Compliance with hormone replacement therapy in postmenopausal women. A comparative study.

OBJECTIVE: To assess compliance with hormone replacement therapy in postmenopausal women. METHOD: Two groups were compared prospectively: 100 women who sought treatment for menopausal symptoms, and 82 women who had undergone a total abdominal hysterectomy with bilateral salpingo-oophorectomy and were using estrogen replacement therapy. RESULTS: Compliance rates after 6 months were 81.0% and 84.1% in the two groups, respectively, and after 12 months, 73.0% and 80.5%. CONCLUSIONS: The high rates are attributed to our investment in patient education of the benefits of treatment and repeated and close follow-up.

Vaginal delivery following caesarean section-the use of oxytocin and prostaglandins.

Five hundred and twenty women with one previous caesarean section underwent a trial of labour in our department during the past five years. They were divided into three groups-those receiving oxytocin, those receiving prostaglandins, and those unstimulated who had spontaneous labour. The obstetric outcomes were compared. Rates of vaginal delivery in the three groups were 65%, 67% and 72%, respectively. No mother died and there were no cases of complete uterine rupture. Our results confirm similar reports that vaginal delivery after a previous caesarean section can be safely achieved in about two-thirds of patients. Serious complications are minimal when the use of oxytocin and prostaglandins is carefully monitored.

Treatment variables in relation to oocyte maturation: lessons from a clinical micromanipulation-assisted in vitro fertilization program.

OBJECTIVE: In an effort to understand the mechanism underlying the improved pregnancy rate observed in IVF cycles when gonadotropin-releasing hormone analogues (GnRH-a) are applied, we investigated a possible relationship between treatment variables and oocyte nuclear maturity. DESIGN: Nuclear maturity was retrospectively assessed in cumulus-free, denuded oocytes, obtained from women undergoing micromanipulation-assisted IVF treatment following controlled ovarian hyperstimulation with GnRH-a and menotropins. SETTING: The setting was the infertility and IVF unit of a tertiary academic medical center. PARTICIPANTS: Two hundred twenty-one patients underwent 435 treatment cycles. MAIN OUTCOME MEASURE: This was the proportion of germinal vesicle-intact immature (GVII) oocytes. RESULTS: One hundred fifty-four of the 3520 oocytes studied (4.4%) were in the GVII stage. These oocytes were found in 66 of the treatment cycles (15.2%) and in 54 of the patients (24.4%). Cycles in which GVII oocytes were detected did not differ from those in which all the aspirated oocytes were mature in the following respects: patient age, type and duration of infertility, controlled ovarian hyperstimulation protocol and time of ovum pickup. However, the GVII group was characterized by a significantly higher peak estradiol level, as well as a higher number of mature follicles visualized sonographically (diameter, > 14 mm) and oocytes retrieved. CONCLUSIONS: Comparing the present findings with previously published data, it appears that the inclusion of GnRH-a in the stimulation regimen is associated with a lower proportion of immature oocytes. A higher occurrence of oocyte-nuclear immaturity is apparently associated with a significantly better ovarian response to stimulation. The high incidence of immature oocytes observed in patients with normospermic partners and low fertilization rates in previous cycles may suggest that the fertilization failure in some of these cases is due to oocyte, rather than sperm, dysfunction.

Augmentation of low ovarian response to superovulation before in vitro fertilization following priming with contraceptive pills.

Poor ovarian response to superovulation treatment is observed in a certain group of patients, the so-called 'low responders'. Despite the evolution of sophisticated controlled ovarian hyperstimulation (COH) regimens prior to the in vitro fertilization (IVF), the ideal stimulation protocol for the low responder has yet to be formulated. The objective of this study was to assess the effect of oral contraceptive pills (OCP), administered before the initiation of superovulation, on ovarian response and IVF treatment results in patients with previous 'low response' to exogenous gonadotropin stimulation. The study group comprised 42 patients who had exhibited poor ovarian response to standard superovulation protocols in at least two previous consecutive treatment attempts. Contraceptive pills were administered for 28-42 days and were immediately followed by menotropin treatment. The study group (n=50 cycles) was compared with the control group consisting of previous cycles (n=88) of the same women. Significant differences were noted in peak estradiol levels (983 +/- 739 vs. 517 +/- 249 pg/ml; P <0.01, paired Student's t test) and number of pre-ovulatory follicles between the study and the control groups. Thirty-three of the cycles (66%) reached the stage of ovum pick-up, compared with 22 (25%) of the previous IVF cycles in these women. The mean number of oocytes retrieved was 6.1 +/- 3.0 and 2.4 +/- 1.3 in the study and control groups, respectively (P <0.01; paired Student's t test). Embryo transfer (ET) was performed in 62% of the treatment cycles and resulted in five clinical pregnancies (16.1% per ET). No pregnancies were recorded in the control group. This study demonstrates the beneficial effect of OCP given prior to IVF treatment, and provides an efficient treatment modality for women who consistently respond poorly to standard COH protocols.

