Revised endometriosis classification: 1996.
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Endometriosis↗
Biomedical subjects
D S Guzick
Publications and source records attributed to D S Guzick.
Prediction of pregnancy in infertile women based on the American Society for Reproductive Medicine's revised classification of endometriosis.
OBJECTIVE: To estimate the empirical relationship between the revised American Society for Reproductive Medicine's classification of endometriosis and pregnancy rates after treatment. DESIGN: Retrospective analysis. PATIENT(S): Patients seen by four practicing physicians. INTERVENTION(S): Medical and/or surgical therapy for endometriosis. MAIN OUTCOME MEASURE(S): Pregnancy defined as ongoing or delivered. RESULT(S): There were no significant differences in pregnancy rates across stages of endometriosis. There was a slight decline in pregnancy rates among patients with Stage IV endometriosis, but statistical significance was not achieved. CONCLUSION(S): The use of an arbitrary weighted system for assigning scores to individual categories of disease, or for computing a total score, has limited the overall effectiveness of the classification system to predict pregnancy.
Adult↗
Endometriosis-associated pelvic pain: evidence for an association between the stage of disease and a history of chronic pelvic pain.
OBJECTIVE: To track the severity and location of pelvic pain associated with endometriosis throughout the reproductive-age years and to evaluate the association between these pain parameters and the stage of disease. DESIGN: Historical prospective study. SETTING: Tertiary care center. PATIENT(S): Forty-eight women with endoscopically staged endometriosis and chronic pelvic pain who had undergone medical and/or conservative surgical therapy. INTERVENTION(S): Each participant was administered a questionnaire that included a determination of the severity and location of her pain. MAIN OUTCOME MEASURE(S): The stage of disease, the area of the pelvis that contained the bulk of disease, the severity of pain, and the location of the most severe pain were recorded. RESULT(S): The mean duration from the initial diagnosis until follow-up was 15.7 +/- 3.1 years, Twenty-one (43.8%) subjects denied any symptoms of pain on follow-up evaluation. Of the 27 patients with persistent pain, 21 (78%) identified the location of their most severe pain as being the same as at initial diagnosis. The stage of disease at initial diagnosis was significantly associated with a higher degree of pain at follow-up. CONCLUSION(S): These data suggest that endometriosis-associated chronic pelvic pain commonly persists throughout the reproductive years and that endometriosis stage is directly related to the persistence of pelvic pain.
Adult↗
Identification of early pregnancy landmarks by transvaginal sonography: analysis by logistic regression.
OBJECTIVE: To assess the feasibility of logistic regression analysis for determining the gestational ages at which detection of early pregnancy landmarks first can be observed. DESIGN: Retrospective analysis. SETTING: University-based tertiary care clinic. PATIENT(S): Eighty-two women with viable singleton pregnancies in whom ovulation had been achieved by an injection of hCG. INTERVENTION(S): Two hundred fifteen transvaginal sonographic scans. MAIN OUTCOME MEASURE(S): Logistic regression was used to estimate the probability of detection of sonographic findings as a function of gestational age. RESULT(S): We found that the likelihood of visualization of a gestational sac or fetal heart motion could be represented accurately by logistic equations. Gestational age at which there was 95% probability of visualization was 35.5 days for the gestational sac and 44.5 days for fetal cardiac activity. The probability of detecting fetal cardiac activity was 95% when the mean gestational sac diameter was 1.6 cm and was 99% at 1.9 cm. CONCLUSION(S): The sonographic appearances of developmental landmarks in early pregnancy occurs within well-defined gestational time periods, and the probabilities for visualization can be closely approximated using a logistic model. Our results suggest that the number of sonographic examinations required to document infertility treatment success can be minimized by surveillance at standardized gestational ages.
Adult↗
Classification of endometriosis.
The evolution of classification schemes for endometriosis has continued since the 1920s, when initial attempts were made to describe endometriosis. The cause, pathophysiology, and natural history of endometriosis remain difficult to characterize. As knowledge about endometriosis increases, classification schemes will change to incorporate new ideas. Evolution of the current American Fertility Society's revised classification of endometriosis is reviewed, as well as evaluation of its use with respect to prediction of fertility and management of pelvic pain. Possible directions for classification in the future are also discussed in this article.
Endometriosis↗
A natural experiment on the effects of ovarian hormones on cardiovascular risk factors and stress reactivity: bilateral salpingo oophorectomy versus hysterectomy only.
