Early Bird or Night Owl: Insights into Dutch Students' Study Patterns using the Medical Faculty's E-learning Registrations

Phenomenon: Educational activities for students are typically arranged without consideration of their preferences or peak performance hours. Students might prefer to study at different times based on their chronotype, aiming to optimize their performance. While face-to-face activities during the academic schedule do not offer flexibility and cannot reflect students' natural learning rhythm, asynchronous e-learning facilitates studying at one's preferred time. Given their ubiquitous accessibility, students can use e-learning resources according to their individual needs and preferences. E-learning usage data hence serves as a valuable proxy for certain study behaviors, presenting research opportunities to explore students' study patterns. This retrospective study aims to investigate when and for how long undergraduate students used medical e-learning modules. Approach: We performed a cross-sectional analysis of e-learning usage at one medical faculty in the Netherlands. We used data from 562 undergraduate multimedia e-learning modules for pre-clinical students, covering various medical topics over a span of two academic years (2018/19 and 2019/20). We employed educational data mining approaches to process the data and subsequently identified patterns in access times and durations. Findings: We obtained data from 70,805 e-learning sessions with 116,569 module visits and 1,495,342 page views. On average, students used e-learning for 16.8 min daily and stopped using a module after 10.2 min, but access patterns varied widely. E-learning was used seven days a week with an hourly access pattern during business hours on weekdays. Across all other times, there was a smooth increase or decrease in e-learning usage. During the week, more students started e-learning sessions in the morning (34.5% vs. 19.1%) while fewer students started in the afternoon (42.6% vs. 50.8%) and the evening (19.4% vs. 27.0%). We identified 'early bird' and 'night owl' user groups that show distinct study patterns. Insights: This retrospective educational data mining study reveals new insights into the study patterns of a complete student cohort during and outside lecture hours. These findings underline the value of 24/7 accessible study material. In addition, our findings may serve as a guide for researchers and educationalists seeking to develop more individualized educational programs.

Epaology and the importance of context

None

How clinical teaching teams deal with educational change: 'we just do it'

BACKGROUND

In postgraduate medical education, program directors are in the lead of educational change within clinical teaching teams. As change is part of a social process, it is important to not only focus on the program director but take their other team members into account. The purpose of this study is to provide an in-depth insight into how clinical teaching teams manage and organize curriculum change processes, and implement curriculum change in daily practice.

METHODS

An explorative qualitative semi-structured interview study was conducted between October 2016 and March 2017. A total of six clinical teaching teams (n = 6) participated in this study, i.e. one program director, one clinical staff member, and one trainee from each clinical teaching team (n = 18). Data were analysed and structured by means of thematic analysis.

RESULTS

The analysis yielded to five factors that positively impact change: shared commitment, reinvention, ownership, supportive structure and open culture. Factors that negatively impact change were: resistance, behaviour change, balance between different tasks, lack of involvement, lack of consensus, and unsafe culture and hierarchy. Overall, no clear change strategy could be recognized.

CONCLUSIONS

Insight was gathered in factors facilitating and hindering the implementation of change. It seems particularly important for clinical teaching teams to be able to create a sense of ownership among all team members by making a proposed change valuable for their local context as well as to be capable of working together as a team. Cultural factors seem to be particularly relevant in a team's ability to accomplish this.

Improving the training of the future gynaecologist: development of a European curriculum in Obstetrics and Gynaecology (EBCOG-PACT)

The European Board & College of Obstetrics and Gynaecology has initiated improvement of the European standards of training in Obstetrics and Gynaecology through the project called 'EBCOG-PACT'. In this project, a pan-European curriculum for postgraduate training in Obstetrics and Gynaecology has been developed. The curriculum is societally responsive, and based on the latest medical educational methodology. It consists of the description of outcomes of training for the common Core Curriculum and Electives, the General competencies and soft skills to be trained, and strategies for training of obstetrical skills, gynaecological skills, ultrasound skills and bio-psychosocial and communicative skills. Also, the curriculum provides strategies for assessment through entrustment, a model for portfolio as well as strategies for faculty development and quality management of training. The implementation of the European curriculum in Obstetrics and Gynaecology will provide opportunities for national scientific and professional societies and ministries of health or education to consider modernisation of national or local OBGYN training programs.

How do medical specialists value their own intercultural communication behaviour? A reflective practice study

BACKGROUND

Intercultural communication behaviour of doctors with patients requires specific intercultural communication skills, which do not seem structurally implemented in medical education. It is unclear what motivates doctors to apply intercultural communication skills. We investigated how purposefully medical specialists think they practise intercultural communication and how they reflect on their own communication behaviour.

