INFERTILITY AND RELATED ISSUES

INFERTILITY AND RELATED ISSUES Infertility is defined as the failure to conceive after one year of attempting pregnancy. Primary...

INFERTILITY AND RELATED ISSUES

Infertility is defined as the failure to conceive after one year of

at-tempting pregnancy Primary infertility denotes those patients who

have never conceived Secondary infertility applies to patients who have conceived previously Approximately 15% of couples experi-

ence infertility, which may result from subfertility or sterility (theinnate inability to conceive) in either partner or both The female

is responsible in 40%–50% of cases The male is responsible in 30%and is contributory in another 20%–30% of couples However, it is

crucial to recall that multiple etiologies are found in 40% of

infer-tile couples.

The incidence of infertility has increased (perhaps 100% over

the past 20 years) in developed countries because of increasing

sexually transmitted disease (especially gonorrhea and

Chlamy-dia, causing subsequent tubal damage), an increased number of

sexual partners (increasing the potential for acquiring STDs),intentionally delaying pregnancy, the contraceptive(s) used, andsmoking (
1 pack/day decreases the chance of pregnancy by

20%) Infertility accounts for 10%–20% of all gynecologicoffice visits

Fertility rates are established using fecundibility (the chance of

pregnancy per month of exposure) Only 25% of young healthy ples having frequent intercourse will conceive per month (60% by

cou-6 months, 75% by 9 months, and 90% by 18 months)

Fecundibil-ity declines with age, and the effect is more pronounced in women

than in men By 36–37 years of age, the chance of pregnancy is lessthan half that at 25–27 years of age

29

INFERTILITY AND RELATED

ISSUES (SPECIAL FERTILITY

PROCEDURES, HYPERANDROGENISM)

769

770 HANDBOOK OF OBSTETRICS AND GYNECOLOGY

Careful evaluation should detect probable cause(s) for ity in 85%–90% Happily, even without therapy, 15%–20% of in-fertile couples may be expected to achieve pregnancy over time.Therapy, excluding in vitro fertilization, will result in pregnancy in50%–60%

infertil-ETIOLOGY

The causes of infertility may be classified as male-coital factors

(40%), cervical (5%–10%), uterine-tubal (30%), ovulatory factors(15%–20%), and peritoneal or pelvic factors (40%) A few geneticcauses (e.g., primary amenorrhea) are recognized

MALE-COITAL FACTORS

Male factors include abnormal spermatogenesis, abnormal

motil-ity, anatomic disorders, endocrine disorders, and sexual tion The anatomic abnormalities possibly responsible are congen-

dysfunc-ital absence of the vas deferens, obstruction of the vas deferens, andcongenital abnormalities of the ejaculatory system

Abnormal spermatogenesis may occur as the result of mumpsorchitis, chromosomal abnormalities, cryptorchidism, chemical orradiation exposure, or varicocele Abnormal motility is seen withabsent cilia (Kartagener’s syndrome), varicocele, and antibody for-mation

The male factor endocrine disorders include thyroid disorders,adrenal hyperplasia, exogenous androgens, hypothalamic dysfunc-tion (Kallmann’s syndrome), pituitary failure (tumor, radiation, sur-gery), and hyperprolactinemia (tumor, drug-induced) An elevatedFSH commonly indicates parenchymal testicular damage, since in-hibin, produced by the Sertoli cells, is the primary feedback con-trol of FSH secretion

Uterine-tubal factors are most commonly structural abnormalities

(e.g., DES exposure, myoma, failure of normal fusion of the productive tract, infections, previous ectopic pregnancy)

re-OVULATORY FACTORS

Ovulatory factors involve CNS function, metabolic disease, or

pe-ripheral defects CNS defects include chronic hyperandrogenemic

anovulation, hyperprolactinemia (empty sella, tumor, or induced), hypothalamic insufficiency (including Kallmann’s syn-drome), and pituitary insufficiency (trauma, tumor, or congenital).Metabolic diseases causing ovulatory factor defects are thyroid dis-ease, liver disease, renal disease, obesity, and androgen excess (ad-renal or neoplastic) Peripheral defects may be gonadal dysgenesis,premature ovarian failure, ovarian tumor, or ovarian resistance

drug-PERITONEAL OR PELVIC FACTORS

The two most common pelvic or peritoneal factors are

endometrio-sis and sequelae or infection (e.g., appendicitis, pelvic

inflamma-tory disease) Laparoscopy in women with unexplained infertilitywill reveal previously unsuspected pathology in at least 30% of pa-tients Endometriosis exerts a greater pejorative effect on fertilitythan can be explained on the basis of physical alterations (p 755)

DIAGNOSIS

Infertility evaluations should follow a progression of testing and

procedures that takes into account probability (including alization for the couple), invasiveness, risks, and expense The ba-

individu-sic evaluation usually requires 6–8 weeks to complete Even if thehistory suggests a probable cause of infertility, completion of theevaluation of all major factors should be accomplished to avoidoverlooking a secondary or contributory factor

The initial assessment should include medical history for female

infertility factors, including pubertal development, present menstrualcycle characteristics, contraceptive history, prior pregnancy and out-come, previous surgery (especially pelvic), prior infection, abnormalPap smears and therapy, drugs and therapy, diet, weight stability, ex-ercise, and history of in utero DES exposure (now rare)

EVALUATION OF MALE FACTORS

The initial test for male infertility is the semen analysis because a

normal semen analysis usually excludes a significant male factor(Table 29-1) The specimen should be obtained after 2–3 daysabstinence and evaluated in the laboratory within 30–60 min ofejaculation

772 HANDBOOK OF OBSTETRICS AND GYNECOLOGY

The frequency of male factors (as well as risk and cost

effec-tiveness) mandates male diagnosis in the initial phase of infertility

investigation The medical history for male factor infertility should

include frequency of intercourse, difficulty with erection or lation, prior paternity, past history of genital tract infections (e.g.,mumps orchitis or chronic prostatitis), congenital anomalies, sur-gery or trauma (e.g., hernia repair, direct testicular trauma), expo-sure to toxins (medications, lead, cadmium, or radiation), diet, ex-ercise, alcohol consumption, smoking
1 pack/d), illicit drug use,

ejacu-in utero exposure to DES, and unusual exposure to high mental heat

environ-The physical examination should consider habitus and hair

dis-tribution (e.g., testosterone effect) The urethral meatus should be

in the normal location Testicular size may be compared to standardovoids Eliciting a Valsalva maneuver in the standing positionshould aid in the detection of a varicocele Transrectal prostatic mas-sage generally will produce sufficient secretions for microscopicexamination Excessive leukocytes in this or the semen analysis in-dicate infection

If the semen analysis is abnormal or borderline, the man’s ical history over the past 2–3 months should be reviewed, recalling

med-that spermogenesis requires 74 d A repeat semen analysis should

be performed 1–2 weeks later for comparison Consider referral to

a urologist specializing in infertility if a significant abnormality sists

per-Because sperm must reach the ovum before fertilization can cur, infertility in the presence of normal semen values suggests that

oc-TABLE 29-1

NORMAL SEMEN ANALYSIS VALUES

there may be an abnormally high attrition of sperm Cervical

mu-cus studies may clarify this problem.

