Further recovery in a potential treatment withdrawal case 10 years after brain injury.

A young woman was rendered tetraplegic and anarthric as a result of a traumatic brain injury in 1993. Two years later, she was considered to be in a minimally conscious state and became the subject of legal debate in the UK with regard to withdrawal of artificial feeding and hydration. Before injury, she made a verbal advanced directive that she would not wish to continue living if ever becoming severely disabled. Neuropsychological assessment found statistically significant evidence for sentience and expression of a wish to live and the application to Court was withdrawn. Further meaningful recovery occurred between 7-10 years after injury. She now lives in the community with 24 hour care. She speaks, initiates conversation and actions, expresses clear and consistent preferences and has a spontaneous sense of humour. She uses an electric wheelchair, eats solid food and drinks through a straw. Her mood is variable and sometimes low. This case demonstrates the need for careful consideration of advanced directives and for specialist neuropsychological assessment in people with severe cognitive and communication difficulties. It supports the view that routine assessment and follow-up of people thought to be in minimally conscious states is important. In addition, it shows that recovery with reduction in disability and significant implications for quality of life can continue for at least 10 years after extremely severe traumatic brain injury.

Neuropsychological assessment of a potential "euthanasia" case: a 5 year follow up.

McMillan reported a neuropsychological assessment procedure which was used to determine whether or not there was evidence for sentience in a young woman who had been rendered tetraplegic and anarthric as a result of a road traffic accident. An application to court had been made to withdraw feeding and this was supported by medical evidence which gave the view that the individual was functioning little beyond vegetative state, had a poor quality of life and had little prospect of further recovery. Evidence for an ability to communicate reliably was found including for a wish to continue living, and as a consequence the application to court was withdrawn. This paper describes further recovery 2-4 years after the original assessment (i.e. 4-6 years post-injury). At follow-up, she remained dependent for all care, but was now feeding orally and was talking. She could learn new information, some of which she retained for at least 12 months and had greater insight into her condition. She now reported low mood and some pain. As before, she consistently reported a wish to live. The implications of the follow-up are discussed in the context of assumptions made about quality of life and decision making about euthanasia in brain injured people who are severely disabled, but are not in a vegetative state.

The in vitro profile of selected 14-membered azalides.

The in vitro antimicrobial potency of 10-aza-9-deoxo-11-deoxyerythromycin A, the first member of a new class of macrolide antibiotic, was determined. Several other members of this family of azalide were prepared and similarly screened in order to begin to define the antibiotic potential of the class. The results indicate that the SAR for this structural type parallels that of other macrolides and that it offers no apparent benefit over known 15-membered azalides.

Cervical pregnancy. A case report.

A cervical pregnancy was treated successfully with systemic methotrexate and folic acid. Serial beta-human chorionic gonadotropin levels, color Doppler velocimetry and hysteroscopy were used to monitor therapy. In view of the substantial morbidity associated with this form of ectopic pregnancy, medical management is an option for treatment.

Selective fallopian tube canalization.

Infertility is an increasingly common problem. Occlusion of the fallopian tubes is one of the principal causes, and until recently surgery was the only available treatment. The success rate of surgery is often low, particularly with occlusion of the proximal tube. Selective fallopian tube canalization under fluoroscopic guidance has been successful in alleviating proximal tubal obstruction. This procedure may be performed in the outpatient setting and is a safe, cost-effective alternative to surgery.

Transvaginal sonography of the endometrium during induced cycles.

The thickness and texture of the endometrium as depicted by transvaginal sonography were assessed in 23 patients who underwent a similar ovulation induction protocol including a gonadotropin-releasing hormone analogue (Lupron) and human menopausal gonadotropin (Pergonal). In the 9 patients who conceived, a multilayered endometrium was more frequently present than in the 14 who did not, even though the number of mature follicles, oocytes retrieved and transferred, and estradiol values were similar.