To test the effects of declining ovarian hormone levels on cardiovascular risk factors, blood pressure, lipids, weight, and physiological responses to stress were evaluated in 29 middle-aged premenopausal women prior to and following elective hysterectomy and/or bilateral salpingo oophorectomy (BSO). Prior to surgery, there were no group differences in standard or putative risk factors, with the exceptions of body composition measures and total cholesterol level. After surgery, women who had undergone BSO (n = 10) had higher levels of atherogenic lipids and stress-induced lipids and tended to have higher circulating levels of epinephrine and stress-induced systolic and diastolic blood pressure than women who had undergone hysterectomy only (n = 19). This study is consistent with the hypothesis that presence of ovarian hormones plays a key role in determining women's risk factor status.
Adult↗
Randomized controlled trial of superovulation and insemination for infertility associated with minimal or mild endometriosis.
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Endometriosis↗
Carotid atherosclerosis in women with polycystic ovary syndrome: initial results from a case-control study.
OBJECTIVE: Our purpose was to determine whether women with polycystic ovary syndrome have greater subclinical atherosclerosis as measured by carotid artery ultrasonography. STUDY DESIGN: Sixteen premenopausal women > or = 40 years old with a history of clinical polycystic ovary syndrome and a current total testosterone concentration > or = 2.0 nmol/L and 16 age-matched (+/- 5 years) cycling women underwent carotid scanning. Intima-media thickness and plaque were compared between cases and controls, as were risk factors for atherosclerosis including body mass index and fasting insulin and lipid levels. Statistical analysis included t tests, Fisher's exact test, and multiple linear regression. RESULTS: Mean +/- SE intima-media thickness was found to be significantly greater for cases with polycystic ovary syndrome (0.680 +/- 0.019 mm) than for controls (0.630 +/- 0.012 mm) (t = 2.31, p = 0.035). Five cases (31.3%) and two controls (12.5%) had ultrasonographic evidence of plaque (not significant). Univariate regressions of intima-media thickness yielded significant coefficients for insulin, total cholesterol, low-density lipoprotein cholesterol and body mass index. When either total cholesterol or low-density lipoprotein were included in the model simultaneously with polycystic ovary syndrome, each retained significance. This was not true for insulin and body mass index, however, suggesting that these factors covaried with polycystic ovary syndrome in a dimension affecting intima-media thickness. CONCLUSIONS: In spite of a major limitation of small sample size, these data suggest that women with polycystic ovary syndrome have an increased risk of subclinical atherosclerosis in their 40s.
Adult↗
Comparison of transdermal versus oral estradiol on endometrial receptivity.
OBJECTIVE: To compare the effects of oral micronized E2 with transdermal E2 on endometrial receptivity in women undergoing oocyte donation. DESIGN: Prospective, randomized, crossover trial. Serum E2 and P concentrations were measured on cycle days 14 and 22 (luteal day +8). Endometrial biopsies were obtained on day 22 and read in a blinded fashion for histology and beta-3-integrin expression. SETTING: University-based donor oocyte program. PATIENTS: Twenty-seven patients presenting for donor oocytes. MAIN OUTCOME MEASURES: Endometrial histology and beta-3-integrin expression. RESULTS: The endometrial glandular histology in women given oral micronized E2 was delayed by a mean of 1.6 days in comparison to that of women given transdermal E2. Seventy percent of women given oral E2 displayed a lag > or = 4 days whereas 29.6% given transdermal E2 displayed a similar lag. Serum E2 levels were 1,194 +/- 108.8 pg/mL (mean +/- SEM; conversion factor to SI unit, 3.671) in women on oral micronized E2 and 117.4 +/- 14.0 pg/mL in those on transdermal E2. CONCLUSION: The supraphysiologic serum E2 levels associated with oral micronized E2 may have a deleterious impact on endometrial receptivity. The development of more physiologic hormone replacement protocols may enhance endometrial receptivity and lead to improved clinical pregnancy rates.
Administration, Cutaneous↗
Adhesion formation from release of dermoid contents in the peritoneal cavity and effect of copious lavage: a prospective, randomized, blinded, controlled study in a rabbit model.
