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Context: Oral contraceptive (OC) pills are effective, but poor compliance increases rates of pregnancy during treatment.Objective: To compare the contraceptive efficacy, cycle control, compliance, and safety of a transdermal contraceptive patch and an OC.Design: Randomized, open-label, parallel-group trial conducted October 1997 to June 1999.Setting: Forty-five clinics in the United States and Canada.Participants: A total of 1417 healthy adult women of child-bearing potential.Interventions: Participants were randomly assigned to receive a transdermal contraceptive patch (n = 812) vs an OC (n = 605) for 6 or 13 cycles. Patch treatment consisted of application of 3 consecutive 7-day patches followed by 1 patch-free week.Main Outcome Measures: Overall and method-failure Pearl Indexes (number of pregnancies/100 person-years of use) and life-table estimates of the probability of pregnancy were calculated. Cycle control, compliance, patch adhesion, and adverse events were also assessed.Results: Overall and method-failure Pearl Indexes were numerically lower with the patch (1.24 and 0.99, respectively) vs the OC (2.18 and 1.25, respectively); this difference was not statistically significant (P =.57 and.80, respectively). The incidence of breakthrough bleeding and/or spotting was significantly higher only in the first 2 cycles in the patch group, but the incidence of breakthrough bleeding alone was comparable between treatments in all cycles. The mean proportion of participants' cycles with perfect compliance was 88.2% (811 total participants, 5141 total cycles) with the patch and 77.7% (605 total participants, 4134 total cycles) with the OC (P <.001). Only 1.8% (300/16 673) of patches completely detached. Both treatments were similarly well tolerated; however, application site reactions, breast discomfort, and dysmenorrhea were significantly more common in the patch group.Conclusion: The contraceptive patch is comparable to a combination OC in contraceptive efficacy and cycle control. Compliance was better with the weekly contraceptive patch than with the OC. [ABSTRACT FROM AUTHOR]

Objectives: Patients admitted with an acute episode of preterm labor who respond to early intravenously administered tocolysis remain at risk of having subsequent episodes of preterm labor and preterm delivery. Several pharmacologic agents have been used in an attempt to reduce subsequent episodes of preterm labor, and all are associated with significant side effects. Atosiban, an oxytocin receptor antagonist, is effective in the treatment of an acute episode of preterm labor. This study was designed to compare the efficacy and safety of atosiban with those of placebo maintenance therapy in women with preterm labor who achieved uterine quiescence with intravenous atosiban.Study Design: A multicenter, double-blind, placebo-controlled trial was designed for patients in preterm labor who responded to early intravenous treatment with atosiban. Five hundred thirteen patients were randomly assigned to receive maintenance therapy, 252 to receive atosiban, and 251 to receive matching placebo. Maintenance therapy was administered as a continuous subcutaneous infusion, via pump, of 30 microg/min to the end of 36 weeks' gestation. The primary end point was the number of days from the start of maintenance therapy until the first recurrence of labor. A secondary end point was the percentage of patients receiving subsequent intravenous atosiban therapy.Results: The time (median) from the start of maintenance treatment to the first recurrence of labor was 32.6 days with atosiban and 27.6 days with placebo (P =.02). At least one subsequent intravenous atosiban treatment was needed by 61 atosiban patients (23%) and 77 placebo patients (31%). Except for injection site reactions, adverse event profiles of atosiban and placebo were comparable. There were 4 neonatal deaths reported in the atosiban group and 5 in the placebo group after the start of maintenance therapy. Infant outcomes (including birth weight) were comparable between maintenance and treatment groups.Conclusions: Maintenance therapy with the oxytocin receptor antagonist atosiban can prolong uterine quiescence after successful treatment of an acute episode of preterm labor with atosiban. Treatment was well tolerated. [ABSTRACT FROM AUTHOR]

