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Purpose: To describe another previous unreported manifestation of the sympathetic neural hyperalgesia edema syndrome - autoimmune hearing loss., Materials and Methods: Dextroamphetamine sulfate 30 mg extended release capsules was given to a woman to try to help her conceive since, with her pelvic pain, chronic fatigue syndrome, and diarrhea, it was thought that an inflammatory condition related to permeation of unwanted chemicals into endometrial tissue related to the sympathetic neural hyperalgesia edema syndrome could be inhibiting her failure from conceiving despite three cycles of embryo transfer., Results: Not only did the symptoms mentioned above disappear, but she also noted marked improvement of hearing loss that had been present for several years. The improvement in hearing was documented by audiology tests and had not responded to many months of 15 mg/day prednisone., Conclusions: Autoimmune hearing loss (diagnosis established by her ear nose and throat specialist) should be added to the long list of manifestation of the sympathetic neural hyperalgesia edema syndrome.

Objective: To determine the effect of extremely low sperm morphology on pregnancy rates following intrauterine insemination (IUI) where all other semen parameters were normal., Materials and Methods: Retrospective review of all IUI cycles over a two-year period on infertile women age ≤ 35 where all parameters, but morphology had to be normal. The data were evaluated according to seven levels of percentage of normal morphology (NM): 0, 1, 2, 3, 4, 5, and ≥ 6%., Results: The percent live delivery was 9.5, 16.7, 8.8, 16.1, 11.4, 12.3, and 10.9%., Conclusions: Morphology of 0% or 1% did not seem to impair pregnancy rates following IUI. More studies are needed but should include determining the confounding effect of the type of morphologic abnormality.

Purpose: To demonstrate that it is important to consider all possibilities when confronted with a decision to terminate a pregnancy because it is likely to be chromosomally abnormal., Materials and Methods: A cell free DNA test was performed on a woman with dichorionic diamniotic twins that followed the transfer of a single embryo., Results: The cell free DNA test was consistent with trisomy 21. Two perinatologists favored identical twins and thus suggested termination since both twins would be trisomy 21 and the couple did not want to raise a child with Down's syndrome. Our group suggested the possibility that these were fraternal twins with one occurring from natural conception. We suggested to forego termination by D&E but to undergo an amniocentesis at 16 weeks. One twin had obvious cardiac abnormalities by ultrasound and this one was reduced while amniocentesis with karyotype was performed on fetus 2. The results showed a normal male., Conclusions: One should consider all possibilities before suggesting termination of a very desired pregnancy. This woman had also been advised by other specialists in reproductive endocrinology that conception with her own oocytes (as did occur here) was not possible and she should consider donor oocytes based on her marked diminished oocyte reserve.

Purpose: To determine if dextroamphetamine sulfate could improve symptoms of post-partum depression., Materials and Methods: A woman with severe post-partum depression that was resistant to standard antidepressant therapy and psychotherapy was treated with dextroamphetamine sulfate extended release capsules 15 mg/day., Results: A quick and complete abrogation of the depression ensued along with improvement of migraine headaches, insomnia, and chronic fatigue., Conclusions: Dextr6amphetamine sulfate should be considered as a treatment modality for post-partum depression.

Purpose: To determine if serum levels of the immunomodulatory protein, the progesterone induced blocking factor (PIBF), which is present in high levels during normal pregnancy, is present in higher levels in women with breast cancer positive for progesterone receptors. The study would also determine whether the presence or absence of the estrogen receptor in any way modifies PIBF expression., Materials and Methods: PIBF using a research ELISA was evaluated in the follicular phase in 21 women with receptor status as follows: seven with estrogen receptor (ER)+ and progesterone receptor (PR)+, seven with ER- and PR+, and seven with ER+ and PR., Results: The results showed no differences in serum PIBF in the three groups. The serum PIBF levels were no different than historical controls in the follicular phase., Conclusions: Measurement of serum PIBF does not seem to be an important marker to use to either detect women with breast cancer or to help determine tumor virulence or potential specific therapies. If PIBF plays a role in helping cancer cells to escape immune surveillance, it seems that the intracytoplasmic PIBF would be the form most likely operative.

Purpose: To compare pregnancy rates following ovulation induction in anovulatory women with clomiphene citrate vs. letrozole and to determine the relative confounding effect of inducing menses or not. The study also evaluated whether starting these anti-estrogen drugs later in the menstrual cycle has-less adverse effect on endometrial thickness., Materials and Methods: Prospective series with choice by physician of inducing menses or not or choosing clomiphene citrate or letrozole for ovulation induction. Peak endometrial thickness was compared between drugs and between those conceiving or not., Results: There were 21 first cycles using letrozole and 42 using clomiphene. Menses were not induced in 18/21 (86%) letrozole cycles and 24/42 (57%) clomiphene cycles. Clinical pregnancies occurred in four (22.2%) letrozole cycles without induced menses with one miscarriage vs. 4/24 (16.6%) clomiphene cycles, no mis- carriage. One of three (33.3%) letrozole cycles with menses induced achieved a clinical pregnancy vs. only 1/18 (5.5%) of clomiphene cycles. There were no miscarriages., Conclusions: Though the endometrial thickness was higher with clomiphene without induced menses vs. menses induced (11 mm vs. 9.5 mm), one cannot explain the trend for lower pregnancy rates in women with induced menses because of thinner endometria since the thickness was 10.3 mm for clomiphene and 10.0 with letrozole.

