Sustainable financing for Immunization Agenda 2030.

Sustainable financing for immunization refers to the sufficient and predictable allocation and use of resources to support the achievement of immunization goals within the framework of overall health financing. The Immunization Agenda 2030 (IA2030) agenda spells out four important focus areas needed for sustainable financing: (1) ensuring sufficient and predictable resources, (2) making optimal use of resources, (3) aligning partnerships, and (4) supporting sustainable transitions from external assistance. This paper summarizes the evidence and proposes interventions under each area. While immunization is one of the best investments and justifies public financing, the COVID-19 pandemic has led to the worst economic recession since the Great Depression and threatens countries' ability to mobilize funding to ensure continuity and access to essential services, including immunization. Strategies for ensuring adequate resources differ by income group but include raising more revenues, reprioritizing the budget towards health, and ensuring that health resources favor Primary Health Care (PHC) and immunization. In low- and lower-middle income countries, support from Gavi, the Vaccine Alliance, which channels the largest amount of external financing, will remain important, but some lower-middle income countries will need to prepare for transition. Countries benefitting from the Global Polio Eradication Initiative (GPEI) are also experiencing a transition from GPEI financing to domestic and other external financing. This paper outlines ways in which countries can improve the use of domestic and external resources to better incentivize high-quality PHC and immunization services and align immunization programs with health sector reforms. While governments must lead, collective action from development partners, the private sector, and civil society is needed to promote health system financing systems that ensure that the world is better prepared for future outbreaks and pandemics, while reinforcing the IA2030 vision and making progress towards universal health coverage and the Sustainable Development Goals.

Safety assessment of intraportal liver cell application in New Zealand white rabbits under GLP conditions.

Liver cell transplantation (LCT) is considered a new therapeutic strategy for the treatment of acute liver failure and inborn metabolic defects of the liver. Although minimally invasive, known safety risks of the method include portal vein thrombosis and pulmonary embolism. Since no systematic data on these potential side effects exist, we investigated the toxicological profile of repeated intraportal infusion of allogeneic liver cells in 30 rabbits under GLP conditions. Rabbit liver cells were administered once daily for 6 consecutive days at 3 different dose levels, followed by a 2-week recovery period. No test item-related mortality was observed. During cell infusion, clinical findings such as signs of apathy and hyperventilation, moderate elevations of liver enzymes ALT and AST and a slight decrease in AP were observed, all fully reversible. Cell therapy-related macroscopic and histological findings, especially in liver and lungs, were observed in animals of all dose groups. In conclusion, the liver and lungs were identified as potential toxicological target organs of intraportal allogeneic liver cell infusion. A NOAEL (no observed adverse effect level) was not defined because of findings observed also in the low-dose group. No unexpected reactions became apparent in this GLP study. Overall, LCT at total doses up to 12 % (2 % daily over 6 days) of the total liver cell count were tolerated in rabbits. Observed adverse effects are not considered critical for treatment in the intended patient populations provided that a thorough monitoring of safety relevant parameters is in place during the application procedure.

[ITAP - 6-month results of a prospective, randomised phase 3 study for evaluation of the combination therapy of PDT and intravitreal triamcinolone in exudative AMD]. / ITAP - 6-Monats-Ergebnisse einer prospektiven und randomisierten Phase-3-Studie zur Evaluation der Kombinationstherapie aus PDT und intravitrealem Triamcinolon bei der exsudativen AMD.

BACKGROUND: Combination therapy of photodynamic therapy (PDT) with intravitreal triamcinolone (IVTA) for choroidal neovascularisation (CNV) in age-related macular degeneration is thought to improve the prognosis. It is therefore widely used, although results are mostly based upon non-randomised and retrospective studies. Here we present the 6-month results of our prospective, randomised, multicentre ITAP trial (Intravitreal Triamcinolone and PDT) for the evaluation of the combination therapy as compared to PDT alone. PATIENTS: This prospective, randomised, multicentre phase III trial was performed for the evaluation of the efficacy and safety of combination therapy (PDT and IVTA) as compared to PDT alone. Three randomised therapy groups (A: PDT alone, B: IVTA on the same day 1 hour after PDT C: IVTA 1 week before PDT) were monitored over 1 year. The patients included had wet AMD with predominantly classic CNV, minimal classic CNV smaller than 4 papillary diameters or occult CNV with recent disease progression. Re-treatment was performed when persistent leakage of the CNV was visible at follow-up. Primary outcome criteria were the comparison between combination therapy and PDT monotherapy concerning visual acuity, and, second, the comparison between the two groups of combination therapy. RESULTS: 92 patients were included in the study. Before treatment, mean best corrected ETDRS letter score was 52, 53 and 51 in groups A, B and C, respectively. At the 6 months follow-up, mean best corrected letter score was 40, 47 and 47, respectively, with only group A loosing more than 10 letters. This change, however, was not statistically significant between the groups. Mean retinal thickness as measured with optical coherence tomography decreased in all groups, and reached statistical significance in both combination groups. Re-treatment rates did not differ significantly between the three groups at 6 months follow-up, nor was there a significant cataract progression requiring operation. CONCLUSION: At 6 months there was no significant difference between mono- and combination therapy groups concerning visual acuity.

