The transCampus Metabolic Training Programme Explores the Link of SARS-CoV-2 Virus to Metabolic Disease

Currently, we are experiencing a true pandemic of a communicable disease by the virus SARS-CoV-2 holding the whole world firmly in its grasp. Amazingly and unfortunately, this virus uses a metabolic and endocrine pathway via ACE2 to enter our cells causing damage and disease. Our international research training programme funded by the German Research Foundation has a clear mission to train the best students wherever they may come from to learn to tackle the enormous challenges of diabetes and its complications for our society. A modern training programme in diabetes and metabolism does not only involve a thorough understanding of classical physiology, biology and clinical diabetology but has to bring together an interdisciplinary team. With the arrival of the coronavirus pandemic, this prestigious and unique metabolic training programme is facing new challenges but also new opportunities. The consortium of the training programme has recognized early on the need for a guidance and for practical recommendations to cope with the COVID-19 pandemic for the community of patients with metabolic disease, obesity and diabetes. This involves the optimal management from surgical obesity programmes to medications and insulin replacement. We also established a global registry analyzing the dimension and role of metabolic disease including new onset diabetes potentially triggered by the virus. We have involved experts of infectious disease and virology to our faculty with this metabolic training programme to offer the full breadth and scope of expertise needed to meet these scientific challenges. We have all learned that this pandemic does not respect or heed any national borders and that we have to work together as a global community. We believe that this transCampus metabolic training programme provides a prime example how an international team of established experts in the field of metabolism can work together with students from all over the world to address a new pandemic.

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.

Intracytoplasmic injection of spermatids retrieved from testicular tissue: influence of testicular pathology, type of selected spermatids and oocyte activation

Spermatid microinjection into oocytes has proven to be a successful assisted reproduction procedure in the animal model and in the human species, since in the latter a few full-term pregnancies were actually obtained. Patients entering our spermatid injection study included those with a total absence of spermatozoa in the testicular tissue notwithstanding previous positive biopsies (n = 29): an obstructive problem (n = 3), secretory azoospermia (n = 26), and those with total arrest at the spermatogenesis level in previous explorative biopsies (n = 15). In the latter group, absence of spermatids was recorded in four cases. Mature, elongated, elongating and round spermatids (ROS) were injected in respectively 3, 2, 3, and 32 attempts. A total of 260 metaphase II oocytes were injected with ROS, 36 oocytes with spermatids at other stages of maturity. The rates of oocytes showing two pronuclei (2PN) and two polar bodies reached 22% and 64% respectively after injection of round or elongated-mature spermatids. The fertilization rate after ROS injection was influenced by the percentage of spermatozoa observed in a previous biopsy. Patients with a positive preliminary biopsy had significantly more 2PN (33%) when compared to those with a severe spermatogenic dysfunction and in whom no spermatozoa were found (only 11%) (P < 0.05). Incubation of oocytes in calcium ionophore after ROS injection had a positive effect on the rate of 2PN formation (36 versus 16%). Ninety per cent of all the normally fertilized oocytes cleaved. The percentage of grade A and B embryos depended on the type of injected cells: 12% after ROS and 30% with the other types of haploid cells. A total of 39 transfers resulted in five pregnancies: three full term with healthy babies delivered (one after ROS injection, and two after injection of an elongating and a mature spermatid), one 4 months ongoing (after elongating spermatid injection) and one miscarriage at 4 weeks (after elongated cell injection). Compared to our conventional intracytoplasmic sperm injection-testicular sperm extraction (ICSI-TESE) programme, the implantation rate after ROS injection was very low (5.5 versus 10.5%).

Intracytoplasmic sperm injection, fertilization, and embryo transfer after retrieval of spermatozoa by testicular biopsy from an azoospermic male with testicular tubular atrophy

OBJECTIVE

To achieve fertilization and cleavage by spermatozoa retrieved by testicular biopsy from a male with testicular tubular atrophy.

DESIGN

Clinical trial.

SETTING

Private reproductive institute.

PATIENT

Azoospermic male with demonstrated testicular tubular atrophy and almost complete spermatogenic arrest.

INTERVENTION

Open biopsy retrieval of testicular tissue and sperm followed by intracytoplasmic sperm injection.

MAIN OUTCOME MEASURES

Fertilization and cleavage.

RESULTS

One four- to six-cell embryo was formed after intracytoplasmic sperm injection of five eggs with extruded polar bodies by retrieved sperm.

CONCLUSION

Intracytoplasmic sperm injection after testicular sperm aspiration may be attempted in cases with severely decreased spermatogenesis and result in fertilization, cleavage, and embryo transfer.

