Women with chronic medical problems are at higher risk for complications during pregnancy and, therefore, they are especially in need of appropriate preconception and contraception care. Furthermore, many women with chronic medical problems do not obtain adequate preconception and contraception care. Despite published guidelines by the Centers for Disease Control and Prevention, there is a substantial gap in medical practice regarding the use of contraception in women with co-existing medical problems. Contraception for the Medically Challenging Patient fills the gap that currently exists in the knowledge of correct contraceptive prescribing practice and shows that inappropriate contraindications can easily become a barrier to effective contraception use among women. Chapters highlight obsolete views about appropriate candidates for contraception and address the complex contraceptive needs of today's medically challenging patients with HIV/AIDS, uterine fibroids, or cardiac, neurologic or thyroid disease. The book gives attention to recommendations on the use of contraception in women with medical problems such as diabetes, obesity, epilepsy, and lupus, among others, and provides comprehensive information regarding the effects that certain drugs may have on contraceptive hormone levels. While national guidelines do exist for contraceptive eligibility, this book discusses in more detail the evidence behind the guideline recommendations and the nuances that clinicians confront in daily practice.

The study of prenatal development provides many clues for understanding the physiology as well as the pathogeny of malformations and many diseases. I became interested in the analysis of human development as a young medical student more than 30 years ago, and I have stayed in this field all my life. In my studies, I always tried to compare the events of different disciplines such as genetics, anatomy, bio chemistry and physiology. I learned that the development of a structure is, under normal circumstances, strictly determined and that the development of structures always precedes their proper function. There are no changes in function without changes in structure. The life of every cell is genetically preprogrammed and the program may be modified by complicated interactions with environment. Recent progress in our knowledge is basicly related to technology. However, using all the tools of today's technology, we are still unable to understand the basic normal development. After almost thirty years of work, I am trying to present a subjective review of the development of the human endocrine glands. I am presenting an image emerging from my experience. I personally studied several hundred human embryos using mostly anatomical, histochemical and some biochemical techniques. I found much additional information in the literature."

Sixteen British specialists pool their extensive knowledge of spontaneous abortion in one source. Their discussion is directly applicable to clinical situations and helps identify areas of debate and alternative methods.

Many women have to spend one third of their lives in a postmenopausal state and they should have a good quality of life during this period. Althoug HRT is well accepted as the logical treatment of climacteric problems, the prevalence rate is very low in some countries. The reasons for not accepting HRT are manifold and complex. The objective of this book is to describe the essential advances in basic and clinical research that forms the basis of current HRT and to give an overview of the efficacy and safety of HRT.

Professor Egon Diczfalusy, a pioneer in gynaecological endocrinology and in particular female contraception, celebrated his 80th birthday with a scientific symposium. The participants were scientists from all over the world who had been scholars and close collaborators at different points in time. The interdisciplinary meeting consisted of lectures on the epidemiological impacts of ageing, its challenge for the pharmaceutical industry, philosophical aspects of the future of mankind, and the history and future of contraception. Three round table discussions addressed the hormonal control of reproduction and ageing, new approaches and future perspectives of contraception for women and men, and hormone replacement in the elderly.

The events of September 11,2001 in the United States will always be r~membered with horror and sadness but also admiration for those who risked, and often lost, their lives attempting to save others. When the Fifth International Germ Cell Tumour Conference began, the US air space was closed and our American friends were unable to join us. We were faced with a programme that now had many gaps. What happened next was an illustration of the sense of community that prevails at the Germ Cell Tumour Conferences. Some of those who could not be there in person, such as Richard Foster and Craig Nichols, sent their slides by email, and we were indebted to those, such as Michael Jewett, Ben Mead and Malcolm Mason, who stepped into the breach to present them. Others gave impromptu, and often thought provoking, talks. The discussion periods were lively and it will come as no surprise to those who regularly attend the meeting that Tim Oliver won the prize for "Most Questions Asked", managing even to ask questions following his own presentations. The quality of the talks was outstanding. There was closer integration of the adult and paediatric sessions than in previous meetings. As a result, the differences and similarities between adult male, female and paediatric germ cell tumours became more apparent. This cross-fertilization of ideas from different groups will no doubt lead to further advances. As a result of all these efforts, the conference was a great success.

