In vitro fertilization has resulted in an estimated 4000-5000 births in the world. The procedure has been accepted in Europe, America and Australia and several hundred IVF clinics are operating successfully. The newer procedures of GIFf, embryo freezing and donor oocyte IVF have become established and are dealt with in several chapters. GIFf has become the procedure of choice for patients with infertility of unknown origin. Oocyte freezing represents an important new technology which is being developed. The routine IVF procedure has improved slightly; variation in results can be reduced by quality control of laboratory and clinical techniques. Male factor infertility has been dealt with by IVF in mild and moderate cases, but newer techniques will be required to deal with severe problems in the male. Most countries have accepted that the straightforward IVF pro cedure is ethical. Limitations concerning the use of donor oocytes and embryo experimentation exist in some religions and countries; legal control of the new reproductive technologies ranges from the passage of statutes to no control at all. Many countries are still considering the need for legislative control. The text endeavours to indicate new areas of importance and to guide those organizing services as to how to introduce newer technolo gies.

ENTERING ON A CREATIVE AND ENTERPRISING PROJECT, DRS. DIZEREGA and Rodgers have taken an innovative look at the peritoneum. They have provided an interesting, informative, and stimulating text about an organ that is rarely considered independently-usually being thought of only as a part of other organs or organ systems. The peritoneum is an active membrane that serves as both a secretory organ and a structure that modulates diffusion and osmosis. Both of these important functions are described in great detail. The text is divided in classic fashion. The authors first examine the peritoneal anatomy from both macro and cellular viewpoints, during which exploration it becomes clear that what appears simply to be a lacy covering over abdominal organs actually is a complex structure. Fur thermore, during the discussion on its embryologic development the au thors make comprehensible the complexity confronting the student of the peritoneum. The authors then proceed to the practicalities associated with this im portant organ. To surgeons, for example, the key to the peritoneum is understanding the organ's repair mechanism, as it is adhesions formed on the peritoneal surfaces that interfere with the surgeon's hope of success."

Conceptual advances in the biological sciences are marked by the applica tion of new techniques and experimental strategies. Nowhere has this ge neric principle been more apparent than in the study of testicular cells, as judged by the evolution of themes presented at the Testis Workshop over the past 23 years. Like its predecessors, the 1995 Testis Workshop was structured to offer fresh insights and approaches for understanding the mechanisms of spermatogenesis and steroidogenesis. The chapters pre sented in this book emphasize three aspects of testicular cell function: first, the molecular analysis of the cell cycle; second, examination of the cell cycle, including the function and identification of specific macromolecules that direct the proliferation and differentiation of germ cells; and third, the development of Leydig cells and the role of specific macromolecules in the formation of testicular steroids. Each chapter is based on a lecture presented at the XIIIth Testis Work shop held on March 30 to April 1, 1995, at the Radisson Plaza Hotel in Raleigh, North Carolina. The selection of topics reflects the recommenda tions of the workshop'S organizing committee. Sincere thanks are due to the speakers who agreed to lecture and prepare chapters."

Interest in bone densitometry methods has recently experienced a resurgence within the medical community. Physicians have become more interested than ever before in the diagnosis and treatment of degenerative diseases of bone such as osteoporosis. The public perception of osteoporosis and its prevention has been recently heightened. Because osteoporosis is widespread, especially in women, and leads to an increase in fractures in our population, many re searchers and clinicians are strongly motivated in their search for more sensi tive and accurate methods of diagnosis. This book was written for physicians, scientists, engineers, medical phy sicists, and others desiring an introduction or further understanding of this exciting field. Beginning with the early development of x-ray film methods for assessing bone status, the field has steadily grown throughout the years. Novel and interesting devices have been designed for the measurement of bone mass, bone density, cortical thickness, and other parameters of bone changes. Both qualitative and quantitative bone methods are described. The techniques include imaging devices such as CT and radiography as well as fixed point methods in which bone characteristics of a region of interest are analyzed."