Purpose: To determine the correlation with detection of antibody on sperm by a new ImmunoSphere™ Immunoglobulin test vs. ImmunoBeads®., Materials and Methods: A sampling of sperm tested for antisperm antibody (ASA) tested by direct Immunobead? assay with levels varying from zero to 100% were compared to the percentage of sperm positive for ASA by a new test using immunospheres., Results: The correlation was not perfect but, in general, there was good correlation., Conclusion: Now that the manufacturer is curtailing the manufacture of immunobeads, it is comforting to see a good correlation with immunospheres.

Purpose: To corroborate or refute a previous study suggesting that intrauterine infusion of granulocyte colony stimulating factor (G-CSF) could significantly improve endometrial thickness into more fertile levels when the endometrial thickness was ≤ five mm., Materials and Methods: Three women whose endometrial thickness never exceeded five mm on the in vitro fertilization-embryo transfer (IVF-ET) cycle or subsequent attempted frozen ETs using graduated estradiol had intrauterine infusion of G-CSF to the estradiol regimen., Results: Not one of the three women improved the endometrial thickness beyond five mm and none conceived on the G-CSF cycle. One woman had a subsequent pregnancy following a frozen ET with only a four-mm thickness with no infusion of G-CSF., Conclusions: These data do not confirm the efficacy of intrauterine infusion of G-CSF for poor endometrial thickness. Perhaps only certain cases will respond. A larger series could take time to accumulate since other studies have shown that only 0.3% of women with ≤ five mm endometrial thickness in the late proliferative phase during an IVF-ET cycle will not improve the endometrial thickness > five mm using graduated estradiol protocols.

Purpose: To determine if mifepristone can lower serum levels of a progesterone (P) induced immunomodulatory protein believed to be needed for the fetus to escape immune surveillance., Materials and Methods: A female volunteer had her serum P induced blocking factor (PIBF) increased by ingestion of oral micronized P. While remaining on P mifepristone, 200 mg/day was given for six days when another serum PIBF level was obtained., Results: The serum PIBF was 273 ng/ml after five days of oral micronized P. It increased further to 737 ng/ml despite taking six days of 200 mg mifepristone., Conclusions: The mechanism for inducing abortion by mifepristone does not seem to be related to decreasing serum levels of PIBF. This does not eliminate the possibility that the mechanism involves reducing the intracytoplasmic PIBF levels.

Purpose: To present an opposing view to the recent conclusions reached by the Practice Committee of the American Society for Reproductive Medicine and a recent review of the role of progesterone in subfertility by Sonntag and Ludwig that there is no evidence to support using progesterone in the luteal phase as exclusive therapy., Materials and Methods: A large quasi randomized study not mentioned by either review is presented., Results: In this study published in 1989 when women with luteal phase deficiencies and subfertil- ity were evaluated for follicular maturation, the majority seemed to form mature follicles. This majority group found far better with pregnancy outcome by taking exclusive progesterone in the luteal phase than follicle maturing drugs. A recent prospective series confirmed its beneficial effect., Conclusions: Physicians should not empirically treat with follicle maturing drugs but should use progesterone in the luteal phase, preferably in those women who seemingly create a mature follicle.

Purpose: To determine if letrozole is less likely to create a hostile cervical mucus than clomiphene citrate., Materials and Methods: Post-coital testing compared at time of peak follicular maturation in women attaining mature follicles in first or second cycle of these two drugs. The study was randomized. Intercourse occurred at least 8-16 hours before., Results: Poor post-coital tests were found in twice the frequency in letrozole cycles than clomiphene citrate cycles., Conclusions: Despite its shorter half-life, letrozole seems to be as least as likely, if not more, to adversely affect cervical mucus.

Purpose: To test sympathomimetic amine therapy on another type of chronic headache syndrome--headaches from temporal mandibular joint (TMJ) syndrome., Materials and Methods: A woman with 20 years of severe daily pain from TMJ refractory to all therapies was treated with dextroamphetamine sulfate., Results: The woman showed immediate 100% relief from sympathomimetic amine treatment saving her from an expensive jaw breaking operation that was only given a slight chance of helping., Conclusions: Unfortunately most treating physicians are unaware of this defect of sympathetic nervous system hypofunction leading to the absorption of toxins, which when it involves brain tissue, leads to severe headaches. Thus, the gynecologist who is aware of this syndrome because sympathetic nervous system hypofunction is the most common cause of pelvic pain, may need to intervene in women with chronic headaches, even TMJ.