Prediction of endometriosis with serum and peritoneal fluid markers: a prospective controlled trial.

BACKGROUND: The objective of this prospective controlled trial was to investigate the ability of a group of serum and peritoneal fluid (PF) markers to predict, non-surgically, endometriosis. METHODS AND RESULTS: Serum and PF samples were obtained from 130 women while undergoing laparoscopy for pain, infertility, tubal ligation or sterilization reversal. Concentrations of six cytokines [interleukin (IL)-1beta, IL-6, IL-8, IL-12, IL-13 and tumour necrosis factor (TNF)-alpha] were measured in serum and PF, and reactive oxygen species (ROS) in PF, and levels were compared among women who were allocated to groups according to their post-surgical diagnosis. Fifty-six patients were diagnosed with endometriosis, eight with idiopathic infertility, 27 underwent tubal ligation or reanastomosis (control group) and 39 were excluded due to bloody PF. Only serum IL-6 and PF TNF-alpha could be used to discriminate between patients with and without endometriosis with a high degree of sensitivity and specificity (P < 0.001). A threshold of 15 pg/ml PF TNF-alpha provided 100% sensitivity and 89% specificity (positive likelihood ratio of 9.1 and negative likelihood ratio of 0). A threshold of 2 pg/ml for serum IL-6 provided a sensitivity of 90% and specificity of 67% (positive likelihood ratio of 2.7 and negative likelihood ratio of 0.14). CONCLUSIONS: By measuring serum IL-6 and PF TNF-alpha, it was possible to discriminate between patients with endometriosis and those without. Before these markers can be used as a non-surgical diagnostic tool, these data should be verified in a larger study.

Superovulation and intrauterine insemination in cases of treated mild pelvic disease.

PURPOSE: Our purpose was to examine the effect of treated mild pelvic disease on the outcome of superovulation with intrauterine insemination (SO/IUI). METHODS: Three hundred cycles of SO/IUI were retrospectively reviewed for 118 women with laparoscopically treated minimal/mild endometriosis and 67 cycles for 28 women with minimal/mild distal tubal disease/adnexal adhesions and compared with 265 cycles in 111 couples with idiopathic infertility. RESULTS: The monthly fecundity rate (MFR) of 6.8% and live birth rate (LBR) of 6% in the endometriosis group were significantly lower (P = 0.002) than those in the idiopathic infertility group (MFR = 13.5%, LBR = 12.1%). The 10.9% MFR and 7.5% LBR in the minimal/mild tubal/adnexal disease were not significantly different from those in the other two groups. CONCLUSIONS: MFR and LBR were higher after SO/IUI in idiopathic infertility compared to those for treated mild/minimal endometriosis or mild/minimal tubal/adnexal adhesions. However, SO/IUI still remains a reasonable option for both these groups prior to IVF-ET.

The effect of follicular fluid reactive oxygen species on the outcome of in vitro fertilization.

OBJECTIVE: To examine the presence of reactive oxygen species (ROS) in the follicular fluid of women undergoing in vitro fertilization (IVF) and identify its role in pregnancy outcome. STUDY DESIGN: In this prospective study, ROS and total antioxidant capacity (TAC) levels were measured by the chemiluminescence method in the follicular fluid of 53 women. Age, number of oocytes recovered, percentage of oocytes fertilized, ROS and TAC levels were compared in women who did and did not become pregnant. RESULTS: Patients who become pregnant had significantly higher log-transformed ROS levels (1.01 +/- 0.14, P = 0.031 than those who did not (0.69 +/- 0.08). Women with endometriosis or male factor infertility who became pregnant had significantly higher ROS levels (1.44 +/- 0.23 and 1.31 +/- 0.19) than those who did not (0.60 +/- 0.17 and 0.67 +/- 0.16; P < .006 and P < .01). CONCLUSION: Follicular fluid ROS, at low concentrations, may be a potential marker for predicting success in IVF patients.

