Successful induction of ovulation in normogonadotrophic clomiphene resistant anovulatory women by combined naltrexone and clomiphene citrate treatment

Patients suffering from normogonadotrophic anovulation and infertility are initially treated with clomiphene citrate. Those who do not respond to clomiphene citrate usually receive gonadotrophin treatment which is labour-intensive, expensive, and associated with an increased risk of multiple pregnancies and ovarian hyperstimulation syndrome. We treated 22 patients with clomiphene resistant normogonadotrophic anovulation with naltrexone (an opioid receptor blocker) alone or naltrexone in combination with an antioestrogen. In 19 patients ovulation and resumption of a regular menstrual cycle was achieved and in 12 out of 19 a singleton pregnancy was observed. In conclusion, ovulation can be induced successfully using naltrexone alone or naltrexone in combination with an anti-oestrogen in clomiphene citrate resistant anovulatory patients. Compared to gonadotrophin induction of ovulation, this method is safe, simple and inexpensive.     

Combined intra-uterine and extra-uterine pregnancy associated with mild hyperstimulation syndrome after clomiphene ovulation induction

We report a combined intra-uterine and tubal pregnancy associated with mild ovarian hyperstimulation syndrome (OHSS) following ovulation induction by clomiphene. The diagnosis of ectopic pregnancy was originally missed until rupture occurred. OHSS confused the clinical picture, the important diagnostic feature being the fall in the haemoglobin concentration. The patient had a left partial salpingectomy and the uterine pregnancy progresses normally.     

A prospective randomized trial of artificial insemination versus intercourse in cycles stimulated with human menopausal gonadotropin or clomiphene citrate

OBJECTIVE: To determine the relative efficacy of intrauterine insemination (IUI), direct intraperitoneal insemination, and intercourse in cycles stimulated with clomiphene citrate (CC) or human menopausal gonadotropins (hMG). DESIGN: A prospective randomized trial with a 2(3) factorial design with eight different treatment alternatives. Only one cycle per couple was performed. SETTINGS: The Departments of Obstetrics and Gynecology, Central Hospital, V?ster?s and Akademiska Hospital, Uppsala University, Uppsala, Sweden. PATIENTS: Of 157 randomized couples with unexplained infertility including 51 cases with minimal or mild endometriosis, 148 were selected for comparison. MAIN OUTCOME MEASURE: Pregnancy rate (PR). RESULTS: Follicular stimulation with hMG gave a higher PR than with CC in the insemination cycles, 19% (10/52) and 4% (2/49), respectively, but the PRs in intercourse cycles were not significantly different for hMG and CC, 13% (3/24) and 17% (4/23), respectively. Insemination cycles and intercourse cycles had a similar overall PR, 12% (12/101) and 13% (7/47), respectively. Furthermore, IUI and direct intraperitoneal insemination did not differ in efficacy. CONCLUSION: Follicular stimulation with hMG is more effective than CC in insemination cycles, but insemination as such seems to have no beneficial effect on the PR in stimulated cycles for treatment of unexplained infertility.     

Influence of human chorionic gonadotropin on pregnancy rates in lactating dairy and beef cows

Single subcutaneous injection of 1500 IU human chorionic gonadotropin or placebo injections were given at the time of insemination in lactating dairy and beef cows to determine their effects on rates of pregnancy. Pregnancy rates at first service in 161 control and 145 treated dairy cows were 52.8% and 44.8%, respectively. Similar rates for 136 control and 145 treated beef cows were 54.4% and 54.5%. Injections of human chorionic gonadotropin were not effective in stimulating conception rates in lactating dairy or beer cows under field conditions.     

Dicavitary uteri with twin gestation: a case following clomiphene citrate therapy and review of obstetric outcomes

We report the first case of dicavitary twin pregnancy, following clomiphene citrate therapy, in a patient with uterus bicornis bicollis and anovulation. A review of the literature is presented, and obstetric outcomes and management of these rare pregnancies are discussed.     