Purpose: To compare the efficacy of vitrification of 2 pronuclear and day 3 cleavage stage embryo vs. a modified slow freeze protocol that historically has achieved good survival and pregnancy rates at these stages., Materials and Methods: Embryos were randomly assigned by day to freezing at the 2 proncular stage or day 3 cleavage stage embryos by either vitrification or a modified slow freeze protocol. Comparisons were made for survival rate, cleaveage rate, and pregnancy rate., Results: The results were comparable with a slight edge to vitrification. Only the implantation rates of day 3 cleavage staged embryos (75% vs. 30.4%) showed a significant difference., Conclusions: Vitrification seems to be equally or possibly slightly superior to freezing embryos at the 2 pronuclear or day 3 cleavage stage vs. a modified slow freeze protocol that had been previously found to be superior to the slow freeze method of LaSalle-Testart.

Purpose: To evaluate the efficacy of intralipid intravenous infusion in achieving a live pregnancy following IVF--embryo transfer in women of advanced reproductive age (40-42 years)., Materials and Methods: A matched control was performed. Women aged 40-42 with a previous history of miscarriage or who failed to conceive despite previous embryo transfer who entered an IVF program were offered intravenous intralipid therapy (four ml of 20% liposyn II in 100 ml normal saline over one hour) during the mid-follicular phase. Clinical pregnancy rates (eight weeks with viable gestation) and live delivered pregnancy rates were then determined and compared., Results: The results were evaluated after ten matched cycles. There were no clinical pregnancies in those receiving intralipid vs. a 40% clinical and a 30% live delivered pregnancy rate in the untreated controls (p = 0.087, Fisher's exact test). The study was terminated because of these preliminary data., Conclusions: In the test tube, adding intralipid to natural killer cells can inhibit their cytolytic action. However, the use of intravenous intralipid to suppress natural killer cell activity does not seem to improve the chance of a live delivery in women aged 40-42 years with a previous history of miscarriage. In fact this therapy may actually be detrimental in this age group. Since efficacy of this therapy was not found in a group of advanced reproductive age, it is not clear why this should be effective for a younger population. A controlled study for the younger group is needed. Perhaps such a study could be limited to only those with miscarriage rather than also concluding failure to conceive despite embryo transfer. Intralipid failed to improve live delivered pregnancy rates in women with prior miscarriage or previous failure with embryo transfer.

Purpose: To present a new side effect of follitropin beta not shared with highly purified urinary follicle stimulating honnone (FSH)., Materials and Methods: Follitropin beta was administered for preparation of in vitro fertilization-embryo transfer (IVF-ET)., Results: Within a few minutes of injection of subcutaneously of follitropin beta, a 27-year-old woman developed a feeling of fever, headache, nausea, vomiting dizziness, and a visual aura consistent with migraine syndrome. These side effects did not occur when switched to highly purified urinary FSH., Conclusions: Since this reaction did not occur when injected with FSH not made with recombinant DNA technology, it is concluded that recombinant FSH (at least with follitropin beta) can produce an immediate migraine-like syndrome.

Purpose: To determine if an injection of granulocyte colony stimulating factor (G-CSF) prevoulatory can enable oocyte release from the follicle in women who have failed to release in natural cycles despite an endogenous luteinizing hormone (LH) surge, and also despite treatment with human chorionic gonadotropin (hCG) or a gonadotropin releasing hormone agonist (GnRHa)., Materials and Methods: A single injection of 100 mg G-CSF was given in the late follicular phase followed by hCG 10,000 units at peak follicular maturation in women with at least three consecutive cycles of luteinization without oocyte release., Results: Six women had ten cycles with G-CSF and hCG. Definite release occurred in four, inconclusive in four, and definitely the luteinized unruptured follicle in two. Biochemical pregnancies occurred in two of the cycles where oocyte release occurred and a live delivered pregnancy in another cycle of release., Conclusions: Without controls one cannot state with certainty that G-CSF enabled oocyte release when hCG and leuprolide failed. Nevertheless, the data do support a trial with G-CSF before proceeding to IVF-ET.

Purpose: To determine if a single injection of one-mg leuprolide acetate three days after embryo transfer (ET) in younger women causes an increase in pregnancy rates, and if so, is it associated with a higher initial serum hCG level?, Materials and Methods: A prospective study was initiated where women aged ≤ 35 years were offered the option of taking the leuprolide or not., Results: Though a significant difference was not found, there was a trend for higher live delivered pregnancy rates in those taking the leuprolide supplement (47.8%) vs. those not taking it (38.6%). There was no difference in the first serum beta hCG level., Conclusions: The trends is interesting enough to continue with a higher powered study.

Purpose: To discover if infertile women with presumed luteal phase deficiency would improve pregnancy rates, mid-luteal sera estradiol (E2) and progesterone (P), and increase the percentage of women achieving a mid-luteal sonographic homogeneous hyperechogenic endometrial texture by the addition of a single injection of human chorionic gonadotropin (hCG)., Materials and Methods: Women with over one year of infertility with regular menses and with no other known infertility factor were presumed to have the need for extra P in the luteal phase based on previous studies. Women aged ≥ 30 years were selected along with women < 30 years who had pelvic pain or dysmenorrhea. Women aged 40-45 were evaluated separately. They were treated with either vaginal micronized P 8% twice daily alone or 10,000 units of hCG at the time of peak follicular maturation was also given. Women were eliminated if they did not achieve an 18-24 average diameter follicle with a serum E2 of > 200 pg/ml. Seven days after ovulation, sera E2 and P were measured along with endometrial thickness and echo patterns., Results: The only significant difference between groups was an increased mid-luteal serum E2 in the group receiving additional hCG. However, this did not result in an increased pregnancy rate., Conclusions: In general, adding a single injection of hCG to P luteal support does not improve pregnancy rates in natural cycles where women were treated with supplemental P.

