An epidemiologic study of eclampsia.

The epidemiologic characteristics of 298 cases of eclampsia treated from 1967 to 1974 in the Siriraj Hospital, Bangkok, Thailand, are described. The incidence of eclampsia was 0.2% of all deliveries, and the nulliparas had a higher incidence than the multiparas in all age groups. About 90% of patients had inadequate or no antenatal care, and 43% of patients suffered their first convulsion after admission to the hospital. Although the patient's own neglect was the major causative factor, physician error played some role in the development of eclampsia. The maternal mortality rate was 4.7%, and factors influencing maternal and perinatal death rates are discussed. The rate of cesarean section for eclamptics was 7%, as compared to a 3% rate for the general obstetric population. The findings suggest that more frequent use of properly timed cesarean section can improve the outlook for both the fetus and mother. An active program aimed at reducing the incidence of eclampsia and its maternal and perinatal mortality is emphasized.     

激素水平与农村围绝经期女性情绪障碍的流行病学探讨

目的:了解江西农村地区围绝经期情绪障碍者体内不同激素水平及变化特点。方法:用多阶段整群随机抽样方法,采用《焦虑自评量表》(self-rating anxiety scale,SAS)、《抑郁自评量表》(self-rating depression scale,SDS)并结合某些临床症状及体征,对靖安和分宜两县40～56岁的妇女进行筛查。内容包括一般情况,焦虑和抑郁的评定,部分女性血中雌二醇(estradiol,E2),促卵泡生成激素(follicle-stimulating hormone,FSH),黄体生成素(luteinizing hormone,LH)等3种激素水平的放射免疫检测。结果:调查围绝经期女性613例,采集有效血样85份,情绪障碍患病率27.89%,其中焦虑患病率24.80%,抑郁患病率14.68%。E2、FSH、LH水平在情绪障碍者与无情绪障碍者之间无明显差异(P0.05);在不同年龄段的情绪障碍者及不同月经周期的情绪障碍者之间有显著差异(P0.05)。处于卵泡期的焦虑者FSH水平比无焦虑者高,月经周期不正常的抑郁者FSH水平高于无抑郁者,且差异均有统计学意义(P0.05)。结论:未发现情绪障碍发生与否同E2水平变化有直接关系,但焦虑和抑郁的发生与FSH水平有统计学上的联系。     

Intractable primary infertility in women exposed to diethylstilbestrol in utero

Fertility factors were examined in 50 women with primary infertility and presumed in utero diethylstilbestrol (DES) exposure and in 50 age-matched controls. Uterine deformities and endometriosis were more frequent in the DES-exposed women than the controls. When managed from one to four years, only 4% of DES-exposed women with primary infertility conceived (with no conceptions resulting in a viable fetus) as compared to 44% of controls. Primary infertility of one to two years' duration with uterine deformities characteristic of DES exposure seems to signal a poor prognosis for pregnancy despite treatment of identifiable fertility factors.     

Fertility and infertility in aging women.

Age is often a dominant factor for women wanting to conceive. The objective of this study was to examine the outcome of an in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) program in relation to a woman's age. Between January 1995 and June 1997 we stimulated 2511 cycles. The mean age of the women was 34 years, with 21.9% under 30, 45.9% between 30 and 35, 24.5% between 36 and 39, and 7.7% over 39 years. All patients aged > or = 40 years had day 3 serum follicle-stimulating hormone (FSH) concentrations < 20 IU/l. The stimulation regimen consisted of 150-450 IU of human menopausal gonadotropin (hMG) or FSH combined with either clomiphene citrate (CC) or gonadotropin-releasing hormone agonist (GnRHa) in a short or long protocol. Age had a significantly negative effect on the stimulation and fertilization failure rates. The clinical pregnancy rate per transfer and the embryo implantation rate declined significantly from 29.4% and 18.9% in women < 30 years to 19.8% and 14.3% in patients between 30 and 35 years, 17.1% and 9.0% between 36 and 39 years and to 12.8% and 7.4% in those aged > or = 40 years. The spontaneous abortion rate was 14.9%, 16.5%, 22.4% and 33.2%, respectively. The clinical pregnancy rate per transfer reflected only imperfectly the performance of the older women because the discharge rate during stimulation and spontaneous abortions reduced the 'take home baby' rate to about 7% per cycle in patients aged > or = 40 years. It is very important in fertility practice to recognize the major impact of advancing maternal age.     