The management of dermoid cysts--a comparative study of laparoscopy and laparotomy.

The aim of our study was to compare laparoscopy with laparotomy for the removal of ovarian dermoid cysts. Thirty-eight women with benign ovarian dermoid cyst were allocated for either laparoscopy (18 patients) or laparotomy (20 patients). The two groups were compared for operative and hospitalization times and postoperative course. Operating time was longer (93.6 +/- 23.8 min) and hospitalization time significantly shorter (22.4 +/- 6.6 h) in the laparoscopy group. No complications were reported in either group. We conclude that operative laparoscopy is a safe procedure for the removal of dermoid ovarian cysts and is as effective as laparotomy.

Women's attitudes towards menopause and hormone replacement therapy.

OBJECTIVES: To determine how women aged 50 years or more feel about menopause, and their knowledge, use of and attitude toward hormone replacement therapy (HRT). METHODS: All study participants resided in a single urban community in central Israel and were selected at random from the computerized government registry. Responses were collected by either telephone interview (n = 171) or mailed questionnaire (n = 41) and were analyzed for the group as a whole and by different demographic and attitudinal factors. RESULTS: Most (80%) of the women had a positive or neutral attitude to menopause. More than 80% had heard of HRT, 55% of whom from a physician. Of these, 12% were currently using HRT and 9.5% had done so in the past. Varied reasons were offered for starting or stopping treatment. CONCLUSIONS: Although the great majority of the participants had heard of HRT, and most of these had spoken about it with a doctor, only a small percentage were currently under therapy or had been in the past. We believe gynecologists should devote more effort to public education, in that those women who had discussed HRT with their physician were more likely to use it.

The impact of GnRH agonist and menotropin therapy on lipoprotein metabolism.

Two groups of women, 48 undergoing controlled ovarian hyperstimulation for in vitro fertilization (IVF) treatment with a gonadotropin-releasing hormone (GnRH) analog and human menopausal gonadotropin daily and a group of 15 treated with a GnRH analog using the 'luteal phase protocol' before the hyperstimulation for IVF, took part in a prospective randomized study at the IVF Unit of the Beilinson Medical Center, Israel. The aim was to evaluate the changes in lipid metabolism occurring in the course of a standard controlled ovarian hyperstimulation protocol during IVF treatment cycles by measuring serum lipid levels before and after treatment. In the former group, in parallel with the 17 beta-estradiol increase, the cholesterol and low-density lipoprotein-cholesterol levels dropped and the high-density lipoprotein-cholesterol levels increased significantly. The resultant atherogenic index demonstrated a statistically significant decrease. In the latter group the mean lipoprotein levels were slightly different after treatment, but no statistically significant difference was observed. Our results indicate that the GnRH analog alone, administered for 10-12 days, does not induce any significant change in serum lipid levels. When using a combination of a GnRH analog and menotropins, the change of lipoprotein levels is favorable.

Intranasal nafarelin versus buserelin (short protocol) for controlled ovarian hyperstimulation before in vitro fertilization: a prospective clinical trial.

The aim of this study was to compare the effect of nafarelin acetate with that of buserelin acetate nasal spray, when administered in a 'short' protocol, as an adjunct to human menopausal gonadotropin (hMG) for controlled ovarian hyperstimulation before in vitro fertilization (IVF). Twenty-two IVF subjects were randomly recruited. Each underwent two consecutive treatment cycles; one with buserelin (900 micrograms/day) and another with nafarelin (400 micrograms/day). The treatment protocol included transnasal gonadotropin-releasing hormone (GnRH) analog from the second cycle day and hMG from the fourth day of the cycle. The buserelin and nafarelin cycles did not differ significantly in the following parameters: baseline hormone profile, duration of GnRH analog treatment, mean hMG dose required, peak estradiol levels, number of preovulatory follicles, number of aspirated oocytes, fertilization rate and number of transferred or frozen embryos. No side-effects or cancellations of treatment were recorded. The average dose required was lower for nafarelin and, because this analog was given only twice a day, it was more convenient to administer. These findings suggest that nafarelin is as effective as buserelin (when administered in a "short' protocol) in achieving controlled ovarian hyperstimulation. It even offers advantages over buserelin with respect to the total dose required (which probably reflects its relatively high potency) and the subjects' compliance.

