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Biomedical subjects

N Gleicher

Publications and source records attributed to N Gleicher.

At least 55 records · Page 3Linked to original sources
PubMed1995

Elevated tubal perfusion pressures during selective salpingography are highly suggestive of tubal endometriosis.

OBJECTIVE: To investigate the possible etiologies of elevated tubal perfusion pressures. DESIGN: Analysis of 48 consecutive female patients with infertility who underwent laparoscopy and a gynecoradiological investigation as part of their infertility work-up. SETTING: Academically affiliated infertility center. INTERVENTIONS: A gynecoradiological investigation was performed using a previously reported standardized contrast injection system. Laparoscopy was performed routinely. RESULTS: Patients who demonstrated by laparoscopy to have endometriosis showed a significantly increased incidence of tubal blockage during initial hysterosalpingography (HSG) (12/26, 46.1%) compared with controls (2/14, 14.3%). Patients with endometriosis also demonstrated significantly more frequently elevated tubal perfusion pressures (22/26; 84.6%) than women without disease (2/14, 14.3%) and significantly higher mean tubal perfusion pressures than women with normal pelvises (576 +/- 264 versus 450 +/- 268 mm Hg). CONCLUSION: Tubal blockage during initial HSG and elevated tubal perfusion pressures during selective salpingography are highly suggestive of tubal endometriosis. These data are the first evidence that tubal involvement with endometriosis may be more frequent than previously suspected. They also suggest that the performance of a gynecoradiological investigation, inclusive of selective salpingography, can greatly contribute to a presumptive diagnosis of endometriosis.

Endometriosis↗
PubMed1995

The bubble test: a new tool to improve the diagnosis of endometriosis.

The objective of this study was to determine the clinical sensitivity and specificity of a bubbling phenomenon, including peritoneal surfaces, as a diagnostic test for endometriosis during laparoscopy. A prospectively controlled study of women with infertility of at least 1 year duration, who underwent laparoscopy, was conducted at a medical school-affiliated private infertility centre and research foundation. The study included 48 prospectively enrolled female infertility patients who underwent laparoscopy. Of these, 32 were found to suffer from endometriosis (group A) and 16 control patients did not show any evidence of disease (group B). The study involved the irrigation of the posterior cul-de-sac with short bursts of either saline or lactated Ringer's solution, utilizing a standard laparoscopic aspiration/irrigation system, and the subsequent observation for an excessive soap-like bubbling phenomenon (positive bubble test) in association with endometriosis. All 32 endometriosis patients (group A) demonstrated a positive bubble test. In contrast, only two of the 16 control patients (group B) were positive (P = 0.00242, Fisher's exact test; odds ratio, 8.000). A positive bubble test during laparoscopy was thus 100% sensitive and 88% specific for the diagnosis of endometriosis by laparoscopy, resulting in positive and negative predictive values of 94 and 100% respectively. Since the literature provides considerable evidence that the diagnosis of endometriosis during laparoscopy is frequently missed, a positive bubble test during laparoscopy therefore may be considered a reason to search further (possibly with biopsies) for endometriosis in the absence of obviously visible disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Ascitic Fluid↗
PubMed1995

The desire for multiple births in couples with infertility problems contradicts present practice patterns.

Paradoxically, the attitude of infertility patients towards multiple births has never been investigated. We therefore generated a survey by questionnaire, which was sent to 3800 consecutive unselected couples with infertility problems: 582 responses were received (15% response rate) and analysed. The percentage distribution of the responses to 21 questions, addressing attitudes towards and knowledge about the risk of multiple gestations, was the main outcome. Worry about multiple births was expressed, independent of the number of multiples, although fear about multiple conceptions was rejected by a large majority (64%). The risk of a twin birth was not strongly perceived, but the perception of risk increased with increasing numbers of multiples: triplets (50-62%), quadruplets or more (71-72%). A desire for the conception of twins was expressed by 67-90% of couples, a desire for the conception of triplets was equally expressed and rejected, and for a multiple gestation beyond triplets was rejected by 73-82% of couples. Patients were educated about the risks of selective embryo reduction and responded in a bimodal fashion to the option of utilizing this procedure, with equal numbers being willing to consider or reject it. Age, parity and length of infertility did not affect the couples' worry or fear about multiples. The desire for twins and triples, however, was correlated significantly with age (twins, P = 0.032; triplets, P = 0.03); there was no such correlation for larger multiples. The length of infertility was correlated with a positive attitude towards multiples beyond triplets (P = 0.029) but was not correlated with a desire for twins or triplets. Prior parity did not affect the attitude towards multiples at all.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1995

Gynaecoradiological uterine resection.