Functional anatomy and physiology of the female breast

As mammals, we define our biologic class by the function of the breast in nourishing our young. As obstetricians, we seek to enhance or diminish function; as gynecologists, the appearance of inappropriate lactation (galactorrhea) may signify serious disease. In this article, development, differentiation, and functional anatomy of the breast is discussed. The hormonal interactions responsible for these events and the physiologic function of this vital reproductive organ during the life cycle of the woman is emphasized.

Incidence of autoimmune antibodies in failed embryo transfer cycles

PROBLEM

The presence of antiphospholipid antibodies lupus anticoagulant (LAC), anticardiolipin antibody (ACA) as well as antinuclear antibody (ANA) has been associated with early spontaneous pregnancy loss and adverse pregnancy outcome. The purpose of this study was to investigate the possible role of autoimmune antibodies (LAC, ACA, and ANA) as a cause of implantation failure following embryo transfer (ET) after in vitro fertilization (IVF).

METHOD

Three groups were studied: Group I, 56 patients who failed to conceive following ET; group II, 14 patients who have conceived following IVF-ET and delivered or are carrying an uncomplicated ongoing pregnancy; and group III, 69 patients who were new candidates for IVF-ET.

RESULTS

Eighteen out of 56 (32.1%) of patients who failed to conceive following previous IVF-ET cycle (group I) tested positive for one or more of the autoimmune antibodies. None of the 14 patients of group II tested positive for autoimmune antibodies (P < .02). Seven out of the 69 patients (10%) of group III were found positive to one or more of the autoimmune factor. This rate is significantly lower than the rate of positive autoimmune antibodies detected in group I (P < .003). Fifteen patients of the 18 who tested positive for autoimmune antibodies and who had previously failed to conceive following ET underwent a subsequent IVF-ET cycle while being treated with prednisone and aspirin. Seven out of the 15 (46.6%) conceived and were able to sustain a clinical ongoing pregnancy.

CONCLUSIONS

Patients receiving ET are carrying viable embryos within the intrauterine environment. Therefore, in this unique group of patients, failure to demonstrate a positive pregnancy test represents an implantation failure or a very early postimplantation loss. The results of this study suggest that periimplantation events may be affected by autoimmune antibodies. Very early miscarriage or implantation failure may be related to the same pathophysiological mechanism that causes recurrent miscarriages and is diagnosed incorrectly as infertility.

Gynecologic manifestations of Sjögren's syndrome

OBJECTIVE

Sjögren's 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 Sjögren's syndrome.

STUDY DESIGN

One thousand questionnaires were sent to women with Sjögren's syndrome in New York, New Jersey, Connecticut, and Pennsylvania. Five hundred thirty-nine women responded.

RESULTS

Women with Sjögren's syndrome reported significant vaginal dryness. There was no relationship of Sjögren's 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 Sjögren's 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 Sjögren's 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.

Successful full-term pregnancy in familial Mediterranean fever complicated with amyloidosis: case report and review of the literature

Pregnancy during familial Mediterranean fever complicated with amyloidosis and severe nephrotic syndrome is rare and may cause several maternal and fetal complications. Asymmetrical intrauterine growth retardation, superimposed preeclampsia, thromboembolic phenomena, resistant anemia and renal failure only partially represent the possible complications. A successful outcome of a full-term pregnancy is presented and the efficiency of colchicine, a high protein diet, acetylsalicylic acid and dipyridamole is discussed.

Multiple pregnancies: risk factors and prognostic variables during induction of ovulation with human menopausal gonadotrophins

Multiple pregnancies still constitute a major and relatively frequent complication of induction of ovulation by human menopausal gonadotrophins (HMG) despite the increasing sophistication of monitoring techniques. In order to define specific variables which may be associated with multiple pregnancies, we have compared 51 multiple pregnancy cycles to 51 consecutive control singleton pregnancy cycles, following HMG induction of ovulation. The aetiology and classification of anovulation, duration of infertility, total amount of HMG utilized per cycle and the duration of stimulation were not associated with an increase in the rate of multiple pregnancy. Basal serum oestradiol levels and its periovulatory pattern were remarkably similar in the singleton and multiple pregnancy groups. The mean age of the multiple pregnancy group (29.4 +/- 4.4 years) was significantly lower than the mean age of the singleton pregnancy group (31.6 +/- 5.3 years) (P less than 0.05). In the multiple pregnancy group, there were significantly more cycles with intermediate sized (15-17 mm). (P less than 0.002), small sized (12-14 mm). (P less than 0.02) and immature follicles (less than 12 mm) (P less than 0.03), at the time of human chorionic gonadotrophin (HCG) administration, as compared with the singleton pregnancy group. Furthermore, a direct linear correlation was observed between the number of intermediate sized follicles and number of implanted embryos. The presence of intermediate sized follicles at the time of HCG administration after HMG induction of follicular maturation is predictive of, and independently associated with, a higher incidence of multiple pregnancy.

