One residency's experience with the electronic residency application service.

For medical students and residency programs alike, the residency application process is time-consuming. This paper examines one program's experience with a computerized system designed by the Association of American Medical Colleges (AAMC) to simplify and standardize the filing and receipt of applications over the Internet. A large-scale pilot test of the Electronic Residency Application Service (ERAS) was implemented in 1995-1996 for applicants to first-year residency positions in OB-GYN. Each student completed the computerized application, which was transmitted, along with other documents, to student-specified programs by the dean's office via the AAMC "electronic post office." ERAS will be extended to family practice residencies in 1997-1998. A major advantage of ERAS to residency programs is that materials were received in a well-organized, complete, and consistent format. Built-in filters allow grouping of applicants according to various criteria. Opening envelopes and filing documents is no longer necessary. Each student completes one application, and faculty write one letter of recommendation per student. Disadvantages of the 1995-1996 system related to the software, which had an inflexible interface and did not allow a spreadsheet view of the database. Personal statements and recommendation letters were often sent as unformatted ASCII text and were difficult to read. Dean's offices reported problems scanning documents such as transcripts and photographs. These problems led to resubmission of materials and receipt of duplicate copies. With the standard application format, ASCII-style personal statements and "generic" recommendation letters caused applicants to lose individuality. Specific recommendations to the AAMC for improving ERAS include providing a spreadsheet view, allowing students and faculty to write personal statements and letters in standard word processing formats, and allowing faculty to send unique letters to specific residency programs.

Identification and treatment of leukocytospermia in couples with unexplained infertility.

OBJECTIVE: To evaluate whether identifying men with leukocytospermia in couples with unexplained infertility and treating them with antibiotics improves pregnancy rates. STUDY DESIGN: A prospective, cohort study of men with and without leukocytospermia was identified on a smear of semen using Bryan-Leishman stain. Cumulative six-month pregnancy rates were determined for members of the leukocytospermic group who responded to treatment with resolution of their leukocytospermia on a semen smear, those who failed to respond to treatment, those not treated and those without leukocytospermia. RESULTS: Thirty-six of 53 men with leukocytospermia responded to antibiotic treatment, and 19 women in these 36 couples (53%) became pregnant within the six-month follow-up period. Only 7 of 17 (6%) of those who failed to respond to treatment had their partner become pregnant (P < .001). Partners of men with leukocytospermia and no treatment had a 6% pregnancy rate, and the women in 13% (5/42) of couples without leukocytospermia became pregnant (P < .001). CONCLUSION: Leukocytospermia exists in a significant number of males with unexplained infertility and normal semen analyses. Identifying and successfully treating such men results in a significant improvement in pregnancy rates. These men may be a subgroup with male infertility that can be identified and treated.

A comparison of the fallopian tube's response to overt and silent salpingitis.

We examined two groups of infertile women who underwent microsurgical repair of their fallopian tube(s) for distal tubal obstruction, one with a history of salpingitis (overt pelvic inflammatory disease) (N = 34) and one without (silent pelvic inflammatory disease) (N = 25). Nine women with normal tubes undergoing hysterectomy and salpingectomy served as controls. Tubal biopsy specimens were studied by light, scanning, and transmission electron microscopy to assess tubal damage. Morphologic damage was scored 0-9, with 0 representing normal tubal architecture and 9 assigned to severe tubal damage. The mean score (+/- SEM) in women with overt pelvic inflammatory disease was 4.2 +/- 0.4; in women with silent pelvic inflammatory disease, 4.3 +/- 0.4; and in the control group, 0.76 +/- 0.2 (P less than .001). Fallopian tube abnormalities seen in women with overt and silent pelvic inflammatory disease included flattened mucosal folds, extensive deciliation, and degeneration of secretory epithelial cells, morphologic changes that are similar to the cellular changes observed in our experimental Chlamydia trachomatis infections in monkeys. Laser light-scattering spectroscopy was used to measure the ciliary activity of the epithelial cells. Ciliary beat frequency was significantly reduced in women with overt pelvic inflammatory disease (N = 13; f = 6.4 +/- 1.2 Hz) and in women with silent pelvic inflammatory disease (N = 11; f = 7.2 +/- 1.2 Hz) as compared with the controls (N = 5; f = 23.4 +/- 1.5 Hz) (P less than .001).(ABSTRACT TRUNCATED AT 250 WORDS)

Postcoital test abnormalities in relation to contraceptive use.

