Vagina Of Women Research Articles

Mayer-Rokitansky-Kuster-Hauser Syndrome

The Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is characterized by congenital aplasia of the uterus and the upper part (2/3) of the vagina in women showing normal development of secondary sexual characteristics and a normal 46, XX karyotype. It affects at least one out of 4,500 women. MRKH may be isolated (type I) but it is more frequently associated with renal, vertebral and, to a lesser extent, auditory and cardiac defects (MRKH type II or MURCS association). The first sign of MRKH syndrome is a primary amenorrhea in young women presenting otherwise with normal development of secondary sexual characteristics and normal external genitalia, with normal and functional ovaries, and karyotype 46, XX without visible chromosomal anomaly. The phenotypic manifestations of MRKH syndrome overlap with various other syndromes or associations and thus require accurate delineation. For a long time, the syndrome has been considered as a sporadic anomaly, but increasing number of familial cases now supports the hypothesis of a genetic cause. In familial cases, the syndrome appears to be transmitted as an autosomal dominant trait with incomplete penetrance and variable expressivity. This suggests that the involvement of either mutations in a major developmental gene or a limited chromosomal imbalance. However, the etiology of MRKH syndrome still remains unclear. Treatment of vaginal aplasia, which consists in creation of a neovagina, can be offered to allow sexual intercourse. As psychological distress is very important in young women with MRKH, it is essential for the patients and their families to attend counseling before and throughout treatment.

A Walk to Beautiful (review)

A Walk to Beautiful (2007) Directed by Mary Olive Smith and Amy Bucher Engel Entertainment (85-minute version), walktobeautiful.com PBS / NOVA (54-minute version), pbs.org/wgbh/nova/beautiful/ Obstetric fistulas remain largely unknown to women living in Western Europe, Canada, and the United States, where medical care or other professional assistance such as midwives is available to women before, during, and after childbirth. In parts of the world where medical care remains unavailable, however, this problem is much more common. Obstetric fistulas develop during obstructed childbirth, when a baby's larger head exerts pressure on a woman's smaller pelvis, cutting off the blood supply and damaging tissues. In obstructed childbirth, women without access to regular medical care endure labor for ten days, with the baby dying in the process. As the damaged internal tissues die, they leave behind holes called fistulas. These fistulas often occur between a woman's bladder and vagina or between a woman's vagina and rectum, resulting in permanent incontinence of urine, feces, or both. In addition to the health problems fistulas create, these women endure public shunning from their spouses and families, and personal humiliation. But this traumatic condition can be resolved in part through surgery and education, at least according to Mary Olive Smith and Amy Bucher's documentary A Walk to Beautiful. The 54-minute NOVA version chronicles the journey from shame to dignity for three Ethiopian women suffering from obstetric fistulas. Ayehu is 25. She lost her child in childbirth, and her husband left her after the incontinence began. Ayehu also suffers embarrassment because her own mother refuses to allow her in the house because people might come visit. As a result Ayehu sleeps in a makeshift hut attached to the back of the main house. Ayehu talks openly about wanting to die, and her situation seems hopeless until her friend, Fikre, suggests she take the journey to the Addis Ababa Fistula Hospital. The journey requires several hours of walking and bus riding, but Fikre claims the trip changed her life. The hospital offers hope fora normal life for Ayehu and other fistula sufferers. Smith and Bucher show the hospital as an oasis, with helpful staff and beautiful grounds. Fistula surgeon Dr. Ambaye Woldemichael explains that just in coming to the hospital, fistula sufferers begin healing because they realize they are not alone. Along with counseling and surgery, the women receive education about their condition's causes and preventions. Women recovering successfully from the surgery also receive new clothes and bus fare home. Along with Ayehu, two other women seek help at the hospital. Twenty-yearold Almaz suffers a double fistula, and she undergoes surgery to correct the problem. Seventeen-year-old Wubete is returning to the hospital for the third time because previous surgeries failed to fix her problem. …

Utero-vaginal aplasia (Mayer-Rokitansky-Küster-Hauser syndrome) associated with deletions in known DiGeorge or DiGeorge-like loci

