Unrecognized Pregnancy Research Articles

Measuring non-events: infertility estimation using cross-sectional, population-based data from four countries in sub-Saharan Africa.

Does the prevalence of 12-month infertility in Burkina Faso, Côte d'Ivoire, Kenya, and Uganda differ between women trying to conceive and the broader population of women exposed to unprotected sex, and how are prevalence estimates affected by model assumptions and adjustments? Estimates of 12-month infertility among tryers ranged from 8% in Burkina Faso to 30% in Côte d'Ivoire, increasing substantially among a larger population of women exposed to unprotected intercourse. While having a child is a fundamental human experience, the extent to which women and couples experience infertility is a neglected area of research, particularly in sub-Saharan Africa. Existing estimates of infertility in this region vary widely from 2% to 32%, however, potential impacts of variability in study populations and model assumptions have not been well-examined. We used cross-sectional nationally representative survey data from Burkina Faso, Côte d'Ivoire, Kenya, and Uganda. We employed a multi-stage cluster random sampling design with probability proportional to the size selection of clusters within each country to produce representative samples of women aged 15-49. Samples ranged from 3864 in Côte d'Ivoire to 9489 in Kenya. We created two analytic samples in each country-tryers and a broader sample of women exposed to unprotected sex-exploring differences in population characteristics and estimating the period prevalence of 12-month infertility using the current duration (CD) approach. We also examined the impact of several model assumptions within each of the two analytic samples, including adjustments for recent injectable contraceptive use, unrecognized pregnancy, infertility treatment, underreported contraceptive use, and sexual activity. Employing the CD approach among tryers produced an overall 12-month infertility prevalence of 7.9% (95% CI 6.6-12.7) in Burkina Faso, 29.6% (95% CI 15.3-100.0) in Côte d'Ivoire, 24.5% (95% CI 16.5-34.6) in Kenya, and 14.7% (95% CI 8.1-22.4) in Uganda. Results among women exposed to unprotected intercourse indicated much higher levels of infertility, ranging from 22.4% (95% CI 18.6-30.8) in Uganda to 63.7% (95% CI 48.8-87.9) in Côte d'Ivoire. Sensitivity analyses suggest infertility estimates are particularly sensitive to adjustments around pregnancy recognition timing and sexual activity, with little impact of adjustments for recent injectable contraceptive use, infertility treatment, and underreporting of traditional and coital dependent contraceptive use. There was substantial digit preference in responses at 12 months, particularly among the tryers, which could introduce bias. Data quality concerns in the reproductive calendar may impact the accuracy of the CD approach among the broader sample of women exposed to unprotected sex, particularly with regard to underreported contraceptive use, induced and spontaneous abortions, and unrecognized pregnancies. Lastly, we lacked information on postpartum amenorrhea or abstinence. Understanding the inconsistencies in definition and analytic approach and their implications for infertility estimation is important for reliably monitoring population-level infertility trends, identifying factors influencing infertility, improving prevention programs, and ensuring access to quality treatment and services. This study was supported by grants from the Bill & Melinda Gates Foundation (INV009639) and the National Institute of Child Health and Human Development (K01HD107172). The funders were not involved in the study design, analyses, manuscript writing, or the decision to publish. The authors have no conflicts of interest to declare. N/A.

Medical Imaging in Pregnancy: Safety, Appropriate Utilization, and Alternative Modalities for Imaging Pregnant Patients.

This article reviews the existing literature on diagnostic and medical imaging of pregnant women, the risks and safety measures of different medical imaging modalities, and alternative modalities for imaging pregnant patients. Different medical imaging modalities such as MRI, CT scan, ultrasound, nuclear medicine, and X-ray imaging help to evaluate women with recognized or unrecognized pregnancies and identify any underlying complications among pregnant patients. Fetuses are more sensitive to radiation and the effects of medical imaging as compared to adults since they have a rapidly developing cell system. During cell proliferation, migration, and differentiation, fetuses suffer greatly from imaging radiationsince they are developing under a dynamic system. To ensure safety, pregnant women should discuss the benefits and risks of medical imaging with their physicians. In addition, radiologists should not perform any medical imaging procedure without the patient's consent, unless the patient cannot make any sound decision. Fetal risks of medical imaging include slow growth and development of the fetus, abortion, malformations, impaired brain function, abnormal childhood growth, and neurological development. Diagnostic imaging procedures are necessary when a condition that needs medical evaluation arises during pregnancy such as appendicitis.