In vitro fertilization is the ultimate test for male factor

infertil-ity A sperm penetration test may be useful This uses a hamster egg

to demonstrate the ability of the sperm to penetrate a zona-freeoocyte using a known fertile donor as control Abnormality is in-dicated by 10% penetration Negative penetration of healthy ap-pearing, mature ova by partner sperm with simultaneous positivepenetration by donor sperm may provide the diagnosis

Normal cervical mucus in the preovulatory phase is thin,

wa-tery and acellular and dries in a ferning pattern Mucus in this state

acts as a facilitative reservoir for sperm Cervical mucus is best

evaluated on days 12–14 of a 28 d cycle The amount and clarity

of the mucus are recorded, and the pH should be 6.5 Spinnbarkeit(the stretchability of a strand of mucus) is ascertained by drawingout the mucus vertically (it should stretch to 6 cm)

The Sims-Huhner test evaluates the initial interaction of the

sperm with cervical mucus The test should be conducted in the

periovular interval Timing of the test may be enhanced using

vagi-nal ultrasound to determine the presence or absence of a dominant

follicle Mucus is collected 2–4 h after intercourse The mucus isplaced on a clean glass slide under a coverslip and observed.There should be
20 sperm/hpf, and large numbers of active

sperm will be seen in the thin, acellular mucus Lower numbers(20/hpf) of motile sperm in favorable mucus may be present innormally fertile couples due to the stress of coitus at a prescribed

time The absence of sperm suggests aspermia or improper coital

technique or specimen collection Finding an adequate number of immobile sperm in favorable mucus requires an investigation for

autoantibodies in the male or serum antibodies in the female If a

sufficient number of sperm are present but poorly motile, further

assessment of the mucus and timing of the test is indicated If themucus tests are repeatedly abnormal despite apparently favorablemucus, a crosscheck using donor mucus and donor sperm is rea-

sonable Antibody studies may determine the antigenic site (sperm

head, midpiece, or tail) and are more likely to be positive in menwho have a history of trauma, infection, or previous surgery

774 HANDBOOK OF OBSTETRICS AND GYNECOLOGY

DIAGNOSIS OF UTERINE-TUBAL

FACTORS

Both history and careful pelvic examination are essential initial

steps in detection of uterine-tubal factors Key details of the history

include menstrual problems, pelvic infections (pelvic pain), STD,

appendicitis, and abdominal trauma or surgery Suggestive findings

on pelvic examination include uterine irregularities, pelvic masses,

and uterine deviation or fixation

It is uncommon for submucous myomata, endometrial polyps,

or bicornuate uterus to cause infertility, although each of these is

associated with an enhanced rate of abortion Tubal fimbrial

occlu-sion is the most common of the three usual locations, followed by

midsegment and isthmus-cornual occlusion Midsegment occlusion

is nearly always due to tubal sterilization but may be secondary to

tuberculosis The major causes of isthmic-cornual occlusions are

infection, maldevelopment, endometriosis, adenomyosis, or gitis isthmica nodosum

salpin-Hysterosalpingography (HSG) (Fig 29-1), hysteroscopy,

la-paroscopy, or a combination of these is required to determine

pa-tency of the tubes HSG is performed as an outpatient procedure

us-ing a radiopaque dye (first water-soluble and, after patency isassured, an oil-based contrast medium) instilled into the uterine cav-ity via a small transcervical catheter Radiographs should document

FIGURE 29-1. Hysterosalpingography.

the fluoroscopically observed findings Uterine contour, tubal tency, and ability of the dye to freely transit the tubes to enter thepelvis are evaluated The oil-based dye provides a better image buthas a greater risk of retention and granuloma formation The wa-ter-based dye causes less cramping and allows better definition of

pa-the rugae Abnormal findings include intrauterine synechiae

(Ash-erman’s syndrome), congenital malformations of the uterus, polyps,submucous leiomyomas, proximal or distal tubal occlusion, andsalpingitis isthmica nodosa

The major risk of HSG is infection Thus, HSG should not be

performed during even suspected active inflammation or whenthere is an adnexal mass Broad-spectrum antibiotic therapy (e.g.,doxycyline) may be prudent if recent STD screening has not been

performed The test is also contraindicated if there is allergy to

the dye

Laparoscopy may demonstrate tubal abnormalities (e.g.,

agglu-tinated fimbria, endometriosis) that probably would not be seen on

HSG Hysteroscopy performed concomitantly with laparoscopy may

give further information regarding uterine contour or polyps dometriosis (Chapter 28) is an important cause of infertility and issuggested by a history of worsening dysmenorrhea or dyspareuniabut usually cannot be diagnosed short of visual inspection Someendometriosis may be eliminated during laparoscopic diagnosis ifinformed consent has been obtained and preparations have beenmade for laser surgery or operative pelviscopy

En-Laparoscopy may be indicated relatively early in the gation of infertility if pelvic factors are suggestive or in olderpatients, whereas it may be the last test performed in a youngwoman when all other studies are negative It may be consideredtogether with ovarian stimulation and ovum collection in long-standing infertility using in vitro fertilization or by placing spermand ovum directly into the tube to allow a trial of normal transport

Substan-FIGURE 29-2. Dating the endometrium Approximate relationship of useful morphologic factors.

(Modified after J.P.A Latour From Noyes, Hertig, and Rock, Dating the endometrial biopsy Fertil Steril 1:3, 1950.)

777

778 HANDBOOK OF OBSTETRICS AND GYNECOLOGY

gonadatropin (FSH and LH) evaluations are more commonly used

to evaluate ovulation

BBT is taken on awakening before any other activity After lation, a temperature elevation of 0.4F occurs due to the thermo-genic effect of progesterone Progesterone levels as low as 5 ng/mLmay indicate ovulation, but midluteal levels usually are
10 ng/mL.Irregular menses, absence of premenstrual molimina, continuedferning of dried cervical mucus, low midluteal progesterone levels,

ovu-and absence of midcycle BBT elevation all indicate probable

fail-ure of ovulation Treatment of ovulation failfail-ure is discussed under

therapy Abnormal BBTs, spontaneous abortion(s), endometriosis,

and poor cervical mucus may indicate a luteal phase defect

Con-firmation of this diagnosis is accomplished by endometrial logic study, including dating of endometrial biopsies (best takenfrom the superior, anterior uterine fundus) in relation to menses.Dating of the endometrium is accomplished by the criteria illus-trated in Figure 29-2 Should the histologic date of the biopsy lag

histo-by more than 2 d in two cycles, this diagnosis is confirmed

An additional ovulatory abnormality is the luteinized unruptured

follicle (LUF) syndrome In LUF, the oocyte is trapped or not

re-leased from the follicle (as determined by laparoscopy) despite direct signs of ovulation

in-When investigating endrocrine associations of infertility, mination of diabetic status as well as any androgen abnormalitieswill reveal a significant number of patients with these causes of re-productive dysfunction

deter-EVALUATION OF PERITONEAL

AND PELVIC FACTORS

In women with unexplained infertility, laparoscopy can identify

pre-viously unsuspected pathology in 30%–50% of patients The most

common condition diagnosed is endometriosis Other conditions(e.g., unexpected adhesions) also may be encountered

