Biomedical subjects
Publications and source records attributed to J L Dehaene.
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It has been reported that the pregnancy rate after in vitro fertilization (IVF) after pituitary desensitization with luteinizing hormone-releasing hormone agonist (LH-RH-a) is twice as low if the luteal phase is not supported. We therefore tested the respective advantages of luteal support using human chorionic gonadotropin (hCG, 1,500 IU three times) and progesterone (P, micronized, oral administration, 400 mg/d) after 171 embryo transfers (ET) in which the cycle was stimulated with the LH-RH-a triptoreline. The type of luteal phase support was randomly selected except when the estradiol level exceeded 2,700 pg/mL. The clinical pregnancy rate and the ongoing pregnancy rate were significantly higher using hCG (after the transfer of 3 embryos, 45% and 43% with hCG versus 23% and 17% with P). The same results were noted for the embryo implantation rate per ET (19% of embryos are viable after 6 months of pregnancy after hCG versus 7.5% after P). Adequate luteal support, therefore, significantly improves the results of IVF when LH-RH-a are used. The poor results obtained with P in this study might be related to its poor bioavailability after oral administration.
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Twenty-seven infertile patients presenting with clomiphene citrate- (CC) resistant polycystic ovary syndrome (PCOS) were treated with purified urinary follicle-stimulating hormone (pFSH). We compared the conventional stepwise protocol with a slow protocol starting with 75 IU/d, not increased until 14 days, supplemented by human chorionic gonadotropins (hCG). The slow protocol was characterized by a slightly longer duration of stimulation but a more physiological ovarian response (mono- or biovulatory cycles in 70% versus 19% with the conventional protocol, less follicles, and a lower plasma estradiol [E2] resulting in significantly less discontinuation of treatment for risk of hyperstimulation or multiple birth). The pregnancy rate per cycle was higher with the slow protocol (23% versus 15%). The slow protocol could thus be the treatment of choice for CC-resistant PCOS, as it appeared safer and more effective.
"Venous incompetence" is thought to be an organic cause of impotence. Its diagnosis is usually based upon Artificial Erection Test (AET); now, the reliability of this procedure is contested. We tested it in 9 controls, 13 psychogenic impotent patients and 65 impotent patients presenting "venous incompetence" according AET (maintenance flow rate needed for erection--MFR greater than 75 ml/min). Organicity of impotence was evaluated by Nocturnal Penile Tumescence monitoring and by the results of a sex-therapy. AET reproducibility was tested in 24 cases. The interest to perform an intracavernous injection of 80 mg papaverine before AET was tested in 18 impotent patients. Our results confirm that MFR is the most reliable criterion for interpreting AET. But 15% of the impotent patients with a MFR greater than 120 ml/min, 32% of those with a MFR greater than or equal to 80 ml/min and 66% of those with a MFR between 80 and 120 ml/min were in fact psychogenic patients. Moreover, we found "excessive" MFR in 3 of the 13 psychogenic patients and one of the normal controls (160 ml/min). In 50% of our patients, AET results were not reproducible. Injecting papaverine before AET significantly reduces MFR, but false positive results do still exist. Some recent physiopathologic data suggest that AET performed after papaverine injection might logically be disturbed by stress. These data should incite to be cautious when interpreting AET results, and results of "venous incompetence" surgery.
This article reports on the effects of human chorionic gonadotropin (hCG) on progesterone (P) and estradiol (E2), luteal phase length, and conception in 116 cycles treated by in vitro fertilization and embryo transfer (IVF-ET). In 60 cycles, the luteal phase was supported by hCG, 1500 IU three times at 2-day intervals from the day of ET. The remaining 56 cycles served as controls. hCG significantly increased the P level (93 +/- 53 versus 62 +/- 46 ng/ml), the P/E2 ratio, and the luteal phase length (17.4 +/- 1.3 versus 12.2 +/- 1.7 days). However, the total pregnancy rate did not significantly differ between the two groups, though the pregnancy rate after transfer of two or three embryos was slightly higher in the hCG group (26.9 versus 22% in the control group), as was the rate of implanted embryo per transferred embryo after transfer of two or three embryos (25 versus 15.3%). It was concluded that, while hCG increased the magnitude and duration of the luteal P secretion, it did not clearly improve the pregnancy rate.
