Normal Menstrual History Research Articles

ROLE OF GENITAL TUBERCULOSIS IN SUB-FERTILE WOMEN

OBJECTIVE: To evaluate role of Acid fast bacilli culture (AFB) in sub-fertile women undergoing laparoscopy and dye test with endometrial biopsy. METHODS: This cross-sectional study was conducted from 1st January 2020 to 30th April 2021, on 108 cases of subfertility, enrolled through non-probability consecutive sampling technique, for diagnostic laparoscopy & dye test with endometrial biopsy for AFB culture. We included all women of reproductive age with ≥2 years of subfertility, normal menstrual history, hormonal assay and normal male-factor. All women with comorbidities, women having contraindications for anaesthesia & couple with male-factor subfertility were excluded. Data analysis was done by SPSS version-20. RESULTS: Seventy-two (66.7%) women had primary and 36 (33.3%) had secondary subfertility. Duration of subfertility was >5 years in 63 (58.3%) cases. Ninety-seven (89.8%) patients had bilateral patent tubes. Majority of patients (n=46/108; 42.6%) were aging 32-38 years. Endometrial biopsy of 22 (20.4%) cases were positive for AFB culture. Out of AFB-positive cases, 17 (77.3%) had primary and 5 (22.7%) had secondary sub-fertility. All AFB-positive cases had patent tubes (unilateral n=5/22; bilateral n=17/22). Common laparoscopic findings were tortuous tubes (n=30; 27.8%) and clumped end fimbrial (n=24, 22.2%). CONCLUSION: In our study, endometrial sampling of 20.4% cases were positive for AFB culture. Although female genital tuberculosis constitutes a small proportion of extra-pulmonary tuberculosis, but it has an immense effect on fertility. Thus without challenging the superiority of laparoscopy, AFB culture could be considered a judicious part of subfertility workup in low resource countries carrying high burden of disease.

Effect of prolonged use of hormonal contraception on ovarian reserve

Background and Objective: Contraception is widely used throughout the world, with 62% of reproductive-aged women. This trial was established to assess the effect of prolonged use of hormonal contraception (HC) on ovarian reserve. Methods: This retrospective randomized controlled trial was performed on 150 healthy females aged (20-35) years with normal menstrual history had at least one offspring after spontaneous pregnancy. Participants were subdivided into equal three groups: first group (study group): used the injectable progesterone for more than four years continuously, second group (study group): used combined oral contraceptive (COC) for more than four years continuously, control group: didn’t use HC (as intrauterine device, natural and non-users of any contraception). Results: Ovarian volume (OV) and antral follicle count (AFC) were significantly decreased in COC group than control group. There was a significant negative correlation between body mass index and OV was found. There was an insignificant correlation between age, gravidity, parity, BMI, usage duration and both AFC, AMH among group 3 controls. Conclusion: The prolonged use of HC in COC group had a significant negative effect on volume of ovary and AFC with no effect on AMH. A significant negative correlation between age and AMH was found among COC users.

Serum kisspeptin levels along reproductive period in women: is it a marker for aging?

Objective To demonstrate the change in serum kisspeptin levels during the reproductive period in healthy women and to investigate the relationship with other reproductive hormones. Methods One hundred thirty-one healthy women with normal menstrual history were included and serum kisspeptin, follicle-stimulating hormone (FSH), luteinizing hormone (LH), thyroid-stimulating hormone (TSH), estradiol (E2), and anti-Müllerian hormone (AMH) levels were determined on cycle day 3. The data were analyzed in 5-year age groups. Results Serum kisspeptin levels of all women were found to be significantly and negatively correlated with age (r= −0.458). The kisspeptin levels were the highest in the group of women aged between 20 and 24 years compared to other age groups above 25 years (p < .01, p < .001, p < .0005, p < .0005). There was not any significant correlation between serum kisspeptin levels and AMH, FSH, LH, TSH, E2, and body-mass index (BMI), respectively. The Scatter and Violin plots showed that most of the women over 35 years of age had serum kisspeptin levels under the level of 500 pg/ml. The kisspeptin levels of women over 35 years of age clustered closely as opposed to the kisspeptin levels of those below the age of 35, which were scattered. The median serum kisspeptin levels were found to be high in women below the age of 35 (p < .0005). Conclusion In healthy women, serum kisspeptin level is the highest in the group of women aged between 20 and 24 years and declines with age. It tends to be below the level of 500 pg/ml in women over the age of 35.

