Biomedical subjects
Publications and source records attributed to J Buvat.
The author exposes a multifactorial physiopathological model of sexual dysfunctions in males. He stresses the usual interconnection of different etiological factors and the need to consider all the factors at the same time: organic, psychological (primary: personal or relational and secondary) to elaborate efficient treatments.
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The authors develop the key position of the wife in male impotence, even if organic. This influence may be positive or negative and plays an important role in the prognosis.
The physiological mechanism of ejaculation is recalled. The different kinds of abnormalities of ejaculation and their etiologies (drugs, post-surgery, neurological, endocrinological, psychological) are specified. The diagnosis and the therapeutical management of the different varieties are discussed and the results of a personal experience of 60 cases are reported.
This article reports on the effects of human chorionic gonadotropin (hCG) on progesterone (P) and estradiol (E2), luteal phase length, and conception in 116 cycles treated by in vitro fertilization and embryo transfer (IVF-ET). In 60 cycles, the luteal phase was supported by hCG, 1500 IU three times at 2-day intervals from the day of ET. The remaining 56 cycles served as controls. hCG significantly increased the P level (93 +/- 53 versus 62 +/- 46 ng/ml), the P/E2 ratio, and the luteal phase length (17.4 +/- 1.3 versus 12.2 +/- 1.7 days). However, the total pregnancy rate did not significantly differ between the two groups, though the pregnancy rate after transfer of two or three embryos was slightly higher in the hCG group (26.9 versus 22% in the control group), as was the rate of implanted embryo per transferred embryo after transfer of two or three embryos (25 versus 15.3%). It was concluded that, while hCG increased the magnitude and duration of the luteal P secretion, it did not clearly improve the pregnancy rate.
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In five per cent of impotent, sexual dysfunction obviously results from an organic factor which can be today qualified as "classical". "Hidden" organic factors have also been implicated in a variable ratio of the other cases. This paper constitutes a critical review of the role they play in impotence, and of the methods allowing their detection. On one hand, methods allowing evaluation of the respective responsibilities of organic and psychogenic factors (the most important of which remain nocturnal penile tumescence monitoring); on the other hand, specific investigations of each factor. It is no longer possible to deny the existence of "hidden" organic factors in impotence. These factors intervene to varying degrees in one third of cases. Among them erectile failure only by themselves. Hyperprolactinaemia, moderate hypogonadism, infraclinical neuropathies, arterial stenoses and moderate venous leakages seem to play a partial role of organic starter or cofactor, the sexual consequences of which are amplified by psychological factors, partly secondary to the initial sexual failures. Nevertheless, the conjunction of several "hidden" organic factors may probably be sufficient to induce an impotence without involvement of psychological factors.
Twenty-five impotent diatetics were investigated by means of nocturnal penile tumescence monitoring, hormone determinations, penile blood pressure measurement, artificial erection test and dynamic cavernosography, bulbocavernous reflex latency time measurement and cortical evoked responses from pudendal nerves. Sexological treatment was then attempted for a better evaluation of the psychogenic element. Penile blood pressure was also measured in 15 non-impotent diabetics and was found to be abnormal as often as in impotent diabetics. The results as a whole demonstrated that impotence was predominantly psychogenic in 9 cases, predominantly organic in 12 cases and mixed psychogenic and organic in 4 cases. Diabetic impotence is often due to several causative factors, as was the case in 12 of our patients. The factors most frequently responsible were psychological (present in 13 cases), neurological (present in 12 cases) and vascular factors (arterial abnormalities in 7 cases, "venous leakage" in 4 cases). Endocrine abnormalities were observed in only 2 cases.
Forty-five cases of nonorganic failure (n = 39) or lack of sexual desire (LSD, n = 6) were treated for one month, either with human chorionic gonadotropins (HCG, 5,000 IU I.M. twice per week) or with placebo using a double-blind method. HCG gave better results than placebo (47% vs 12%, p less than 0.05) and improved a higher number of sexual parameters (6/7) than placebo (2/7). HCG effect on sexual behavior did not correlate with the increase in plasma testosterone level: it seems HCG is a useful option in sexologic treatment of erectile failure and LSD.
