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AIM: To assess the effects of vision screening, and subsequent management of visual impairment, on visual acuity and vision-related quality of life among frail older people. DESIGN: Randomised controlled trial. SETTING: Community in Sydney, Australia. PARTICIPANTS: 616 men and women aged 70 years and over (mean age 81 years) recruited mainly from people attending outpatient aged care services. CONTROL: No vision assessment or intervention INTERVENTIONS: Comprehensive vision and eye examinations conducted by an optometrist. Three hundred subjects were seen by the study optometrist, with 146 judged to need treatment for a vision or eye problem. The optometrist arranged new glasses for 92 subjects; 24 were referred for a home visit by an occupational therapist; 17 were referred for glaucoma management; and 15 were referred for cataract surgery. MAIN OUTCOME MEASURE: Distance and near visual acuity (logMAR) and composite scores on the 25-item version of the National Eye Institute Visual Function Questionnaire, both assessed at a 12-month follow-up home visit. RESULTS: After 12 months' follow-up, the mean (logMAR) distance visual acuity was 0.27 in the intervention group and 0.25 in the control group (p = 0.32). The mean (logMAR) near visual acuities were -0.01 in the intervention group and -0.03 in the control group (p = 0.26). The mean composite score on the National Eye Institute Visual Function Questionnaire was 84.3 in the intervention group and 86.4 in the control group (p = 0.49). CONCLUSIONS: Vision screening by an optometrist for frail older people living in the community in Australia does not lead to improvements in vision or vision-related quality of life after 1 year's follow-up.

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The bioactivity of prolactin (PRL) in follicular fluid (FF) obtained from mature preovulatory follicles was measured by the Nb2 lymphoma-cell bioassay and compared with the immunoreactivity as measured by radioimmunoassay (RIA-PRL). There was a good correlation between the two assay systems (P less than 0.01), and when RIA-PRL was more than 25 ng/ml, both assay systems yielded comparable values, with a mean bioassay/RIA ratio of 1.06 +/- 0.03; however, when RIA-PRL was 25 ng/ml or less, a discrepancy between the two assay systems was evident, with a bioassay/RIA ratio of 1.55 +/- 0.15. The estradiol (E2) concentration of FF obtained from follicles that contained oocytes which were subsequently fertilized was greater than that in follicles containing oocytes which were not fertilized: 588 +/- 62 vs 376 +/- 37 ng/ml (P less than 0.01), respectively. No differences were found in bioassay-PRL, RIA-PRL, progesterone (P), and FF volumes between fertilized and unfertilized groups of follicles. FF from mature preovulatory follicles contained greater concentrations of RIA-PRL compared to immature follicles (34.6 +/- 3.1 vs 8.5 +/- 1.6 ng/ml; P less than 0.001).

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To examine the disparity between clinical presentation and prolactin (PRL) measured by radioimmunoassay (RIA), serum samples from 128 patients with galactorrhea and/or reproductive disorders were evaluated by RIA for immunoassayable PRL (RIA-PRL) and by Nb2 lymphoma cell proliferation assay for bioassayable PRL (bioassay-PRL). One hundred fifteen patients had normal RIA-PRL and 13 patients had high RIA-PRL (greater than 25 ng/ml). Twenty patients had galactorrhea, two of whom had hyperprolactinemia. The reproductive disorders in female patients included infertility, amenorrhea, oligomenorrhea, irregular menstrual cycles, and luteal phase defects. Six oligospermic males also were studied. Twenty-three male and female volunteers with no evidence of reproductive disorders served as controls. Appropriate comparisons showed that PRL bioassay/RIA ratio, an index of agreement between the two assay systems, did not differ for the various patient groups compared with controls. It is concluded that Nb2 lymphoma bioassay does not provide additional diagnostic value to RIA in defining the cause of euprolactinemic galactorrhea and/or reproductive disorders.

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To determine whether anesthesia affects in vitro fertilization (IVF), the authors examined 3 1/2 years' experience with IVF. Anesthesia length significantly predicted fertilization and cleavage at stage 0 of stepwise multiple logistic regression analysis, but not at the final step. Oocyte grade, retrieval order, and a quadratic term for grade remained significant for fertilization; cleavage, order, the interaction of order and grade, and the quadratic term for grade remained significant. Order correlated with anesthesia (r = 0.675, P less than 0.001). Also inherent in order are CO2 pneumoperitoneum, increased prolactin, decreased gonadotropins, ovarian trauma, and time. First oocytes of equivalent grade from contralateral ovaries were compared. Fertilization rates were equivalent, but significantly fewer mature oocytes from the second ovary cleaved. Anesthetic agents and CO2 appear to adversely affect fertilization and cleavage in vitro.

