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Despite sporadic ovarian follicle development, hormonal contraception consistently and uniformly prevents steroidogenesis and ovulation. For their suppressive activity on ovarian androgen production, oral contraceptives remain the treatment of choice for acne and hirsutism in most hyperandrogenic women. Inhibition of the synthesis of endometrial estrogen receptors explains the effectiveness of hormonal contraception in the therapy of dysfunctional uterine bleeding and in the treatment of pain associated with pelvic endometriosis. Through the inhibition of ovarian cyclicity, the contraceptive pill lowers the incidence of functional ovarian cysts, benign breast disease, dysmenorrhea and premenstrual syndrome and shows a consistent and long-lasting protection against ovarian and endometrial cancer.

Background/purpose: Neonates who have ovarian torsion caused by an ovarian cyst often lose their ovary because the torsion and infarction occurred antenatally. Because ultrasound scan has been so effective in diagnosing ovarian cysts in utero, we have a better understanding of their natural history and can select appropriate cases for cyst decompression in utero to prevent torsion. The authors reviewed experience with seven fetuses who had fetal ovarian cyst., Methods: During a 26-month period, seven patients were referred for the evaluation of fetal ovarian cyst. The mean gestational age at presentation was 31.9 +/- 3.6 weeks (+/-SD; range, 27 to 37 weeks). There was no history of maternal risk factors such as diabetes mellitus or fetal risk factors such as hyperthyroidism or placentomegally. All seven cases involved isolated unilateral cysts without associated anomalies or chromosomal abnormalities. Mean initial cyst diameter was 3.4 +/- 1.7 cm (+/-SD; range, 1 to 6.1). Indications used for ovarian cyst decompression included anechoic cysts with a diameter > or =4 cm, a cyst "wandering" about the abdomen on serial sonograms, or demonstrating rapid enlargement (>1 cm/wk)., Results: All but one cyst progressed in size during observation. One fetal ovarian cyst (diameter, 2 cm) subsequently regressed spontaneously and another (diameter, 2.1 cm) stabilized during prenatal ultrasound surveillance. One "cyst" observed with a diameter of 3.5 cm proved to be a persistent cloaca. Four fetal ovarian cysts met criteria for decompression. Because of fetal position, decompression could not be performed in one. One cyst (seen before defining criteria for decompression) with a diameter of 5 cm was observed only and underwent torsion. Two cysts (diameters, 6.1 cm and 4 cm) were decompressed in utero under local anesthesia with ultrasound guidance, of 95 mL and 35 mL, respectively. High cyst fluid progesterone (12,041 and 1,990 ng/dL, respectively) and testosterone (1,298 and 2,900 ng/dL, respectively) confirmed the etiology of the cyst as ovarian. Neither cyst recurred, and postnatal ultrasound scan confirmed resolution. There was no maternal or fetal morbidity or mortality and only the patient observed before development of criteria for decompression lost her ovary because of torsion., Conclusions: Fetal ovarian cysts tend to present as isolated unilateral lesions in normal fetuses in the third trimester. Spontaneous regression of fetal ovarian cysts may occur. Fetal ovarian cyst decompression, in select cases, may preserve ovaries at risk for torsion.

The efficacy of an oxidized regenerated cellulose barrier (Interceed) in reducing postoperative adhesion formation and improving reproductive outcome after ovarian surgery was evaluated in a prospective randomized trial. Twenty-nine New Zealand White female rabbits were submitted to a mid-line laparotomy and a standardized surgical incision was made on both ovaries. At random, one ovary was entirely wrapped in a sheet of Interceed, whereas the contralateral ovary was left uncovered. Four weeks following surgery, the rabbits were mated with a male of proven fertility. Two weeks later, a second-look laparotomy was performed by a blinded observer who evaluated the incidence and score of adhesions, the number of corpora lutea in each ovary, the number of embryos in the ipsilateral uterine horn and also calculated the nidation index for each side. Adhesions were observed in 66% of Interceed-covered and in 97% of control ovaries (P < 0.0001). The adhesion score on the Interceed side was significantly lower than on the control side. The nidation index for the Interceed side was significantly higher than for the control side. The authors conclude that, in the rabbit model, Interceed significantly reduces the incidence and score of postoperative ovarian adhesions and significantly improves reproductive outcome.

Objective: To evaluate the subsequent pelvic sonographic characteristics as well as the clinical outcome following hysterectomy with and without oophorectomy., Study Design: A prospective study of sonographic evaluation of 164 women, aged 29-72 years, with a history of hysterectomy was performed. Ninety-one patients underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and 73 women had either hysterectomy (abdominal or vaginal) only or hysterectomy with unilateral salpingo-oophorectomy., Results: The mean time interval between surgery and sonographic evaluation was 4.3 years (range, 1-25 years). Out of the 73 women with left ovaries, 37 (50.7%) were found to have pelvic lesions and four women underwent re-operations following these findings. The histologic finding were cystadenoma, hydrosalpinx with periovarian adhesions and two paraovarian cysts. In comparison, only five of the 91 women (5.5%) following bilateral salpingo-oophorectomy were found to have pelvic lesions (P < 0.0005). None of the women with prophylactic oophorectomy were operated upon following these findings., Conclusions: In comparison to patients after total hysterectomy and bilateral salpingo-oophorectomy, women with prior hysterectomy and ovarian preservation are prone to subsequent pelvic lesions. They need to be closely followed with clinical, laboratory and sonographic means, and may undergo reoperations in order to rule out the possibility of neoplasia.