METHODS

Using reflective practice, 17 medical specialists independently watched two fragments of videotapes of their own outpatient consultations: one with a native patient and one with a non-native patient. They were asked to reflect on their own communication and on challenges they experience in intercultural communication. The interviews were open coded and analysed using thematic network analysis.

RESULTS

The participants experienced only little differences in their communication with native and non-native patients. They mainly mentioned generic communication skills, such as listening and checking if the patient understood. Many participants experienced their communication with non-native patients positively. The participants mentioned critical incidences of intercultural communication: language barriers, cultural differences, the presence of an interpreter, the role of the family and the atmosphere.

CONCLUSION

Despite extensive experience in intercultural communication, the participants of this study noticed hardly any differences between their own communication behaviour with native and non-native patients. This could mean that they are unaware that consultations with non-native patients might cause them to communicate differently than with native patients. The reason for this could be that medical specialists lack the skills to reflect on the process of the communication. The participants focused on their generic communication skills rather than on specific intercultural communication skills, which could either indicate their lack of awareness, or demonstrate that practicing generic communication is more important than applying specific intercultural communication. They mentioned well-known critical incidences of ICC: language barriers, cultural differences, the presence of an interpreter, the role of the family and the atmosphere. Nevertheless, they showed a remarkably enthusiastic attitude overall was noteworthy. A strategy to make doctors more aware of their intercultural communication behaviour could be a combination of experiential learning and ICC training, for example a module with reflective practice.

Quality specifications in postgraduate medical e-learning: an integrative literature review leading to a postgraduate medical e-learning model

BACKGROUND

E-learning is driving major shifts in medical education. Prioritizing learning theories and quality models improves the success of e-learning programs. Although many e-learning quality standards are available, few are focused on postgraduate medical education.

METHODS

We conducted an integrative review of the current postgraduate medical e-learning literature to identify quality specifications. The literature was thematically organized into a working model.

RESULTS

Unique quality specifications (n = 72) were consolidated and re-organized into a six-domain model that we called the Postgraduate Medical E-learning Model (Postgraduate ME Model). This model was partially based on the ISO-19796 standard, and drew on cognitive load multimedia principles. The domains of the model are preparation, software design and system specifications, communication, content, assessment, and maintenance.

CONCLUSION

This review clarified the current state of postgraduate medical e-learning standards and specifications. It also synthesized these specifications into a single working model. To validate our findings, the next-steps include testing the Postgraduate ME Model in controlled e-learning settings.

[CanMEDS 2015: better doctors?]

Recently, the CanMEDS model, which forms the basis for competency-based learning in both undergraduate and postgraduate training, has been renewed by the introduction of CanMEDS 2015. The most prominent change is the emphasis on leadership skills, which is also reflected by the name change for the role of 'manager' to 'leader'. The addition of milestones provides clearly defined targets for learning and assessment, which facilitates the monitoring of the progression in competence. Furthermore, CanMEDS 2015 strongly focusses on the overall coherence of the separate competencies. CanMEDS, designed as a model that helps to train young doctors to become good doctors, also helps us - the trainers - to become better doctors ourselves.

[Integral obstetrics impeded by history? Midwives and gynaecologists through the ages]

There is a long and complicated history concerning the interprofessional collaboration between midwives and gynaecologists, which is still evident in current practice. Yet, in the analysis of collaborative problems, history and its lessons are often overlooked. Consequently, less effective solutions to problems may be found, because the root cause of a problem is not addressed. In this historical perspective we show how policies of the respective professions have often focused on self-preservation and competition, rather than on effective collaboration. We also highlight how the independent midwives lost and regained authorisation, status and income. Finally, using a theoretical model for interprofessional collaboration, we reflect on where history impedes the development of integral obstetrics. The focus must be averted away from professional self-interest and power struggles, but this proves to be a complex exercise.

[Drawn towards a career in elderly care medicine, but not till after medical school. Elderly care medicine as a career choice]

In order to develop strategies for raising the interest of medical students in a career in elderly care medicine (a specialty in The Netherlands) we should start by gaining more insight into the process influencing career choices among medical students and graduates. In this qualitative study we conducted three focus group discussions with trainees in elderly care medicine and two focus group discussions with obstetrics and gynaecology trainees. We found that all trainees made their career choice after clinical exposure in the field. The elderly care medicine trainees did not make their choice until after graduation, working in temporary employment in a nursing home. The obstetrics and gynaecology trainees made their specialty choice during medical school after their clerkship. Almost all focus group participants had a very negative perception during medical school about geriatrics and elderly care medicine. Once they were employed in a nursing home they changed their minds. They came to realize the work was more interesting, more difficult, more intensive and more meaningful than they had initially thought.