AYURVEDIC MANAGEMENT OF APATHYA NIMITTAJA PITTAJA PRAMEHA – A CASE STUDY.

A 30 years old, married female patient of Vata Pittaja Prakruti having normal obstetrical history of G3P3L3A0 with normal menstrual history approached OPD with chief complaints of burning micturition, yellowish urine, turbid urine, increased frequency of urination at night. After detailed history taking, Rogi Pareeksha &amp; Roga Pareeksha it is diagnosed clinically as "Apathya Nimittaja Pittaja Prameha" and treated with classical Ayurvedic Pramehagna drugs told by Acharyas along with strict diet &amp; good life style. Medicines used were Chandraprabha vati, Nishamalaki churna, Haritaki churna, Bibhitaki churna, Avipattikar churna. Every month laboratory investigations like FBS, PPBS were done and at every three months HbA1c was done to find the changes in objective criterias and examination was done to know the changes in subjective criterias. After 6 months of treatment the disease was cured completely and the patient was advised to continue with the same healthy life style and pathya apathya throughout life to prevent the reoccurance of the disease.

AYURVEDIC MANAGEMENT OF APATHYA NIMITTAJA PITTAJA PRAMEHA – A CASE STUDY.

A 30 years old, married female patient of Vata Pittaja Prakruti having normal obstetrical history of G3P3L3A0 with normal menstrual history approached OPD with chief complaints of burning micturition, yellowish urine, turbid urine, increased frequency of urination at night. After detailed history taking, Rogi Pareeksha &amp; Roga Pareeksha it is diagnosed clinically as "Apathya Nimittaja Pittaja Prameha" and treated with classical Ayurvedic Pramehagna drugs told by Acharyas along with strict diet &amp; good life style. Medicines used were Chandraprabha vati, Nishamalaki churna, Haritaki churna, Bibhitaki churna, Avipattikar churna. Every month laboratory investigations like FBS, PPBS were done and at every three months HbA1c was done to find the changes in objective criterias and examination was done to know the changes in subjective criterias. After 6 months of treatment the disease was cured completely and the patient was advised to continue with the same healthy life style and pathya apathya throughout life to prevent the reoccurance of the disease.

The effectiveness of quick starting oral contraception containing nomegestrol acetate and 17-\u03b2 estradiol on ovulation inhibition: A randomized controlled trial

To determine the effectiveness of quick starting combined oral contraception (COC) contain 2.5 mg nomegestrol acetate and 1.5 mg estradiol (NOMAC/E2) comparing with 0.075 mg gestodene and 0.02 mg ethinyl estradiol (GS/EE) on ovarian ovulation inhibition rate, we conducted a non-inferiority randomized controlled trial involving 69 healthy female volunteers aged 18–40 years who had normal menstrual history and were randomized at a 2:1 ratio to take one pack of COC containing either NOMAC/E2 (study group) or GS/EE (control group) starting on menstrual cycle Day7–9. The ovarian activity was assessed by using Hoogland and Skouby grading. Forty-six and 23 participants were randomized to NOMAC/E2 and GS/EE groups, respectively. Baseline characteristics were similar between groups. No significant difference was observed between the study and control groups for ovulation inhibition rate (93.4% vs. 95.6%, risk difference: –2.2%, 95% CI: –13.1, 8.8), ovarian quiescence rate (91.2% vs. 91.2%, P = 1.000), persistent cyst rate (2.2% vs. 4.4%, P = 1.000), and ovulation rate (6.6% vs. 4.4%, P = 1.000). Quick starting COC during day7–9 of menstrual cycle can inhibit ovulation for more than 90%. The quick starting NOMAC/E2 is non-inferior to GS/EE for preventing ovulation and suppressing follicular growth.