Transvaginal hydrolaparoscopy vs. conventional laparoscopy for evaluating unexplained primary infertility in women

OBJECTIVE: To verify the usefulness and reliability of transvaginal hydrolaparoscopy (THL) as a screening tool for evaluating infertility in women in comparison with conventional diagnostic laparoscopy. STUDY DESIGN: Sixty consecutive women with unexplained primary infertility were prospectively enrolled into the study. After examination of the whole pelvic cavity, tubal patency was evaluated and the uterine cavity studied by hysteroscopy. Immediately after THL, conventional laparoscopy was performed. Main outcome measures were the success rate of accessing the pouch of Douglas, rate of complete examinations, rate of complications and accuracy of THL in comparison with laparoscopy. RESULTS: Success rate of accessing the pouch of Douglas and performing THL was 93.3%. The rate of complete evaluation of all the pelvic structures was 76.8%. In studying tubal pathology, 77.8% agreement was found between the two techniques. Diagnosis of endometriosis was correct in 55.5% of patients. Overall, THL results correlated closely with conventional laparoscopic results in 92.86%, but the diagnostic accuracy of THL was 100% in cases of complete pelvic evaluation. CONCLUSION: THL is a feasible, reliable and safe procedure and can be considered an alternative procedure for evaluating infertility in women. In cases of incomplete pelvic evaluation or abnormal findings, conventional laparoscopy is indicated as the second step in the evaluation.     

Peritoneal fluid and serum leptin concentrations in women with primary infertility

Aim  Leptin is proposed to participate in the reproductive system of women by acting on either ovaries or hypothalamic-pituitary axis. The objective of the present study is to investigate the leptin concentrations in peritoneal fluid and serum samples of women diagnosed with primary infertility. Methods  A prospective study was carried out in women who underwent laparoscopy within the diagnostic process of primary infertility between January 2005 and January 2007. Leptin concentrations were determined in blood samples obtained before surgery and in peritoneal fluid samples collected during laparoscopy. Results  Peritoneal fluid was obtained from 112 subjects; 21 with unexplained infertility 28 with polycystic ovary syndrome (PCOS), 30 with bilateral tubal occlusion, and 33 with endometriosis. Subjects with PCOS have significantly higher body weights, BMI values and plasma leptin levels when compared to other study groups. Peritoneal fluid levels of leptin were significantly higher in the endometriosis group compared to other three study groups. A positive correlation was found between peritoneal fluid leptin levels and the endometriosis stage (r = 0.51, P = 0.01). However, plasma leptin levels were unrelated to the disease extent. Discussion  It might be hypothesized that leptin may be an active factor in the pathogenesis of PCOS and endometriosis, which are two major causes of primary infertility. A mild leptin deficiency in peritoneal environment may interrupt follicular development and ultimately lead to PCOS. Leptin has angiogenic and mitogenic properties, which trigger inflammatory cytokines and eventually result in the development of endometriosis implants. Significantly, higher levels of leptin in peritoneal environments of endometriosis subjects strongly imply the important role of this common pathology.     

Minihysteroscopy as routine diagnostic procedure in women with primary infertility

STUDY OBJECTIVE: To evaluate the importance of routine minihysteroscopy in the diagnosis of primary infertility. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: Endoscopic center at a university hospital. PATIENTS: Three hundred seventy-nine patients with primary infertility. INTERVENTION: Diagnostic minihysteroscopy without anesthesia or sedation. MEASUREMENTS AND MAIN RESULTS: Hysteroscopy was normal in 337 patients (89.9%). In 38 patients (10.1%) an intrauterine pathology was found: 26 intrauterine adhesions, 12 cases of uterus subseptus. The procedure could not be completed in four women. CONCLUSION: Minihysteroscopy should become a routine diagnostic procedure in women with primary infertility, even those with no suspected intrauterine pathology or other risk factors.     