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Because access into ovarian tissue of drugs used during anesthesia may be potentially harmful to the oocyte and/or follicular structure, we measured concentrations of thiopental (n = 15) and thiamylal (n = 9) in follicular fluid (FF) aspirates of 24 patients who underwent laparoscopic oocyte retrieval. In both groups, measurable amounts of the respective drug were found in all FF aspirates. Within individual patients, plasma concentrations of both drugs declined during the period of sampling between initial and final follicular aspiration. The mean plasma drug concentration was 7.99 +/- 3.97 micrograms/ml in the thiamylal group and 4.13 +/- 0.90 micrograms/ml in the thiopental group. Mean drug concentrations in FF were similar in both groups (thiopental 1.62 +/- 0.61 micrograms/ml; thiamylal 1.67 +/- 0.83 micrograms/ml). The mean FF/plasma concentration ratio during the sampling period was greater in the thiopental group (0.41 +/- 0.19) as compared with the thiamylal group (0.22 +/- 0.14). Several steps in the clinical management of these patients can be taken to reduce exposure of oocytes to drugs used during anesthesia.

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This study was designed to evaluate the effectiveness of three therapeutic modalities in the management of stage I and II endometriosis. Management modalities consisted of no treatment (controls, n = 56); oral medroxyprogesterone acetate (MPA), 30 mg orally per day for 90 days (n = 36); and danazol, 600 to 800 mg daily for 6 months (n = 52). All patients were followed for at least 18 months of exposure to pregnancy. Cumulative pregnancy rates were determined by life-table analysis. At 30 months, pregnancies resulted in 55% of group I (controls), 71% of group II (MPA), and 46% of group III (danazol). There were no significant differences among these rates. Similarly, there was no significant difference between the cumulative pregnancy rates for stage I (59%) and for stage II (57%). Abortion rates for the various treatment modalities were the following: MPA 6.3%, danazol 11%, and no treatment, 14.3%. The spontaneous abortion rate in stage I and stage II disease was not significantly different. The results of this study suggest that a period of expectant management with correction of other infertility factors may be warranted in patients with mild to moderate endometriosis before medical therapy is contemplated.

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Thirty-eight patients underwent 38 cycles of induction of ovulation using stepwise human menopausal gonadotropin and human chorionic gonadotropin (hCG) administration. Ultrasonography was performed on the day of hCG injection. The mean age +/- standard error of the mean (SEM) of the patients was 32.9 +/- 0.8 years, and the duration of infertility ranged from 1 to 14 years (median, 2.8). Ultrasonographic measurements were obtained of the largest diameter and the volume of the dominant follicles as well as all other follicles in both ovaries. Data were analyzed by Student's t-test, regression analysis, and analysis of variance. The mean +/- SEM diameter of dominant follicles was 1.8 +/- 0.1 cm, and the volume of dominant follicles was 3.5 +/- 0.8 cm. The mean +/- SEM serum estradiol (E2) level before hCG administration was 659 +/- 62 pg/ml. Significant correlations were found between preovulatory serum E2 levels and the total follicular volume of both ovaries (r = 0.41, P less than 0.05) and follicular volume of the ovary containing the dominant follicle (r = 0.42, P less than 0.01). No significant correlation was observed between the diameter of the dominant follicle and serum E2 levels. These results suggest that ultrasound findings reflect growth, whereas serum E2 levels primarily detect functional activity of follicles.

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In the past 100 years, interest in intrauterine insemination for cervical factor has waxed and waned. Recently the advent of in vitro fertilization, with improved methods of sperm washing and preparation, has revived interest in intrauterine insemination as a modality for the treatment of infertility. Twenty-seven couples with infertility resulting from cervical factor and/or oligospermia were entered into our intrauterine insemination protocol. A total of 107 intrauterine inseminations were performed in 85 menstrual cycles. Nineteen couples with a cervical factor as the major factor in their infertility experienced three pregnancies (16%). The remaining eight couples who had oligospermia with or without cervical factor produced no pregnancies. No major complications occurred from this procedure. In view of the low pregnancy rate experienced in this study, we must seriously question the value of intrauterine insemination in the treatment of cervical factors and/or oligospermia.