Antiestrogens are widely used to treat eugonadal anovulation, luteal phase deficiency (LPD) and oligospermia. This paper reviews the rationales, endocrine effects, profertility effects and side effects of these treatments. Furthermore, we present our own experience of the use of antiestrogens in this field. We have compared the results of clomiphene citrate (CC) to those of tamoxifen (TAM) in a randomized study including 66 infertile women presenting eugonadal anovulation (n = 26) or LPD (n = 40). Both drugs obtained the same pregnancy rate of 80% at 9 months in the anovulatory patients. Conversely, CC was superior to TAM in the LPD cases (pregnancy rates at 6 months of respectively 40 and 11%). The abortion rates were of 11% on CC versus 36% on TAM. Both drugs significantly increased the luteal phase length and plasma progesterone level to the same extent. The results of endometrial biopsies suggest that the difference in their effects on female fertility could result from a detrimental effect of TAM on endometrium. The rates of the side effects proved to be almost identical on both drugs. Thus the use of TAM is not justified as a first-step treatment in ovulation disturbances. TAM should be reserved for patients who experience severe visual side effects on CC. We have also tested TAM in 100 subfertile males. In the 92 oligospermic males, TAM significantly increased the mean sperm count only in the normogonadotropic patients, but as much whether oligospermia was idiopathic or not. Sperm improvement was not significantly related to any hormone criterion except basal serum FSH. The cumulative pregnancy rate was of 41.2% at 1 year. Whether TAM actually improves male fertility, and is superior to CC in this indication, remains to be confirmed in controlled studies.
To determine whether intracavernous injection of papaverine can discriminate vascular versus psychogenic impotence 80 mg. papaverine were injected intracorporeally into 27 impotent patients without any hormonal or neurological abnormality. The patients also underwent dynamic cavernosography, the artificial erection test and selective internal iliac arteriography. In addition, 21 of the patients underwent nocturnal penile tumescence monitoring. The response to intracavernous papaverine injection was noted as positive (fully rigid erection), intermediate or negative (soft or absent erection). Among 14 patients with severe arterial lesions and/or severe venous leakage the response was negative in 11 and positive in none. Among the remaining 13 patients (moderate or absent vascular abnormalities) the response was positive in 4 but negative in 4. Of 15 patients with an abnormal nocturnal penile tumescence test the response to intracavernous papaverine injection was negative in 12 and positive in none. However, of 6 patients with a normal nocturnal penile tumescence test the response was positive in only 1. Over-all, the results of the intracavernous papaverine injection test are correlated only fairly with those of the nocturnal penile tumescence test and the vascular investigations. This test could be useful to save some nocturnal penile tumescence tests in cases of suspected vascular impotence. However, the safety of this procedure must be confirmed in larger series. Indeed, 1 of our patients suffered priapism after a second intracavernous papaverine injection performed for a therapeutic purpose.
We tested whether the necessity for high flow rates of saline to maintain an artificial erection actually corresponds to an organic abnormality able to induce impotence as claimed recently. A total of 56 patients with presumed vascular impotence and 13 with typical psychogenic impotence underwent dynamic cavernosography followed by the artificial erection test. The former 56 patients also underwent bilateral selective internal iliac arteriography. A severely elevated maintenance flow rate (more than 120 ml. per minute) was found in 19 of the 56 patients with vascular and none of the 13 with psychogenic impotence, while a moderately elevated maintenance flow rate (80 to 120 ml. per minute) was found in 11 and 3, respectively. In most cases a severely elevated maintenance flow rate was associated with arterial (16 patients) or neurological abnormalities able to disturb erection. However, a severely elevated maintenance flow rate seemed to correspond to an organic abnormality able to induce impotence or to worsen erectile failure induced by other organic factors. Indeed, we found no severely elevated maintenance flow rates among our 13 patients with psychogenic impotence and the nocturnal penile tumescence test was normal in only 1 of 12 tested patients, although 7 had no other organic impairment sufficient to induce impotence (only moderate arterial stenoses in 4). In addition, sexual treatment succeeded in only 1 of the 13 patients, while our success rate is 43 per cent among patients with arterial impotence exclusively and this treatment succeeded in 6 of 10 patients with a moderately elevated maintenance flow rate. On the contrary, a moderately elevated maintenance flow rate does not seem to correspond to a genuine organic abnormality able to induce impotence. Indeed, we found it in 3 of 13 patients with psychogenic impotence, and every patient with a moderately elevated maintenance flow rate and normal arteries had a normal nocturnal penile tumescence test or was cured by sexual therapy. In conclusion, a maintenance flow rate exceeding 120 ml. per minute seems to reveal a genuine venous incompetence but in most cases this abnormality is only the cofactor of an arterial obstruction.
