nor insemination clinics registered by the Royal College of Obstetricians and Gynaecologists do not implement a structured and rationalized approach to recruiting semen donors. We would welcome the comments of other author's experiences on their methods of recruiting semen donors.
C. L. R. Barratt, M.D. M. Chauhan, M.D. S. Cooke, M.D. I. D. Cooke, F.R.C.O.G. Department of Obstetrics and Gynaecology The University of Sheffield Sheffield, England October 30, 1989 REFERENCES 1. Schroeder·Jenkins M, Rothman SA: Causes of donor rejection in a sperm banking program. Fertil Stetil51:903, 1989 2. Chauhan M, Barratt CL, Cooke S, Cooke ID: A protocol for the recruitment of screening of Semen Donors for an artificial insemination by donor programme. Hum Reprod 3:873,1988 3. Monteiro EF, Spencer RC, Kinghorn GR, Barratt CLR, Cooke S, Cooke ID: Sexually transmitted disease in potential semen donors. Br MedJ [Clin Resj295:418, 1987 4. Barratt CL, Monteiro EF, Chauhan M, Cooke S, Cooke ID: Screening donors for sexually transmitted disease in donor insemination clinics in the UK, a survey. Br J Obstet Gynaecol96:461, 1989 5. Chauhan M, Barratt CL, Cooke SM, Cooke ID: Screening for cytomegalovirus antibody in a donor insemination program: difficulties in implementing The American Fertility Society Guidelines. Fertil Steril51:901, 1989
Reply of the Authors: We appreciate the comments of Barratt et al. We regrettably did not have access to his particular protocoP as it was not in print before our article went to press. Before these articles, the donor screening process had not been well characterized. The authors' excellent article describes a structured screening process that is somewhat different from ours, which apparently reflects different economic considerations. Our donor selection criteria and rejection rates are similar. Our initial questionnaire apparently contains much ofthe same information as Dr. Barratt's. We believe that the information in our questionnaire, particularly family medical history, is useful to know before proceeding with interviews or laboratory testing. We have found that the considerable time required to participate in a sperm donor pro-
182
Letters-to-the-editor
gram, beginning with the questionnaire, is in itself a reason for some donors to withdraw from the program, and believe that the questionnaire reinforces the serious implications and responsibility of being a sperm donor. The time period from return of the questionnaire to the interview and initial semen analysis (usually 10 days to 2 weeks) probably serves the same purpose as your intentional waitingperiod. We feel that an interview with the prospective donors early in the screening protocol is important as it gives the donor a clear understanding of our expectations before significant resources are spent. In our clinic, the highest expenses to the laboratory are microbiological cultures, blood work, and the physical examination. In our institution, nurse practitioners are highly experienced and well qualified to perform the history and physical examination. In one instance referred to in our paper, the nurse practitioner discovered a medical disqualifier that was not revealed earlier in the protocol. We are in agreement that all donor sperm banking programs should utilize a defined protocol for donor screening. Both papers describe similar protocols that can be used to provide a safe, high quality product at a reasonable cost.
