Age of the female partner is a prognostic factor in prolonged unexplained infertility: a multicenter study

Among 2,106 couples registered in 12 Canadian infertility clinics, 470 (22.3%) were classed as unexplained infertility after a uniform evaluation of the male ejaculate, ovulation, and tubal patency. The unexplained group included more older female partners; 44% were over 30 years of age at registration in the participating clinics, compared with 36% in other infertility diagnostic groups. The mean duration of infertility was 40.1 months, and the cumulative pregnancy rate was 36.6 +/- 2.9% at 2 years after registration. When the variables were examined with the use of proportional hazards analysis, each additional month of duration of infertility reduced the expected prognosis by 2%, and a history of pregnancy in the partnership improved the prognosis by 80%. Among couples with 3 years or more duration of infertility (cumulative pregnancy rate, 27.5 +/- 3.9%), an additional year in the age of the female partner when conception was first attempted (mean, 26.8 years) reduces the prognosis by 9%.

Unexplained infertility: evaluation of treatment with clomiphene citrate and human chorionic gonadotropin

A double-blind, randomized, prospective therapeutic trial was conducted in 148 couples with unexplained infertility. Treatment consisted of 4 consecutive months of placebo or clomiphene citrate (CC) (100 mg) by mouth on cycle days 5 to 9, and placebo or human chorionic gonadotropin (hCG) (5,000 IU) intramuscularly on cycle days 19, 22, 25, and 28. There were 14 pregnancies during the trial and 39 pregnancies during observation before and after the trial. Placebo treatment resulted in no pregnancies over 4 months. Clomiphene citrate was significantly better than placebo (P less than 0.04), with a pregnancy rate of 19% over the course of 4 months. The pregnancy rate with hCG either alone (11%) or in combination with CC (7.6%), was not significantly better than placebo. Treatment-independent pregnancies, defined as those before treatment (but after enrollment), or more than 1 month after therapy, occurred in 16% of the couples, with a mean time to conception of 8.8 months. As part of their follow-up, 39 of the study couples subsequently underwent in vitro fertilization (IVF), and 43% were found to have a previously unrecognized male factor or fertilization defect. A pregnancy rate of 16% was achieved after a mean of 1.1 cycles in these 39 couples. The authors conclude that CC is useful in treating unexplained infertility and is a reasonable initial therapy. For couples who fail to conceive, IVF may be diagnostic as well as therapeutic.

Metastatic malignant struma ovarii presenting as paraparesis from a spinal metastasis

A 42-yr-old woman had a solitary metastases to her spine (T2) from a malignant struma ovarii. The thyroid was excluded as the site of the primary cancer. The lesion caused paraparesis. The spinal metastasis was treated by surgery and two doses of 131I (200 mCi each time). The patient responded very well and is entirely free of symptoms and signs. Repeat whole-body 131I scan shows no abnormality.

Efficacy and safety of constant-rate intravenous cyclosporine infusion immediately after heart transplantation

Oral cyclosporine therapy immediately after heart transplantation is erratic and difficult to predict. The purpose of this study was to evaluate the relative efficacy and safety of cyclosporine when administered by constant-rate infusion immediately after transplantation. Nineteen patients (17 men and two women) aged 50 years (range 25 to 61 years) who weighed 71 +/- 9 kg, participated in the study and received cyclosporine, 7 to 10 mg/hr (117 +/- 15 micrograms/kg/hr). The infusions were initially maintained for 26 +/- 5 hours (range 18 to 42 hours) without adjustments in dosage. Whole blood samples were obtained at hourly intervals for the first 8 to 12 hours and then daily throughout the 7-day study period and were analyzed by high-performance liquid chromatography. Constant-rate cyclosporine infusion resulted in therapeutic blood levels (350 to 450 ng/ml) at 6 hours. These levels remained relatively steady throughout the 7-day infusion, requiring only minimal dosage adjustments. Kidney function was not altered significantly after 7 days of intravenous cyclosporine therapy as evidenced by a mean serum creatinine level of 1.3 mg/dl before therapy and 1.4 mg/dl after therapy. There, however, was a transient rise in serum creatinine level in most patients on the second or third day after transplantation that resolved without a reduction in cyclosporine dosage. The mean endomyocardial biopsy score at 1 week after transplantation was 0.1, and only four of the patients required additional immunosuppressive therapy to treat rejection during the first 6 weeks after transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of technetium pertechnetate as a radionuclide marker of pulmonary aspiration of gastric contents in rabbits

