Biomedical subjects
Publications and source records attributed to D S Guzick.
Although reports of local injection of MTX in the treatment of EP appeared to be promising, our results do not confirm the efficacy of this approach. Our experience was sufficiently discouraging to prompt discontinuation of a randomized trail; our hope is that others will add to the accumulating data base so that the role of local injection of MTX can be clarified.
A three-county program in southern West Virginia was developed by an obstetric practice to deliver prenatal care to a population of uninsured patients. Between January 1984 and December 1986, 1331 (29.4%) of 4534 patients were delivered at a level 2 hospital after prenatal care within the clinic program. The hospital-wide fetal death ratio declined from 11.8 to 7.2 per 1000 live births during the years of clinic operation, a statistically significant reduction (P = .02). Uninsured patients experienced a statistically significant reduction in fetal death ratio during the program, from 35.4 to 7.0 per 1000 live births (P = .02), whereas those covered by medical assistance did not experience a reduction. Privately insured patients also had a significant decrease, from 10.0 to 3.1 per 1000 live births (P less than .001). The increasing operating expense, mainly due to rising malpractice insurance premiums, required suspension of the program in December 1986. The fetal death ratio returned to 10.3 deaths per 1000 live births in 1987. Factors that varied significantly during the "clinic" phase included: higher rates of cesarean, diagnosed maternal hypertension, and diabetes mellitus; and lower rates of premature rupture of membranes and non-white population. Other factors, including age over 35 years, postdatism, incidence of twins, incidence of lethal congenital anomalies, and single marital status, did not vary significantly before, during, or after the clinic program. This study identified a high-risk population of patients who did not qualify for medical assistance coverage and were de facto "uninsured." The results suggest that prenatal care for this high-risk population of uninsured patients can reduce the fetal death rate.
OBJECTIVE: To develop a simple estimation procedure that will always converge on a solution for a two-parameter model of cumulative pregnancy curves. DESIGN: Utilize raw data from a previous study in which estimation of the two-parameter model did not converge on a solution, and re-estimate the model with the new estimation method. PATIENTS, SETTING, TREATMENT: Infertile women with endometriosis treated as outpatients with laser laparoscopy. MAIN OUTCOME MEASURES: Pregnancy and ability of the new computer program to converge on a solution. RESULTS: The new estimation procedure converged on a solution. Over all stages of endometriosis, the cure rate from laser laparoscopy was 56%, and the monthly probability of pregnancy among those cured was 9.7%. CONCLUSIONS: The new estimation procedure, written for a personal computer, is easy to use and will virtually always converge on a solution for the two-parameter model of cumulative pregnancy after infertility treatment.
To determine an age-adjusted, clinically meaningful depressive diathesis, we have implemented Receiver Operator Characteristic (ROC) analysis for mean rapid eye movement (REM) latency in patients with unipolar depression. Depressed patients were compared with age-matched normal control subjects. Sensitivity and specificity estimates were calculated for selected threshold values on the ROC curves as well as for the Research Diagnostic Criteria endogenous/nonendogenous subtype. The mean REM latency value of 65.0-66.0 min was most sensitive and specific for depressed patients aged 35-72. The threshold value of 70.0 min appeared optimally sensitive and specific for depressed patients aged 20-34. There was no effect of age on REM latency in the normal control sample. Among depressed patients there was an effect of age but this was clearly observable only in nonendogenous depressed patients.
A substantial amount of data are generated from a single cycle of in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), or related techniques. Maintaining an accurate and timely record of the flow of information is complicated by provision of service to many patients concurrently, diverse origins of data, and the use of donor sperm, donor oocytes, and/or cryopreservation. We have developed a data base management system for use on a network of personal computers that takes into account the volume, intricacy, and specialized features of data generated by IVF and GIFT programs. The major products of the system are (1) compact, individual patient reports on virtually all details of each treatment cycle; (2) reports on aggregate data (e.g., monthly, quarterly, or yearly); (3) automated summaries for submission to the American Fertility Society National Registry; and (4) creation of raw data files of user-specified variables that could be used for statistical analysis.