Ovarian cancer has been described in association with three autosomal dominant syndromes: familial site-specific ovarian cancer, familial breast and ovarian cancer, and the hereditary nonpolyposis colon cancer syndrome. It appears that most breast-ovarian and site-specific ovarian cancer families are explained by mutations in the BRCA1 tumor suppressor gene. Other genes associated with inherited susceptibility to ovarian cancer include BRCA2, p53, and the DNA mismatch repair genes.

Ovarian ultrasound is applicable to all ages, from the fetus through childhood and adolescence to the premenopausal and finally postmenopausal women. Indications include the chance finding of an ovarian lesion in the fetus, the diagnosis of ovarian pathology resulting in symptoms and the uses of follicle monitoring in infertility and screening for ovarian cancer in high-risk groups.

Objective: To compare the efficacy of heparin-saturated oxidized regenerated cellulose absorbable adhesion barrier, Interceed (TC7; Johnson and Johnson Medical Inc., New Brunswick, NJ) to oxidized regenerated cellulose alone for the prevention of postoperative adhesions., Design: Clinical trial. By random assignment, one ovary was wrapped in oxidized regenerated cellulose, and the contralateral ovary was wrapped in oxidized regenerated cellulose saturated with a heparin solution (1,000 U/mL)., Patient(s): Forty women with defects on both ovaries due to adhesiolysis and/or ovarian cystectomy., Main Outcome Measure: Adhesion formation and raw ovarian surface area were assessed at second-look laparoscopy 10 days to 16 weeks later., Result(s): At the second-look laparascopy-adhesions were present on 52.5% (21/40) of the ovaries treated with oxidized regenerated cellulose plus heparin and in 65% (26/40) of the contralateral ovaries treated with oxidized regenerated cellulose alone. For ovaries treated with oxidized regenerated cellulose plus heparin, the raw surface area was reduced from 9.41 +/- 1.27 cm2 (mean +/- SE) at laparotomy to 1.33 +/- 0.52 cm2 at second-look laparoscopy. The corresponding figures for ovaries treated with oxidized regenerated cellulose alone were from 10.24 +/- 1.08 to 1.92 +/- 0.54 cm2, respectively. The mean difference between the reductions in raw surface area (85.9% for oxidized regenerated cellulose plus heparin; 81.3% for oxidized regenerated cellulose alone) was not significantly different from zero (difference = - 0.24 cm2; 95% confidence interval = -2.56 to 3.04)., Conclusion(s): Adding heparin did not enhance significantly the adhesion-reducing capacity of oxidized regenerated cellulose adhesion barrier when applied to ovarian surfaces after cystectomy and/or ovariolysis at laparotomy. This conclusion is subject to the possibility of a type II error.

Objective: To address the controversy of ovarian preservation during a hysterectomy for benign indications by using our experience with residual ovary syndrome (ROS)., Study Design: Over a period of 20 years, 2561 hysterectomies (during which one or both ovaries were preserved) were performed at the Golda Medical Center, Israel. A retrospective, quasi, case-control analysis was undertaken., Results: The incidence of ROS was 2.85%. While chronic pelvic pain was the principle indication for subsequent reexploration in 52 patients (71.3%), an asymptomatic pelvic mass noted during routine follow-up examination accounted for 24.6% of operations for ROS. The majority (75.4%) of patients underwent surgery during the first 10 years, while the highest incidence occurred within the first 5 years (46.6%). Furthermore, histological examination revealed functional cysts, benign neoplasm and ovarian carcinoma in 50.7%, 42.6% and 12.3% of the cases, respectively (in nine patients more than one pathology was observed)., Conclusions: Since ROS was found to occur in 1/35 women who had undergone previous hysterectomies mainly due to physiologic ovarian function and benign cyst formation, but not malignancy, we believe that routine oophorectomy is justified in premenopausal women over 45 years of age. However, the final decision to perform elective oophorectomy at the time of hysterectomy for benign disease should be established on an individual basis, taking into consideration age, individual and family risk factors, the patient's preference and ability to ensure long-term compliance to exogenous hormone replacement therapy.