Menopause medicine: current treatment options and trends

Demographic trends and increasing demand, as well as the intricacy of the emerging field of menopause medicine, dictates the need for a multidisciplinary approach for the care of the peri- and postmenopausal patient. A menopausal program benefits the individual patient by obviating the acute symptoms and by preventing long-term consequences. As morbidity and mortality rates associated with the long-term implications are reduced, substantial public health aspects are also beneficially affected. Cost effectiveness of a menopause program and routine HRT should be calculated as the net present value (NPV) for the health care financing program, and should prove to be greater than the NPV of future costs anticipated without an investment in primary preventive menopause program. We believe that the educated use of a menopause counseling program will yield an increasing benefit for the individual patient and the community. Should menopause be regarded as an endocrinopathy, thus justifying routine HRT, or are we engaged in the "medicalization" of a physiologic process? Bearing in mind the data reviewed above, it seems to us that ample reason exists to make every woman aware of the opportunity to receive long-term HRT. The decision to use it depends heavily on the patient's own informed assessment of her particular benefit-risk equation. Combined-continuous estrogen-gestagen replacement seems to provide the desired multisystem beneficial effects, and at the same time be the most convenient and associated with the least short-term side effects. Although emerging trends regarding the long-term risks associated with the use of such regimes are reassuring, more information needs to be elaborated before final conclusions can be offered.

Preovulatory luteinization during induction of follicular maturation with menotrophin and menotrophin--clomiphene combination

Late follicular phase levels of 17 beta-oestradiol (E2) and progesterone (P) in serum were studied during the induction of follicular maturation with human menopausal gonadotrophin (HMG) (n = 23) and HMG-clomiphene citrate (CC) (n = 18). For each patient one hormonal profile was studied between 6 days to 2 h before administration of human chorionic gonadotrophin (HCG). Ultrasonographic follicular measurement at the time of evaluation demonstrated preovoulatory ovarian follicles of various number and size in all patients studied. Sixteen endometrial biopsies were performed at the time of evaluation (eight for each subgroup), before HCG administration. Mean late follicular phase levels of E2 did not differ significantly between the two groups (436 +/- 348 and 475 +/- 267 pg/ml for the HMG and HMG-CC groups respectively). The mean progesterone levels in the HMG-CC group (1.233 +/- 0.67 ng/ml) was significantly higher than that for the HMG group of (0.86 +/- 0.55 ng/ml, P less than or equal to 0.04). The mean time interval between ovulation and HCG administration for the two groups was 2.5 and 2.4 days for the HMG and HMG-CC groups, respectively. In all eight biopsies taken from the HMG group, various stages of endometrial proliferation were demonstrated. Premature glandular secretory transformation and oedematous stroma were observed in three out of eight biopsy specimens obtained from the HMG-CC group. Taken together, these results demonstrate that subtle or full premature luteinization in the late follicular phase occurs more frequently with the use of HMG-CC for induction of follicular maturation.

Endometrial glandular haemosiderosis in homozygous beta-thalassaemia

Female patients with beta-thalassaemia major usually suffer from hypogonadotropic hypogonadism associated with amenorrhea, anovulation and infertility, attributed to the deposition of haemosiderin in the pituitary gland as well as in the ovaries. Pregnancies are rare and, with few exceptions, occur mainly in patients with beta-thalassaemia intermedia. Our study presents histopathological evidence that deposition of haemosiderin occurs in the endometrial glandular epithelium of 3 patients with beta-thalassaemia major. This deposition is mainly evident in the apical part of these cells above the nuclei, and should be taken into consideration as a contributing factor to the infertility in these patients by altering endometrial receptivity for implantation. In 2 patients who received effective iron chelating treatment with desferrioxamine the endometrial haemosiderin deposits either disappeared (patient C.R.), or were significantly reduced (patient G.L.).

Successful full-term pregnancy in homozygous beta-thalassemia major: case report and review of the literature

Patients afflicted by homozygous beta-thalassemia suffer from severe anemia and hypersplenism and are dependent on blood transfusions. The consequent hypoxia and massive tissue iron deposition lead to concomitant cardiac, hepatic, and endocrine system failure. Hemodynamic changes related to gestation may aggravate the underlying multiorgan damage of the pregnant mother and lead to high fetal wastage. These entanglements may be prevented by performing thorough maternal and fetal surveillance and by maintaining the hemoglobin concentration above 10 g/dL. We describe a successful full-term pregnancy in a patient with transfusion-dependent homozygous beta-thalassemia major.

