Raphael Jewelewicz

Mood disorders, psychiatric symptoms, and distress in women presenting for infertility evaluation.

Women who undergo treatment for infertility frequently report depression, but it is crucial to distinguish between subjective distress, symptoms, and clinical depressive disorders. In the initial assessment of a prospective, longitudinal study, 59 women presenting for infertility treatment were compared with 35 women presenting for routine gynecological care. Infertility patients and controls were not significantly different on self-report measures of partner satisfaction, sexual functioning, or self-esteem. There was also no difference in psychiatric symptomatology, or in the percentage of subjects who were currently experiencing or had ever experienced a major depressive episode. However, the infertility patients perceived themselves to have been already quite affected by their inability to conceive. For instance, 49.2% reported changes in their sexual functioning and 74.6% reported changes in their mood.

Reproductive potential in the older woman

There is a definite increase in the number of women bearing children in the 30- and 40-year-old age groups. The total number of women who are 35 to 40 years of age in the United States is projected to increase 42% and the percent births to this age group is projected to increase 37%. This is apparently because of a trend to postpone childbearing and first birth due to womens career priorities, advanced education, control over fertility, financial concerns, late and second marriages, and infertility. Associated with this is an increase in visits to the infertility specialist for older women who have an intrinsic decrease in fecundity with advancing age. Although, on the average, a woman will not experience menopause until about 50 years of age, her effective childbearing period may stop almost a decade earlier. A woman in her late 30s and, especially, early 40s is at some disadvantage in terms of conception delay, ability to carry a chromosomally normal fetus until term, and risk of trisomic conception. Certain endocrinologic parameters have been identified for the woman entering the transition to menopause. Biologic aging of the hypothalamic-pituitary-ovarian axis is intertwined with changes in the endocrine milieu of the perimenopause and preperimenopause. Despite a clear association of decreased fecundity in older women due to multiple biologic and social influences, so long as the individual has regular cycles and essentially normal endocrine parameters, she should be a candidate for an expedited infertility workup and ovulation induction, if not more aggressive treatment. Her obstetric profile is much improved, except for an increase in congenital anomalies and chromosomal defects. Chorionic villus biopsy study or amniocentesis is advised in all cases, regardless of therapy.

Management of infertility resulting from anovulation

Recent methods for induction of ovulation in the woman are described. The only indication for use of these medications is induction of ovulation and pregnancy. In properly selected patients, the success rate is quite high, but treatment has undesirable side effects which occasionally may be severe.

Current concepts in estrogen replacement therapy in the menopause

OBJECTIVE To provide a review of the risks and benefits of hormonal replacement therapy in the menopause, including new therapeutic regimens and modes of delivery. DESIGN A review of the literature to identify published studies was accomplished using a computerized bibliographical search (Medline). RESULTS Replacement therapy is effective in treating symptoms of estrogen deficiency and in lowering the risk of osteoporosis and cardiovascular disease. The daily administration of an estrogen and progestin eliminates the withdrawal bleed and increases patient compliance. This continuous form of therapy also consistently suppresses the endometrium, decreasing the risk of hyperplasia. More studies investigating the effect of continuous therapy on the lipid profile and cardiovascular disease are needed. CONCLUSIONS New therapeutic regimens and modes of delivery decrease risk and increase patient acceptance of hormonal replacement therapy.

The use of human menopausal and chorionic gonadotropins for induction of ovulation

Gonadotropin therapy for anovulation is highly successful: 58.6% of treated patients conceive. Better results are achieved in patients with galactorrhea-amenorrhea (77.1%) and hypogonadotropic hypogonadism (63.3%) than in patients with normal gonadotropin levels (45.4%). The spontaneous abortion rate (27.5%) is somewhat higher than that in spontaneous pregnancies. The multiple pregnancy rate is 31% and was slightly lower in cycles with preovulatory estrogen levels in the physiologic range. In patients treated with human menopausal and chorionic gonadotropins for 7 to 9 days per cycle, the multiple pregnancy rate is considerably less (12.9%) than in patients with longer treatment. The efficacy of treatment does not diminish with repeat-treatment cycles.