At present, there is no sensitive and specific test to confirm the clinical impression that a respiratory disorder is due to aspiration of gastric contents. Since intravenous technetium pertechnetate (99mTcO4-) has been shown to be safe, actively concentrated in the gastrointestinal tract, and secreted into gastric juice, we sought to determine whether 99mTcO4-, when given intravenously, is suitable to detect pulmonary aspiration of small amounts of gastric contents in rabbits. Biodistribution studies over 24 h revealed that 99mTcO4- persistently appeared in the stomach, thyroid, and salivary glands and did not appear in the lungs. Pharmacokinetic studies showed that 99mTcO4- was rapidly picked up by the stomach wall and secreted promptly into the stomach lumen and that the stomach wall persistently secreted 99mTcO4- into stomach contents for 24 h. By injecting 99mTcO4- through an intratracheal catheter in order to simulate aspiration, the radioactive threshold for imaging intrapulmonary 99mTcO4- was determined to range between less than 0.5 microCi and 2 microCi, depending on the amount of background activity in the blood pool. By measuring the radioactivity in stomach contents (microCi/g), over 24 h after intravenous injection of 2 mCi of 99mTcO4-, we were able to calculate the amount of aspirated stomach contents that our technique should reveal at various time points. We concluded from this preliminary feasibility study that 99mTcO4-, when given intravenously, is suitable to detect pulmonary aspiration of small amounts (less than or equal to 4 ml for 8 h after an intravenous dose of 2 mCi) of gastric contents in human patients. Since our biodistribution studies show that saliva as well as stomach contents are potential sources for any aspirated 99mTcO4-, how to distinguish aspiration of oropharyngeal from stomach contents remains to be determined. It also remains to be determined how long 99mTcO4- remains in the lungs after it has been instilled; clearance that is too rapid significantly decreases the ability of this agent to reveal aspiration.

Receiver-operating characteristics curves for semen analysis variables: methods for evaluating diagnostic tests of male gamete function

This study draws on decision analysis to estimate the utility of seminal variables in predicting pregnancy. The infertile couples selected (n = 709) excluded those who had donor insemination or known female factors (history of pelvic infection, ovulatory disorders, endometriosis, and tubal disease). Diagnostic test properties were calculated with respect to pregnancy for two variables derived from the semen analysis report: sperm density, and the total number of motile sperm in the ejaculate (TMS). Receiver-operating characteristic (ROC) curves based on sensitivity and specificity revealed that none of the proposed thresholds for sperm density or TMS is clearly a best choice. The highest positive predictive values for sperm density (75%) and TMS (75%) were associated with cutoff points at five million sperm per milliliter and five million motile sperm per ejaculate, respectively. The false positive rates when these cutoff points were used were 4.3% (sperm density) and 5.6% (TMS). ROC analysis provides visual and numeric evidence of the quality of a diagnostic test and constitutes a set of procedures for incorporating information from new tests of male gamete function into the diagnostic assessment of infertility.

Interpretation of semen analysis among infertile couples

Among the male partners of 1074 infertile couples the mean results of semen analysis were sperm count 78 X 10(6)/ml, seminal volume 4.0 ml, proportion of progressively motile sperm 54%, proportion of sperm with normal morphologic features 81.4% and total motile sperm count 152.3 X 10(6) per ejaculate. After excluding 65 couples who chose donor insemination and 300 with known female causes of infertility, the cumulative pregnancy rates in the remaining 709 couples were higher with increasing sperm density and motility and seminal volume, but the higher rates were significant only when these variables were combined into total motile sperm count per ejaculate. The cumulative pregnancy rates were 20% with a total motile sperm count of 9 X 10(6) or less, 37% with a count of 10 to 19 X 10(6) and 52% with a count of 20 X 10(6) or more (p = 0.001). Counts higher than 20 X 10(6) were not associated with a further improvement in pregnancy rates, but variability in the results was high, which suggests that the test should be repeated as necessary to determine the true range. Although standards for these and other seminal variables are ill defined, the total motile sperm count incorporates the most useful prognostic information from semen analysis, and the associated pregnancy rates can help guide clinical decisions.