The frequency of pregnancy recognition across the gestational spectrum and its consequences in the United States

The frequency of pregnancy recognition across the gestational spectrum and its consequences in the United States

A. Rosner. Fibroids and pregnancy. (Przeglad lekarski, 1893, №№: 39-41)

An instructive case of laparotomy in an unrecognized pregnancy complicated by numerous, large fibroids is described by Dr. Alex. Rosner from Clinic Prof. Madurowicz'a in Krakow.

Preoperative pregnancy testing in surgical patients: How useful is policy of routine testing.

Surgery in a patient with unrecognised pregnancy has serious ethical and medicolegal implications. There are no guidelines in India for preoperative pregnancy testing (POPT) in surgical patients. This review was undertaken to ascertain utility of routine POPT and whether any specific indication for POPT could be suggested. We performed a literature search to identify publications pertaining to POPT in surgical patients. Searches included PubMed, Google Scholar and internet search for national guidelines. Studies pertaining to incidence of unrecognised pregnancy, cost-effectiveness of POPT, effect of surgery and anaesthesia on pregnancy are included. We excluded articles which were available in languages other than English and those whose full texts were unavailable. Most of the literature about reproductive outcomes after anaesthesia exposure is based on old data. The evidence for teratogenic effect of anaesthetic drugs on human foetus is still inconclusive. Apart from anaesthesia and surgery, the outcome after surgery in unrecognised pregnant patient depends on other factors such as indication for surgery, high incidence of foetal loss in early pregnancy, stress and lifestyle of patient. As it is difficult to unsnarl the effect of these factors, POPT should be offered to all patients who based on history could be possibly pregnant. The cost-effectiveness of POPT appears doubtful, but considering costs associated with miscarriages and medicolegal litigations due to unclear association with anaesthesia, it may indeed be cost-effective.

1299. Iowa TelePrEP: Preliminary Experience with a Public Health-Partnered, Telemedical PrEP Delivery Model in a Rural State

BackgroundAccess to HIV pre-exposure prophylaxis (PrEP) is often poor in small urban and rural areas due to long distances to PrEP providers and stigma. In 2017, the Iowa Department of Public Health (IDPH), University of Iowa (UI), and community representatives collaborated to develop a public health-partnered telemedical PrEP delivery model to overcome these barriers (TelePrEP). IDPH personnel working in five sexually transmitted infection (STI) clinics and partner services (PS) programs in Eastern Iowa screened clients for PrEP indications and referred those with need to TelePrEP pharmacist providers at UI. Via collaborative practice, pharmacists completed initial and follow-up PrEP home video visits with clients on smart phones and laptops. Clients obtained laboratory monitoring and STI screening in public health-affiliated and local laboratories in accordance with USPHS/CDC guidelines, and received PrEP medication by mail. PS personnel linked TelePrEP clients with newly-identified STIs to local treatment.MethodsUsing the PrEP continuum as framework, we used IDPH databases and UI medical records to conduct a retrospective process evaluation of the TelePrEP model (February 2017–April 2018).ResultsTelePrEP received 44 referrals from public health and 59 self-referrals via advertising. Pharmacists completed 84 initial visits (81% of referrals), including 37 visits (84%) with clients referred by public health. Most (94%) started emtricitabine/tenofovir after initial visits. Retention in TelePrEP at 6 months was 87%. 96% of guideline-indicated laboratory tests (HIV, creatinine, STI, hepatitis) were completed at baseline and follow-up. Rates of extragenital chlamydia and gonorrhea screening were lower (74 of 104 completed screens) due to variable availability of swabs at local laboratories. 15 clients were diagnosed with 20 STIs on screening (6 syphilis, four gonorrhea, 10 chlamydia) and one unrecognized pregnancy was identified. PS linked all clients with STIs on screens to treatment within 14 days (80% in 3 days).ConclusionUsing telemedicine, healthcare systems can partner with public health administered STI clinics and PS programs to create virtual PrEP delivery models in rural settings. Public health partnerships enhance client identification and ensure linkage to care for new STI diagnoses in telemedicine programs.Disclosures A. Hoth, Gilead Sciences, Inc.: Research team member, Research support. M. Ohl, Gilead Sciences, Inc.: Grant Investigator, Research grant.