Atrophy of gonadotrophin producing cells Exogenously LH synthesis administered androgens and release or anabolic steroids are decreased Prostate Testes Normal function. Testosterone synthesis in The deficit of endogenously Leydig cells is decreased. The synthesized testosterone is exogenously administered compensated for by the steroid is not able to exogenously administered compensate for the deficit of steroid endogenously synthesized testosterone Figure 2 Intratesticular and serum testosterone concentrations after treatment with andro gens or anabolic steroids in order to substitute for the peripheral androgen deficiency and to achieve azoospermia. Because this steroid is alkylated in position 17, toxic effects on liver function can not be excluded. Danazol offers no advantages as compared with other anabolic steroids; rather, disadvantages. Numerous experiments of this type have been performed during the last 40 or 50 years. The outcome in each case was more or less identical: with a certain dose of an androgen or anabolic steroid it is possible to inhibit spermatogenesis without interfering with other androgen-dependent func tions, including libido (potentia coeundi) and accessory sexual glands. On the basis of this pharmacological-endocrinological background, androgens and anabolic steroids can be used for male fertility control, and several clinical trials have been performed during the last 10-15 years. Some of 1 these studies 2-23 are mentioned in Table 2."

For the third time, specialists from all over the world met to present their most recent scientific results and to update their knowledge in the expand ing field of nutrition and, osteoporosis. Major nutrition-al factors, such as calcium and vitamin D, were reexamined, with special attention on the ef fects of calcium, given either as a supplement or in dairy products in chil dren and adolescents, and to vitamin D supplementation in the elderly. The RDA for calcium was questioned, and the calcium requirement was rede fined. Special attention was paid to proteins and their growth promoting action via IGF-l, as well as to the profound effects on calcium and bone metabolism of vegetarian diets or diets rich in acidic or alkaline foods. Although considered an environmental factor influencing the pathogenesis of osteoporosis, nutrition was discussed in relation to genetic conditions, because certain genetic conditions modifY patients' responses to nutritional deficiencies and to supplementary interventions. These proceedings report the wide spectrum of research currently being undertaken and the new perspectives this presents and emphasize the sig nificant and important impact of nutrition on bone health and disease."

Each new volume of this publication brings the privilege of expressing some of my thoughts on subjects of interest to its readers. In the past year or so public concern about environmental and societal dangers has largely turned to those of cosmic proportion-Chernobyl, the thinning ozone layer, AIDS, and the like-and thankfully our subject matter has been allowed a respite. Even the miniepidemic of craniofacial and other malformations caused by the retinoid antiacne drug Accutane made no headlines. Incidentally, this might have been a tragedy of far greater proportions had it not been nipped in the bud by the historical ground work that quickly permitted it to be recognized as due to an environ mental teratogen-the sort of fact the public and authorities inadequately appreciate. But there is a warning connected with this abeyance of media focus on teratological matters. Disquiet over cosmic imbalances will sub side as they are corrected or horrendous projections fail to materialize, and even cures for dread infectious diseases, or Puritan revolution in terdicting such plagues, will be forthcoming, and these things will occur long before congenital malformations are no more. And as the year-in and year-out recurrence of over 100,000 an nual births of seriously malformed infants in the United States alone continues to force itself on the public consciousness, we can expect a heightened demand that "a cure" be found, because "if we can land a man on the moon, if we can prevent polio, why can't we . . ."

In the middle of the 17th century, the great French philosopher Rene Descartes wrote (L'Homme, J. Le Gras, Paris, 1669) that a suitable stimulation of the brain results in two types of "movements": exterior movements, designed to seek desirable ends and to avoid undesirable or harmful ones and interior movements or "passions" which through the release of "animal spirits" regulate the heart, the liver, and other organs. When it appears appropriate to meet a threat with force, the passion of rage causes the release of strong spirits, whereas when avoidance appears to be the better choice, the passion of fear causes the brain to release weak spirits. We do not know what influence, if any, Descartes had on the thinking of Walter B. Cannon (Bodily Changes in Pain, Hunger, Fear and Rage, Appleton and Co. , New York, 1920), of Hans Selye (The Story of the Adaptation Syndrome, Acta, Inc. , Montreal, 1952), ofG. W. Harris or of R. Guillemin (Hypothalamic-Hypophysial Interrelationships. A Sym posium. c. c. Thomas, Springfield, 1956), but it is interesting to reflect upon the durable value of great ideas which constantly resurface even if modified by other ideas and by new techniques, as if propelled by a preordained intellectual imperative.