The art of medical education

Is the art of medical education just making sure to provide sufficient up to date medical knowledge and a lot of clinical experience? It is much more. The art of medical education is about a teaching program that is designed to serve the community of the near future. The program is the result of a thorough evaluation of societal needs and is capable of influencing the properties of future care. New care professionals who are trained in the program will -become instrumental in solving complex problems in health systems. The art of medical education is about the change of traditional ideas of how to cope with these health systems. This change will raise anger and resistance. Effective change management is essential to survive attacks from laggards and to maintain enthusiasm to invest in the health care of the future. Educationalist science provides several important insights that help us find the optimal shape of the program. Good role models and a learning environment that is an example of the intended professional and organisational behaviour, learning by doing, simulation programs, educational tools like e-learning systems, a good assessment and feedback system, and a portfolio to prove and discuss professional progress are all pivotal components of the ideal program. To achieve mastery within the art of medical education, a quality improvement program will be the crown of the process. Medical education is a multifaceted process and so the quality improvement should be. The art of medical education is a great challenge. The health care of your future deserves it.

Progress testing in postgraduate medical education

BACKGROUND

The role of knowledge in postgraduate medical education has often been discussed. However, recent insights from cognitive psychology and the study of deliberate practice recognize that expert problem solving requires a well-organized knowledge database. This implies that postgraduate assessment should include knowledge testing. Longitudinal assessment, like progress testing, seems a promising approach for postgraduate progress knowledge assessment.

AIMS

To evaluate the validity and reliability of a national progress test in postgraduate Obstetrics and Gynaecology training.

METHODS

Data of 10 years of postgraduate progress testing were analyzed on reliability with Cronbach's alpha and on construct validity using one-way ANOVA with a post hoc Scheffe test.

RESULTS

Average reliability with true-false questions was 0.50, which is moderate at best. After the introduction of multiple-choice questions average reliability improved to 0.65. Construct validity or discriminative power could only be demonstrated with some certainty between training year 1 and training year 2 and higher training years.

CONCLUSION

Validity and reliability of the current progress test in postgraduate Obstetrics and Gynaecology training is unsatisfactory. Suggestions for improvement of both test construct and test content are provided.

Validation and implementation of surgical simulators: a critical review of present, past, and future

BACKGROUND

In the past 20 years the surgical simulator market has seen substantial growth. Simulators are useful for teaching surgical skills effectively and with minimal harm and discomfort to patients. Before a simulator can be integrated into an educational program, it is recommended that its validity be determined. This study aims to provide a critical review of the literature and the main experiences and efforts relating to the validation of simulators during the last two decades.

METHODS

Subjective and objective validity studies between 1980 and 2008 were identified by searches in Pubmed, Cochrane, and Web of Science.

RESULTS

Although several papers have described definitions of various subjective types of validity, the literature does not offer any general guidelines concerning methods, settings, and data interpretation. Objective validation studies on endourological simulators were mainly characterized by a large variety of methods and parameters used to assess validity and in the definition and identification of expert and novice levels of performance.

CONCLUSION

Validity research is hampered by a paucity of widely accepted definitions and measurement methods of validity. It would be helpful to those considering the use of simulators in training programs if there were consensus on guidelines for validating surgical simulators and the development of training programs. Before undertaking a study to validate a simulator, researchers would be well advised to conduct a training needs analysis (TNA) to evaluate the existing need for training and to determine program requirements in a training program design (TPD), methods that are also used by designers of military simulation programs. Development and validation of training models should be based on a multidisciplinary approach involving specialists (teachers), residents (learners), educationalists (teaching the teachers), and industrial designers (providers of teaching facilities). In addition to technical skills, attention should be paid to contextual, interpersonal, and task-related factors.

The influence of context on residents' evaluations: effects of priming on clinical judgment and affect

Different lines of research have suggested that context is important in acting and learning in the clinical workplace. It is not clear how contextual information influences residents' constructions of the situations in which they participate. The category accessibility paradigm from social psychology appears to offer an interesting perspective for studying this topic. We explored the effect of activating medically irrelevant mental concepts in one context, so-called 'priming', on residents' interpretations as reflected in their judgments in another, work-related context. Obstetric-gynecologic residents participated in two unrelated-tasks experiments. In the first experiment residents were asked to indicate affect about a change in a routine procedure after performing an ostensibly unrelated 'priming' task which activated the concept of either ineffective coping or effective coping. The second experiment concerned residents' patient management decisions in a menorrhagia case after 'priming' with either action or holding off. Contextually activated mental concepts lead to divergent affective and cognitive evaluations in a subsequent medical context. Residents are not aware of this effect. The strength of the effect varies with residents' level of experience. Context influences residents' constructions of a work-related situation by activating mental concepts which in turn affect how residents experience situations. Level of experience appears to play a mediating role in this process.