Maternal thyroid function in multiple pregnancy: the variable thyrotropic activity of human chorionic gonadotropin

The present study was undertaken to evaluate thyroid function and thyrotropic action of hCG in multiple pregnancy. We examined serum samples from 9 multiple pregnant women (3 triplets and 6 twins) and 27 singleton pregnant women as control subjects. Serum hCG levels in multiple pregnancy were higher than those in singleton pregnancy in the second and third trimesters (P < 0.01). The mean free T3 and T4 concentrations in multiple pregnancy did not differ from those in singleton pregnancy in each trimester. Serum hCG levels showed a statistically significant positive correlation with free T3 and T4 levels in singleton pregnancy (P < 0.001). However, these correlations were not observed in multiple pregnancy. Thyroid stimulation activity (TSA) determined by cAMP accumulation in FRTL-5 cells in multiple pregnancy sera was significantly higher than that in singleton pregnancy in the first trimester (P < 0.05), but did not differ in the second and third trimesters. Moreover, TSA did not show any correlation with serum hCG levels in multiple pregnancy in contrast with the results in normal pregnancy. A bioactivity/immunoreactivity ratio of hCG in multiple pregnancy was lower than in singleton pregnancy in the second and third trimesters. The discrepancy between immunoreactivity and thyrotropic activity of hCG may be caused by the variable thyrotropic potency of heterogeneous hCG molecules in multiple pregnancy.     

Relaxin: a product of the human corpus luteum of pregnancy

Plasma samples from peripheral and ovarian veins were obtains from women at cesarean section. A peptide that immunologically cross-reacts with a specific antiserum to porcine relaxin is present in all samples. Its concentration is four times higher in the ovarian vein draining the ovary, which contains the corpus luteum of pregnancy, than in either the peripheral vein or the contralateral ovarian vein. Secretion of ovarian relaxin correlates with secretion of ovarian progesterone, thus providing another index of luteal function.     

Gonadal function and response to human chorionic and menopausal gonadotrophin therapy in male patients with idiopathic hypogonadotrophic hypogonadism

The incidence of hereditary nonpolyposis colorectal cancer (HNPCC) is not precisely known. Common estimates are 4 to 6% of all colorectal cancers (CRCs), but lower figures have been published. In an attempt to obtain an independent new estimate of this proportion and to identify more HNPCC families, we designed a new method. Based on the fact that age at diagnosis is considerably lower in hereditary than in sporadic CRC, a cohort of 227 CRC patients aged 44 years or younger diagnosed during the years 1985-1989 and reported to the Finnish Cancer Registry was chosen as probands. Pedigrees of the probands were constructed by combining information from the Finnish Population Register Center and Finnish Cancer Registry using only automatically processed data. Sixteen pedigrees were extended further by the help of parish registers. Six of these turned out to be new possible HNPCC families but none met the stringent criteria of the cancer syndrome. Our results can be interpreted to suggest that the proportion of HNPCC of all CRCs is between 0.5 and 0.9%, depending on the diagnostic criteria used. Modifications of our method should be useful in other research projects dealing with diseases in which a subset is due to genetically or environmentally determined susceptibility.     

The relationship of corpus luteum volume to relaxin, estradiol, progesterone, 17-hydroxyprogesterone and human chorionic gonadotropin levels in early normal pregnancy

Current suture techniques limit the postoperative management for flexor tendons. A double loop locking suture (DOLLS) technique has been described that provides sufficient in vitro strength (average 4,400 g) for early active mobilization of the flexor tendon. This paper details four cases in which the flexor digitorum profundus (FDP) tendons were repaired using the DOLLS technique. Early active mobilization was initiated 3 to 7 days postoperatively. Results were classified according to Strickland's formula. Two patients achieved excellent results, one a good result, and one a fair result. One rupture of a flexor digitorum superficialis (FDS) tendon, which had been repaired with a modified Kessler technique, occurred. Although this FDS tendon ruptured, the FDP tendon, which had been repaired with the DOLLS technique, remained intact. With the use of a protective splint, early active mobilization of tendons repaired by the DOLLS technique appears to be an effective method for postoperative management.     