Gonadotropin-releasing hormone for infertility in women with primary hypothalamic amenorrhea. Toward a more-interventional approach

OBJECTIVE: To assess the effectiveness of a protocol of pulsatile gonadotropin releasing-hormone (GnRH) in treating infertility in women with primary hypothalamic amenorrhea. STUDY DESIGN: Retrospective analysis of 44 cycles treated at an infertility center. Twenty-four patients with primary hypothalamic amenorrhea were treated intravenously with pulsatile GnRH using 5 micrograms per bolus every 90 minutes. Ultrasound monitoring and cervical assessment by Insler's scoring system allowed timed injection of human chorionic gonadotropin (hCG) and intrauterine insemination if needed. Luteal support was provided with hCG. RESULTS: The ovulation rate was 95% with the 5-microgram dose. A single follicle was produced in 91% of cycles. The overall pregnancy rate per ovulatory cycle was 45%, and the pregnancy rate per patient was 83%. In patients treated previously with exogenous gonadotropins, poor results were observed. Only one case of mild overstimulation was reported. CONCLUSION: Pulsatile GnRH is an effective and safe method of treating infertility in women with primary hypothalamic amenorrhea, thus simulating normal ovulation; however, more-interventional management, including the qualitative estrogenic response, may lead to optimal results and increase the pregnancy rate.     

Hysteroscopic findings in women with primary and secondary infertility due to genital tuberculosis

Objective

To evaluate hysteroscopic findings of infertile women with genital tuberculosis.

Method

A retrospective study of the records of 94 women who underwent diagnostic hysteroscopy for infertility at All India Institute of Medical Sciences, New Delhi, India. Genital tuberculosis was diagnosed by laboratory studies of an endometrial biopsy and/or laparoscopic findings.

Results

For women with primary or secondary infertility, respectively, the hysteroscopic findings were normal in 15 (20.5%) vs 4 (9%) cases; and adhesions were grade 2 in 11 (15.1%) vs 3 (14) cases, grade 2a in 0 vs 1 (1.4%) cases, grade 3 in 11 (15.1%) vs 9 (42.9%) cases, grade 3b in 6 (8.2%) vs 0 cases, and grade 4 in 28 (38.4%) vs 2 (9.5%) cases.

Conclusion

Genital tuberculosis causes significant pelvic morbidity due to uterine adhesions and infertility.     

Doppler study of uterine hemodynamics in women with unexplained infertility

Objective

To evaluate uterine artery blood flow using pulsed Doppler, and endometrial and subendometrial microvascularization using three-dimensional (3D) power Doppler, in women with unexplained infertility.

Study design

In a prospective clinical trial at a university teaching hospital, 40 women with unexplained infertility were compared to 40 fertile parous controls. In the mid-luteal (peri-implantation) phase, the endometrial thickness and volume, uterine artery pulsatility index (PI) and resistance index (RI), endometrial and subendometrial 3D power Doppler vascularization index (VI), flow index (FI), and vascularization flow index (VFI), and serum estradiol and progesterone levels were measured in both groups.

Results

The uterine artery PI (P = 0.003) and RI (P = 0.007) were significantly increased and the endometrial VI (P = 0.029), FI (P = 0.031), and VFI (P = 0.001) and subendometrial VI (P = 0.032), FI (P = 0.040), and VFI (P = 0.005) were significantly decreased in the unexplained infertility group. The endometrial thickness and volume and serum estradiol and progesterone levels, however, were not significantly different between the two groups.

Conclusion

Peri-implantation endometrial perfusion is impaired in women with unexplained infertility: Doppler study of uterine hemodynamics should therefore be considered in infertility work-up.     