The effect of surgical castration on lipid metabolism in premenopausal and postmenopausal women.

OBJECTIVE: To investigate the effect of endogenous estrogen on lipid and lipoprotein metabolism in premenopausal and postmenopausal women. DESIGN: Prospective randomized study. SETTING: Department of Obstetrics-Gynecology, Beilinson Medical Center and Tel-Aviv University Medical School, Israel. SUBJECTS: Twenty-seven women, 15 premenopausal and 12 postmenopausal, undergoing surgical castration (total abdominal hysterectomy and bilateral salpingo-oophorectomy). METHOD: Blood samples were drawn before the surgical intervention and after a 6-month interval. MAIN OUTCOME MEASURES: Assays were performed for estradiol, luteinising hormone and follicle-stimulating hormone, and triglycerides, total cholesterol, HDL-cholesterol, LDL-cholesterol and total cholesterol/HDL as well as HDL/LDL ratio. RESULTS: No significant differences were found in both groups, before castration and after 6 months. A modest, but statistically significant, rise in triglycerides was observed in the premenopausal group. CONCLUSIONS: The serum lipid and lipoprotein profile encountered in premenopausal and postmenopausal women were unchanged 6 months after surgical castration. The clinical significance indicates that the effect of endogenous estrogen on lipid metabolism is doubtful and should be further investigated.

The impact of D-Trp6 LH-RH on plasma lipid levels.

BACKGROUND: There is increasing evidence regarding the correlation between the risk of death from cardiovascular disease and low levels of HDL-cholesterol or high plasma concentrations of LDL-cholesterol, total cholesterol, and triglycerides. Gonadotropin releasing hormone (GhRH) analogues are widely used in assisted reproduction programs. Therefore, it seems important to evaluate possible changes in serum lipoprotein levels following treatment with these compounds. PURPOSE: Our purpose was to assess possible lipoprotein changes following administration of the long-acting GnRH analogue, D-Trp6 luteinizing hormone-releasing hormone (LH-RH). DESIGN: Serum levels of cholesterol, HDL-cholesterol, LDL-cholesterol, and triglicerydes were determined before and after 6 weeks of treatment. RESULTS: No significant changes in either cholesterol or HDL-cholesterol, LDL-cholesterol, or triglicerydes following treatment with D-Trp6 LH-RH were demonstrated in the group of 25 patients investigated. CONCLUSIONS: Short-term use of D-Trp6 LH-RH is not associated with any significant change in plasma lipid levels. Further studies are still required with patients undergoing repeated treatment cycles, especially those who exhibit elevated pretreatment plasma lipid levels, to confirm the long-term safety of GnRH analogues with respect to lipid metabolism.

The grand multipara.

Grandmultiparity (GMP) has long been considered an obstetric complication for both mother and fetus, although recent studies indicate that, with proper perinatal care, women with high-parity rates are no longer at high risk. The current study examines the outcome of delivery in 1700 women in their fifth or more delivery, as compared with two control groups: 622 primiparas and 735 multiparas (two to three previous deliveries). Excellent prenatal care was available free of charge to all parturients. Our objectives were to evaluate the management of GMP in contemporary obstetrics and to assess whether grand multiparas are still high-risk patients. The age of the grandmultiparas was significantly higher compared with with the control groups, which may explain the higher incidence among them of antenatal medical disorders, such as diabetes mellitus and hypertensive disease. No significant differences were found among the three groups for preterm or post-term births, small-for-gestational-age infants, polyhydramnios, oligohydramnios, perinatal death, fetal distress, multiple births, placenta previa, abruptio placentae or cord prolapse. Macrosomia was markedly higher in the grandmultiparas and multiparas than in nulliparas. Thus, our results indicate that good perinatal care can ensure better results in grandmultiparas, and that grandmultiparity no longer needs to be considered a high-risk obstetric category in our population.

Great grand multiparity--beyond the 10th delivery.

OBJECTIVE: To investigate the perinatal outcome and obstetric complications of women delivering for the 10th time or more. METHODS: Four hundred twenty women of great grand multiparity were analyzed in a modern health care setting and compared with our general population of obstetric patients, with regard to past history, maternal age, gestational age, mode of delivery, fetal outcome and intercurrent medical/obstetric problems. RESULTS: The study group showed significantly lower rates of low birth weight infants and instrumental delivery. No significant difference was seen in the incidence of cesarean section, pathologic fetal presentation, maternal hypertension, gestational diabetes, hemorrhage, or perinatal morbidity or mortality. There was a slightly higher incidence of twin births compared with the general population. CONCLUSION: It is probable that women capable of reaching their 10th delivery are basically healthy. If offered adequate perinatal care, they are not a high-risk group during subsequent deliveries.