Direct demonstration of iron in a term placenta in a case of beta-thalassemia major

Successful term pregnancy in homozygous beta-thalassemia is rare. A pregnant patient with thalassemia usually is found to have chronic anemia concurrent with tissue and circulatory iron overload. We have demonstrated and localized iron deposits in a term placenta of a patient with homozygous beta-thalassemia with the use of routine histochemical staining.

Endometrial reaction to intrauterine device in pregnancy

It is generally assumed that the intrauterine device (IUD) exerts its action by altering endometrial receptivity for the implanting embryo. The most frequently encountered endometrial reaction reported in the presence of an IUD is a chronic inflammatory reaction which may be responsible for the alterations in the normal physiology of the human endometrium. In order to evaluate the endometrial response to the IUD when pregnancy occurs with the device in situ, we have examined the morphology of decidual tissue obtained during interruptions of pregnancy of 32 patients who had conceived in the presence of IUDs. Twenty-three decidual specimens, obtained during interruption of pregnancies without an IUD, served as controls. The incidence of chronic inflammatory reaction was 6.25% in the presence of an IUD and 4.34% in the control group. The incidence of chronic endometritis reported in nonpregnant IUD users is higher (14-100%) than the incidence of chronic endometritis observed in both groups. This observation may be the result of the generally observed alterations in the immune system during a normal pregnancy, but may also be interpreted as a primary reduced endometrial reaction to the IUD, consequently leading to the contraceptive failure in this group.

Indication of selective growth of human endometrial epithelial cells on extracellular matrix

The culturing of human endometrium in conventional plastic dishes and media is only partially successful, mainly because a growth of a heterogeneous population of cells is achieved. Naturally produced extracellular matrix closely resembles the subepithelial basement membrane and seems to affect both growth and differentiation of cells. These qualities of the extracellular matrix (ECM) were applied for obtaining endometrial epithelial cultures. Endometrial tissue specimens were plated after slicing on ECM-coated dishes and kept for up to 8 d. The growth of a confluent homogeneous tissue composed of polygonal epithelial-like cells was demonstrated. To further characterize these cells, cultures were examined by scanning electron microscopy and transmission electron microscopy. Scanning electron microscopy revealed flattened polygonal cells covered with microvilli, among which ciliated cells were observed. By transmission electron microscopy the cells were seen as a monolayer, with some cells overlapping, closely adherent to the matrix. Microvilli, as well as intracellular vacuoles and glycogen granules were observed. Cell type specific cytoskeletal markers were demonstrated by antibodies to intermediate filament proteins (keratin and epithelial membrane antigen). Taken together, the morphologic and immunohistochemical studies indicate that a selective growth of the epithelial component of endometrial tissue was obtained after plating unprocessed endometrial tissue fragments on ECM-coated culture dishes.

Risk factors and prognostic variables in the ovarian hyperstimulation syndrome

This study was undertaken to clarify discriminative roles of multiple epidemiologic, hormonal, and biophysical variables for causation of ovarian hyperstimulation syndrome. Three hundred ninety-six patients with anovulatory infertility had ovulation induction with human menopausal gonadotropin throughout 1822 treatment cycles; 54 cycles (3%) were complicated by ovarian hyperstimulation syndrome. Early follicular serum estradiol and prolactin levels were higher in this group than in controls: 75.5 versus 46.2 pg/ml and 18.5 versus 11.7 ng/ml, respectively (p less than 0.01). On the day of human chorionic gonadotropin administration (day 0) the mean serum estradiol level was 1047 +/- 381 in the group with ovarian hyperstimulation syndrome and 719 +/- 339 pg/ml in controls (p less than 0.0001). In all follicular sizes and in all grades of ovarian hyperstimulation syndrome there was a tendency for more recruited follicles, with significantly more small follicles (12 to 14 mm) present on day 0 in all grades of ovarian hyperstimulation syndrome than in controls. Stepwise logistic regression performed on 22 variables identified a high-risk group for this syndrome; the major features are illustrated by young, lean patients who, after relatively few ampules of human menopausal gonadotropin, develop high estradiol levels and multiple small follicles.