To examine whether the concomitant administration of a gonadotrophin-releasing hormone agonist (GnRHa) during combination chemotherapy to young women with lymphoma may facilitate preservation of gonadal function, a prospective clinical protocol was undertaken in 18 cycling women with lymphoma, aged 15-40 years. Thirteen patients suffered from Hodgkin disease (HD) and 5 from non-Hodgkin lymphoma. After informed consent a monthly injection of depot D-TRP6-GnRHa was administered for a maximum of 6 months starting prior to chemotherapy. Most of these patients (15/18) were treated with the MOPP/ABV(D) combination chemotherapy followed by mantle field irradiation in 10 patients. Hormonal profile [luteinizing hormone (LH), follicle stimulating hormone (FSH), oestradiol, testosterone, progesterone, insulin-like growth factor (IGF)-1, prolactin] was taken before the GnRHa/chemotherapy co-treatment, and monthly thereafter until resuming spontaneous ovulation and menses. This group of prospectively treated lymphoma patients was compared to a matched control group of 18 women (aged 17-40 years) who have been treated with chemotherapy, mostly MOPP/ABV (14/18), with (11) or without (7) mantle field radiotherapy. Fourteen had Hodgkin's and four non-Hodgkin's lymphoma. Gonadal function was determined clinically, hormonally (LH, FSH, oestradiol, progesterone), and sonographically. Two of the patients in each group died from refractory disease. Of the remaining 16 patients, 15 (93.7%) resumed spontaneous ovulation and menses within 3-8 months of termination of the combined chemotherapy/GnRHa co-treatment. In contrast, only seven (39%) of the 18 similarly treated patients in the control group (chemotherapy without GnRHa) resumed ovarian cyclic activity (regular menses). The other 11 experienced premature ovarian failure (POF) (61%). Out preliminary data suggest a possible significant protective effect of GnRHa co-treatment with chemotherapy from irreversible ovarian damage (POF).

Objective: To evaluate the biocompatibility, adhesion prevention properties and ability to preserve reproductive capacity of polytetrafluoroethylene surgical membrane in ovarian surgery on the rabbit., Study Design: In two groups of female rabbits a standard lesion was made on each ovary. In group 1, one ovary was partially covered with a flat sheet of the surgical membrane, and the other was left uncovered so that each rabbit served as its own control. In group 2, one ovary was again left uncovered to serve as an internal control, and the other was completely covered with a "cap" of the surgical membrane. Laparotomies were performed several weeks postoperatively after the rabbits were mated with fertile males; adhesions were evaluated, and the number of cornual pregnancies was determined., Results: In group 1, 67.9% of the control ovaries and 7.1% of the partially covered ovaries had adhesions (P < .001); in the uterine horn on the control side, 32.1% of the rabbits exhibited cornual pregnancies (1.14 +/- 1.72 [mean +/- SD] pregnancies per rabbit), whereas on the experimental side, 89.3% of the rabbits exhibited cornual pregnancies (3.89 +/- 1.58 per rabbit). In group 2, 83.3% of the control ovaries and 11.1% of the covered ovaries had adhesions (P < .001); in the uterine horn on the control side, 23.5% of the rabbits exhibited cornual pregnancies (2 +/- 1.1 per rabbit), whereas on the experimental side, 100% of the rabbits exhibited cornual pregnancies (4.8 +/- 0.9 per rabbit)., Conclusion: The surgical membrane is an excellent device for preventing the formation of adhesions to the ovary after surgery in rabbits, preserving the reproductive capacity of the ovary.

Background and Objective: Interstitial laser treatment (ILT) of the ovary might be a new surgical approach to restore ovulation with a minimal risk of adhesion formation in patients with chronic hyperandrogenic anovulation who are unresponsive to hormone therapy. The objective was to investigate the feasibility of inducing a lesion limited to the center of the ovary in an animal model., Study Design/materials and Methods: ILT was performed in seven goats using Nd:YAG laser in combination with ultrasound monitoring. The extent of direct thermal damage was investigated in two goats, treating both ovaries during a laparotomy at 2, 4, 6, and 8 W, respectively, for 5 min. Adhesion formation was evaluated in five goats 81 days after an unilateral laparoscopic ILT at 1, 2, 4, 6, or 8 W for 5 min. During treatment temperatures on the surface of the ovary were measured., Results: Histology after 1 day showed sharply demarcated necrotic lesions located centrally or subcapsularly at low powers, whereas at higher powers the lesions extended to the surface of the ovary. At low powers no adhesions were observed, whereas higher powers resulted in periovarian adhesions. Temperatures measured on the ovarian surface during treatment ranged between 38 degrees C and 90 degrees C. Ultrasound monitoring of the extent of thermal damage failed due to poor positioning., Conclusion: Although this pilot study does not warrent firm conclusions, the results indicate that ILT of the ovary is feasible and that lesions without adhesions can be produced at low powers. The use of ultrasound to monitor the extent of thermal damage in the ovary should be a subject of further evaluation.