Unrecognized pregnancy prior to bariatric surgery: case report and review of implications

SummaryA substantial proportion of patients undergoing bariatric surgery are female and of reproductive age. Guidelines suggest that pregnancy should be avoided for 12–18 months following bariatric surgery, and that women be appropriately counselled regarding contraception. We present a case in which a patient underwent a Roux‐en Y gastric bypass while unknowingly in the early stages of pregnancy. After a six‐week period liquid meal replacement for perioperative weight loss, a laparoscopic Roux‐en Y gastric bypass, and a short course of oral antibiotics for a post‐operative wound infection, the patient developed epigastric pain, odynophagia, oesophageal dysphagia, bloating and nausea with oral intake. Only after an abdominal X‐ray, two upper endoscopies and an upper gastrointestinal series was an intrauterine pregnancy seen incidentally on abdominal ultrasound. Ultimately, the patient underwent elective termination of her pregnancy. Patients who are, or are planning to soon become, pregnant should not undergo bariatric surgery. All female patients of reproductive age should be counselled on the importance of effective birth control prior to planning bariatric surgery. Beta‐human chorionic gonadotropin testing should be routinely considered before embarking on meal replacement or surgery.

Retrospective Review of Universal Preoperative Pregnancy Testing: Results and Perspectives.

Unrecognized pregnancy in patients presenting for elective surgery is of particular concern due to the potential for significant complications. Accurate and inexpensive urine pregnancy tests are widely available in the developed world. As a result, universal preoperative pregnancy screening is commonly implemented. However, the utility of such routine testing is controversial. We retrospectively studied 8245 immediate presurgery pregnancy tests at Mayo Clinic Hospital, Phoenix, AZ, and found 11 positive tests of which 6 were false positives. We constructed a census-based approximation for unrecognized pregnancies, which shows significantly low pretest probability in this patient population. Taken together, the utility of immediate universal presurgical pregnancy testing is questionable.

Discrepancies in the Evidence and Recommendation Levels of Pregnancy Information in Prescription Drug Labeling in the United States, United Kingdom, Japan, and Korea.

To compare the evidence-of-risk and recommendation levels of new drugs' label information in pregnancy among US, UK, Japan, and Korea. Despite the importance of drug labels in guiding decisions, officially approved prescribing information in drug labels is often inconsistent across countries and contains misleading content. Women are unintentionally exposed to drugs during early stages of unplanned or unrecognized pregnancies when treated for medical conditions. We selected 81 drugs approved in all 4 countries mentioned above from 2008 to 2016. Evidence level was classified into five categories ("Definite," "Probable," "Possible," "Unlikely," and "Unclassified"), and recommendation level was classified into four categories ("Contraindicated," "Cautious," "Compatible," and "Unclassified"). We calculated kappa coefficient with 95% confidence intervals (CIs) to estimate the agreement of each category. For evidence level, "Unclassified" was the highest in Japan (33.3%), while representing a much smaller proportion in US (2.5%), UK (6.2%), and Korea (6.2%; p < 0.01). For recommendation level, "Contraindicated" was the lowest in US (9.9%), while it was greater in UK (50.6%), Japan (50.6%), and Korea (42.0%; p < 0.01). Korea-UK presented substantial agreement for both evidence-of-risk (kappa = 0.80, 95% CI: 0.67-0.94) and recommendation level (kappa = 0.64, 95% CI: 0.46-0.82), while Korea-Japan and Korea-US were in fair or moderate agreement. Label information in pregnancy was discrepant among the four countries. Discrepancies in labeling information among countries may cause confusion to patients and healthcare professionals alike. To better assist healthcare professionals and patients in the use of prescription drugs, global harmonization of safety information is needed to minimize confusion with potential risk.

Antibiotics Dispensed to Privately Insured Pregnant Women with Urinary Tract Infections — United States, 2014

Urinary tract infections (UTIs) occur in about 8% of pregnant women, and untreated UTIs can have serious consequences, including pyelonephritis, preterm labor, low birth weight, and sepsis (1). Pregnant women are typically screened for UTIs during early pregnancy, and those with bacteriuria are treated with antibiotics (1,2). Antibiotic stewardship is critical to improving patient safety and to combating antibiotic resistance. Because of the potential risk for birth defects, including anencephaly, heart defects, and orofacial clefts, associated with use of sulfonamides and nitrofurantoin during pregnancy (3), a 2011 committee opinion from the American College of Obstetricians and Gynecologists (ACOG) recommended that sulfonamides and nitrofurantoin may be prescribed in the first trimester of pregnancy only when other antimicrobial therapies are deemed clinically inappropriate (4). To assess the effects of these recommendations, CDC analyzed the Truven Health MarketScan Commercial Database* to examine antibiotic prescriptions filled by pregnant women with UTIs. Among 482,917 pregnancies in 2014, 7.2% of women had an outpatient UTI diagnosis during the 90 days before the date of last menstrual period (LMP) or during pregnancy. Among pregnant women with UTIs, the most frequently prescribed antibiotics during the first trimester were nitrofurantoin, ciprofloxacin, cephalexin, and trimethoprim-sulfamethoxazole. Given the potential risks associated with use of some of these antibiotics in early pregnancy and the potential for unrecognized pregnancy, women's health care providers should be familiar with the ACOG recommendations and consider the possibility of early pregnancy when treating women of reproductive age.