The use of gonadotropin releasing hormone agonist (GnRHa) in good responders undergoing repeat in vitro fertilization/embryo transfer (IVF/ET).

The use of gonadotropin releasing hormone agonists (Gn-RHa) has been shown to improve the response in patients classified as "poor responders" undergoing ovarian stimulation for in vitro fertilization/embryo transfer (IVF/ET). This study sought to determine whether GnRHa therapy would benefit patients undergoing IVF/ET who had been classified as "good responders" in prior attempts. Twenty-three patients who had completed a prior IVF/ET attempt but who failed to conceive underwent ovarian stimulation using a combination of GnRHa and human menopausal gonadotropin (hMG). Each patient's prior stimulation served as her control and consisted of clomiphene citrate (CC)/hMG in 18 patients and follicle stimulating hormone (FSH) and/or hMG in 5 patients. The numbers of oocytes retrieved, oocytes fertilized, embryos cleaved, and embryos transferred were all significantly greater in cycles treated with GnRHa/hMG compared to control cycles. The clinical pregnancy rate was 39% and the ongoing pregnancy rate was 26% during the cycle when GnRHa pretreatment was utilized. These data suggest that GnRHa therapy is of benefit even to those patients previously classified as "good responders" undergoing ovarian stimulation for IVF/ET.

Cardiomyopathy in a patient undergoing laparoscopy for oocyte retrieval during in vitro fertilization/embryo transfer. A case report.

Most patients undergoing laparoscopic procedures experience no complications; however, a major complication rate of approximately 0.3% has been documented. Cardiomyopathy is also rare. A patient who underwent laparoscopy for oocyte retrieval during in vitro fertilization/embryo transfer developed congestive heart failure and pulmonary edema. A cardiomyopathy was diagnosed subsequently.

Complications of pregnancy in infertile couples: routine treatment versus assisted reproduction.

Ninety pregnancies conceived by infertile couples using assisted reproductive technologies and 86 pregnancies conceived by infertile couples with routine infertility treatment were analyzed to determine the outcome of and the complications experienced during the pregnancies. Pregnancies ending after 24 weeks' gestation were evaluated for the following complications: pregnancy-induced hypertension, diabetes mellitus, preterm labor, premature rupture of membranes, placenta previa, and fetal growth retardation. A matched control group of normal fertile patients admitted to the obstetric service at Vanderbilt University Medical Center was used to compare the incidence of pregnancy complications among the groups. In the group treated by assisted reproduction, 81 pregnancies were singleton and nine were multiple gestations, whereas in the routine group, 84 were singleton and two were multiple gestations. In the group treated by assisted reproduction, 29 of 90 gestations (32%) ended before 24 weeks, compared with 18 of 86 (21%) in the routine group, a nonsignificant difference. Mean birth weight and gestational age were similar among the three groups for singleton gestations. Among multiple gestations, the mean (+/- standard error of the mean [SEM]) birth weights were 2513 +/- 115, 724 +/- 57, and 2282 +/- 132 g in the group treated by assisted reproduction, the group receiving routine methods, and the control group, respectively (P less than .001 when those treated by routine methods were compared with the other two groups). The mean (+/- SEM) gestational ages were 36 +/- 1.2, 26.5 +/- 2.0, and 35.5 +/- 1.2 weeks, respectively (P less than .01 comparing those treated by routine methods and the other two groups).(ABSTRACT TRUNCATED AT 250 WORDS)

Retained trophoblast after conservative management of ectopic pregnancy. A report of two cases.

With the advent of conservative management of ectopic gestation, several patients have had persistent trophoblastic tissue after their surgical procedure. In the past such patients required repeat laparoscopy or laparotomy and further conservative or radical surgery. However, the use of methotrexate with leukovorum rescue offers a new alternative in the management of patients with persistent trophoblastic tissue after conservative surgery. Two patients with persistent trophoblastic tissue were treated successfully with methotrexate and leukovorum rescue. The use of medical therapy in such patients avoids a second surgical procedure, is associated with few side effects and appears to be an acceptable management alternative.