TREATMENTMALE AND COITAL FACTORS

Smoking, alcohol, and drug use should be stopped Eliminate sources of increased scrotal temperature (e.g., saunas, hot tubs, or

jockey shorts underwear) with their adverse effect on

spermatoge-nesis Lubricants and douching should be eliminated The woman should lie on her back for at least 15 min following coitus (to

facilitate semen retention and progression) Infrequent or poorly

timed intercourse is a common cause of infertility Hence, coitus

every 2 d during the periovulatory interval (e.g., days 12–16 of a

28 d cycle) should be advised

Azoospermia because of chromosomal abnormalities,

congeni-tal abnormalities (other than congenicongeni-tal absence of the vas

defer-ens), and elevated FSH cannot be reversed Therefore, artificial

in-semination with donor sperm or adoption are the only alternatives.There have been occasional reports of successful pregnancy in con-genital absence of the vas deferens by using sperm aspirated from

the epididymis and in vitro fertilization Hypothalamic or pituitary

hormone insufficiency-induced azoospermia may be treated by placement hormone therapy, with varying results Successful re-

re-versal of azoospermia secondary to vasectomy by performance of

a vasovasostomy is influenced by the duration of occlusion and

whether or not autoantibodies have formed Patency can be achieved

in 75%–90%, with resultant pregnancy rates of 33%–70%

Varicoceles are present in approximately one third of men

eval-uated for infertility, and varicocelectomy has been shown to prove sperm parameters in up to two thirds However, postopera-tive pregnancy rates in controlled studies reveal no statisticaldifference between the treated and untreated

im-Low semen volume is a problem notoriously difficult to treat.

This is usually treated by artificial insemination with the man’s

semen (AIH) Here, 0.1 mL of liquefied semen is placed in the endocervical canal and the rest in a cervical cup When high semen

volume is accompanied by low sperm count, a split ejaculate technique may be useful In this technique, the first portion of the

ejaculate, which has a much higher sperm count, is collected andused for AIH If necessary, several first ejaculates may be pooledand saved by freezing, to be used later for AIH

Oligospermia (low sperm count) or asthenospermia (low sperm

motility) if due to an endocrinopathy may respond to specific

hor-monal therapy (e.g., human menopausal gonadotropin—hMG)—forhypothalamic–pituitary failure, bromocriptine for hyperprolactine-mia, or thyroid replacement for hypothyroidism) In idiopathic

oligoasthenospermia, clomiphene (not FDA approved for this

pur-pose) may be useful When specimen quality cannot be improved

by other means, the semen may be washed and the sperm

concen-trated into a smaller volume by slow centrifugation The resultant

semen then is only used for intrauterine insemination accuratelytimed by daily LH levels or ovulatory stimulation

If sperm autoantibodies are present, suppression of the immune

response by steroids may be initiated However, in vitro

fertiliza-tion may be necessary in some of these cases to achieve pregnancy

780 HANDBOOK OF OBSTETRICS AND GYNECOLOGY

Intrauterine insemination with washed semen (to eliminate

prostaglandins) has been shown to be effective in cases where thesperm parameters are normal and the postcoital examinations areabnormal This is not true in the reverse instance If postcoital testsare normal but the sperm characteristics are not, intrauterine in-semination of the abnormal sperm offers little benefit

In vitro fertilization and gamete intrafallopian transfer (GIFT)

offer therapy most likely to be successful in male factor infertilitywith abnormal sperm factors Both are invasive and expensive pro-cedures Moreover, several attempts may be necessary to achievepregnancy (reported pregnancy rate per cycle is 15%–20%)

CERVICAL FACTORS

If the cervix is abnormal as a result of treatment (e.g., coagulation,

cryotherapy) or congenital malformation, intrauterine inseminationwith washed sperm over three cycles should achieve pregnancy in

30%–40% If cervical mucus is not adequate at midcycle, low-dose

estrogen administered during the mid- to late follicular phase of thecycle may be effective Human menopausal gonadotropins may benecessary to improve the cervical mucus when low-dose estrogen

is ineffective Nonetheless, close monitoring is recommended toavoid multiple gestation or hyperstimulation syndrome If these areineffective, intrauterine insemination may be performed When the

cervical mucus is altered by inflammation or infection, empiric

tetracycline therapy (doxycycline 100 mg bid for both partners) isadvocated

UTERINE-TUBAL FACTORS

Microsurgical tuboplasty is 60%–80% effective in achieving nancy with tubal occlusion However, correction of isthmic occlu-

preg-sions and neosalpingostomy are significantly less successful

Ec-topic gestation occurs in 10% of conceptions after surgical tubal repair Fibroids significantly distorting the endometrial cavity or

submucous myomas may warrant removal in the treatment ofinfertility Periadnexal adhesions may be lysed by operative la-paroscopy

OVULATORY FACTORS

When anovulation is the etiology of female factor infertility,

suc-cessful induction of ovulation will result in pregnancy 1 y in 80%.

If pregnancy does not occur despite documented ovulation, other

factors must be investigated Ovulation can be induced in 90%–95%

of anovulatory patients, except those with an elevated FSH An

el-evated FSH is pathognomonic of ovarian failure or ovarian tance, and no further testing is warranted The only hope for preg-

resis-nancy is embryo or ovum donation A pregresis-nancy rate of up to 20%

per transfer is likely, but the ethical, psychologic, and legal issues

of this procedure must be considered

The initial drug used to induce ovulation is clomiphene citrate.

Of anovulatory women whose ovaries are producing estrogen, 70%will ovulate with this drug Ideally, it is given for 5 d in the early fol-licular phase because it acts as an antiestrogen Ultrasound and hor-monal testing may be required to evaluate patient response Dosage

or timing adjustment or additional hormone therapy (e.g., steroids,estrogen, or midcycle hCG) may be necessary to achieve success

Stimulation with human menopausal gonadotropins (hMG)

gen-erally is reserved for those who do not respond to clomiphene, thosewho respond but no pregnancy results, in cases of hypothalamic in-sufficiency, or in unexplained infertility Monitoring of estrogen lev-els and ultrasonic determination of the number of follicles stimu-lated as well as the degree of maturity of ova are requisites Mostoften, administration of hCG is necessary to trigger ovulation Al-

though ovulation can be achieved in 85%–90% using hMG, the risk

of multiple births is 20%.

If investigation reveals an elevated prolactin level, a TSH

de-termination is necessary to rule out hypothyroidism If present, pothyroidism should be treated Many drugs can elevate prolactinlevels, and these should be terminated After pituitary adenoma andhypothyroidism have been eliminated in the etiology of elevatedprolactin, bromocriptine therapy may be initiated and continued un-til pregnancy is confirmed Despite its use in early pregnancy, there

hy-is no documented increase in the incidence of malformation or taneous abortion over that seen in the general population

spon-If the infertility is secondary to an inadequate luteal phase,

clomiphene may be used successfully in the early follicular phase

to recruit additional follicles (thus enhancing progesterone levels inthe luteal phase) Other methods of therapy to be considered for aninadequate luteal phase are progesterone supplementation duringthe luteal phase and hCG injections

PERITONEAL AND PELVIC

(re-782 HANDBOOK OF OBSTETRICS AND GYNECOLOGY

COMBINED FACTORS

When combined factors are documented, therapy can be performedsequentially or simultaneously depending on individual circum-stances

UNEXPLAINED INFERTILITY

When no etiology for infertility can be found, no specific therapy

is likely to be successful Even without therapy, the couple can be

given the statistical chance of pregnancy of 60% within 3–5 years.