Use of cyclosporine and ketoconazole without nephrotoxicity in two heart transplant recipients

A cyclosporine-ketoconazole drug interaction was first described in 1981. It has been suggested that the two drugs should not be used concomitantly because of the danger of severe nephrotoxicity. Two reported cases indicate that cyclosporine and ketoconazole can be safely coadministered, provided that the dosage of cyclosporine is reduced appropriately. Two patients were initially given 8 mg/kg/day of cyclosporine at the time of heart transplantation, and the dosage was tapered to meet appropriate blood levels (250 to 350 ng/ml by whole blood high-performance liquid chromatography). During ketoconazole therapy (400 mg daily for 4 weeks), patient 1 received 80 to 100 mg/day of cyclosporine, which is equal to approximately 1 mg/kg/day, and patient 2 received between 40 and 80 mg/day of cyclosporine, which is equivalent to 0.4 to 0.8 mg/kg/day. Neither patient exhibited a creatinine value above 1.4 mg/dl while on combined therapy, and there were no problems with allograft rejection. Both patients had inappropriately high cyclosporine blood levels even with this marked reduction in dosage (patient 1, 520 to 1310 ng/ml and patient 2, 320 to 600 ng/ml). Thus it appears that cyclosporine and ketoconazole can be administered together safely, provided that there is an appropriate reduction in the dosage of cyclosporine; this results in the maintenance of adequate immunosuppression without development of nephrotoxicity.

The effects of prostaglandin E1 on the adult respiratory distress syndrome in septic primates

The effects of prostaglandin E1 (PGE1) on the adult respiratory distress syndrome were studied in the septic primate (Macaca fascicularis). A 30-min infusion of Escherichia coli (1 X 10(10)/kg) resulted in severe septic shock and adult respiratory distress syndrome. Primates, if living, were killed 4 h after completion of the E. coli infusion. Three groups of primates were studied (n = 4 in each group). The control group (Group 1) received PGE1 at 100 ng/kg/min throughout the experiment. The septic group (Group 2) received a 30-min infusion of E. coli. The treatment group (Group 3) received a continuous PGE1 infusion (100 ng/kg/min) along with the E. coli infusion which was begun 30 min after the PGE1 infusion was started. Control primates had hemodynamic changes consistent with the vasodilatory effect of PGE1 (heart rate and cardiac output increased; blood pressure and systemic vascular resistance (SVR) decreased). All control animals survived the experiment and had no evidence of pulmonary damage. Primates given E. coli developed severe hypotension, decreased SVR, and lung injury evidenced by pulmonary edema, decreased oxygenation, and increased extravascular lung water. Primates treated with both PGE1 and E. coli developed similar cardiovascular and pulmonary changes as the septic group. There was no statistically significant difference between Group 2 and Group 3 animals with regard to mean arterial blood pressure, SVR, extravascular lung water, alveolar-arterial oxygen difference, or survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of anti-C5a antibodies on the adult respiratory distress syndrome in septic primates

In vitro and in vivo studies have suggested that human complement component C5a plays a key role in neutrophil injury in the adult respiratory distress syndrome (ARDS). First, using leukocyte aggregometry, we demonstrated that the addition of a recently developed rabbit anti-human polyclonal antibody to C5a des arg to endotoxin-activated plasma prevented leukocyte aggregation in vitro. We then administered the anti-C5a des arg antibody to septic primates (Macaca fascicularis). Three groups of primates, control, septic, and anti-C5a antibody treated septic, were studied (n = 4 in each group). A 30-min infusion of Escherichia coli (1 X 10(10)/kg) resulted in severe sepsis and ARDS. Primates were killed 4 h after completion of the E. coli infusion. Septic animals not treated with anti-C5a antibody had 75% mortality (3/4), decreased oxygenation, severe pulmonary edema, and profound hypotension. Septic primates treated with anti-C5a antibodies did not die and did not develop decreased oxygenation (P less than 0.05) or increased extravascular lung water (P less than 0.05). They also had a marked recovery in their mean arterial blood pressure (P less than 0.05). This study demonstrates that treatment with rabbit anti-human C5a des arg antibodies attenuates ARDS and some of the systemic manifestations of sepsis in nonhuman primates.