The present study was undertaken to compare adhesion formation and reproductive outcome after reproductive surgery with or without the application of fibrin sealant. At laparotomy, the ovaries and uterine horns of 20 rabbits were longitudinally incised on the antimesenteric side using a monopolar microneedle. At random, one ovary and the ipsilateral uterine horn were covered with fibrin sealant, while those on the contralateral side were left uncovered without application of sutures. The rabbits were then mated, and 2 weeks later a second-look laparotomy was performed by a blinded observer. No statistically significant differences were found in postoperative adhesions, number of corpora lutea in each ovary, number of embryos in the ipsilateral uterine horn, and nidation index for each side. Fibrin sealant for conservative surgery does not appear to significantly affect either postoperative adhesion formation or reproductive outcome.

Objective: To evaluate the efficacy of Interceed (TC7) Absorbable Adhesion Barrier, an oxidized regenerated cellulose fabric, as a barrier to the development of postsurgical ovarian adhesions after surgery involving the ovaries., Methods: In a multicenter randomized study, 55 patients with bilateral ovarian disease were treated at initial laparotomy. At the end of the procedure, one ovary was assigned randomly to be wrapped with Interceed and the other was left uncovered. A second-look laparoscopy was performed 10-98 days later to evaluate the occurrence and severity of adhesions and the raw ovarian surface area exposed after lysis of adhesions., Results: At second-look laparoscopy, 26 of 55 Interceed-treated ovaries were free of adhesions, compared with 14 of 55 untreated control ovaries, a statistically significant difference (P = .028, Fisher exact test). At second-look laparoscopy, ovaries treated with Interceed formed adhesions less extensively (1.66 +/- 0.34 cm2) than did untreated ovaries (2.75 +/- 0.60 cm2) and with a greater reduction of raw ovarian surface area (difference in area differential -1.89 +/- 0.96 cm2; P = .055, paired t test). Adhesion scores at second-look laparoscopy were reduced significantly for ovaries treated with Interceed compared with untreated ovaries (P = .02, Wilcoxon signed-rank test). No adverse events were recorded during the course of the study., Conclusion: Treatment of ovaries with Interceed significantly reduced the occurrence and severity of postsurgical ovarian adhesions.

Objective: To evaluate the efficacy of Interceed as an adjuvant in the prevention of postoperative adhesion reformation to the ovary, fallopian tube, and fimbria when used together with microsurgical techniques., Design: Prospective, randomized, multicenter, controlled clinical study., Setting: Normal human volunteers in an academic research environment., Patients: Sixty-six women suffering from infertility due at least in part to bilateral tubal disease with bilateral adhesions attached to ovaries, fallopian tubes, and fimbriae., Intervention: Adhesiolysis bilaterly through laparotomy with microsurgical techniques, application of Interceed on one of the sides randomly assigned not known by the surgeon before application, follow-up laparoscopy 4 to 10 weeks postoperatively, with each patient serving as her own control., Main Outcome Measures: Adhesion severity scores at all sites and number of adhesion free organs after laparotomy and follow-up laparoscopy., Results: When the initial scores registered at the operation for fertility were compared with those registered at the second-look laparoscopy, the results indicated that gentle microsurgical techniques resulted in a significant reduction of postoperative adhesions. Adnexa, which were covered with Interceed, had significantly lower adhesion scores than the control adnexa, representing an improvement of 39% compared with microsurgery alone (control) in reducing adhesion reformation scores. When combined with microsurgical techniques, Interceed reduced adhesion reformation scores by 70%. The number of ovaries, fallopian tubes, and fimbriae without adhesions at the time of second-look laparoscopy was significantly increased by approximately twofold when organs were covered with Interceed., Conclusion: In a prospective, randomized, multicenter, controlled clinical study using a protocol in which other adjuvants have been shown not to be efficacious, Interceed was shown to reduce significantly the incidence and severity of adhesion reformation to the ovary, fallopian tube, and fimbria after infertility surgery.

Between 1982 and 1992, 695 consecutive abdominal hysterectomies and prophylactic oophorectomies in premenopausal women for benign uterine diseases were performed in our department. The trend of prophylactic oophorectomy has declined since 1988 to a minimum in 1990. 60 per cent were 41-45 years of age, 28 per cent were more than 46 years, 12 per cent were 36-40 years. Uterine fibroid was the most frequent indication (77.7%), followed by adenomyosis (21.0%). Ovarian histologies revealed abnormalities only in 1.3 per cent of the removed ovaries, the remainder appeared to be normal.

Objective: To compare the efficacy of a resorbable hydrogel material with oxidized regenerated cellulose and hyaluronic acid in an ovarian adhesion model., Design: Controlled, blinded, and randomized study involving female rabbits., Setting: Academic research environment., Interventions: A water-soluble hydrogen precursor was applied to the ovary as a liquid and converted to a hydrogel by exposure to long wavelength ultraviolet light, a 0.4% solution of hyaluronic acid was applied to the ovary, or an oxidized regenerated cellulose patch was applied to the ovary after wedge resectioning., Main Outcome Measures: Extent and severity of adhesion formation., Results: Application of the hydrogel reduced adhesion formation by 88%. Neither oxidized regenerated cellulose nor hyaluronic acid reduced adhesion formation., Conclusion: The photopolymerized, resorbable hydrogel material is highly effective for the reduction of periovarian adhesions in this model.