Abnormalities of cervical mucus can have a bearing on a woman's fertility. One means of detecting the presence of such abnormalities is the postcoital test (PCT). As part of a population-based case control study of risk factors for infertility, the reproductive, contraceptive, medical, and sexual histories of women seeking treatment for infertility who had abnormal PCT results were compared with those of fertile controls. A greater proportion of infertile women with an abnormal PCT had previously used a diaphragm than had control women (relative risk (RR) = 3.5, 95% CI = 1.1-11.3). The excess risk associated with use of a diaphragm was particularly high for women who had used one for longer than one year (RR = 7.3, 95% CI = 1.4-37.8), or within one year of attempting to conceive (RR = 5.5, 95% CT = 1.4-22.1). No increased risk was associated with the use of other barrier methods, oral contraceptives, or the intrauterine device.

Tubal pregnancy and the risk of subsequent infertility.

One hundred forty-one women with tubal infertility, all of whom had been pregnant at least once before, were interviewed concerning their reproductive, contraceptive, medical, and sexual histories. Their responses were compared with those of a control group of 467 fertile women. A higher percentage of cases (13%) than controls (1%) had had a tubal pregnancy. From these percentages, we estimate that 92% of tubal infertility in women who have had a tubal pregnancy results from tubal pregnancy itself or factors that predisposed to its occurrence. We also estimate that approximately one-fifth of women who suffer a tubal pregnancy will subsequently be infertile because of a tubal abnormality. After controlling for the joint effects of several known risk factors for tubal pregnancy that independently predispose to infertility (eg, a history of pelvic inflammatory disease), the relative risk of tubal infertility associated with tubal pregnancy was 15.0 (95% confidence interval 5.2-43.6). However, because we had no sensitive indicator of antecedent tubal disease, we were extremely limited in our attempt to determine the extent to which this association was actually due to the consequences of the tubal pregnancy itself.

Appendectomy and the risk of tubal infertility.

We studied the importance of a history of appendectomy for appendicitis in 279 women with laparoscopically or surgically diagnosed tubal infertility and a control group of 957 fertile women. After controlling for the effects of age, use of an intrauterine device for contraception, a history of pelvic inflammatory disease, and other potential confounding variables, we found that no excess risk of tubal infertility was associated with a simple appendectomy without rupture. However, when the operation was reportedly for a ruptured appendix, the relative risk of tubal infertility was 4.8 (95 percent confidence interval, 1.5 to 14.9) for women who had never been pregnant and 3.2 (95 percent confidence interval, 1.1 to 9.6) for women with one or more previous pregnancies. We conclude that the early diagnosis and treatment of suspected appendicitis in girls and women of reproductive age may reduce the incidence of tubal infertility resulting from the sequelae of a ruptured appendix.

Primary tubal infertility in relation to the use of an intrauterine device.

Women who use an intrauterine device (IUD) are at increased risk of acute pelvic inflammatory disease, but the relation of the IUD to subsequent infertility is not established. We interviewed 159 nulligravid women with tubal infertility to determine their prior use of an IUD. Their responses were compared with those of a matched group who conceived their first child at the time the infertile women started trying to become pregnant. The risk of primary tubal infertility in women who had ever used an IUD was 2.6 times that in women who had never used one (95 per cent confidence interval, 1.3 to 5.2). The observed difference between cases and controls was not uniform for different types of IUD. The relative risk associated with use of a Dalkon Shield was 6.8 (1.8 to 25.2), and that associated with use of either a Lippes Loop or Saf-T Coil IUD was 3.2 (0.9 to 12.0). The smallest elevation in risk was found among users of copper-containing IUDs (relative risk, 1.9 [0.9 to 4.0] for all women who had ever used a copper-containing IUD). The relative risk for women who used only a copper-containing IUD was 1.3 (0.6 to 3.0). We conclude that use of the Dalkon Shield (and possibly of plastic IUDs other than those that contain copper) can lead to infertility in nulligravid women.