BackgroundMayer-Rokitansky-Küster-Hauser (MRKH) syndrome is characterized by congenital aplasia of the uterus and the upper part of the vagina in women showing normal development of secondary sexual characteristics and a normal 46, XX karyotype. The uterovaginal aplasia is either isolated (type I) or more frequently associated with other malformations (type II or Müllerian Renal Cervico-thoracic Somite (MURCS) association), some of which belong to the malformation spectrum of DiGeorge phenotype (DGS). Its etiology remains poorly understood. Thus the phenotypic manifestations of MRKH and DGS overlap suggesting a possible genetic link. This would potentially have clinical consequences.MethodsWe searched DiGeorge critical chromosomal regions for chromosomal anomalies in a cohort of 57 subjects with uterovaginal aplasia (55 women and 2 aborted fetuses). For this candidate locus approach, we used a multiplex ligation-dependent probe amplification (MLPA) assay based on a kit designed for investigation of the chromosomal regions known to be involved in DGS.The deletions detected were validated by Duplex PCR/liquid chromatography (DP/LC) and/or array-CGH analysis.ResultsWe found deletions in four probands within the four chromosomal loci 4q34-qter, 8p23.1, 10p14 and 22q11.2 implicated in almost all cases of DGS syndrome.ConclusionUterovaginal aplasia appears to be an additional feature of the broad spectrum of the DGS phenotype. The DiGeorge critical chromosomal regions may be candidate loci for a subset of MRKH syndrome (MURCS association) individuals. However, the genes mapping at the sites of these deletions involved in uterovaginal anomalies remain to be determined. These findings have consequences for clinical investigations, the care of patients and their relatives, and genetic counseling.

PP-238. Study of common pathogenic microbes which are present in the vagina of women of reproductive age

PP-238. Study of common pathogenic microbes which are present in the vagina of women of reproductive age

Alteration of Vaginal Elastin Metabolism in Women With Pelvic Organ Prolapse

To compare elastin metabolism in the vagina of women with and without pelvic organ prolapse and to define the regulation of this process by hormone therapy (HT). Eighty-seven histologically confirmed full-thickness vaginal biopsies were procured from study participants at time of surgery. Premenopausal women with no prolapse served as controls. Women with prolapse were divided into three groups: premenopausal, postmenopausal not on HT, and postmenopausal on HT. The epithelium was excised leaving the subepithelium, muscularis, and adventitia for analyses. The elastin precursor, tropoelastin, was measured by immunoblotting and mature elastin protein via a desmosine cross-link radioimmunoassay. Matrix metalloproteinases (MMPs)-2 and -9 were quantitated by gelatin zymography. Data were analyzed using Kruskal-Wallis test and post hoc analysis using the Mann-Whitney U test. Tropoelastin (432%), mature elastin (55%), proMMP-9 (90%), and active MMP-9 (106%) were increased in women with prolapse relative to those in the control group while active MMP-2 (41%) was decreased. Comparison of tropoelastin and mature elastin values obtained from the same women showed them to be independently regulated (r=0.19). Interestingly, the highest amount of both proteins occurred in postmenopausal patients not on HT. Elastin metabolism is altered in the vagina of women with prolapse relative to those in the control group, suggesting that vaginal tissue is rapidly remodeling in response to mechanical stretch. We found that elastin levels are highest in the absence of hormones.

Mayer-Rokitansky-Kuster-Hauser syndrome: Surgical management of two cases

The Mayer-Rokitansky-Kuster-Hauser (MRKH) Syndrome is a rare anomaly characterized by congenital aplasia of the uterus and vagina in women showing normal development of secondary sexual characters and normal 44 XX karyotype. We report our experience in the management of two patients with congenital absence of the vagina due to the MRKH syndrome. The first case was a 24-year-old student, who presented with primary amenorrhea, uterovaginal agenesis, right pelvi-ureteric junction obstruction, and left renal agenesis. The second patient was a 24-year-old housewife, who presented with primary amenorrhea and inability to achieve penetrative sexual intercourse. She had vaginal atresia and a grossly hypoplastic uterus. Both had successful sigmoid colovaginoplasty and are sexually active. Vaginal reconstruction using the sigmoid colon saw an immediate and satisfactory outcome in both patients

Comparison of main lactobacillus species between healthy women and women with bacterial vaginosis

