Mechanism of ovulation.

This article provides a fundamental basis for a better understanding of normal ovarian physiologic processes relevant to the pathophysiology of ovarian dysfunction and the treatment of infertility. The discussion centers on the pelvic clock, which regulates by steroidal and nonsteroidal endocrine and paracrine messages both hypothalamic-pituitary and intraovarian functions essential to successful reproduction, and the steroidal milieu that generates the approximately 28-day human menstrual cycle.

Male factor infertility and assisted reproductive technologies.

Male infertility has many facets that need to be evaluated in an initial screening. Once these are known, recommendations become clearer for aggressively pursuing assisted reproductive techniques. Progress has been made in defining more clearly the severe male factor: concentration less than 5 x 10(6) sperm/mL, motility less than 10%, morphology less than 4% normal forms (by strict criteria), and recovered swim-up sperm less than 1.5 x 10(6). Sperm preparation techniques may be improved by use of Percoll separation medium, and morphology may be used in prediction of cleavage rate in in vitro fertilization. Hopefully, these techniques will lead to more specific guidelines for successful use of assisted reproductive technology in male factor patients.

Management of pituitary gonadal function via gonadotrophin releasing hormone (GnRH) antagonists, including ovulation induction by co-administration of either gonadotrophins or pulsatile GnRH.

GnRH agonists are now familiar clinical agents and are often the drugs of choice for suppression of the pituitary gonadal axis as part of various clinical indications. GnRH antagonists, which are likely to become clinically available soon, offer several advantages over the currently available GnRH agonists for many applications including ovulation induction. Here, we review the results from a series of pre-clinical studies designed to evaluate the potential clinical utility of this new class of compounds for ovulation induction protocols.

Influence of number of pre-embryos transferred, progesterone level and oestradiol/progesterone ratio at thaw on pregnancy results during replacement of cryopreserved pre-embryos in natural cycles.

When frozen-thawed pre-embryos were transferred in a natural menstrual cycle, a clinical pregnancy rate of 22% per transfer cycle was obtained. The pregnancy rates were higher when serum progesterone levels at thaw were less than or equal to 3.4 ng/ml than when they were greater than or equal to 3.5 ng/ml. This was reflected in a significantly higher oestradiol/progesterone ratio at thaw in the conception cycles than in the non-conception cycles.

Therapeutic intrauterine insemination improves with gonadotropin ovarian stimulation.

Therapeutic intrauterine insemination (IUI) is frequently used as a first line of treatment of infertility. The reported results vary, depending on the indication and the use of ovulation simulation protocols. In the present study, we review the experience at the Jones Institute for Reproductive Medicine in Virginia from January 1989 to January 1991. The patients were preferentially treated with ovulation induction with gonadotropins. With the addition of gonadotropin stimulation, the total and term pregnancy rates per cycle were 14% and 11%, respectively, including all etiologic factors. These rates were improved over the 3% and 2.6% rates reported in our previous study in which ovarian stimulation was not generally used. In male factor patients, the term pregnancy rate was 9%, higher than the 4% term pregnancy rate reported in our previous study. In the present series, morphology was the only severely impaired parameter. The term pregnancy rate was 11% for patients with ovulatory dysfunction, 10% for those with cervical factor, and 10.5% for those with unexplained infertility.

Therapeutic intrauterine insemination (TII)--controversial treatment for infertility.

The literature on therapeutic intrauterine insemination (TII) is confused because of lack of homogeneity in case selection, differences in executing the procedural steps, and the manner of evaluating and reporting results. This review compares results from Norfolk with those in the English literature. Special emphasis has been placed on separately analyzing each step of the procedure and presenting results of different authors in a comparable fashion. Including all etiologic factors and types of cycles, the term pregnancy rate per cycle was 3% for Norfolk, 2.6% to 6.2% elsewhere. Patients receiving TII in stimulated cycles did significantly better than those receiving TII in natural cycles, in terms of total pregnancy rate per cycle (p = 0.002). In male factor infertility, term pregnancy rate per cycle was 1.1% in Norfolk, 4.7% to 6.2% elsewhere (perhaps because of stricter criteria in Norfolk). In cervical factor infertility, term pregnancy rate per cycle was 4.5% in Norfolk, 2.7% to 11% for others. For unexplained infertility, Norfolk had 5.8% term pregnancy rate per cycle for natural cycles, 8.3% for stimulated cycles. Best published prospective results were 23% for stimulated cycles. TII seems to have a very low efficiency rate judging from term pregnancy rates per cycle. There are clear data indicating the need for redefining the indications.

[Maternal and child health: a proposal for preventive care during pregnancy, labor and puerperium]. / Salud maternoinfantil: propuesta de prevención durante el embarazo, parto y puerperio.

PIP: This paper presents a proposal for preventive care during pregnancy, labor, and puerperium; such care should be implemented by one interdisciplinary team with 3 main tasks: of education, control, and assistence. The professionals engaged in the proposal would be a trained midwife, who would contact the woman and give preliminary information; an obstetrician, who would be in charge of lectures on psychoprophilaxis available to all expectant mothers, and who would also be in charge of the delivery; a pediatrician, to control the baby after birth and to guide the parents about proper care for the infant; and a psychologist, to help the couple with any conscious or unconscious problems. The method proposed can be modified in function of its implementation in a private clinic or in a public service institution, which cater to different types of patients. Participation of the father is encouraged at every stage of the program, including delivery. The program has already been tested in a private clinic, with excellent results.^ieng