Nathan Kase

Ovulation and pregnancy rates with clomiphene citrate.

A review of recent experience with clomiphene citrate at the Yale-New Haven Medical Center yields the following conclusions: 1) Clomiphene citrate administered at high doses (150 mg and 200 mg) is effective in inducing ovulation in women who would otherwise have failed to conceive if treatment were restricted to only lower dosage regimens. 2) Therapy with clomiphene citrate should be initiated with the 50-mg dose. The 100-mg dose should be reserved for those who fail with the lower dose. 3) Children resulting from clomiphene-induced ovulations appear to be developing normally both mentally and physically. Congenital malformations found in children from clomiphene-induced pregnancies are those seen commonly in general obstetric practice resulting in no significant problems for the children. 4) After 3 ovulations with clomiphene citrate approximately 50% of the patients can be expected to conceive. A 50% conception rate after 3 ovulations with clomiphene citrate does not represent a discrepancy between ovulation rates and pregnancy results, for it agrees statistically with the results obtained for the general population.

Menopause-related Oral Alveolar Bone Resorption: A Review of Relatively Unexplored Consequences of Estrogen Deficiency

OBJECTIVE The alveolar processes of the maxilla and mandible provide the bony framework for tooth support. Osteoporotic changes of these bones may directly affect tooth stability and retention. This report reviews studies that have evaluated the relationship between systemic osteoporosis and oral alveolar bone mass as well as the effect of estrogen use on oral alveolar bone and tooth retention. DESIGN Ten years (1989-1998) literature review. RESULTS Studies reviewed demonstrate a positive correlation between systemic bone mass and systemic osteoporosis to oral bone resorption. Estrogen replacement therapy affects oral bone in a manner similar to the way it affects other sites. CONCLUSIONS It is evident that postmenopausal estrogen users may retain more teeth after menopause. Sustained oral health and better tooth retention are potentially additional benefits for hormone replacement therapy users after menopause.

Biosynthesis of steroid sulfates by normal human testis

Abstract Incubations of normal adult testis tissue with dehydroepiandrosterone-4-14C and testosterone-4-14C has resulted in the isolation and identification of dehydroepiandrosterone-4-14C sulfate and testosterone-4-14C sulfate among other products. Using dehydroepiandrosterone-7α-3H ammonium sulfate as the substrate, testosterone-7α-3H sulfate was also isolated. Identification of certain free steroid metabolites following each incubation is included.

Clomid therapy for anovulatory infertility

Abstract The results of Clomid treatment of 81 infertile patients seeking pregnancy are reported: 60.5 per cent of patients ovulated and 25.9 per cent became pregnant. No unusual side effects of therapy were noted. In general, patients who were oligoovulatory or amenorrheic with evidence of estrogen production had successful responses. These results are comparable to other series. The disparity between ovulation and pregnancy rates in all these studies is noted and a case indicating a Clomid-induced non-corpus luteum source of progesterone production is included.

Effect of clomiphene citrate on oligospermia

Abstract Clomiphene is thought to have an antiestrogenic effect and to enhance the release of gonadotropins from the pituitary. For these reasons, it was administered to 15 oligospermic infertile males that exhibited varying testicular derangements on biopsy to correlate any response with a particular histologic picture. Regardless of the pathology, no improvement in semen count was noted. In 4 cases, semen count depression followed therapy.

Time and the risk of ruptured tubal pregnancy.

OBJECTIVE: Tubal pregnancy remains an important cause of maternal morbidity and mortality. We sought to quantify the relationship of time between symptom onset and treatment and the risk of tubal rupture. METHODS: We reviewed inpatient, clinic, and physician office charts of 221 women with tubal pregnancy. We assessed the conditional risk of rupture with passing time and other factors related to rupture. RESULTS: Time between symptom onset and treatment varied from 3 hours to 66 days with an average of 7 days. There was a 32% rupture rate. The conditional risk of rupture was highest within the first 48 hours of symptom onset (5–7%). The risk dropped, leveled off, and remained fairly steady at approximately 2.5% per 24 hours of untreated symptoms. Classic tubal pregnancy signs, symptoms, and tests were not helpful in predicting rupture. CONCLUSION: The rate of rupture is highest in women with the shortest times between symptom onset and treatment. With passing time, the risk declines, but remains steady despite womens getting into care. LEVEL OF EVIDENCE II-2

