchorionic hemorrhage 0010 Dichorionic twins 37W-3D, C/S for Breech 2 36–8/98 Prim Inf: Lt salpingectomy for hydrosalpinx/Clomiphene IUI 0000 Single 27W-5D, C/S for Placenta Previa 3 35–2/00 Prim Inf: asthenospermia/Gonadotropin IUI 0000 Monochorionic twins Delivered at 32W-3D for Preterm labor 4 27–2/00 Prim Inf: azospermia. IVF, one TVOR 0000 Not pregnant 5 26–2/00 Prim Inf 0000 Moved out of area 6 36–3/00 See Inf: left hydrosalpinx/ Clomiphene IUI 1001 Stopped trying 7 28–5/00 Prim Inf: PCOS, morbid obesity, extensive lf ovarian adhesions. Failed Clomiphene/ metformen, left S & O 0101 Not pregnant 8 28–5/00 Prior preterm delivery at 24W 0101 Not pregnant 9 17–7/00 Pelvic pain 0000 Not trying Conclusions: This form of metroplasty is safe, easily performed, does not require laparoscopy, and does not appear to result in cervical incompetence. Ultrasound monitoring obviates the need for laparoscopy unless required for other reasons, thereby decreasing morbidity and shortening recovery time. SOCIETY FOR REPRODUCTIVE ENDOCRINOLOGY AND INFERTILITY Wednesday, October 24, 2001 2:00 P.M. O-285 Induction of cyclooxygenase-2 and prostaglandin E2 biosynthesis by epithelial cell derived factors is mediated mainly by p42/p44 mitogen- activated protein (MAP) kinase in stromal cells in endometrium. M. Tamura, S. Yang, B. Gurates, Z. Fang, S. Sebastian, S. E. Bulun. Univ of Illinois at Chicago, Chicago, IL. Objective: We previously reported that medium conditioned with endo- metrial epithelial cancer (Ishikawa) cells (ECM) differentially regulated the FERTILITY & STERILITYt S107

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objective was to determine if peritoneal TGFb1/b2 mRNA ratios are locallyelevated in adhesive as compared to normal peritoneal tissue in the rat.

Design: A prospective, randomized, double-blinded study.Materials/Methods: Cecal abrasion using a previously validated, stan-

dardized method was performed on five Sprague-Dawley rats. Seven dayslater necropsy was performed with adhesion and adjacent normal peritonealtissues collected from the cecal abrasion sites from all the operated rats; and,normal cecal tissue was also harvested from a previously non-operated rat(baseline). Total RNA was extracted from all tissues. Multiplex reversetranscriptase / polymerase chain reaction (RT-PCR) using rat-specificTGF-b1 and b2 primers, with b-actin as the normalizing control, wasutilized to quantitate the relative changes in TGF-b1 andb2 mRNA levelsin the tissues.

Results: In the four cecal adhesion tissue specimens the normalized ratiosranged as follows:b1, 0.845 to 5.77, andb2, 0.292 to 2.87. In thepostoperative normal cecum the ratios were:b1, 0.291, andb2, 0.301. In thebaseline rat the ratios were:b1, 0.684, andb2, 0.659. Comparing respectivesample TGF-b1/b2 isoform ratios yielded these Results: adhesion tissue,2.09, 2.34, 2.01, 4.10; normal peritoneal tissue, 0.97; and baseline, 1.04.There was at a minimum a doubling in the TGF-b1/b2 ratio in adhesiontissue specimens over that observed in the adjacent normal tissue andnon-operated baseline specimens.

Conclusions: The TGF-b1/b2 ratio is increased in adhesion as comparedto normal peritoneal cecal tissue in the rat. Normally healing postoperativetissue, maintains the same TGF-b1/b2 ratio seen in fresh, non-operatedtissue. The rat peritoneum demonstrates an increase in the TGF-b1/b2 ratioafter wounding and adhesion formation as seen in other animal models andtissues. Manipulation of TGF-b1 andb2 to achieve ratios associated withless adhesions and scarring is a potential avenue to decrease postoperativeadhesion formation.

Wednesday, October 24, 20014:30 P.M.

O-283

A 5 MHz finger grip ultrasound probe for real-time intraoperativeguidance during complex reproductive surgical procedures.G. S. Let-terie. Virginia Mason Medical Ctr, Seattle, WA.

Objective: To investigate the usefulness of a 5 MHz finger grip probe forintraoperative guidance of complex intra-abdominal reproductive surgicalprocedures.

Design: Case series.Materials/Methods: A 5 MHz finger grip probe was used to monitor

intra-abdominal reproductive surgery in 2 sets of patients. The first setunderwent uterine reconstruction and excision of obstructive uterine horn(n 5 3) and a second group underwent transabdominal myomectomy formultiple uterine leiomyomata (n5 3). Intraoperative real-time imaging wasaccomplished by direct application of the finger grip probe to the uterineserosa using saline solution as a transmission media. Ultrasound imagingand surgical dissection were carried out both sequentially and simulta-neously. Images were taken with an Aloka unit, model SSD-1700.