Unusual presentation of lichen sclerosuis in an adolescent

Background: The presentation of lichen sclerosus has been described in detail in the adult literature. Typically present with symptoms of itching and soreness in the vulvar area at which time a vulvar evaluation reveals a specific appearance. The presentation is believed to be similar in prepubertal children and adolescents. In this case report we encountered an unusual initial presentation of this disease.Methods: Case presentation.Results: An 18-year-old female presented for the first time to her gynecologist with complaint of difficulty with complete emptying of bladder and dribbling. She had noted the onset of these symptoms two months prior to presentation. She denied any long-term history of vulvar itching or irritation. Her menses were normal with no complaints of dysmenorrhea. Onset of menarche and pubertal development were also normal. She denied any pre-pubertal history of labial adhesions or lichen sclerosis. The patient was not sexually active. She was diagnosed with labial adhesions and her first course of treatment included topical estrogen therapy for 8 weeks. Her second course of therapy included topical testosterone for 6 weeks without any improvement or side effects. On evaluation at our institution the posterior aspect of the labia minora could not be seen and the area of the vaginal introitus was completely obstructed (see picture). The clitoral hood could not be retracted and the surrounding vulva appeared atrophic and white. The degree of obstruction was such that the urethra could not be seen. In the operating room the labia minora were manually separated. The patient applied clobetasol.05% ointment for the next two weeks to the vulva and then switched to a less potent steroid. Follow-up evaluation 2 and 4 weeks after the procedure did not show any adhesions. Punch biopsy was consistent with diagnosis of lichen sclerosis.Conclusion: The presentation of lichen sclerosis may be variable in adolescents; thus, a high index of suspicion must be maintained to make this diagnosis.

Comparison of intrauterine and intracervical insemination with frozen donor sperm: a meta-analysis.

OBJECTIVE: To determine whether artificial insemination with frozen donor sperm yielded a higher pregnancy rate per cycle by intracervical (ICI) or intrauterine (IUI) techniques. A meta-analysis was performed. DATA IDENTIFICATION: A computerized MEDLINE search of the English-language literature on artificial insemination with donor sperm was performed and augmented by a review of meeting abstract books and references in published papers. STUDY SELECTION: Only prospective randomized studies that reported monthly fecundity rates for IUI and ICI with frozen donor sperm were included. DATA ANALYSIS: Seven studies were identified. The odds ratios (OR) and 95% confidence intervals (CI) were determined with use of the general estimating equation method for the three studies for which raw data could be obtained. For the remaining four studies, the OR and CI were assessed with use of the published summary data. A random-effects meta-analysis was then performed. RESULT: Intrauterine insemination resulted in a significantly higher monthly fecundity rate with a common OR of 2.4 (CI 1.5-3.8). CONCLUSION: On the basis of this meta-analysis of the seven prospective studies, IUI results in higher pregnancy rates than ICI for frozen donor insemination.

Review of newer contraceptive agents.

Advances in contraceptive technology have made birth control more effective, convenient, and safe. We review the newer products and some under development, including the latest oral contraceptives, injectable progesterone, subdermal progestin implants, progesterone-releasing IUDs, emergency contraception, and male contraception.

PIP: This paper reviews the latest developments in oral contraceptives (OCs), long-acting contraceptives such as injectable progesterone, subdermal progestin implants, progesterone-releasing IUDs, emergency contraception, and male contraception. Latest developments of OCs contain much lower doses of estradiol than the older preparations and uses newer progestins with less androgenic activity, thus causing fewer side effects. Depot-medroxyprogesterone acetate injections every 3 months prevent conception by suppressing the luteinizing hormone surge, thereby inhibiting ovulation. These contraceptive options are good for women in whom compliance may be low. Subdermal progestin implants have a failure rate of 0.8/100 woman-years for the first 5 years of use, increasing to 2/100 woman-years by the 6th year. They acts primarily by rendering the cervical mucus impenetrable to sperm. The progesterone-releasing IUDs, on the other hand, induce decidualization of the endometrium, thus inhibiting implantation. Among the postcoital contraceptives briefly discussed in this paper are the combined OCs (ethinyl estradiol and norgestrel), progestin-only compounds, the copper IUD, and mifepristone. The new developments of condoms, which are the mainstay of male contraception, include the new polyurethane condom, which is thinner, stronger, and less allergenic.

