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One hundred sixteen cycles of human menopausal gonadotropin (hMG) treatment for ovulation induction were studied. The ovarian response to hMG treatment was monitored by the daily determination of serum estradiol (E2) or by daily serum E2 and repeated ultrasonic examination of the ovaries. There were more follicles 18 mm in diameter or larger at the time of human chorionic gonadotropin (hCG) administration in the pregnancy than in the non-pregnancy cycles, and in the hyperstimulated than in the nonhyperstimulated cycles. The ovulatory rate and the pregnancy rate per cycle did not improve with the use of ultrasound. The number of treatment cycles required to achieve pregnancy was less in patients who had ultrasonic examination of the ovarian follicles. These results suggest that ultrasonic examination of the ovarian follicle helps to reduce the number of hMG cycles required to achieve pregnancy. The development of multiple follicles results in more pregnancies. However, the use of ultrasound does not improve the pregnancy rate.

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Twenty-seven anovulatory women who had episode(s) of ovarian hyperstimulation during ovulation induction with hMG were studied. Twenty-nine of the total 89 treatment cycles were complicated by ovarian hyperstimulation. Twenty-four-hour urinary estrogen concentrations 3 days prior to hCG administration were significantly higher in the hyperstimulated (H) than in the nonhyperstimulated cycles (NH). Patients who had progesterone withdrawal bleeding (Group I) were more prone to be hyperstimulated in the first treatment cycle than patients who had no progesterone withdrawal bleeding (Group II). In all instances, the syndrome resolved spontaneously with time. The pregnancy rate of H was threefold NH. It is concluded that hyperstimulation in patients who had evidence of endogenous estrogen activity as demonstrated by progesterone withdrawal bleeding tend to occur in the first treatment cycle. Strict monitoring decreased the incidence of severe hyperstimulation. A minimal amount of hyperstimulation might be beneficial to improve the pregnancy rate.

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Ninety-three couples of which the female partner was over 36 years of age were studied. Tubal factor was the most common etiologic factor in the women aged 36 to 40 years, and unexplained infertility was the most common factor in the women over the age of 40. It appears that in the aging infertile population, the ovulatory factor is not the most important cause of infertility. The over-all pregnancy rate (33%) is lower and the abortion rate (31%) is increased with advancing age as compared with the general infertile population. The implication of aging as a cause of infertility is discussed.

PIP: 93 infertile couples with the female partner over age 36 were studied. Tubal factor was the most common etiologic factor in women ages 36-40 and unexplained infertility was the most common factor in women over age 40. It appears that in the aging infertile population, the ovulatory factor is not the most important cause of infertility. The overall pregnancy rate (33%) is lower and the abortion rate (31%) is increased with advancing age as compared with the general infertile population. The implication of aging as a cause of infertility is discussed.

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Twenty-three patients presenting with infertility were found to have uterine anomalies. Eighteen had primary infertility. Six (86%) of seven patients with arcuate uterus achieved a term pregnancy. Five patients of these seven had primary infertility. Of the 13 patients with bicornuate uterus, 6 subsequently underwent a metroplasty and 4 (67%) of these latter patients achieved a term pregnancy. Of the remaining seven patients with bicornuate uterus, one achieved pregnancy during investigations, one refused surgery, and five were not operated upon because of uncorrected nonuterine factors. One other patient was found to have uterus didelphys and two had a unicornuate uterus. No patients with septate uterus were found. The implications of a uterine anomaly as a cause of primary infertility are discussed.

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Serum prolactin and cortisol levels were measured in 24 patients entering the Royal Victoria Hospital infertility center both before and after a thorough physical examination that included a pelvic examination and a search for galactorrhea in both breasts. There was no significant change in the levels of prolactin or cortisol in the group as a whole in those with normal prolactin values and those with high basal prolactin values (P less than 0.05). The possible role of stress in the mediation of occasional elevation of basal prolactin values is discussed in relation to the serum cortisol levels.

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Thirty-one couples in whom the only apparent abnormality was polyspermia in the male partner were studied in light of a suggested new definition of polyspermia. The rate of infertility was 22.5% versus 17.6% in a control group of couples with no apparent abnormalities; the difference was not statistically significant. The spontaneous abortion rate was 25.5% versus 9.7% in the controls (P less than 0.05). Semen analysis of the men showed signifcantly low fructose levels and high percentages of necrospermia and agglutination compared to controls. Various hypotheses for the etiology of polyspermia are discussed.

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A simplified technique for hysterosalpingography, based on over 5,000 studies, is described. This method is quickly and easily performed. Patient acceptance is high.

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This is a case report of 47,X,i(Xq),Y in a 24-year-old infertile male with Klinefelter's syndrome. C staining indicated that this isochromosome X had a single small centromere. BUdR incorporation revealed the isochromosome X to be late replicating.

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Human menopausal gonadotrophins (HMG) were used together with human chorionic gonadotrophin (HCG) in 19 women and 39 treatment cycles in an attempt to induce ovulation. Daily 24 hours urinary total estrogen excretion rates were measured and HMG daily dosage was varied according to levels obtained. HCG injections were timed to coincide with an estimated urinary total estrogen excretion rate of 100-150 g per 24 hours. Thirty-one ovulatory cycles occurred (79%) and there were nine pregnancies (23%) of which five were multiple. Eleven cycles were complicated by hyperstimulation (25.6%) of which six were severe. The variable HMG dosage regimen was found to offer no advantages when compared with our standard daily dosage regimen. A rapid rise of estrogen excretion occurred in over 80% of hyperstimulation cycles, including all severe ones, and it was found that this rise could occur after the last dosage of HMG had been given. Because of this, it is proposed that HCG injections be delayed until 48 hours after the last injection of HMG. The finding of a value for the last available 24 hour urinary total estrogen excretion of less than 150 microgram can be taken as an indicator that hyperstimulation is unlikely to occur, and that HCG can safely be given. No indication was found that such a procedure would diminish ovulation or pregnancy rates.

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