The better prognosis in secondary infertility is associated with a higher proportion of ovulation disorders

To determine the reason for the higher pregnancy rate in couples with secondary infertility, the authors compared 237 infertile couples who had a previous pregnancy in the current partnership (secondary infertility) with 135 infertile couples in whom the woman had been pregnant only in a previous partnership and 925 couples with primary infertility. Couples with secondary infertility had the highest proportion of ovulation disorders (36%); these couples with secondary infertility and an ovulation disorder had the shortest duration of infertility (26 months). Cumulative pregnancy rates at 36 months were 56% in secondary fertility, 44% in primary infertility, and 42% in pregnancy in a previous partnership (P = 0.001). In this study, the better prognosis in secondary infertility may be related to the higher proportion of couples with ovulation disorders, who had a shorter duration of infertility. Abortion rates in the earlier pregnancies with current or previous partners were 37% and 30%, respectively; after the period of infertility, the abortion rates were 14% and 12%, respectively.

Effects of dexamethasone, progesterone, and testosterone on IOP and GAGs in the rabbit eye

The effects of steroids on intraocular pressure and on aqueous outflow pathway (AOP) and adjacent anterior segment tissue glycosaminoglycans (GAGs) were studied in New Zealand Red rabbits treated for 4 wk with dexamethasone, hydroxymethyl-progesterone and methyl-testosterone. Only topical administration of dexamethasone resulted in a significant increase in intraocular pressure. The eyes were labeled in vitro for 1 hr with GAG precursors, [3H]-glucosamine and [35S]-sulfate, and maintained as whole organ cultures. The GAGs were biochemically isolated, fractionated by gel filtration chromatography and subjected to selective GAG degradative procedures. The total content of hyaluronic acid and chondroitin sulfate was analyzed by high performance liquid chromatography. In dexamethasone-treated eyes, the total content of hyaluronic acid was decreased in the AOP, although the specific activity of [3H]-glucosamine did not change. The total content of chondroitin sulfate was increased in the AOP and iris-ciliary body, while the specific activity of the [35S]-label was decreased in the AOP, iris-ciliary body, and sclera. The changes in the AOP GAGs in dexamethasone-treated eyes may be important factors for the development of dexamethasone-induced ocular hypertension in the rabbit.

Microbiological and histological findings in the fallopian tubes of women using various contraceptive methods

The oviducts of seventy-three women undergoing sterilization by partial salpingectomy were submitted for microbiological and histologic studies. Twenty women were intrauterine device users, twenty-five women were oral contraceptive pill users and twenty-eight women used natural or barrier methods of contraception. Among intrauterine device users, there was an excess of mild and severe acute inflammatory histologic changes involving both the lumen and the tubal mucosa. Five of the eight intrauterine device users with acute inflammatory change had sterile tubal cultures.

The postcoital test as a predictor of pregnancy among 355 infertile couples

Late follicular phase postcoital tests in 355 infertile couples (selected to exclude severe defects in ovulation, seminal or tubal function) were scored for mucus characteristics and sperm motility. Cervical mucus characteristics were associated with postcoital sperm motility (P less than 0.001) but not with pregnancy. Postcoital sperm motility in cervical mucus was strongly associated with total motile sperm count per ejaculate (F = 5.38, P less than 0.001). Postcoital sperm motility was a weak predictor of pregnancy when more than five motile sperm were observed per high power microscopic field. When the log rank tests for postcoital sperm motility were repeated in groups with low (less than 10 million) and high (10 million or more) total motile sperm count per ejaculate, the association between postcoital sperm motility and pregnancy was not statistically significant. Regression analysis controlling for other potential predictors revealed no independent association between postcoital sperm motility and the later occurrence of pregnancy in this group of infertile couples.