Direct correlation between plasma renin activity and severity of the ovarian hyperstimulation syndrome

Plasma renin activity (PRA) and aldosterone were measured throughout the luteal phase in 21 anovulatory patients who developed ovarian hyperstimulation syndrome (OHSS) during menotropin induction of ovulation. The pattern of PRA in hyperstimulated cycles is characterized by a midluteal peak, which declines to normal in the late luteal phase in nonconceptual cycles, whereas a sustained elevation of PRA occurs in conceptual cycles. Midluteal PRA is significantly (P less than 0.001) elevated in patients with OHSS compared with controls. In the mild form of the disease, the median of PRA is 7.5 (range 6 to 11) ng angiotensin I (AI)/ml/hr, significantly higher than the median for controls, 3.0 ng AI/ml/hr (range, 1.4 to 5). In moderate OHSS, PRA was 24.5 (range, 10 to 40) ng AI/ml/hr, whereas, in the severe form of OHSS, PRA was 55.0 (range, 29 to 95) ng AI/ml/hr. A significant correlation (P less than 0.05) was demonstrated between PRA and either progesterone or 17 beta estradiol (E2). The renin-angiotensin cascade is implicated in new vessel formation. Angiogenesis itself is associated with a rapid increase in capillary permeability. The recent demonstration of high plasma renin-like activity in human follicular fluid and the present observation of high PRA in patients with OHSS may imply that the locally active renin angiotensin system, through induction of new vessel formation and increase in capillary permeability, may have a casual relationship to the ovarian enlargement and extracellular fluid accumulation that are the hallmarks of OHSS.

The effect of estradiol valerate and allylestrenol on endometrial transformation in hypergonadotropic hypogonadic women

The effect of estradiol valerate and allylestrenol on the endometrial transformation of five hypergonadotropic hypogonadic women was evaluated. Estradiol valerate was administered throughout the whole induced cycle (28 days), while allylestrenol was added during the second half of the cycle. Endometrial biopsies were performed during allylestrenol treatment and were evaluated histologically. Samples of endometrium were also subjected to one-dimensional SDS electrophoresis. Of ten biopsies performed, only one was interpreted to be in-phase, while the others were dated proliferative (4 biopsies) or showed abortive or out-of-phase secretory transformation. The highest mean serum progesterone level, detected under allylestrenol treatment, was 1.5 ng/ml. Protein electrophoresis demonstrated relative sequential changes in the protein patterns of the 115 kDa and 150 kDa protein bands. It is concluded that allylestrenol, although having gestagen properties, may not be efficient for the induction of an adequate secretory transformation of human endometrium in the absence of ovaries.

Stress proteins in the human endometrium and decidua

Protein synthesis in response to heat shock was induced in the proliferative and secretory human endometrium as well as in human decidua during a 2-h incubation period at 41 degrees C. A major 70 K stress protein and two minor stress proteins of 88 and 94 K were detected after [35S]methionine incorporation followed by SDS polyacrylamide gel electrophoretic separation and autoradiography of dried gels. Two dimensional isoelectric focusing followed by fluorography showed the major 70 K stress protein to consist of at least six polypeptides of pH 4.6 to 5.5, the 88 K to consist of at least four polypeptides, of pH 5.5 to 6.0, and the 94 K to consist of at least three polypeptides of pH 4.6 to 5.2. Stress proteins in the human endometrium and decidua may prove to be of physiological significance in reproductive events.

Periovulatory 17 beta-estradiol pattern in conceptional and nonconceptional cycles during menotropin treatment of anovulatory infertility

The value of multiple parameters in the prediction of fertile cycles was prospectively evaluated in 52 menotropin-induced cycles. The periovulatory pattern of estradiol (E2) was found to correlate with conceptional cycles. E2 levels greater than 500 pg/ml on the day of human chorionic gonadotropin administration (day 0) with a further increase on day +1 (high ascending pattern--A1) were found to have a 51% predictive value for fertile cycles. Twelve of the 17 fertile cycles had an A1, type of response (71%), whereas the overall incidence of an A1 pattern was 42% (22 of 52). No pregnancies have occurred with preovulatory follicles less than or equal to 14 mm in diameter. The number of preovulatory follicles, E2 level on day 0, and midluteal progesterone had no predictive value for fertile cycles.

Fryns syndrome: a predictable, lethal pattern of multiple congenital anomalies

Fryns syndrome is a unique pattern of lethal multiple congenital malformations with variable expression. A family in which all four sibs conformed to Fryns syndrome is detailed and substantiates the criteria for definition of the syndrome; perinatal mortality, hypoplastic lungs, and facial deformities should be highly suggestive of the syndrome. The addition of a strong family history, diaphragmatic hernias, distal limb deformities, and early onset of polyhydramnios with subsequent premature delivery should definitely confirm the diagnosis.