If age is a factor or infertility has been long-standing, advanced productive technologies warrant discussion with the involved cou-ple The option of giving hMG (Pergonal) combined with timed in-seminations offers some hope short of IVF If the former isunsuccessful, IVF should be offered

re-PSYCHOLOGIC ASPECTS OF INFERTILITY

Infertile couples need considerable psychologic support Infertility

may engender feelings of inadequacy, loss of self-image, or fearsregarding their own sexuality This is particularly true of the onefound to be infertile Anger, accusations, or depression may pre-dominate as frustration and disappointment recur on a monthly ba-sis when pregnancy is not achieved Some may become so obsessedwith basal body temperatures, timed intercourse, and other aspects

of therapy that the couple’s interpersonal relationship suffers Anadditional burden or stress may be the expense of investigation andtherapy Many insurance carriers pay little or nothing toward theexpense involved

Infertility can engender the progression through all of the phases

of the grief reaction: denial, anger, bargaining, depression, and

ac-ceptance Many couples become willing to try any technique thatthey may read or hear about, especially from well-meaning friends

or relatives Support groups may be of help—the national zation RESOLVE can provide informal support and referral for pro-fessional counseling

organi-Emphasize the fact that unlike many disorders (e.g., tis), infertility can rarely be reversed overnight and that the coupleshould accept a process that may take months rather than days orweeks to diagnose and treat Pregnancy usually occurs in 6–9 cy-cles if a true cause can be found A time limit must be set for theexpected resolution of the problem to avoid endless procedures orregimens delaying acceptance of failure and initiation of alterna-tives (e.g., acceptance of childlessness or adoption)

appendici-ASSISTED REPRODUCTIVE

TECHNOLOGY (ART)

IN VITRO FERTILIZATION

In vitro fertilization-embryo transfer (IVF-ET) is the technique of

removing the ovum (egg) from the ovary, fertilizing it in the ratory, then placing the resulting embryo into the uterus Since thefirst IVF-ET success in 1978, it has become invaluable in the treat-ment of otherwise untreatable infertility Success in achieving preg-

labo-nancy after ovum retrieval is 15%–20% per cycle, and 70%–80%

of those carry the pregnancy to term The usual indications for

IVF-ET are bilateral tubal abnormality (e.g., postsalpingectomy, postsevere salpingitis), antisperm antibodies, extensive endometriosis,oligospermia, and long-standing unexplained infertility

TECHNIQUE

Superovulation

Several methods may be used, including (alone or in combination)luprolide acetate, clomiphene citrate, hMG, hFSH, and GnRH.Ultrasound Scans

Determining the number and growth of ovarian follicles is sary, since at least 2–3 follicles should be developing simultane-ously to enhance the possibility of successful ovum retrieval.Hormonal Monitoring

neces-Serum estradiol levels are useful in predicting which cycle is most likely to result in pregnancy LH levels are closely followed because

an unexpected LH peak may result in ovulation before a scheduledovum aspiration

Ova Retrieval

Ova are aspirated 24–36 h after injection of hCG or the onset of

a spontaneous LH surge Aspiration may be accomplished via

laparoscopy or under indirect visualization using ultrasound and apercutaneous-transvesical or transvaginal approach The advantage

of the ultrasonographic technique is that this program may be patient oriented and there is no need for anesthesia After the ovary

out-is identified, each preovulatory follicle out-is punctured, and the tents are aspirated The aspirate is immediately transferred to thelaboratory

con-784 HANDBOOK OF OBSTETRICS AND GYNECOLOGY

Ova Identification and Classification

The ova are identified microscopically and classified as mature panded cumulus oophorus) or immature (compact cumulus) Ma-

(ex-ture ova have undergone the first meiotic division and are fertilized

5 h after aspiration Immature ova may be incubated for up to 36 hbefore fertilization

Sperm Capacitation

Because freshly ejaculated sperm cannot fertilize an ovum, the

sperm must be capacitated by a short incubation in culture medium.

presence of pronuclei (fertilization has occurred) or blastomeres

(cleavage has occurred)

Embryo Transfer

The fertilized ova are placed in the uterus after 48–72 h

incuba-tion, usually at the 2-cell to 8-cell stage, although more recentlymany are awaiting blastocyst stage for embryo transfer This is ac-complished by aspiration of the ova into a small catheter, which isthen passed transcervically The ova are injected into the uterinecavity to complete the process

Potential complications of the procedure are those associatedwith anesthesia and laparoscopy and those of any pregnancy For

example, ectopic pregnancy may occur Because of the increased risk of multiple gestation with subsequent fetal wastage, most cen-

ters implant only three to four embryos a cycle If there are excessfertilized ova, the options include freezing (for later use or dona-tion to another infertility patient), discarding them (unwise), or ex-perimentation (controversial)

OVUM TRANSFER

Ovum transfer is removal of an ovum from a fertile woman after

insemination (usually by an infertile woman’s husband) at the time

of ovulation (LH peak) The ovum donor and the recipient mustovulate within 2 days of each other Three to 4 days after insemi-nation, the uterus of the donor is lavaged to attempt ovum retrieval(hopefully fertilized) Because the process is patented, the technique

may be performed only in clinics licensed to do so The major plication is failure to lavage a fertilized ovum from the donor, re-sulting in undesired pregnancy.

com-GAMETE AND ZYGOTE

INTRAFALLOPIAN TUBE TRANSFER

(GIFT, ZIFT)

Both GIFT and ZIFT are used only in patients with patent uterinetubes GIFT is usually accomplished with superovulation The ovaare collected, ova and sperm are mixed, and then immediatelyplaced into the uterine tube, where natural fertilization can occur

In ZIFT the process is similar to IVF-ET, except the zygote is ferred into the fallopian tube as opposed to the uterus

trans-OUTCOMES OF ASSISTED REPRODUCTIVE

TECHNOLOGY

Annually, the United States Assisted Reproductive Technologyresults are reported from the American Society for ReproductiveMedicine and the Society for Assisted Reproductive Technology’s

Registry in the journal Fertility and Sterility The interested reader is referred to this source for timely information Recent

trends indicate: an increasing number of programs reporting

as-sisted reproductive technology treatment, an increase in reportedcycles, and increasing overall success rates (as measured by de-liveries per retrieval) In 1996 (at the time of writing the latestdata available), 300 assisted reproductive technology programs(likely all of the U.S centers) contributed data to the registry, re-vealing the following:

● 65,863 total assisted reproductive technology cycles (average

of 219.5 cycles per program) were performed

● 44,647 cycles were IVF (with and without tion—ICSI) with 26.0% deliveries per retrieval

micromanipula-● 2879 cycles of gamete intrafallopian transfer (GIFT) sulted in 29.0% deliveries per retrieval

re-● 1200 cycles of zygote intrafallopian transfer (ZIFT) wereperformed with 30.9% deliveries per retrieval