MON-LB044 Bilateral Ovarian Hyperthecosis: A Benign and Unusual Cause of Postmenopausal Hirsutism

Introduction-: Postmenopausal hirsutism is a rare presentation. The presentation of clinical hyperandrogenism , its severity and the pace of presentation along with the hormonal profiles help in determining the cause. Once iatrogenic cause is ruled out, one has to assess for the endocrine causes of postmenopausal hirsutism. There are various benign and malignant causes of ovarian hyperandrogenism. Case Presentation- A 62 years post menopausal lady came with complaints of increasing facial hair, coarseness of facial skin and alopecia for two years. She had no significant medical illness and had not received androgens in any form. She had a normal menstrual history during her reproductive years and has two children born of natural conception. Clinically there was no evidence of other endocrine causes of hyperandrogenism like Acromegaly, Cushing’s syndrome, Late onset CAH. Her hormonal profile showed significantly elevated testosterone levels with normal DHEAS levels. Investigations - TSH 1.898 uIu/ml (NR 0.5-5.0); Testosterone 216.10 ng/dl ( NR 20-90); DHEAS 40 mcg/dl ( NR 17-90); USG abdomen and pelvis showed thickened endometrium 8 mms in size and submucosal fibroid. Further investigations-Serum Testosterone 145 ng/dl (NR 20-90); DHEAS 23.8 mcg/dl ( NR 17-90); 17 OH Progesterone 0.86 ng/ml ( NR 0.2- 0.5); Post Dexamthasone 1 mg cortisol < 1.0 mcg/dl (normal response< 1.8- 2.0); Alpha Fetoprotein 2.08 ng/ml ( NR <10 ng); IGF1 71 ng/ml ( NR 70-140) ; Estradiol 10 pg/ml ( NR <30). Her assessment for other causes of hirsutism ruled out Acromegaly, Late onset CAH and Cushing syndrome. MRI abdomen and pelvis revealed normal ovaries and uterus for her menopausal status. In view of persistent symptoms and very high levels of testosterone along with endometrial hyperplasia, patient was counselled to get her ovaries and uterus removed.She underwent a total hysterectomy with bilateral oophorectomy. Postoperatively the patients symptoms have improved, her skin hue is better and the facial hair growth has significantly reduced. The testosterone levels have returned to normal. Postoperative Total Testosterone 16.12 ng/dl ( NR 20-90) and Free Testosterone 1.63pg/ml ( NR 0.3-2). The histopathology showed bilateral ovarian hyperthecosis along with benign endometrial hyperplasia. Conclusion: Polycystic ovaries is a common cause of hirsutism in young women of reproductive age group. It is not commonly seen in the post menopausal state. Even though the hormonal profile points towards an ovarian cause, localisation of an ovarian pathology is sometimes difficult. Diagnostic and therapeutic bilateral oophorectomy points towards the diagnosis which can be unusual and curable like bilateral ovarian hyperthecosis. This was an unusual , curable and rewarding case of postmenopausal hirsutism. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

First-trimester crown-rump length affects birth size symmetrically

Objective: To investigate the relationship between crown-rump length (CRL) and birth weight, length and head circumference of the newborn.Methods: From a database of delivery records of 12 000 pregnancies, we identified 999 women with singleton pregnancies who had no medical problems, a normal menstrual history and a first trimester ultrasound scan in which CRL had been measured. All of the pregnancies resulted in live births without evidence of chromosomal and congenital abnormalities. The population in this study was divided into three groups according to CRL measurement; Group A (smaller-than-expected CRL), Group B (normal CRL) and Group C (larger-than-expected CRL).Results: The incidence of low birth weight infant was higher in Group A than in Group C (p = 0.010). The rate of small for gestational age (SGA) infants was similar between groups. The number of macrosomic or large for gestational age (LGA) infants was higher in Group C than Groups A and B. Both birth head circumference and length of infant were greater in Group C than Groups A and B. No significant difference for ponderal index value was observed between the groups (p = 0.927).Conclusion: The growth pattern in the first trimester affects neonatal birth weight and length symmetrically without changing the ponderal index.