PIP: This study compared the contraceptive histories of 159 nulligravid women with tubal infertility with those of matched group of 159 controls who conceived their 1st child at the time the infertile women began attempting pregnancy. Results were adjusted for the confounding effects of cigarette smoking, number of sexual partners, and income. A higher percentage of cases (35%) than controls (14%) reported ever-use of an IUD (relative risk, 2.6; 95% confidence interval, 1.3-5.2.). The relative risk associated with use of the Daklon shield was 6.8 (1.8-25.2) and that associated with use of either the Lippes Loop or Saf-T-Coil was 3.2 (0.9-12.0). The smallest elevation of risk was noted among users of copper-containing IUDs, 1.9 (0.9-4.0); the relative risk for women who used only a copper IUD was 1.3 (0.6-3.0). The relative risk to tubal infection in women with a history of IUD-related pelvic inflammatory disease was 3.0 compared with women who had no history of such disease. The risk of tubal infection associated with an IUD in women with no prior or subsequent history of pelvic inflammatory disease was 2.6 (1.2-5.5). These results strongly suggest that the elevated risk of tubal infection observed in Dalkon Shield users reflects a casual relationship. The relatioonship. The relationship of tubal infection to the prior use of other types of IUDs is less clear, however. There is a possibility that the association noted between the use of Lippes Loop or Saf-T-Coil and tubal infertility may have been due to chance since the number of users of these devices in this sample was small. In addition, generalizations drawn from these results should be restricted to nulligravid women; the influence of IUD use on subsequent fertility may differ between women who have not been previously pregnant.

Tubal infertility in relation to prior induced abortion.

One hundred twenty-seven women who had been given diagnoses of tubal infertility between 1979 and 1981 in King County, Washington, yet previously had been pregnant, were interviewed to determine their prior history of legally induced abortion. Their responses were compared with those of 395 women who conceived a child at the same time the infertile women began their unsuccessful attempt to become pregnant. In making the comparison, we adjusted for the effects of variables that in this population were related both to having an induced abortion and to the occurrence of infertility, i.e., age, number of prior pregnancies, number of sexual partners, cigarette smoking habits, Dalkon Shield (A. H. Robins Company, Richmond, VA) use, and whether the woman worked outside the home. The risk of tubal infertility in women who had had an induced abortion was not increased above that of other women (relative risk, 1.15; 95% confidence interval, 0.70 to 1.89). For women with two or more abortions, the relative risk was 1.29 (95% confidence interval, 0.39 to 4.20). When only the most recent pregnancy was considered, the relative risk was 1.19 (95% confidence interval, 0.72 to 1.97). Our results suggest that legal abortion, as performed during the past decade in the United States, does not carry an excess risk for future tubal infertility.

PIP: 127 women who had been given diagnoses of tubal infertility between 1979-81 in King County, Washington, yet previously had been pregnant, were interviewed to determine their prior history of legally induced abortion. Their responses were compared with those of 395 women who had conceived a child at the same time the infertile women began their unsuccessful attempt to become pregnant. In making the comparison, the authors adjusted for the effects of variables that in this population were related to both having an induced abortion and to the occurrence of infertility; i.e., age, number of prior pregnancies, number of sexual partners, cigarette smoking habits, Dalkon Shield (A.H. Robins Co., Richmond, Virginia) use, and whether the woman worked outside the home. The risk of tubal infertility in women who had had an induced abortion was not increased above that of other women (relative risk, 1.15; 95% confidence interval, 0.70-1.89). For women with 2 or more abortions, the relative risk was 1.29 (95% confidence interval, 0.39-4.20). When only the most recent pregnancy was considered, the relative risk was 1.19 (95% confidence interval, 0.72-1.97). Results suggest that that abortion, as performed during the past decade in the U.S., does not carry an excess risk for risk tubal infertility.