● 9610 frozen embryo transfers (FET) resulted in 16.8% liveries per transfer

de-● 3768 donor oocyte cycles had an overall success of 39.1%deliveries per transfer

● 1076 cryopreserved embryo transfers from donated oocytesresulted in 20.8% deliveries per transfer

786 HANDBOOK OF OBSTETRICS AND GYNECOLOGY

● 688 assisted reproductive technology cycles using a hostuterus resulted in 31.3% deliveries per embryo transfer

● 1341 cycles were reported as combinations of more than onetreatment type

● Overall 14,702 deliveries were reported resulting in 21,196neonates

These pooled data do not define variation in the patient acteristics known to affect prognosis, including (but not limited to):maternal age, the duration of infertility, the presumed cause(s) ofinfertility, the patient’s prior history of treatment of infertility, anddiethylstilbestrol exposure As such, the pooled data should be usedwith caution in counseling individual patients for their characteris-tics may alter prognosis more than the particular assisted repro-ductive technology employed

char-The complex process of assisted reproductive technology iscostly, involving: history, physical examination, endocrine testingwith rapid turn around times, ultrasonic monitoring of follicle ripen-ing, surgical fees, gamete and embryo laboratory fees, anesthesia,facility use fees, and medications The expenses vary per conditionand per technique as well as not being comparably reported There-fore, only a gross estimate of cost per cycle is possible, probably be-ing between $7,000–12,000 Infertility diagnostic and therapeutictechniques are generally not covered by traditional payers; there-fore, most patients usually pay directly Undoubtedly this decreasesutilization by those without sufficient economic resources Thus, it

is difficult to assess utilization strictly on a population base In tries where there is payer coverage for infertility (e.g., Denmark),IVF has been utilized up to 6500 cycles per 1 million women in thereproductive age

coun-HYPERANDROGENISM

The primary androgen produced by the ovaries is androstenedione,and the primary androgen from adrenal glands is dehy-droepiandrostene sulfate (DHEAS) Androgen production in theovary is stimulated by pituitary LH and in the adrenal is stimulated

by pituitary ACTH Most androgens are bound to specific proteins

in the circulation and, while bound, are largely biologically tive On reaching the target tissue, androgens are further metabo-lized, often regaining biologic activity For example, testosterone

inac-is 99% bound while in the circulation but, on reaching the skin, inac-isconverted to dihydrotestosterone (by 5 a-reductase), an even morepotent androgen than testosterone The sebaceous glands are verysensitive to androgens, and oily skin and acne are early signs

of hyperandrogenism The hair follicle is moderately responsive

to androgens, and hirsutism is a further response to increasingandrogenicity Finally, with marked androgenicity, signs of mas-culinization appear in the woman (virilization) These include tem-poral balding, deepening of the voice, breast atrophy, increasedmuscle mass with loss of female body contour, male type pubic hairpattern, and cliteromegaly.

The total testosterone produced by a mature female is 0.35mg/day Ovarian secretion accounts for 0.1 mg, 0.2 mg comes fromperipheral conversion of androstenedione, and 0.05 mg is from pe-ripheral conversion of DHEAS The ovary and adrenal gland se-crete about equal amounts of androstenedione and DHEA Thus,about two thirds of a woman’s daily testosterone comes from theovaries Therefore, increased levels of testosterone suggest an ovar-ian origin Hyperandrogenism may be associated with several dis-orders

hyperan-catecholamine abnormalities, obesity, and stress are associated

fac-tors The most common symptom is infertility, which occurs in 75% of patients Other manifestations of PCO include hirsutism (70%), menstrual irregularities (amenorrhea 50%, functional bleed- ing 30%, and dysmenorrhea 25%), obesity (40%), insulin resistance,

and virilization (20%) Only 15% of those with PCO will have

biphasic body temperature, and even less will have cyclic menses

A feature of PCO is enlarged ovaries (often 5 cm) that have

a smooth, white, thickened pseudocapsule, immediately beneathwhich are numerous follicular cysts surrounded by hyperplasticluteinized theca interna cells

PCO is marked by increased gonadotropin-releasing hormone

(GnRH) pulse frequency and tonically elevated levels of LH erally
20 mIU/mL) Estradiol not bound to sex hormone-bindingglobulin (SHBG) is increased (total estradiol is not) because of adecreased SHBG (due to increased androgen levels and obesity),

(gen-which stimulates GnRH pulsatility This results in androgen excess (from both ovaries and adrenals) and anovulation However, the hy-

perandrogenism is mild (if elevated, testosterone 70–120 ng/dL and

androstenedione 3–5 ng/dL); about one half have elevated DHEAS

levels

Because the FSH levels are usually low, an LH/FSH ratio
3

may be useful in diagnosis of PCO (when LH is
8 mIU/dL)

GnRH, gonadotropin-releasing hormone; LH, luteinizing hormone; FSH, follicle-stimulating mone; E 2 , estradiol; T, testosterone; A 2 , androstenediol; SHBG, sex hormone-binding globulin.

Ovaries of PCO patients do not produce more estradiol from drostenedione (in fact, because of less FSH, the ovaries have loweraromatase levels) The increased circulating androstenedione is pe-ripherally converted to estrone, resulting in elevated estrone levels.The important interrelationships in PCO are graphically demon-strated in Table 29-2.

an-Mild hyperprolactinemia is found in 20% of women with PCO Transvaginal sonography is of increasing importance in women

with PCO to detect the characteristic ovarian image as well as tomeasure the endometrial thickness (a gross measure of hyperpla-sia) Prior to therapy, endometrial sampling is nearly always indi-cated to rule out endometrial hyperplasia and endometrial carci-noma

Therapeutic goals in women with PCO must be highly ualized and may include: pregnancy, control of hirsutism, and pre-

individ-vention of endometrial hyperplasia (from unopposed estrogen) tients should be made aware that therapy for this condition islong-term and that although short-term treatment may achieve a de-sired goal, the underlying condition persists, placing them at risk

Pa-When the PCO patient is anovulatory, not hirsute, and does not

desire pregnancy, therapy with intermittent progestin or oral

con-traceptive agents (if not contraindicated) is recommended to vent the risk of endometrial hyperplasia and carcinoma When the

pre-PCO patient is mildly hirsuite and does not desire pregnancy, oral

contraceptives will: arrest the hirsuitism, lower gonadatropin els, and decrease the risk of endometrial hyperplasia Continuousprogestin therapy is a less attractive alternative because of the sideeffects (mastodynia, bloating, depression) For greater amounts ofhirsutism there are no effective pharmacological agents; thus, phys-ical adjuncts (bleaching, electrolysis, depilation, etc.) are usually

lev-recommended If pregnancy is desired, medical therapy is the

ther-apeutic choice Clomiphene citrate is the ovulatory agent arily used first and should achieve ovulation in ⬃75% and preg-nancy in 35%–40% Other ovulation methods used (largely ifclomiphene citrate fails) include: hMG-hCG, purified human FSHand hCG, and pulsatile GnRH Ovarian wedge resection was com-monly used in the past, but today is indicated when: all other ther-apies fail, there is a question of ovarian tumor (ovarian size or highandrogen levels), and fertility is not an issue

custom-STROMAL HYPERTHECOSIS

The peak age of women with stromal hyperthecosis is 50–70 years,

in keeping with the gradual onset of this uncommon disorder Like

790 HANDBOOK OF OBSTETRICS AND GYNECOLOGY

PCO, stromal hyperplasia is associated with enlarged ovaries (5–7

cm in diameter) Stromal hyperthecosis is usually bilateral and ischaracterized by stromal proliferation with foci of luteinization.There are no subcapsular cysts like those found in PCO The thecacells produce gradual but ever increasing amounts of androstene-dione, leading to elevated testosterone (usually
2 ng/dL) Again,

in contrast to PCO, stromal hyperthecosis patients tend to have vancing virilization over a course of years

ad-ANDROGEN-PRODUCING

OVARIAN NEOPLASMS

Neoplastic androgen-secreting ovarian disorders typically have a

rapid onset of hirsutism, amenorrhea, and virilization These

neo-plasms are usually unilateral and palpable on pelvic examination.