The quality of ovulation is strained in normal women

‘Ovulatory dysfunction’ bears the imprimatur of a succinct medical diagnosis, but what does it really mean and above all, how do you diagnose it, especially in women with a normal menstrual history? Although we have multiple measures in our modern toolbox: ultrasound for daily follicular monitoring, hormonal assays of serum, urine and saliva (some for instance LH available over the counter to our patients), and even, heaven forbid, an endometrial biopsy; these are expensive, invasive and labor intensive for both physician and patient to document, and often lacking in evidence-based cutoffs. The bottom line is that the most common clinical practice to screen for ovulatory dysfunction is a menstrual history. Much of our knowledge of the normal length of the menstrual cycle and the effects of age on the menstrual cycle comes from the classic studies of Treloar et al. (1967) which were based on menstrual diaries collected on the back of a postcard, beginning in young women recruited during their college years and then collected over their lifetimes. We are likely to assume that a woman is ovulating regularly if her menstrual cycle length is 21–35 days (thanks to Treloar). Therefore, the BioCycle study by Hambridge et al. (2013) reported in this issue of the journal offers important and novel data about ovulatory function in normal women, including the frequency of anovulation (12%), and the influence of anovulation upon ovulatory cycles (adversely in terms of integrated serum estrogen and progestin measures). The BioCycle study investigators prospectively enrolled a cohort of 259 healthy, menstruating women, 18 –44 years of age (excluding confounders such as hormonal use, history of ovulatory disorders, etc.). Women were asked to provide eight timed serum specimens during each of two menstrual cycles, and these were timed in relation to self-monitoring for ovulation using urinary LH and estrogen kits, to allow for comparison at similar phases of the cycle. The current study includes 250 women who provided (at least some) data from two menstrual cycles. A significant strength of the study is the retention and compliance in the protocol for such a large number of women. Over 94% of the women completed seven or more of the planned visits per cycle (far exceeding the average dropout in randomized clinical trials!) and all women had at least five visits per cycle. An additional strength is that the investigators studied more than one menstrual cycle in each subject, and carefully collected confounders of the menstrual cycle in the cohort. The investigators used a serum progesterone cut-off point (.5 ng/ml) to categorically determine whether ovulation took place in the cycle, analogous to our own clinical practice of documenting ovulation with a mid-luteal serum progesterone level. Overall 12% of the women with a normal menstrual history had at least one anovulatory cycle and of these 3% had two anovulatory cycles. Women with two ovulatory cycles were older (mean age of this group was 28 years) and women with anovulatory cycles were significantly younger (the mean age of women with one anovulatory cycle was 5 years younger and with two anovulatory cycles 8 years younger). Women with anovulatory cycles were also more likely, not surprisingly, to be unmarried and nulliparous, and anovulation was not associated with smoking, former OCP use or physical activity. However, the most important and novel observation of this study is the effect of anovulation on subsequent ovulation, and hence the title of this editorial. The investigators utilized complex modeling to construct the menstrual cycle (and also created some elegant figures) based on their repeated serum hormonal measures, and divided the subjects categorically on the basis of their ovulatory status. They found diminished integrated levels of serum sex steroids in the ovulatory cycles of women who also had one anovulatory cycle (and this was independent of the temporal relation of the ovulatory cycle to the anovulatory cycle), compared with those women who had two ovulatory cycles. In regard to integrated progesterone levels there was a dose– response stepdown in integrated progesterone levels with highest in the women with two ovulatory cycles, followed by those with one ovulatory/one anovulatory cycle followed by those with two anovulatory cycles. This may be (in the periodic ovulators) the clearest depiction of the long hypothesized luteal phase defect (Jones, 2008) that I have seen. While these hormone levels represent only a surrogate of oocyte quality or endometrial function, and ultimately fecundity, they offer evidence, that documentation of an anovulatory cycle in a women suggests altered and likely diminished ovulatory quality (with potential downstream endometrial effects) in these women when they do ovulate. In other words, the anovulatory