Objectives: This study was designed to evaluate the efficacy and safety of the oxytocin receptor antagonist atosiban in the treatment of preterm labor.Study Design: A multicenter, double-blind, placebo-controlled trial with tocolytic rescue was designed. Five hundred thirty-one patients were randomized to receive, and 501 received, either intravenous atosiban (n = 246) or placebo (n = 255), followed by subcutaneous maintenance with the assigned agent. Standard tocolytics as rescue tocolysis were permitted after 1 hour of either placebo or atosiban if preterm labor continued. The primary end point was the time from the start of study drug to delivery or therapeutic failure. Secondary end points were the proportion of patients who remained undelivered and did not receive an alternate tocolytic at 24 hours, 48 hours, and 7 days.Results: No significant difference was found in the time from start of treatment to delivery or therapeutic failure between atosiban and placebo (median, 25.6 days vs 21.0 days, respectively; P =.6). The percentages of patients remaining undelivered and not requiring an alternate tocolytic at 24 hours, 48 hours, and 7 days were significantly higher in the atosiban group than in the control group (all P < or =.008). A significant treatment-by-gestational age interaction existed for the 48-hour and 7-day end points. Atosiban was consistently superior to placebo at a gestational age of > or =28 weeks. Fourteen atosiban-treated patients and 5 placebo-treated patients were randomized at <24 weeks; the incidence of fetal-infant deaths was higher for the atosiban group at <24 weeks. Maternal-fetal adverse events were similar except for injection-site reactions, which occurred more often with atosiban.Conclusions: In this trial the treatment of patients in preterm labor with atosiban resulted in prolongation of pregnancy for up to 7 days for those at a gestational age > or =28 weeks, and this occurred with a low rate of maternal-fetal adverse effects. In addition, at a gestational age > or =28 weeks, the infant morbidity and mortality of atosiban-initiated standard care were similar to those with placebo-initiated standard care. Given that all patients in this study were eligible for tocolysis and that, in practice, nearly all patients who are eligible for a tocolytic receive one, the benefit of using atosiban is the placebo-like maternal-fetal side effect profile. These observations support the use of this oxytocin receptor antagonist in the treatment of patients in preterm labor with intact membranes. Efficacy and infant outcome data at <28 weeks are inconclusive. [ABSTRACT FROM AUTHOR]

This randomized, multicenter, parallel group study evaluated four new oral contraceptive regimens of norgestimate (NGM) and ethinyl estradiol (EE) relative to ORTHO TRI-CYCLEN (NGM 180/215/250 microg/EE 35 microg). Healthy women (50/group) received three cycles of either ORTHO TRI-CYCLEN Lo (NGM 180/215/250 microg/EE 25 microg), one of three cyclophasic regimens (NGM cycling 180-250 microg/EE 35 microg or 25 microg) or ORTHO TRI-CYCLEN. Among all five regimens, ovulation suppression, cycle control and safety were generally comparable. Presumed ovulation (serum progesterone levels >or=3 ng/mL during Days 19-21 of Cycle 3), occurred in 0/41 (0%) subjects on ORTHO TRI-CYCLEN Lo and 3/43 (7%) subjects on ORTHO TRI-CYCLEN. Breakthrough bleeding and/or spotting (BBS; % total cycles) was 17.2% for ORTHO TRI-CYCLEN Lo and 14.4% for ORTHO TRI-CYCLEN. The mean number of days of BBS/cycle for ORTHO TRI-CYCLEN Lo and ORTHO TRI-CYCLEN was 3.7 and 3.1, respectively, for those subjects with such bleeding. Thus, ORTHO TRI-CYCLEN Lo appears similar to ORTHO TRI-CYCLEN in inhibiting ovulation and providing cycle control.

Objective: The objective of this study was to identify the dose for a contraceptive patch that provides a predetermined level of ovulation suppression and cycle control and that is well tolerated., Study Design: In this randomized study, 610 subjects received 10-, 15-, or 20-cm(2) patch dose sizes (20-cm(2), Ortho Evra/Evra) (Janssen Pharmaceutica, NV Belgium) or Ortho-Cyclen/Cilest (Janssen Pharmaceutica, NV Belgium) for up to 4 cycles. As with Ortho-Cyclen, patch regimens included 21 dosing days (3 consecutive 7-day patches) followed by 1 dose-free week., Results: The patch regimens demonstrated a dose-response for ovulation suppression and cycle control. Presumed ovulation, determined on the basis of serum progesterone concentrations > or = 3 ng/mL in cycles 1 and 3, occurred in 6.2% (Ortho Evra) and 7.2% (Ortho-Cyclen) of subjects. At cycle 3, breakthrough bleeding/spotting was reported by 10.5% and 15.0% of subjects, respectively. Compliance with each patch was superior to that with Ortho-Cyclen (all P <.001). All regimens had safety profiles typical of oral contraceptives., Conclusion: The 20-cm(2) patch (Ortho Evra) provided ovulation suppression, cycle control, and safety similar to that of Ortho-Cyclen, with significantly better compliance.