Objective: To determine whether an Interceed patch would decrease adhesion formation in ovarian surgical wounds healing by second intention in the rabbit model., Methods: Twenty-five New Zealand White female rabbits underwent midline laparotomy. Using microsurgical technique, each ovary was bivalved longitudinally with a no. 15 blade scalpel, and hemostasis was achieved with bipolar electrocautery. One ovary was then covered with an Interceed patch in a randomized fashion, while the other ovary served as a control. The animals were then allowed to recover routinely. Four weeks later, the rabbits were euthanized and the adhesions were graded by a blinded observer. Adhesion scores between the Interceed-treated ovaries and the control ovaries were compared by Wilcoxon signed-rank test., Results: The mean adhesion score of the Interceed-treated ovaries (1.65 +/- 0.87) was not significantly different from the mean adhesion score of the control ovaries (1.5 +/- 1.0) (P = .51). Some degree of atrophy was noted in 14 of the 50 ovaries. The mean adhesion score in the atrophied ovaries was significantly higher than in the nonatrophied ovaries, regardless of whether the ovaries had been treated with Interceed (2.21 versus 1.40; P = .01). There was no difference in the incidence of atrophy between the Interceed-treated and untreated sides. Exclusion of the ovaries with atrophy again demonstrated no difference in the mean adhesion scores between the treated and untreated sides., Conclusion: We were not able to demonstrate any benefit from using Interceed to decrease postoperative adhesion formation of ovarian surgical wounds in the rabbit model.

The case of an 11 year old girl who suffered torsion of the left ovary 8 months following right oophorectomy for a similar event is presented. The left ovary was saved by immediate surgical intervention. The value of prophylactic oophoropexy in unilateral ovarian torsion is discussed.

Postoperative infection after operative hysteroscopy is uncommon. However, patients who have a past history of pelvic inflammatory disease appear to be at risk of developing such infections, including tuboovarian abscesses. Prophylactic antibiotics during operative hysteroscopy appear to be effective in preventing this problem.

Objective: Our objective was to determine whether impaired ovarian function induced by short-term creation of a galactosemic state in the rat might be prevented by the coadministration of an aldose reductase inhibitor., Study Design: Prepubertal Sprague-Dawley rats were fed four different diets including (1) control, (2) 40% galactose, (3) 40% galactose and an aldose reductase inhibitor, and (4) an aldose reductase inhibitor with the control diet. Percentage germinal vesicle breakdown, postovulatory oocyte quantities, hormonal parameters, ovarian histologic evaluation, and ovarian galactitol concentrations were determined., Results: The galactose-fed animals (group 2) had decreased germinal vesicle breakdown (47%) versus control (69%, p < 0.05). Galactose-exposed animals had significantly decreased quantities of postovulatory eggs (6.4 per animal) after menotropin ovarian stimulation in comparison with controls (14.1, p < 0.01). In rats exposed to high dietary levels of galactose (group 2) ovarian galactitol concentrations were significantly higher (protein 42.12 mumol/gm versus 0.0 for controls, p < 0.005). When galactose-fed animals received the aldose reductase inhibitor, ovarian accumulation of galactitol was significantly reduced and the observed detrimental effects on the oocyte were prevented., Conclusion: Galactitol accumulation or metabolic flux through aldose reductase in galactosemic rodents may be involved in the demonstrated ovarian dysfunction.

Since serosal drying and tissue abrasion play an important role in adhesion formation, we tested the hypothesis that the peritoneal instillation of 32% high-molecular-weight dextran 70 (H) before, rather than after, a surgical procedure results in less postoperative adhesion formation and reformation. Twenty rabbits were subjected to a standardized surgical injury on one ovary, the ipsilateral uterine horn and adjacent parietal peritoneum. Three weeks later the animals underwent a second laparotomy to blindly score the adhesions and subsequently lyse them using microsurgical techniques. The animals were randomly assigned to one of two treatment groups, with H administered either before or at the end of each surgical procedure. Three weeks after the second surgical procedure, the animals were killed to blindly score adhesions. There was no difference in the mean adhesion scores between the two groups after either the first (2.0 versus 2.9, NS) or second surgical procedure (5.5 versus 5.1, NS). Thus, we conclude that preoperative instillation of H does not offer any advantage over postoperative instillation in the prevention of either adhesion formation or reformation.

A study was designed to determine the efficacy of second-look laparoscopy adhesiolysis in preventing adhesion recurrence seven days after conservative microsurgical reconstructive surgery on the uterotuboovarian complex. Third-look laparoscopy was used to evaluate the second-look laparoscopy adhesiolysis 6-18 months later. It indicated that second-look laparoscopy adhesiolysis was beneficial in preventing adhesion recurrence.

