Abraham Benshushan

The role of estrogen support during the luteal phase of in vitro fertilization-embryo transplant cycles: a comparative study between progesterone alone and estrogen and progesterone support

OBJECTIVE To evaluate the possible role for estrogen supplementation to the P luteal phase support of GnRH agonists (GnRH-a)- and hMG-induced IVF-ET cycles. SETTING In vitro fertilization unit in a tertiary care university hospital. DESIGN A prospectively randomized study. PATIENTS One hundred consecutive patients undergoing ET after IVF were assigned into one of two luteal supplementation regimens. INTERVENTIONS In all patients enrolled in the study, ovulation was induced using the midluteal regimen for pituitary down regulation with GnRH-a followed by follicular stimulation with hMG. The first group received IM P 50 mg/d, as luteal phase support, starting the day of ET. The second group received the same dosage of P, combined with oral E2 valerate, 2 mg/d. Serum levels of P and E2 were monitored every 4 days for 16 days after ET. MAIN OUTCOME MEASURES Pregnancy rates (PRs) and live birth rates per ET. RESULTS No significant difference in E2 or P levels throughout the cycle was observed between groups. Similar PRs per ET and the live birth rates were also observed between group A and B (28% versus 26.5% and 78.6% versus 76.1%, respectively). CONCLUSION No advantage was found in the addition of E2 valerate to P luteal phase support of GnRH-a- and hMG-induced IVF-ET cycles.

Is there really a decrease in sperm parameters among healthy young men? A survey of sperm donations during 15 years.

Purpose: Our purpose was to measure changes in semen quality and quantity in young healthy sperm donors in Jerusalem over time.Methods: A retrospective analysis of semen parameters over 15 years using linear regression analysis, in a single sperm bank in a tertiary university center. Study population consisted of 188 young, healthy medical students, aged 20 to 30 years, who donated sperm samples for Artificial insemination between 1980 and 1995.Results: There were no statistically significant changes in semen concentration and motility during the study period. The mean semen volume increased by 0.1 ml (5.1%) per year (P < 0.0001), with a concomitant mean rise of 5.8 × 106 (7.7%) per year in total motile sperm count. The percentage normal morphology decreased by a mean of 1.04% per year during the entire period (P < 0.0001).Conclusions: During the past 15 years, there has been an increase in total motile sperm count, secondary to an increase in semen volume, and a decline in normal morphology that are independent of the age and the duration of abstinence in fertile men.

Periurethral Injection for the Treatment of Urinary Incontinence

Periurethral injection of substrates that compress, support, or narrow the bladder neck for the treatment of stress incontinence is not new. Several injectable compounds have been used in a small number of patients during the 1940s and through the 1960s; however, the results were not very successful and often led to significant complications. More recently, two major materials have been developed that seem to be useful in treating stress incontinence by periurethral injection: Polytef paste and GAX collagen. Other injectables include autologous fat tissue and silicone microimplants. The most suitable patients for periurethral injection are elderly women, patients who constitute high operative risk, and those with stress incontinence due to intrinsic sphincter failure. Patients with stress incontinence due to a combination of urethral hypermobility and intrinsic sphincter deficiency with failure of suspension procedure may also benefit from the procedure. The reported long-term (more than 24 months) success rates according to the various substances are as follows: Teflon (Polytef) (E.I.du Pont de Nemours and Co, Wilmington, DE): 30 to 38 percent cured or improved; repeated injections usually do not improve the outcome; mostly minor complications with case reports of more serious side effects such as periurethral granuloma formation and bladder outlet obstruction. GAX collagen: 69 to 77 percent subjectively cured or improved after 24 months; 54 to 57 percent objectively cured or improved, the reported morbidity in these procedures is minimal; repeated injections can improve the outcome. The experience with autologous fat and silicone microimplants is insufficient, with an overall success rate of 70 percent (1-40 months follow-up; mean 12 months) and 58 to 70 percent (17-36 months), respectively. Most of the procedures are performed as outpatient cases, and some under local anesthesia. These procedures are minimally invasive, usually safe and well tolerated, require shorter hospitalization, and are cost effective. In conclusion, in carefully selected patients, periurethral injection seems to be a reasonable option in the modern treatment of female stress incontinence.

The effect of progesterone administration in the follicular phase of an artificial cycle on endometrial morphology: a model of premature luteinization

OBJECTIVE To evaluate the effect of premature P administration on artificially prepared endometrium in women with ovarian failure. DESIGN To mimic premature luteinization, patients with ovarian failure were treated with continuous estrogen and episodic P during the follicular phase of artificial cycles. SETTING In vitro fertilization unit at a university hospital. PATIENTS The study group included 16 patients with ovarian failure who were randomly divided into two groups. Group A (8 patients) was treated by episodic P administration during the artificial follicular phase on days 2 and 7 (12.5 mg of P in oil IM), and in group B (8 patients), P (6.25 mg) was added on days 3, 4, and 5. Another 16 patients (group C), age matched to the study group, were arbitrarily allocated to serve as controls and had standard preparatory cycles without P supplementation in the follicular phase. Serum E2 and P levels and endometrial biopsies were taken on days 14 and 26. RESULTS Serum E2 levels were comparable between the study group (group A+B) and controls on both days 14 and 26. Although serum P levels did not differ between the groups on day 26, it was higher in the follicular phase of the study group than in the controls (1.9 +/- 4.0 and 0.2 +/- 0.1 ng/mL, respectively). In the study group, 8 of 16 patients demonstrated early secretory changes in the late follicular phase biopsies, and 9 of 16 women developed stromal-glandular discrepancy in the late luteal phase. This differed significantly from the controls in which only one late luteal biopsy was out of phase. CONCLUSIONS Episodic surges of P during the follicular phase may result in impaired endometrial development that cannot be corrected by P supplementation during the luteal phase. This unique model provides evidence for the potential detrimental effect of premature P secretion in the follicular phase on endometrial function.