We tested the hypothesis that the efficacy of clomiphene citrate (CC) in the treatment of luteal phase defect (LPD) is related more to the number of ovulatory follicles than to the quality of a single follicle. Eighteen ovulatory women with LPD as defined by endometrial biopsies that lagged behind chronological dates by at least 3 days on two separate menstrual cycles were studied. During the menstrual cycle before treatment and also during a treatment cycle (100 mg of CC, on days 5 to 9), we obtained an endometrial biopsy 9 to 12 days after ovulation. All biopsies were read in a blinded fashion by the same gynecological pathologist. During the treatment cycle, 10 women had more than one preovulatory follicle (greater than 15 mm, mean of three dimensions), while 8 had one preovulatory follicle. Luteal phase defect was corrected according to biopsy in 8 of the 10 women with more than one preovulatory follicle, but in only 2 of the 8 women with a single preovulatory follicle.
Ovarian stimulation after pituitary suppression with gonadotropin-releasing hormone agonists (GnRH-a) has been effective in women who have exhibited a poor response to conventional superovulation strategies. Their effectiveness in unselected women undergoing their first cycle of in vitro fertilization or gamete intrafallopian transfer, however, remains to be established. To address this question, we randomized 114 women to one of two treatment protocols. Protocol 1 consisted of 100 mg of clomiphene citrate on days 5 to 9, followed by 150 IU human menopausal gonadotropin (hMG) beginning on day 9. Protocol 2 consisted of daily GnRH-a beginning in the midluteal phase. Stimulation with 150 IU hMG commenced after pituitary down regulation and ovarian suppression were achieved. Human menopausal gonadotropin was continued in both protocols until adequate follicular development and serum estradiol concentrations were obtained. Protocol 2 patients reached egg retrieval significantly more often (87%) than Protocol 1 patients (61%), but the mean number of mature eggs retrieved and the pregnancy rate per retrieval were not significantly different between the two groups.
This study, like that of Veersema et al. demonstrates the feasibility of direct intrauterine transfer of gametes in initiating pregnancy. Whether the success of this procedure can be further improved with modification (preincubation, in vitro insemination) remains the subject of continued investigation. Notwithstanding this uncertainty, we feel that transcervical transfer of gametes may be an alternative to IVF for patients with ethical concerns regarding IVF.
A total of 4591 indigent patients were scored for risk of preterm labor and birth by the Creasy et al. scoring system and delivered at greater than or equal to 20 weeks' gestation. Of 462 preterm deliveries (less than 37 weeks), only 39.6% were contributed by the 18.1% of patients who scored at high risk (score greater than or equal to 10). Of the 44 risk factors in the scoring system, 25 were not statistically significant by univariate chi 2 analysis. The spontaneous preterm birth rate was 8.0%. The positive predictive value of the Creasy et al. system was 18.3%. With multiple logistic analyses we excluded infrequent risk factors and identified five factors that remained significant (prepregnancy weight less than 45.5 kg, black race, single marital status, one preterm labor and delivery, preterm labor, and delivery greater than or equal to 2). With these five risk factors we created an equation that allowed identification of 12% of patients at high risk of preterm delivery with a positive predictive value of 21.9%. Because of the importance of previous preterm delivery, risk scoring of primigravid patients is of limited value.
The ontogeny of serum prolactin and its relation to several variables, especially lung function, in 543 neonates was studied. Umbilical cord serum prolactin levels rose between 24 and 42 weeks' gestation, correlating significantly (p less than 0.001) with gestational age (r = 0.44) and birth weight (r = 0.32). Among infants of similar ages, however, there was no variation in serum prolactin level as a function of birth weight, sex, Apgar scores, or delivery method. Infants of women with pregnancy-induced hypertension had higher than normal prolactin levels; infants of diabetic women had normal prolactin levels. At 31.5 to 37 weeks' gestation, infants who developed respiratory distress syndrome had lower serum prolactin levels than those whose lung function was normal or else was abnormal from causes other respiratory distress syndrome. The risk for respiratory distress syndrome was higher in newborns whose prolactin level was low (10th percentile) than in infants whose prolactin level was high (90th percentile). These results are suggestive that prolactin may play a role in fetal lung maturation.