Heterotopic abdominal pregnancy following in-vitro fertilization/embryo transfer presenting as massive lower gastrointestinal bleeding.

We present a case that, as far as we know, is the first report of lower gastrointestinal haemorrhage as a complication of heterotopic pregnancy induced by artificial reproductive technology. The heterotopic abdominal pregnancy caused erosion of the intestinal wall and massive rectal bleeding, 8 weeks after in-vitro fertilization/embryo transfer. The source of the bleeding could not be identified despite comprehensive investigation including gastroscopy, ultrasonography, sigmoidoscopy, 99Tc (technetium) scanning and angiography. Tagged-erythrocyte isotope scanning revealed an abnormal concentration in the left lower quadrant, compatible with active bleeding in the area of the terminal ileum. Laparotomy disclosed a heterotopic abdominal pregnancy, causing erosion of the intestinal wall at this site. As assisted reproductive technologies become more and more common this rare complication of intestinal erosion should be kept in mind in case of lower gastrointestinal bleeding.

Successful external version of B-twin after the birth of A-twin for vertex--non-vertex twins.

OBJECTIVE: To determine the optimal intrapartum management of twins, especially those in vertex--non-vertex presentation. STUDY DESIGN: The study population consisted of 408 sets of twins delivered between 1988 and 1992, weighing at birth over 1500 g. According to our protocol, vaginal delivery was attempted in the vertex-vertex presentations. If non-vertex presentation was first, we performed cesarean section. In vertex--non-vertex cases, the first was delivered vaginally and external cephalic version or breech delivery was performed on the second. Apgar scores were compared according to presentation and delivery mode. RESULTS: Vaginal delivery was accomplished in 122 (73%) of 169 vertex--vertex presentations, 96 (68%) of 142 vertex--non-vertex presentations, and 4 (5%) of 99 non-vertex--other presentations. External cephalic version (ECV) of the second twin and subsequent vaginal delivery in vertex--non-vertex was successful in 75% of cases, and internal podalic version and assisted breech delivery were performed in 20 cases, and the remaining two were delivered by cesarean section. Apgar scores were not significantly different among the various groups, and no complications arose from external cephalic version performed on second non-vertex twins. CONCLUSIONS: External cephalic version was found safe for delivering second non-vertex twins in cases where the first twin is in vertex presentation. In our opinion routine cesarean section is thus no longer justified in such cases.

The outcome of post-term pregnancy. A comparative study.

The aim of this study was to evaluate whether prolonged pregnancy was associated with dangers to the fetus, and to assess the incidence of cesarean section as well as fetal distress. The outcome for mother and baby in both groups of patients with post-term pregnancies was generally good. Furthermore, the improvement of prognosis for postdate pregnancy is due to the availability of electronic fetal monitoring and ultrasound, making possible the identification of fetal distress, as well as the use of prostaglandin to ripen a stubborn cervix, and induce labor successfully in most cases. Consequently, we feel that fetal jeopardy with continued intrauterine existence, as well as the excellent results of induction of labor, justify the active approach. The routine induction of labor in postdate pregnancy may reduce perinatal morbidity, as indicated in previous reports [2], and confirmed in this study.

Idiopathic transient osteoporosis of the hip in pregnancy.

OBJECTIVE: To study the nature of a condition called transient osteoporosis of the hip (TOH) in pregnancy. METHOD: Fifty-three cases of this syndrome of unknown etiology have been reviewed and an additional case has been added. RESULT AND CONCLUSION: TOH is characterized by hip joint pain during the 3rd trimester of pregnancy and signs of demineralization of the femoral head. The course is benign with recovery shortly after birth. No specific therapy is required except bed rest.

Ovarian tumors in women over 70.

OBJECTIVES: To discuss and evaluate the management of ovarian masses in women over 70. METHODS: The nature of adnexal masses and the outcome of surgical intervention in 38 women over 70 was reviewed. RESULTS: There were seven cases of malignant ovarian tumors in our series of 38 patients reviewed. The most frequent presenting sign was abdominal pain (11 cases). The presence of an adnexal mass was suspected on the basis of routine gynecologic examination in 8 cases, whereas by routine ultrasound scan in 30 patients. Postoperative complications were rare. CONCLUSIONS: It is suggested that in all postmenopausal women routine yearly pelvic examination and ultrasound scan is advisable. Furthermore, in view of our favorable results in recent years, we feel that surgical intervention is justified in all cases of adnexal tumors in the woman over 70.