Maternal arrhythmias of normal labor and delivery.

Labor and delivery are associated with significant hemodynamic changes, as well as pain and anxiety, all of which could be fertile ground for arrhythmias. In order to establish whether cardiac arrhythmias occur more frequently during labor and delivery in healthy parturients and whether it clinically affects the mother or the newborn, 100 pregnant women admitted for delivery had Holter monitoring before, during, and up to 1 h postpartum. Our results show that, excluding sinus rhythm variations, only a slight majority of the study subjects had arrhythmia at all, while only 2% had more complex arrhythmias, none of which required any therapeutic intervention. We conclude that cardiac arrhythmias occurring during labor, delivery, and postpartum in the healthy parturient are no more frequent than in the general female population of the same age and are without clinical consequences for the mother and the newborn.

A controlled study for gender selection using swim-up separation.

OBJECTIVE: To evaluate the success for gender selection using a sample of semen separated by a modified swim-up technique. DESIGN: We retrospectively compared the gender outcome of two treatments (A and B) for either a male or female offspring with those who conceived spontaneously. SETTING: Private practice of one author (M. A.K.). PATIENTS, PARTICIPANTS: The treatment groups consisted of 52 total pregnancies for couples who conceived by the separation technique. Of these 52 participants, 15 desired a female offspring and were placed into treatment A and 37 desired a male offspring and were placed into treatment B. The control groups consisted of 162 women who were presented with initial consultation for gender selection and conceived spontaneously. Control group A consisted of 80 women who initially chose a female offspring, and control group B consisted of 82 participants who initially chose a male. INTERVENTIONS: In treatment group A, one timed intrauterine insemination (IUI) was carried out with the bottom 0.5 ml of the separated semen on cycle days 12-14, when the follicle was 18-22 mm. Patients in this group were also administered clomiphene citrate and human chorionic gonadotropin. In treatment group B, one timed IUI was done with the top 0.5 ml of the separated semen, when the follicle was 18-22 mm. MAIN OUTCOME MEASURE: The gender outcome of the pregnancies of two treatment and control groups was evaluated based on the known desired gender. RESULTS: The success rate for conceiving a female child after intervention (treatment group A) was 86.7% effective (p = 0.002) as compared to the control group A. Couples seeking a male child (treatment group B) were 89.2% effective (p = 0.0002) as compared to the control group B. CONCLUSIONS: This study reveals that the modified swim-up method with additional monitoring results in statistically significant gender preselection.

New developments in topical estrogen therapy.

OBJECTIVE: To review new developments in transdermal E2 therapy in postmenopausal women. DESIGN: A bibliographic search (Medline) of the medical literature from 1966 through 1995 was used to identify new studies evaluating transdermal E2. PATIENT(S): Menopausal and postmenopausal women. RESULT(S): Like oral estrogen, transdermal E2 relieves menopausal symptoms, reverses urogenital atrophy, and conserves bone economy. Initial studies have demonstrated beneficial effects of transdermal E2 on cardiovascular function. Quality of life, patient satisfaction, and compliance also improve with transdermal E2. Advances in transdermal delivery continue to emerge, including low-dose systems and patches that maintain serum E2 levels for a full 7-day period. CONCLUSION(S): New developments in transdermal administration have the potential to increase the number of postmenopausal women who accept and are compliant with long-term estrogen replacement therapy.

Estrogens and Parkinson's disease.

There is substantial evidence that estrogens modulate the activity of dopamine in the extrapyramidal system. However, there is conflicting data as to the exact mechanism of estrogen's effects. The majority of clinical reports support an antidopaminergic effect of estrogens on Parkinsonian symptoms. Generally, Parkinsonism worsens with estrogen therapy. We report a case of improvement in Parkinsonian symptoms in a premenopausal patient when placed on leuprolide acetate. The pharmacologic menopause induced by leuprolide acetate leads to a hypoestrogenic state. We hypothesize that the decrease in estrogen improves Parkinson's disease symptoms via the relief of its antidopaminergic effects on the nigrostriatal pathway.