Cigarette smoking and urinary incontinence in women.

OBJECTIVE: The goal of this case control study was to evaluate the relationship between smoking and female urinary incontinence. STUDY DESIGN: The study included 606 women whose smoking histories were known; 322 were incontinent and 284 were continent. The condition(s) causing each subject's incontinence was determined by urodynamic testing; 40% of the continent subjects had the same testing. RESULTS: There were highly significant overall differences (p = 0.000009) in the distribution of current, former, and never smokers between incontinent (35%, 16%, 49%) and continent (24%, 8%, 68%) groups. The odds ratio for genuine stress incontinence was 2.20 for former (95% confidence interval 1.18 to 4.11) and 2.48 for current smokers (95% confidence interval 1.60 to 3.84); for motor incontinence it was 2.92 for former (95% confidence interval 1.58 to 5.39) and 1.89 (95% confidence interval 1.19 to 3.02) for current smokers. Increasing daily and lifetime cigarette consumption was associated with an increasing odds ratio for genuine stress incontinence but not for motor incontinence. The increased risk for incontinence was not due to differences in age, parity, weight, or hypoestrogenic status. CONCLUSION: The data establish a strong statistical relationship between current and former cigarette smoking and both stress and motor urinary incontinence in women.     

Medical abortion complications. An epidemiologic study at a mid-Missouri clinic

A study of 420 cases of vacuum aspiration abortions in a central Missouri family planning clinic found 33 postabortal complications, 14 of which occurred over 10 weeks; 12 under 7. Most patients were white nulliparous females under 30. 41.5% of complications were incomplete abortions, only one of which occurred between 7 1/2-9 1/2 weeks, 4 times more at less than 7 weeks, 11 times more for women over 10 weeks. 25% were cervical lacerations, which occurred less frequently at advanced stages of gestation, 21.2% were postabortal hemorrhage, occurring most frequently over 10 weeks. The optimum time for less risk of postabortal complications is 7 1/2-9 1/2 weeks gestation. 18% complications, 7% incomplete abortions occurred at 7 1/2-9 1/2 weeks. During early pregnancy the progesterone block influences uterine motility and may be a survival mechanism for the fetus. The corpus luteum of pregnancy secretes large amounts of progesterone for the first 60 days and lesser quantities for the next 30 days.     

Subclinical hypothyroidism and thyroid autoimmunity in women with infertility.

OBJECTIVE: To determine the prevalence of different subclinical hypothyroidism (SH) grades and thyroid autoimmunity (TAI) in infertile women. DESIGN: Retrospective study. Setting. Endocrinology division of a public hospital in Argentina. PATIENTS: Group I comprised 244 women consulting on infertility (>1 year without pregnancy); Group C (controls) comprised 155 healthy women with confirmed fertility. INTERVENTION: Thyroid-stimulating hormone and thyroid peroxidase antibodies were measured in all patients, and a thyrotropin-releasing hormone (TRH) stimulation test was performed in 71 patients to diagnose SH grade 1. The pregnancy rate in hypothyroid women on levothyroxine treatment was also evaluated. RESULTS: SH was diagnosed in 13.9% of the patients in Group I and in 3.9% of Group C (p < 0.002). The TRH stimulation test was useful to detect SH grade 1 in 12.7% of the infertile patients. Patients with precocious ovarian failure, tubal disturbances and ovulatory dysfunction presented higher SH rates (40.0, 18.2 and 15.4%, respectively) than control patients (p < 0.0001, p < 0.002 and p < 0.003). No significant difference in TAI prevalence was shown in Group I relative to Group C. Pregnancy rate of 44.1% was achieved under levothyroxine treatment. CONCLUSIONS: We observed a higher prevalence of SH, but not of TAI, in patients with infertility. Our results support thyroid screening in women with reproductive failure.     