Ovulation induction with clomiphene citrate complicated by deep vein thrombosis

A case of recurrent deep vein thrombosis following standard clomiphene citrate treatment, in a patient with a history of a previous episode of deep vein thrombosis, is described. This case indicates that deep vein thrombosis might be a rare but hazardous complication of clomiphene citrate treatment in patients with certain risk factors. We recommend that the use of clomiphene citrate in such cases be undertaken with caution and under close surveillance.

Ovum donation: an overview

Ovum donation is now an integral part of the management of infertility, providing a solution for patients previously considered permanently infertile. The indications now include not only patients with premature ovarian failure, but also patients who are carriers of genetic disorders, patients with repeated failures in IVF, and patients after surgical castration and after X-ray therapy or chemotherapy. OD is simpler than IVF and has better pregnancy and delivery rates per transfer. Yet this modality of treatment raises serious legal, social, religious, and ethical issues such as the maximal age for treatment and donor selection; these aspects are discussed elsewhere (70).

TAMOXIFEN EFFECTS ON MENOPAUSE-ASSOCIATED RISK FACTORS AND SYMPTOMS

UNLABELLED This study reviewed the available data on the influence of prolonged tamoxifen treatment on postmenopausal women. Tamoxifen might induce or increase vasomotor symptoms, such as hot flushes and night sweats, and occasionally cause vaginal discharge, irritation, and bleeding. Long-term use of tamoxifen by premenopausal women lowers total serum cholesterol and LDL-cholesterol, with a resultant reduction in cardiovascular mortality. In postmenopausal women, tamoxifen has a similar effect on serum lipids, but its cardioprotective effect has not yet been substantiated. Tamoxifen has a beneficial effect on bone density presumably through its estrogen agonistic effects. It has an antiresorptive action primarily on trabecular bone and to a lesser extent on cortical bone, thus preserving bone mass. Its long-term effect on the risk of osteoporotic fractures has yet to be proven. The authors conclude that prolonged tamoxifen treatment of postmenopausal women is associated with beneficial effects on serum lipid profiles and bone density; however, its effects on the morbidity and mortality from cardiovascular disease and osteoporosis and how it compares with the benefits of estrogen therapy remain to be determined by long-term comparative studies. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this article, the reader will be able to be aware of the new indications for tamoxifen use prophylactically. To understand the various effects of tamoxifen on post-menopausal women and how they differ from the effects on premenopausal women.

Hormonal manipulations and breast cancer.

Breast cancer is the most common cancer among women and the leading cause of death in women, 40 to 55 years of age. The lifetime odds of developing breast cancer are apparently up to 1 in 8 women in North America and 1 in 12 in Western Europe. According to the American Cancer Society, some 200,000 women (and 1,500 men) will be diagnosed with breast cancer this year. Although the incidence of breast cancer in women has been rising since the mid-1940s, the mortality has dropped modestly over the past decade, probably due to earlier and improved diagnosis and treatment. Evidence from both epidemiological and experimental studies points to an important role of reproductive variables in the development and promotion of human breast neoplasia. Hormonal manipulations, in the form of contraceptives, hormone replacement therapy, or antiestrogens, affect the incidence and course of breast cancer and may be useful in prevention and treatment of the tumor. In this review we summarize the current status of the use of hormones and antihormones in regard to breast cancer and outline possible areas of additional development and investigation. Target Audience: Obstetricians and Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be able to summarize the effects of estrogen and progestogens on the breast and to list the effects of other hormonal modulators on the breast.

Maternal Morbidity following Routine Second Trimester Genetic Amniocentesis

Two cases of septic complications of routine second trimester amniocentesis are presented. The first case is a 37-year-old gravida suffering from ulcerative colitis who was admitted for amniocentesis in the 18th week of her third pregnancy. An uncomplicated transabdominal amniocentesis was performed using a sterile technique and ultrasound guidance. Twenty-eight hours later the patient had a septic abortion and sepsis. The second case is a 34-year-old gravida in the 24th week of her pregnancy who was admitted with amnionitis 10 h after an uncomplicated amniocentesis, and subsequently had a septic abortion. A high index of suspicion and rapid intervention were crucial in both cases.

Triplets are not so rare any more

Triplet gestations present a considerable management challenge due to a high rate of antenatal, intrapartum and neonatal complications. The introduction of ovulation inducing agents resulted in a marked increase of these pregnancies. Consequently, triplet conceptions are not considered a rare phenomenon and have become almost routine high risk pregnancies. In our department the triplet gestation frequency increased 2-4 times in a 10 year period from a rate of 0.07-0.14% during 1978-84 to 0.28% of all deliveries in 1987. This high incidence of triplet deliveries results in a threefold increase in the frequency of triplet neonates and their associated complications. It is reasonable to assume that the wide application of various assisted reproductive techniques will result in continuous increase in the incidence of triplets which will in turn require coordinated management of a high risk pregnancy unit, delivery room and neonatal intensive care unit.