A prospective randomized comparison of quadruple versus triple therapy for first cadaver transplants with immediate function

In January 1988, we initiated a prospective, randomized comparison of prophylactic antilymphoblast globulin (ALG; quadruple therapy) versus no prophylactic ALG (triple therapy) in the setting of immediate graft function (defined by a brisk diuresis and a 20% decline in serum creatinine within 24 hr). Recipients were stratified according to presence of diabetes and age greater or less than 50 years. Recipients on quadruple therapy (n = 61) received 7 days of prophylactic Minnesota ALG (5 mg/kg on day 1, 10 mg/kg on day 2, 20 mg/kg on days 3-7). CsA, 10 mg/kg/day, began on day 6. AZA began at 2.5 mg/kg/day and was adjusted according to white blood cell count. Recipients on triple therapy (n = 60) began immediate CsA, 10 mg/kg/day orally and AZA, 5 mg/kg/day, tapering to 2.5 mg/kg/day by day 8. Both groups received identical prednisone tapers beginning at 1 mg/kg/day, decreasing to 0.5 mg/kg/day by 2 weeks and to 0.15 mg/kg/day by 6 months. Demographic characteristics between groups were not different with respect to diabetes, age, sex, race, per cent panel-reactive antibodies (PRA), or HLA matching. Follow-up ranged from 2 to 4.5 years. Patient survival was 93% for the quadruple therapy group and 90% for triple therapy. Actuarial graft survival was 79% in the quadruple group and 72% in the triple group (P = 0.18). Graft loss due to rejection occurred in 6/61 receiving ALG versus 7/60 in the immediate CsA group. Three of 4 high PRA recipients in the immediate CsA group lost their grafts within 30 days compared with none in the ALG group. The mean time to graft loss was significantly longer for the quadruple therapy group (17 +/- 8 months) compared with the triple therapy group (4 +/- 5 months), P = 0.006. The total number of rejection episodes was similar for both groups (29/61 vs. 31/60), as was the number who were rejection free (51% vs. 47%). The use of OKT3 was also similar between groups (28% vs. 30%). The quadruple therapy group had a higher incidence of CMV infection: 20% vs. 7% (P < 0.05), but no grafts or patients were lost as a result. Serum Cr was not different at 1 and 12 months (1.5 and 1.6 vs. 1.6 and 1.7, respectively), nor were Cr clearances (63 and 68 vs. 60 and 63). Conclusion. Early initiation of oral CsA in the setting of immediate graft function is not associated with significant nephrotoxicity.(ABSTRACT TRUNCATED AT 400 WORDS)     

Intrauterine insemination after ovarian stimulation with clomiphene citrate: predictive potential of inseminating motile count and sperm morphology

This retrospective study aimed to evaluate the prognostic value of the inseminating motile count (IMC) and sperm morphology (using strict criteria) on success rates after homologous intrauterine insemination (IUI) combined with clomiphene citrate (CC) stimulation. A total of 373 couples underwent 792 IUI cycles in a predominantly (87.4%) male subfertility group. The overall cycle fecundity (CF) and baby take-home rate (BTH) was 14.6 and 9.9% respectively. The cumulative CF and BTH (per couple) after three cycles were 30.6 and 21.1% respectively. Overall, sperm morphology and IMC were of no prognostic value using receiver operating characteristic (ROC) curve analysis, but after classifying the study population into different subgroups according to IMC, sperm morphology turned out to be a valuable prognostic parameter in subgroup 1, i.e. IMC <1 x 10(6). In this subgroup, no pregnancies were seen when the morphology score was <4% and the mean value of sperm morphology was significantly different in the pregnant (8.3%) versus non-pregnant group (5.0%; P <0.05). The cumulative CF and BTH after three IUI cycles were comparable for all couples with the exception of those cases in which the IMC was <1 x 10(6) with a morphology score of <4% normal forms. We recorded only two twin pregnancies (2.5%) and no moderate or severe ovarian hyperstimulation syndrome. We conclude that in a selected group of patients without CC resistance and normal ovarian response following CC stimulation [maximum of three follicles with a diameter of >16 mm at the time of administration of human chorionic gonadotrophin (HCG)], IUI combined with CC-HCG can be offered as a very safe and non-expensive first-line treatment, at least with an IMC of >1 x 10(6) spermatozoa. In cases with <1 x 10(6) spermatozoa, CC-IUI remains important as a first-choice therapy provided the morphology score is > or =4%.     

