Disruptive changes in mood and low energy level are among the most common reasons women consult a physician. Usually no clear physiological explantation for these changes can be found. Many physicians feel uncomfortable dealing with patients with these complaints. The purpose of this paper is to discuss a practical approach to helping women with such conditions. A variety of terms have been utilized to refer to the situation in which a female patient has decreased energy or labile mood. Premenstrual Syndrome (PMS) and chronic fatigue syndrome (CFS) are currently popular terms. An association of low mood with menstrual cycle phase is undoubted, with the late luteal-early premenstrual phase most commonly associated with depression and irritability. It seems likely that women with PMS and those without it do not differ in circulating hormone levels during their cycles but rather in the brain response to these. Estrogen and progesterone receptors exist in the brain and change during the cycle. Elaborate diagnostic efforts are rarely rewarding in managing mood and energy disorders. Of more value is a careful history particularly concerned with the pattern of mood changes and with life stresses, accompanied by a thorough physical examination and laboratory tests. In most cases, changes in mood and energy are a variant of clinical depression. Changes in energy and sleep may be more evident than low affect. Treatment with an appropriate antidepressant, usually a selective serotonin re-uptake inhibitor (SSRI), benefits most of these patients. Allowing the patient to express concerns about stressful life situations is often of great value.
Objective-Comparison of the effects of treatment of two transdermal therapeutic systems for estrogen replacement therapy with regard to efficacy, tolerability, and acceptance. Design-Open randomized. Setting-Multicenter. Patients and Interventions-A study population of 104 postmenopausal women was randomized on a 1:1 basis to treatment with one of two estradiol patches, Systen(R) (Cilag) and Estraderm(R) (Ciba-Geigy). Outcome Measures-Systolic and diastolic BP, hot flushes, night sweating, fatigue, insomnia, depression, nervousness, headache, vaginal discomfort (efficacy variables); bleeding, dermatological symptoms, comfort and adhesiveness of patch, and other possible causes of discontinuation (tolerability); general evaluation by patient (acceptance). Results-Considering all efficacy variables, 53% of Systen and 46% of Estraderm patients found the therapy satisfactory. Tolerability was somewhat higher in the Systen group. Adhesiveness of the patch was significantly better for Systen. Overall, 79% of Systen patients and 62% of Estraderm patients evaluated treatment as ''good'' or ''very good.'' The majority of patients in both groups found the patch very comfortable or only slightly obtrusive.
OBJECTIVE To examine the effect of oophorectomy on response to gonadotropin releasing hormone-agonist/human menopausal gonadotropin (GnRH-a/hMG) for in vitro fertilization (IVF). DESIGN Retrospective review. SETTING Tertiary care academic institution. PATIENTS Ninety-one infertile patients undergoing IVF. Eighty-four women had two ovaries and seven had only one ovary. RESULTS There was no difference observed between women with one versus two ovaries with regard to response to medications, hormone production, number of oocytes retrieved and fertilized, or the number of embryos cleaved and transferred. CONCLUSION Women with only one ovary are at no reproductive disadvantage when undergoing ovulation induction for IVF.
The relationship between endometriosis and infertility is observed frequently. Patients with both conditions require a conservative approach to their management. Since hormonal therapy is one of those approaches, we sought to compare the efficacy of Danazol and Gestrinone in 80 infertile patients (48 and 32, respectively). Therapy lasted 6 months in both treatment groups, and all patients studied had laboratory tests performed and were clinically evaluated and classified through laparoscopy before and after therapy. The improvement of symptoms and favorable follow-up were similar with both treatments. The reestablishment of menstrual patterns and fertility were also nearly alike in both groups. However, Gestrinone was associated with fewer secondary effects and is easier to administer than Danazol. We conclude that Gestrinone is a useful medication in the management of the infertile patient with endometriosis.