Polycystic ovarian disease, or polyfollicular ovarian disease, as Dr. Fut terweit prefers to call it, is a disease of uncertain etiology and for which numerous modes of therapy have been advanced. Understanding of its pathophysiology should shed light on factors regulating normal ovarian function; the converse is also true. Recent years have brought about great understanding of the neuro endocrine regulation of gonadal function, as well as of factors in the microenvironment of the ovary which affect its function. It is also ap preciated that cases classified as polycystic ovarian disease actually rep resent a clinical and pathological spectrum which may reflect the effects of diverse etiological factors. In the present volume, Dr. Futterweit presents the fruits of his long interest in and extensive experience with this disease. He thoroughly and thoughtfully reviews the vast amount of basic and clinical information that has been garnered with regard to this condition over the past decade. The numerous theories that have been advanced to explain its etiology are presented in balanced fashion, in addition to a hypothesis, which is well formulated and amenable to clinical testing. His clinical interests and judgment are well represented by his presentation of the diverse manifestations of this condition, the approach to proper diagnosis, and the available therapeutic options. Patients with this disease represent diagnostic and therapeutic prob lems in a situation where manifestations of disease may lead to major emotional stress."

The perimenopause is an extremely important time in a woman's life. In a similar but reverse sequence to puberty, it signals a change in ovarian status. Although some women pass through this transition without symptoms or concern, for many women, the perimenopause, which can last several years, is of great concern. Symptoms of estrogen deficiency, menstrual irregular ity, concerns over changes in mood, as well as reproductive concerns lead to anxiety and frustration. Because it is poorly understood, many clinicians are equally frustrated in finding ways to help their patients and question the appropriateness and/or need for treatment. This Serono Symposia USA, Inc., meeting was designed to help address some of these issues from both a basic science and a clinical perspective, and to provide a forum for discussion. The waning of ovarian function can be divided into two events that are dissociated: gametogenic and endocrine failure. Thus, the symposium was divided into three parts to address these two phenomena and to discuss treatment options. An outstanding international group of clinicians and investigators assembled to first address oocyte depletion and possible markers. Next the complex endocrine changes were discussed as well as the physiologic consequences of these changes. This included a discussion of hot flushes, bone and cardiovascular changes, menstrual irregularity, mood disturbances and depression, and anatomical changes in the ovary and breast. The third part of the symposium addressed treatment options, both in terms of symptoms as well as reproductive and fertility concerns."

Ultrasonic surgical techniques were first used by Dr. Kelman in the 1960s to fragment cataracts through a 2-mm incision allowing for minimally invasive surgery. The results from this procedure stimulated the development of a larger, move powerful ultrasonic unit that was used in neurosurgery. This instrument allowed the neurosurgeon to selectively remove tumor tissue with decreased blood loss and tissue trauma. The ability now of ultrasonic equipment to selectively fragment, irrigate, and aspirate tissue with minimal coagulation effect spurred its rapid use in surgery on the liver, spleen, kidney, and other intra-abdominal organs. This instrument has been invaluable in ovarian cancer cytoreduction and intricate segmental organ resection. The newest technical developments include electro cautery capability built into the hand piece and extended hand pieces for laparoscopic surgery. The impetus for assembling this volume has been to provide an extensive review of the field of ultrasonic surgery as it has currently developed including principles, equipment features, and surgical tech niques. It is hoped that the information will be of use to physicians in training and surgeons in practice. The book takes a multidisciplinary approach with chapters authored by a diversity of subspecialists in gen eral surgery, urology, surgical oncology, and gynecologic oncology. Each chapter contains basic information on surgical techniques. Together, these chapters cover surgery of the GI tract, kidney, liver, and lower genital tract, and present a number of personal approaches."