Purpose: To describe a cause and treatment for chronic unremitting lower abdominal pain of long duration with unknown origin., Materials and Methods: A 50-year-old woman with 30 years of unexplained right lower quadrant pain was treated with dextroamphetamine sulfate., Results: Dramatic complete abrogation of the pain occurred within two weeks. The complete relief persisted for two years while she remains on therapy., Conclusions: Symphathetic neural hyperalgesia edema syndrome should be considered whenever there is refractory pelvic or abdominal pain.

Purpose: To determine if severe periovulatory diarrhea in a woman with Crohn's disease for just one day may be related to increased permeability of the large bowel related to hormonal changes that occur at this time of menstrual cycle., Materials and Methods: Dextroamphetamine sulfate was given to a woman whose Crohn's disease was markedly improved by adalimumab but who still had one day of severe diarrhea at mid-cycle., Results: She did not have any diarrhea or frequent defecation for the first two periovulatory times before she achieved pregnancy. Previously for two years there had not been one month where she did not have the severe periovulatory diarrhea., Conclusions: This case helps support the concept that the classic symptoms of Mittelschmerz in women with endometriosis may be related to periovulatory events which either cause increased permeability of an already compromised tissue, whether it be pelvic or bowel or other tissues, or these periovulatory events impair sympathetic nervous system function, which is already impaired.

Purpose: To determine the frequency of ovulation induction, obtaining oocytes leading to embryos, and pregnancy rates per embryo transfer in women with premature menopause., Materials and Methods: Prospective observational study of women hoping to have in vitro fertilization-embryo transfer (IVF-ET) with their own oocytes despite being in menopause. Ethinyl estradiol was used to lower follicle stimulation hormone (FSH) and restore sensitivity of follicles to mild FSH stimulation., Results: Three of five women had a live baby. Only one woman failed to induce ovulation and thus failed to have an embryo to transfer. One woman conceived two times and delivered a live healthy baby twice. The live delivered pregnancy rate per transfer was 20% (4/20) with generally one or occasionally two embryos transferred. The pregnancy rate per retrieval was 9.3% (4/43)., Conclusions: These data can help other women in this circumstance to decide on IVF with their own eggs or switch to donor eggs.

Purpose: To determine the frequency of failed fertilization with conventional oocyte insemination and to determine the ability of intracytoplasmic sperm injection (ICSI) to overcome the failed fertilization according to binding or failing to bind to the zona pellucida., Materials and Methods: Retrospective review of 12,448 in vitro fertilization (IVF) cycle to identify cycles where failed fertilization occurred following conventional oocyte insemination with seemingly normal sperm. A number of three oocytes retrieved was required., Results: There were only 12 cases of failed fertilization (0.1%). Six were related to failure of any or few sperm attaching to the zona pellucida These six had high fertilization rates with ICSI. Six had normal attachment and five attempted another cycle, this time with ICSI. Only 60% had good fertilization., Conclusions: When there is failed fertilization with normal sperm oocyte binding following conventional oocyte insemination, ICSI may still be effective in 60% of the cases, but it would be probably recommended to combine ICSI with artificial oocyte activation by calcium ionophore.

Purpose: To determine if the use of a single injection of one-mg leuprolide acetate in mid-luteal phase can increase pregnancy rates in donor oocyte recipients., Materials and Methods: Prospective study where couples were made aware of a study using the gonadotropin releasing hormone agonist (GnRHa) triptorelin that in the mid-luteal phase found improved pregnancy rates following embryo transfer in donor oocyte recipients. They were given the option of a single one-mg injection of the GnRHa leuprolide acetate. Pregnancy outcome was compared according to whether leuprolide was given or not. Also compared were the average first serum beta-hCG level in those who conceived according to taking leuprolide or not., Results: Chi-square analysis showed a significantly higher clinical and live delivered pregnancy rate (63.9% and 52.8%) in those supplementing with leuprolide than those who did not (39.5% and 32.9%). Similarly implantation rates were significantly higher (44.2% vs. 25.2%). The average first serum beta-hCG level for those conceiving and taking leuprolide was 294 mIU/mL vs. 325 mIU/mL for those who did not., Conclusions: Similar to triptorelin the mid-luteal injection of leuprolide acetate improves pregnancy outcome in donor oocyte recipients.

Purpose: To determine if a better response than anticipated to controlled ovarian stimulation in a woman assumed to have diminished oocyte reserve based on an increased day 3 serum follicle stimulating hormone (FSH) level, could be related to a gonadotropinoma., Materials and Methods: Magnetic resonance imaging (MRI) with and without gadolinium contrast was used in a woman who made 21 mature oocytes despite a history of day 3 serum FSH as high as 20 mIU/mL., Results: A pituitary microgonadotropinoma was detected., Conclusions: The presence of a better response than anticipated to controlled ovarian hyperstimulation (COH) with exogenous gonadotropins despite an increase in day 3 serum FSH should prompt a search for a possible gonadotropinoma.