Previous studies on the efficacy of bromocriptine for the treatment of patients with the polycystic ovary syndrome failed to include control groups. This study, therefore, was undertaken to determine the clinical and endocrine effects of bromocriptine and a placebo (given in a random double blind fashion) in 55 patients with PCOS. The plasma levels of estrone, estradiol, testosterone, androstenedione, dehydroepiandrosterone, dehydroepiandrosterone sulfate, 17-hydroxyprogesterone, and serum PRL and gonadotropins (LH and FSH) were measured before treatment. In addition the serum PRL response to TRH and the serum LH and FSH response to GnRH were determined. The effects of acute administration of bromocriptine (2 X 2.5 mg at 12-h intervals) on serum gonadotropins and their response to GnRH were studied to explore the possibility that this test might predict the response to chronic bromocriptine treatment. Bromocriptine then was given at an initial dose of 1.25 mg twice daily. If no clinical improvement occurred 2.5 mg were given twice daily for at least 6 months. Hormonal measurements and dynamic tests were repeated after 3 and 6 months of therapy. The endocrine profile of the two groups was not different before treatment. The clinical results were not better in the treatment group than in the placebo-treated patients: therapy was successful (restoration of ovulatory cycles of less than 35 days duration) in 12 of 28 patients taking bromocriptine vs. 8 of 27 taking placebo. Slight improvement (1 or 2 ovulations) occurred in 3 of 28 vs. 3 of 27, and failure (no clinical change) in 13 of 28 taking bromocriptine vs. 16 of 27 taking placebo, respectively. Serum PRL fell significantly in the bromocriptine group, and there was a significant fall in the serum LH response to GnRH in both groups. No hormonal measurement or response predicted the clinical response to treatment. The only significant effect of chronic bromocriptine therapy (5 mg/day) in patients with the polycystic ovary syndrome was to lower the serum PRL concentration.
We analyzed data from 20 patients with late-onset 21-hydroxylase deficiency (LOHD). Three clinical phenotypes could be distinguished among the 18 women. Seven (39%) presented with clinical features suggesting polycystic ovarian disease (PCOD). However, despite androgen levels similar to those of patients with typical PCOD, high serum LH to FSH ratios were not consistently found. Seven other women (39%) presented with isolated hirsutism, suggesting idiopathic hirsutism. The remaining 4 women (22%) had no manifestations of androgen excess and were considered to have the cryptic form of LOHD. Serum 17-hydroxyprogesterone (17-OHP) and androgen levels were similar in the 3 phenotypes, suggesting that the clinical expression of LOHD in women is modulated by individual factors, such as androgen sensitivity. The 2 men were detected by family study and were clinically normal. Since clinical diagnosis of LOHD is impossible, we concentrated on hormonal data with the aim of providing guidelines for the biological diagnosis of LOHD. Assay of basal serum 17-OHD at 0800 h in both sexes and in the early follicular phase in women was sufficient to establish the diagnosis of LOHD in most patients. If doubtful results are obtained, i.e. serum 17-OHP levels between 2 and 5 ng/ml, an ACTH test must be performed. Post-ACTH serum 17-OHP levels exceeding 10 ng/ml confirm the diagnosis of LOHD. Such results should avoid confusion with heterozygotes for 21-hydroxylase deficiency, whose frequency is high within the general population and may be even higher in patients with idiopathic hirsutism or PCOD.