Breast Care: A Clinical Guidebook for Women's Primary Health Care Providers presents the expertise and protocols of the renowned Breast Diagnostic Center at USC School of Medicine's Department of Obstetrics and Gynecology. A user-friendly reference for the primary care physician, this book details the management of both benign and malignant breast diseases. Topics include: * the clinical examination and instruction for self-exam * mammography for both screening and diagnosis, management of the abnormal mammogram * lactation and breast feeding * diagnosis and treatment of lumps, cysts, fibroadenomas * fine-needle aspiration and ultrasound guided tissue core needle biopsy * evaluation and management of mastalgia * menstrual and hormonal therapy effects on the breast * the cosmetically treated breast * guidelines for follow-up and surveillance An important section on consultation and referrals reviews the roles of the radiologist, oncologist, and surgeon and provides the primary care physician with the information necessary to counsel the patient on the myriad aspects of multidisciplinary treatment planning. The text includes more than 100 illustrations and algorithms -- with 16 in color -- as well as "Practice Guides" which organize the key practice points, signs, and symptoms. This is a must-have handbook for all providers of health care to women.

Since the awarding of the Nobel Prize to Drs. Guillemin and Schally iJ) 1971 for isolation and chemical characterization of gonadotropin releasing hormone, we have experienced a remarkable period of growth of interest in this hormone. The last 20 years have been characterized by a swift translation of basic science discovery into clinical utility. Approval of GnRH and its analogs for treatment of prostate cancer, endometriosis, of ovulation indicate the range and precocious puberty and for induction of these agents. of usefulness In order to bring together the leaders in the basic and clinical science of GnRH, a conference was organized on "Modes of Action of GnRH and GnRH Analogs" and held in Scottsdale, Arizona, February 26 to March 2, 1991. The presentations, given as chapters in this volume, show both the advances in the body of information in this discipline and the efforts underway to reduce basic science to clinical practice. The audience was a combination of representatives from universities, government, industry, and physicians in practice. The lively discussions and insightful questions indicated the interest in the topics discussed and frequently served to catalyze planned interactions of the meeting participants. The organizers are grateful to the speakers and poster presenters for their contributions and for the timely preparations of the manuscripts included in the present volume. We are also thankful to the staff of Serono Symposia, USA, for the organizational skills and support that allowed the meeting organizers to focus on the science and medicine presented.

Why Efforts to Expand the Meaning of "Teratogen" Are Unacceptable Disagreement about nomenclature in teratology is not new. Dissent even about the very fabric of the discipline-what congenital malformations consist of-has often been voiced. Time, instead of resolving such diffi culties, has sometimes worsened them. For example, in the past it was agreed that congenital malforma tions are abnormalities of structure present at birth, but differences of opinion concerning where the line between normal and abnormal was to be drawn prevailed. It was obvious that, in order to discover the causes of congenital malformations and cast strategies for their prevention, it would be necessary to have knowledge of the baseline of their frequency, and that this required uniformity of definition of terms. Since malfor mations of primary social concern are those having grave outcomes (and are, paradoxically, also the commonest ones), it is logical that such condi tions were the first consideration of investigators and were the defects whose frequency was considered to comprise the required baseline.

Proceedings of the NATO Advanced Study Institute, San Miniato, Italy, September 2-13, 1985

For many years now, our understanding of the somatotrophic and reproduc tive axes has evolved essentially independently, both fields of study reaching a highly advanced, although far from complete, level of under standing. Along the way, however, it became apparent that in some circumstances the reproductive and somatotrophic axes may be inter dependent. Inklings to this effect were at times feeble and at other times more convincing. Among those inklings are the clinical recognition by pediatric endocrinologists of the apparent association between isolated GH deficiency and delayed puberty, as well as of the apparent permissive, pUberty-promoting property of GH. Equally important is a body of experi mental studies establishing the ovary of multiple species as a site of GH reception and action. Arguing against an essential role for GH in the reproductive process is the observation that individuals who have GH resistance of the Laron variety are fertile arid that isolated GH deficiency does not constitute an absolute barrier to the attainment of sexual maturation and fertility. The intraovarian insulin-like growth factor (IGF) hypothesis proposes that IGFs may serve as amplifiers of gonadotropin action. Although the dependence of intraovarian IGFs on systemic GH action has never been unequivocally demonstrated, that leap of faith has often been made. The intraovarian IGF hypothesis serves as the rationale for the adjunctive use of GH in the induction of ovulation."