Objective: To use gonadotropin-releasing hormone agonist (GnRH-a) instead of human chorionic gonadotropin (hCG) to induce oocyte maturation for in vitro fertilization (IVF)., Design: Pituitary and ovarian responses to GnRH-a and the outcome of IVF were studied prospectively. Data from patients injected with hCG were analyzed retrospectively., Setting: Program of IVF at the Rambam (Governmental) Hospital, Haifa, Israel., Patients and Interventions: One or two doses of buserelin acetate 250 to 500 micrograms were administered to six patients with moderate response (Estradiol [E2], 1,494 +/- 422 [+/- SD] pg/mL) and 8 patients with exaggerated response (E2, 7,673 +/- 3,028 pg/mL) to gonadotropin stimulation. Progesterone (P) and E2 were administered for luteal support., Main Outcome Measures: Gonadotropin-releasing hormone agonist effectively triggered luteinizing hormone (LH)/follicle-stimulating hormone (FSH) surge. Mature oocytes were recovered in all patients. Luteal E2 and P were lower than in patients injected with hCG. No signs of ovarian hyperstimulation syndrome were observed., Results: Serum LH and FSH rose over 4 and 12 hours, respectively, and were significantly (P less than 0.05) elevated for 24 hours. Of all mature oocytes, 67% fertilized and 82% cleaved. Four pregnancies were obtained., Conclusions: A bolus of GnRH-a is able to trigger an adequate midcycle LH/FSH surge, resulting in oocyte maturation and pregnancy. Our preliminary results also suggest that it allows a more accurate control of ovarian steroid levels during the luteal phase and may prevent the clinical manifestation of ovarian hyperstimulation syndrome.

Objective: The study was undertaken to minimize the rate of ovarian hyperstimulation and to avoid cancellation of human treatment cycles in women treated with human menopausal gonadotropin (hMG) for induction of ovulation., Setting: Patients were treated in the fertility clinic and in vitro fertilization unit of our institution, which is a government, university-affiliated hospital., Patients: Ninety anovulatory patients were treated with hMG. Of these, 12 were at high risk for ovarian hyperstimulation. The criteria for potential ovarian hyperstimulation syndrome were rising excessive 17 beta-estradiol levels of greater than 1,500 pg/mL in the presence of multiple follicles with a mean diameter greater than 15 mm. These patients were transferred for continuation of treatment to our in vitro fertilization-embryo transfer (IVF-ET) unit., Interventions: The patients underwent ova retrieval by the ultrasonically guided transvaginal approach., Results: Of the 12 patients, 5 conceived (41.6%). Two patients had a mild ovarian hyperstimulation syndrome, and 1 had a moderate syndrome and was hospitalized for observation for 48 hours., Conclusion: In view of the results, we suggest that IVF-ET should be considered in cases in which ovarian hyperstimulation syndrome is imminent, rather than withhold human chorionic gonadotropin and cancelling the treatment cycle.

Between 1979 and 1989 a total of 113 women underwent treatment for Hodgkin's disease at the Department of Radiation Oncology of the University of Erlangen-Nürnberg. Only 17 female patients of child bearing age received total lymphoid irradiation including pelvic and inguinal nodes. 15/17 patients underwent prophylactic bilateral oophoropexy during staging laparotomy: ten had lateral, five had midline ovarian transposition. Reproductive and ovarian function was investigated in 13 patients--all in complete remission after a minimum follow-up of three years--by menstrual history and serum levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL), testosterone, dehydroepiandrosteronsulfate (DHEAS), androstendion, estradiol, progesterone, 17-OH progesterone, sexual hormone binding globulin (SHBG), free androgen index (FAI). Thyroid function was assessed by measuring thyroxine (T4), triiodothyronine (T3), thyroxine stimulating hormone (TSH) and thyroxine binding globulin (TBG). Normal cyclic ovarian activity was found in seven out of nine patients following lateral oophoropexy (including one pregnancy), but only in one out of four cases after midline fixation. Median calculated dose was 325 cGy (range 260 to 500 cGy) to the laterally fixed ovaries and 490 cGy (range 390 to 500 cGy) for midline transposition. We conclude, if ovarian protection is required prior to pelvic radiation, lateral oophoropexy should be preferred.

A 35-year retrospective review of all surgically significant pathological lesions of the ovary was conducted. Fifty-one children had 53 ovarian lesions which required surgical intervention. Of the 53 ovarian lesions seen in this series, 21 had presented with torsion. Five of these torted ovaries were microscopically normal. Three children were castrated. One of these castrations could have been prevented if contralateral oophoropexy was done. In addition, one child, who had lost an ovary previously because of torsion, presented with major cystic disease of the remaining ovary. Torsion was aborted by ovarian cystectomy. Contralateral oophoropexy at the time of ipsilateral oophorectomy is recommended to prevent castration.

