I. Gerhard

Auricular Acupuncture in the Treatment of Female Infertility

Following a complete gynecologic--endocrinologic workup, 45 infertile women suffering from oligoamenorrhea (n = 27) or luteal insufficiency (n = 18) were treated with auricular acupuncture. Results were compared to those of 45 women who received hormone treatment. Both groups were matched for age, duration of infertility, body mass index, previous pregnancies, menstrual cycle and tubal patency. Women treated with acupuncture had 22 pregnancies, 11 after acupuncture, four spontaneously, and seven after appropriate medication. Women treated with hormones had 20 pregnancies, five spontaneously, and 15 in response to therapy. Four women of each group had abortions. Endometriosis (normal menstrual cycles) was seen in 35% (38%) of the women of each group who failed to respond to therapy with pregnancy. Only 4% of the women who responded to acupuncture or hormone treatment with a pregnancy had endometriosis, and 7% had normal cycles. In addition, women who continued to be infertile after hormone therapy had higher body mass indices and testosterone values than the therapy responders from this group. Women who became pregnant after acupuncture suffered more often from menstrual abnormalities and luteal insufficiency with lower estrogen, thyrotropin (TSH) and dehydroepiandrosterone sulfate (DHEAS) concentrations than the women who achieved pregnancy after hormone treatment. Although the pregnancy rate was similar for both groups, eumenorrheic women treated with acupuncture had adnexitis, endometriosis, out-of-phase endometria and reduced postcoital tests more often than those receiving hormones. Twelve of the 27 women (44%) with menstrual irregularities remained infertile after therapy with acupuncture compared to 15 of the 27 (56%) controls treated with hormones, even though hormone disorders were more pronounced in the acupuncture group. Side-effects were observed only during hormone treatment. Various disorders of the autonomic nervous system normalized during acupuncture. Based on our data, auricular acupuncture seems to offer a valuable alternative therapy for female infertility due to hormone disorders.

Heavy metals and fertility.

Heavy metals have been identified as factors affecting human fertility. This study was designed to investigate whether the urinary heavy metal excretion is associated with different factors of infertility. The urinary heavy metal excretion was determined in 501 infertile women after oral administration of the chelating agent 2,3-dimercaptopropane-1-sulfonic acid (DMPS). Furthermore, the influence of trace element and vitamin administration on metal excretion was investigated. Significant correlations were found between different heavy metals and clinical parameters (age, body mass index, nationality) as well as gynecological conditions (uterine fibroids, miscarriages, hormonal disorders). Diagnosis and reduction of an increased heavy metal body load improved the spontaneous conception chances of infertile women. The DMPS test was a useful and complementary diagnostic method. Adequate treatment provides successful alternatives to conventional hormonal therapy.

Comparison between tamoxifen and clomiphene therapy in women with anovulation.

SummaryForty-eight women with various types of menstrual disorder were treated with tamoxifen: 30 of them ovulated as judged by serum progesterone concentrations and the basal body temperature (BBT) record. Serial determinations of serum FSH, LH, prolactin, and estradiol-17β showed that tamoxifen acts primarily on the hypothalamic-pituitary axis.Before or after the tamoxifen treatment cycles, 30 women received clomiphene. The ovulation rate in women with primary and secondary amenorrhea was similar, while women with oligomenorrhea tended to be more responsive to tamoxifen than to clomiphene. There was no difference between the drugs in the duration of the luteal phases nor in the pregnancy rate. The side effects during treatment with clomiphene were pronounced than during tamoxifen therapy.

Long-term exposure to wood-preserving chemicals containing pentachlorophenol and lindane is related to neurobehavioral performance in women