Purpose: To review treatment options for hair loss in women., Materials and Methods: Suggestions for treatment were based on a thorough literature search plus the present authors' experience., Results: There are controlled studies that support the present authors' typical treatment regimen of identifying if there are increased androgens, and if so, identify the source (ovary and/or adrenal) and then suppress with drugs, e.g., oral contraceptives or glucocorticoids. If serum androgens are normal, agents that block dihydrotestosterone at the hair shaft level, e.g., spironolactone or 5a reductase inhibitors seem to be effective. However, a recent Cochrane systematic review concludes that the only drug proven to improve alopecia by randomized controlled studies using rigorous criteria is minoxidil., Conclusions: The present authors will add minoxidil to their normal treatment paradigm based on this later study. The previous reasons for it was the quality of the hair produced (generally much shorter than other head hair). For alopecia related to inflammation, the present authors may have discovered a novel therapy--dextroamphetamine sulfate.

Purpose: To present a diagnostic and treatment paradigm for infertility designed for the obstetrician gynecologist generalist., Materials and Methods: Simple methods of tubal evaluation, e.g., the hysterosalpingogram (HSG) and post-coital test to evaluate both male and cervical factor are discussed. Treating paradigms will be discussed for ovulatory disorders and luteal phase defects. The role of the OB/GYN generalist on performing surgery in the modem era will be mentioned., Results: If an HSG shows a unilateral hydrosalpinx the generalist should consider performing the unilateral salpingectomy since the advent of in vitro fertilization-embryo transfer (IVF-ET) with a de-emphasis on surgery has made the reproductive endocrinologist/infertility specialist (REI) less skillful in laparoscopic surgery. The REI rarely performs tuboplasty today. Not only does the exclusive treatment in the luteal phase with progesterone save the women money and side effects (including multiple births), but may actually improve pregnancy rates compared to the usual technique of follicle stimulating drugs plus intrauterine insemination., Conclusions: Because the generalist will not be tempted to suggest therapies, e.g., IVF-ET because this effective therapy is the best option for the financial success of the REI, but at the expense of financial depletion of the patient, there is plenty of room for generalists taking over as the first line physicians for infertility rather than just a referral service. Reproductive endocrinologists/infertility will almost invariably perform IUI each month even if not doing IVF which is also profitable to the REI, but costly in time and money to the patient. In contrast, the generalist, aimed with the knowledge that IUI does not improve pregnancy rates if the post-coital test is normal, will save the patient and/or the insurance money if the woman conceives. Obviously certain circumstances, e.g., bilateral blocked fallopian tubes or very severe oligoasthenozoospermia (but not teratozoospermia) will prompt an immediate referral to an REI.

Purpose: To determine if blood type A protects against developing diminished oocyte reserve., Materials and Methods: Retrospective evaluation of incidence of blood type A (or AB) in women with normal oocyte reserve (day 3 serum follicle stimulating hormone (FSH) < or = 11 mIU/ml) vs. diminished oocyte reserve (FSH > or = 18 mIU/ml)., Results: Five hundred forty-seven of 1,232 (44.4%) women with normal reserve had blood type A or AB vs. 33.8% (44/130) with diminished oocyte reserve (p = 0.027, chi-square)., Conclusions: Lack of blood type A or AB may link to some other gene that may be responsible for premature depletion of oocytes.

Purpose: To determine if an immunomodulatory protein (progesterone induced blocking factor [PIBF]) that is progesterone induced and found in higher concentration during pregnancy is similarly found with increased levels in women with gynecologic cancers., Materials and Methods: A newly developed enzyme linked immunoabsorbent assay (ELISA) assay was used to measure PIBF in the sera of six women with various gynecologic cancers and compare them to five controls (three with benign tumors and two having gynecologic procedures for non-tumors., Results: The PIBF levels in women with gynecologic cancer did not rise precipitously as historical controls of women or men exposed to progesterone. The two highest PIBF levels of the 11 subjects were in women with gynecologic cancer., Conclusions: The data suggest that if PIBF helps cancer cells to evade immune surveillance, it probably operates through an intracytoplasmic presence. If an increase in sera PIBF could have been detected in women with gynecologic cancer, then this ELISA test could have been used to detect tumor recurrence. Future studies may concentrate on evaluating intracytoplasmic PIBF to possibly help determine which tumors may respond to progesterone antagonist receptors.

Purpose: To describe a distinctive pharmacological treatment for chronic pelvic pain and sciatica after spinal surgery with a laminectomy and spinal fusion failed to provide relief., Materials and Methods: Dextroamphetamine suflate was prescribed to a woman with a history of chronic back pain which was attributed to a ruptured disc. The pain was still unbearable after surgery., Results: After adjusting dosage, within three months of the correct dose, 25 mg twice a day, relief was provided and has persisted for ten months., Conclusions: Chronic pelvic pain and sciatica both may be symptoms of hypofunction of the sympathetic nervous system. In addition, with other pain symptoms, this can be effectively treated with sympathomimetic amines.