Estimating infertility prevalence in low-to-middle-income countries: an application of a current duration approach to Demographic and Health Survey data.

STUDY QUESTIONCan infertility prevalence be estimated using a current duration (CD) approach when applied to nationally representative Demographic and Health Survey (DHS) data collected routinely in low- or middle-income countries?SUMMARY ANSWEROur analysis suggests that a CD approach applied to DHS data from Nigeria provides infertility prevalence estimates comparable to other smaller studies in the same region.WHAT IS KNOWN ALREADYDespite associations with serious negative health, social and economic outcomes, infertility in developing countries is a marginalized issue in sexual and reproductive health. Obtaining reliable, nationally representative prevalence estimates is critical to address the issue, but methodological and resource challenges have impeded this goal.STUDY DESIGN, SIZE, DURATIONThis cross-sectional study was based on standard information available in the DHS core questionnaire and data sets, which are collected routinely among participating low-to-middle-income countries. Our research question was examined among women participating in the 2013 Nigeria DHS (n = 38 948). Among women eligible for the study, 98% were interviewed.PARTICIPANTS/MATERIALS, SETTING, METHODSWe applied a CD approach (i.e. current length of time-at-risk of pregnancy) to estimate time-to-pregnancy (TTP) and 12-month infertility prevalence among women ‘at risk’ of pregnancy at the time of interview (n = 7063). Women who were 18–44 years old, married or cohabitating, sexually active within the past 4 weeks and not currently using contraception (and had not been sterilized) were included in the analysis. Estimates were based on parametric survival methods using bootstrap methods (500 bootstrap replicates) to obtain 95% CIs.MAIN RESULTS AND THE ROLE OF CHANCEThe estimated median TTP among couples at risk of pregnancy was 5.1 months (95% CI: 4.2–6.3). The estimated percentage of infertile couples was 31.1% (95% CI: 27.9–34.7%)—consistent with other smaller studies from Nigeria. Primary infertility (17.4%, 95% CI: 12.9–23.8%) was substantially lower than secondary infertility (34.1%, 95% CI: 30.3–39.3%) in this population. Overall estimates for TTP >24 or >36 months dropped to 17.7% (95% CI: 15.7–20%) and 11.5% (95% CI: 10.2–13%), respectively. Subgroup analyses showed that estimates varied by age, coital frequency and fertility intentions, while being in a polygynous relationship showed minimal impact.LIMITATIONS, REASONS FOR CAUTIONThe CD approach may be limited by assumptions on when exposure to risk of pregnancy began and methodologic assumptions required for estimation, which may be less accurate for particular subgroups or populations. Unrecognized pregnancies may have also biased our findings; however, we attempted to address this in our exclusion criteria. Limiting to married/cohabiting couples may have excluded women who are no longer in a relationship after being blamed for infertility. Although probably rare in this setting, we lack information on couples undergoing infertility treatment. Like other TTP measurement approaches, pregnancies resulting from contraceptive failure are not included, which may bias estimates.WIDER IMPLICATIONS OF THE FINDINGSNationally representative estimates of TTP and infertility based on a clinical definition of 12 months have been limited within developing countries. This approach represents a pragmatic advance in our ability to measure and monitor infertility in the developing world, with potentially far-reaching implications for policies and programs intended to address reproductive health.STUDY FUNDING/COMPETING INTERESTSThere are no competing interests and no financial support was provided for this study. Financial support for Open Access publication was provided by the World Health Organization.

Fetus dose estimation in thyroid cancer post-surgical radioiodine therapy.