Mari Schroeder-Jenkins, M. T.(A.S.C.P.)S.H. Susan A. Rothmann, Ph.D. Andrology Laboratory and Sperm Bank The Cleveland Clinic Foundation Cleveland, Ohio March 28, 1990 REFERENCE 1. Chauhan M, Barratt CLR, Cooke S, Cooke ID: A protocol for the recruitment and screening of semen donors for an artificial insemination by donor programme. Hum Reprod 3:873,1988
Polycystic Ovary Syndrome
To the Editor: The definition of the polycystic ovary syndrome (PCOS) is a contentious issue. Multiple ovarian cysts are a common feature ofthis "syndrome," yet similar cysts are seen on ultrasound examination of normal women. The term itself is misleading since polycystic ovary is only a clinical finding sim-
Fertility and Sterility
1
ilar to splenomegaly or hepatomegaly. Cystic ovaries are found in a multiplicity of states, which have nothing in common etiologically. The clinical management varies and is dependant on the etiology. Cystic ovaries can be observed within the context of two broad categorical etiologies. One category is the androgenic ovarian dystrophy characterized by extreme oligomenorrhea, absence of pain, monophasic basal body temperature chart, and hirsutism. The ovaries are usually moderately enlarged, ovoid in appearance, and consistently hard with a smooth surface. Plasma levels ofluteinizing hormone (LH), testosterone (T), and ,::l4-androstenedione (,::l4A) are notably increased in this first category. The second category, reactional ovarian dystrophy is different in that oligomenorrhea is infrequent or· absent, whereas pain is a common finding. Temperature graphs are usually biphasic, hirsutism is lacking, and one or both ovaries may vary enormously in volume within and between ovarian cycles. The surface of the ovaries in this second group is irregularly swollen by large cysts. Plasma levels of LH, T, and ,::l4A are within the normal range or at the upper limits of normal values. Contrary to the findings in an androgenic ovarian dystrophy case, progesterone is present during the premenstrual phase ofthe cycle. Androgenic ovarian dystrophy is idiopathic and probably has genetic origins in 95% of all cases. Androgenic ovarian dystrophy may rarely be associated with hyperprolactinemia. It may also occur during the early developmental phase of congenital adrenal hyperplasia. Virilizing tumors of the ovary and the adrenal cortex may rarely be accompanied by androgenic ovarian dystrophy. Unique subjects with brain tumors and temporal epilepsy may have ovarian changes consistent with androgenic ovarian dystrophy. Reactional ovarian dystrophy is always secondary to some other cause. Reactional ovarian dystrophy appears in individuals with chronic salpingitis and peritoneal adhesions. It is a reaction to pelvic inflammatory disease. Reactional ovarian dystrophy, when it occurs secondary to emotional stress, is usually quite painful. There are frequently accompanying neurotic symptoms. Reactional ovarian dystrophy also appears as a sequelae to extensive ovarian resection. It is a reaction to the increased secretion of follicle-stimulating hormone (FSH) and in this sense it is iatrogenic. A parallel mechanism of increased FSH secretion may ex-
Vol. 54, No.1, July 1990
plain the physiological ovarian cysts that occur during the peripubertal and perimenopausal periods. A similar pathophysiological mechanism may explain the ovarian cyst formation in some individuals on the progestin micropill and the triphasic pill. The terminology of PCOS is meaningless in terms of diagnosis and may lead to considerable confusion. It is probably wise to eliminate it from the clinician's vocabulary and replace it with idiopathic androgenic ovarian dystrophy or secondary androgenic ovarian dystrophy. Reactional ovarian dystrophy, whether it be infectious, iatrogenic, or otherwise, might designate the other form. A restructuring of the terminology might encourage a therapeutic approach that is consistently based on etiology.
Professeur Albert Netter, M.D. Medecin Honoraire de L'Hopital Necker Paris, France March 13,1990
Editorial Comment
This section of the journal rarely publishes correspondence that is not directed at a specific article in the journal. Special Papal dispensations are allowed by our editor for unique letters, especially of historical interest or from individuals who have made historical contributions to our specialty. Correspondence from Professeur Albert Netter concerning the nomenclature of cystic, or "mystic cystic" ovaries as the late Don Christian used to refer to them, is clearly a case in point. Over the past 60 years, Professeur Netter has made innumerable scientific contributions to our discipline. In spite of these notable contributions, his most enduring legacy will be the perennial course he holds each spring in Paris. This course covers the entire spectrum of reproductive endocrinology and has distinguished speakers from all over the world. For those who know Professeur Netter, it is no surprise that this course is traditionally held at a time when the foliage and vitality of Paris springtime is emerging. The singular aspect of this meeting is the "moniteur." Professeur Netter moderates the entire meeting and provides extemporaneous comments in both French and English on each topic. It is a remarkable tour de force, demonstrating the radius of information in the mind of this man. It