Background The normal microbial flora of the vagina plays an important role in preventing genital and urinary tract infections in women. Thus an accurate understanding of the composition and ecology of the ecosystem is important to understanding the etiology of these diseases. This study aimed to compare the characteristics of main lactobacillus species between healthy women and women with bacterial vaginosis (BV) by quantitative culture and PCR methods. Main lactobacillus species include L. crispatus, L. gasseri, L. jensenii and L. iners. Methods A total of 150 Women attending Gynecology Outpatient Clinic of Beijing Friendship Hospital, were diagnosed as having BV because three or more of the following criteria were met (standard of Amsel's composite criteria): homogeneous discharge, elevated vaginal pH (pH >4.5), production of amines, and presence of “clue” cells. Those with less than three of the criteria were considered as healthy. Simultaneously, smears were made of vaginal fluid and Gram stained, then were assessed qualitatively as normal (grade I), intermediate (grade II), or consistent with BV (grade III). Gardnerella vaginalis were identified by using Vitek 2 Compact and PCR methods. Lactobacillus species were identified by PCR methods. Gardnerella vaginalis and lactobacilli colony counts were determined by calculating the most number of colonies of each species in the appropriate plates (colonies between 10 and 300), corrected by the dilution of the sample in the plates, and multiplied by 10 (to account for plating 100 μl), in order to get colony forming units per milliliter of vaginal secretion. Results BV was diagnosed in 31% (46/150) patients using the composite criteria, the remainder being regarded as healthy. The majority of patients with BV had a smear assessed as grade III (91%, 42/46) and minority of them had a smear assessed as grade II (9%, 4/46). The majority of healthy women had a smear assessed as grade I (64%, 67/104). Smears assessed as grade II were found (36%, 37/104) among patients diagnosed as healthy, with less than three of the composite criteria. L. crispatus was cultured from 94% of healthy women and 83% of women with BV, with the former colonies count average value of 106 and the latter of 103. L. gasseri, L. iners, and L. jensenii were cultured from 85%, 68% and 43% of healthy women; and 28%, 89% and 44% of BV women, respectively. Conclusions The quantities of four lactobacillus species except L. jensenii had a significant difference between healthy women and women with BV. Our results provide support for the negative association between L. iners and L. gasseri. Although L. crispatus were existent both in healthy and BV positive women's vagina, the numbers of L. crispatus were significantly different for the dominant number in healthy women. Smears of vaginal fluid and Gram stain play an important guiding role in bacteria culture.

Preliminary characterization of vaginal microbiota in healthy Chinese women using cultivation‐independent methods

The normal microbiota plays an important role in maintaining the vaginal health of women. The aim of this study was to characterize the numerically dominant populations of vaginal microbial communities in Chinese women. Genomic DNA was isolated from samples of vaginal swabs of five healthy women, 16S ribosomal ribonucleic acid libraries were constructed and the sequences of 300 clones from each library were determined and subjected to phylogenetic analyses. The phylotypes were classified based on sequence similarity to known organisms. All vaginal microbial communities were dominated by the Lactobacillus species, and they constituted from 96.4% to 100% of the clones sequenced. Sequences homologous to L. crispatus and L. iners were most common, which were highly homologous with those of Caucasian women in the USA. The numerically dominant microbial populations in healthy Chinese women's vaginas were L. crispatus and L. iners. The limited number of Lactobacillus phylotypes found in the human vagina suggested that host factors have a role in the selection of specific organisms, which have specific characteristics that allow them to successfully colonize the vagina.

Caldesmon expression is decreased in women with anterior vaginal wall prolapse: a pilot study

The purpose of this study is to compare vaginal caldesmon expression in women with and without anterior vaginal wall prolapse. Vaginal tissues were sampled in women with (n = 11) or without (n = 11) vaginal wall prolapse. Caldesmon messenger RNA (mRNA) expression was assessed by quantitative real-time polymerase chain reaction. Immunohistochemistry and digital image analysis were used to determine caldesmon protein expression in the histologic sections. There were no significant differences in demographic data between the two groups. Caldesmon mRNA expression was significantly decreased in the vaginal tissue from women with anterior vaginal wall prolapse compared to women without prolapse [(caldesmon mean +/- SD mRNA expression in relative units) 0.03 +/- 0.03 vs 0.17 +/- 0.17, P = 0.02]. The fractional area of nonvascular caldesmon staining in the vagina of women with anterior vaginal wall prolapse was significantly decreased compared to women without prolapse [mean +/- SD (0.09 +/- 0.04 vs 0.16 +/- 0.09, P = 0.03)]. Vaginal caldesmon expression is significantly decreased in women with anterior vaginal wall prolapse compared to normal subjects.