Assisted reproduction in contemporary Jewish law and ethics.

This article recapitulates and extends a discussion of the position of halakhic Judaism (traditional Jewish law and ethics) on various issues that relate to assisted reproduction, including genetic and legal relationships, disposal of untransplanted embryos, embryo tissue research, multifetal pregnancy reduction, preimplantation genetic screening and sex selection and donor gametes.

Current concepts in estrogen replacement therapy in the menopause.

OBJECTIVE: To provide a review of the risks and benefits of hormonal replacement therapy in the menopause, including new therapeutic regimens and modes of delivery. DESIGN: A review of the literature to identify published studies was accomplished using a computerized bibliographical search (Medline). RESULTS: Replacement therapy is effective in treating symptoms of estrogen deficiency and in lowering the risk of osteoporosis and cardiovascular disease. The daily administration of an estrogen and progestin eliminates the withdrawal bleed and increases patient compliance. This continuous form of therapy also consistently suppresses the endometrium, decreasing the risk of hyperplasia. More studies investigating the effect of continuous therapy on the lipid profile and cardiovascular disease are needed. CONCLUSIONS: New therapeutic regimens and modes of delivery decrease risk and increase patient acceptance of hormonal replacement therapy.

Incidence of severe ovarian hyperstimulation syndrome with extremely elevated serum estrogen levels.

The incidence of ovarian hyperstimulation syndrome (OHSS) is directly correlated with the pre-human chorionic gonadotropin blood estrogen (E) levels. The higher the E content, the greater the chances of OHSS. However, even when the E levels are very high, only 2.96% of the patients developed severe OHSS. Younger women with primary ovarian dysfunction are more at risk than older women. Human chorionic gonadotropin should be withheld when the estradiol levels are over 4,000 pg/ml; however, the patients should be individualized, since some patients--particularly older women--may require higher blood estradiol levels for successful ovulation induction.

Nonclassical 3 beta-hydroxysteroid dehydrogenase deficiency: a review of our experience with 25 female patients.

OBJECTIVE: To report 15 new menarcheal women affected with nonclassical 3 beta-hydroxysteroid dehydrogenase deficiency (nonclassical 3 beta-HSD) and evaluation of glucocorticoid therapy in treated patients. DESIGN: Diagnosis of these new patients using a standard adrenocorticotropin test. Effects of glucocorticoid therapy on clinical hormonal and sonographic features of each patient are appreciated for periods varying between 4 months and 7 1/2 years. SETTING: All at The New York Hospital-Cornell Medical Center. The Pediatric Endocrinology Ambulatory Service; the Children's Clinical Research Center Core Laboratories; and the Department of Radiology. PATIENTS, PARTICIPANTS: Fifteen menarcheal women (14 to 30 years of age) newly diagnosed and 10 women previously diagnosed were evaluated for symptoms of hyperandrogenism and/or irregular menses. MAIN OUTCOME MEASURE(S): Positive effect of glucocorticoid therapy on signs and symptoms, hormonal levels, and ovarian imaging. RESULTS: Polycystic ovarian syndrome is noted in approximately half the cases. Glucocorticoid treatment greater than 3 months duration results in a reversal of symptoms in most cases.

Cytogenetics of müllerian agenesis. A case report.

A 38-year-old woman presented with primary infertility and primary amenorrhea. The evaluation revealed müllerian agenesis and mosaicism, 45,X/46,XX/47,XXX.

A controlled study for gender selection.