[Plea for more attention to the importance of gender during medical training]

Gender is an important factor in disease and health. Male and female patients with the same disease may present with different complaints. This is especially true in cardiology. Basic medical training should specifically address this topic. Moreover, the gender of the physician is an important factor in patient care. Physicians are unaware of the influence of their gender on their performance. Reflective practice is an essential educational tool in modern specialist training. As medical specialist training in The Netherlands is being modernized at present, this may be the perfect time for physicians to become aware of their gender and its impact on their performance. This will improve medical care for both male and female patients by male and female doctors.

Attending doctors' perspectives on how residents learn

CONTEXT

Graduate medical education is currently facing major educational reforms. There is a lack of empirical evidence in the literature about the learning processes of residents in the clinical workplace. This qualitative study uses a 'grounded theory' approach to continue the development of a theoretical framework of learning in the clinical workplace by adding the perspective of attending doctors.

METHODS

A total of 21 Dutch attending doctors involved in the training of residents in obstetrics and gynaecology participated in 1 of 3 focus group sessions. They discussed their perceptions of how residents learn and what factors influence residents' learning. A grounded theory approach was used to analyse the transcribed discussions.

RESULTS

Three related themes emerged. The first concerned the central role of participation in work-related activities: according to attending doctors, residents learn by tackling the everyday challenges of clinical work. The second involved the ways in which attending doctors influence what residents learn from work-related activities. The final theme focused on attending doctors' views of the essential characteristics of residents and their development during residency.

CONCLUSIONS

Attending doctors' perspectives complement current insights derived from similar research among residents and from related literature. As part of an ongoing effort to further develop understanding of how residents learn, this study adds several ways in which attending doctors strive to combine guidance in both patient care and resident training. Furthermore, attending doctors' perspectives draw attention to other aspects of learning in the clinical workplace, such as the role of confidence and the balance between supervision and independence.

How residents learn: qualitative evidence for the pivotal role of clinical activities

OBJECTIVES

Medical councils worldwide have outlined new standards for postgraduate medical education. This means that residency programmes will have to integrate modern educational views into the clinical workplace. Postgraduate medical education is often characterised as a process of learning from experience. However, empirical evidence regarding the learning processes of residents in the clinical workplace is lacking. This qualitative study sought insight into the intricate process of how residents learn in the clinical workplace.

METHODS

We carried out a qualitative study using focus groups. A grounded theory approach was used to analyse the transcribed tape recordings. A total of 51 obstetrics and gynaecology residents from teaching hospitals and affiliated general hospitals participated in 7 focus group discussions. Participants discussed how they learn and what factors influence their learning.

RESULTS

An underlying theoretical framework emerged from the data, which clarified what happens when residents learn by doing in the clinical workplace. This framework shows that work-related activities are the starting point for learning. The subsequent processes of 'interpretation' and 'construction of meaning' lead to refinement and expansion of residents' knowledge and skills. Interaction plays an important role in the learning process. This is in line with both cognitivist and sociocultural views on learning.

CONCLUSIONS

The presented theoretical framework of residents' learning provides much needed empirical evidence for the actual learning processes of residents in the clinical workplace. The insights it offers can be used to exploit the full educational potential of the clinical workplace.

[The basic biomedical subjects are now less important in the training of medical doctors]

Medical doctors that neglect the roles of communicator, team worker, organizer and professional can be expected to perform inadequately. The content of the training of medical doctors should be reconsidered. A selection should be made of the biomedical sciences that are required during the training for later medical practice. Thus, these basic sciences should, in part, make way for social sciences to ensure the development of team skills.

Psychometric properties of an instrument to measure the clinical learning environment

OBJECTIVES

The clinical learning environment is an influential factor in work-based learning. Evaluation of this environment gives insight into the educational functioning of clinical departments. The Postgraduate Hospital Educational Environment Measure (PHEEM) is an evaluation tool consisting of a validated questionnaire with 3 subscales. In this paper we further investigate the psychometric properties of the PHEEM. We set out to validate the 3 subscales and test the reliability of the PHEEM for both clerks (clinical medical students) and registrars (specialists in training).

METHODS

Clerks and registrars from different hospitals and specialties filled out the PHEEM. To investigate the construct validity of the 3 subscales, we used an exploratory factor analysis followed by varimax rotation, and a cluster analysis known as Mokken scale analysis. We estimated the reliability of the questionnaire by means of variance components according to generalisability theory.