Letters-to-the-editor
183
is even more astonishing when you scan the topic list which may include anything from the messenger ribonucleic acid for the androgen receptor in testes to tissue characterization in 3-D ultrasound imaging. At the same time he communicates the joy of learning in two languages. In this age of increasing specialization, watching him perform makes one realize that you are observing a member of a vanishing species. It is a species of clinicians who strove for a broad knowledge of their discipline to include the rel-
184
Letters-to-the-editor
evant basic science. Albert Netter epitomizes an idea or ideal that we should try to reclaim, resurrect, or preserve, as the case may be. Otherwise, the inability to see the whole may become our most serious scientific disability. Continued research is needed, and I am sure Professeur Netter would agree, to find better ways to ensure the preservation of this imperiled species-they are the best of us. Paul G. McDonough, M.D., Editor, Letters
Fertility and Sterility
C. L. R. Barratt, M.D. M. Chauhan, M.D. S. Cooke, M.D. I. D. Cooke, F.R.C.O.G. Department of Obstetrics and Gynaecology The University of Sheffield Sheffield, England October 30, 1989 REFERENCES 1. Schroeder·Jenkins M, Rothman SA: Causes of donor rejection in a sperm banking program. Fertil Stetil51:903, 1989 2. Chauhan M, Barratt CL, Cooke S, Cooke ID: A protocol for the recruitment of screening of Semen Donors for an artificial insemination by donor programme. Hum Reprod 3:873,1988 3. Monteiro EF, Spencer RC, Kinghorn GR, Barratt CLR, Cooke S, Cooke ID: Sexually transmitted disease in potential semen donors. Br MedJ [Clin Resj295:418, 1987 4. Barratt CL, Monteiro EF, Chauhan M, Cooke S, Cooke ID: Screening donors for sexually transmitted disease in donor insemination clinics in the UK, a survey. Br J Obstet Gynaecol96:461, 1989 5. Chauhan M, Barratt CL, Cooke SM, Cooke ID: Screening for cytomegalovirus antibody in a donor insemination program: difficulties in implementing The American Fertility Society Guidelines. Fertil Steril51:901, 1989
Reply of the Authors: We appreciate the comments of Barratt et al. We regrettably did not have access to his particular protocoP as it was not in print before our article went to press. Before these articles, the donor screening process had not been well characterized. The authors' excellent article describes a structured screening process that is somewhat different from ours, which apparently reflects different economic considerations. Our donor selection criteria and rejection rates are similar. Our initial questionnaire apparently contains much ofthe same information as Dr. Barratt's. We believe that the information in our questionnaire, particularly family medical history, is useful to know before proceeding with interviews or laboratory testing. We have found that the considerable time required to participate in a sperm donor pro-
182
Letters-to-the-editor
gram, beginning with the questionnaire, is in itself a reason for some donors to withdraw from the program, and believe that the questionnaire reinforces the serious implications and responsibility of being a sperm donor. The time period from return of the questionnaire to the interview and initial semen analysis (usually 10 days to 2 weeks) probably serves the same purpose as your intentional waitingperiod. We feel that an interview with the prospective donors early in the screening protocol is important as it gives the donor a clear understanding of our expectations before significant resources are spent. In our clinic, the highest expenses to the laboratory are microbiological cultures, blood work, and the physical examination. In our institution, nurse practitioners are highly experienced and well qualified to perform the history and physical examination. In one instance referred to in our paper, the nurse practitioner discovered a medical disqualifier that was not revealed earlier in the protocol. We are in agreement that all donor sperm banking programs should utilize a defined protocol for donor screening. Both papers describe similar protocols that can be used to provide a safe, high quality product at a reasonable cost.
Mari Schroeder-Jenkins, M. T.(A.S.C.P.)S.H. Susan A. Rothmann, Ph.D. Andrology Laboratory and Sperm Bank The Cleveland Clinic Foundation Cleveland, Ohio March 28, 1990 REFERENCE 1. Chauhan M, Barratt CLR, Cooke S, Cooke ID: A protocol for the recruitment and screening of semen donors for an artificial insemination by donor programme. Hum Reprod 3:873,1988
Polycystic Ovary Syndrome
To the Editor: The definition of the polycystic ovary syndrome (PCOS) is a contentious issue. Multiple ovarian cysts are a common feature ofthis "syndrome," yet similar cysts are seen on ultrasound examination of normal women. The term itself is misleading since polycystic ovary is only a clinical finding sim-
Fertility and Sterility
1