This book is a collection of preclinical and clinical reports on the appli cation of gene therapy to human disease. The focus of these studies is on cancer and cardiovascular disease. There are two fundamental technologies for delivering therapeutic genes to diseased ceHs: either viral vectors, as discussed by Dr. Bal main, or non-viral vector systems, as discussed by Dr. Felgner. The strengths and limitations of each of these delivery systems are charac terized. The use of a therapeutic gene to treat a disease has taken two general approaches. The first is to introduce anormal (i. e., wild type) gene into the patient that will restore normal gene function. Dr. Weiss man has characterized the tumor suppressor gene (pS3), and has shown that it can restore normal ceH function in cancer cells. The second ap proach is to treat the disease with antisense molecules. Abnormal gene expression can be down-regulated and selectively inhibited by anti sense molecules, which can reverse the pathologie process in cancer cells. Dr. Gewirtz has demonstrated this with anti sense genes on leuke mia, while Dr. Scanlon has applied this principle using ribozymes in human carcinomas. During this symposium, Dr. Engler described clinical studies of gene therapy using growth factors to stimulate new blood vessels in patients with cardiovascular disease. Several gene therapy strategies were used for cancer: overcoming drug resistance by Dr. Bertino, a pro-drug strategy with ganciclovir by Dr."

The introduction of colposcopy and exfoliative cytology as a means of examining the cervix uteri has opened up the possibility of studying the preceding and early stages of invasive carcinoma of the cervix and has also brought to light a number of conditions which are possibly only indirectly related, if related at all, to cervical neo with histological evaluation it is possible to plasia. Using these methods combined gain some insight into the natural history of cervical carcinoma. The importance of this is not confined to the cervix for, in this respect, the cervical lesions may prove a paradigm for those of the bladder, stomach and elsewhere. At present the broad outline of the natural history of these cervical lesions is emerging but the temporal and spatial relationships of the various phases is unclear, largely because of the number of possibilities envisaged which involves more vari ables than can be controlled in anyone investigation. In this monograph we have endeavoured to indicate the limitations of the various approaches and to stress the need for controlling the accuracy of assessment whether it be histological, cytological or colposcopic."

The world's population is growing at an unsustainable rate. From a baseline ?gure of one billion in 1800, global population is predicted to exceed nine billion by 2050 and 87. 8% of this growth will be localized in less developed countries. Such uneven population growth will yield a harvest of poverty, malnutrition, disease and en- ronmental degradation that will affect us all. Amongst the complex mixture of political, social, cultural and technological changes needed to address this issue, the development of improved methods of fertility regulation will be critical. The inadequacy of current contraceptive technologies is indicated by recent data s- gesting that the contraceptive needs of over 120 million couples go unmet every year. As a direct consequence of this de?cit 38% of pregnancies are unplanned and more than 50% end in an abortion, generating a total of 46 million abortions per annum particularly among teenagers. If safe, effective contraceptives were ava- able to every couple experiencing an unmet family planning need, 1. 5 million lives would be saved each year (UNFPA 2003). Progress in contraceptive technology should not only generate more effective methods of regulating fertility, but should also provide a range of methods to meet the changing needs of the world's population. Contraceptive practice was revo- tionized in 1960 in the US and 1961 in Europe by the introduction of the oral contraceptive pill by Gregory Pincus, MC Chang and colleagues, based on fun- mental hormone research conducted in Germany.