Congenital Atresia of the Uterine Cervix and Vagina: Three Cases

The outcome of surgical intervention in three patients with congenital atresia of the cervix seen at our institution is reviewed. The results are compared with results in all cases reported in the literature. The embryologic mechanisms that are involved in lower Müllerian tract formation are discussed. In our opinion surgery to preserve fertility in these patients offers little chance of success at great risk and should not be attempted.

Ovarian hyperstimulation syndrome: Report of a case with notes on pathogenesis and treatment☆

Abstract A case of ovarian hyperstimulation is described. This syndrome infrequently appears as a complication of induction of ovulation with human menopausal and chorionic gonadotropins. The clinical manifestations are weight gain, extreme ovarian enlargement, ascites with pleural effusion, oliguria, and hypotension. Severe cases may become life-threatening due to marked fluid shifts, electrolyte imbalance, intravascular hypovolemia, and hypercoagulability. The pathogenesis of this syndrome is discussed, and suggestions are made about management. Therapy is symptomatic, expectant, and conservative unless surgical intervention becomes necessary in cases of intraperitoneal bleeding due to ovarian rupture. Physicians using gonadotropins for the treatment of infertility should be thoroughly familiar with the physiopathology of this complication.

Pulsatile administration of gonadotropin-releasing hormone for induction of ovulation

Chronic pulsatile administration of gonadotropin-releasing hormone (GnRH) was used to induce ovulation in 12 women with various ovulatory disorders. In the first group of eight patients with normal to low baseline levels of gonadotropin, seven responded favorably to the treatment. Follicular maturation was observed in 57% of the treated cycles, and normal ovulatory cycles were induced in 24% of the patients. Two patients became pregnant. The intravenous route of administration was more effective than the subcutaneous one, possibly in response to the GnRH profile after each pulse. (The amplitude of GnRH peaks after an intravenous pulse was four times that seen after a subcutaneous one.) In contrast, follicular maturation and ovulation could not be induced in four women of a second group of patients with normal baseline levels of follicle-stimulating hormone but with high and frequent pulses of luteinizing hormone. The conclusion reached was that pulsatile administration of GnRH can be a new therapeutic tool in the treatment of ovulatory disorders in women who have an insufficient endogenous release of GnRH.

Intravenous infusion of prostaglandin F2α in the mid-luteal phase of the normal human menstrual cycle

The luteolytic effect of PGF2alpha was studied in 3 normal women. Plasma levels of estrogens progesterone and gonadotropins were measured daily. Following a control cycle an infusion of 100 mcg/minute of PGF2alpha over an 8 hour period was given. 2 subjects received the PGF2alpha on the 9th and one on the 5th postovulatory day. The steroid patterns during the control and treatment cycles were not significantly different and the length of the luteal phases was identical. To accentuate luteal activity 2 subjects received in subsequent cycles 10000 i.u. HCG 48 hours prior to the PGF2alpha infusion. In these cycles despite the PGF2alpha the steroids continued to rise and then gradually declined in a normal fashion. The luteal phase was not curtailed. All subjects experienced nausea vomiting painful uterine contractions staining and temperature elevations above 100 degrees Fahrenheit during infusion. It is concluded that in the human PGF2alpha at the given dose was not luteolytic. (authors)

A controlled study for gender selection

OBJECTIVE To evaluate the success for gender selection of insemination with a sample of semen separated by a serum albumin density separation gradient. DESIGN We retrospectively compared the gender outcome of conceptions of couples who conceived spontaneously with those who conceived secondary to an insemination with separated semen. SETTING Private practice of one author (M.A.K.). PATIENTS, PARTICIPANTS The study group consisted of 48 pregnancies of couples who conceived by the separation technique. The control group consisted of 46 pregnancies of couples who initially presented for consultation for gender selection but conceived spontaneously. INTERVENTIONS In the study group, one timed intrauterine insemination with separated semen was performed per cycle, with a mean of 2.3 cycles per couple. Patients desiring a female were also treated with clomiphene citrate and human chorionic gonadotropin. MAIN OUTCOME MEASURE The gender outcome of the pregnancies of the two groups was evaluated based on the known desired gender. RESULTS The success rate for conceiving a desired male was 56.5% in the study group and 60.9% in the control group (P = 1.000). Of couples seeking females, 78.6% of the procedure group versus 35.3% of the control group were successful (P = 0.019). CONCLUSIONS This study debates the albumin gradient as definitively enriching the proportion of Y-bearing sperm after in vitro separation.