BACKGROUND The adverse neurobehavioral effects of long-term low exposure to wood-preserving chemicals (WPC) containing solvents, pentachlorophenol (PCP) and gamma-hexachlorocyclohexane (gamma-HCH; lindane), and other neurotoxicants were investigated in a neuropsychological group study. METHODS Out of a population of 2,000 women visiting the outpatient practice of a gynecological department, a sample of 15 women aged 31-56 (mean 43) with long-term exposure to WPC verified by self-report, biological monitoring, and environmental samples was investigated. Fifteen controls aged 42 (31-56) years were drawn from the same population and pair-wise matched with respect to sex, age, education, and estimated intelligence. RESULTS For the exposed group, mean PCP serum level was 43.6 micrograms/l and mean gamma-HCH blood level was 0.085 microgram/l. Mean duration of exposure was 10 (5-17) years. Intellectual functioning, attention, memory, and visuo-motor performance were examined, suggesting significant group differences in visual short-term memory (Benton Test; d = 1.5, P = .005), verbal memory (paired associate learning and Peterson paradigm; d = 4.3 and 1.6, P < .001), and an incidental learning task (d = 2.3; P = .001). Frequent subjective complaints as assessed by questionnaire were attenuated motivation (d = 1.7; P = .001), increased fatigue (d = 1.6; P = .001), distractibility (d = 1.0; P = .003), and depressed mood (d = 1.9; P = .004). PCP blood level was significantly associated with paired-associate learning, Benton Test, and reading/naming speed. CONCLUSIONS Long-term low-dose exposure to WPC in the domestic environment could be related to subjective complaints (attention, mood, and motivation) and to subtle alterations of neurobehavioral performance (e.g., working memory) in women.

Estrogen screening in evaluation of fetal outcome and infant's development

In an unselected obstetric population of 869 women serial determinations of estriol in serum and urine were performed from the 28th week of pregnancy until delivery. Clinical management was based on ultrasound and nonstress/contraction stress tests only. Data on the development of the infants were available after 1 year in 759 cases (89%) and after 2 years in 661 cases (78%). Serum free estriol (E3) screening during weeks 28-34 of pregnancy revealed a significantly increased risk for reduced Apgar scores, growth retardation and postnatal complications in pregnancies with decreased levels (p less than 0.001). The development of the children was disturbed by a higher incidence of childhood diseases, retardation in speech and bowel and bladder control. The urinary estrogen determinations (UE) during this period of pregnancy showed only a vague connection with birth weight and Apgar scores (p less than 0.05) and no connection to the infants development. Serial determinations of E3 after the 35th week of pregnancy increased the significance for all parameters tested. If the estrogen concentration was determined in the last 2 weeks before delivery, 50% of the SGA and 60% of the endangered cases could be diagnosed. After reduced E3 serial levels neurological sequelae, reduced body weight, retarded speech and late development of bowel and bladder control were significantly more frequent at age two than after normal E3 levels. The differences obtained by serial UE determinations were less evident. Considering cost-benefit-calculations, an E3 screening of every pregnant woman cannot recommended. In pregnancies at risk serial E3 determinations allow better prognostication of fetal well-being. In the case of reduced E3 values maximum post partum care should be made available for all newborns. Special support should be given to the early infants development after reduced E3 values have been observed.

Thyrotropin-releasing hormone (TRH) and metoclopramide testing in infertile women.

Thyroid stimulating hormone (TSH) determinations before and after thyrotropin-releasing hormone (TRH) stimulation were obtained in 834 infertile women, from 1982 until 1985. Thyroid function disturbances were seen in 20% of the women, in accordance with the prevalence in South Germany. Postcoital tests were significantly poorer in women with subclinical hypothyroidism than in euthyroid patients. Spontaneous conception was more frequent in euthyroid (16%) than in hypothyroid (6%) women. During the same period, prolactin was determined after TRH stimulation in the early follicular phase and after metoclopramide stimulation in the luteal phase, in 759 women. The pregnancy rate was not improved by administration of dopamine agonists in women with an exaggerated response to TRH or metoclopramide. Our results suggest that subclinical hypothyroidism as well as disorders of prolactin secretion may play a role in infertility. The TRH test is proposed to rule out thyroid dysfunction. Neither the TRH nor the metoclopramide test was useful for the prognostic differentiation of prolactin secretion disorders.