OBJECTIVE: To evaluate the success for gender selection of insemination with a sample of semen separated by a serum albumin density separation gradient. DESIGN: We retrospectively compared the gender outcome of conceptions of couples who conceived spontaneously with those who conceived secondary to an insemination with separated semen. SETTING: Private practice of one author (M.A.K.). PATIENTS, PARTICIPANTS: The study group consisted of 48 pregnancies of couples who conceived by the separation technique. The control group consisted of 46 pregnancies of couples who initially presented for consultation for gender selection but conceived spontaneously. INTERVENTIONS: In the study group, one timed intrauterine insemination with separated semen was performed per cycle, with a mean of 2.3 cycles per couple. Patients desiring a female were also treated with clomiphene citrate and human chorionic gonadotropin. MAIN OUTCOME MEASURE: The gender outcome of the pregnancies of the two groups was evaluated based on the known desired gender. RESULTS: The success rate for conceiving a desired male was 56.5% in the study group and 60.9% in the control group (P = 1.000). Of couples seeking females, 78.6% of the procedure group versus 35.3% of the control group were successful (P = 0.019). CONCLUSIONS: This study debates the albumin gradient as definitively enriching the proportion of Y-bearing sperm after in vitro separation.

Incompetent cervix: pathogenesis, diagnosis and treatment.

The incompetent cervix is a diagnostic dilemma. There are no well-defined or strict criteria to diagnose cervical incompetence, and therefore the indications for treatment are not always clear. Forty years ago, when the basic methods of treatment were first described, the diagnosis seemed relatively simple and the treatment acceptable. There have been very few large, prospective, randomized, well-controlled studies to determine the efficacy of the various surgical methods. Liberal use of cerclage procedures in situations of moderate risk for premature delivery or as prophylactic measures in multiple pregnancy does not appear to improve outcome as judged by prematurity or fetal survival. At the present, fetal survival cannot be a measure of the success of a surgical procedure because so many other factors play a role in outcome, such as the quality of obstetrical and neonatal care. Therefore, outcome of surgical procedures should be judged by more objective criteria, such as prolongation of pregnancy (in weeks) and birth weight. The methods that would allow making an unequivocal and objective diagnosis of incompetent cervix are not yet available. Until we reach this goal, the subject of cervical incompetence and effectiveness of its treatment will remain challenging and elusive.

Alternate regimens for ovulation induction in polycystic ovarian disease.

The patient with PCOD remains a challenge to the reproductive endocrinologist. Although successful induction of ovulation can often be achieved using standard therapeutic regimens of CC or hMG, too often this group of anovulatory patients fails to respond as expected. Over the past 10 to 15 years, alternate approaches to ovulation induction have been investigated with encouraging results. Whereas no one method is productive in all patients, these varied regimens offer us a number of options in dealing with this difficult clinical problem.

Mood disorders, psychiatric symptoms, and distress in women presenting for infertility evaluation.

Women who undergo treatment for infertility frequently report depression, but it is crucial to distinguish between subjective distress, symptoms, and clinical depressive disorders. In the initial assessment of a prospective, longitudinal study, 59 women presenting for infertility treatment were compared with 35 women presenting for routine gynecological care. Infertility patients and controls were not significantly different on self-report measures of partner satisfaction, sexual functioning, or self-esteem. There was also no difference in psychiatric symptomatology, or in the percentage of subjects who were currently experiencing or had ever experienced a major depressive episode. However, the infertility patients perceived themselves to have been already quite affected by their inability to conceive. For instance, 49.2% reported changes in their sexual functioning and 74.6% reported changes in their mood.

Cervical incompetence.

In the early 1950s, when treatment of cervical incompetence was first described, diagnosis seemed relatively simple and management favorable, but after more than 35 years of trying multiple variations of procedures and treatment regimens, no advances have been made. In 1959, Neser questioned the very existence of cervical incompetence as an entity, and concluded that, in the final analysis, the problem is a diagnostic one. Liberal use of cerclage in situations of moderate risk of preterm delivery or as a prophylactic measure for multiple gestation does not appear to improve outcome, as judged by prematurity or survival. Because of advances in neonatal care in the last decade, fetal survival has improved tremendously. It is hoped that, in the future, more objective and accurate criteria for the diagnosis of cervical incompetence will emerge, and that outcome of treatment will be measured not by fetal survival, but by prolongation of pregnancy and by birth weight. At present, making an unequivocal diagnosis of cervical incompetence remains an elusive, challenging, and unsolved problem.