Transvaginal catheterization of the fallopian tube has gained increased popularity for transfer of embryos and gametes. Forty-five ITIs were performed on 32 patients using the novel approach of tubal transfer via tactile sensation. This group of patients had undergone an average of 5.2 IUIs before ITI. There were a total of 11 pregnancies, 6 occurring with hMG stimulation and 5 with CC-stimulated cycles (34% PR per patient). Three pregnancies ended with spontaneous abortion, and one patient developed acute salpingitis necessitating laparotomy. These data suggest ITI may be effective in assisted reproduction but, as other invasive procedures, is not without risk.

We have examined the pharmacology of the voltage-sensitive Ca2+ channels (VSCCs) that mediate gonadotropin secretion from primary cultures of rat pituitary cells, stimulated by either cell depolarization or by binding of gonadotropin-releasing hormone (GnRH). We also measured single-cell [Ca2+]i transients using fura-2 in gonadotropes identified by a reverse hemolytic plaque assay employing an antiserum to luteinizing hormone (LH). Cell depolarization evoked by either 50 mM K+ or 30 microM veratridine induced 2- to 6-fold increases in gonadotropin secretion over basal levels. GnRH caused 6- to 20-fold increases in follicle-stimulating hormone (FSH) and LH secretion, respectively, with maximal stimulation at 100 nM GnRH. K(+)- or GnRH-induced FSH release was largely prevented by co-incubation with 1 mM CdCl. Tetrodotoxin (TTX, 5 microM) prevented the veratridine-, but not the K(+)- or GnRH-induced, stimulation of FSH secretion. Nitrendipine (Ntd, 1 microM) produced 35-50% inhibition (NS) of both FSH and LH release stimulated by either 50 mM K+ or 100 nM GnRH. Ntd also inhibited the K(+)-induced [Ca2+]i rise (greater than 90%), as well as the secondary, plateau phase of the GnRH-induced elevation of [Ca2+]i (100% inhibition). Omega-conotoxin (omega-CgTx, 100 nM) partially suppressed FSH and LH release (NS) due to both K+ (33% each) and GnRH (44% and 18%, respectively). omega-CgTx showed variable effects on [Ca2+]i transients evoked by K+ or GnRH ranging from clear inhibition to no effect. We conclude that influx of extracellular Ca2+ is one of several fundamental events underlying the depolarization- or receptor-activated release of LH and FSH, and that this influx can be inhibited by dihydropyridine-sensitive ('L') Ca2+ channels. Two classes of L-channels may exist in gonadotropes, that differ in their sensitivity to omega-CgTx.

Our data indicate that an appropriate therapy for the infertility associated with retrograde ejaculation is isolation of sperm from voided urine after orgasm, plus IUI. This technique is simple and can be performed in the physician's office, in contrast to more complex techniques such as GIFT or in vitro fertilization.

Neuropeptide Y (NPY) has been shown to be capable of both the enhancement and suppression of gonadotropin secretion from pituitary cells. In order to elucidate the underlying cellular mechanisms which might account for these actions, we have examined the effects of NPY on gonadotropin secretion stimulated by either cell depolarization or by GnRH from primary cultures of rat pituitary cells. In one set of experiments, we measured single-cell [Ca2+]i using the Ca2(+)-sensitive intracellular fluorescent indicator Fura-2, in gonadotropes which had been identified using a reverse hemolytic plaque assay employing an antiserum to LH. In another group of investigations, we measured FSH and LH secretion in response to depolarization or stimulation with GnRH, and examined the influence of NPY on these patterns of secretion. NPY was active in inhibiting the amplitude of the [Ca2+]i signal induced by depolarization with 20 mM K+, as well as in substantially blocking the secondary plateau phase of the GnRH-induced elevation of [Ca2+]i. However, the peak [Ca2+]i transients occurring in response to either depolarization with 50 mM K+ or the initial phase of the GnRH-induced response, were not sensitive to blockade by NPY. Moreover, treatment of the cells for 24 h with pertussis toxin prevented the NPY-mediated inhibition of the GnRH-stimulated [Ca2+]i plateau. Cell depolarization by 50 mM K+ induced 3-fold increases in FSH and LH release over 2-h incubations. GnRH (100 nM) elicited a 9-fold increase in FSH and a 14-fold stimulation of LH over the same time period. NPY had insignificant effects upon depolarization-induced hormone release, but at 1 microM partially suppressed LH release elicited by 100 nM GnRH over 2 h. We conclude that NPY is capable of inhibiting [Ca2+]i signals in gonadotropes that are stimulated by GnRH, and that these effects are mediated through activation of a pertussis toxin-sensitive G-protein. These effects on [Ca2+]i may underly the inhibitory effects of NPY on gonadotropin secretion.