Robotically assisted laparoscopic microsurgical uterine horn anastomosis.

OBJECTIVE: To evaluate the feasibility, safety, and sterility issues with regard to the use of a robotic device to perform uterine horn anastomosis in a live porcine model. DESIGN: Prospective animal study. SETTING: Landrace-Yorkshire pigs in a conventional laboratory setting. INTERVENTION(S): Six female pigs underwent laparoscopic bipolar electrocoagulation of the distal uterine horns. Two weeks later, the uterine horns were reanastomosed laparoscopically with use of a robotic system for microsuturing. Necropsy was performed 4 weeks later to assess postoperative adhesions and anastomosis patency. MAIN OUTCOME MEASURE(S): Tubal patency; secondary measures were operative time, complications, and surgeon fatigue. RESULT(S): The mean (+/-SD) total operative time per animal was 170+/-34 minutes including setting up and dismantling the robotic arms. The robot functioned well with only minor technical problems. All pigs survived both surgeries with no perioperative complications related to the use of the robot. Patency was confirmed after completing each anastomosis (12 anastomoses; 100% patency). Four weeks later, necropsy showed that eight anastomoses were still patent (67%). Only one pig had bilateral occlusion. Surgeon's fatigue was mild for each animal study. CONCLUSION(S): Robotic technology can be used safely in creating laparoscopic microsurgical anastomoses. The robot functioned properly in a sterile operating room environment. Adequate patency rates were achieved during the acute phase and at 4-week follow-up. Robotic technology has the potential to make laparoscopic microsuturing easier.

A study of risk factors for ruptured tubal ectopic pregnancy.

Ruptured ectopic pregnancy is a leading cause of maternal mortality in the United States. The purpose of this study was to identify predictors of tubal rupture. A retrospective chart review of 236 ectopic pregnancies in 215 patients treated at the Cleveland Clinic Foundation from 1983 through 1996 was performed. Patients were stratified by rupture status of the ectopic pregnancy and compared for the following parameters: age, gravida, parity, aborta, gestational age, preoperative and postoperative hemoglobin level, need for blood transfusion, serum human chorionic gonadotropin (hCG) levels, and findings on ultrasonogram and at surgery. We also compared the two groups in multiple risk factors for ectopic pregnancy. We used the generalized estimating equation (GEE) methodology and unbalanced repeated measures analysis of variance to compare the two groups. Tubal rupture was found in 26.3% of ectopic pregnancies. Tubal rupture occurred with any serum hCG level, even with those under 100 mIU/ml. There was no significant difference between the two groups in gestational age, serum hCG levels, or ultrasound findings except that the frequency of ruptured pregnancies increases as the fluid amount documented on ultrasonography increases (p < 0.001). There was no association between any of the risk factors or the number of risk factors and frequency of tubal rupture. There was no significant decrease in the rupture rate over time (p = 0.34). There was an increased morbidity associated with tubal rupture. Tubal rupture cannot be predicted on the basis of any known risk factor, ultrasonogram findings, or serum hCG levels. Early diagnosis and treatment of ectopic pregnancy are the only modality available to prevent tubal rupture and its associated morbidity.

Attitudes about genetic risk of couples undergoing in-vitro fertilization.

Many couples undergoing in-vitro fertilization (IVF) are at a higher risk of having a child with a genetic abnormality. In a sample of 55 consecutive couples starting IVF, only 33% had no genetic risk factor. The most common genetic risks were advanced maternal age and possible abnormalities associated with severe male infertility. Despite education on these risks, 71% of couples had no interest in receiving formal genetic counselling. Only 14% of couples at risk would consider using a gamete donor to avoid transmitting a genetic disorder to a child. The triple test to screen for fetal abnormalities was acceptable to 82% of couples, but only 47% planned to have amniocentesis or chorionic villi sampling. Couples were significantly more likely to opt for prenatal testing if they would consider terminating a pregnancy should the fetus have a severe genetic abnormality (P < 0.01). Roman Catholic couples tended to have more conservative attitudes about pregnancy termination. Socio-economic status and whether the infertility factor was male or female were not predictors of a couple's attitudes.