RESULTS

A total of 256 clerks and 339 registrars filled out the questionnaire. The exploratory factor analysis plus varimax rotation suggested a 1-dimensional scale. The Mokken scale analysis confirmed this result. The reliability analysis showed a reliable outcome for 1 department with 14 clerks or 11 registrars. For multiple departments 3 respondents combined with 10 departments provide a reliable outcome for both groups.

DISCUSSION

The PHEEM is a questionnaire measuring 1 dimension instead of the hypothesised 3 dimensions. The sample size required to achieve a reliable outcome is feasible. The instrument can be used to evaluate both single and multiple departments for both clerks and registrars.

Postmenopausal hormone replacement in the woman with a reproductive risk factor for breast cancer

OBJECTIVE

to assess the interaction between postmenopausal hormone replacement therapy (HRT) and various reproductive risk factors for breast cancer such as early menarche, late menopause, late first delivery and nulliparity.

DESIGN

three cohort studies and fourteen case control studies, published between 1975 and 1997, provided relative risks (RRs) of HRT use in women with, as well as in those without, a reproductive risk factor for breast cancer.

METHODS

using an additive RR model reported before, we investigated whether the RR for breast cancer in women with a combination of HRT and a given reproductive risk factor result from a simple addition of RRs of HRT on the one hand, and of the pre-existing reproductive risk factor on the other hand, or that synergism between both risk factors occurs.

RESULTS

simple addition of RRs was shown in the case of early menarche and late menopause. Less increase of risk, suggesting antagonism, was found for both late first delivery and nulliparity in combination with HRT use.

CONCLUSION

we could not observe any synergistic effect of the combined risks of any of the following reproductive risk factors for breast cancer: early menarche, late menopause, late first delivery or nulliparity on the one hand, with the risk resulting from HRT use on the other hand. Therefore, as far as the risk of breast cancer is concerned, the use of HRT appears not to be highly detrimental in women with a reproductive breast cancer risk factor, as it results in not more than a simple addition of risks at the most.

Hormone replacement therapy in women treated for gynaecological malignancy

Can we prescribe hormone replacement therapy (HRT) safely for women, with postmenopausal complaints who were treated for a gynaecological malignancy? Only three retrospective studies have investigated this issue in endometrial cancer patients. No recurrences or deaths occurred in these treated groups. However, the physician introduced bias through the selection of favourable groups. At present, combined estrogen and progestogen therapy is probably not contra-indicated in endometrial cancer stage I and probably also not in stage II, although so far there is only circumstantial evidence. Squamous cell cancers of the cervix, vulva, and vagina are unlikely to be influenced by HRT. In the only study available of women with ovarian cancer, < or = 50 years, estrogen replacement therapy did not have a negative influence on (disease-free) survival. According to the data currently available, no evidence exists that HRT adversely influences survival and overall survival after treatment for ovarian cancer. In general, adenocarcinomas of the cervix and leiomyosarcomas of the uterus may be managed such as the adenocarcinomas of the uterus. During the last 25 years, HRT has been shown to substantially reduce the risk of cardiovascular diseases, osteoporotic fractures and colon carcinoma. On the other hand there is a significant increase of the risk in breast cancer with prolonged use of > 5 years. Re-evaluation of the current view that HRT should no be given to women treated for a gynaecological malignancy is strongly warranted after evaluating the advantages and the disadvantages of HRT use in each individual patient. Long-term HRT in women treated for a gynaecological cancer must be based on the medical history of the individual patient (and her family).

Hormone replacement therapy and breast cancer morbidity, mortality and recurrence

The effects of short-term and long-term HRT (in its various forms, unopposed oestrogens, sequentially combined HRT and continuous combined HRT) on the female breast are reviewed. The question is addressed whether HRT will increase the risk of breast cancer as well as the risk of dying from breast cancer in healthy women, and whether or not women who already run an increased risk on the basis of a positive family history, use of DES during pregnancy or because of the presence of premalignant epithelial abnormalities in the breast, increase their risk for breast cancer further. The risks of HRT and the options for HRT in patients who have a history of breast cancer are discussed and alternative treatment modalities for climacteric complaints (e.g. clonidine, paced-respiration) or for preventive HRT (e.g. tamoxifen, tibolone) are reviewed.

A case of a neurological complication after transvaginal oocyte retrieval

A patient is described who developed neurological signs of the left leg following transvaginal ultrasound-guided puncture. A hypodense lesion of the obturator space above the lumbosacral plexus was seen on ultrasound which could explain her signs, due to compression by a hematoma. She recovered completely.

