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.

Accommodative esotropia in adults.

The accommodative convergence/accommodation (AC/A) ratio is thought to be fixed throughout life. We present 11 patients who, in adulthood, show a situational increase in their AC/A ratio. Since all patients had a history of accommodative esotropia with and without a nonaccommodative component, we feel the situational increase in the AC/A ratio is in response to the additional effort needed to correct the patients' facultative hyperopia. These patients demonstrate the importance that all adults with acute onset of commitant esotropia and a history of accommodative esotropia should wear full correction before a prism is incorporated into their glasses or surgical intervention is considered.

Sex preselection in New York City: who chooses which sex and why.

With its increasing success, sex preselection has become a matter of general concern, and interest in it is growing. Three aspects of sex preselection in New York City were considered. Who is choosing the sex? Which sex is being chosen? Why have the choices been made? In this investigation, 178 couples were studied and all 57 non-American couples chose boys; however, 120 American couples chose boys and girls with equal frequency depending upon the gender of the children at home. Non-American couples chose boys for economic and business reasons (40%), cultural reasons (30%), and personal reasons (30%). Sex preselection is valuable in preventing sex-linked genetic disorders. Many are fearful of a sudden change in sex ratios should sex preselection be successfully and inexpensively carried out.

Unusual ocular findings in identical twins.

We report an unusual case of dissimilar strabismus in monozygotic twins and describe the anatomical features which caused it.

Tamoxifen in clomiphene-resistant hypothalamic anovulation.

Seventeen patients with clomiphene-resistant hypothalamic anovulation were given tamoxifen 10 mg per day from cycle day 5 to 9 during two consecutive menstrual cycles. Not included were patients with hyperprolactinemia and PCOD. Treatment was monitored using measurement of follicle size by ultrasound and assessment of serum estradiol. Failure to ovulate persisted in 15 patients. Of the two patients who ovulated, one received hCG on day 16, and became pregnant. We were unable to demonstrate that clomiphene-resistant patients were likely to ovulate with tamoxifen. Forty-five patients with hypothalamic anovulation not previously treated were then given tamoxifen in the same dosage. This part of the study indicated that tamoxifen was successful in inducing ovulation in 84% of the cycles. There was marked improvement in cervical mucus in tamoxifen cycles as compared with clomiphene cycles. Tamoxifen was effective, and had some advantages compared with clomiphene in patients responding to both drugs. This preliminary study suggests that tamoxifen may be a useful addition to the treatment of ovulatory failure.

Iridoschisis and the corneal endothelium.

Iridoschisis has been known as a rare entity for the past 60 years, since its first description by Schmitt. It has been reported most frequently in eyes with a history of trauma or one of the glaucomas. While freely floating fibers of disrupted iris mesenchyma may be seen to brush against the corneal endothelium in many patients, there has never been a report of corneal compromise secondary to iridoschisis. A patient with bilateral glaucoma is described. Iridoschisis was present in one eye, and specular microscopy revealed a marked decrease in cell density (600 cells per square millimeter) directly over the split iris fibers. A high degree of polymegethism was also present over the involved sector of iris. Cell counts and morphological findings elsewhere in the cornea were normal for the patient's age. Iridoschisis may be a hitherto unrecognized cause of endothelial decompensation. In selected cases, prophylactic surgical iridectomy should be considered in order to remove the disrupted iris fibers that may play a role in corneal changes.

Paradoxical inferior oblique muscle overaction with A-pattern esotropia.

The presence of overacting inferior oblique muscles in A-pattern esotropia is a rarely documented finding. During the last three decades, three basic schools of thought have evolved to explain A and V patterns. In certain cases an individualized approach synthesizing these three theories is needed. We saw two patients with paradoxical A-pattern esotropia with inferior oblique muscle overaction. Both cases were treated surgically by weakening both inferior oblique muscles with recession and supraplacement of both medial rectus muscles. The synthesis of these two approaches resulted in good postoperative alignment.

The preoperative diagnosis of adenomyosis.

The charts of 46 patients between the ages 30-50 years having a hysterectomy for a fibroid uterus were reviewed. The diagnosis of adenomyosis was correctly made preoperatively in four patients. The diagnosis was not made preoperatively in 13 patients in whom adenomyosis was demonstrated on pathologic examination of the surgical specimen. The preoperative diagnosis of adenomyosis is difficult. Pain and abnormal bleeding are frequent symptoms. There is uterine enlargement which is demonstrated on pelvic ultrasound. Occasional characteristic findings may be noted on hysterogram. Adenomyosis and fibroids often coexist. The treatment of choice is hysterectomy.

Habitual abortion. Two factors of increasing frequency.

This paper deals with two major uterine factors in infertility and habitual abortion that are now occurring with increasing frequency. They are Asherman's syndrome and the syndrome of the incompetent internal cervical os. By focusing on the uterus whenever a history is suggestive, it is possible to arrive swiftly at a diagnosis. A fresh approach to the problem of investigating these patients is suggested. Tests can be based on clues provided by the patient. Methods of diagnosis and treatment are discussed. If patients are evaluated with an etiology in mind, a comprehensive study and management can be planned that will save time and expense.

A new study of intrauterine synechiae.

This study is based on a series of 37 hysteroscopies performed in the knee-chest on patients undergoing culdoscopy as part of an infertility work-up. Local anesthesia was used for the two procedures. All the patients had a thorough infertility work-up that was completely negative. Ruled-out by hysterogram prior to the procedure were congenital abnormalities of the uterus, endometrial polyps, and submucous myomas. There were several different types of endometrial scars in nine patients and this was the only intrauterine pathology discovered. They were intrauterine synechiae typical of the Asherman's syndrome in four cases, cesarean section scars in two, adhesions due to an infected IUD in two, and in one patient there were vertical linear scars secondary to an endometrial biopsy. In this study, the hysterogram was particularly accurate in predicting major endometrial abnormalities, but specific evidence as to the type of minor intrauterine pathology had to be obtained with a hysteroscope. The firmer adhesions that were not of the Asherman's type were difficult to remove and could not be broken up with a hysteroscope. The types of scar visualized are described in some detail. Intrauterine synechiae probably derive ultimately from any type of trauma to a decidual or predecidual endometrium and need not be pregnancy related.