Clinical hyperstimulation is the most serious complication of ovulation induction, occurring in approximately 3% of cases (0.8% in the severe form). Paradoxically, it seems to be rare following in vitro fertilization, probably because all the follicles are aspirated. High-risk patients are those with polycystic ovarian disease, hyperprolactinaemia and hypothyroidism. All forms of ovulation induction have been implicated. Use of LHRH agonists have not reduced the incidence of hyperstimulation and they may even have increased it. An ongoing pregnancy seems to predispose to the occurrence of hyperstimulation, due to the secretion of hCG. Clinically, three stages of hyperstimulation have been described by the WHO (mild, moderate and severe). The pathophysiology is not completely understood, although prostaglandins, histamines and, especially, the ovarian renin-angiotensin system may be involved. Local ovarian complications and thromboembolic complications have also occurred. The treatment of severe hyperstimulation is both symptomatic (fluid replacement, aspiration of effusions, moderate sodium and water restriction, small doses of diuretics) and specific (corticosteroids, aspiration of ovarian cysts, even voluntary interruption of pregnancy in the most serious forms). If the hyperstimulation occurs in the absence of pregnancy, antihistamines or antiprostaglandins can be given. Prevention is exceedingly important. This can be helped by recognition of polycystic ovarian disease and stimulation of these cases by clomiphene citrate or pure FSH associated, for use in in vitro fertilization, with prolonged desensitization using LHRH agonists. Daily ultrasound and hormonal monitoring of ovulation induction is required. When there is excessive response to stimulation, it is prudent not to induce ovulation with hCG or, alternatively, to aspirate all the follicles and freeze the embryos obtained without giving further injections of hCG in the luteal phase. Clinical ovarian hyperstimulation is the classic form of iatrogenic disorder and is the most important complication of ovulation induction treatments, since it can be life-threatening in its most severe form. In this chapter we review current knowledge concerning the frequency, factors associated with its occurrence, clinical aspects, physiopathological mechanisms and, finally, the possibilities for treatment and prevention.

During six years (1982-1987) in our Department 965 consecutive hysterectomies were performed: 583 abdominal and 260 vaginal hysterectomies performed for benign indications (total = 843) have been reviewed. Preservation of ovaries was chosen in 234 cases (27.8%), while 609 women had their ovaries removed (72.2%). Indications and choice of surgical procedure have shown more significant correlation with ovariectomy than different age groups and parity. Incidence of subsequent signs and symptoms of menopause and osteoporosis has been detected and compared between premenopausal patients who had oophorectomy and those who had not. In removed ovaries no undiagnosed malignant ovarian diseases were found.

Severe ovarian hyperstimulation syndrome (OHSS) was recorded in 8 of 413 patients after the use of gonadotropin-releasing hormone agonists (GnRH-a) associated with gonadotropins for in vitro fertilization. Seven of the 8 patients were pregnant. Common factors associated with the development of OHSS were high serum estradiol values on the day of ovulation induction and many follicles greater than or equal to 12 mm. Based on this experience, a new therapeutic schedule was used in a group of 10 patients who, after GnRH-a and gonadotropin stimulation, were judged to be at high risk of OHSS on the day of human chorionic gonadotropin (hCG). No hCG was administered and gonadotropins were stopped. The administration of GnRH-a was continued and, after a further period of pituitary desensitization, follicular stimulation was recommended with a lower dose of gonadotropins. No cases of OHSS occurred and 3 patients became pregnant.

Progesterone (P) has been shown to have antiinflammatory and immunosuppressive properties. This study was designed to evaluate these effects on operative adhesion formation. Forty guinea pigs received standardized injuries to their uterine horns. Four groups were examined. Normal saline was used as an irrigant in the first, or control, group. Aqueous P (50 mg or 1 ml) was dripped over the injured site and instilled intraperitoneally in the second group. The third group received intramuscular aqueous P (3.3 mg/kg body weight) 1 day postoperatively, the day of surgery, and either 6 or 13 days postoperatively until reexploration. In the fourth group 1 ml of 32% dextran 70 (Hyskon) was administered in the same manner as aqueous P in the second group. The animals in all groups were reexplored 1 or 2 weeks after the initial surgical procedure, and the adhesions were scored. Adhesion formation was significantly reduced (P less than 0.001) in all treatment groups when compared with the control group. Aqueous P may have a role in the prevention of adhesion formation associated with pelvic surgery and, in particular, microscopic tubal and ovarian surgery.

Antihistamine can prevent the ovarian hyperstimulation syndrome in the rabbit. The mechanism underlying this experimental observation has not been elucidated. Our experiments were directed at the question of whether antigen-antibody complexes are a factor in the development of the ovarian hyperstimulation syndrome. The results do not support the theory that antigen-antibody complexes play a role in the pathogenesis of this syndrome.