The optimal function of the placenta and thus fetal well being largely depends upon the integrity of both the fetal and maternal circulations of the placenta. Intense basic research concerned with placental vascularization and blood flow has been performed for the past 30 years, beginning with the classical morphological descriptions of the placental vessels by Boe (1953) and Arts (1961), as well as with the radioangiographic studies of maternal placental circulation in the human by Borell (1958) and in the rhesus monkey by Ramsey (1962). The scientific framework presented by these investigators has been filled and completed by numerous investigators, leading to more morphological details, functional considerations, and pathological understanding. For an extended period of time, this research has been of primarily academic interest by increasing our insights into one important system of the placenta, yet having nearly no practical importance. Recently, this situation has changed dramatically: in vitro studies of the isolated, dually perfused human placenta and in vivo studies of placental circulation for diagnostic purposes have raised an enormous interest in basic research data. New methods like Doppler Ultrasound and NMR became available. These technics have enabled the obstetrician to study fetal and placental hemodynamics in vivo. Meanwhile, such methods are becoming incorporated into the daily obstetrical routine, to some degree without an adequate background knowledge of placental vascularization and blood flow, since such experience is currently available to only a small group of experts.

This book is intended as a reference manual that will provide the busy clinician with up-to-date information on the diagnosis and treatment of uncommon and rare gynecological cancers. While standard textbooks briefly cover these tumors, this is intended as a more comprehensive yet easy-to-use guide. After opening chapters on epidemiology, pathology, and diagnostic imaging, the full range of infrequently encountered gynecological cancers (ovarian, uterine, cervical, vaginal, and vulval) is presented and discussed with the aid of high-quality illustrations. In each case, detailed attention is paid to both differential diagnosis and current treatment options. The book has been written by an international panel of experts and is the first to gather all the uncommon and rare gynecological cancers together within one volume.

Bladder Pain Syndrome: A Guide for Clinicians provides a comprehensive update in the pathophysiology, epidemiology, terminology, evaluation and treatment of patients with pelvic pain perceived to be related to the urinary bladder. The volume covers the tremendous evolution during the last decade in our understanding of pain syndromes and their diagnosis and treatment. It is now clear that Bladder Pain Syndrome belongs to the family of pain syndromes, and therefore treatment has moved from the treatment of the bladder to the treatment of a pain syndrome with the special problems this presents when the pain syndrome involves urinary symptoms. Interstitial Cystitis was poorly defined and the interpretation and patient selection differed enormously around the world in many ways, making exchange of information unreliable and confusing. Bladder Pain Syndrome is clearly defined and the result is a much better patient selection. This volume provides state of the art background for making a correct evaluation and diagnosis of patients with pelvic pain and voiding problems resulting in a more focused treatment to the benefit of the patients. The volume also covers the close relationship between different pain syndromes including those outside the pelvis. Bladder Pain Syndrome: A Guide for Clinicians will be of great utility to urologists, gynecologists and all health professionals dealing with patients with pelvic pain.

Operative Gynecologic Endoscopy, Second Edition is completely revised and expanded with 17 new chapters that provide, step-by-step, the latest operative techniques for both laparoscopic AND hysteroscopic procedures. New and updated chapters include: - laparoscopic assisted vaginal hysterectomy - vaginal prolapse and bladder suspension - ectopic pregnancy - tubal reconstructive surgery - assisted reproductive technologies - lymphadenectomy and urologic procedures - operative hysteroscopy. In addition, this volume includes comprehensive chapters on instrumentation, photo documentation, anesthesia, operating room personnel, credentialing, and legal issues. More than 350 superb illustrations - with many in full color - complement and clarify the operative techniques. For every surgeon and resident performing gynecologic procedures, this is the definitive, most up-to-date text on gynecologic endoscopy.

These two volumes are unique in that they take into consideration the enormous progress made in the field over the last few years. Expert knowledge is given by Professor Runnebaum, whose department was appointed WHO Collaboration Center for Research in Human Reproduction. These extensively illustrated books provide detailed information on the function and detection of new hormones and growth factors, on therapy with female sexual hormones, on environmental factors, and on the diagnostic and surgical techniques employed in reproductive medicine. This English edition of a standard German reference has been expanded to include an appendix containing a comprehensive list of pharmaceutical agents used in hormone therapy, including international and trade names and compositions.