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The routine use of intraperitoneal 32% dextran 70 has been suggested as an adjuvant to prevent postsurgical pelvic adhesions. Two hundred thirty-four women received an antiadhesion regimen consisting of intraperitoneal 32% dextran 70, dexamethasone, and promethazine. Ten women (4%) experienced spontaneous leakage of the dextran-peritoneal fluid mixture through their abdominal incisions. Painless bilateral swelling of the labia was noted in 18 women (8%). Mild abdominal bloating and weight gain of from 2.5 to 11 pounds were common. No anaphylactic reactions, peritonitis, or wound infections were experienced by any woman. Intraperitoneal dextran 70 appears to be a safe, well-tolerated antiadhesion adjuvant for routine use in gynecologic operations.

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Regional anesthesia, in selected cases, is a useful alternative method of providing anesthesia for the retrieval of oocytes when general anesthesia is not indicated. We report our experience in managing anesthesia in four patients in whom we used a subarachnoid block. Ova were obtained in three patients, and two became pregnant and delivered healthy full-term infants. Although the high pregnancy rate was noted with delight, it is clearly a statistical happenstance. It would be interesting, however, to carry out prospective studies to determine whether a relationship between the incidence of pregnancy and anesthetic method might exist.

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Serum samples from groups of men and women with normal and elevated prolactin (PRL) levels were assayed by radioimmunoassay (RIA) and by Nb2 lymphoma cell bioassay (BA) for the presence of PRL. Because the Nb2 lymphoma cells respond to both PRL and growth hormone, BA for PRL activity was carried out before and after neutralization of growth hormone in the serum samples. There were excellent correlations between RIA and BA both in euprolactinemic (r = 0.7587; P less than 0.002) and hyperprolactinemic (r = 0.9558; P less than 0.001) subjects. On an absolute basis, RIA and BA values were similar in the euprolactinemic group (6.6 +/- 0.8 versus 6.2 +/- 1.0), whereas in the hyperprolactinemic group, RIA values were significantly higher than the BA results (89.41 +/- 22.4 versus 62.1 +/- 21.2). The two assay systems also appeared to correlate better in women who were hyperprolactinemic, with obvious menstrual cycle disturbances, than in hyperprolactinemic women without menstrual cycle disturbances.

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Dexamethasone and promethazine are widely used as an antiadhesion regimen in infertility surgery. A major argument against the routine use of dexamethasone has been the concern that suppression of the hypothalamic-pituitary-adrenal axis may result. To investigate this concern, 25 healthy women undergoing surgery for infertility were administered dexamethasone and promethazine preoperatively, intraoperatively, and postoperatively for 48 hours. Insulin hypoglycemia testing was performed on postoperative day 6. A normal rise in cortisol of at least 7 micrograms/dl was observed in 19 of 21 women. Two women failed to achieve this rise, despite adequate hypoglycemia. Short-term suppression of the hypothalamic-pituitary-adrenal axis may occur after administration of the dexamethasone-promethazine regimen. Patients receiving this regimen should be carefully supervised during the postoperative period.

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The objective of this study was to determine how well bovine estrus cervical mucus could be substituted for human cervical mucus in the in vitro sperm penetration test (SPT) and how well the SPT compares with the postcoital test (PCT). The subjects were couples chosen at random from our infertility clinic population. The complete infertility evaluation of these couples included a PCT performed at the time of anticipated ovulation. Human cervical mucus quality was assessed using a scoring system which evaluated amount, spinnbarkeit, ferning, viscosity, and cellularity. SPT's were performed in flat capillary tubes filled with cervical mucus and exposed to semen samples for 90 minutes. Thirty-five couples had SPT's performed with wife's mucus and bovine mucus. Test results showed that PCT results correlated significantly with the SPT (P 0.02) but r was low (r = 0.37). The cervical mucus score correlated well with the SPT (P 0.001, r = 0.52) but less well with the PCT (P 0.03, r = .30). It is concluded that the SPT performed with either wife's mucus or bovine mucus is not an adequate substitute for the PCT but provides complementary information.

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Immediate postoperative complications in 160 surgical patients were retrospectively reviewed. Complications were analyzed by system, and mortality was evaluated.

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