Purpose: To determine if treatment with dextroamphetamine sulfate can reduce pelvic pain that was attributed to adenomyosis., Materials and Methods: Dextroamphetamine sulfate was given to a 32-year-old woman who suffered on a daily basis from severe chronic pelvic pain that was not relieved by laparoscopic removal of endometriosis by oral contraceptive and ibuprofen. The adenomyosis was diagnosed by magnetic resonance imaging., Results: Within three months the pain was completely gone and has remained absent for six months., Conclusions: Dextroamphetamine sulfate relieved pain from adenomyosis similar to its effect on endometriosis.

Purpose: To determine the effect of a drop in serum estradiol the day after injection of human chorionic gonadotropin (hCG) in in vitro fertilization-embryo transfer (IVF-ET) cycles in women aged 40-42 with diminished oocyte reserve., Materials and Methods: Retrospective study with further requirement that the female partner had a day 3 serum follicle stimulating hormone (FSH) of ≥ 12 miU/mL and ≥ five antral follicles., Results: A drop in serum estradiol the day after hCG injection is not associated with a lower chance of pregnancy compared to those women whose serum estradiol increases. However, their chances of releasing the oocyte before retrieval is significantly higher., Conclusions: A drop in serum estradiol in women of advanced reproductive age with diminished oocyte reserve should not signal the need to cancel the retrieval.

Purpose: To describe an unusual case of Müllerian agenesis associated with gonadal agenesis and thus sexual infantilism., Materials and Methods: Pelvic magnetic resonance imaging (MRI) and sonography were performed and MRI of the kidneys. Pelvic sonography and serum follicle stimulating hormone (FSH) were also obtained., Results: The only pelvic organ that this 15-year-old girl had was the distal portion of the vaginal canal. The kidneys were normal., Conclusions: This case suggests that at least in some cases some possible viral damaging process may lead to damage to both the ovaries and the Müllerian system. If there was a problem with the anti-Müllerian hormone (AMH), the kidney may be affected. Furthermore, AMH has nothing to do with the ovaries and a chance association of these two entities though possible, seems less likely than a common factor causing both problems.

Purpose: To compare pregnancy outcome in women with normal oocyte reserve according to whether they received conventional or mild follicle stimulating hormone (FSH) controlled ovarian hyperstimulation (COH) further stratified by age., Materials and Methods: A ten-year retrospective study including all cycles (even multiple in given patients) was performed. Mild stimulation including all cycles initiated and continued with 150 IU FSH or less from early follicular phase. Everything else was considered conventional stimulation. Mild stimulation included natural cycles or those with just a boost of 75 IU FSH from the mid to late follicular phase. Only women with normal oocyte reserve were selected--serum FSH < 12 mIU/mL and serum E2 < 50 pg/mL. Live delivered pregnancy rates within three age groups (≤ 35, 36-39, and 40-42 years) were compared per embryo transfer and per embryo retrieval, i.e., the percentage of women having a live baby without proceeding to another IVF-ET cycle. Also compared were the average number of babies born from one retrieval., Results: For aged ≤ 35 there were no differences in pregnancy rates per transfer but a trend for higher pregnancy rates per retrieval with conventional stimulation. For all other age groups both pregnancy rates per transfer and retrieval were significantly higher with conventional stimulation. This was reflected with a higher average number of babies born per retrieval with conventional., Conclusions: For women with normal oocyte reserve in general, there is no advantage of mild vs. conventional COH other than cost saving. Of course there are exceptions, e.g., ovarian hyperstimulation with conventional COH.

Purpose: To see if the single injection of one mg of the gonadotropin releasing hormone agonist (GnRHa) leuprolide acetate given in the mid-luteal phase can increase live delivered pregnancy and implantation rates. Furthermore the purpose was to determine if improvement was found, did the mechanism involve increased secretion of human chorionic gonadotropin (hCG)., Materials and Methods: A prospective study was conducted in women aged 35 who were undergoing in vitro fertilization-embryo transfer (IVF-ET). They were advised of data from Tesarik et al. and a previous pilot study conducted in the present IVF center showing improved pregnancy rates with the injection of a GnRHa three days after embryo transfer. They were offered the option of returning for a one-mg injection s.c. of leuprolide acetate or not. Clinical and live delivered pregnancy rates were compared according to those taking or not the leuprolide acetate one-mg injection. Chi-square analysis was used for statistical comparisons. Serum beta-hCG levels were compared between those conceiving with or without the extra injection of leuprolide., Results: There was a non-significant trend for higher live delivered pregnancy rates in those taking leuprolide (47.8%, 64/134) vs. those not taking it (38.6%, 76/197). For those pregnant there was no difference in hCG levels according to taking the GnRHa or not., Conclusions: The 25% increased live delivered pregnancy rate per transfer was insufficiently powered to detect a significant difference. The results do justify continuing the study. Perhaps the difference could be wider using a slightly older age group whose embryos are frequently less hearty.