Type 1 diabetes is a serious and common disease, afflicting one per 200 of the population worldwide. It is widely believed to cause harmful physical maldevelopment--congenital malformations--and other consequences in the unborn children of women with the disease. This book considers the history of the disease in pregnant women and this belief that it causes anomalies since the time of the discovery of insulin in 1921, and presents a profound and critical appraisal of the subject of its supposed prenatal harmfulness.

This concise drug guide lists 500 substances, such as pharmaceutical drugs, lifestyle drugs, and environmental toxicants, which show documented untoward effects on the male sexual organs and their functions. All substances are listed in user-friendly alphabetical order with a uniform structure throughout the book. Each listing includes evidence-based information with up-to-date references and all studies mentioned are evaluated and categorized according to study and sample types. This unique compendium provides more detailed information on each drug than any other standard pharmacology title.

Molecular biology emerged from advances in biochemistry during the 1940s and 1950s, when the structure of the nucleic acids and proteins were elucidated. Beginning in the 1970s, with nucleic acid enzymology and the discovery of the restriction enzymes, the tools of molecular biology became widely available and applied in cell biology to study how genes are regulated. This new knowledge impacted endocrinology and reproductive biology since it was largely known that the secretion of the internal glands affected the phenotypes, and expression of genes. Modern reproductive biology encompasses every level of biological study from genomics to ecology, encompassing cell biology, biochemistry, endocrinology and general physiology. All of these disciplines require a basic knowledge, both as a tool and as an essential aid to a fundamental understanding of the principles of life in health and disease. Overall, molecular biology is central to scientific studies in all living matter, impacting disciplines such as medicine, related health sciences, veterinary, agriculture and environmental sciences. In this book, the basic biochemistry of nucleic acids and proteins are reviewed. Methodologies used to study signaling and gene regulation in the endocrine/reproductive system are also discussed. Topics include mechanisms of hormone action and several endocrine disorders affecting the reproductive system. Professionals in the medical, veterinary and animal sciences fields will find exciting and stimulating material enhancing the breadth and quality of their research.

The body of any animal can be viewed as a society or ecosystem whose individual members are cells, reproducing by cell division and organized into collaborative assemblies or tissues. In this ecosystem, the cells are born, live and die under various forms of selection pressure such as territorial limitation, population size, source of nutrients provided, infectious agents, etc. The body is a highly organized society of cells whose main task is the maintenance of homeostasis of the whole organism. The failure of control mechanisms which make the cell the unit of society, marking the beginning of its asocial behaviour, is most frequently a malignant alteration. This process is not abrupt, nor is it based on a single event. It is, rather, a long-term process characterized mainly by mutation, competition and natural selection operating within the population of cells. The basic mechanisms controlling the cell sociability represent the first defence line against the altered cells, while the second line of defence is supposed to be made up of the immune system cells.Speaking in Darwinian terms, within the ecosystem of an organism, cells of the immune system operate as predators of the altered and mutated cells or cells infected by the intracellular parasites. The biological phenomena whose mechanisms are, at present, explored and largely understood, certainly had their own evolution. Searching for the origin and details of the evolution of advanced solutions as well as selection pressures that might justify their emergence and existence, we often fail to see that many such phenomena are, in fact, co-evolutionary by-products of evolutionary innovations. In other words, the evolutionary emergence of advanced solutions is sometimes, if not always, accompanied by certain by-products and by the co-evolution of compensatory mechanisms acting as a counterbalance to these. An example of the evolution of advanced solutions is the evolution of adoptive immunity, and co-evolution of auto-immunity and alloimmunity. Alongside the diversification of the mechanisms of adoptive immunity, auto-immunity and alloimmunity gain attributes of the evolutionary by-products and become sources of selection pressure.To that effect, alloimmunity could be a source of very strong selection pressure in mammals, simply because it is directly connected with the reproductive efficacy. At the same time, new forms of selection pressure that are connected with adoptive immunity gave rise to new mechanisms controlling killer machinery of the immune system. Finally, the last in a line of by-products in the processes of evolutionary modelling and re-modelling of vertebrate immune systems can be regarded as the failure of anti-tumor immunity. There is now much evidence that tumors can be immunogenic. Tumor cells very often express antigens in a form recognizable by the host immune system, but most frequently without consequences on tumor progression. This has been shown in many experimental models and different experimental conditions. Immediate mechanisms for the escape of tumors from the immune response are very similar to mechanisms for the escape of the fetoplacental unit (as allograft) from the maternal immune response. The similarity between these two mechanisms is so significant that any randomness must be banished.Mechanisms of anti-tumor immunity in mammals are probably substantially different from mechanisms of anti-tumor immunity in other classes of vertebrates. Moreover, the type of most frequent tumors in non-mammalian vertebrates is also significantly different. Finally, the incidence of malignant tumors in non-mammalian vertebrates is significantly lower than the incidence of malignant tumors in mammals. These facts indicate that the mammalian immune system during the anti-tumor immune response is tricked by the similarity between tumor cells and trophoblast or other placental cells. From this aspect, anti-tumor immunity failure in mammals can be defined as an immunoreproductive phenomenon, which is developed under the evolutionary pressure of auto-immunity and alloimmunity/reproductive effectiveness. It may be a specific evolutionary approach in the rendering of anti-tumor immunity failure in mammals, and a new possibility for anti-tumor immunotherapy.