Significant advances have been made in the previously unexplored areas of the mechanisms involved in cyclophosphamide (CTX)-induced ovarian toxicity and the protective effects of luteinizing hormone-releasing hormone (LHRH agonists. The structure and function of granulosa cells and oocytes are affected by the chemotherapeutic agent, CTX. Results of experiments in female rats indicate that LHRH agonists may protect the ovaries from the toxic effects of chemotherapy. The protective effect may be related to the inhibition of ovarian mitotic activity during LHRH agonist administration. This inhibition is much more pronounced in female compared to male rats. This may be related to the observed better gonadal protective effects in females compared to males. Further experiments are underway to determine whether similar protective effects occur in female primates.

There are no generally accepted criteria for the removal or conservation of the apparently normal ovary during surgery for other conditions. In this article the benefits and disadvantages of prophylactic oophorectomy are reviewed and a schema for clinical practice is suggested.

Autotransplantation of the ovary by microvascular anastomoses was performed in 42 rabbits by three different procedures: orthotopic replantation with selective end-to-end anastomoses of the ovarian vessels; heterotopic transplantation in the groin area, with anastomosis of the ovarian vessels on the inferior epigastric vessels; heterotopic transplantation in the groin with the ovary included in a peritoneal sac to prevent adhesions. Three weeks later, at day 3 of a pseudo-pregnancy, the grafts were examined and morphology, presence of adhesions and ovulation were compared with those of a control group. The long-term vascular patency rate was 78%. The ovulation rate was 71.5% in the orthotopic group, 50% in the heterotopic group and 83.5% in the heterotopic group with the ovary in a peritoneal sac. Subcutaneous transplantation of the ovary within a peritoneal sac provides a new and useful experimental model for the study of tubo-ovarian function and for recovery of postovulatory oocytes.

A new approach to the treatment of endocrine-dependent tumors based on analogs of hypothalamic hormones is in the early stages of development, but appears promising and significant. Administration of hypothalamic hormones can mimic hypophysectomy and gonadectomy, and is essentially devoid of side effects. A successful use of agonistic analogs of LH-RH for treatment of endocrine-dependent prostate cancer has been documented in several hundred patients. Experimental studies suggest that agonists and/or antagonists of LH-RH might be useful for treatment of breast cancer and pituitary tumors. Our work in animal models also indicates that analogs of somatostatin, alone or combined with LH-RH agonists, could be considered for therapy of chondrosarcomas, osteosarcomas, and pancreatic cancer. Experiments are in progress on the use of LH-RH analogs for treatment of ovarian cancer, neoplasms of the female genital tract, and for protection against gonadal damage during chemotherapy. These investigations should extend the concepts of endocrine treatment of cancers.

The effects of pharmacologic doses of gonadotropin-releasing hormone, danazol, and indomethacin on the clinical and endocrinologic features of the ovarian hyperstimulation syndrome were studied in the rabbit. The ovarian hyperstimulation syndrome was induced with Pergonal (75 IU of follicle-stimulating hormone and 75 IU of luteinizing hormone) and a follicle-stimulating hormone-dominant gonadotropin preparation (85 IU of follicle-stimulating hormone and 53 IU of luteinizing hormone). None of the three agents tested were effective in suppressing the ovarian enlargement and ascites formation in these animals. Ascites developed despite quite significant variations in plasma and intraovarian sex steroid hormone and intraovarian prostaglandin F levels induced by danazol and indomethacin. Ascites develops in hyperstimulated women in association with both follicular and luteal hyperstimulation. In contrast, the ascites response in the hyperstimulated rabbit develops in the presence of follicular hyperstimulation alone without a significant degree of luteal hyperstimulation.

Formulation of pelvic cysts afer proctectomy is an entity which is described in this paper with the cause supposed to be due to descent of the ovary from an intraperitoneal to an extraperitoneal position at the time of proctectomy. A simple surgical technique for fixing the ovary out of the pelvis to prevent this complication is described.

The immediate and long term fertility after bilateral ovarian wedge resection in 53 women with clomiphene citrate-resistant hyperandrogenic chronic anovulation is related to the histology of the ovarian wedges. Patients with polycystic ovaries and hyperplastic stromal abnormalities had most spontaneous conceptions and a normal fertility during follow-up. Apparently, chronic anovulation in these cases had been caused by ovarian disease in the face of normal hypothalamic function. Patients with polycystic ovaries without stromal abnormalities often needed postoperative stimulation of ovulation in order to conceive, which may indicate hypothalamic involvement. Patients with large ovaries, normal stroma, and small follicles, who as a group had the lowest serum levels of luteinizing hormone, and patients whose ovaries contained large follicles and cysts without theca cell activity did not benefit from the bilateral ovarian wedge resection. Generally, their postoperative response to medical induction of ovulation did not improve either. Measures to prevent adhesions were not completely successful. Nevertheless, our results suggest that anovulation rather than formation of adhesions causes persistent infertility after bilateral ovarian wedge resection.