Purpose: To determine if the injection of a gonadotropin releasing hormone agonist (GnRHa) three days after embryo transfer will improve pregnancy and implantation rates., Materials and Methods: One mg s.c. of leuprolide acetate was randomly given based on patient decision three days after embryo transfer to some patients undergoing in vitro fertilization-embryo transfer (IVF-ET)., Results: For women aged ≤ 43 the clinical pregnancy rate for those not taking the GnRHa was 39.5% (68/122) vs. 54.5% (42/77) for those taking leuprolide acetate (Chi-square, p = 0.0275). The respective implantation rates were 22.6% vs. 30.2% (p = 0.0495). There was no difference in first serum beta human chorionic gonadotropin (beta-hCG) levels according to whether leuprolide was used or not., Conclusions: Leuprolide acetate similar to other GnRH agonists can improve implantation rates following IVF-ET when injected once in mid-luteal phase. The beneficial effect may be on GnRH receptors in the endometrium rather than the embryo (which had been hypothesized to direct increased placental production of hCG).

Purpose: To determine the relative effect of diminished oocyte reserve on clinical viable and live delivered pregnancy rates per transfer and live delivery pregnancy rate per oocyte harvest in women aged 36-39., Materials and Methods: A retrospective comparison of pregnancy outcome was performed over a ten-year time period in women with normal oocyte reserve (day 3 serum FSH ≤ 11 mIU/mL) vs. diminished reserve (day 3 serum FSH ≥ 12 mIU/mL). Pregnancy rate per oocyte harvest equals the odds of conceiving with fresh or frozen embryos from a given retrieval before proceeding to another oocyte retrieval., Results: The clinical and viable (at end of first trimester) pregnancy rate per transfer was only 20% lower for the group with diminished oocyte reserve, but was 50% lower for the pregnancy rate per oocyte harvest., Conclusions: Mild stimulation for women with diminished oocyte reserve allows a higher percentage of chromosomally normal embryos in women with diminished oocyte reserve, leading to only a 20% lower clinical and viable pregnancy rate per transfer. However, overall, there are less normal total number of normal embryos leading to a pregnancy rate per oocyte harvest only half as good in the group with lower reserve vs. normal.

Purpose: To evaluate the effect of idiopathic orthostatic edema and the effect of thyrotoxicosis on weight fluctuation and fluid retention in the presence of surgically induced panhypopituitarism and diabetes insipidus controlled with hormone replacement., Materials and Methods: Dextroamphetamine sulfate was used for weight gain when no other etiologic factor was found. Methimazole was used when weight loss occurred when serum T4 and free T4 indicated thyrotoxicosis., Results: Sympathomimetic amine therapy very effectively controlled the weight gain and methimazole controlled the weight loss., Conclusions: Hypopituitarism and diabetes insipidus controlled with hormone replacement do not protect against fluid retention from idiopathic edema.

Purpose: To evaluate the efficacy of dextroamphetamine sulfate for idiopathic frozen shoulder in a woman being treated for blad- der urgency and inability to lose weight despite dieting., Materials and Methods: Dextroamphetamine sulfate was initiated at 15 mg extended release capsules increasing to 25 mg extended release capsules to a 47-year-old woman., Results: She lost 19 pounds in four months, her bladder urgency disappeared, and she had complete resolution of the idiopathic frozen shoulder problem., Conclusions: Idiopathic frozen shoulder syndrome can be added to the long list of conditions that are related to hypofunction of the sympathetic nervous system and all respond to dextroamphetamine sulfate therapy. They gynecologist is more familial with this syndrome be- cause of it being the main cause of pelvic pain. Thus the gynecologist may become the physician who subsequently treats orthopedic or rheumatological problems or other health issues.

Purpose: To determine if sympathomimetic amines may relieve migraine headache pain from pseudotumor cerebri (PTC) similar to its effect on helping other types of migraine headaches that were recalcitrant to other therapies., Materials and Methods: A woman with severe migraine headaches which did not respond to treatment with acetazolamide was treated with dextroamphetamine sulfate sustained release capsules 25 mg daily., Results: The patient demonstrated marked improvement within a month. The marked decrease in headache pain has persisted over a year. Her papilledema also completely disappeared., Conclusions: The sympathetic neural hyperalgesia edema syndrome can manifest as PTC. Besides headaches, other symptoms that the patient manifested were part of this syndrome including chronic fatigue, inability to lose weight despite dieting, and backache. All of these additional symptoms also improved with sympathomimetic amine therapy.

Purpose: To describe a unique disorder where a transient 6th nerve palsy leading to diploplia following orgasm developed in a 28-year-old woman. This coincided with a weight gain of 100 pounds in a short time without a corresponding change in dietary habits., Materials and Methods: She was treated with the sympathomimetic amine dextroamphetamine sulfate., Results: Indeed she immediately responded to treatment with dextroamphetamine sulfate sustained release capsules with complete resolution of the episodes of 6th nerve palsy following orgasm., Conclusions: The main importance of this case is that it suggests that orgasm causes a transient generalized decrease in sympathetic nervous system activity and that the achievement of an orgasm may require an increase in the sympathetic nervous system activity.