Twenty-five impotent diatetics were investigated by means of nocturnal penile tumescence monitoring, hormone determinations, penile blood pressure measurement, artificial erection test and dynamic cavernosography, bulbocavernous reflex latency time measurement and cortical evoked responses from pudendal nerves. Sexological treatment was then attempted for a better evaluation of the psychogenic element. Penile blood pressure was also measured in 15 non-impotent diabetics and was found to be abnormal as often as in impotent diabetics. The results as a whole demonstrated that impotence was predominantly psychogenic in 9 cases, predominantly organic in 12 cases and mixed psychogenic and organic in 4 cases. Diabetic impotence is often due to several causative factors, as was the case in 12 of our patients. The factors most frequently responsible were psychological (present in 13 cases), neurological (present in 12 cases) and vascular factors (arterial abnormalities in 7 cases, "venous leakage" in 4 cases). Endocrine abnormalities were observed in only 2 cases.
To determine whether intracavernous injection of papaverine can discriminate vascular versus psychogenic impotence 80 mg. papaverine were injected intracorporeally into 27 impotent patients without any hormonal or neurological abnormality. The patients also underwent dynamic cavernosography, the artificial erection test and selective internal iliac arteriography. In addition, 21 of the patients underwent nocturnal penile tumescence monitoring. The response to intracavernous papaverine injection was noted as positive (fully rigid erection), intermediate or negative (soft or absent erection). Among 14 patients with severe arterial lesions and/or severe venous leakage the response was negative in 11 and positive in none. Among the remaining 13 patients (moderate or absent vascular abnormalities) the response was positive in 4 but negative in 4. Of 15 patients with an abnormal nocturnal penile tumescence test the response to intracavernous papaverine injection was negative in 12 and positive in none. However, of 6 patients with a normal nocturnal penile tumescence test the response was positive in only 1. Over-all, the results of the intracavernous papaverine injection test are correlated only fairly with those of the nocturnal penile tumescence test and the vascular investigations. This test could be useful to save some nocturnal penile tumescence tests in cases of suspected vascular impotence. However, the safety of this procedure must be confirmed in larger series. Indeed, 1 of our patients suffered priapism after a second intracavernous papaverine injection performed for a therapeutic purpose.
We tested whether the necessity for high flow rates of saline to maintain an artificial erection actually corresponds to an organic abnormality able to induce impotence as claimed recently. A total of 56 patients with presumed vascular impotence and 13 with typical psychogenic impotence underwent dynamic cavernosography followed by the artificial erection test. The former 56 patients also underwent bilateral selective internal iliac arteriography. A severely elevated maintenance flow rate (more than 120 ml. per minute) was found in 19 of the 56 patients with vascular and none of the 13 with psychogenic impotence, while a moderately elevated maintenance flow rate (80 to 120 ml. per minute) was found in 11 and 3, respectively. In most cases a severely elevated maintenance flow rate was associated with arterial (16 patients) or neurological abnormalities able to disturb erection. However, a severely elevated maintenance flow rate seemed to correspond to an organic abnormality able to induce impotence or to worsen erectile failure induced by other organic factors. Indeed, we found no severely elevated maintenance flow rates among our 13 patients with psychogenic impotence and the nocturnal penile tumescence test was normal in only 1 of 12 tested patients, although 7 had no other organic impairment sufficient to induce impotence (only moderate arterial stenoses in 4). In addition, sexual treatment succeeded in only 1 of the 13 patients, while our success rate is 43 per cent among patients with arterial impotence exclusively and this treatment succeeded in 6 of 10 patients with a moderately elevated maintenance flow rate. On the contrary, a moderately elevated maintenance flow rate does not seem to correspond to a genuine organic abnormality able to induce impotence. Indeed, we found it in 3 of 13 patients with psychogenic impotence, and every patient with a moderately elevated maintenance flow rate and normal arteries had a normal nocturnal penile tumescence test or was cured by sexual therapy. In conclusion, a maintenance flow rate exceeding 120 ml. per minute seems to reveal a genuine venous incompetence but in most cases this abnormality is only the cofactor of an arterial obstruction.
