Outcome comparison of in vitro fertilization treatment with highly purified subcutaneous follicle-stimulating hormone (Fertinex, a urofollitropin) versus intramuscular menotropins.

OBJECTIVE: The aim of this study was to investigate various outcome measures of stimulation with highly purified subcutaneous follicle-stimulating hormone (Fertinex, a urofollitropin) compared with first- and second-generation urinary human menopausal gonadotropin standards (Pergonal, Metrodin). STUDY DESIGN: Retrospective analysis was restricted to our most efficient in vitro fertilization age group (23-34 years). Data from Institute for Assisted Reproduction in vitro fertilization cycles 1 through 11 with Pergonal, Metrodin, or both were tabulated for hormonal values, oocyte quality, and embryo outcome as baseline data. Patients in cycles 12 through 13 were treated with Fertinex and Pergonal or Fertinex alone and then reviewed for the same parameters. RESULTS: Two hundred thirty-eight in vitro fertilization records with embryo transfer were analyzed. Clinical pregnancy rates per embryo transfer in an optimal age group were similar despite use of first- through third-generation urinary gonadotropin preparations: Pergonal and Metrodin, 67%; Metrodin, 64%; Fertinex and Pergonal, 62%; and Fertinex, 54%. There were no discernible differences in hormonal response, oocyte recovery, or embryonic growth. CONCLUSION: Administered subcutaneously, the third-generation urinary gonadotropin preparation Fertinex is effective in in vitro fertilization treatment in young women.

Miconazole-induced fatal dysrhythmia.

Miconazole is an imidazole antifungal agent that is available in topical, vaginal, and parenteral formulations. Indications for the parenteral product have become rare with the development of newer, more effective agents. A 54-year-old man who had undergone orthotopic heart transplantation developed a widespread subcutaneous Scopulariopsis infection that progressed despite treatment with amphotericin B and itraconazole. Intravenous miconazole was added to his regimen. During the infusion he developed a bradyarrhythmia that resolved after miconazole was discontinued. On rechallenge with a lower dosage, bradyarrhythmia recurred and progressed to ventricular fibrillation. The patient died despite full resuscitation efforts. Only a few case reports exist of miconazole-induced cardiac arrhythmias, and these events were attributed to rapid intravenous administration, insufficient dilution, and the drug's vehicle. We believe that intravenous miconazole should be given with caution to patients with underlying heart disease.

Laparoscopic removal of pelvic splenosis. A case report.

Splenosis is the autotransposition of splenic tissue and is rarely encountered by the gynecologist. Most patients with splenosis are asymptomatic but may present with gynecologic symptoms. There are few reports in the gynecologic literature describing the management of pelvic splenosis. This paper reports the first case of laparoscopic management of pelvic splenosis.

Verapamil overdose: case report and review of the literature.

OBJECTIVE: To report the presentation and controversies regarding therapy of an 18-year-old man following a life-threatening ingestion of verapamil. CASE SUMMARY: An 18-year-old man ingested large quantities of dipyridamole, trimethoprim/sulfamethoxazole, amoxicillin, and verapamil. He presented to an outlying hospital and was initially conscious. Soon thereafter, the patient had a seizure; he required intubation, developed cardiac conduction abnormalities, and became hypotensive. The patient required pharmacologic pressors and a pacemaker for transfer to our institution. At our institution, vigorous fluid resuscitation, cardiac pacing, and careful attention to acid/base and electrolyte management provided the basis of therapy. The patient recovered without deficit and was discharged from the intensive care unit five days later. DISCUSSION: Current controversies regarding the management of verapamil overdose are reviewed. Removal of the drug by gastric lavage is a mainstay of therapy. Administration of syrup of ipecac is contraindicated. Although specific recommendations for calcium dosing in the overdose situation have not been rigorously studied, maintenance of a normal serum ionized calcium concentration is suggested. An exogenous catecholamine, rather than dopamine, may be the drug of choice for treating hypotension. Cardiopulmonary bypass provides a method for drug removal in cases of severe toxicity; however, this invasive method requires further study. Management of fluid/electrolyte, acid/base, and ventilation abnormalities is required to treat large ingestions of verapamil. Treatment guidelines for critical care clinicians are provided.

A tax strategy for healthcare workers. Section 403(b) plans are an alternative to weakened IRAs.

After the Tax Reform Act of 1986 reduced the tax-deduction benefits of investing in IRAs, many healthcare employees went looking for alternative tax-shelter investments. Several options are available. One alternative for taxpayers employed by tax-exempt organizations is Section 403(b) tax-deferred annuities (TDAs). Although the Tax Reform Act left Section 403(b) TDAs largely intact, it established a comprehensive set of nondiscrimination rules for certain statutory fringe-benefit plans--including Section 403(b) plans. The new rules are designed to restrict situations that favor participation by highly paid employees to the exclusion of other employees. Perhaps one of the harshest adjustments the 1986 law mandated is the imposition of an additional 10 percent income tax on withdrawals an investor makes from Section 403(b) plans before reaching the age of 59 years and 6 months. This excise tax had already applied to early withdrawals from an IRA, but the new law extends the penalty tax to cover all qualified plans, including TDAs.

Ovum donation by sisters in ovarian failure: simplified priming and early withdrawal of exogenous support.

Two cases of successful pregnancy and delivery by patients with ovarian failure are reported. In both cases ova were donated by the sister of the patient. A high degree of success (two pregnancies in three attempts) is discussed, as is the significance of simplified pretransfer "priming" and very early withdrawal of exogenous hormonal support.

Ovarian sex cord tumor with annular tubules: steroid profile.

The pre- and postoperative endocrine profile in a patient with an ovarian sex cord tumor with annular tubules resembles a granulosa cell tumor despite morphologic features of a Sertoli-Leydig cell tumor. Gonadotropin and prolactin levels were compatible with estrogen-progesterone synergy on hypothalamic pituitary function.

Peritoneal fluid evaluation in infertility.

Cul-de-sac fluid collected at laparoscopy from 58 women during various stages of the menstrual cycle was evaluated by volume and by estradiol and progesterone content. Volumes were consistently higher in the third cycle week, especially with evidence of a fresh corpus hemorrhagicum. Peritoneal hormonal values were equal to serum values before ovulation, but were significantly elevated after ovulation. In the present study, maximal fluid volume was 78 ml, maximal peritoneal estradiol exceeded 3000 pg/ml, and maximal peritoneal progesterone exceeded 265 ng/ml. Luteal phase peritoneal fluid volumes and hormonal values were not significantly different in women with or without endometriosis. Aspiration of peritoneal fluid at laparoscopy in the infertile woman may provide significant information regarding ovulation.