We assessed the feasibility of performing uterine surgery under fluoroscopic control in an ambulatory setting that does not require operating room time and general anaesthesia. Four uterine septae were resected and two cases of Asherman's syndrome were treated using fluoroscopically guided scissors. All six surgical procedures were successfully completed. Gynaecoradiological uterine resection (GUR) procedures, utilizing fluoroscopy guided scissors, are promising new techniques, which may allow the successful performance of uterine surgery in a cost effective ambulatory setting with no requirement of general anaesthesia.

Ambulatory Care↗
PubMed1995

Immune dysfunction--a potential target for treatment in endometriosis.

The treatment approach towards endometriosis has been traditionally either surgical or hormonal in nature. Since endometriosis is, to a large extent, a microscopic disease, a surgical approach cannot be expected to eradicate the disease. Treatment is, therefore, generally attempted by hormonal manipulation, an approach based on the known oestrogen sensitivity of endometriosis. Hormonal manipulation can only temporarily affect endometriosis, and quite clearly does not address the underlying aetiology and/or pathophysiology of the disease. Since neither is, at present, well understood, one can only speculate as to the treatment approach that would, in fact, affect the pathophysiology of the condition. Endometriosis has, in recent years, been characterized by a large number of immunological abnormalities in the host. It is, therefore, very tempting to speculate that an immunological defect represents the basic abnormality which later leads to the occurrence of the disease. This assumption is supported by the observation that those immunological defects are already present in the mildest forms of the disease. In fact, if one believes that many cases of unexplained infertility represent undiagnosed microscopic endometriosis, then evidence suggests that this precursor stage of the disease is basically characterized by an identical immunological profile to that of endometriosis. An immunological aetiology and/or pathophysiology of endometriosis should lead to an immunological treatment approach toward the disease. Specifically, a number of non-specific immunomodulators, presently utilized in a variety of medical conditions with immunological aetiologies, would seem to represent promising new therapeutic strategies to conquer endometriosis at its roots. A new treatment approach to endometriosis appears urgently needed since, at least with regard to the effects of endometriosis on fertility and pregnancy loss, present approaches have proven ineffective.

Autoantibodies↗
PubMed1995

Target antigen(s) in endometrial autoimmunity of endometriosis.

OBJECTIVE: To obtain the molecular weights (MW) of endometrial antigens eliciting immunoglobulin (Ig) G auto-antibodies in all endometriosis patients irrespective of their place of origin or race, and to verify their specificity and immunogenicity. STUDY DESIGN AND RESULTS: We tested the serum and peritoneal fluid (P.F.) of 76 endometriosis patients and 24 controls from 4 cities against endometrial and implant antigens by Western blot analysis. Endometrial and implant antigens with MW of 34, 46/48, 64, 84, 94 and 120 kDa bound with IgG in serum and PF of most patients, but not the controls. Antigen(s) with MW of 64 kDa was reactive against serum or P.F. IgG of patients from all cities. Specificity: Endometrial and implant extracts did not react with monoclonal antibodies to WBC subsets and 5 sera with nuclear antibodies. Also, the presence of nuclear and endometrial antibodies did not correlate in 20 other patients with endometriosis. Immunogenicity: We immunized rabbits with the native and eluted (MW 29 to 68 kDa and > or = 68 kDa) endometrial and implant proteins. The antiserum had specific IgG binding to the same glandular epithelial antigens as those bound by the patient's serum. CONCLUSIONS: Endometrial antigens with MW of 34, 46/48, 64, 94 and 120 kDa, especially 64 kDa appear to be specific, immunogenic and relevant to endometrial autoimmunity in all patients with endometriosis.

Adult↗
PubMed1995

[What do we really know about autoantibody abnormalities and reproductive infertility? A critical review].

UNLABELLED: The diagnosis and treatment of autoantibody-associated forms of reproductive failure is critically reviewed. OBJECTIVE: To critically evaluate the published literature in reference to autoantibody-associated forms of reproductive failure. LOCATION: Medical School-affiliated private Infertility Center. MATERIALS: A review of over 200 published reflecting on the topic. RESULTS: Autoantibody associated reproductive failure, characterized by a decrease in fecundity and an increase in the risk of pregnancy loss, appears established. Autoantibody abnormalities, as routinely detected by standard laboratory assays, are, however, neither immunologically nor biologically specific since cross reactivities between autoantibodies are frequent and a specific autoantibody may cause a biological effect in one but not in another affected individual. CONCLUSIONS: The evaluation of autoantibody abnormalities in all cases of suspected autoimmune-associated reproductive failure is valuable and will improve clinical care of affected patients. Clinicians need, however, to recognize the limitations of autoantibody testing and have to adjust their clinical management to the degree and quality of autoantibody evaluation available to them in their community.