Effect of time of artificial insemination on pregnancy rates, calving rates, pregnancy loss, and gender ratio after synchronization of ovulation in lactating dairy cows

In order to assess the optimal time of artificial insemination (AI) in relation to ovulation, lactating dairy cows (n = 732) from herds with rolling herd averages of 9980 to 11,800 kg from three milkings per day were randomly assigned to five groups by stage of lactation and parity. Ovulation was synchronized by administration of GnRH followed 7 d later with PGF2 alpha followed 2 d later with a second treatment with GnRH. Cows were inseminated at 0, 8, 16, 24, or 32 h after the second injection of GnRH (ovulation occurs between 24 and 32 h after GnRH). Pregnancy diagnoses were performed by ultrasound at 25 to 35 d post-AI. Pregnancy rates per AI were similar for the groups inseminated at 0, 8, 16, and 24 h and lower for the group inseminated at 32 h. A significant quadratic effect of treatment suggests that the middle time periods (8, 16, and 24 h) may produce the greatest pregnancy rate per AI. However, the group inseminated at 0 h had lowest pregnancy loss, and the group inseminated at 32 h tended to have the greatest pregnancy loss compared with that of the other groups. The calving rate was similar between the groups inseminated at 0, 8, 16, and 24 h and lower in the group inseminated at 32 h. The time of AI also appeared to affect gender of calf: cows bred at 0 and 32 h having a higher percentage of female offspring. In conclusion, there appears to be substantial flexibility in the time of AI after the second injection of GnRH, and lower reproductive rates were observed only when AI was after the time of ovulation.     

Single versus double insemination: a retrospective audit of pregnancy rates with two treatment protocols in donor insemination

Our objective was to evaluate the effect of a change in treatment protocols, suggested following an inspection visit by the regulatory authority, from single to double inseminations during donor insemination treatment cycles. We therefore conducted a retrospective audit of pregnancy rates in the reproductive medicine clinic of a major teaching hospital. All patients were treated for male factor infertility by donor insemination, without ovulation induction with gonadotrophins between October 1992 and December 1995. The main outcome measures were cumulative conception and live birth rates. During the study period 250 patients underwent treatment and 650 single insemination and 277 double insemination treatment cycles were undertaken. The pregnancy rate per cycle was 0.054 and 0.119 for single and double insemination respectively. After six cycles the cumulative pregnancy rates were 0.28 and 0.47 and the take-home baby rates were 0.25 and 0.37 for single and double inseminations respectively. The change in practice from single to double insemination resulted in a doubling of the pregnancy rate per treatment cycle. Cumulative pregnancy rates after two treatment cycles of double insemination were comparable with those achieved after six cycles of single insemination. These results have significant implications for both patients and purchasers.     

Effect of prostaglandin F2 alpha-and gonadotropin releasing hormone-induced luteinizing hormone releases on ovulation and corpus luteum function of beef cows

Luteinizing hormone (LH) concentrations were measured in suckled beef cows treated during the postpartum period with prostaglandin F2 alpha (5 mg Alfaprostol; PGF2 alpha) and then gonadotropin releasing hormone (100 micrograms Cystorelin 30 h after PGF2 alpha; GnRH). The objective was to determine if PGF2 alpha would cause a release of LH in the absence of progesterone and affect the GnRH-induced LH release and ovulation (Experiment 1). LH concentrations increased (P < 0.05) after PGF2 alpha treatment in both anestrous and cyclic cows but to a greater extent (P < 0.05) in anestrous cows. The GnRH-induced LH release and ovulation response in previously anestrous cows were greater (P < 0.05) when PGF2 alpha was administered 30 h earlier. In Experiment 2, 49 beef cows received PGF2 alpha (5 mg Alfaprostol) and GnRH (100 micrograms Cystorelin) 30 h later to determine if the profile of the preovulatory LH surge was associated with the occurrence of subnormal luteal phases in postpartum beef cows suckling calves. Cows that had normal luteal phases had a greater (P < 0.05) mean area under the GnRH-induced LH response curve and a greater (P < 0.05) mean GnRH-induced LH peak amplitude than cows that had subnormal luteal phases. In summary, results suggest that PGF2 alpha may exert a fertility effect by causing a LH release independent of progesterone withdrawal; administration of PGF2 alpha 30 h before GnRH elevated the GnRH-induced LH release and ovulation response. In addition, cows with subnormal luteal phases had GnRH-induced LH surges of less area and peak amplitude than cows with normal luteal phases.     