Although the overall incidence of ectopic gestation has been rising over the past 30 years, unilateral twin tubal gestation is still a relatively rare event. In the 93 cases reported to date, zygosity determined solely by subjective observations of the fetuses indicated monozygosity in more than 95%. We report a case of unilateral twin tubal gestation in which zygosity of the twins was determined by using DNA probes that detect restriction fragment length polymorphisms. We used six human DNA probes and M13 phage DNA to compare the genotypes of the twins. Three of the six human probes and the M13 probe showed differences, proving that these twins were dizygotic. We speculate that many of the unilateral ectopic twins who were thought to be monozygotic may actually have been dizygotic.

The epidemic of sexually transmitted diseases has placed young, sexually active women at risk of infertility from tubal and pelvic factors. Salvaging reproductive function in women desiring fertility depends upon an accurate diagnosis and early, aggressive therapy for all cases of salpingitis. Conservative surgical management of tubal pregnancy in such women is now standard practice. Less-aggressive surgical approaches to chronic pelvic inflammatory disease and even tuboovarian abscess, when possible, can preserve some part of the pelvic anatomy in these women, who may then undergo reconstructive pelvic surgery or in vitro fertilization. Due to the recent technological revolution in infertility therapy, preservation of a women's uterus alone is all that is necessary to sustain the hope for a pregnancy.

Clomiphene citrate has been utilized for ovarian stimulation for human in vitro fertilization and embryo replacement (IVF-ER) procedures quite successfully. The optimal time and the amount of drug necessary for optimal development have not been identified. In this investigation, 58 patients participating in a human IVF-ER program were stimulated with clomiphene citrate, 150 mg/day for 5 days, beginning on day 3, 4, 5, or 7 of the menstrual cycle. Maximal numbers of oocytes recovered, fertilized, and transferred occurred when stimulation was initiated on the fifth day of the cycle. It is concluded that if clomiphene alone is utilized for multiple follicle development, cycle day 5 is optimal for drug initiation.

Previous studies of cells from various species have indicated that exogenous calcium is necessary for gonadotropic stimulation of steroidogenesis. To determine whether this requirement for exogenous calcium is a universal attribute of steroidogenic cells, we studied baseline and stimulated progesterone (P) production by cultured human granulosaluteal cells obtained at the time of oocyte retrieval for in vitro fertilization (IVF). During 4 hours in culture, both cholera toxin (1.25 micrograms/mL) and human chorionic gonadotropin (hCG, 1 IU/mL) stimulated a significant (P less than 0.05) 2- to 4-times increase in P production. Both baseline and stimulated (cholera toxin or hCG) increases in P were unaffected when cellular uptake of exogenous calcium was inhibited by the calcium channel blocker nitrendipine (10 microM), or by culturing the cells in calcium-free medium or in calcium-free medium with [ethylenebis(oxyethylenenitrilo)]-tetra-acetic acid (EGTA, to chelate any possible free extracellular calcium). At later time points (24 and 48 hours), lack of available exogenous calcium began to have an inhibitory effect on P production, and the hCG effect was more sensitive to the lack of exogenous calcium than was the cholera toxin effect. We speculate that this apparent independence from exogenous calcium over a short culture period is due to the prior stimulation of these cells by exogenous gonadotropins employed in IVF cycles.