Antibodies, Antiphospholipid↗
PubMed1994

Autoantibody profiles and immunoglobulin levels as predictors of in vitro fertilization success.

OBJECTIVE: Our aim was to determine the predictive value of autoantibody and immunoglobulin determinations as indicators of the success of in vitro fertilization. STUDY DESIGN: This was a blinded study in which laboratory evaluations were performed on coded samples obtained from another institution. Codes were broken and data were analyzed after results of all laboratory tests had been reported out. One hundred five infertility patients who had undergone in vitro fertilization were randomly chosen. Among those, 46 were considered low responders (six or fewer oocytes were retrieved) and 59 as high responders (13 to 30 oocytes were retrieved). Total immunoglobulin G, M, and A levels and 15 autoantibody levels (6 antiphospholipids, 5 antihistones, and 4 antipolynucleotides) were determined separately for immunoglobulin G, immunoglobulin M, and immunoglobulin A isotypes. RESULTS: High and low responders demonstrated an unusual incidence of autoantibody (25% and 30%, respectively) and immunoglobulin (46% and 48%, respectively) abnormalities. They did not differ from each other, however, in either immunoglobulin or autoantibody parameters. Autoantibody and immunoglobulin abnormalities alone or in combination did not predict pregnancy success (24% vs 16%), incidence of chemical pregnancies (15% vs 24%), or clinical pregnancy loss (9% vs 11%) when such women were compared with those without either abnormality. However, the occurrence of hypergammaglobulinemias, in contrast to hypogammaglobulinemias, was associated with a significant decrease in the clinical pregnancy rate (6% vs 24%, p = 0.05). CONCLUSIONS: Neither autoantibody abnormalities nor total immunoglobulin abnormalities allow differentiation between high and low responders in in vitro fertilization cycles. The presence of autoantibody and total immunoglobulin abnormalities also does not predict low clinical pregnancy rates. Within a group of women with immunoglobulin abnormalities, those with hypergammaglobulinemias appear, however, at significant risk for low pregnancy rates with in vitro fertilization. This observation suggests that high total immunoglobulin levels may serve as a marker for an as yet to be determined immunologic factor that adversely affects the chance of conception. The evaluation of total immunoglobulin levels may be indicated as part of a routine infertility workup.

Adult↗
PubMed1994

Laparoscopic removal of twin cornual pregnancy after in vitro fertilization.

The laparoscopic management of tubal pregnancies by salpingostomy has become a clinical standard of care (5). Those surgeries usually are performed for tubal pregnancies that are located distally to the cornua and the intramural piece of the tube. We previously reported on the conservative surgical management of interstitial pregnancies (3). To our knowledge, cornual pregnancies have never before been approached laparoscopically. Such a surgical approach is reported here, involving a twin gestation in the left uterine cornua conceived by IVF in a women with bilaterally absent tubes.

Adult↗
PubMed1994

beta 2-Glycoprotein I-dependent and -independent anticardiolipin antibodies in healthy pregnant women.

The purpose of this study was to determine the association between beta 2-glycoprotein I (beta 2GPI)-dependent anticardiolipin antibodies (aCL) and beta 2GPI-independent aCL and their respective relevance to adverse pregnancy outcomes. Therefore, we prospectively studied 210 normal pregnant women, utilizing a modified enzyme-linked immunosorbent assay method for beta 2GPI-dependent and -independent aCL. Seven of the 210 pregnant women (3.3%) demonstrated evidence for beta 2GPI-independent immunoglobulin G (IgG)-aCL. Two patients, who also appeared positive for beta 2GPI-dependent IgG-aCL, were proven to be false positives. Amongst the 210 patients, not one was thus positive for beta 2GPI-dependent aCL. Women with beta 2GPI-independent aCL demonstrated no adverse pregnancy outcomes. These results suggest that the presence of beta 2GPI-independent aCL is not associated with the presence of beta 2GPI-dependent aCL, though it may give rise to false positive results. Since the presence of beta 2GPI-independent aCL does not appear to be associated with adverse pregnancy outcomes, beta 2GPI-dependent assays may represent better markers of miscarriage risk.

Adult↗
PubMed1994

Wire guide cannulation alone is no treatment of proximal tubal occlusion.

