Effects of exogenous testosterone supplementation in gonadotrophin stimulated cycles.

BACKGROUND: Various experiments suggest that ovarian follicular recruitment and growth may be increased by testosterone priming. Our aim was to determine the effects of exogenous testosterone supplementation in older women on ovarian folliculogenesis and steroidogenesis. METHODS: A prospective randomized double-blind placebo-controlled crossover study was carried out. Twelve regularly menstruating non-obese women aged 38-45 years received a 12-day course of transdermal testosterone (2.5 mg per patch) or placebo patch, followed by 7 days of gonadotrophin stimulation. After at least a 1 month washout period, subjects underwent the same protocol using the opposite treatment. The main outcomes were follicular development (ultrasound measures) and hormone levels. RESULTS: Following gonadotrophin stimulation, there were no differences in average number of follicles over 10 mm diameter in cycles pre-treated with testosterone versus placebo [2.10 (95% confidence interval (CI) 1.11, 3.22) versus 2.08 (95% CI 1.03, 3.14), P = 0.55]. No crossover, period (first or second test) or sequence (order of treatment) effects were noted. As expected, total and free testosterone levels were increased following testosterone treatment (312.7 +/- 122.4 versus 12.3 +/- 4.5 ng/dl and 45.5+/- 16.7 versus 1.4 +/- 0.5 ng/dl, respectively, P < 0.001) but no differences in free or total testosterone were noted by period. LH, FSH, estradiol and antral follicle counts before gonadotrophin stimulation were not altered by testosterone pretreatment or by period. CONCLUSIONS: Despite increased testosterone levels, a short course of androgens had no significant effect on the number of follicles over 10 mm during stimulation with FSH in women of late reproductive age.

A mandatory single blastocyst transfer policy with educational campaign in a United States IVF program reduces multiple gestation rates without sacrificing pregnancy rates.

OBJECTIVE: To reduce the twin rate in our IVF program. DESIGN: A prospective educational study of infertile couples; a retrospective review of IVF outcomes before vs. after mandatory single embryo transfer (mSBT) policy change. SETTING: University-based infertility center. PATIENT(S): One hundred ten of 120 consecutive new infertile couples completed the educational study. Outcomes of all embryo transfers (n = 693) performed 17 months before and 17 months after mSBT were evaluated. INTERVENTION(S): A 1-page educational summary of comparative risks of twins vs. singletons to maternal and child health. MAIN OUTCOME MEASURE(S): Knowledge of twin risks and desired number of embryos transferred before and after education. Pregnancy rates, number of embryos transferred, and multiple-gestation rates before and after mSBT policy. RESULT(S): After education, knowledge of twin risks improved and a significant number of subjects changed their desired outcome to a lower gestational number. There was no change in ongoing pregnancy rates with blastocyst transfer before and after mSBT (63% vs. 58%; NS). Program-wide number of embryos transferred (2.1 +/- 0.6 vs. 1.9 +/- 0.7) and multiple-gestation rates (35% vs. 19%) decreased significantly while pregnancy rates were maintained. CONCLUSION(S): Simple educational materials can improve knowledge of twin pregnancy risks and affect decision making. In high-risk patients, mSBT results in pregnancy rates similar to two-blastocyst transfer, with decreased twin rates.

Testosterone patch improves ovarian follicular response to gonadotrophins in a patient with Kallmann's syndrome: a case report.

Achieving ovulation in women with Kallmann's syndrome requires both exogenous FSH and LH to successfully stimulate follicular maturation and ovarian steroidogenesis. We present a case of a woman with Kallmann's syndrome, who had poor ovarian response to stimulation by exogenous gonadotrophins. When she was given testosterone by patch before initiation of gonadotrophins, her stimulation dramatically improved. Once we ceased to pretreat her cycle with testosterone, she again had a poor stimulation. This suggests that testosterone administration may be a useful adjunct in improving ovarian response to gonadotrophins in Kallmann's syndrome patients.

A prospective randomized trial comparing anastrozole and clomiphene citrate in an ovulation induction protocol using gonadotropins.

OBJECTIVE: To compare the ovarian and endometrial effects of anastrozole and clomiphene when used with gonadotropins in a combination protocol. DESIGN: Prospective randomized trial. SETTING: Academic infertility center. PATIENT(S): Fifty infertile women. INTERVENTIONS(S): Women were randomized to receive either 1 mg anastrozole or 100 mg clomiphene citrate for 5 days (cycle days 3-7) followed by FSH injections (days 7-11) for ovulation induction. A subset participated in a crossover arm of the study. MAIN OUTCOME MEASURE(S): Ovarian follicle number and size, E(2) levels, endometrial thickness, pregnancy, and cancellation rates. RESULT(S): On cycle day 12, anastrozole cycles were associated with fewer total follicles (1.4 vs. 3.6, P=0.01), fewer mature follicles (0.6 vs. 1.6, P<.01), lower serum E(2) (131 pg/mL vs. 613 pg/mL, P<.01,) and the same endometrial stripe thickness compared with clomiphene citrate cycles. Cycle cancellation rates were similar between the two groups. On the day of hCG administration in noncancelled cycles, anastrozole cycles were associated with fewer total follicles (1.6 vs. 3.8, P<.01), fewer mature follicles (1.3 vs. 2.1, P<.01), and an equal endometrial stripe thickness compared with clomiphene citrate cycles. Pregnancy rates were similar between clomiphene (20%) and anastrozole (12%) cycles. CONCLUSION(S): Anastrozole when used in conjunction with gonadotropins results in lower E(2) levels and fewer follicles than clomiphene citrate. A combination protocol of anastrozole and gonadotropins may be a safer protocol for patients at higher risk of hyperstimulation and multiple births after infertility treatments.

Attitudes of faculty and students toward case-based learning in the third-year obstetrics and gynecology clerkship.

OBJECTIVE: This study was undertaken to compare the attitudes of faculty and medical students toward case-based learning and lecture format during the obstetrics and gynecology clerkship. STUDY DESIGN: For this prospective comparative study, student presentations were alternately assigned to traditional lecture- or case-based format every 6 weeks. Presentations were made to other students and a single faculty. A total of 31 faculty members, 30 student presenters, and 122 student participants completed evaluations. Teaching methods were compared. RESULTS Faculty members favored lecture format over case-based learning for "attentiveness and interaction of the group" (3.9 vs 4.5, P < .018) and for "meeting the objectives" (3.7 vs 4.5, P < .002). Student participants favored case-based learning in "understanding the relationship between knowledge and clinical practice" (4.34 vs 4.06, P < .05) and "enjoyed" (4.34 vs 3.90, P < .008). Student presenters showed no differences between groups. CONCLUSION: Faculty favored lecture format whereas student participants favored a case-based presentation. Student presenters were comfortable with both formats.