Unrecognised pregnancy during radioisotope therapy of thyroid cancer results in hardly definable embryo/fetus exposures, particularly when the thyroid gland is already removed. Sources of such difficulty include uncertainty in data like pregnancy commencing time, amount and distribution of metastasized thyroid cells in body, effect of the thyroidectomy on the fetus dose coefficient etc. Despite all these uncertainties, estimation of the order of the fetus dose in most cases is enough for medical and legal decision-making purposes. A model for adapting the dose coefficients recommended by the well-known methods to the problem of fetus dose assessment in athyrotic patients is proposed. The model defines a correction factor for the problem and ensures that the fetus dose in athyrotic pregnant patients is less than the normal patients. A case of pregnant patient undergone post-surgical therapy by I-131 is then studied for quantitative comparison of the methods. The results draw a range for the fetus dose in athyrotic patients using the derived factor. This reduces the concerns on under- or over-estimation of the embryo/fetus dose and is helpful for personal and/or legal decision-making on abortion.

Pregnant Bodies in Social Context: Natural, Disruptive, and Unrecognized Pregnancy

This article examines the role of social context in the construction of meanings attached to the pregnant body. Analyzing interviews with 42 women who, during the time of the interview, were either pregnant or had given birth to a child within the last 12 months, I explore (1) the role of social context in assigning social value to the pregnant body; and (2) how the meaning attached to pregnancy changes as pregnant women move from one social context to another. I suggest that the role of social context is central to our understanding of how pregnant women are perceived and evaluated by others.

Challenges in defining and classifying the preterm birth syndrome

In 2009, the Global Alliance to Prevent Prematurity and Stillbirth Conference charged the authors to propose a new comprehensive, consistent, and uniform classification system for preterm birth. This first article reviews issues related to measurement of gestational age, clinical vs etiologic phenotypes, inclusion vs exclusion of multifetal and stillborn infants, and separation vs combination of pathways to preterm birth. The second article proposes answers to the questions raised here, and the third demonstrates how the proposed system might work in practice.

A case of unrecognized pregnancy during chemotherapy in non-small cell lung cancer patient

807 A CASE OF UNRECOGNIZED PREGNANCY DURING CHEMOTHERAPY IN NON-SMALL CELL LUNG CANCER PATIENT Jee Yoon Park, MD, Jeong Woo Park, MD, Dong Ock Lee, MD, Chan-Wook Park, MD, PhD, Joong Shin Park, MD, PhD, Jong Kwan Jun, MD, PhD, Hee Chul Syn, MD, PhD Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul; Center for Uterine Cancer, National Cancer Center, Goyang, Korea

One-Year Experience with Day-of-Surgery Pregnancy Testing Before Elective Orthopedic Procedures

Elective surgery is generally postponed in pregnancy. A policy of testing for urine human chorionic gonadotropin (hCG) in all women of childbearing age on the day of surgery was initiated at an elective orthopedic surgery facility. This is a retrospective report of our 1 yr experience and the associated costs. Records were reviewed from January 3, 2005, through January 2, 2006, to determine the number of urine hCG tests performed, and the disposition of all patients with a positive result. Costs were calculated using the charges for testing supplies and laboratory labor. During the first year of policy implementation, 2588 of 2595 women of childbearing age underwent urine hCG testing. Five patients had a positive result, and surgery was cancelled. Of these five, three were previously unrecognized pregnancies, one an unrecognized asymptomatic ectopic pregnancy, and one a false-positive result in a perimenopausal woman. Three other women had a "weak positive" urine result, followed by a negative serum hCG. Surgery proceeded in all three. The calculated cost was $5.03 per urine test, and $3273 for each true positive result. A policy of routinely performing urine hCG pregnancy tests in women of childbearing age on the day of surgery was effective in detecting unrecognized pregnancy. This resulted in a postponement of elective surgery in all cases. Of 2588 women tested, one had surgery postponed because of a false-positive result. The cost of $3273 per true positive test must be compared with the benefit.

Congenital Atresia of the Fallopian Tube

A 36-year-old woman was brought into the operating room for tubal sterilization. During laparoscopy, the proximal portion of the left fallopian tube could not be identified (Figure 1). The fimbria and the distal ampullary portion were found attached to the left pelvic sidewall near the pelvic brim (Figure 2). These structures were resected, and histological examination confirmed that they were a segment of the fallopian tube. The uterus, right fallopian tube, and both ovaries appeared normal. Right tubal coagulation was performed. Hysterosalpingography performed two months later showed a unicornuate right uterine cavity with no dye entering the left fallopian tube, supporting the impression of atresia. The patient had no history of pelvic surgery except for Caesarean section performed three years earlier. The operative report did not describe any abnormality. Atresia of the fallopian tube can be congenital or acquired (because of unrecognized torsion or ectopic pregnancy). The presence of associated uterine anomaly in this patient indicated that her tubal atresia was presumably congenital in origin.