The importance of endogenous feedback for monofollicular growth in low-dose step-up ovulation induction with follicle-stimulating hormone in polycystic ovary syndrome: a randomized study

OBJECTIVE

To evaluate the role of endogenous feedback in monofollicular growth during low-dose gonadotrophin therapy in polycystic ovary syndrome (PCOS) by measuring FSH levels in a group of patients cotreated with a GnRH agonist (GnRH-a) (group B) compared with patients not cotreated with an agonist (group A).

DESIGN

Prospective randomized study.

SETTING

University tertiary care Reproductive Endocrinology Unit.

PATIENTS

Women with clomiphene citrate-resistant PCOS.

MAIN OUTCOME MEASURES

Follicle-stimulating hormone, E2, and inhibin levels, follicular growth.

RESULTS

In group A, FSH levels decreased significantly from 7.3 mIU/mL (conversion factor to SI unit, 1.00) at day -5 to 5.9 mIU/mL at day 0 (day that hCG was administered) despite a constant dose, whereas they remained at a level of 7.4 mIU/mL in group B. The rate of monofollicular growth was significantly higher in group A (80%) than in group B (22%). No significant differences in E2 levels or inhibin levels were found between the groups.

CONCLUSIONS

The absence of a decrease of FSH during GnRH-a treatment in association with a lower rate of monofollicular growth suggests that endogenous feedback during low-dose step-up ovulation induction in PCOS plays an important role. The absence of this feedback mechanism in the presence of normal inhibin levels suggests that negative feedback control by inhibin during follicular stimulation is minimal.

The GnRH challenge test: a quantitative measure of pituitary desensitization during GnRH agonist administration

OBJECTIVE

The use of GnRH agonists for desensitization of the pituitary is widespread in gynaecological practice. For indications such as contraception and treatment of uterine leiomyomata partial desensitization may suffice. With respect to partial desensitization of the pituitary we have addressed three basic questions: (1) Is the degree of pituitary desensitization dependent on the dose of agonist used? (2) What is the optimal way to measure the degree of pituitary desensitization? (3) Is it possible to create a standard to express the degree of pituitary desensitization?

DESIGN AND PATIENTS

Twenty-four women were randomized into 4 groups of 6 women. To achieve pituitary desensitization, the groups received 0.1, 0.25, 0.5 and 1.0 microgram/min GnRH respectively, for 6 weeks.

MEASUREMENTS

Pituitary desensitization was measured by gonadotrophin levels and responses to a 100-micrograms bolus of GnRH and an oestradiol benzoate challenge-test.

RESULTS

The level of LH and the responses of LH and FSH to the GnRH challenge showed significant dose-dependent suppression. Multiple regression indicated the LH response to the GnRH challenge was the best way to measure pituitary desensitization. From the LH responses to the GnRH-challenge a 'standard curve' was established for the assessment of the degree of pituitary desensitization.

CONCLUSION

The LH response to the GnRH challenge test is the best available measure of pituitary desensitization during GnRH agonist treatment.

The role of follicle-stimulating hormone in the selection of follicles in human ovaries: a survey of the literature and a proposed model

A review of the literature resulted in a model consisting of three follicle-stimulating hormone (FSH)-related mechanisms of follicle selection in the human ovarian cycle. The FSH-dependent selection of dominant follicles is the result of varying FSH serum levels on the one hand, and a varying follicular sensitivity to FSH on the other hand. The first FSH-related mechanism of follicle selection is the intercycle rise of FSH which induces the ongoing development of a reasonable number of follicles during the early follicular phase. The intercycle FSH level should surpass the FSH threshold of the follicles with the highest FSH sensitivity, but the FSH level should not be too high because many other less sensitive follicles might also be stimulated to develop. The second and third mechanisms act together during the mid- to late follicular phase. During the mid- and late follicular phases, the number of dominant follicles is reduced by the synergistic actions of a decreasing FSH level and the differentiation of the follicular sensitivity to FSH. Follicles destined to become dominant gain sensitivity to FSH, whereas follicles destined to become atretic lose their sensitivity to FSH. This differentiation of follicular sensitivity to FSH is the result of several endo-, para- and autocrine factors which modulate the effect of FSH on the growing follicle. The differentiation of follicular sensitivity to FSH supports the effect of the decreasing FSH level. Only the most sensitive follicle will become dominant. The other follicles will become atretic. The presented model may be of use not only for interpretation of the results of ovarian stimulation, but also to put the growing amount of data on growth factors and other substances which modulate the effects of FSH in the dynamic context of follicle selection.