Cancer and Pregnancy covers the clinical challenges to diagnosing and treating malignancies in the pregnant patient; however, the book also shows how an understanding of the common features of both processes (rapid cell proliferation) may lead to novel anti-cancer treatment options. The book should be read by obstetricians and gynaecologists, clinical oncologists, reproduction specialists, and those involved in investigation of development, biology, toxicology, immunology, as well as cancer research.

Current Perinatology, II, explores the most recent major research techniques utilized in the evaluation, diagnosis, and management of the high-risk mother and her newborn. The volume should be a major reference for pediatricians, perinatologists, and neonatologists, as well as for nurses and allied health personnel closely involved with the care of the high-risk mother, fetus, and newborn. Topics presented include perinatal Doppler; Doppler echocardiography of the human fetus; invasive fetal assessment by fetal blood sampling; prediction, prevention, and treatment of preterm labor; percutaneous umbilical blood sampling and intravascular fetal therapy; current and future perspectives for fetal genetic diagnosis; current concepts of substance abuse during pregnancy; newer methods of diagnosis and treatment of neonatal sepsis; clinical applications of neonatal pulmonary function testing; and current management of hypoplastic left heart syndrome. Discussions of stabilization and transportation of the critically ill obstetric patient and of pain management in the neonatal intensive care unit will be of interest to both physicians and nurses.

Trophoblast cells coordinate the activities of maternal and embryonic tissues by secreting hormones, cytokines, and various growth factors that selectively and specifically gain access to maternal and embryonic compartments. Abnormalities associated with trophoblast cell growth, differentiation, or function result in impaired embryonic development. Understanding the complexities of the trophoblast cell signaling system was the focus of the Serono Symposia, USA conference entitled Tropho blast Cells: Pathways for Maternal-Embryonic Communication, held August 6-9, 1992, in Las Vegas, Nevada. The conference was designed to provide a forum for morphologists, cell biologists, endocrinologists, and molecular biologists and for scientists investigating primate, ru minant, and rodent trophoblast biology. An important outcome of the conference was the communication achieved between basic scientists and clinicians. This volume represents the contributions of the invited symposium speakers. The opening keynote address of the conference was entitled "Chorio carcinoma and the Embryo" and was presented by G. Barry Pierce, M. D., Centennial Distinguished Research Professor of the University of Colorado School of Medicine. The address is not represented in this volume, but deserves a special comment. Dr. Pierce's scientific con tributions have significantly influenced our understanding of trophoblast cells. Dr. Pierce, together with Dr. A. Rees Midgley, identified the origin of syncytial trophoblast cells of the primate placenta and discovered that these cells were responsible for the production of chorionic gonadotropin (J Exp Med 1962;115:289-94; Am J Pathol 1963;43:929-43; and Science 1963;141:349-50)."

A little over 12 years ago I wrote a small volume entitled Infertility. It seemed to me at that time that significant advances in the field called for the publication of such a volume. The following is from the preface to that volume: During the past 15 years considerable progress has been made in the field of infertility diagnosis and management. It is perhaps a paradox that much of this increased knowledge has come about because of Western medicine's preoccupation with the search for a means to control reproduction. As a result, we have achieved new insights into the physiologic mechanisms involved in reproduction, and we have found better methods for measuring physiologic changes in reproductive health and disease. To these advances can be added improvements in the utilization of endoscopic and surgical techniques, in the diagnosis and treatment of infections and endometriosis, and in the treatment of hormonal disorders. During this period, too, through workshops and conferences and in journals and texts, these latest advances have been made available to physi cians, an outstanding example being the two volumes of Progress in Infer tility, edited by Drs. Jan Behrman and Robert Kistner. As necessary as these publications are, they do not offer an overall view of infertility diag nosis and management."