Intracavernous injection (IC) of vasoactive drugs (papaverine (ICP) in 115 cases and different alpha-blockers in 65 cases) were administered to 65 patients with erectile impotence to evaluate diagnostic and therapeutic interest of this procedure. Immediate (induction of erection) and medium term (lasting improvement in impotence) results were correlated with those of investigations of multidisciplinary etiologies. Comparison of results of ICP with those of plethysmography of nocturnal erections (PEN, 52 cases) gave negative results for the papaverine test (lack of erection or one without rigidity) in 67% of cases of impotence of organic origin (PEN abnormal). However, the test was positive (totally rigid erection) in 17% of cases of organic etiology and only 40% of psychogenic cases (PEN abnormal). Comparison of results with those of selective hypogastric arteriography and of the artificial erection test with dynamic cavernography (43 cases) showed that the papaverine test was never positive in patients with severe arterial occlusion or obvious venous leaks. However, an elevated proportion of cases with a negative test failed to show signs of marked vascular anomalies. Integration of results of total multidisciplinary explorations showed that most patients with organic or mixed impotence producing a positive or intermediary type papaverine test were cases of neuropathic impotence or had major neuropathic elements. Repeated IC of different vasoactive drugs (excluding the use of autoinjection techniques) failed to provide lasting improvement except for psychogenic impotence (5 of 9 cases). But it is in this group that IC is the most dangerous (2 cases of priapism and 8 cases of rigid erection prolonged over more than 4 hours).(ABSTRACT TRUNCATED AT 250 WORDS)
Fourty nine men seeking advice for erectile impotence, in whom the serum flow rate necessary to maintain an artificial erection (MFR) exceeded the upper limit of the normal range proposed by most authors (75 ml/mn), underwent different investigations (including a study of their penile arteries, Nocturnal Penile Tumescence monitoring (NPT) and a papaverine test) in order to ascertain the organic basis of their impotence, and to define the diagnostic criteria for "venous incompetence". Several other types of treatments were attempted. Two thirds of the patients were found to have occlusions of their sexual arteries, and these were severe in one third of cases. Our overall results suggest that only cases of MFR exceeding 120 ml per mn. were due to a true organic abnormality (severe venous incompetence, SVI), able to induce impotence, and possibly warrant surgical treatment, on condition that the organic nature is confirmed by NPT. 40% of the cases of impotence with SVI start before the age of 40, and 15% are primary. 37.5% of the cases never achieve rigid erection, and 37.5% have only rigid erections of short duration. Very few plausible etiological factors were found, except fibrosis of the cavernous bodies in 5 cases. The prognosis of impotence with SVI seems very bad, since only 4 of the 35 patients were clearly improved by non surgical treatments, while only 1 out of the 10 patients who underwent a surgical ligation of the deep dorsal vein of the penis was improved.
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We studied 29 cases of penile impotence to determine whether thermography could be used to screen for cases of vascular origin and, therefore, candidates for arteriography. Sixteen thermographic parameters were used to compare 3 groups of patients having normal, mildly altered and severely stenotic arteries on arteriography of the aortic bifurcation and selective catheterization of the hypogastric arteries. The averages of these parameters were computed for each of the 3 groups, and 104 comparisons then were made using student's t test. A significant difference was found between 2 groups in only 2 of the comparisons (p less than 0.05) and no threshold for significant differences was found. Penile thermography did not correlate with pelvic arteriography and does not appear useful in the selection of candidates for arteriography.
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The use of anterograde pyelography to assess morphological changes revealed the presence of obstruction in the upper urinary tract, previously undetected by urography, in 61 patients studied. The technique, used almost exclusively to expose the pelvis over the last year, is described. Only in very rare cases was there a failure to puncture the renal pelvis, and no complications occurred. The relative indication of anterograde and retrograde pyelography are discussed, as well as the morphological data obtained by each method in different types of obstruction: complete, severe incomplete, and partial. The main indications for this procedure are reviewed as a function of the etiology.
Apart from special types encountered in neonates and during pregnancy, spontaneous sub-capsular haematoma (SCH) of the liver is a rare condition which is usually not recognized before operation. The diagnostic value of arteriography is emphasized by this case of SCH in a 29 year old man which presented spontaneously with the appearance of a large mass in the right hypochondrium with fever and pain. Angiographic changes identical to those seen with a traumatic SCH were found and, in this case, were accompanied by a local reversal in intra-hepatic portal flow related to a tumoural Budd-Chiari phenomenon (compression of the hepatic veins by the haematoma). Despite histological study of the liver, no tumoural, vascular, infective or parasitic aetiology could be found to explain this apparently idiopathic spontaneous SCH.
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