First established pregnancy and birth after induction of ovulation with recombinant human follicle-stimulating hormone in polycystic ovary syndrome

This case report describes the first established pregnancy and birth after induction of ovulation with recombinant human follicle-stimulating hormone (FSH) in a woman suffering from chronic clomiphene-resistant anovulation due to polycystic ovary syndrome (elevated serum luteinizing hormone and testosterone concentrations together with polycystic ovaries). Starting on day 3 of a progestagen withdrawal bleeding, 75 IU of rFSH was administered i.m. daily until a single preovulatory follicle was seen upon transvaginal ultrasound examination at day 13. Ovulation was induced by a single i.m. administration of 10,000 IU of human chorionic gonadotrophin, after which a viable singleton pregnancy was revealed at a gestational age of 6 weeks. The course of pregnancy and labour was uneventful and no abnormalities were found upon a paediatric examination.     

Programmed cell death in human ovary is a function of follicle and corpus luteum status

Although extensive investigation on follicular apoptosis (programmed cell death) has been conducted in the infraprimate ovary, there is little information regarding apoptosis and its relationship to follicular status in the human. In this study, apoptosis was investigated in 116 human ovarian follicles (primordial to dominant) and 5 corpora lutea from a total of 27 premenopausal women. Follicles and corpora lutea were evaluated for the presence of DNA fragmentation, characteristic of apoptosis, by two methods: in situ hybridization using 3' end-labeling of DNA with digoxigenin-labeled nucleotides and subsequent digoxigenin antibody and peroxidase staining, and/or biochemical analysis of low molecular weight DNA laddering. Follicle functional status was evaluated by determining follicle sizes and follicular fluid androgen/estrogen (A/E) ratios. No apoptosis was observed in 67 primordial, primary, or secondary follicles. Positive staining for DNA fragmentation was found in a few granulosa cells in 0.1- to 2-mm follicles, whereas abundant staining in granulosa was detected in 2.1- to 9.9-mm follicles. In contrast, no DNA fragmentation was detected in dominant follicles (10-16 mm). The frequency of apoptosis in follicles was calculated to be 37% in 0.1- to 2-mm follicles, 50% in 2.1- to 5-mm follicles, and 27% in 5.1- to 9.9-mm follicles. Abundant low molecular weight DNA laddering was only found in androgen-dominant follicles and not in estrogen-dominant follicles. Positive staining for DNA fragmentation and low molecular weight DNA laddering were observed in degenerating but not healthy-appearing corpora lutea. In the former, DNA fragmentation was found primarily in large luteal cells. These data suggest that follicular atresia in human ovary results from normal programmed cell death and primarily occurs in the granulosa cell layers of the early antral and < 10-mm antral follicles primarily. Furthermore, because apoptosis occurs as early as the 200-mm stage, follicle selection may begin as early as the initial formation of the antrum. The results also suggest that degeneration of the corpus luteum occurs by apoptotic mechanisms.     