The use of the intravenous glucose tolerance test to evaluate nonobese hyperandrogenemic women.

To better define the association of hyperandrogenemia and insulin resistance, we evaluated nonobese, nonacanthotic hyperandrogenemic women utilizing intravenous glucose tolerance tests (IVGTT). Six women (group 1) all of whom had elevated serum testosterone (T) and were less than 5% above their ideal body weight for height underwent IVGTTs. A control group (group 2, n = 5) with equivalent weight and height but normal levels of T were similarly tested. The T values (normal 0.1 to 0.6 ng/mL) in group 1 (0.93 +/- 0.05 ng/mL, mean +/- SEM) were significantly different from those in group 2 (0.34 +/- 0.03 ng/mL). Area under the curve (AUC) was calculated for the glucose and insulin values. The glucose AUC for group 1 (15,000 +/- 1,100) was not significantly different from the glucose AUC for group 2 (15,853 +/- 788). Interestingly, the insulin AUC for group 1 (3,829 +/- 583) was not significantly different from the insulin AUC for group 2 (2,987 +/- 456). Within group 1, a correlation between serum T and insulin AUC could not be established. We conclude that in these nonobese, nonacanthotic hyperandrogenemic females, although individual variation exists, collectively a significantly increased insulin response to an IVGTT challenge cannot be demonstrated. This data further challenges the concept of androgens being etiologic in insulin resistance.

Use of hypothalamic releasing factors to examine the effects of increased testosterone on pituitary response in a postmenopausal woman. A case report.

Hyperandrogenic states in women may alter hypothalamic pituitary response. The pituitary function of a 64-year-old postmenopausal woman with a testosterone-secreting (T-secreting) ovarian neoplasm was assessed with a combined infusion of ovine corticotropin releasing hormone, 1 microgram/kg; GnRH, 100 micrograms; human growth hormone releasing hormone, 1 microgram/kg; and TRH, 200 micrograms preoperatively when T and estradiol (E2) were elevated, six weeks postoperatively when T and E2 were low and 16 months postoperatively while the patient was on micronized E2 (low T, high E2). The principal findings were a reduction in luteinizing hormone response by both T and E2, no effect of either T or E2 on follicle stimulating hormone and greater growth hormone and TSH responses in an estrogenic milieu.

Selective fallopian tube cannulation: initial experience in an infertile population.

We have studied a group of 19 patients presenting with proximal tubal occlusion. Seventy-three percent (22/30) of tubes attempted were successfully cannulated. Sixty-two percent (5/8) of tubes remained patent in limited follow-up at 3 to 6 months. We conclude that selective fallopian tube cannulation may provide an alternative to microsurgical tubal anastomosis in selected patients.

Ectopic pregnancy: features at transvaginal sonography.

A retrospective review of the transvaginal sonograms of 50 women with laparoscopically confirmed ectopic pregnancy was performed to determine whether certain sonographic findings can be detected to confirm the diagnosis. Forty-seven of the 50 pregnancies were tubal. A tubal ring (a 1-3-cm mass consisting of a 2-4-mm concentric, echogenic rim of tissue surrounding a hypoechoic center) was seen in 23 of 34 (68%) ectopic pregnancies in which the fallopian tube had not ruptured, and the tubal ring could be distinguished from a corpus luteum cyst in most cases. Transvaginal sonography also depicted simple (n = 22) or particulate (bloody) (n = 13) peritoneal fluid associated with ectopic pregnancy. In each case in the series, at least one abnormal uterine, adnexal, or peritoneal finding was detected at transvaginal sonography. Because of its improved resolution of uterine and adnexal structures, transvaginal sonography is recommended as a means for detailed evaluation of patients suspected of having an ectopic pregnancy.

Use of a sensitive urine pregnancy test before endometrial biopsies taken in the late luteal phase.