Relationship of Sperm Acrosin Activity to Semen and Clinical Parameters in Infertile Patients/Die Beziehung der Akrosinaktivität zu verschiedenen Sperma- und klinischen Parametern bei infertilen Patienten

Summary: Acrosin activity (aa) was routinely measured in 189 infertile men who attended the hospital between March 1984 and January 1985. The evaluation of the male included semen analysis, microbial screening, postcoital testing (PCT), in vitro sperm penetration test (SPMT), and screening for anti‐sperm antibodies in serum. The strongest positive correlations of aa were found for sperm motility, count, morphology, vitality and volume. In presence of a poor PCT result, aa was significantly reduced, even in patients with good motility in native semen. A similar result was obtained with the SPMT: reduced sperm density and poor sperm motility in the capillary after 2 hours were significantly correlated to reduced aa. Smokers exhibited lower aa in presence of normal sperm count and motility. In the infertile group aa was significantly lower than in the group of men whose spouses conceived. On the basis of our results, the routine determination of aa is not necessary, but it provides additional prognostic information in couples with unexplained infertility.

Human placental lactogen and unconjugated estriol concentrations in twin pregnancy: Monitoring of fetal development in intrauterine growth retardation and single intrauterine fetal death

Human placental lactogen and unconjugated estriol concentrations in maternal serum were evaluated in 100 uneventful twin pregnancies, and these values were compared with those observed in 16 twin pregnancies associated with intrauterine growth retardation or single intrauterine fetal death. In pregnancies associated with intrauterine growth retardation (n = 8), human placental lactogen levels were at the lower limit of normal range for singleton pregnancies, whereas estriol levels were normal in most cases. When one of the fetuses had died before week 33 of pregnancy (n = 5), both human placental lactogen and estriol levels were low and they were almost at the levels in singleton pregnancy. When intrauterine fetal death occurred after week 36 of pregnancy (n = 3), both hormone levels remained normal until term. Thus human placental lactogen rather than estriol is a good indicator of intrauterine growth retardation in twin pregnancy. Both human placental lactogen and estriol are useful for the monitoring of the surviving fetus in the case of single intrauterine fetal death.

Hormone Load Tests in Infertile Male Patients

The recognition that discreet hormonal abnormalities may cause ovulation disorders in women suggested that the male partner of infertile women might also suffer from unrecognized hormonal dysfunction amendable to substitution therapy. We obtained a combined stimulation test with gonadotropin-releasing hormone (GnRH), thyreotropin-releasing hormone (TRH), and ACTH in 225 males with childless spouses, when the couple sought to have children for at least one year. The following hormone levels were determined: estradiol (E), thyroid-stimulating hormone (TSH), prolactin, testosterone (T), dihydrotestosterone (DHT), androstenedione(A), 17-OH-pregnenolone (17-OH-Preg), 17-OH-progesterone (17-OHP), dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), cortisone (F), and 21-desoxycortisone (21DF). Basal and stimulated, and adrenal-testicular steroids with and without ACTH stimulation failed to demonstrate a relevant relationship to semen parameters. Gonadotropin levels had a significant negative correlation to all important semen parameters (testicular volume, sperm count, motility, morphology, and vitality) and were positively correlated to spermiogenetic defects. Stimulated LH values were more clearly associated with spermiogenetic defects than basal LH. Nonetheless, basal FSH concentrations were more informative than LH. Stimulated prolactin values were positively correlated with both gonadotropin and with sperm morphology. E concentrations had a significant positive correlation with both basal and poststimulation DHEAS values, and showed a highly negative correlation with sperm count, morphology, and vitality. In comparison, good sperm parameters were associated with high poststimulation T concentrations. The results of this study suggest that basal FSH and E concentrations, as well as the stimulated LH, T, and prolactin determinations, should be included in the evaluation of male sterility.

Routine hormone load tests are unnecessary in infertile men.

Summary. A sample of 225 men examined at the Infertility Service Unit of this hospital had spermiograms, standardized in accordance with WHO guide lines, and a hormone stimulation test with injection of gonadotropin releasing hormone, thyrotropin releasing hormone, and ACTH. The serum concentrations of the following hormones were assessed: follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, oestradiol (E), thyroid stimulating hormone, cortisol, 21‐desoxycortisol, 17‐hydroxypregnenolone, 17‐hydroxyprogesterone, dehydroepiandrosterone, dehydroepiandros‐teronesulphate, androstenedione, testosterone (T), and dihydrotestosterone. The results of the spermiograms were found to be related to the concentrations of the following hormones: FSH, LH, T, and E. Thyroid and adrenal function in men without signs of endocrinological diseases failed to influence spermatic parameters.