Purpose: To evaluate the efficacy of sympathomimetic amine therapy on a mitochondrial abnormality known as the mitochondrial encephalopathy lactic acidosis and stroke-like symptoms syndrome (MELAS syndrome)., Materials and Methods: Dextroamphetamine sulfate 15 mg extended release capsule was prescribed to a woman with a 25 year history of MELAS syndrome refractory to most other therapies., Results: Within one month of therapy the woman noticed considerable improvement in her chronic fatigue, pain, and edema., Conclusions: The MELAS syndrome is thus another condition to add to the list of various chronic refractory disorders that improve considerably after dextroamphetamine therapy. This is the first mitochondrial disorder shown to improve with sympathomimetic amines which could suggest that dextroamphetamine could prove useful in decreasing the risk of aneuploidy in women of advanced reproductive age.

Purpose: To determine if treatment with sympathomimetic amines could improve the pain from complex regional pain disorder (CRPD) which was keeping a woman from trying to conceive her second child., Materials and Methods: Dextroamphetamine sulfate was prescribed., Results: Within a short length of time the woman's wrist pain considerably improved to the point that she is ready to try in vitro fertilization once again to have a second baby., Conclusions: Though sympathomimetic amines are used by some reproductive endocrinologists for unexplained infertility and unexplained recurrent miscarriages, the most common use by the gynecologist is for pelvic pain. Despite the thought by some clinicians and researchers that the etiology for CRPD may be related to sympathetic nervous system hyperactivity (and thus sympathomimetic amines could theoretically exacerbate the symptoms), in fact, the treatment with dextroamphetamine sulfate may turn out to be a new and possibly the most effective, least risky, and least expensive treatment to date for CRPD.

Purpose: To report an exception to the rule that once slow rising serum beta human chorionic gonadotropin (hCG) levels are observed, a live fetus after 12 weeks is not possible even if fetal viability was detected earlier., Materials and Methods: The fetus of a woman with a slow rising serum beta-hCG levels which even plateaued was evaluated by serial pelvic sonography., Results: The fetal pole grew appropriately but at one point the sac size was a week behind. Nevertheless the woman completed the first trimester with a viable fetus and a normal fetal heart rate., Conclusions: Though rare, a live fetus at the end of the first trimester is possible if even if there is a slow rise of sera hCG levels where there is at least one instance when the hCG levels do not double in two days.

Purpose: To determine if treatment with the sympathomimetic amine dextroamphetamine sulfate, which has been so effective in treating a variety of pain syndromes, including severe pelvic pain and interstitial cystitis in women with the sympathetic neural hyperalgesia edema syndrome would also mitigate pain from fibromyalgia which was resistant to multiple therapies., Materials and Methods: Dextroamphetamine sulfate extended release capsules once daily was gradually increased to 25 mg per day in a woman with treatment resistant fibromyalgia of 20 years duration., Results: Within a short time, the woman experienced dramatic relief of pain. Furthermore, her edema improved resulting in a 27 pound weight loss and her chronic fatigue improved., Conclusions: Fibromyalgia can be effectively treated with an innocuous dose of dextroamphetamine sulfate.

Purpose: To present a novel therapy for pediatric vulvovaginitis., Materials and Methods: An eight-year-old girl with persistent severe vulvovaginitis of unknown origin also complained of unexplained weight gain and sudden academic difficulties. She was treated with dextroamphetamine sulfate., Results: She not only showed very quick and excellent relief from her vulvovaginitis but she also lost weight and improved her mentality., Conclusions: Sympathomimetic amine therapy may benefit pediatric vulvovaginitis when an infectious cause cannot be ascertained.

Purpose: To evaluate whether ocular migraines can be related to sympathetic nervous system hypofunction, especially when associated with interstitial cystitis and dyspareunia., Materials and Methods: Dextroamphetamine sulfate was administered to a 34-year-old woman with a history of long-term interstitial cystitis, dyspareunia, and ocular migraines that were resistant to all other therapies., Results: In a short length of time the sympathomimetic amine therapy almost completely abrogated all of her symptoms and they have remained controlled while she continues on the drug., Conclusions: This is the first report of effectively treating ocular migraines with dextroamphetamine sulfate. The gynecologist should not be afraid to initiate therapy without referral to other specialists, especially if other symptoms of the sympathetic neural hyperalgesia edema syndromes exist, e.g., bladder pain of pelvic origin and dyspareunia.

Purpose: To determine if dextroamphetamine sulfate therapy could relieve severe headaches related to keratoconus of the eyes., Materials and Methods: Dextroamphetamine sulfate 20 mg daily was prescribed to a 45-year-old woman who complained of 20 plus years of severe stabbing retrorbital pain who was diagnosed with keratoconus but failed to gain relief from bilateral corneal implants., Results: Dextramphetamine sulfate quickly and very effectively relieved the pain which has remained completely abrogated for over five years. Proof that the improvement was not fortuitous was demonstrated by quick return of symptoms when the drug was temporarily stopped after 2.5 years of relief but quickly dissipated upon resumption of therapy., Conclusions: Headaches are common in women. It is the gynecologist (who is more familiar with the condition of sympathetic neural hyperalgesia edema syndrome because it is the most common cause of pelvic pain) who may be the physician to introduce dextroamphetamine sulfate as a treatment since this condition is unknown by many specialists in other fields.