Testosterone is the most commonly secreted androgen (usually

200 ng/dL) in these disorders The most common of the tumors

causing hyperandrogenism are the Sertoli-Leydig cell and hilus

cell tumors The neoplasms produce testosterone and almost

always lead to virilization The less common ovarian neoplasms

leading to hyperandrogenism include lipoid cell (adrenal rest)

tu-mors (produce testosterone or DHEAS or both), granulosa-theca cell tumors (can produce testosterone in addition to increased

estradiol), Brenner tumors, and Krukenberg tumors (unusual, rarely produce testosterone) Also to be considered are ovarian tu-

mors, whether benign or malignant, primary or metastatic in

ori-gin They do not secrete androgens but stimulate the ovarianstroma to do so

Sertoli-Leydig cell tumors are uncommon (1% of solid ian tumors) They are most often diagnosed in menstruating women(20–40 years) and are associated with hirsutism, virilization, and a

ovar-palpable ovarian mass (85%) Hilar (Leydig) cell tumors are most

frequent after the menopause They are not usually palpable butcause rapid development of virilization Testosterone levels are

high, but DHEAS levels are normal Gonadoblastomas are a very

rare cause of hyperandrogenism, most often occurring in typic females with gonadal dysgenesis and a Y chromosome

pheno-Hyperandrogenism during pregnancy may be caused by a teoma of pregnancy or by hyperreactio leuteinalis Hyperreactio

lu-leuteinalis is defined as bilateral cystic ovarian enlargement Theovaries may be 20–30 cm in diameter and consist of innumerablethin-walled cysts These give the mass a bluish to gray ovarian colorand a honeycombed appearance The cysts are lined by luteinizedthecal lutein cells from the ovarian connective tissue

A luteoma of pregnancy is a unilateral or occasionally bilateral(30%) benign solid ovarian tumor (50%) caused by a hyperplasticreaction of ovarian theca lutein cells They are discrete and brown

to reddish brown and may have a cystic component Luteomas aremore common in black multiparas

Both luteoma and hyperreactio leuteinalis are benign and dependent They regress after pregnancy and should not be removedunless other problems intervene (e.g., torsion) The majority of casesare asymptomatic and are found incidentally Should symptoms oc-cur, they are usually nonspecific (i.e., a sense of pressure, ascites,

hCG-or increasing abdominal girth) Although the majhCG-ority are not perandrogenic, some produce high levels of testosterone and an-drostenedione Thus, the mother is virilized in 30%, and a femalefetus is at risk of virilization

hy-HYPERANDROGENISM OF

ADRENAL ORIGIN

Excess androgens from the adrenal glands may be the result of

neo-plasia, inborn errors of biosynthesis of adrenal hormones, or propriate stimulation of the adrenal gland Adrenal neoplasias typ-ically produce DHEA with blood levels
7000 ng/mL On rareoccasions, testosterone will be secreted (blood levels
200 ng/mL).Androgens are intermediates in the biosynthetic pathway for corti-sol Consequently, a disorder that causes an increase in cortisol pro-duction (e.g., Cushing’s syndrome) may concomitantly increase an-drogen levels

inap-CUSHING’S SYNDROME

Cushing’s syndrome may have three etiologies: adrenal tumors,

ec-topic production of adrenocorticotropic hormone (ACTH) by a pituitary tumor, or excess production of ACTH by the pituitary

non-(Cushing’s disease) All result in excessive production of

glucocor-ticoids The classic findings include centripetal obesity, dorsal neck

fat pads, abdominal striae, muscle wasting, weakness, hirsutism,and menstrual irregularity Cushing’s syndrome is diagnosed by the

dexamethasone suppression test The test involves administering

dexamethasone 1 mg PO at 11 PMfollowed by an 8 AMblood tisol (normal is 5 nanog/mL)

cor-Androgen-producing adrenal tumors are usually adenomas orcarcinomas Characteristically, symptoms have a rapid onset Thetumors produce DHEA, DHEAS (
8 m /mL), and androstenedione

CT or MRI scan of the adrenals facilitates diagnosis

792 HANDBOOK OF OBSTETRICS AND GYNECOLOGY

CONGENITAL ADRENAL

HYPERPLASIA (CAH)

CAH results from enzymatic deficiencies (21-hydroxylase or

11B-hydroxylase) inherited as autosomal recessive traits The

21-hydroxylase deficiency is the most common form Because bothconditions result in diminished cortisol biosynthesis, ACTH is in-creased ACTH leads to enhanced intermediate compounds beforethe enzymatic defect Thus, elevations of 17-hydroxypregnenoloneand 17-hydroxyprogesterone (17-OHP) occur and are subsequentlyconverted to DHEA and androstenedione The latter compounds are

in turn peripherally converted into testosterone Female infants withthis disorder are often diagnosed shortly after birth due to ambigu-ous genitalia CAH is the most common cause of ambiguous gen-italia in the newborn

Milder deficiencies also occur and may not be diagnosed until

puberty or later CAH may account for 5% of women with hirsutism.

Characteristically, these women have a history of prepubertal celerated growth but overall reveal short ultimate height and post-pubertal hirsutism They may exhibit mild virilization and DHEASlevels
5 mg/mL Measurement of 17-OHP
8 ng/mL facilitatesdiagnosis However, when 17-OHP is 3–8 ng/mL, an ACTH stim-ulation test may be diagnostic

ac-DIAGNOSIS

A complete medical history is essential This must include the

men-strual and family history Onset of symptoms should be noted aswell as drug ingestion, whether current or in the recent past Use

of body building programs and food supplements should not beoverlooked Physical examination should include vital signs, bodyhabitus, hair pattern, and presence or absence of skin and fat changesconsistent with Cushing’s syndrome, as well as signs of virilization

in addition to hirsutism The pelvic examination should considerovarian size or masses