Robotically assisted laparoscopic tubal anastomosis in a porcine model: a pilot study.

As with standard microsurgical procedures performed at laparotomy, laparoscopic tubal anastomosis requires great dexterity. Handling fine suture materials under magnification to anastomose tubal segments with lumens less than 3 mm in diameter while working with your hands at a distance from the tissue makes these fine movements even more difficult. This is exacerbated by the tremor induced by the fatigue caused by a prolonged laparoscopic procedure and the need for precise control. We conducted a pilot study to evaluate the feasibility of performing laparoscopic tubal anastomosis with robotic assistance in a live porcine model. Two anastomoses were performed on one uterine horn via each of the following techniques: laparoscopy, laparoscopy with robotic assistance, and open microsurgery. Immediate necropsy demonstrated all the anastomoses to be patent. There were no intraoperative complications. Laparoscopic tubal anastomosis was associated with surgeon fatigue and neck, shoulder, and back pain. The surgeons were more comfortable performing the procedure with robotic assistance. The device functioned well and without incident. This acute animal study suggests that robotic assistance in laparoscopic tubal anastomoses is safe and feasible. It enhances surgeons' dexterity and precision while reducing fatigue. It is promising for future use in chronic experimental studies.

The relationship of human granulosa-lutein cell proliferative index to follicular diameter and serum estradiol.

OBJECTIVE: To examine the relationships of follicular diameter and serum estradiol (E2) to the percentage of granulosa cells undergoing mitosis as reflected by the proliferative index of granulosa cells. METHODS: In this prospective study, we enrolled 44 consecutive women undergoing controlled ovarian hyperstimulation for in vitro fertilization. Deoxyribonucleic acid histograms were generated by flow cytometry from granulosa cells isolated at the time of transvaginal aspiration. Proliferative index was defined as the sum of G2/M and S phases. We assessed the correlation between proliferative index and age, maximum serum E2, number of oocytes retrieved, percent mature oocytes, and follicular diameter. RESULTS: Follicles less than 16 mm had a significantly higher proliferative index (19.9 +/- 3.3%) than follicles 20 mm or greater (14.8 +/- 3.9%, P = .016). However, there was no significant difference between proliferative index of the latter group and proliferative index of follicles 16-19 mm (17.8 +/- 4.7%). An inverse correlation between patient age and proliferative index of granulosa cells was noted (r = -.39, P = .018). There was no significant relationship between serum E2 and proliferative index (P = .97). CONCLUSION: Mitotic activity tends to decrease as follicular diameter increases after a threshold diameter is achieved. Proliferative index of granulosa cells provides insight into the underlying cell biology of a follicle.

Previous fertilization failure with conventional in vitro fertilization is associated with poor outcome of intracytoplasmic sperm injection.

OBJECTIVE: To evaluate the outcome of intracytoplasmic sperm injection (ICSI) in patients with a history of fertilization failure with conventional IVF. DESIGN: Retrospective analysis of 2 years of clinical experience with ICSI. SETTING: Clinical IVF-ET program in a tertiary care referral center. PATIENT(S): The results of ICSI performed between January 1995 and December 1996 were compared between patients with normal semen parameters and a history of fertilization failure (< 20% of oocytes) with conventional IVF and patients with male factor infertility. INTERVENTION(S): In vitro fertilization with ICSI. MAIN OUTCOME MEASURE(S): Parameters examined included oocyte survival, fertilization, embryo cleavage, implantation rates, and clinical pregnancy rates. RESULT(S): Fertilization was achieved with ICSI for all patients during the study period. Although oocyte survival and fertilization did not differ between groups, the pregnancy and implantation rates for patients with a history of idiopathic fertilization failure (20% and 6%, respectively) were significantly lower than those for other patients undergoing ICSI (47% and 22%, respectively). CONCLUSION(S): The outcome of ICSI varied depending on the indication for treatment. Patients who had a history of failed or poor fertilization in vitro with apparently normal semen parameters had significantly lower pregnancy and implantation rates than did patients with either obstructive azoospermia or impaired semen quality.

Sonohysterographic evaluation of uterine abnormalities noted on hysterosalpingography.