Erlotinib administration for advanced non-small cell lung cancer during the first 2 months of unrecognized pregnancy

Although several antineoplastic agents have been proven to be safe for the fetus after the organogenesis period, there is limited information on their use during the first trimester of pregnancy. Herein we report the first case of a patient with metastatic lung cancer treated with erlotinib during the first 2 months of an unrecognized pregnancy. A 30-year-old woman was diagnosed with stage IV non-small cell lung cancer with bone and lung metastasis. The patient received 4 months of palliative cisplatin/gemcitabine chemotherapy and biphosphonates. After 12 months the disease progressed and the patient received erlotinib 100 mg/day. During this period the patient became pregnant. Since she recalled the date of her last menstrual period at about 15 days prior to the start of the therapy, we did consider the possibility of conception at the time of the first day of erlotinib administration. Informed about the risk for the fetus due to erlotinib, the patient stopped anticancer treatment. After 42 weeks of regular gestation, cesarean section was performed, delivering a 3490 g female new-born with no evidence of congenital malformations. The disease evaluation performed with thoracic CT scan, after 1 month from the childbirth, showed a progressive lung metastasis and erlotinib treatment was resumed at the dose of 150 mg/day.

Docetaxel, gemcitabine, and cisplatin administered for non-small cell lung cancer during the first and second trimester of an unrecognized pregnancy

Although several chemotherapeutic agents have been proven to be safe for the fetus after the organogenesis period, there is limited information on their use during the first trimester of pregnancy. We here report the first case of a patient with lung cancer who was treated with platinum-based chemotherapy from the first trimester of an unrecognized pregnancy. A 35-year-old woman was diagnosed with stage IV non-small cell lung cancer with brain metastasis. Since she recalled the date of her last menstrual period at about 20 days prior to consult, we did not consider the possibility of conception at the time of diagnosis. With an object of controlling the increased intracranial pressure, we initially performed a craniotomy with tumor removal, followed by whole brain irradiation. Without our knowledge of her pregnancy, she received a palliative chemotherapy with docetaxel and cisplatin followed by gemcitabine and cisplatin as the second-line chemotherapeutic agents between weeks 9 and 22 of gestation. Follow-up computed tomographic scans performed 2 months after the last chemotherapy showed a fetus in the patient's abdomen. Cesarean section was performed at 33 weeks of gestation, delivering a 1490 g female newborn with no evidence of congenital malformations.

The Rationale for Banning Human Chorionic Gonadotropin and Estrogen Blockers in Sport

The objective of the study was to review the rationale underlying the banning of human chorionic gonadotropin (hCG) and estrogen blockers (antiestrogens, specific estrogen receptor modulators, aromatase inhibitors) in sports for male and female athletes in the light of gender differences in regulation of reproductive physiology. We reviewed well-controlled clinical studies of exogenous testosterone effects on human muscle size and strength in men and all available evidence relevant to the effects of hCG and estrogen blockers on blood testosterone in men and women. Well-designed placebo-controlled clinical studies in men with suppressed pituitary-testicular axis establish a strong case that, across a wide range from sub- to supraphysiological doses, muscle growth and strength is proportional to exogenous testosterone dose and resulting blood testosterone concentrations. In men, there is unequivocal evidence that hCG and estrogen blockers cause consistent and sustained rise in blood testosterone concentrations. In women, although there has been no direct testing of ergogenic or myotrophic properties of exogenous testosterone in healthy women, either hCG or estrogen blockers do not produce any consistent or biologically significant increase blood testosterone concentrations. In men undergoing potential stimulation of endogenous blood testosterone concentrations, blood testosterone concentration is a reasonable surrogate measure for muscle growth and increased strength in men. Because hCG and estrogen blockers produce marked increase in blood testosterone concentration in men, this provides strong evidence to support the banning of hCG and estrogen blockers in men. In women, however, the negligible effect on blood testosterone suggests that drug-induced performance enhancement by hCG or estrogen blockers is highly unlikely. Furthermore, routine urinary hCG testing in young women risks invasion of privacy by detecting unrecognized pregnancy. These considerations suggest that prohibition of hCG and estrogen blockers should be restricted to men in which they are well justified.