ilar to splenomegaly or hepatomegaly. Cystic ovaries are found in a multiplicity of states, which have nothing in common etiologically. The clinical management varies and is dependant on the etiology. Cystic ovaries can be observed within the context of two broad categorical etiologies. One category is the androgenic ovarian dystrophy characterized by extreme oligomenorrhea, absence of pain, monophasic basal body temperature chart, and hirsutism. The ovaries are usually moderately enlarged, ovoid in appearance, and consistently hard with a smooth surface. Plasma levels ofluteinizing hormone (LH), testosterone (T), and ,::l4-androstenedione (,::l4A) are notably increased in this first category. The second category, reactional ovarian dystrophy is different in that oligomenorrhea is infrequent or· absent, whereas pain is a common finding. Temperature graphs are usually biphasic, hirsutism is lacking, and one or both ovaries may vary enormously in volume within and between ovarian cycles. The surface of the ovaries in this second group is irregularly swollen by large cysts. Plasma levels of LH, T, and ,::l4A are within the normal range or at the upper limits of normal values. Contrary to the findings in an androgenic ovarian dystrophy case, progesterone is present during the premenstrual phase ofthe cycle. Androgenic ovarian dystrophy is idiopathic and probably has genetic origins in 95% of all cases. Androgenic ovarian dystrophy may rarely be associated with hyperprolactinemia. It may also occur during the early developmental phase of congenital adrenal hyperplasia. Virilizing tumors of the ovary and the adrenal cortex may rarely be accompanied by androgenic ovarian dystrophy. Unique subjects with brain tumors and temporal epilepsy may have ovarian changes consistent with androgenic ovarian dystrophy. Reactional ovarian dystrophy is always secondary to some other cause. Reactional ovarian dystrophy appears in individuals with chronic salpingitis and peritoneal adhesions. It is a reaction to pelvic inflammatory disease. Reactional ovarian dystrophy, when it occurs secondary to emotional stress, is usually quite painful. There are frequently accompanying neurotic symptoms. Reactional ovarian dystrophy also appears as a sequelae to extensive ovarian resection. It is a reaction to the increased secretion of follicle-stimulating hormone (FSH) and in this sense it is iatrogenic. A parallel mechanism of increased FSH secretion may ex-
Vol. 54, No.1, July 1990
plain the physiological ovarian cysts that occur during the peripubertal and perimenopausal periods. A similar pathophysiological mechanism may explain the ovarian cyst formation in some individuals on the progestin micropill and the triphasic pill. The terminology of PCOS is meaningless in terms of diagnosis and may lead to considerable confusion. It is probably wise to eliminate it from the clinician's vocabulary and replace it with idiopathic androgenic ovarian dystrophy or secondary androgenic ovarian dystrophy. Reactional ovarian dystrophy, whether it be infectious, iatrogenic, or otherwise, might designate the other form. A restructuring of the terminology might encourage a therapeutic approach that is consistently based on etiology.
Professeur Albert Netter, M.D. Medecin Honoraire de L'Hopital Necker Paris, France March 13,1990
Editorial Comment
This section of the journal rarely publishes correspondence that is not directed at a specific article in the journal. Special Papal dispensations are allowed by our editor for unique letters, especially of historical interest or from individuals who have made historical contributions to our specialty. Correspondence from Professeur Albert Netter concerning the nomenclature of cystic, or "mystic cystic" ovaries as the late Don Christian used to refer to them, is clearly a case in point. Over the past 60 years, Professeur Netter has made innumerable scientific contributions to our discipline. In spite of these notable contributions, his most enduring legacy will be the perennial course he holds each spring in Paris. This course covers the entire spectrum of reproductive endocrinology and has distinguished speakers from all over the world. For those who know Professeur Netter, it is no surprise that this course is traditionally held at a time when the foliage and vitality of Paris springtime is emerging. The singular aspect of this meeting is the "moniteur." Professeur Netter moderates the entire meeting and provides extemporaneous comments in both French and English on each topic. It is a remarkable tour de force, demonstrating the radius of information in the mind of this man. It
Letters-to-the-editor
183
is even more astonishing when you scan the topic list which may include anything from the messenger ribonucleic acid for the androgen receptor in testes to tissue characterization in 3-D ultrasound imaging. At the same time he communicates the joy of learning in two languages. In this age of increasing specialization, watching him perform makes one realize that you are observing a member of a vanishing species. It is a species of clinicians who strove for a broad knowledge of their discipline to include the rel-
184
Letters-to-the-editor
evant basic science. Albert Netter epitomizes an idea or ideal that we should try to reclaim, resurrect, or preserve, as the case may be. Otherwise, the inability to see the whole may become our most serious scientific disability. Continued research is needed, and I am sure Professeur Netter would agree, to find better ways to ensure the preservation of this imperiled species-they are the best of us. Paul G. McDonough, M.D., Editor, Letters
Fertility and Sterility