Sustained effects of opioid antagonism during the normal human luteal phase.

The luteal phase of the menstrual cycle is characterized by a progressive decrease in LH pulse frequency. Short term administration of opiate receptor antagonists during the luteal phase increases the release of both LH and PRL. However, the effects of prolonged opioid antagonism throughout the luteal phase are unknown and, hence, the precise role of endogenous opioid peptides in the reproductive cycle remains to be elucidated. In this study, we examine the ability of longer term opioid antagonism during the luteal phase to alter pulsatile LH and PRL release. Naltrexone (NTX), a long-acting oral opioid antagonist, at a dose of 50 mg, was administered daily for 7 days during the luteal phase in five women. Blood samples were obtained at intervals of 10 min starting at 0800 h for 11-12 h on matched days of the luteal phase of both a control and the experimental cycle. LH and PRL pulse frequencies were significantly increased at the end of the 7-day NTX administration period compared to those in the control cycle [LH, 0.22 +/- 0.04 (+/- SE) vs. 0.07 +/- 0.03 pulse/h (P less than 0.01); PRL, 0.20 +/- 0.02 vs. 0.13 +/- 0.02 pulse/h (P less than 0.05)]. The concordance between LH and PRL pulses increased from 50% in the control cycle to 70% in the NTX cycle, and there was a significant positive correlation between the amplitudes of the concomitant LH and PRL pulses (r = 0.72; P = 0.01). In conclusion, prolonged oral opioid antagonism increased pulsatile LH and PRL secretion during the luteal phase in normal women. The results underscore the important role of endogenous opioid peptides in controlling LH pulse frequency during the luteal phase of the cycle.

Induction of ovulation--past, present and future.

Attempts to induce ovulation have been made since the early 1920s, but the major breakthrough came in the early 1960s with the introduction of clomiphene citrate and the gonadotropins. Additional progress was made in the early 1970s with the introduction of bromocriptine and in the early 1980s with the introduction of pulsatile GnRH. At the present, 'pure' FSH and GnRH agonists are being evaluated as adjuncts to HMG for induction of ovulation. As more insight is gained in the neuroendocrine control of the ovulating cycle, we may soon be able to induce ovulation by direct manipulation of the central nervous system.

Polycystic ovarian disease.

Polycystic ovarian disease has a variety of biochemical and clinical features with great individual variation. In our clinical experience, oligo-ovulation, manifested as oligomenorrhea or frank amenorrhea, associated with an acyclic estrogen milieu, is a consistent finding. This may be associated with hyperandrogenemia, hirsutism, inappropriate gonadotropin levels, hyperprolactinemia, obesity, insulin resistance, and ultrasound evidence of multicystic enlarged ovaries. A common presentation is infertility or irregular menstruation secondary to oligo-ovulation and hirsutism secondary to altered androgen metabolism. A challenge in diagnosis is to differentiate polycystic ovarian disease from latent cases of congenital adrenal hyperplasia. Although the precise mechanism in the pathogenesis of polycystic ovarian disease remains undefined, altered function of the hypothalamic-pituitary-ovarian and adrenal axes is both involved and integrated. Results from clinical trials of ovulation induction using different agents have implicated one site or another as the major progenitor of the "vicious cycle" but with no definitive pathway established. Restoring fertility to these patients can be challenging in that not all patients with polycystic ovarian disease respond to clomiphene or do so satisfactorily. The use of glucocorticoid suppression, pituitary suppression with GnRH analogues, or the use of FSH alone may be of benefit in clomiphene treatment failures.