OBJECTIVES: To determine, in a rabbit model, whether peritoneal exposure to dermoid cyst material produces inflammation and adhesions above control levels and whether saline lavage reduces the degree of peritoneal reaction. DESIGN: A prospective, randomized, blinded, controlled study of adhesion formation. Thirty New Zealand white female rabbits were assigned randomly to five experimental groups: [1] laparoscopy with intraperitoneal injection of human dermoid material, [2] laparoscopy with intraperitoneal injection of human dermoid material and subsequent lavage to clear all visible dermoid material, [3] laparoscopy with saline lavage, [4] laparoscopy with intraperitoneal injection of human follicular fluid (antigenic control), and [5] laparoscopy alone. MAIN OUTCOME MEASURES: Six weeks after initial laparoscopy, inflammation and adhesions were scored in several categories via visual assessment (range 0 to 15) and histologic microscopic evaluation (range 0 to 24). Data were evaluated using Kruskal-Wallis and Mann-Whitney U nonparametric tests. RESULTS: For groups 1, 2, 3, 4, and 5, respectively, mean +/- SEM total inflammation-adhesion scores were 13.85 +/- 0.55, 2.90 +/- 1.15, 0 +/- 0, 1.50 +/- 1.00, and 0 +/- 0 for clinical evaluation and 16.83 +/- 1.22, 7.33 +/- 1.76, 0 +/- 0,0 +/- 0, and 0 +/- 0 for histologic evaluation. Using nonparametric tests, significant differences were found between groups in clinical and histologic scores. CONCLUSIONS: Dermoid material produces a significant peritonitis. Results of the clinical evaluation demonstrate that saline lavage brings inflammation and adhesion formation close to control levels. However, results of the histologic evaluation suggest that the decrement in inflammation as a result of lavage may be less dramatic than that found by clinical evaluation.
Animals↗
Cardiovascular risk in women with polycystic ovarian syndrome.
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Cardiovascular Diseases↗
Basic statistical testing, including interim analysis.
Clinical trials, due to the randomization process, require statistical methods for testing key hypotheses that are straightforward and involve simple comparisons of group proportions or group means. Differences between group proportions are tested using a chi 2 statistic or a Fisher's exact test. Differences between group means are tested using a two-sample t statistic. When there are more than two groups, the F statistic is calculated. When ordinal data or data not normally distributed are analyzed, nonparametric testing is performed. A critical decision prior to analysis is the choice of the endpoint, which must be clearly defined and consistently applied. Monitoring a clinical trial is important, and may lead to interim analysis. This should be done by independent study monitors. Interim results play an important role in analyzing clinical trials; however, they create problems due to multiple testing. An early stoppage rule is frequently applied when independent interim results are obtained. The statistical methods for interim analysis are discussed.
Data Interpretation, Statistical↗
Vascular permeability factor and vascular endothelial growth factor in ovarian hyperstimulation syndrome: a preliminary report.
OBJECTIVE: To determine whether serum levels of vascular permeability factor (VPF) are elevated in patients with ovarian hyperstimulation syndrome (OHSS) and to determine if luteinizing granulosa cells may be a source of VPF. DESIGN: Prospective observational study. SETTING: University IVF and GIFT program. PATIENTS: Eight consecutive IVF and GIFT patients at high risk for OHSS. MAIN OUTCOME MEASURES: Vascular permeability factor concentration in serum and follicular fluid. RESULTS: Serum VPF was significantly higher (15.2 +/- 4.0 pM; mean +/- SEM) on day +14 in the group who developed severe OHSS compared with those who did not. Follicular fluid VPF (171.5 +/- 18.5 pM) was approximately 100-fold greater than serum (1.7 +/- 1.3 pM) or peritoneal fluid (2.5 +/- 1.3 pM) 36 hours after hCG administration. CONCLUSION: Vascular permeability factor is elevated in patients with severe OHSS and the ovary may be a source of VPF secretion.
Adult↗
Effects of surgical menopause on psychological characteristics and lipid levels: the Healthy Women Study.
The authors examined the effects of surgical menopause, with or without hormone replacement therapy (HRT), on psychosocial functioning and lipid levels in a population-based study of initially premenopausal women. Within 5 years of study entry, 28 women underwent hysterectomy, with 9 retaining their ovaries and 19 having bilateral salpingo oophorectomy (BSO), and with 173 premenopausal women as a comparison group. Women undergoing hysterectomy reported fewer stress symptoms and a more optimistic attitude at follow-up, whereas BSO cases without HRT had lower mean total high-density lipoprotein (HDL) and HDL2, relative to premenopausal women. Subject to limited power, the authors' findings suggest that surgical menopause among middle-aged women does not lead to negative psychological outcomes but that BSO in the absence of hormone use has significant adverse effects on the HDL and HDL2.
Adaptation, Psychological↗
Do infertility tests discriminate between fertile and infertile populations?
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Female↗
Sperm recovery and survival: two tests that predict in vitro fertilization outcome.