Lung function in Indian twin children: comparison of genetic versus environmental influence

The relative contributions of genetic and environmental components in the variability of lung function measurements were studied in 54 twin pairs. Thirty pairs of monozygote (MZ) twins and 24 pairs of dizygotic (DZ) twins were examined. All measurements were made with 9-litre closed-circuit-type expirographs using standard spirometric techniques, except for peak expiratory flow rate (PFER) which was recorded with a Wright peak flow meter. Within-pair variances for inspiratory capacity (IC), vital capacity (VC), forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), forced mid-expiratory flow (FEV25-75%), forced end-expiratory flow (FEF75-85%), maximum expiratory flow (FEF200-1200ml), forced maximum voluntary ventilation MVVF) and PEFR were significantly smaller (p < 0.01) in MZ twins than in DZ twins. Tidal volume (VT), inspiratory reserve volume (IRV), expiratory reserve volume (ERV), forced expiratory volume in 1 second as a percentage of forced vital capacity (FEV1%), and forced expiratory time (FET) were not significantly different. Within-pair correlations were all higher in MZ than DZ twins. All measurements except for VT and PEFR showed high levels of heritability (23-99%). All measurements were positively and significantly correlated with physical characteristics such as weight, standing height, surface area, arm-span, chest circumference and age, except FEV1% and FET. Residual values adjusted for physical characteristics showed similar results to unadjusted values in most cases. These data indicate that major lung function measurements are possibly influenced more by genetic than environmental factors. Genetically influenced measurements show higher levels of heritability estimates and suggest that genetic determination of lung function is possibly independent of the influence of physical characteristics.     

Transvaginal sonography and human chorionic gonadotrophin measurements in suspected ectopic pregnancy: a detailed analysis of a diagnostic approach

In this prospective study among 208 high-risk patients with suspected ectopic pregnancy, the diagnostic value of transvaginal sonography and serum human chorionic gonadotrophin (HCG) measurements were analysed in detail. The absence of an intra-uterine gestational sac obviously was the most constant sonographic finding among patients with ectopic pregnancy (n = 89), with a very high sensitivity (0.99) but a low specificity (0.41). The application of different HCG cut-off levels improved specificity to 1.00 for values exceeding 4500 IU/l. Clinical utility obviously decreased, as many patients presented with HCG values well below this level. The additional effect of adnexal findings was analysed. Sonographic identification of an ectopic pregnancy was very specific (0.99) but had low sensitivity (0.56) because many ectopics were not detected. The additional effect of HCG values on these results was minor. The low HCG cut-off levels advocated in recent studies are questioned by the results of our analysis: whereas the combined use of sonography and HCG measurements is shown to be of great benefit, the limitations are also documented, underlining the need for re-evaluation at intervals of patients with low HCG values. The question of which cut-off level should be used in practice, however, hinges on a difficult choice between a certain specificity and clinical utility.     

Ramipril and felodipine: a comparison of the efficacy and safety of monotherapy versus combination therapy

A multinational, double-blind, randomised study was conducted to investigate the efficacy and safety of a low-dose combination of the angiotensin converting enzyme inhibitor, ramipril, and the calcium antagonist, felodipine ER, in 642 patients with mild to moderate hypertension [supine diastolic blood pressure (DBP) = 95-115 mm Hg]. After a 4-week single-blind placebo run-in, patients were randomly allocated to once-daily felodipine extended release (ER; 2.5 mg), ramipril (2.5 mg) or felodipine ER/ramipril (2.5/2.5 mg) for 12 weeks. In the intention-to-treat analysis, mean DBP decreased significantly (p < 0.0001) after felodipine ER, ramipril and the combination (-9.1, -9.8 and -11.4 mm Hg, respectively). The decrease was significantly greater with the combination than with felodipine ER monotherapy (p = 0.02). The number of responding patients (final DBP < or = 90 mm Hg or a decrease of > or = 10 mm Hg) was also higher with the combination than with felodipine ER or ramipril monotherapy (65.1%, 53.1%, 55.7%, respectively). There were no differences between the three groups with respect to the incidence of adverse events overall or those considered treatment-related. There were fewer cases of peripheral oedema with combination therapy than with felodipine ER monotherapy. Thirty-three patients (5.1%) withdrew from the study because of adverse events, but there was no clear pattern with regard to the specific events leading to withdrawal. There were no clinically relevant changes in laboratory or clinical safety variables. Ramipril/felodipine ER 2.5/2.5 mg is an appropriate starting dosage when initiating combination antihypertensive therapy.