Endometrial biopsies for evaluation of the luteal phase should be taken within 2 days of the onset of menses. When these guidelines are followed and patients present at least 12 days after the thermogenic shift on BBT, the ICON pregnancy test is extremely rapid, sensitive, specific, and has predictive values close to 100%. If a biopsy is undertaken before this time there may be an increased risk of false negative results (i.e., a decreased sensitivity). The improved technology in urine pregnancy tests has now made it feasible to obtain accurate urine pregnancy tests before endometrial instrumentation with an increased level of confidence. It is recommended that this technology be used in the management of patients undergoing endometrial biopsies in the late luteal phase.

A laparoscopic method for excision of large retroperitoneal paraovarian cysts.

Large retroperitoneal paraovarian cysts often present in reproductive-age women as an adnexal mass, with the appearance of a simple cyst on ultrasound. This report describes a laparoscopic method for removal of large paraovarian retroperitoneal cysts. Use of this technique permits successful removal of these cysts while avoiding laparotomy.

The influence of oocyte maturity and embryo quality on pregnancy rate in a program for in vitro fertilization-embryo transfer.

An important factor influencing the pregnancy rate after in vitro fertilization-embryo transfer (IVF-ET) appears to be the number of embryos transferred to the uterus. In this study, the influence of oocyte maturity and embryo quality on pregnancy rate was assessed in patients undergoing IVF-ET. Ovarian hyperstimulation was performed by human menopausal gonadotropin (hMG [n = 29]), clomiphene citrate (CC)/hMG (n = 81), and hMG/follicle-stimulating hormone (FSH [n = 13]) protocols. Oocyte maturity was graded on a scale from 1 to 5 based on the morphology of the ooplasm, cumulus mass, corona radiata, and membrana granulosa cells. Embryos were graded according to the symmetry of the blastomeres and the presence or absence of fragmentation. Mature preovulatory oocytes yielded the highest fertilization rates. No differences were found among the protocols in terms of fertilization rate, embryo quality, or pregnancy rate. When all protocols were combined, patients who conceived had a significantly higher number of embryos transferred than those who did not conceive (3.6 +/- 0.1 [mean = SEM] versus 2.7 +/- 0.1). When embryo quality was compared, there was no difference in the number of "B" embryos transferred between patients who conceived and those who did not (1.2 +/- 0.2 versus 1.2 +/- 0.1), but the patients who conceived had significantly more "A" embryos transferred (1.6 +/- 0.3 versus 0.8 +/- 0.1). These data suggest that the treatment protocol did not determine embryo quality. Furthermore, the increase in pregnancy rates seen with an increase in embryos transferred is the result of the transfer of more "A" embryos.

Results of in-vitro fertilization in normal ovulatory women treated with pure follicle stimulating hormone. Analysis of the oestradiol response.

The relationship between various measures of oestradiol (E2) secretion and the total number of oocytes retrieved (OR) and cleaved embryos (CE) was characterized in normal ovulatory women stimulated with pure follicle-stimulating hormone (FSH) in a programme for in-vitro fertilization and embryo transfer (IVF-ET). Patients in this study included women with tubal factor as their only cause for infertility. Cycles were monitored with serum E2 concentration and ultrasonography. Human chorionic gonadotrophin (HCG) was administered when two follicles had a maximum diameter greater than 15 mm. The variables used to characterize the E2 secretory response included: (i) the difference between the highest and lowest E2 concentration during stimulation; (ii) the ratio of terminal to initial E2 concentration; (iii) E2 concentration on the day of HCG administration; and (iv) the slope of the E2 curve. These measures of E2 secretion each correlated with both the number of OR and the number of CE. When all E2 variables were considered simultaneously in a stepwise multivariate regression procedure, variations in the number of OR (r2 = 0.84) or CE (r2 = 0.77) could be explained by variation in the E2 secretory profile. Equations derived from these E2 variables may help to identify and improve problem areas within IVF-ET programmes when actual results differ from expected.