Objective-The purpose of this study was to compare the frequency with which pituitary suppression by gonadotropin releasing hormone agonists (GnRHa) for IVF is achieved according to hormonal vs. ultrasound criteria. Methods-The criteria selected for comparison were a luteinizing hormone (LH) level of <5 mIU/mL, an estradiol of <100 pmol/L and the absence of follicular development >10 mm on ultrasound. Results-Pituitary suppression was achieved in 184/215 cases (85.6%) according to the LH level, in 103/215 cases (47.9%) according to the estradiol level, and in 95/117 cases (81.2%) when ultrasound criteria were satisfied. All three criteria were met in only 16/139 (11.5%) of cases after 3 weeks' pretreatment with the GnRHa. Conclusion-Neither estradiol nor LH levels were predictive of the sonographic evidence of pituitary suppression, nor did they correlate with IVF outcome.
Objective-To compare the 4-day human sperm-survival (SS) assay, the murine 2-cell zona-free assay, and the murine 1-cell zona-intact assay for capacity to detect toxins and culture conditions known to adversely affect the survival/developmental potential of human embryos during IVF. Methods-Three studies were carried out. In Study I, human sperm survival (SS) and two-cell zona-free (2CZF) assays were evaluated for their sensitivity and precision in testing a wide array of items for IVF quality control. For general laboratory items containing a rubber component, the SS and 2CZF assays were able to detect 72% and 44%, respectively, of the items with known toxicity. For testing of oil overlays, media, and water, the SS and 2CZF assays detected only 6% and 16%, respectively, of toxins/culture solutions considered inadequate for human IVF. In Studies II and III, we investigated whether oil overlays could decrease the sensitivity of the murine bioassays by absorbing toxins from the test media. For the 2CZF and 1-cell zona-intact (1CZI) assays, the oil overlays resulted in a decreased number of tests in which a toxin was identified (10% vs. 35% and 35% vs. 42%, respectively). In the absence of oil overlays, significantly lower development of test embryos exposed to toxins was noted in 8/20 (40%) and 3/18 (17%) tests for the 2CZF and 1CZI assays, respectively. Under the best assay conditions used in this study (no oil overlays), only 6%, 35%, and 42% of toxins were detected with the SS, 2CZF, and 1CZI assays, respectively. Conclusions-The results of these studies indicate that oil overlays decrease the sensitivity of IVF quality control assays. The SS assay appears to be adequate for quality control testing of items with a rubber component. Using the methods and end points employed in these studies, all of the assays investigated appeared to be too insensitive for IVF quality control testing of oil, media, and water.
Objective-To evaluate the relationship between high early pregnancy levels of serum CA-125 and the presence of chromosomally abnormal abortuses. Design-Prospective. Setting-Center for assisted reproductive treatments. Patients-Four groups of patients who underwent assisted reproductive treatments: (A) ten pregnant women who delivered a healthy term infant; (B) ten women who delivered healthy twins; (C) nine women who spontaneously aborted chromosomally normal fetuses, and (D) nine women who aborted genetically abnormal fetuses. Outcome Measures-Serum CA-125 at the day of hCG injection, day 18 post assisted conception treatment, and 6 weeks of pregnancy. Results-A significant, 3- to 10-fold rise of average maternal serum levels of CA-125 was noted with the establishment of a biochemical pregnancy (day 18). A wide variation and substantial overlap in serum CA-125 values were observed in all groups. Serum CA-125 of patients carrying chromosomally abnormal fetuses did not differ from those carrying normal ones. Conclusions-Determination of maternal serum CA-125 in early pregnancy does not provide clinically useful information for the detection of women at risk for spontaneous abortion with either chromosomally normal or abnormal fetuses.