POI: Premature ovarian insufficiency/pregnancy or infertility?

Dear Editor, Premature ovarian insufficiency (POI) is a condition associated with female infertility that affects approximately 1% of women under the age of 40.[1] It is characterized by amenorrhea, hypoestrogenism and elevated level of gonadotropins. Although the causes of POI are largely unknown, autoimmune diseases, chromosomal abnormalities and environmental factors seem to play an important role in the etiopathology.[2] Most women have normal menstrual history, age of menarche and possible fertility prior the onset of POI symptoms (i.e., vaginal dryness, night sweats, or hot flushes). A definitive diagnosis of POI is difficult to make, and the diagnostic criteria are not always standard.[3] Most clinicians would make the diagnosis based on (i) 3-6 months of amenorrhea, (ii) Follicular Stimulating Hormone (FSH) levels above 40 mIU/ml and (iii) low estrogens levels.[2] In this syndrome, the ovarian failure is not permanent. Indeed, some women experience intermittent and unpredictable ovarian function and in some cases may even conceive spontaneously.[4] We report a case of a 28-year-old woman, who was presented to our infertility unit, with 16 months of primary infertility. Her personal history for previous surgery or other relevant pathologies was negative. Menarche occurred at age of 12, followed by regular menstrual bleeding. At 22, she commenced on birth-control pill that stopped 2 years later. Before starting any treatment, hormonal profile of the couple and a sperm test for the partner were planned. They all resulted normal. After 4 failed intrauterine insemination (IUI) cycles, the couple underwent 2 in vitro fertilization (IVF) cycles preceded by a karyotype analysis that resulted normal. They both ended with few oocytes retrieved (3 and 1 respectively) and none fertilized. Before all procedures, the patient was stimulated with high doses of recombinant-FSH, followed by daily dose of GnRH antagonist ganirelix when at least two follicles had reached 14 mm diameter. Ovulation triggering was performed using a subcutaneous injection of corio gonadotropin alpha. Five months after the last IVF-cycle, the patient came back referring amenorrhea. Laboratory tests revealed FSH level at 65 and 75 mUI/mL (menopause > 40 mUI/mL), estradiol (E2) at 33 and 26 pg/mL (menopause < 40 pg/mL) and anti-mullerian hormone (AMH) at 0.0 ng/mL in two serial determinations. A diagnosis of POI was made. The couple was then listed for oocyte donation. One year later, the patient experienced a menstrual bleeding and a month after a pregnancy test resulted positive. Nine months later a healthy baby was delivered. Although pregnancy in POI patients is a rare event, it should be always taken into consideration, given the possibility of spontaneous resumption of the ovarian function.

Addison’s Disease, Idiopathic Intracranial Hypertension and Empty Sella - In a 40-Year-Old Woman

A 40-year-old woman having normal menstrual history got admitted into Bangabandhu Sheikh Mujib Medical University (BSMMU) because of vomiting for previous two months, with a background history of irregular steroid intake for her bodyache for about six years. She was gaining weight and gradually losing vision in her right eye and noticed increased body pigmentation. Physical examination revealed BMI 29 kg/m2, generalized pigmentation more marked in palmar crease and oral mucosa, secondary optic atrophy in right eye and papilloedema in left eye. After biochemical and radiological investigation she was diagnosed as a case of Addison’s disease with idiopathic intracranial hypertension (IIH) with empty sella DOI: http://dx.doi.org/10.3329/jbcps.v30i1.11368 J Bangladesh Coll Phys Surg 2012; 30: 53-55