Initial laboratory testing should include serum testosterone and

DHEAS levels Serum testosterone 200 ng/mL rules out terone-secreting neoplasms, whereas serum DHEAS 7000 ng/mLeliminates significant adrenal pathology A testosterone level
200ng/mL is indicative of ovarian tumor until proven otherwise (i.e.,study of the adrenals is essential only if no ovarian mass is pres-ent) If the patient is anovulatory or oligoovulatory, FSH, LH, andprolactin levels may be helpful Elevated LH levels (especiallyLH/FSH ratio
3) suggest PCO Prolactinoma may cause elevatedprolactin levels

testos-Screening for hypercortisolemia requires a 24-h urine for

uri-nary-free cortisol or 17-hydroxycorticosteroids (17-OHCS) Moredefinitive testing includes an overnight dexamethasone suppressiontest Obtain an outpatient baseline plasma cortisol determination.Administer dexamethasone 1 mg PO at 11 PMthe same day Obtain

a plasma cortisol level again at 8 AMthe next day The cortisol levelwill be suppressed (5 ng/mL) in normal patients but not in Cush-ing’s syndrome False positives may occur in obesity, chronic ill-ness, or with phenytoin use

If cortisol suppression does not occur, a 2-day low-dose amethasone test is in order This is performed after two baseline 24-h urine collections for free cortisol and 17-OHCS levels havebeen obtained Dexamethasone 0.5 mg is given q6h PO for 2 d A24-h urine is collected during the second day for free cortisol and17-OHCS Normal patients’ 17-OHCS will be suppressed to

dex-2 mg/g of creatinine Moreover, free cortisol levels will be belownormal values In contrast, in Cushing’s syndrome, the 17-OHCSwill be
2.5 mg/g of creatinine

Cushing’s disease may be distinguished from Cushing’s drome by using higher doses of dexamethasone over a 2-day test(disease shows suppression from baseline levels) Then, ACTH lev-els should be elevated

syn-Late-onset congenital adrenal hyperplasia is uncommon in adultwomen It may be diagnosed by documenting increased serum 17-OHP Mild deficiency may be detected only by ACTH stimula-tion to demonstrate the partial block of 21-hydroxylase activity

DIFFERENTIAL DIAGNOSIS

The differential diagnosis of hyperandrogenism must include

idio-pathic hirsutism, polycystic ovary syndrome, stromal sis, androgen-producing ovarian tumors, Cushing’s syndrome ordisease, congenital adrenal hyperplasia (adult manifestations), an-drogen-producing adrenal tumors, androgen excess in pregnancy(luteoma or hyperreactio luteinalis), exogenous or iatrogenic an-drogen administration (testosterone, danazol, anabolic steroids, orsynthetic progestins), and abnormal gonadal or sexual development(idiopathic hirsutism, polycystic ovarian syndrome, and stromal the-cosis are the most frequent)

hypertheco-TREATMENT

Therapy depends on the etiology of the hyperandrogenism as well

as the desire for childbearing Ovarian and adrenal tumors must be

794 HANDBOOK OF OBSTETRICS AND GYNECOLOGY

treated surgically Congenital or acquired adrenal hyperplasiashould be treated with hydrocortisone Cushing’s disease (tumor) istreated by transsphenoidal pituitary surgery If unsuccessful, pitu-itary radiation or bilateral adrenalectomy is indicated Acromegaly

is treated by transsphenoidal hypophysectomy

After serious disease and neoplasm are ruled out and a decision

is made regarding further childbearing, medical therapy is indicated.

This entails ovarian or adrenal suppression or the blocking of ripheral androgen effects If infertility is a problem, ovulation in-duction is advisable after complete evaluation using appropriatedrugs (clomiphene, bromocriptine, hMG, GnRH)

pe-GnRH inhibits the secretion of gonadotropins from the pituitary

to inhibit the secretion of androgens and estrogens from the ovary.Although reported to be effective in
60%, long-term effects areunknown Further studies are warranted before general use of GnRH

is advocated Wedge resection of the ovary is not recommended astreatment for hyperandrogenism Although it may induce ovulation,androgen levels decrease only transiently, and its success rate to de-crease hirsutism is only 15%

PROGNOSIS

Although the underlying cause may be corrected, the signs of perandrogenism may be difficult or impossible to reverse There-fore, therapeutic efforts focus primarily on hirsutism

hy-HIRSUTISMANDROGEN-DEPENDENT HIRSUTISM

Hirsutism, the excessive growth of terminal hair, is the most

com-mon sign of female hyperandrogenism Terminal hair is one of the

two types of body hair It is longer, coarser, pigmented, and in someareas of the body hormonally responsive The other type of bodyhair is vellus hairs (short, fine, nonpigmented, and not responsive

to hormones) Whereas the amount of terminal hair is hereditarilydetermined, endocrine factors influencing the sebaceous gland andhair follicle include: androgen secretion (amount and duration), con-centration of sex hormone-binding globulin, peripheral conversion

of weaker to stronger androgens, and sensitivity to androgens sutism is but one manifestation of hyperandrogenism Hirsutismgenerally has a gradual onset and, in milder forms, occurs prima-rily on the upper lip and chin

Hir-With increasing severity, hair growth progresses to thecheeks, intermammary chest, abdomen, inner thighs, lowerback, and intergluteal areas Whereas the testosterone levels invirilization are usually
2 ng/mL, with hirsutism, the levels are

1.5 ng/mL

The disorders to be differentiated from hirsutism are virilism (as

noted earlier and characterized by more extensive lated changes, (see p 786), idiopathic hirsutism, and hypertrichosis.Hypertrichosis denotes excessive growth of the vellus hair (e.g.,

androgen-stimu-forehead, distal extremities) Hypertrichosis may result from

star-vation, traumatic skin irritation, drugs (e.g., phenytoin, diazoxide,minoxidil), and such disorders as acromegaly, porphyria, dermato-myositis, hypothyroidism, Hurler’s syndrome, trisomy E, and Cor-nelia de Lange syndrome

Most women with hirsutism will have no specific cause fied These cases are probably the result of altered androgen me- tabolism (increased conversion of testosterone to dihydrotestos-

identi-terone (see the discussion that follows) Increased androgen

production may occur from the ovaries and adrenal glands by

hy-persecretion of testosterone precursors that are converted to terone at other sites or by direct secretion of testosterone or con-

testos-version to dihydrotestosterone (by 5 a-reductase) Adrenal causes

of excessive androgen production include: dysfunctional excesses,

congenital adrenal hyperplasia, Cushing syndrome and androgen

se-creting neoplasms Ovarian causes of excess androgen production

include: PCO, sertoli-Leydig cell tumors, granulose cell tumors, and

gynandroblastomas Only free androgen is biologically active andalmost all androgens in the circulation are bound to sex hormone-

binding globulin or albumin Thus, decreased androgen binding

may lead to may cause relative hyperandrogenicity Hirsutism from

exogenous androgen administration must be considered in every

case

The evaluation of hirsutism includes thoughtful documentation

of the physical extent Androgen producing tumors are ruled out bytotal testosterone and DHEAS If the testosterone is
200 ng/mL

a transvaginal sonography should be performed to rule out ovarianneoplasms If the testosterone is 200 ng/mL, the DHEAS assists

in sorting different therapeutic classes When the DHEAS 500nanog/mL, the patients may be treated symptomatically If theDHEAS is 500–700 nanog/mL, cosyntropin stimulation is neces-sary to rule out congenital adrenal hyperplasia If the DHEAS is