Objective-To improve understanding of follicular paracrine interactions. Patients and Methods-The levels of insulin-like growth factor I (IGF-I) and the IGF-binding protein-I (hIGFBP-1) in 28 follicular fluid samples obtained from 10 in vitro fertilization patients were measured. Only samples containing mature oocytes which subsequently fertilized and cleaved were studied. These levels were then related to follicular fluid steroid levels in the individual follicle, pregnancy outcome, and the use of leuprolide acetate. Results-Linear regression analysis demonstrated a positive relationship between individual follicular fluid levels of IGF-I and hIGFBP-1, as well as between levels of estradiol and hIGFBP-1. There was a negative relationship between follicular fluid progesterone/estradiol ratios and the levels of both IGF-I and hIGFBP-1. Mean follicular fluid levels of IGF-I and hIGFBP-1 were not statistically related to pregnancy outcome or leuprolide use. Lower mean follicular fluid levels of estradiol and consequently higher follicular fluid progesterone/estradiol ratios were found among patients who achieved pregnancy compared to nonpregnant patients. Conclusion-Our results support the concept that critical interactions involving IGF-I, hIGFBP-1, and steroid hormones are necessary for the maintainence of an intrafollicular milieu favorable for optimal oocyte development.
Objective-To investigate the influence of different doses of gonadotropin-releasing hormone analogue (GnRH-a) on hormone pattern and testicular histology in patients with prostatic cancer. Design-Twelve aged males with prostatic cancer were given subcutaneous injections of 0.9, or 1.8, or 3.6 mg of a depot formulation of GnRH-a D-Ser-(BU(t))6-azgly10-GnRH. Plasma levels of LH, FSH, and testosterone were measured before the start of treatment and on days 28 and 56. Testicular biopsies were performed before the treatment and from 8 to 16 weeks (median 12 weeks) after the start of treatment. Results-Circulating levels of gonadotropins and testosterone were significantly reduced after treatment with GnRH-a in all groups, but there was no significant difference among the three groups. The administration of GnRH-a resulted in inhibition of spermatogenesis, reduction of tubular diameter, and tubular wall thickening in all groups. However, testicular changes were not considerably different among the three groups. Conclusions-Subcutaneous administration of a depot formulation of low dose GnRH-a is sufficient to affect not only plasma levels of gonadotropins and testosterone but also testicular histology.
Today the common practice for donor insemination is to use frozen-thawed semen. Semen should be quarantined while the donor is retested for sexually transmitted diseases in general and human immune deficiency virus (HIV) in particular. Semen properties are changed during the freezing-thawing procedure. Literature review and our experience concerning treatment modalities with frozen-thawed semen are presented. Donor insemination with fresh semen was practiced for years, and most of our knowledge concerning modes of treatment, insemination timing, and success rate were based upon this experience. Criteria concerning semen quality, ovulation monitoring, semen preparation, timing and frequency of insemination, methods of insemination, and success rates might all be influenced by the properties of the frozen-thawed semen.
This randomized trial was designed to assess the efficacy, tolerability, and acceptability of two different transdermal estradiol replacement therapies: Cilag Estradiol-TTS (a matrix system) and Ciba-Geigy Estradiol-TTS (a reservoir system). Five hundred and fourteen patients were evaluable for efficacy, and all patients who had received the study medications were evaluated for safety (n = 530). Both treatments significantly improved systemic and urogenital symptoms as evidenced by a decrease in the number of hot flushes and the Kupperman Index score; there was no difference in effectiveness between the two treatments. Safety evaluation revealed a low incidence of adverse events, mainly compatible with exogenously administered estrogen and progestagen. Endometrial biopsies at the end of treatment were similar between groups and consistent with balanced hormone replacement therapy. Analyses of acceptability data revealed a low incidence of skin reactions and an added benefit with the Cilag-Estradiol-TTS patch in terms of convenience owing to the adhesiveness of the patch. In conclusion, both transdermal estradiol replacement therapies were effective and well tolerated in the treatment of postmenopausal estrogen deficiency symptoms, and the Cilag Estradiol-TTS patch had an advantage in terms of convenience and adhesiveness.