Influence of osteoporosis risk faktors on bone mass loss in postmenopausal women

Introduction: Estrogen deficiency plays a critical role in the development of osteoporosis. However, some other factors may contribute to bone loss as well. Aim: To show presence of osteoporosis risk factors and to examine its influence on bone mass loss in women with normal menstrual history.Methods: The study included 30 postmenopausal women, ages from 50 to 65 with osteoporosis who entered into menopause before the age of 45, and 30 postmenopausal women, ages from 50 to 65 with osteoporosis who had normal menstrual history. Presence of risk factors has been calculated for both groups and statistical significance of differences between two groups presented.Results: In the group with normal menstrual history 33.33% women had low level of physical activities, 56.66% suffered from insuficient intake of calcium, 63.33% of women were active smokers. Body mass index bellow 19 had 6.66% women, insuficient exposure to the sun was registered in 60%, and 23.33% women were either taking medicaments or had diseases that could cause osteoporosis. Statistical significance of differencies in presence of certain risk factors between two groups was registered for : insuficient daily intake of calcium (p &lt;0.001), insuficient exposure to the sun (p&lt;0.001), and smoking (p &lt;0.001).Conclusion: Results of the study indicate high presence of osteoporosis risk factors in women with normal menstrual history and indicate influence of certain factors (calcium, sun exposure, smoking) on occurence ofosteoporosis in this group.

Patterns of menstrual disturbance in eating disorders

To describe menstrual disturbance in eating disorders (ED). We describe menstrual history in 1,705 women and compare eating, weight, and psychopathological traits across menstrual groups. Menstrual dysfunction occurred across all eating disorder subtypes. Individuals with normal menstrual history and primary amenorrhea reported the highest and lowest lifetime body mass index (BMI), respectively. Normal menstruation and oligomenorrhea groups reported greater binge eating, vomiting, and appetite suppressant use. Amenorrhea was associated with lower caloric intake and higher exercise. Harm avoidance, novelty seeking, perfectionism, and obsessionality discriminated among menstrual status groups. No differences in comorbid Axis I and II disorders were observed. Menstrual dysfunction is not limited to any eating disorder subtype. BMI, caloric intake, and exercise were strongly associated with menstrual function. Menstrual status is not associated with comorbidity. Menstrual irregularity is an associated feature of all ED rather than being restricted to AN only.

Lifelong menstrual histories are typically erratic and trending

Menstrual cycles are composites of complex events; the data describing them are correspondingly rich. We seek to quantitatively represent menstrual histories from menarche to menopause and to evaluate the clinical belief that regular and stable cycle lengths are the most normative histories. Using prospective data from the Tremin Trust, we classified the menstrual histories of 628 women as very stable (type I), stable but with greater variability in cycle lengths (type II), oscillating and erratic with a downward trend in cycle length (type III), oscillating and erratic with no downward trend in cycle length (type IV), or highly erratic and variable (type V). Classification criteria were created by examining basic summary statistics of menstrual cycle lengths. Specifically, we identified key features describing variability of median cycle length, the mean of the interquartile range, the consistency of the interquartile range, the slope of median cycle lengths, and the number of stable 5-year intervals between ages 15 and 45+. We present the first characterization of full menstrual histories. Our taxonomy captures the essential features of menstrual bleeding patterns for a heterogeneous population. Persistently stable histories (types I and II) were seen in only 28% of the women; erratic histories (types III through V) characterized 72%. When examining all participants, significant differences were seen in age at menarche (P < 0.05), age at menopause (P < 0.01), and number of births (P < 0.01) between these stable and erratic groups. Although clinicians have traditionally thought of "normal" menstrual histories as being regular and stable, the distribution of women in our five categories suggest that variable histories are most common. Clinically, these results may suggest the need for a paradigm shift in what gynecologists view as normal and abnormal menstrual cycle histories.