For out of olde hokes, in good feyth, Cometh all this newe science that men lere. Geoffrey Chaucer The Parliament of Fowls During the past two decades knowledge of the human menstrual cycle and of normal and abnormal reproduc- tive function has increased at a dramatic rate. As rec- ognized in this volume, this explosion of knowledge is due in large measure to the development of radio- immunoassays for the measurement of the minute quantities of reproductive hormones found in the cir- culation. Yet the foundations for the many recent developments were laid well in advance. The concepts and hypotheses tested were often suggested even be- fore the hormones involved were identified and iso- lated. A consideration of the historic aspects of re- search in this field places recent research in the appropriate perspective. Moreover, as presented by Drs. vii viii FOREWORD Gruhn and Kazer, the history of progress in this field makes fascinating reading. A review of the history of reproductive endocri- nology should be required reading for all students of the subject and reproductive endocrinologists in train- ing. Dr. Griff T. Ross, a noted reproductive endocri- nologist, often instructed his students that every hy- pothesis he tested could be found in some form in the publications of previous scientists. The answers to present and future questions are often hidden in the lessons of the past.

Almost every aspect of energy and nutrient metabolism is altered by hormonal and other physiological changes during pregnancy and lactation. While it is evident that hormonal adjustments affect nutrient requirements, these are rarely considered when nutrient recommen dations are made for pregnant or lactating women, and often neglected during evaluation of nutritional status. In addition, changes in nutrient metabolism during the stages of pregnancy and oflactation are usually considered separately, while in reality events during pregnancy can have a major influence on nutritional status and nutrient requirements during lactation. The purpose of this volume is to describe changes in the metabolism of important nutrients during pregnancy and lactation, including the physiological basis for these changes and their implications for nutrient requirements and assessment. Authors have considered such issues as inter-relationships between endocrine changes and nutrient metabolism at the tissue, cellular and molecular level; alterations in nutrient binding proteins; the efficiency of nutrient absorp tion and retention; and the impact on maternal as well as fetal nutritional status. Another unique aspect of this book is the focus on pregnancy and lactation as a continuum."

Ovulation: Evolving Scientific and Clinical Concepts presents the proceedings of the International Symposium on Ovulation: Evolving Scientic and Clinical Concepts held in Salt Lake City, Utah. Internationally recognized experts provide new insights in the most recent developments in the area of mammalian ovulation, incorporating basic scientific and clinical concepts in the process. Topics include an overview of 37 years of research on ovulation, the follicle, the gonadotropin surge, the intraovarian steroid microenvironment, putative periovulatory intraovarian regulators and messengers, and clinical frontiers. More than 80 illustrations round out the text. The book is essential for all reproductive endocrinologists and Ob-Gyns.