Hypersensitivity reaction to doxorubicin

A 42-year-old woman with synovial sarcoma developed a skin flare during doxorubicin therapy. With a subsequent dose, erythema, urticaria, and asthma occurred, despite pretreatment with antihistamines. Skin flares occur in about three percent of patients receiving doxorubicin. Rarely, generalized urticaria, angioneurotic edema, or anaphylaxis occur. Local reactions may represent molecular extravasation through vessels, or histamine release from mast cells or basophils. Generalized reactions may involve alternative complement-activation pathways. Pretreatment with antihistamines or corticosteroids sometimes is helpful in preventing recurrences.

A proportional hazards analysis of the clinical characteristics of infertile couples

Evaluated were methods of ordering the many possible predictors of infertility outcome. The clinical characteristics of infertile couples were studied with respect to the occurrence of pregnancy during follow-up, by means of the methods of survival analysis. Among 1,297 couples who were infertile for 12 months or more, the cumulative pregnancy rate at 36 months with 95% confidence limits was 49% +/- 4%. The proportional hazards analysis identified three independent predictors of the occurrence of pregnancy from the couple's history (with P values in brackets): a history of pregnancy in the partnership (0.0001); shorter duration of infertility (0.0001); and shorter length of marriage (0.005). The predictors arising from the diagnostic process (with P values in brackets) were: fewer infertility diagnoses (0.0001); a favorable primary clinical diagnosis (0.001); and the presence of any tubal disease, regardless of the primary clinical diagnosis (0.001). The analysis selected an economical set of significant predictor variables and demonstrated that a longer period of contraception was associated with a lower pregnancy rate among infertile couples. Also, three simple questions from the history were nearly equivalent to the entire diagnostic process as predictors of the outcome.

Clinical factors affecting pregnancy rates among infertile couples

In a follow-up study of 1297 couples registered at a Nova Scotia infertility clinic with a complaint of infertility of at least 12 months' duration, the cumulative pregnancy rate at 36 months, with 95% confidence limits, was found to be 49 +/- 4%. The predictors of pregnancy by univariate analysis were a favourable primary clinical diagnosis (p less than 0.001), a duration of infertility of less than 3 years (p less than 0.001), a single diagnosis for the infertility (p less than 0.001), a previous pregnancy in the partnership (p = 0.001) and a length of marriage of less than 4 years (p = 0.002). Proportional hazards analysis confirmed these variables as predictors of pregnancy. The highest cumulative pregnancy rates after 12 and 36 months of follow-up were observed in cases of ovulation deficiency, and the lowest were seen in cases of tubal defects. However, before the process of diagnosing infertility begins, useful prognostic information can be determined from the length of marriage, the duration of infertility and the partnership's history of previous pregnancy.

Aqueous outflow pathway complex carbohydrate synthesis in vitro

A technique is described for examining the in vitro synthesis of glycosaminoglycans and glycoproteins in the aqueous outflow pathway (AOP). New Zealand red rabbit eyes were maintained at near-physiologic conditions and were infused by anterior chamber exchange with 30 muCi [3H] glucosamine and 100 muCi [35S] sulfate. At 0.5, 1.0, and 2.0 hours, the anterior segment tissues were dissected, isolated, and fractionated by gel filtration chromatography on Sephadex G-50 columns. The elution profiles demonstrated an increase of labeled material with time in the glycosaminoglycan (GAG) fractions and in the glycopeptide fractions. The relative rate of synthesis of labeled material was: central cornea greater than peripheral cornea greater than iris-ciliary body greater than AOP greater than anterior sclera. In order to characterize the profiles of each tissue, the isolated material was analyzed for hexosamine, hexuronic acid, and sulfate. The AOP cells synthesized a heterogenous mixture of GAGs and glycoproteins which biochemically appeared to be distinct from other anterior segment tissues. In addition, the percent distribution of GAG polymers in each tissue was determined by selective GAG degradative procedures and by gel filtration chromatography. The AOP cells synthesized four types of GAGs, and the percent distribution of the labeled GAGs was different from the other tissues. The present results suggest that this technique may provide a well-controlled method to probe the metabolic activity of complex carbohydrates in the AOP and in the anterior segment.