Second primary genital malignancies associated with endometrial cancer

Epidemiological data on Israeli patients with second primary genital malignancies associated with endometrial cancer is presented. During the 7 years of study, 29 (2.9%) of 1,007 patients with endometrial cancer had additional primary malignancy involving the genital organs. Of these, there were 25 (2.5%) ovarian and 4 (0.4%) cervical malignancies. The occurrence of a second malignancy was related to ethnic origin. The ratio of European/American to Asian/African Jewish descendants was 8.7 to 1. A significantly greater than expected incidence of ovarian and cervical malignancy was detected in the endometrial cancer patient (P less than 0.0001). The prognosis was mainly influenced by the clinical staging of disease at the time of diagnosis. Recognition of the fact that second primary cancers occur at a higher than expected frequency in patients with endometrial cancer, offers an opportunity for their early detection.

Advanced secretory changes in the proliferative human endometrial epithelium following clomiphene citrate treatment

In an effort to characterize the effect of clomiphene citrate (CC) on the human endometrium, we took biopsy specimens of the endometrium 24 to 48 hours after CC treatment (100 to 250 mg/day for 5 consecutive days). Nineteen biopsy specimens were taken from 19 patients. Fifteen of the patients suffered from anovulatory infertility associated with oligomenorrhea or normal cycle length. The other four patients were amenorrheic, two in association with hypogonadotropic hypogonadism and two with hypergonadotropic hypogonadism. The histopathology of all samples was evaluated with the use of light microscopy, including periodic acid-Schiff (PAS) and PAS-diastase staining for glycogen demonstration. All samples were also examined with the use of scanning electron microscopy (SEM). Serum levels of estradiol (E2), progesterone (P), luteinizing hormone, and follicle-stimulating hormone were determined on the day of biopsy. In 10 of the 19 biopsy specimens, local or diffuse signs of early secretory events were demonstrated by the presence of subnuclear vacuolization and glycogen in the glandular epithelial cells. SEM corroborated these findings of advanced secretory changes by demonstrating apical protrusions at luminal epithelial cells and secretory products within the glands' openings. The E2 levels ranged between 110 and 1500 pg/ml (mean, 371 pg/ml) and P levels were either undetectable or less than 1.1 ng/ml. The two patients with hypogonadotropic hypogonadism both exhibited the same phenomena; those with primary ovarian failure had atrophic endometrium even after high-dose CC treatment. This observation, together with the low P levels detected, indicating the lack of luteinization, suggests a possible direct effect of CC on the endometrium.(ABSTRACT TRUNCATED AT 250 WORDS)

Artificially induced endometrial cycles and establishment of pregnancies in the absence of ovaries

In eight women with ovarian failure, we induced histologically normal endometrial function during a preparatory cycle consisting of sequential administration of estrogen and progesterone. During a subsequent cycle, endometrial stimulation was synchronized with surrogate-embryo transfer performed on days 16 to 21. Among the eight women, two pregnancies were established by embryo transfer on days 18 and 19. In both women, ovarian tissue was absent, and these patients therefore serve as an in vivo model for the isolated effects of estrogen and progesterone on implantation and maintenance of pregnancy. Treatment with exogenous estrogen was mandatory up to the 11th week of gestation, and treatment with progesterone until the 18th to 22nd weeks. We conclude that it is biologically feasible to simulate the essential hormonal and endometrial milieu of a fertile menstrual cycle and early gestation solely by the administration of estrogen and progesterone. Days 18 to 19 of the cycle are recommended for successful embryo implantation with this treatment program.

[Relative bioavailability of paracetamol from tablets and suppositories as well as of paracetamol and codeine in a combination tablet]

Eight healthy male volunteers took part in this study to determine the relative bioavailability of Treuphadol oblong tablets (500 mg paracetamol), Treuphadol Plus oblong tablets (500 mg paracetamol, 30 mg codeine phosphate) and Treuphadol suppositories (750 mg paracetamol) against commercial tablets (500 mg paracetamol). Plasma levels of paracetamol and codeine, plus saliva levels of paracetamol for the two paracetamol only formulations, were determined by HPLC and the pharmacokinetic parameters established. The AUC data for paracetamol showed that all four preparations were bioequivalent. The saliva levels of paracetamol demonstrated a good correlation to the corresponding plasma levels. The pharmacokinetic data of codeine from the Treuphadol Plus tablet were compared with corresponding data from the literature. The bioequivalence of codeine when based on this comparison can also be assured.