Objective-To assess the effect of asymptomatic pelvic organ infection, as revealed by ultrasound, on sperm quality. Patients and Methods-Clinical and andrological examination and rectal ultrasonography were performed on 100 consecutive asymptomatic men attending our fertility laboratory, without the physician having any prior knowledge of their sperm quality. Results-In general, the presence of the following could be statistically related to sperm pathology: (a) a tender prostate gland upon palpation, (b) ultrasonographic evidence of chronic vesiculitis, (c) unilateral or bilateral testicular atrophy, and (d) the presence of a varicocele. Seminal leukocytosis, a tender epididymis, and the presence of prostatic calculi had less or no predictive value for poor sperm quality. Conclusion-In a large number of cases, sperm pathology may reflect asymptomatic infections in the reproductive tract, and rectal ultrasonography is a valuable aid in demonstrating inflammation in the deep pelvic organs.
Objective-To determine whether women with endometriosis are more likely than controls to have systemic lupus erythematosus (SLE), or other autoimmune disorders. Design-One-time observational study on a presenting group. Patients-All women undergoing hysterectomy at Sinai Hospital of Baltimore between July 1988 and December 1989 for endometriosis (cases, N = 22) or uterine fibroids (controls, N = 185). Methods-Fisher's exact test was used to compare the proportion of patients in each group with a history of SLE, autoimmune disorder, or past glucocorticoid treatment. Results-Cases were significantly more likely than controls to have a history of SLE-2/22 vs. 0/85, P < .01. Conclusions-This is the first study to demonstrate that women with endometriosis are more likely to have a history of SLE than a similar group of women unaffected by endometriosis.
Objective-To study sperm chromosomes from subfertile men and to determine whether these gametes carry a higher genetic risk in addition to an impaired sperm quality when compared to fertile men. Setting-University clinic. Subjects and Methods-We selected the male partners (group S) of 15 couples suffering from fertility problems for at least 2 years. A male factor was suggested to be the primary etiology in all cases. The age of these patients ranged from 28 to 41 years with a mean of 34.2 years. Visualization of sperm chromosomes was attempted by fusion of spermatozoa with zona-free golden hamster eggs. Results-Sperm metaphases could not be analyzed for seven patients because of low penetration rates or inadequate development and spreading of chromosomes. The remaining eight patients yielded a total of 146 sperm chromosome sets that were compared with those obtained from an earlier control group (C). Our results indicate no significant difference between the two groups for the total rates of aneuploidy (S: 2.1%, C: 2.0%) and structural anomalies (S: 10.3%, C: 7.0%). Conclusions-Though we found no significant differences between the two groups concerning the incidence of cytogenetic anomalies, the number of karyotypes is still too small to draw any definitie conclusions. It should also be kept in mind that these findings relate only to spermatozoa capable of fusing with zona-free hamster eggs. It cannot be implied that the two groups are identical so far as total sperm populations are concerned.
OBJECTIVE:To examine the effect of mono- and triphasic desogestrel-containing oral contraceptives on cycle control.SETTING:Multicenter, international (U.S. and Canada).PATIENTS AND INTERVENTIONS:About 4,000 women, aged 18-35, healthy, neither pregnant nor lactating, were followed for almost 37,700 cycles of use of a monophasic 150 micrograms desogestrel/30 micrograms ethinyl estradiol OC or Sunday- or day-1 start regimens of a triphasic preparation containing 50/100/150 micrograms desogestrel/35/30/30 micrograms ethinyl estradiol administered on a 7/7/7 schedule. Standard diary methods were used to collect data on breakthrough bleeding, spotting, and absence of withdrawal bleeding.RESULTS:The two formulations demonstrated very low and, in fact, remarkably similar rates of breakthrough bleeding, spotting, and absence of withdrawal bleeding. A statistical analysis of these characteristics of the total study populations, per cycle, revealed no statistically significant differences between the formulations.CONCLUSION:Although the triphasic formulation contains the lowest estrogen dose of any triphasic available, 33% less progestin than the monophasic formulation, it maintains comparable cycle control.