Intracavernous injection (IC) of vasoactive drugs (papaverine (ICP) in 115 cases and different alpha-blockers in 65 cases) were administered to 65 patients with erectile impotence to evaluate diagnostic and therapeutic interest of this procedure. Immediate (induction of erection) and medium term (lasting improvement in impotence) results were correlated with those of investigations of multidisciplinary etiologies. Comparison of results of ICP with those of plethysmography of nocturnal erections (PEN, 52 cases) gave negative results for the papaverine test (lack of erection or one without rigidity) in 67% of cases of impotence of organic origin (PEN abnormal). However, the test was positive (totally rigid erection) in 17% of cases of organic etiology and only 40% of psychogenic cases (PEN abnormal). Comparison of results with those of selective hypogastric arteriography and of the artificial erection test with dynamic cavernography (43 cases) showed that the papaverine test was never positive in patients with severe arterial occlusion or obvious venous leaks. However, an elevated proportion of cases with a negative test failed to show signs of marked vascular anomalies. Integration of results of total multidisciplinary explorations showed that most patients with organic or mixed impotence producing a positive or intermediary type papaverine test were cases of neuropathic impotence or had major neuropathic elements. Repeated IC of different vasoactive drugs (excluding the use of autoinjection techniques) failed to provide lasting improvement except for psychogenic impotence (5 of 9 cases). But it is in this group that IC is the most dangerous (2 cases of priapism and 8 cases of rigid erection prolonged over more than 4 hours).(ABSTRACT TRUNCATED AT 250 WORDS)
We have seen a patient who became pregnant. She was suffering from cystic fibrosis diagnosed late in life at the age of 26 years. Her case has allowed the authors to make some observations on this association of pregnancy with cystic fibrosis which will become increasingly common. 5% of individuals are heterozygous for this condition. The prospect for these patients surviving gets better and better. Although their fertility seems to be lowered it is possible for them to become pregnant. They are caught in the web of almost constant episodes of broncho-pulmonary infection with lasting effects on their respiratory capacities in 50% of cases. About 83% of these patients will deliver prematurely because of the respiratory distress they suffer. It is difficult to predict the long-term effects of pregnancy on the survival of these patients since the mortality rate anyhow is about 10% per year. According to the literature pregnancy will cause a permanent deterioration in respiratory function in about 37% of cases. The history of this particular case should be able to give new hope to some women suffering from this condition. All the same, there are a large number of problems that still have to be dealt with.
Fourty nine men seeking advice for erectile impotence, in whom the serum flow rate necessary to maintain an artificial erection (MFR) exceeded the upper limit of the normal range proposed by most authors (75 ml/mn), underwent different investigations (including a study of their penile arteries, Nocturnal Penile Tumescence monitoring (NPT) and a papaverine test) in order to ascertain the organic basis of their impotence, and to define the diagnostic criteria for "venous incompetence". Several other types of treatments were attempted. Two thirds of the patients were found to have occlusions of their sexual arteries, and these were severe in one third of cases. Our overall results suggest that only cases of MFR exceeding 120 ml per mn. were due to a true organic abnormality (severe venous incompetence, SVI), able to induce impotence, and possibly warrant surgical treatment, on condition that the organic nature is confirmed by NPT. 40% of the cases of impotence with SVI start before the age of 40, and 15% are primary. 37.5% of the cases never achieve rigid erection, and 37.5% have only rigid erections of short duration. Very few plausible etiological factors were found, except fibrosis of the cavernous bodies in 5 cases. The prognosis of impotence with SVI seems very bad, since only 4 of the 35 patients were clearly improved by non surgical treatments, while only 1 out of the 10 patients who underwent a surgical ligation of the deep dorsal vein of the penis was improved.
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