Georgeanna Seegar Jones

The Luteal Phase Defect

In summary, the luteal phase defect is a deficiency of corpus luteum progesterone steroidogenesis, either in amount or duration, or both. The clinical manifestations include either primary infertility or repeated first trimester abortions. The diagnosis can only be made clinically on the basis of a well-timed endometrial biopsy that is read histologically as 2 or more days out of phase with the next period in at least two cycles.

The Use of Clomiphene Citrate

Two hundred and fifty-five women received clomiphene citrate during a 10-year period. Fifty-six were treated diagnostically and one hundred and ninty-nine therapeutically for infertility. It is concluded that clomiphene may aid in confirming the diagnosis and establishing a prognosis in patients with primary or secondary amenorrhea. The success of clomiphene therapy in patients with anovulatory infertility is related to the etiologic factor responsible for the anovulation, but results can be improved by adjustment of the therapeutic regimen used. In the present series, 48% of the patients who ovulated became pregnant, and 25.3% of the pregnancies were miscarried. Those patients who ovulated spontaneously and became pregnant after having discontinued clomiphene therapy showed only a 10% abortion rate. A review of the results indicates that both the ovulation rate and the pregnancy rate can be improved if adjustments are made in therapy to ensure normal follicular maturation and corpus luteum function.

Efficacy of 17α-Hydroxyprogesterone Caproate in the Prevention of Premature Labor

Abstract We conducted a double-blind study to determine the efficacy of 17α-hydroxyprogesterone caproate in preventing premature delivery in 43 high-risk patients. Premature delivery did not occur in 18 patients receiving the progestational agent, whereas 41 per cent of the 22 receiving the placebo had premature delivery (P < 0.01). The mean duration of pregnancy and the mean birth weight in the former group (38.6 weeks ± 1.6 S.D., and 2836 g ± 412 S.D.) were both significantly greater (P <0.025) than that in the latter (35.2 weeks ± 6.7 S.D.; 2361 g ± 1085 S.D.). The perinatal mortality rate in the group given the progestational agent (0 per cent) was significantly less than that observed in the placebo group (27 per cent) (P < 0.05). Although there were no complications attributable to the progestational drug, the study population was too small for assessment of immediate or long-term safety. However, the results indicate a possible obstetric use for this drug. (N Engl J Med 293:675–680, 1975)

Fertility Following Bilateral Ovarian Wedge Resection: A Critical Analysis of 90 Consecutive Cases of the Polycystic Ovary Syndrome

Fertility following bilateral ovarian wedge resection (BOWR) was evaluated in a retrospective cohort study of 90 consecutive cases of the polycystic ovary syndrome. Post-BOWR follow-up was available for varying time spans of up to 10 years. BOWR resulted in the resumption of menstrual cyclicity in 91.1% (82/90) of the cases. However, within this ovulatory group, 26 patients were characterized by oligo-ovulation and a significantly reduced conception rate (29.2%), as compared with that of 56 normo-ovulatory counterparts (60.3%). Although the crude overall conception rate for this series was 47.8%, the overall cumulative probability of conception at the end of follow-up as determined by life table analysis was 73%. The likelihood of conception at any given point in time was estimated by a monthly fecundability rate of 1.34%. Our findings also indicate that the probability of post-BOWR conception was unaffected by age, race, ward status, or duration of infertility. In contrast, persistent post-BOWR oligo- or anovulation and the presence of concurrent tuboperitoneal disease were reaffirmed as the most important determinants of the likelihood of post-BOWR conception. A minimum incidence of 7.8% was documented for acquired post-BOWR pelvic disease.

Autoimmunity and ovarian failure.

Abstract The incidence of ovarian autoantibodies in 55 patients with various forms of complete and partial ovarian failure, including spontaneous premature menopause, gonadal agenesis, luteal phase defect, and various other forms of secondary amenorrhea was determined. In addition, antibodies against thyroglobulin and the cytoplasm of thyroid follicle cells, parietal cells, and adrenal cortical cells were investigated. Specificity was evaluated with the use of differential adsorption. Ovarian cytoplasmic antibodies were found in 8 patients, all in a group of 16 patients with premature menopause and associated immune disorders. Antiovarian antibodies against nuclei were demonstrated in a ninth patient, 1 of 11 with a luteal phase defect. These antinuclear antibodies were adsorbed out of the serum by extracts of all the tissues used. A high incidence of autoantibodies to other tissue antigens was found in patients with complete ovarian failure, even in the absence of associated overt immune disorders. A possible role of an as yet undefined generalized autoimmune diathesis is postulated as a potential factor in the development of at least some cases of premature menopause.