Health promotion for women: reduction of smoking in primary care settings

Unnecessary deaths of women under age 65 should be a high priority among physicians and the medical community as a whole. In the discussion of the promotion of health for women and the reduction of smoking, the idea of health promotion is 1st embellished upon with smoking and the preventable diseases incurred by it being used as an example for consideration. A good base of health promotion is the development of a health education strategy. Health promotion is defined by the following activities: the advocation of healthy behaviors, the continuation of the promotion of such choices or the promotion of changes in unhealthy behavior, the parleying of preventive and curative health services and the acceptance of such facilities and the condoning of activities at a societal level that are supportive of preventative and health choices. As the number of young women who smoke now exceeds the number of young men, smoking among women is a growing concern. Although white women capture the greatest percentage in the ethnic division of smokers, black women are only a few percentage points behind. In addition, smoking increases inversely according to level of education with the greatest percentage occuring among women with little education. The consequences of smoking, lung cancer, cardiovascular disease and additional risks relative to oral contraceptive use, are both apparent and serious. Measures such a mutually agreeable "quit plan," the creation of a smoke-free office and firm reinforcement in the discussion of smoking control are only a few of the steps a physician can undertake to support the process.     

Adverse obstetric outcome in women with a history of infertility: a retrospective study.

Women with a history of infertility are associated with a higher incidence of adverse pregnancy outcome. This retrospective study reviewed 105 women with a known history of infertility; of these 105 women, 77 (73%) conceived spontaneously and 28 (27%) had assisted conception. Our finding confirms higher perinatal complications; relative ratios (RR) for pre-eclampsia was 4.6 (95% CI=2.1-9.9), intrauterine growth restriction 4.8 (95% CI=1.9-12.0), gestational diabetes 1.8 (95% CI=0.5-5.8), pre-term premature rupture of membrane 2.3 (95% CI=0.6-8.8) and pre-term labour 2.6 (95% CI=1.1-5.9). We postulate that women with a history of infertility are at high risk of such obstetric complications and may benefit from intensified antenatal care.     

Cigarette smoking: male and female infertility

Despite problems of methodology, epidemiologic studies of women who smoke have clearly indicated that they suffer a lowering of fertility. Harmful effects are particularly noted in the periodicity of the menstrual cycle, tubal function and embryo transfer, development and viability of the ovocyte, age at menopause, and bone metabolism. Several epidemiologic studies have shown that the rate of infertility among women smoking is 21% vs. 14% among nonsmokers. Fertility declines significantly with daily cigarette consumption among women smoking 16 cigarettes a day or more. Nevertheless, in some cases such as tubal infertility, further research is needed to determine clearly whether there is a true causal mechanism or whether there is simply an association related to differences in the lifestyle of smoking women. In general, studies in women and animals confirm the possible alteration of physiological characteristics of the tubes in smokers, resulting in a disturbance of intratubal transport of the embryo, a premature or delayed arrival of the blastocyst in the uterus, and alterations of the immune system that could explain the epidemiologic association of smoking and lowered fertility. Studies in mice and rats have shown that smoking can destroy ovocytes, but observations in women have not been completely convincing. It has been concluded however that smoking can decrease the number of viability of ovocytes, ending in premature extinction of reproductive function and early menopause. Results of a small number of studies tend to demonstrate that compared to nonsmokers, smokers experience a greater frequency of secondary amenorrhea, increased vaginal bleeding, and a significant lowering of urinary estrogens in the luteal phase. Taken together, clinical reports on women and animal studies demonstrate the effect of nicotine and smoke on the basic hormonal homeostasis of women, an effect which can change the timing of cycles and reduce fertility. The risk of osteoporosis after menopause is known to be greater among smokers than nonsmokers, probably because of hormonal modifications caused by elements in cigarette smoke. Available data on effects of smoking on male fertility are inconclusive, but a certain number of studies have shown an increased incidence of morphologic anomalies and a lowering of mobility and density in the sperm of smokers. Fluctuations in the levels of androgens and gonadotropins have also been observed in men who smoke. The evidence suggests that all persons wishing to reproduce but especially those with fertility impairments should avoid smoking.