To clarify whether there is a variation of dopamine effect throughout the normal menstrual cycle, 24 studies were performed during the follicular, periovulatory, and luteal phase in seven ovulatory women. The subjects were studied for 24 hours after receiving two different dopamine agonists, 2.5 mg of bromocriptine in one cycle and 50 micrograms of pergolide in a subsequent cycle. Baseline plasma luteinizing hormone, follicle-stimulating hormone, prolactin, and thyrotropin were followed through time, and the dynamic responses to gonadotropin-releasing hormone and thyrotropin-releasing hormone before and at 6 and 22 hours after medication were studied. Since the results obtained with both agonists were similar, the data have been combined in a single group. Baseline luteinizing hormone levels (but not follicle-stimulating hormone) were significantly suppressed (p less than 0.01) during the follicular phase only, and the plasma luteinizing hormone and follicle-stimulating hormone response to gonadotropin-releasing hormone was not affected by the agonists in any of the three cycle phases. Baseline plasma prolactin was suppressed equally (p less than 0.005) in all phases of the cycle, and the response to thyrotropin-releasing hormone was similarly suppressed in all phases only at 6 hours (p less than 0.002). Baseline thyrotropin also was suppressed (p less than 0.01) in all phases but the degree of inhibition was greater in the luteal than in the follicular phase (p less than 0.05). The response to thyrotropin-releasing hormone was inhibited, with the smallest response seen at 22 hours (p less than 0.01). In conclusion, these results suggest that the modulatory effect of dopamine on pituitary hormone secretion is variable and selective throughout the normal menstrual cycle. The greatest inhibition is on prolactin release, which is similar in all phases, followed by thyrotropin, which is greater in the luteal phase, and then by luteinizing hormone in the follicular phase only; it has no effect on follicle-stimulating hormone release.

Many types of medication regimens have been used to produce ovarian stimulation for in vitro fertilization and embryo replacement. However, few comparative studies have been reported. In this investigation, 105 patients were given either clomiphene citrate alone, human menopausal gonadotropins alone, or a combination of these drugs; and the resulting number of oocytes collected, embryos produced, and pregnancies initiated are reported. The data demonstrate optimal follicle development and fertilization rates with combinations of drugs, rather than the use of a single agent. Further studies are needed to determine whether there is a statistically significant difference in pregnancy rates between groups.

We have pharmacologically characterized voltage sensitive calcium channels (VSCCs) in GH3 cells, an anterior pituitary clonal cell line known to secrete prolactin and growth hormone. Raising the medium K+ concentration from 5 to 50 mM caused an immediate increase in net 45Ca2+ uptake which remained apparent over a 15 minute time course. 45Ca2+ uptake was maximally stimulated nearly 10-fold over basal levels. This K+-induced stimulation of Ca2+ uptake was not prevented by 10-5M tetrodotoxin or by replacing sodium with choline in the assay medium. Ca2+ uptake was, however, inhibited by several VSCC antagonists: nitrendipine, D-600, diltiazem and Cd2+. Further, the novel dihydropyridine VSCC agonists, BAY K8644 and CGP 28392, enhanced 50 mM K+-stimulated 45Ca2+ uptake and these effects were blocked by nitrendipine.

A group of 95 women with unexplained hyperprolactinemia (over 20 ng/mL) underwent radiologic examination of the sella turcica with hypocycloidal polytomography (N = 58), computed axial tomography (N = 8), or both (N = 29). All patients also underwent a thyrotropin-releasing hormone (TRH) stimulation test, with serum prolactin (PRL) measurement before and 20 and 30 minutes after a 500-micrograms intravenous bolus of TRH. Their PRL responses were compared with those of two control groups, nine normal women in the follicular phase of the menstrual cycle, and 13 women in the first five months of gestation with pregnancy-related hyperprolactinemia. Both control groups exhibited PRL increases with 95% confidence limits at least 200% above baseline levels. In all, 12 patients from the study group also had a normal PRL response (more than a 200% increase) to TRH, and none of these women had tomographic findings consistent with a pituitary tumor. The remaining 83 women all had diminished or absent PRL increases after TRH administration; 46 (55%) of these patients had radiographic evidence of an adenoma, whereas 37 (45%) had no clear signs of a tumor on either polytomography or computed axial tomography. No patient with a baseline PRL level in excess of 60 ng/mL had a normal PRL response to TRH. The results of the study indicate that 1) in patients with PRL between 20 and 60 ng/mL, a normal TRH test can be relied upon to avoid the expense and radiation of tomography (computed axial tomography or polytomography), 2) there is no benefit to be obtained in performing a TRH test in patients with a baseline PRL level over 60 ng/mL, and 3) about 45% of patients with hyperprolactinemia and an abnormal TRH test have a normal computed tomography or polytomography. These patients may have a small adenoma, and thus warrant closer follow-up than patients with a normal TRH test.