Coexistence of pituitary macroadenoma and Mayer-Rokitansky-Küstner-Hauser syndrome

The Mayer-Rokitansky-Küstner-Hauser (MRKH) syndrome is characterized by congenital aplasia of the uterus and upper part (2/3) of the vagina in women showing normal development of secondary sexual characteristics with a normal 46, XX karyotype. We report a case of a 30-year-old woman who presented with complaints of headache. Pituitary macroadenoma and MRKH syndrome were diagnosed. To the best of our knowledge, pituitary macroadenoma has not been reported in association with MRKH syndrome. However, no genetic links between MRKH syndrome and pituitary macroadenoma have been observed. Thus, the association may be incidental rather than causal.

ORIGINAL ARTICLE: Prenatal Priming of Cord Blood T Lymphocytes by Microbiota in the Maternal Vagina

Problem In the vagina of women at the reproductive age, more than 170 strains of bacteria and yeasts are found. The effect of vaginal flora on neonatal T cells is yet to be investigated.Method of study We analyzed CD45RA and CD45RO expression on neonatal CD4+ T cells and cytokine production in CBMC cultures (interferon‐γ (IFN‐γ ), interleukin‐4 (IL‐4) and IL‐12) related to vaginal bacteria isolated from a maternal vagina. We collected vaginal swabs from 36 women at the first stage of the delivery and cord blood from their newborns. IFN‐γ, IL‐4, and IL‐12 in stimulated CBMC were measured and the expression of CD45RA/CD45RO on CD4+ T cells was assessed.Results We noted the difference in CD45RO CD4+ expression and IL‐12 levels between the newborns whose mothers were or were not colonized with Lactobacillus in the vagina (newborns whose mothers were colonized with Lactobacillus: CD45RO‐10%±3; IL‐12‐0.2 pg/mL ± 0.05; newborns whose mothers were not colonized with Lactobacillus: CD45RO‐6%±3; IL‐12‐2.0 pg/mL ± 0.7).Conclusion Our results may indicate that lactobacilli in maternal vagina influence the development of neonatal immune system. Yet, more research is needed using specified bacterial antigens.

The relationship between superior attachment points for anterior wall mesh operations and the upper vagina using a 3-dimensional magnetic resonance model in women with normal support

We examined structural relationships between anterior mesh kit suspension points and the upper vagina in women with normal support. Eleven women with normal support underwent supine, multiplanar magnetic resonance pelvic imaging at rest and maximal Valsalva. Using 3-dimensional models generated from these images, anterior wall mesh kit anchoring points were identified along the arcus tendineus fascia pelvis. We then measured the percentage of anterior vagina above and posterior to superior suspension points. The anterior vagina extended above superior attachment points in 100% of women at rest and in 73% during Valsalva. It extended posterior to them in 82% and 100% (rest and Valsalva, respectively). The mean percentage of anterior vaginal length above superior anchoring sites was 40 +/- 14% at rest and 29 +/- 12% during Valsalva. The upper vagina lies above and posterior to superior suspension points in the majority of women with normal support.

Maternal–Infant Perinatal Transmission of Methicillin-Resistant and Methicillin-SensitiveStaphylococcus aureus

Because of the increasing importance of Staphylococcus aureus (SA), including methicillin-resistant SA (MRSA) in serious neonatal infections, we studied the contribution of perinatal maternal-infant transmission of SA to the colonization and infection of newborn infants. Cultures for SA, including MRSA, were obtained from nares and vagina of women in labor at term. Each mother's infant, if delivered vaginally, was cultured from nares and skin at delivery and again after 48 hours (at discharge). All MRSA and selected SA isolates were studied by pulsed field gel electrophoresis (PFGE). Infants were monitored after discharge for staphylococcal infection for 4 weeks. Of 304 women completing the study, 43 were colonized with SA, and 9/43 had MRSA. Of 252 evaluable infants, 25 were colonized with SA, and 9/25 had MRSA. Six of 252 mother-infant pairs were concordant for SA colonization, and one of these for MRSA. Isolates from five of these six infants were indistinguishable from their mother's isolates by PFGE, including the pair with MRSA. One SA-colonized infant and four noncolonized infants subsequently developed staphylococcal infections during the monitoring period. About 20% of SA isolates in this maternal population were MRSA. Perinatal maternal-infant transmission accounted for 20% of instances of perinatal colonization of infants with SA. Molecular confirmation of perinatal maternal-infant transmission of MRSA was first documented. In this population of term infants, most SA infections in the first 4 weeks of life appeared to result from colonization that occurred after discharge from the nursery.