OBJECTIVES: To determine if human sperm recovery during swim-up and sperm survival after 24 hours, as obtained from a screening semen specimen, are predictive of subsequent IVF and clinical pregnancy rates (PRs) and to determine if these techniques can identify men with normal semen analysis parameters and poor IVF success. DESIGN: Historical prospective study. SETTING: All semen evaluations and IVF cycles were performed at the University of Pittsburgh, Magee-Womens Hospital, Pittsburgh, Pennsylvania. PATIENTS, PARTICIPANTS: Couples undergoing IVF at Magee-Womens Hospital from August 1988 through June 1993. INTERVENTIONS: A screening semen analysis and swim-up procedure were performed on all couples undergoing IVF. The number of spermatozoa recovered after swim-up and the percentage of motile spermatozoa present after a 24-hour incubation were recorded. MAIN OUTCOME MEASURES: Fertilization and PRs were compared according to the parameters obtained from routine semen analysis, the number of spermatozoa obtained with swim-up, and the percentage of motile spermatozoa at 24 hours. RESULTS: Using chi2 or Fisher's exact test, fertilization rates were significantly different according to the number of spermatozoa recovered after swim-up (< or = 2.0 and > 2.0 x 10(6) spermatozoa recovered, 48.3% versus 71.4%) as were PRs (16.9% versus 29.8%). Similarly, the percentage of motile spermatozoa present at 24 hours (< or = 20% and > 20%) discriminated between fertilization rates (45.9% versus 65.8%) and PRs (16.4% versus 36.5%). Among a subset of men with normal semen analyses and total motile sperm counts > or = 40 x 10(6), the results from swim-up and survival discriminated between men with high and low fertilization and PRs. Receiver operating characteristic analysis revealed that swim-up results better discriminated between pregnant and nonpregnant IVF patients than sperm motility, but that the percentage of motile spermatozoa present at 24 hours was no better in this regard than sperm motility. CONCLUSIONS: The number of spermatozoa recovered after swim-up and the percentage of spermatozoa that maintain their motility after 24 hours were both helpful in assessing IVF and PRs and may be helpful in altering physicians to a subset of men having normal semen analysis parameters yet poor IVF success.
Cell Survival↗
Infertility evaluation in fertile women: a model for assessing the efficacy of infertility testing.
A standard infertility evaluation consists of a semen analysis, hysterosalpingogram, post-coital test, endometrial biopsy and laparoscopy. Although these tests are well grounded in clinical experience, information on their ability to discriminate between fertile and infertile couples is limited. In this study, we performed standard infertility tests plus two others--sperm antibodies and cervical culture for Mycoplasma hominis and Ureaplasma urealyticum--on fertile and infertile couples. Women in the fertile group were selected from those who had delivered a child within the previous 2 years and who were scheduled for a laparoscopic tubal ligation. Women in the infertile group were selected from those presenting for an infertility evaluation (mean duration of infertility 4.2 years), and they were matched by age (+/- 3 years) and race with fertile subjects. Subjects were recruited from both private and clinic patients. A total of 64 couples (32 matched pairs) completed the evaluation. At least one 'abnormal' infertility test was found in 69% of fertile and 84% of infertile couples. With the exception of tubal damage and endometriosis, which as expected were more common in infertile couples, no significant differences between groups for remaining infertility factors could be demonstrated. Despite the small size of the current study, these results confirm the feasibility and importance of comparisons of the prevalence of infertility factors in fertile and infertile couples.
Adult↗
Endometriosis impairs the efficacy of gamete intrafallopian transfer: results of a case-control study.
OBJECTIVE: To determine whether pelvic endometriosis impairs the efficacy of GIFT. DESIGN: Matched follow-up study. SETTING: University-based assisted reproduction program. PARTICIPANTS: Patients undergoing GIFT between 1987 and 1991. Cases had a primary diagnosis of endometriosis. Controls had no endometriosis and were matched with cases according to age, number of mature eggs transferred, and sperm grade. INTERVENTION: Gamete intrafallopian transfer was performed in all patients in an identical manner independent of their underlying diagnosis. MAIN OUTCOME MEASURES: Pregnancy and delivery rates. RESULTS: Of 114 laparoscopic egg retrievals performed in the endometriosis group, there were 37 pregnancies (32.5%) and 27 deliveries (23.7%). Of the 214 retrievals in the control group, there were 101 pregnancies (47.2%) and 76 deliveries (35.5%). Mantel-Haenszel estimates of relative risk indicated that endometriosis significantly impaired pregnancy and delivery rates. There was no statistically significant difference in pregnancy rates according to severity of disease among endometriosis cases. There was no statistically significant difference in pregnancy rates according to severity of disease among endometriosis cases. CONCLUSIONS: Our finding that GIFT pregnancy rates were lower in women with a primary diagnosis of endometriosis than in matched controls suggests that endometriosis is associated with reduced efficacy of GIFT.
Adult↗