Assisted hatching in the treatment of poor prognosis in vitro fertilization candidates

OBJECTIVE To access the effect of augmenting IVF with assisted hatching in the treatment of poor-prognosis patients. DESIGN Thirty-three poor-prognosis IVF patients were treated with assisted hatching and were compared with 43 control subjects without assisted hatching. SETTING Center for Reproductive Medicine, Swedish Medical Center, Englewood, Colorado. PARTICIPANTS Seventy-six women undergoing IVF with a poor prognosis for pregnancy. Poor prognosis was defined as Elevated day 3 FSH level; age > or = 39 years; and multiple prior IVF failures. MAIN OUTCOME MEASURES Pregnancy and implantation rates per embryo. RESULTS The incidence of ongoing pregnancy in the assisted hatching group was 64% compared with 19% in the control group. Implantation rate per embryo transferred was 33% in the assisted hatching group versus 6.5% in the control group. CONCLUSIONS These results demonstrate that assisted hatching, when applied to poor-prognosis patients, improves embryonic implantation and pregnancy rates.

Gestational Outcome of Clomiphene-Related Conceptions *

The experience of the gynecologic endocrinology and infertility clinic at The Johns Hopkins Hospital has been subjected to a nonconcurrent prospective analysis in an attempt to evaluate the gestational fate of clomiphene-related conceptions (study series, n = 86). This latter series was contrasted with a series of pregnancies following bilateral ovarian wedge resection (BOWR) (n = 51) in a comparative analysis of gestational outcome event rates. Post-therapy follow-up was available for varying time spans of up to 15 years. A 12.8% twinning rate constituted the single most important complication of clomiphene therapy, resulting in measurable increments in perinatal morbidity and mortality rates. The observation of a 26.5% spontaneous abortion rate would seem to suggest that clomiphene-related conceptions are at little or more risk for spontaneous abortion than would have been expected from the infertile population under discussion. A 3.1% incidence of post-clomiphene birth defects was not increased as compared with commonly quoted rates for the population at large. The corresponding incidence rates of twinning, spontaneous abortion, and birth defects for the BOWR series were 0%, 21.6%, and 0%, respectively.

The Triple-X Syndrome

No definite relationship was seen between the number and duration of the lesions in any particular patient and the total number of nasal swabs from him which yielded Staph. pyogenes. Moreover, lesions were frequently present when the nasal swab was negative, and vice versa. In fact, we obtained no useful information from the nasal swabs after we had made the preliminary survey of the types of staphylococci involved in the outbreak. Clinical The subsequent course of the epidemic is shown by the following numbers of lesions which appeared in successive months: November Ito 15 39 i 41 1960 {January 5 19591 , 15 to 30 2i February.. . 5 December .. .. 8

Infertility due to endometriosis: Conservative surgical therapy

Abstract One hundred and one patients with endometriosis were treated with conservative operation because of infertility. Fifty-two patients followed at least one year subsequently conceived. Fifty-eight per cent of the 73 patients followed for 3 or more years achieved a pregnancy. A total of 87 conceptions occurred. The age of the patient at the time of operation, the duration of preoperative infertility, the patients previous parity, and the location of the disease did not appear to be significant factors in the results. Sixty per cent of the patients who conceived did so in the first year following operation. All but one of the patients who conceived did so within 3 years of the operation. Thirteen women required subsequent operation for symptomatic endometriosis; however, 5 of them had conceived.

Differential ovarian and adrenal vein catheterization.

Twenty-two hirsute women underwent percutaneous adrenal and ovarian vein catheterization to differentiate and localize excessive hormonal output. All studies were done under fluoroscopic control; catheter placement was verified by venography, and blood samples were withdrawn for hormonal analysis. The right ovarian vein was successfully sampled in 42 per cent of attempts; the left ovarian vein, in 75 per cent; the right adrenal vein, in 56 per cent; and the left adrenal vein, in 100 per cent. Bilateral catheterization did not prove clinically useful. First, anatomic variations in venous size and drainage made catheterization and bilateral sampling difficult. Second, adrenal secretion is both episodic and parallel, necessitating both simultaneous catheterization and serial sampling for adequate diagnosis. The stress of the procedure may provoke increased adrenal output. Third, since ovarian secretion is not parallel, and since increased hormone output has been documented in that ovary containing developing follicles or a corpus luteum, distinguishing ovarian dysfunction proved difficult. Finally, for a time-consuming procedure, patient discomfort cannot be disregarded. This technique has not proved to be a reliable means of determining the site of androgen hypersecretion and thus cannot be recommended in the routine evaluation of female hirsutism.