Antagonistic Potential against Pathogenic Microorganisms and Hydrogen Peroxide Production of Indigenous Lactobacilli Isolated from Vagina of Chinese Pregnant Women

To investigate the indigenous lactobacilli from the vagina of pregnant women and to screen the isolates with antagonistic potential against pathogenic microorganisms. The strains were isolated from pregnant women's vagina and identified using the API50CH system. The ability of the isolates to produce hydrogen peroxide was analyzed semi-quantitatively using the TMB-HRP-MRS agar. The antagonistic effects of the isolates on pathogenic microorganisms were determined with a double layer agar plate. One hundred and three lactobacilli strains were isolated from 60 samples of vaginal secretion from healthy pregnant women. Among them, 78 strains could produce hydrogen peroxide, in which 68%, 80%, 80%, and 88% had antagonistic effects against Candida albicans CMCC98001, Staphylococcus aureus CMCC26003, Escherichia coli CMCC44113, and Pseudomonas aeruginosa CMCC10110, respectively. The recovery of hydrogen peroxide-producing lactobacilli decreases with the increasing pregnant age and time. The most commonly isolated species from vagina of Chinese pregnant women are Lactobacillus acidophilus and Lactobacillus crispatus. Most of L. acidophilus and L. crispatus produce a high H2O2 level.

Vaginal smooth muscle cell apoptosis is increased in women with pelvic organ prolapse

To compare the smooth muscle content and apoptosis of the vagina in women with and without anterior vaginal wall prolapse. Vaginal tissues were sampled in women with (n = 6) or without (n = 6) anterior vaginal wall prolapse undergoing hysterectomy. Smooth muscle of the vagina was studied by immunohistochemistry. Digital image analysis was used to determine the fractional area of smooth muscle in the histologic cross-sections. Apoptosis was assessed by TUNEL assay. The fractional area of non-vascular smooth muscle in the vagina of women with anterior vaginal wall prolapse was significantly decreased compared to women without prolapse (0.36 +/- 0.12 vs. 0.16 +/- 0.12 P = 0.021) and the apoptotic index was significantly higher compared to women without prolapse (0.04 +/- 0.01 vs. 0.02 +/- 0.03, P = 0.041). The fraction of smooth muscle in the vagina is significantly decreased and the rate of apoptosis is higher in women with anterior vaginal wall prolapse compared to women without prolapse.

Comparación de medios de cultivos y procedimientos para detectar colonización por Streptococcus agalactiae en mujeres embarazadas

Detection of Streptococcus agalactiae in pregnant women's vagina and rectum and intrapartum antibiotic prophylaxis administered to colonized women are currently recommended to prevent neonatal precocious infections by this organism. In turn, it is very important to select the culture media and adequate sample collection site for S. agalactiae detection in colonized women. To standardize this methods in laboratory, different culture media and procedures for S. agalactiae recovery in pregnant women with obstetric and gynecologic complications were compared. Vaginorectal and endocervical swab specimens were collected from 60 pregnant women. The first sample was placed onto selective Columbia blood agar directly and onto selective Todd-Hewitt broth incubated at 37 degrees C and subcultured onto selective Columbia blood agar at 4 and 18 hours. The second sample was cultured on selective Columbia blood agar. Both culture media were incubated in a microaerophilic atmosphere at 37 degrees C from 24 to 48 hours. S. agalactiae was identified using conventional tests. 21 patients colonized with S. agalactiae were detected using vaginoanorectal samples. 19 (31.7%) patients tested positive for S. agalactiae through the culture of specimens directly onto selective Columbia blood agar; 21 (35%) and 20 (33%) patients were found to be positive for S. agalactiae by the selective Todd-Hewitt broth at 4 and 18 hours, respectively. Only one patient tested positive for S. agalactiae in the endocervical tract. The results show that the three procedures followed for S. agalactiae recovery are effective. Nevertheless, the procedure in which the sample was placed directly onto selective Columbia blood agar permits reducing costs and the time for bacteria identification. On the other hand, the vaginoanorectal swab was the best sample to detect colonization by S. agalactiae in pregnant women.