Fetal response to vibratory acoustic stimulation in periods of low heart rate reactivity and low activity

The fetal response to vibratory acoustic stimulation during periods of low fetal activity and low fetal heart rate reactivity was studied in 10 healthy pregnant women at term. In each case, two periods of low reactivity were studied. Consecutive cases alternated: The vibratory acoustic stimulus was applied 10 minutes after the first nonreactive period in half of the cases; the remainder were stimulated during the second nonreactive period. The unstimulated period served as a control. After vibratory acoustic stimulation the baseline fetal heart rate, the mean number of fetal heart rate accelerations, and, the number of fetal movements were significantly increased with values in the control nonstimulated periods (p less than 0.0001). This consistent response to vibratory acoustic stimulation may prove to be clinically useful in altering periods of low reactivity observed during nonstress testing of normal fetuses.

The effect of clomiphene citrate on blastocyst development and implantation in the rabbit

The induction of ovulation with clomiphene citrate (CC) in human patients results in a high ovulation rate but achieves a relatively low pregnancy rate. To clarify the possible role of CC in interfering with the normal reproductive physiology and embryology, we have used our rabbit model and transferred 4-day-old blastocysts from untreated donors to CC-treated pseudopregnant recipients and from CC-treated donors to untreated pseudopregnant recipients to study embryonic development and implantation. Each group was further subdivided into two subgroups, one receiving CC before and the other after ovulation. CC was administered subcutaneously in three consecutive doses of 10 mg/kg body weight. Ovulation was induced with pregnant mare serum gonadotropin (PMS) and human chorionic gonadotropin (hCG). The implantation rate of the control group, evaluated on day 8 of pregnancy, reached 62.0%. When recipients were treated with CC before ovulation, implantation rate was reduced to 18.8% (P less than 0.0002), and to 20.0% (P less than 0.003) when CC was administered after ovulation. The implantation rate of blastocysts transferred from donors, treated before ovulation, is 22.2% (P less than 0.0055), however, reached 70.8% when treatment was started after ovulation. All implantations were analysed microscopically and showed normal morphological features. Our results demonstrate a potential multiple effect of CC, first on the endometrium by altering its receptivity for the implanting conceptus, second, on tubal physiology by altering egg transport, and finally on ovum maturation before ovulation interfering with development of blastocysts. These parameters may all result in rapid decrease in establishment of implantations and in turn in very low pregnancy rates.

Second primary malignancy in endometrial carcinoma patients

An epidemiologic study of multiple primary malignant neoplasms in endometrial cancer patients in Israel is presented. During the 7-year period of the study, 104 patients (10.3%) out of 1007 patients diagnosed as having endometrial cancer had another primary cancer. There was a significant difference in the incidence of multiple primary cancers between various ethnic groups, women of European/American origin having higher incidence than women of Asian/African origin. A significantly higher than expected incidence of second primary cancers occurred at the following sites: breast (relative risk, 4.1), ovary (relative risk, 11.6), cervix (relative risk, 5.1), and colon (relative risk, 5.9). The prognosis was mainly influenced by the site of the second primary cancer. The increased incidence of multiple primary malignancies justifies a high level of alertness to the possibility of second primary cancer in endometrial cancer patients.

Effect of clomiphene on the functional morphology of oviductal and uterine mucosa

The effect of clomiphene on the functional morphology of the uterine and oviductal mucosa was studied in rabbits by means of light and electron microscopy (SEM and TEM). Tissues were obtained from mature nulliparous animals receiving subcutaneous doses ranging from 0.01-10 mg/kg per day. In all cases the effects were evaluated 2 days after termination of treatment. With 2 and 10 mg, effects were studied up to 12 and 7 days, respectively. Normally appearing oviductal and endometrial tissues, corresponding to various stages of the cycle, were observed with doses up to 5 mg. However, a burst of cellular secretory activity becomes evident with the administration of higher doses. Apical protrusions or cytoplasmic portions seem to be extruded, and draw attention. These cytologic events are concentrated near gland openings in the endometrium and can be seen abundantly among cilia of oviductal cells. Other ultrastructural changes are evident as well. These histologic changes may reflect nonsynchronous cellular activities which in turn interfere with oviductal and endometrial functions before implantation.

Effect of clomiphene citrate on the rabbit ovary

The effect of clomiphene citrate on the rabbit ovary was studied in mature nulliparous rabbits pretreated with three consecutive doses ranging from 0.01-10.0 mg/kg per day. With increasing doses a trend of decrease in mean ovarian weight (mg/kg body weight) is observed 2 days after termination of treatment. Five days later a significant increase occurs, which then subsides again to control values on day 12 after termination of treatment. During this period, no matings or injections of luteinizing hormone were performed to trigger ovulation; consequently no ovulations are observed. Folliculogenesis appears as normally; number and morphology of follicles are within normal ranges. No endogenous, spontaneous gonadotropin surges are detected in blood serum up to the 7th day after termination of treatment (2 and 10 mg doses). The surface epithelium of the ovary resembles normal germinal epithelium; however, after treatment with high doses a "secretory"-like activity is observed, accompanied with ultrastructural changes.