Medicine is changing at a speed never witnessed before in history. With each passing year, medical technology achieves the capacity to provide cures and improve treatments that even a short time before were difficult to con ceptualize and impossible to provide. Reproductive technology personifies this concept perhaps better than any other field of medicine. The 1990s have seen an explosion in endoscopic and ambulatory procedures, the application of molecular biology to clinical conditions, and the refinement of assisted reproduction to allow third parties (donors and surrogates) into the process of family building. More than ever before, comprehensive medical care requires a team approach. However, the team comprises not only medical and scientific personnel, but also mental health professionals, lawyers, and ethicists. This integrated and multidisciplinary approach to medical care will become even more necessary as medical capabilities continue to develop faster than society can respond. This book reflects such an approach. It is based on a Harvard Postgraduate Course in June 1990 entitled Infertility in the 1990s: Technological Advances and Their Psychosocial Implications that was sponsored by the Faulkner Centre for Reproductive Medicine. The first half of the course was directed by Drs. M. Seibel, A. Kiessling, and C. Richards. The second half of the course was directed by Dr. M. Seibel, J. Bernstein, R. N. and S. Levin, LICSW."

The critical role of growth factors in normal as well as abnormal cellular growth and function has become overwhelmingly apparent in recent years. The significant advances in reproductive biology within this rapidly expanding field were highlighted at the Serono Symposia, USA, symposium entitled Growth Factors in Reproduc tion. The conference focused on growth factors as polyfunctional regulators of growth and development in the reproductive system. The program was organized into five areas: (1) growth factors as polyfunctional regulators of growth and development, (2) growth factors and gonadal function, (3) regulation of normal and neoplastic mammary growth, (4) regulatory peptides in reproductive tract development and function, and (5) embryo-maternal signaling. This volume constitutes the contributions ofthe invited symposium speakers and is organized into sections representing the five topic areas of the sessions. Drs. Eli Y. Adashi, Robert B. Dickson, David C. Lee, James Hammond, John A. McLachlan, and R. Michael Roberts, who served as chairmen ofthese sessions, not only provided invaluable advice and assistance in organizing the symposium, but contributed significantly to its content. The enthusiasm and esprit de corps of the poster presenters and discussion participants also helped make this symposium succeed as the first of its kind. Finally, special thanks are due Drs. James Posillico and Lisa Kern ofSerono Symposia, USA, for their guidance and support in the conception and planning of the symposium and in the publication of this volume."

Fully revised for this fourth edition, the Oxford Handbook of Obstetrics and Gynaecology fully reflects new developments in the field. Featuring new sections on the outcomes of the MBRRACE report, abnormally adherent and invasive placenta, pregnancies in mothers of advanced age, assisted reproduction, and ovarian cancer screening, it provides a contemporary overview of this complex and important specialty. Written and reviewed by a team of highly experienced clinicians, academics, and trainees, this Handbook is a perfect starting point for preparation for postgraduate exams. Practical advice is presented with key evidence-based guidelines, supported by visual algorithms and top clinical tips. The previous edition was Highly Commended in the Obstetrics and Gynaecology category of the BMA Book Awards. The indispensable, concise, and practical guide to all aspects of obstetric and gynaecological medical care, diagnosis, and management, this fourth edition continues to be the must-have resource for all specialist trainees, junior doctors, and students, as well as a valuable aide memoire for experienced clinicians.

Thoroughly illustrated, this second edition provides the primary care physician with detailed information on the most commonly encountered clinical situations and the most frequently asked questions. The chapters address everything the primary care physician will regularly face and will need to know about the breast, pregnancy, sexually transmitted diseases, contraception, infertility, gynecologic cancers, urogynecology and gynecology.