Tubal catheterization procedures have become standard of care as a primary treatment of proximal tubal occlusions. They successfully utilize a variety of catheter techniques, though all usually include a wire guide. This raises the question whether guide wire catheterizations alone can be used to treat proximal tubal occlusions. We therefore investigated consecutively 25 women with at least one proximally occluded oviduct by attempting wire guide cannulations bilaterally in 10 and unilaterally in 12 women with two tubes and in three women with a single tube. Among the 10 patients with bilateral occlusion, seven were recanalized bilaterally (70%), one unilaterally (10%) and two not at all (20%). Among the 15 patients with unilateral tubal occlusion, 12 (80%) were recanalized. In total, 27 out of 35 (77%) obstructed oviducts were recanalized. In a follow-up period of 5-17 months only one pregnancy was, however, recorded and this was a tubal pregnancy. We conclude that wire guide cannulation of proximally obstructed tubes achieves tubal patency in a large percentage of cases, comparable to other catheter techniques reported in the literature. In contrast to those, however, wire guide cannulations alone result in much lower pregnancy rates. This observation strongly suggests that wire guides, used with co-axial and balloon catheter systems, are not responsible for the pregnancy success reported for these procedures. Wire guide cannulation alone does not therefore represent adequate treatment for patients with proximally occluded Fallopian tubes.

Catheterization↗
PubMed1994

The role of humoral immunity in endometriosis.

In many ways endometriosis represents yet another form of unexplained infertility. The disease is clearly associated with a decrease in fecundity and while in advanced stages of the condition this infertility can be attributed to tubal factors, in mild stages of the disease the cause for the decrease in fertility is unknown. As in unexplained infertility, we have suggested that the impairment in fertility is due to autoantibody abnormalities. Endometriosis patients exhibit the same immunologic profile as previously described in women with unexplained infertility and repeated pregnancy loss. In fact, endometriosis is not only characterized by unexplained infertility but also by repeated and excessive pregnancy wastage. Its clinical presentation mimics that of an autoimmune disease, raising the question whether endometriosis is, in fact, an autoimmune disease. Endometriosis demonstrates immunologic abnormalities not only in respect to autoreactivity. Abnormalities in immune function have been widely reported in reference to almost any lymphocyte and macrophage function and, once again, the similarity to findings in patients with unexplained infertility is blatant. Abnormalities can be found in peripheral blood and especially prominently in peritoneal fluid. Treatment of immunologic abnormalities, and especially of autoantibody abnormalities, restores a level of fertility in endometriosis patients. It has also been demonstrated, in an animal model, that non-specific immune modulation may improve fertility.

Antibody Formation↗
PubMed1993

Autoantibodies and pregnancy history in a healthy population.

OBJECTIVE: Our purpose was to determine whether the presence of autoantibodies is associated with pregnancy history in healthy adults. STUDY DESIGN: Antibodies against phospholipid, histone, and nucleotide antigens were determined in 102 male and 99 female subjects. The effects of age, sex, marital status, and pregnancy history on antibody positivity were assessed. RESULTS: Women showed higher levels of autoantibodies, but differences were not statistically significant in this sample. Age was not associated with antibody positivity in men. In women age was associated with positivity for (1) immunoglobulin G antibodies (p = 0.009), (2) antihistone antibodies (p = 0.024), and (3) more than one antibody (p = 0.020). Immunoglobulin M antibodies were more common in unmarried than married females (p = 0.020). In contrast, the prevalence of immunoglobulin G antibodies was increased in married women, although differences did not reach statistical significance (p = 0.167). Gravidity and history of fetal loss were not associated with increased antibody positivity. In subjects in whom follow-up data were available, positive antibody titers were not associated with subsequent adverse pregnancy outcome. CONCLUSIONS: In this population autoantibodies are not associated with adverse pregnancy outcome. However, an increased prevalence of immunoglobulin M in unmarried women and immunoglobulin G in married women suggests that a switch from immunoglobulin M to immunoglobulin G autoantibodies is associated with marriage, as a result of either exposure to semen or trophoblast antigens.

Adult↗
PubMed1993

The Mount Sinai cesarean section reduction program: an update after 6 years.

A six year follow-up evaluation of our original cesarean section reduction program is presented. While establishing obstetric practice guidelines was accomplished, two prerequisites remain critical: lowering cesarean utilization was to be accomplished without harm to mother or fetus, and a target rate was prospectively determined. The results after 6 years indicate that total cesarean rates of 10-12% can consistently be achieved without adverse outcome. Additionally, operative vaginal procedures were employed less that 3% of cases. Separate analysis of 580 breech deliveries failed to show an effect of route of delivery on mortality. This effort indicates that long-term reductions and cesarean utilization are possible with a comprehensive departmental program designed to accomplish achieving a target rate of 11%.

Breech Presentation↗