700 nanog/mL, an MRI is necessary to rule out adrenal tumors.Exceptions to this schema includes Cushing syndrome, hyperpro-lactinemia, and adult onset congenital adrenal hyperplasia (see pre-vious discussion)

796 HANDBOOK OF OBSTETRICS AND GYNECOLOGY

The most common drugs used to treat hirsutism are oral

con-traceptives, medroxyprogesterone, dexamethasone, and tone Dexamethasone is effective in many whose hirsutism is of ad-renal origin The dose is 0.5–1 mg orally at night Morning cortisollevels must be monitored to prevent oversuppression of the adren-als, however

spironolac-Combination oral contraceptives (estrogen and progestins) areeffective in decreasing hair growth in 50%–60%, although achiev-ing normalized testosterone levels may require 3 months The ef-fect of therapy is the inhibition of LH secretion by progestins andincreased testosterone binding by SHBG (estrogen elevates SHBG).SHBG-bound testosterone will not be bound by receptors In addi-tion, combination oral contraceptives decrease DHEAS levels, pos-sibly by suppressing ACTH release This, in turn, decreases adre-nal androgens Progestins alone may be given in regular form(Provera, 30–40 mg/d) or in depot form (Depo-Provera, 150–400

mg IM every 3 months) Because the depot form may cause term suppression of the ovary, it should not be used if pregnancy

long-is desired in the near future In addition to the LH suppression,medroxyprogesterone acetate acts by increasing metabolic clearance

of testosterone

The growth cycle of terminal hair is long (6–24 months), and

once stimulated, much lower levels of androgen are necessary to

sustain that growth Therefore, patients should be cautioned not to

expect a therapeutic response for 6–12 months However, some

de-crease in hair diameter and lightening of hair color may be notedduring that time If adequate suppression of testosterone andDHEAS for 6–12 months has been documented without a decrease

in hirsutism, the dose may be increased and another medication may

be added or substituted If the androgen levels do not decrease asexpected with therapy or if hirsutism is progressive despite therapy,further evaluation for a slow-growing neoplasm should be initiated

IDIOPATHIC HIRSUTISM (FAMILIAL

OR CONSTITUTIONAL HIRSUTISM)

When hirsutism is present without ovarian or adrenal dysfunction

and exogenous sources of androgens are absent, it is termed

idio-pathic Idiopathic hirsutism is particularly common in those of

Mediterranean or Near East descent This condition is caused

by abnormal peripheral androgen metabolism, (i.e., increased 5a-reductase activity converting normal levels of testosterone

into higher than normal levels of DHT and adiol-G)

Spironolac-tone, cimetidine, and cyproterone acetate afford effective therapy

by blocking peripheral testosterone activity or interfering with 5a-reductase activity.

Spironolactone lowers testosterone levels by inhibiting thebiosynthesis of androgens and by competing for androgenic recep-tors in the hair follicle itself The dosage is 50–200 mg/d Cimeti-dine reduces hirsutism by peripheral inhibition of binding of dihy-drotestosterone to androgen receptors The dose is 300 mg PO

5 times per d

Cosmetic therapy consists of bleaching, waxing, or depilatoryuse Shaving and plucking may cause infection or scarring and arenot recommended Because permanent hair removal via electroly-sis is expensive and painful, its use should be recommended onlyafter 6–12 months of medical therapy

This page intentionally left blank.

UTERINE POSITION AND

MALPOSITIONUTERINE POSITION

Uterine position and axis are described by both the relationship to

an imaginary line, equidistant from all bony structures through thetrue pelvis, and the relationship of the uterine axis to the cervical

axis The term version, with the appropriate prefix, ante- or

retro-designates the uterine axis vis-à-vis the central pelvis Flexion is the angulation of the axis of the uterus in relation to the axis of the cervix (Figs 30-1 and 30-2)

The uterine axis usually deviates from that of the cervix by ing anterior or posterior, and this is termed anteflexion or retroflex-

be-ion The corpus of the uterus is anteflexed in nearly 80% of women,

and in the remaining 20% the corpus is retroflexed Thus, version implies that the axis of the body of the uterus is directedtoward the hollow of the sacrum, but the cervix remains in its nor-

retro-mal axis (Fig 30-3) Retrocession implies that both uterus and

cervix (to a lesser degree) are displaced backward toward thesacrum—away from the midpoint of the pelvis (Fig 30-4) Normally, because of the flexibility of the uterine supports, theposition of the uterus may vary transiently as a result of pelvic in-clination during sitting, standing, or lying down In nulliparas andmultiparas with good pelvic support, the cervical axis is usually

directed posteriorly in the vaginal vault, almost at a right angle to

the vaginal axis Enlargement of the uterus by pregnancy or tumor

may alter the relative fundal position The uterus and cervix areoften aligned with the vaginal axis following parturition or with relaxation of the pelvic floor because of laxity of the transversecervical and round ligaments

30

OTHER GYNECOLOGIC

PROBLEMS

FIGURE 30-2. Retroflexion in an anteverted uterus

FIGURE 30-3. Degrees of retroversion of uterus without retroflexion

800

UTERINE MALPOSITION

Uterine prolapse (even moderate) is nearly always associated with

uterine retroversion or retrocession Nonfixed lateral uterine

dis-placement generally indicates disdis-placement by tumors or

shorten-ing of the supports Fixed (adherent) lateral uterine displacement

may indicate endometriosis, adhesions, a tuboovarian mass, or mor Pelvic infections or endometriosis may obliterate the cul-de-sac and result in fixed uterine retroversion A pyosalpinx or hy-drosalpinx may draw the corpus backward and downward by itsweight, whereupon adhesions add restriction to cause immobility.Speculum examination of the patient with retroflexion and retro-version of the uterus will reveal the cervix to be anterior, higher inthe vagina than normally encountered, and pointing toward the sym-physis pubis (as opposed to its normal posterior vaginal inclina-tion) Bimanual examination ordinarily confirms this finding

tu-Differential diagnosis of unusual uterine positions includes a

fundal fibroid, an ovarian tumor resting in the cul-de-sac, adherentretroposition of the uterus, salpingitis, or endometriosis The diagno-sis is most frequently clarified by a pelvic ultrasound examination

Of women with retroposed uteri, ,5% will have a complaint

referable to posterior flexion or version of the uterus When toms occur, they are most frequently backache, dysmenorrhea, ordyspareunia These symptoms usually respond to correction of theretroposition of the uterus, which may be accomplished by manualreplacement (rectovaginal manipulation of the corpus) (Fig 30-5)and support using a vaginal pessary (Hodge type) (Fig 30-6)

symp-FIGURE 30-4. Retrocession of uterus

802 HANDBOOK OF OBSTETRICS AND GYNECOLOGY

During early pregnancy, a retroflexed uterus may become

in-carcerated, often because of adhesions, and lead to acute urinary

retention In addition, because adherence interferes with normalfetal growth and development, abortion may result This has beensimply treated by catheterizing the bladder and using a vaginalmercury-filled balloon to gently displace the uterus anteriorly Adherent uterine fixations rarely cause uterine symptomatology.However, evaluation and appropriate therapy may be indicated for

FIGURE 30-5. Bimanual replacement of uterus.

FIGURE 30-6. Insertion of Hodge pessary if bimanual replacement of uterus is not successful