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The relative contribution of factors affecting the probability of pregnancy from gamete intrafallopian transfer was estimated using data from 218 cycles performed in San Antonio, Texas, and Orange, California. Mature eggs, all of which contained an expanded cumulus, were subclassified according to the corona radiata; those with a starburst corona were considered the most fully mature. Sixty-two clinical pregnancies were established, representing a pregnancy rate of 28.4%. Excluding 49 cases of male factor infertility, the pregnancy rate was 34.9%. Pregnancy rates were not significantly different according to age, cause of female factor infertility, parity, duration of infertility, stimulation protocol, or estradiol level. The only variables having a strong association with pregnancy were sperm and egg parameters. Sperm motility and morphology were statistically more important than sperm density. Based on odds ratios calculated from multiple logistic analysis, pregnancy was 3.80 times more likely if three or more fully mature eggs were transferred, 0.34 times as likely if motility were less than or equal to 30%, and 0.22 times as likely if normal morphology was less than or equal to 50%, controlling for other egg and sperm factors. If all egg and sperm factors in a given cycle were unfavorable, the probability of pregnancy estimated by the logistic model was 4%, whereas if all were favorable the probability of pregnancy in that cycle was 59%.
In a longitudinal study of 30 successfully treated unipolar depressed patients, the authors evaluated number of depressive episodes, early onset of depression, and lifetime prevalence of affective disorders other than major depression as risk factors for recurrence. Early onset of depression (before age 20) and a history of affective disorders other than major depression were each significantly associated with recurrence. Number of episodes was not as powerful in predicting recurrence as either early onset or lifetime prevalence of other affective disorders.
Evidence from clinical epidemiologic research is reviewed in relation to the prevalence of endometriosis, characteristics associated with its development, the association between endometriosis and infertility, and the efficacy of treatment.
Long- and short-term reactions of reproductive tract tissue to microsurgical suture materials were compared. The five materials were: polyglactin 910 (Vicryl), polyglycolic acid (Dexon-S), polypropylene (Prolene), nylon (Ethilon and Dermalon) and chromic catgut; the calibers ranged from 6-0 to 10-0. Sixteen days after suture placement the smallest tissue reaction was seen with 9-0 and 10-0 suture materials; Dexon-S caused a slightly greater reaction than did Vicryl. Prolene, 8-0 and 9-0, produced the smallest tissue response when compared to other sutures of similar size. Larger sutures incited greater tissue reactions. Forty-two days after placement, each suture was associated with similar or lower reaction scores than those observed at 16 days. At 90 days all the Dexon-S sutures had been absorbed. Vicryl had less of a late reaction as compared to the other sutures. Reactions persisted longer with nonabsorbable suture, and the tissue response depended on both the suture material and caliber. Vicryl, 8-0 to 10-0, incited the smallest short- and long-term tissue reaction; at those sizes it seems optimal for reconstructive tubal surgery.
Data were collected prospectively on factors that might affect the success or failure of external cephalic version, using a protocol including fetal monitoring, ultrasound, tocolysis, and external version after 37 weeks' gestation. Patients were accepted into the protocol whether or not risk factors for failure were present. Sixty-seven patients were admitted to the study and 40 (60%) underwent successful version. Using chi 2 analysis, we found that failure of external version was significantly associated with obesity, descent of the breech into the pelvis, decreased fluid, and fetal back positioned posteriorly. Thirteen women were in active labor; this had no effect on the success rate providing that descent had not occurred. Two factors, descent of the breech into the pelvis and posterior position of the fetal back, had an independent effect on success after controlling for other variables.
Prediction of twin birth weight discordancy was tested in 116 gestations using sonographic measurements of biparietal diameter (BPD) and abdominal perimeter. Abdominal perimeter measurement differences of 20 mm or greater were more sensitive and specific than BPD difference in detecting twins with dissimilar birth weights.
106 women between 24 and 33 weeks' gestation and in preterm labour, rigidly defined to include cervical dilatation plus regular uterine contractions, were randomly allocated to receive either intravenous ritodrine hydrochloride or no tocolytic treatment. Ritodrine treatment significantly delayed delivery for 24 hours or less but did not significantly modify the ultimate perinatal consequences of preterm labour.