Exploring the recovery phase after treatment with a gonadotrophin-releasing hormone-agonist for ovulation induction in polycystic ovary syndrome: three pilot trials

OBJECTIVE

Guided by the favorable results of pulsatile gonadotrophin-releasing hormone (GnRH) in the recovery phase after GnRH agonist (GnRH-a) in PCOS, two hypotheses concerning the recovery phase were tested: (1) The resistance to clomiphene citrate will be broken in the recovery phase. (2) Stimulation with (i) a fixed dose of follicle stimulating hormone (FSH) or (ii) with the GnRH-a itself is equally effective in inducing ovulation as pulsatile GnRH.

DESIGN

After discontinuation of a 17-21 days GnRH-a treatment, ovulation induction was attempted with clomiphene citrate (CC) or with a fixed dose of FSH or with GnRH-a itself in three separate pilot trials. A previously reported group of 12 patients, treated with pulsatile GnRH in the recovery phase served as control.

PATIENTS

Three groups of six patients having PCOS. The group treated with CC was a selected CC-resistant group.

RESULTS

No CC-treated patient ovulated. After FSH stimulation two patients ovulated, and one patient ovulated on stimulation with a low dose of the GnRH-a. Endocrine observations in the recovery phase showed an early rise of FSH as compared to the rise of LH and androgens.

CONCLUSION

This study could not demonstrate any effect of the recovery phase with respect to facilitation of follicular growth in PCOS. Both tested hypotheses were rejected: (1) The resistance to CC appeared not to be broken by the GnRH-a treatment and (2) subsequent stimulation with FSH or with the GnRH-a itself were not as effective as stimulation with pulsatile GnRH. An extensive further study of the mentioned modalities did not seem feasible.

Echinococcosis of the liver during pregnancy

A 20-year-old Turkish woman with three huge echinococcus cysts of the liver was admitted in the third trimester of pregnancy. During pregnancy she received albendazole and during vaginal delivery she received both albendazole and medication aimed at preventing anaphylactic reaction. We believe that the presence of large hydatid cysts during pregnancy should be managed conservatively with courses of albendazole after the first trimester of pregnancy.

Follicle stimulating hormone (FSH) dynamics of low dose step-up ovulation induction with FSH in patients with polycystic ovary syndrome

Pharmacodynamics of follicle stimulating hormone (FSH) were studied during low dose step-up gonadotrophin therapy in patients with polycystic ovary syndrome (PCOS). To obtain stable levels of FSH, Metrodin was administered i.v. By making daily determinations, the FSH concentration was slowly increased in steps of approximately 1 IU/l. A total of 16 patients were treated for a maximum of three treatment cycles. Out of 38 treatment cycles, in 26 (68%) a single dominant follicle developed. The overall ovulation rate was 78%. FSH concentrations were evaluated with regard to intra- and interindividual variability of the FSH threshold and with regard to the relationship between FSH concentrations, FSH dose and treatment outcome. The high variability of the FSH threshold, ranging from 5.7 to 12 IU/l, appeared to be mainly a function of inter-individual variability. Higher FSH concentrations were associated with multifollicular growth as opposed to monofollicular growth, whereas the increases in concentration from a substimulating to a stimulating level were not. Multifollicular growth might thus be associated with a higher elevation of FSH concentration above the threshold. Different patterns of FSH concentration in the course of the growth phase of the dominant follicle in mono- compared to multifollicular cycles suggested a difference in the effect of endogenous FSH on the plasma concentration. Endogenous feedback on FSH release may therefore still play a role during treatment with exogenous FSH.

Pulsatile gonadotrophin releasing hormone stimulation after medium-term pituitary suppression in polycystic ovary syndrome

Ovulation induction in the polycystic ovary syndrome with pulsatile gonadotrophin releasing hormone (GnRH) in the recovery phase after treatment with a GnRH agonist (GnRHa) during 6-8 weeks has been reported to improve ovulation and pregnancy rates and to normalize follicular phase luteinizing hormone (LH) levels. We studied the results of stimulation with pulsatile GnRH after a shorter 'medium-term' period of 3 weeks of treatment with a GnRHa by comparing a cycle without GnRHa pre-treatment with a cycle with GnRHa (post-GnRHa) pre-treatment in 12 patients. We could prove no significant clinical improvement in post-GnRHa cycles. Ovulation rates were similar. However, in the post-GnRHa cycles, two ongoing pregnancies were observed versus one spontaneous abortion in the cycles without GnRHa pre-treatment. This observation might be explained by the fact that follicular phase LH levels in post-GnRHa cycles were significantly decreased.

The relationship between follicle-stimulating hormone dose and level and its relevance for ovulation induction with adjuvant gonadotropin-releasing hormone-agonist treatment

OBJECTIVE

To investigate the effect of a GnRH agonist (GnRH-a) on the FSH threshold level and the relationship between the FSH dose and the FSH level of patients suffering from polycystic ovarian syndrome (PCOS).