Reproductive tract infections (RTis) have become a silent epidemic that is devastating women's lives. Each year, thousands of women die needlessly from the consequences of these infections, including cervical cancer, ectopic pregnancy, acute and chronic infections of the uterus and the fallopian tubes, and puerperal infections. For many women, this happens because they receive medical attention too late, if at all. The terrible irony of this tragedy is that early diagnosis of and treatment for many RTis do not require high-technology health care. For the hundreds of millions of women with chronic RTis acquired from their sexual partners, life can become a living hell. Infection is a major cause of infertility, and it leads to scorn and rejection in many countries. These women may experience constant pain, have festering lesions of the genital tract, be at enhanced risk of second ary diseases, and endure social ostracism. The problems associated with RT s have grown even greater in the past decade with the emergence of human immunodeficiency virus (HIV) and AIDS. Preexisting sexually transmitted disease, particularly when associated with genital tract ulcers, raises women's vulnerability to the transmission of HIV 3-5 fold."

Since 2005 a dozen states and more than 15 specialties have reported a physician shortage or anticipate one in the next few years. This anticipated shortage and a worsening of physician distribution are compounded by a projected increased demand for women's healthcare services.

Women's healthcare is particularly vulnerable, because the obstetrician-gynecologist workforce is aging and is among the least satisfied medical specialists. Furthermore, fellowship training in women's healthcare in internal medicine and in maternal child health in family and community medicine involves only a small portion of general internists and family physicians.

In response to this challenge, the Association of American Medical Colleges called for an expansion of medical schools and graduate medical education enrollments. As we cope with significant and rapid changes in organizations and reimbursement, academic departments of obstetrics and gynecology, family and community medicine, and internal medicine have opportunities to create a unified women's health curriculum for undergraduate students, share preventive health and well-woman expertise in training programs, provide improved continuity of care, instill concepts of lifelong learning to our graduates, and better develop our research programs.

This volume's chapters focus on strategic planning on behalf of academic faculty who will train the anticipated additional load of students, residents, and fellows in women's healthcare.
-changing demographics of faculty
-expanding roles of clinician educators
-physician investigators and their future
-the hidden value of part-time faculty
-faculty salaries
-required skillsets of academic leaders
-the meaning of tenure and faculty satisfaction and retention.

Recommendations presented here from authors with distinguished leadership skills indicate a consensus, but not unanimity. In furthering these goals, we summarize in the final chapter our collective expertise and offer ways to implement recommendations to better prepare for tomorrow's needs in academic women's healthcare.

In Vitro Fertilization, Embryo Transfer and Early Pregnancy is undoubtably the most exciting and onwardly progressing field in reproductive medicine today. It forms the major subject matter of this the second volume of the Proceedings and the first book of Related Communication papers given at the XI International Federation of Fertility Societies World Congress on Fertility and Sterility held in Dublin, Ireland from June 26th to July 1st 1983. The papers have been grouped into closely allied topics covering sequentially in three parts: Follicle and Ovum in the Human, Follicle and Ovum in the Animal Model, and Semen and Spermatozoa. Preceding a timely reminder on Ethical and Legal Aspects of IVF are some of the remarkable clinical results now been obtained throughout the world. The final section concerns various aspects of Pregnancy in Animals and Humans and is included in this volume because of its close relationship to the main subject matter. Related Communications sessions often produce the largest amounts of up-to-date information to be given on a particular subject during a Congress. IFFS Dublin '83 proved to be no exception. So although scientific and medical endeavour will ensure that knowledge and progress in the field will soom overtake many of the conclusions reached in these papers, nevertheless we hope you will agree in the merit of producing such a record of the state of the art at this time. Robert F. Harrison John Bonnar William Thompson Dublin 1983.