Improvement in the sperm penetration (hamster ova) assay (SPA) results after doxycycline treatment of infertile men.

Thirty-two men with abnormal (less than or equal to 11% penetration) Sperm Penetration (hamster ova) Assay (SPA) results were treated with doxycycline and reevaluated by SPA and seminal fluid analysis. Eighteen of the 32 infertile men with initially abnormal SPAs had normal SPAs (greater than or equal to 15% egg penetration) after treatment. None of 30 untreated infertile men with abnormal SPAs had a normal SPA on repeat testing (P less than 0.001). Improvement in SPA results was associated with a decrease in the number of leukocytes/ml in seminal fluid. Seven of the wives of the treated men conceived, while none of the wives of the untreated infertile men conceived during comparable intervals of time.

Increased frequency of serum antibodies to Chlamydia trachomatis in infertility due to distal tubal disease.

186 infertile women underwent standard infertility investigations (including hysterosalpingography and, in 87 women, laparoscopy) and tests for the presence of antibody to Chlamydia trachomatis. 73% of the women with distal occlusion of the fallopian tubes and 21% with peritubal adhesions alone had antibodies to C. trachomatis, but none of those with normal tubes did (p less than 0.001 and less than 0.005, respectively). No other infertility factors were associated with an increased frequency of antibodies to C. trachomatis. Since the presence or absence of antibodies to C. trachomatis was as discriminatory in the detection of tubal disease in infertile women as was the hysterosalpingogram, the serological test for C. trachomatis should become part of a routine infertility investigation.

Benefits of the sperm (hamster ova) penetration assay in the evaluation of the infertile couple.

The males of 310 infertile couples and 30 control couples (current pregnancy) were evaluated with the sperm (hamster ova) penetration assay (SPA) and seminal fluid analysis (SFA). The SPA was found to have a sensitivity of 100% and a specificity of 97% compared to 41% and 90%, respectively, for the SFA. The highest degree of concordance of the two tests existed when both tests were abnormal and no female factor was identified. The poorest concordance occurred when the SFA was normal and no female infertility factor was identified. In almost all cases of unexplained infertility where no female infertility factor was present, the problem could be assigned to the man, as evidenced by an abnormal SPA. The SFA seemed to have some predictive value with respect to the outcome following treatment of the man.

Role of induced abortion in secondary infertility.

The medical histories of 105 patients with secondary infertility were studied to determine whether or not induced abortion contributes to the occurrence of secondary infertility. One hundred ninety-nine control cases were matched to these cases according to age, number of previous pregnancies, race, marital status, and socioeconomic status. It was found that women with a history of prior induced abortion did have a sligtly higher risk (risk ratio = 1.31) of secondary infertility, but that the 95% confidence interval (0.71 to 2.43) was consistent with no association at all. When the analysis was restricted to women without ovulatory problems the risk was of similar magnitude. Prior spontaneous abortion was also found to be unrelated to secondary infertility in this series of women.

Tubal and peritubal surgery without magnification: an analysis.

From June, 1973, through August, 1977, thirty consecutive tubal or peritubal operations, exclusive of sterilization reversal procedures, were performed by Dr. Spadoni at the University Hospital in Seattle, Washington, without any form of magnification. Fifty-seven percent of the patients became pregnant, with a term pregnancy rate of 53%. There was a 30% abortion rate, but no ectopic pregnancies. Of those patients with distal tubal disease who became pregnant, 89% had postoperative hydrotubation, whereas of those who did not become pregnant, only 22% had postoperative hydrotubation. Some of the possible etiologic factors in the development of tubal and peritubal disease are discussed.