Results: Monitoring surgery with the finger grip probe provided anadditional dimension in planning surgical incisions and assessing the extentof dissection. In the first group of patients, use of the finger probe delineatedintrauterine anatomy in 1 patient who had a normally sized and shapeduterus with an obstructed intracavitary horn and hematometra. In 2 otherpatients, the obstructed uterine horn extended deep into the pelvis lateral tothe vagina. Real-time imaging provided intraoperative monitoring of depthof dissection into the paravaginal space. In those patients undergoing amyomectomy, finger grip probe provided precise location of the leiomyo-mata and intraoperative guidance for dissection.

Conclusions: The finger grip probe demonstrated intrauterine anatomyand enabled a more directed surgical approach, both in placement of uterineincisions for surgical reconstruction and excision of obstructed horns formullerian abnormalities and in identification and dissection for leiomyo-mata. It may have a role in complex reproductive surgical procedures tomonitor both the location of uterine incisions and depth of dissection.

Wednesday, October 24, 20014:45 P.M.

O-284

Metroplasty of the class Va uterus Italian style. T. C. Nagel. Repro-ductive Medicine Ctr, Univ of Minnesota, Minneapolis, MN.

Objective: To present a series of ten patients treated with an alternative,simpler and safer method of surgical correction of the Class Va uterineanomaly by which method the cervix is transected, and subsequent coursein those patients who conceived.

Design: Case studies of ten patients with Class Va class uterus.Materials/Methods: In 1996 Vercellini (1) et al described a technique for

metroplasty in patients the Va uterus in which the cervix was dividedhysteroscopically with laparoscopic monitoring. They described ten womenwho underwent the procedure. Six subsequently conceived. Four deliveredvaginally at term, one by C-section at another hospital, and one aborted inthe second trimester. Transection of the cervix did not result in cervicalincompetence. We report nine additional cases done between April 1997and June 2000 using a similar procedure. Our procedures were done withultrasound monitoring to obviate the need for laparoscopy. Three of thepatients have conceived, in two instances with twins. The twins weredichorionic, diamniotic in one instance and monochorionic, diamniotic inthe other.

Results: The pertinent data regarding the patients is presented in the tablebelow. The operative technique was essentially that of Vercellini et alexcept that laparoscopy was done only if indicated for other reasons. Themetroplasty was done with ultrasonic monitoring.

Nine cases studies of patients with class VA uterus.

Patient

Age-SurgDate Diag/Treat Parity Post-op preg. Weeks gest’n

1 40–5/97 Sec Inf: prior loss at 9 weekwith subchorionic hemorrhage

0010 Dichorionictwins

37W-3D, C/S forBreech

2 36–8/98 Prim Inf: Lt salpingectomyfor hydrosalpinx/ClomipheneIUI

0000 Single 27W-5D, C/S forPlacenta Previa

3 35–2/00 Prim Inf:asthenospermia/GonadotropinIUI

0000 Monochorionictwins

Delivered at32W-3D forPreterm labor

4 27–2/00 Prim Inf: azospermia. IVF,one TVOR

0000 Not pregnant

5 26–2/00 Prim Inf 0000 Moved out ofarea

6 36–3/00 See Inf: left hydrosalpinx/Clomiphene IUI

1001 Stopped trying

7 28–5/00 Prim Inf: PCOS, morbidobesity, extensive lf ovarianadhesions. Failed Clomiphene/metformen, left S & O

0101 Not pregnant

8 28–5/00 Prior preterm delivery at 24W 0101 Not pregnant

9 17–7/00 Pelvic pain 0000 Not trying

Conclusions: This form of metroplasty is safe, easily performed, does notrequire laparoscopy, and does not appear to result in cervical incompetence.Ultrasound monitoring obviates the need for laparoscopy unless required forother reasons, thereby decreasing morbidity and shortening recovery time.

SOCIETY FOR REPRODUCTIVE ENDOCRINOLOGYAND INFERTILITY

Wednesday, October 24, 20012:00 P.M.

O-285

Induction of cyclooxygenase-2 and prostaglandin E2 biosynthesis byepithelial cell derived factors is mediated mainly by p42/p44 mitogen-activated protein (MAP) kinase in stromal cells in endometrium. M.Tamura, S. Yang, B. Gurates, Z. Fang, S. Sebastian, S. E. Bulun. Univ ofIllinois at Chicago, Chicago, IL.

Objective: We previously reported that medium conditioned with endo-metrial epithelial cancer (Ishikawa) cells (ECM) differentially regulated the

FERTILITY & STERILITY t S107