Colposcopy in the localization of missing intrauterine devices

The use of colposcopy as an office procedure is shown to be an effective method in localizing the IUD's string deep in the cervical canal, and for following those patients who wish to continue with IUD, thus avoiding replacement of the device. In 24 patients with missing string, colposcopy was used, and was found to be an effective procedure which obviates the use of unnecessary x-ray exposure, invasive procedures and expensive ultrasonography.

Age associated changes in intracellular cyclic adenosine monophosphate

Cyclic adenosine monophosphate (cAMP) levels of isolated human peripheral blood lymphocytes show age associated changes. These changes are apparent in basal cAMP levels as well as in cAMP levels after trypsin treatment. Both cord blood lymphocytes and lymphocytes isolated from the blood of old people exhibit lower basal levels of cAMP and diminished increase in cAMP by trypsin treatment, in comparison to lymphocytes isolated from the other age groups. The results seem to indicate a low number of reactive cells and a low reactivity of the cells in the case of cord blood lymphocytes, and a decrease in number of the reactive cells without a decrease in specific reactivity of isolated lymphocytes of old people.

The effect of ampicillin and colistin on post-Caesarean section endometritis with identification of possible risk factors

Two hundred and seventy eight women undergoing Caesarean section were evaluated retrospectively to determine the value of prophylactic antibiotic treatment. The patients were divided into 2 groups: 180 women who received no prophylactic treatment and 98 who were treated prophylactically with ampicillin and colistin (Colymycin). Significantly lower rates of infection with prophylactic treatment were found in all groups studied (P less than 0.001) (P less than 0.05 in the group with premature rupture of membranes). Premature rupture of membranes was found to be the only risk factor significantly altering the rate of infection in the untreated group. Patients with premature rupture of membranes or with prolonged stay in the labour room prior to surgery had a significantly higher rate of infection even after the introduction of prophylactic treatment with ampicillin and colistin (P less than 0.001).

Endometrial cancer in Israel, 1969-1975

Epidemiological data on 1017 cases of primary cancer of endometrium in Israel diagnosed over a 7-year period are presented. Incidence of corpus cancer in Israel has not changed in the last decade; the mean incidence for the current study is 18.73/100,000 women above the age of 25. Eight percent of patients were above the age of 51, with a steep increase of incidence being found above the age of 35. Endometrial carcinoma was four to five times more prevalent in Jewish women of European-American origin than in those of Asian-African background. In 85% of the patients diagnosis was made while the disease was in Stage I. A strong correlation was found between endometrial cancer and infertility, but no correlation was found with diabetes and hypertension. The five-year survival rate in the present survey was 65.0%. Factors affecting prognosis and clinical stage of the disease at diagnosis, degree of myometrial invasion, tumor differentiation, age of the patient and type of treatment are discussed.

Vacuum extraction and neonatal jaundice

Various fetal scalp lesions are related to the use of the vacuum extractor. Blood sequestered in these lesions could result in an increased bilirubin load on the functionally limited neonatal liver, leading to the development of hyperbilirubinemia. In the present study bilirubin levels of vacuum extracted neonates were compared with those of non-instrumentally delivered babies during the first 72 hours of life. Sixty-nine vacuum extracted neonates had higher bilirubin levels than 56 non-instrumentally delivered babies at 24 (114 mumol/l vs. 96 mumol/l), 48 (163 vs. 141) and 72 (194 vs. 144) hours of age. The p values were 0.05, less than 0.025 and less than 0.001 respectively. This trend was apparent in both oxytocin induced and non-induced deliveries and whether or not phototherapy cases were included in the analysis. The incidence of hyperbilirubinemia requiring phototherapy was higher after vacuum extraction than after non instrumental delivery (27.5% vs. 12.5%; p less than 0.04). Analysis of our results unexpectedly indicated that oxytocin induction was generally associated with an attenuation of bilirubin levels after both vacuum extraction and spontaneous delivery. The clinician attending newborn babies should be aware of the higher incidence of neonatal hyperbilirubinemia associated with vacuum extraction.

Sinusoidal fetal heart rate pattern with severe fetal anaemia. Case report

A sinusoidal fetal heart rate pattern, associated with Kell incompatibility, severe fetal anaemia, maternal hypertension and intrauterine fetal growth retardation, is described. The mechanism and management are discussed.