A Case of Mayer-Rokitansky-Küster-Hauser Syndrome

The Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is characterized by congenital aplasia of the uterus and the upper part (2/3) of the vagina in women showing normal development of secondary sexual characteristics and a normal 46, XX karyotype. It affects at least 1 out of 4500 women. MRKH may be isolated (type I) but it is more frequently associated with renal, vertebral, and, to a lesser extent, auditory and cardiac defects (MRKH type II or MURCS association). The first sign of MRKH syndrome is a primary amenorrhea in young women. It is usually with normal development of secondary sexual characteristics and normal external genitalia, with normal and functional ovaries, and karyotype 46, XX without visible chromosomal anomaly. The phenotypic manifestations of MRKH syndrome overlap with various other syndromes. Treatment of vaginal aplasia is creation of a neovagina to allow sexual intercourse. Psychological distress is very important in young women with MRKH, so counseling before and throughout the treatment is essential.A case of Mayer-Rokitansky-Küster-Hauser syndrome is reviewed with brief literature.

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome

The Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is characterized by congenital aplasia of the uterus and the upper part (2/3) of the vagina in women showing normal development of secondary sexual characteristics and a normal 46, XX karyotype. It affects at least 1 out of 4500 women. MRKH may be isolated (type I) but it is more frequently associated with renal, vertebral, and, to a lesser extent, auditory and cardiac defects (MRKH type II or MURCS association). The first sign of MRKH syndrome is a primary amenorrhea in young women presenting otherwise with normal development of secondary sexual characteristics and normal external genitalia, with normal and functional ovaries, and karyotype 46, XX without visible chromosomal anomaly. The phenotypic manifestations of MRKH syndrome overlap with various other syndromes or associations and thus require accurate delineation. For a long time the syndrome has been considered as a sporadic anomaly, but increasing number of familial cases now support the hypothesis of a genetic cause. In familial cases, the syndrome appears to be transmitted as an autosomal dominant trait with incomplete penetrance and variable expressivity. This suggests the involvement of either mutations in a major developmental gene or a limited chromosomal imbalance. However, the etiology of MRKH syndrome still remains unclear. Treatment of vaginal aplasia, which consists in creation of a neovagina, can be offered to allow sexual intercourse. As psychological distress is very important in young women with MRKH, it is essential for the patients and their families to attend counseling before and throughout treatment.

Sound of a woman: drums, gender, and myth among the asabano of papua new guinea

ABSTRACTPrior to their conversion to Christianity, Asabano boys and women were forbidden to play drums, lest they become aroused and promiscuous. The origin myth of the drum, revealed during male initiations, identifies its sound as that which emanates from a woman's vagina during sex. Therefore, to play the drum is to have sex on a mythological-symbolic level. Boys married only after hearing this myth and drumming in an all-night public celebration. Initiates knew the secret significance of their performance, providing them with a sense of manly security and power. To women who listened and danced, the celebration displayed handsomely presented, marriageable young men. In 1994–5, Christian rhetoric held that prohibiting women from drumming belongs to the Satanic past. Yet, while initiations were no longer held, the drum still figured prominently in celebrations, played only by men. By 2005, both sexes drummed during Baptist church services symbolizing universal access to God's bounty, but outside of church drum making and leadership in performance remained a male activity. In spite of the loss of a religious ideology of male secret knowledge, masculine gender identity retained its strength in part through the continued practice of male drumming.

Cost-effective approaches to in vitro fertilization: Means to improve access

Many childless couples would like to have access to in vitro fertilization (IVF) through public-sector programs, but such programs are scant because of the high costs that IVF entails today. A solution for health departments worldwide might be to leave IVF methods requiring expensive equipment and ovarian stimulating hormones — such as human recombinant gonadotropins, plus gonadotropin-releasing hormone analogues to prevent a surge of luteinizing hormone — to the private sector. Rather, health departments could focus on methods using less equipment and no ovarian stimulating agent at all if possible. If not possible, inexpensive clomiphene citrate could be used, combined with human menopausal gonadotropin if needed. Before embryo transfer, oocyte maturation could occur in vitro or in a makeshift incubator: a tube closed, wrapped, and left in the woman's vagina for 24 h. To prevent short- and long-term costs as well as possible lifelong problems, the transfer of multiple embryos should not be performed.