Anaemia as A Cause Of Infertility: Focus On Management Of Anaemia As First Line Management Of Infertility

We report a series of 5 infertile couple who were seen in a free camp in India. The women were found to be clinically anaemic, treated with dietary supplements (Vitamin B12 and folic acid and Iron) 4 out of 5 couples treated conceived between 4 months and 1 year of treatment . The 5th couple is undergoing further treatments. INTRODUCTION Infertility has been seen as a social stigma since dark ages and still remains to be so in the deprived and uneducated population of the developing world. Anaemia is a common manifestation of economic deprivation in societies. Infertility has been a focus of research and groundbreaking advances have been made for its treatment. But basic clinical judgement and simple measures may still be more effective than most advanced treatment. We report a series of 5 women complaining of inability to conceive. 4 of whom conceived with improved nutrition and only one needed any further investigations to help with infertility. CASE REPORT 5 women were reviewed in a health camp organised in a poor deprived community organised by a Charity .They had all been complaining of inability to conceive. Clinically they all looked pale and were from low socio economic status, uneducated and a dietary history indicated a poor diet. They all had normal menstrual history and three of five women had one or more children while two had none. Haemoglobin was accessed in the camp and was fund to be low In all cases table 1 the slides indicated mixed iron and foliate B12 deficiency .The proposed management plan was to start with dietary supplements ( Iron and Folic acid ) and give dietary advise and a course of Albendazole ( due to high prevalence of helminthic infections ) in the first place and advise contraception for next few months as a pregnancy was not desirable with such low haemoglobin. Keeping in view the poor socio-economic status and the family dietary history, nutritional supplements were distributed for the husband and children as well and the women were advised to visit with their husbands and children on the next visit. Check at 3 month reported improved general well being improving haemoglobin table 1 treatment was continued and advise to continue contraception was given. 6 month review revealed rising haemoglobin level chart 1 and 3 of 5 women were already pregnant. One lady got pregnant 2 months later. One lady( kd ) is still under treatment and husbands sperm count was found to be low. DISCUSSION Surveys suggest that 65 per cent of adult women, 75 per cent of pregnant women, 77 per cent of pre-school children, and nearly 45 per cent of adult men in India are anaemic 1, 2 Perinicious anaemia and folate deficiency are known to cause secondary infertility 3,4,5,6 in both men and and women. Anaemia as a cause of infertility has been seen only in the cases of malabsorption syndromes in the developed world. In economically deprived communities of developing countries dietary deficiency anaemias are still a cause of infertility. Besides causing infertility folate deficiency may also cause increased risk of miscarriage 7 The high incidence of anaemia amongst the deprived populations of developing world makes it a common cause Anaemia as A Cause Of Infertility: Focus On Management Of Anaemia As First Line Management Of Infertility 2 of 3 of infertility. Pregnancy in a severely anaemic woman is a risk to both mother and foetus. Any efforts to treat infertility or to even start preliminary investigations should be deferred until anaemia is treated. Empirically treating both partners for dietary deficiency was reasonable in our case as we were in a one day camp away from our base hospital, but in an other situation checking partners haemoglobin would be a better option. Treatment of anaemia itself may resolve the infertility issues and should be taken as a first line treatment in all cases. If the couple is still unable to conceive further treatments and investigations can be planned in he healthy mother. Figure 1 CORRESPONDENCE TO Pooja Singh 7 Teal Mews Skipton Road Steeton Keighley West Yorkshire United Kingdom BD 20 8UW Tel: 07983385585 E-mail singhrahul1975@gmail.com