Transvaginal sonohysterography was performed on 40 consecutive patients with infertility or recurrent pregnancy loss and uterine abnormalities on hysterosalpingography. The findings were correlated with the hysterosalpingogram and subsequent diagnostic and/or operative hysteroscopy. Hysterosalpingography was incorrect in nine cases. Sonohysterography was more accurate than hysterosalpingography and provided more information about uterine abnormalities. Sonohysterography was in complete agreement with hysteroscopy. Diagnostic hysteroscopy can therefore be avoided if the sonohysterogram is normal. Sonohysterography also provides additional information on the relative proportion of the intracavitary and intramyometrial components of submucus myomas, as well as extracavitary myomas and the adnexae. This may help in planning the surgical procedure.

Preferences for intracytoplasmic sperm injection versus donor insemination in severe male factor infertility: a preliminary report.

With the advent of intracytoplasmic sperm injection (ICSI), our programme noted a drop in the number of couples using donor insemination (DI) for severe male factor infertility. Over the first 8 months in which our infertility programme offered both treatments, 27 consecutive couples scheduled for ICSI and 15 consecutive couples scheduled for DI were evaluated Since all patients in our infertility programme beginning in-vitro fertilization (IVF) with planned ICSI or starting DI undergo a semi-structured psychological interview, the psychologist's clinical notes as well as the medical chart were reviewed and coded retrospectively to determine factors related to a couple's treatment choice. Couples who chose IVF-ICSI over DI had a higher occupational status and included husbands with higher educational levels. Their most common motivation was to have the husband's biological child (93% of couples in the ICSI group). The most common motivation for choosing DI (60% of DI couples) was that IVF was not financially affordable. Choice of treatment was not related to psychological adjustment, the husband having prior biological children, or his risk of passing on a genetic defect to offspring. These preliminary data raise the concern that, with the success of ICSI, DI may change in the USA from being an option dictated by semen quality to a second choice treatment utilized for economic reasons.

Sonohysterography to Evaluate Uterine Defects on Hysterosalpingography and Its Correlation with Hysteroscopy

Sonohysterography (SHG) may replace hysteroscopy as the standard method to evaluate intrauterine filling defects noted on hysterosalpingography (HSG). Twenty-six patients with evidence of intrauterine filling defects on HSG underwent SHG in the office with transvaginal ultrasonography before diagnostic or operative hysteroscopy. Polyps were identified in 11 women by SHG and were confirmed by hysteroscopy and histology. Adhesions seen on SHG in four women were also confirmed by hysteroscopy. Thus SHG not only correctly identified myomas in all six patients, but helped determine which ones could be resected by hysteroscopy and which might benefit from preoperative gonadotropin-releasing hormone analog treatment. Five patients with intrauterine filling defects on HSG were subsequently shown to have normal endometrial cavities at SHG and hysteroscopy. We believe SHG is a useful technique for evaluating patients with abnormal HSGs, reducing the requirement for more expensive and invasive diagnostic hysteroscopy. In addition, it provides more thorough assessment before operative hysteroscopy.

The effect of estrogen administration in vivo upon catecholamine release in vitro from superfused hypothalamic tissue of ovariectomized pre-pubertal and adult mice.

In the present report we examined the effects of estrogen upon catecholamine release from superfused medial basal hypothalamic tissue fragments of pre-pubertal ovariectomized CD-1 mice. Prepubertal mice treated with estradiol benzoate (EB--5 micrograms x 2 days, sc), showed significantly reduced amounts of dopamine but no changes in norepinephrine release in response to a depolarizing concentration of potassium (30 mmol/L) compared with their respective groups receiving the oil vehicle. Since EB treatment reduced potassium stimulated dopamine release in these pre-pubertal mice, in a second experiment we compared the effects of EB versus oil vehicle treatment upon potassium stimulated dopamine release from the hypothalamus of the ovariectomized adult female mouse. Similar to that observed in the pre-pubertal mouse, EB treatment significantly reduced the amount of potassium stimulated dopamine release. Interestingly, the absolute amounts of potassium stimulated dopamine release was substantially greater in adult compared with pre-pubertal mice. These results demonstrate that the hypothalamic dopaminergic system of both pre-pubertal and adult mice show relatively similar responses to estrogen treatment but differ in absolute amounts of dopamine released.