A Comparison of Treatment for Bilateral Fimbrial Occlusion

Eighteen patients with bilateral tubal occlusion were divided in an alternating fashion just prior to surgery into two groups for definitive treatment. One group consisted of nine women who underwent a two-stage procedure utilizing a Rock-Mulligan prosthesis; the other nine women underwent terminal salpingostomy utilizing microsurgical technique. Microsurgical technique was defined as the use of microcautery, lavage, and careful handling of tissues; the operating microscope was employed to achieve better visualization and hence better hemostasis and minimized tissue trauma. Both groups received pre-, intra-, and postoperative antibiotics, Decadron, and Phenergan. Hysterosalpingography revealed a patency rate of 89% in the hood group and in the group in which microsurgical technique was used. The term intrauterine pregnancy rates were 22.2% in the hood group (two of nine) and 44.4% in the group in which microsurgical technique was used (four of nine). In this small series there were no ectopic pregnancies or early pregnancy wastage. Subsequently, a series of 54 patients was treated by terminal salpingostomy with an over-all term intrauterine pregnancy rate of 26%. From this study, we conclude that the use of Rock-Mulligan hoods offers no distinct advantage over microsurgical salpingostomy, but has the disadvantage of requiring two surgical procedures.

Steroid synthesis in abnormal ovaries

Abstract 1.1. A case of a granulosa cell tumor, found unexpectedly during laparotomy for confirmed acute appendicitis and associated with polypoid endometrial hyperplasia, is presented. 2.2. In vitro incubation studies of this tumor utilizing precursor pregnenolone-7H 3 and progesterone-7H 3 reveal small quantities of radioactivity incorporation in estrone and estradiol. The bulk of this biosynthetic transformation appears to have proceeded via the intermediary production of dehydroepiandrosterone. 3.3. Comparison of in vitro data from a variety of estrogen producing tissues suggests that whereas nonluteinized tissue forms estrogen via dehydroepiandrosterone without significant elaboration of intermediary progesterone, the reverse is true of the biosynthetic processes of the corpus luteum. 4.4. The considerable inefficiency of this tumors steroid production as opposed to similar processes in the normal follicle is noted.

Gynecologic manifestations of Sjögren's syndrome * ** *

OBJECTIVE Sjögrens syndrome is a chronic, inflammatory autoimmune disease in which the salivary and lacrimal glands are progressively destroyed by lymphocytes and plasma cells. Because women are affected 10 times more often than men, we studied gynecologic manifestations of Sjögrens syndrome. STUDY DESIGN One thousand questionnaires were sent to women with Sjögrens syndrome in New York, New Jersey, Connecticut, and Pennsylvania. Five hundred thirty-nine women responded. RESULTS Women with Sjögrens syndrome reported significant vaginal dryness. There was no relationship of Sjögrens syndrome to either the incidence of infertility or miscarriage, although the 4% incidence of congenital anomalies in offspring was relatively high. Of the congenital anomalies, nine of 19 (47%) were cardiac. A long menstrual cycle (> 35 days) was associated with infertility and neuropathy. CONCLUSIONS The vaginal dryness in women with Sjögrens syndrome is not surprising, because the nasal and esophageal mucosae are also dry in this disorder. The relationship of infertility to a long menstrual cycle may simply indicate the presence of ovulatory dysfunction or inadequate luteal phase unrelated to Sjögrens syndrome. The relationship of neuropathy to a long menstrual cycle may be related to repeated, prolonged estrogen or progesterone exposure during the long cycles or to involvement of hypothalamic-pituitary-ovarian function.

Microsurgical technique in the management of tubal ectopic pregnancy.

Microsurgical techniques employing fine instruments and suture, microelectrocautery and continuous lavage, and careful handling of tissue have been applied to a variety of gynecologic procedures in which the microscope itself is not warranted. The thesis underlying this practice is straightforward: if successful outcome in chronic tubal disease is enhanced by these procedures, then they may have a beneficial role in acute tubal disease. To test this premise, in the past 2 years nine patients with tubal ectopic pregnancies have been managed by microsurgical techniques at Yale-New Haven Hospital. Five of the ectopic pregnancies were unruptured and four were ruptured. The products of conception were removed either by meticulous debridement or linear antimesenteric salpingostomy in association with the microsurgical methods noted above. Tubal healing was by secondary intention. All patients were treated with prophylactic antibiotics and intra-abdominal low molecular weight dextran. Four months postoperatively, all tubes operated upon were patent by salpingography. Subsequently, three of the five women with unruptured pregnancies and two of the four with ruptured pregnancies achieved intrauterine pregnancies. However, one has spontaneously aborted. According to these preliminary results, microsurgical techniques may be beneficially applied in the treatment of selected cases of ectopic pregnancy.