Oviductal motile response to penile cervical buffeting

We investigated the hypothesis that the oviduct exhibits increased motile activity during cervical buffeting. The response of oviductal and uterine pressures to cervix uteri (CU) stimulation was recorded in 16 women (mean age 32.4+/-3.6 years) with normal menstrual history. Pressure measurements, performed by means of saline-perfused catheters introduced into each of the uterus and oviduct, were recorded upon both electrical and mechanical CU stimulation before and after CU anesthetization. CU stimulation produced a significant uterine pressure decrease with no significant difference between electrical and mechanical stimulation. Latency recorded mean of 17.6+/-1.2 ms for electrical stimulation and 17.2+/-1.2 for mechanical stimulation. CU stimulation caused also significant pressure rise in ampullary and isthmic parts of oviduct and a decrease of intramural oviduct with no significant difference between electrical and mechanical stimulation. Mean latency of electrical and mechanical response was 18.7+/-1.1 ms and 19.1+/-1.1 ms, respectively. Uterine and tubal pressure showed insignificant response to stimulation of the anesthetized CU. Cervical stimulation reduced uterine and intramural oviduct pressure and elevated pressure of ampullary and isthmic parts. These utero-tubal responses seem to be mediated through a reflex which we call "cervico-utero-tubal reflex" and to assist in sperm-ovum transport and fertilization.

First-trimester growth and the risk of low birth weight.

Previous studies have demonstrated a correlation between first-trimester size and birth weight. It is not known, however, whether low birth weight is related to first-trimester growth. We sought to determine whether the risk of low birth weight and birth weight that was low for gestational age is related to the size of the embryo or the fetus in the first trimester. From a data base of ultrasound records of more than 30,000 pregnancies, we identified women who had no important medical problems, a normal menstrual history, and a first-trimester ultrasound scan in which the crown-rump length of the embryo or fetus had been measured. We examined the relation between the outcome of 4229 pregnancies and the difference between the measured and the expected crown-rump length in the first trimester, expressed as equivalent days of growth. A first-trimester crown-rump length that was two to six days smaller than expected was associated with an increased risk (as compared with a normal or slightly larger than expected crown-rump length) of a birth weight below 2500 g (relative risk, 1.8; 95 percent confidence interval, 1.3 to 2.4), a birth weight below 2500 g at term (relative risk, 2.3; 95 percent confidence interval, 1.4 to 3.8), a birth weight below the fifth percentile for gestational age (relative risk, 3.0; 95 percent confidence interval, 2.0 to 4.4), and delivery between 24 and 32 weeks of gestation (relative risk, 2.1; 95 percent confidence interval, 1.1 to 4.0), but not with delivery between 33 and 36 weeks (relative risk, 1.0; 95 percent confidence interval, 0.7 to 1.5). Suboptimal first-trimester growth may be associated with low birth weight, low birth-weight percentile, and premature delivery.

Seminoma in a postmenopausal woman with a Y;15 translocation in peripheral blood lymphocytes and a t(Y;15)/45,X Turner mosaic pattern in skin fibroblasts.

We report an unusual case of a 55 year old Japanese woman with a seminoma but relatively normal menses. The patient was a phenotypic female with late onset menarche (18...

Unrecognized pregnancy in the overdosed or poisoned patient

A 22-year-old woman was found in bed unresponsive and hypotensive after an apparent overdose. Subsequent workup in the emergency department identified a ruptured ectopic pregnancy and extensive hemoperitoneum. A significant delay occurred when emergency physicians excluded the possibility of pregnancy because of the patient's normal menstrual history. A qualitative serum or urine pregnancy test is recommended in all women of child-bearing age who present with poisoning or drug overdose.

Androgen Excess and the Infertile Woman

Hyperandrogenism is not infrequently encountered in infertile women. However, elevated levels of androgen in blood may or may not be associated with hirsutism. Therefore, the presence of hirsutism alone may not be adequate to rule out hyperandrogenism as a factor in infertility. Although most patients with hyperandrogenism will have menstrual irregularity, some patients may give a normal menstrual history. Specific markers in blood may be used to direct therapy. Not all suppressive therapy is appropriate for use in the infertile patient.