DESIGN

The stimulation with low-dose FSH in PCOS (group 1) was compared with the subsequently performed stimulation with low-dose FSH combined with GnRH-a in another group of patients suffering from the same syndrome (group 2).

SETTING

Specialist Reproductive Endocrine Unit.

PATIENTS

Suffering from clomiphene citrate-resistant PCOS.

MAIN OUTCOME MEASURES

The FSH threshold level for ongoing follicular growth and the relationship between dose and level of FSH.

RESULTS

In 15 patients in group 1 and in 13 patients in group 2, respectively, 39 and 32 stimulation cycles were performed. Below and above threshold values of FSH of group 1 and 2 did not differ significantly. For the equation stable level of FSH (Y mIU/mL) = A X infusion rate of FSH (X IU/24 h) + basal level of FSH (B mIU/mL), the median A of group 1 was 0.027 and A of group 2 was 0.055 (significant difference).

CONCLUSIONS

In PCOS, a change of the FSH threshold level for ongoing follicular growth induced by the GnRH-a could neither be proven nor ruled out. The use of a GnRH-a resulted in larger FSH level increases per IU/24 h of FSH administered and might therefore interfere with the effect of low-dose FSH treatment.

The effects of a gonadotrophin-releasing hormone agonist on treatment with low dose follicle stimulating hormone in polycystic ovary syndrome

The objective of this study was to investigate whether the incidence of monofollicular growth during stimulation with low dose follicle stimulating hormone (FSH) changes when adjuvant gonadotrophin-releasing hormone agonist (GnRHa) pre-treatment is administered in polycystic ovary syndrome (PCOS). One group of patients (group 1) suffering from clomiphene resistant PCOS was stimulated with low dose FSH. The results were compared with those from another group of similar patients (group 2) subsequently stimulated with low dose FSH combined with GnRHa. In group 1 15 patients had 39 stimulation cycles performed; in group 2 13 patients had 33 stimulation cycles performed. In group 1 44% of cycles were monofollicular, whilst the corresponding figure in group 2 was 14% (P = 0.04). Evidence was found for postponed atresia in group 2. In both groups 1 and 2 inter-individual and intra-individual variability of the FSH dose inducing follicular growth were observed. We concluded that during the use of GnRHa, stimulation with low dose FSH less frequently resulted in monofollicular growth, possibly due to postponed atresia. Furthermore, the use of GnRHa does not abolish the inter- and intra-individual variability of the FSH dose inducing ongoing follicular growth.

Severe ovarian hyperstimulation: a case report and essentials of prevention and management

A case of ovarian hyperstimulation syndrome is presented occurring in a young woman with polycystic ovary-like disease after induction of ovulation with the combined treatment of a luteinizing hormone releasing hormone analog and human menopausal gonadotrophins. Prevention and management based on pathophysiological considerations are reviewed.

Pulsatile secretory patterns of luteinizing hormone in two patients with secondary amenorrhea suffering from Cushing's disease, before and after transsphenoidal adenectomy

In two infertile women with Cushing's disease, LH pulse frequency increased after pituitary adenectomy; both conceived within 4 months. This finding suggests that defective LH-RH-stimulation of LH secretion accounted (partially) for their infertility.

Patterns of LH and FSH in men during high-frequency blood sampling

The aim of the study was to test the hypothesis that in serial determinations of concentrations of LH and FSH involving blood samples taken every minute, the observed pulses of LH and FSH which last less than 3-4 min might not be a physiological phenomenon but part of the 'noise' of the radioimmunoassay or blood-sampling technique. Blood was sampled every minute for a period of 90 min in six men. During the first 45 min, blood was sampled by means of vacuum tubes only. During the second 45 min, sampling took place with a syringe via a rubber stopper, either using a tourniquet (n = 3) or flushing the cannula with heparinized saline. Three criteria were used to identify variations in the patterns of LH and FSH as true hormonal changes. First, a threshold was used which had to be exceeded by the difference between nadir and maximum values before a pulse could be identified. An average of approximately six pulses per 90 min was found in both the LH and FSH series. The majority of these pulses lasted less than 3-4 min. In two subjects, larger LH pulses of longer duration were measured. Secondly, differences between duplicate measurements of nadir and/or maximum values of more than one-third of the amplitude of a pulse were considered unacceptable. This involved about 75% of the pulses. Thirdly, the reproducibility of the hormone variations was estimated. In one subject, concentrations of LH were measured four times in four separate assays.(ABSTRACT TRUNCATED AT 250 WORDS)