OBJECTIVE:To establish base-line data on cord length among Igbo parturients of Eastern Nigeria, especially relationship between age and parity, gestation length, sex and weight of newborn, placental weight.DESIGN:Retrospective analysis of 1,000 consecutive deliveries.SETTING:Mission hospital.MATERIALS AND METHODS:Placental length of umbilical cord, placental weight, and prenatal data.RESULTS:Cord length varied between 15 cm and 130 cm (mean, 51.5 cm). No relationship found to parity, maternal age, or sex of baby. Increase in cord length with birthweight and gestational age, up to term. Correlation between umbilical length and placental weight, with a variation according to lie of the fetus: longest in cord encirclement and unstable lie, shortest in breech presentation, transverse lie, and twin birth.
This study investigates the psychological concomitants and sequelae of surgical reversal (tubal reanastomosis) or of IVF after tubal ligation. We held semi-structured interviews and used the Giessen test and the Strauss-Appelt body image questionnaire. The sample comprised 25 women; a new partner was the leading reason for reversal in 16 cases ('New Partner'), while in 9 cases experiences of loss (of a child or of ideal values) prevailed ('Loss'). The two groups differed in a number of relevant demographic and psychological data. 'New Partner' patients showed a pattern of factors known to be associated with regret of sterilization. 'Loss' women were less satisfied with reversal than 'New Partner' subjects (P < .01). Satisfaction with reversal was independent of an achieved pregnancy. Patients considered surgical reversal to be preferable to IVF because of the "restoration of the mutilation." In the Giessen test, 'New Partner' women were more depressive (P < .05) and more submissive (P < .05) than 'Loss' subjects. Cluster analysis of the whole sample revealed four well distinguishable profiles. 'Loss' patients experienced less insecurity of their body image than both 'New Partner' women and the general female population. We conclude that reversal of sterilization helps to restore body-image and self-esteem, but it may counteract mourning. Consequences for pre-reversal counseling are discussed.
While homologous artificial insemination (AIH) and gamete intrafallopian transfer (GIFT) can be viewed as compatible with the teachings of Roman Catholicism and Halakhic Judaism, their permissibility is much more strongly rooted in the latter. Nevertheless, AIH and GIFT cannot be dismissed as unacceptable to Roman Catholics, provided the semen is licitly obtained.
Between December 1988 and September 1990, 132 patients were treated with 432 cycles of superovulation with hMG and timed IUI for various infertility subgroups in a private office setting. All patients had a complete infertility evaluation, including semen analysis, postcoital testing, hysterosalpingogram, endometrial biopsy and laparoscopy, and immunological testing in most cases. Abnormal factors were treated by conventional surgical and/or medical means. Most patients had at least a 6-month trial at achieving normal conception prior to hMG-IUI therapy. Patients received up to six cycles of treatment. Forty-five patients (34%) are still under treatment; thus far, the overall pregnancy rate is 58 of 132 or 44%. Of the 58 pregnancies, there were 13 abortions (22.5%) and two ectopic pregnancies (3.5%). The pregnancy rate per cycles has been 58/432, or 13.5%. The on-going pregnancy rate is 43/132, or 32.6%, or 32/432 (10%) per cycle. Treatment with hMG-IUI seems to approach that for IVF for most conventionally treated infertility subgroups. It can be done at a much lower cost per cycle, thus allowing a greater number of couples the availability of treatment. The authors suggest that most infertility patients be offered hMG-IUI therapy prior to IVF referral.
Abnormal uterine bleeding is probably one of the most common gynecologic complaints in the perimenopause. It is a significant cause of hysterectomy, which is the second most common surgical procedure performed on women in the United States, and thus is a major health issue. Management consists of a stepwise evaluation of all possible organic causes of uterine bleeding. Advancements in technology have allowed considerable improvements in the resolution of many diagnostic tools. Direct visualization of the uterine cavity is now an invaluable adjunct to blind endometrial sampling. Consequently, therapy can be tailored more appropriately and efficiently, either by newly developed medical strategies or through selective, minimally invasive surgery. In light of these perspectives, some of the recent diagnostic and therapeutic trends in the management of abnormal uterine bleeding in perimenopausal women are presented.
