Androgen insensitivity syndrome in its complete form is a disorder of hormone resistance characterised by a female phenotype in an individual with an XY karyotype and testes producing age-appropriate normal concentrations of androgens. Pathogenesis is the result of mutations in the X-linked androgen receptor gene, which encodes for the ligand-activated androgen receptor--a transcription factor and member of the nuclear receptor superfamily. This Seminar describes the clinical manifestations of androgen insensitivity syndrome from infancy to adulthood, reviews the mechanism of androgen action, and shows examples of how mutations of the androgen receptor gene cause the syndrome. Management of androgen insensitivity syndrome should be undertaken by a multidisciplinary team and include gonadectomy to avoid gonad tumours in later life, appropriate sex-hormone replacement at puberty and beyond, and an emphasis on openness in disclosure.

To assess the risk of miscarriage after in-vitro fertilization (IVF) with respect to age, cause of infertility, ovarian morphology and treatment regimen, a retrospective analysis was performed of the first 1060 pregnancies conceived between June 1984 and July 1990 as a result of 7623 IVF cycles. Superovulation induction was achieved with human menopausal gonadotrophin (HMG) and/or purified follicle stimulating hormone (FSH) together with either clomiphene citrate or the gonadotrophin hormone-releasing hormone (GnRH) agonist buserelin, the latter either as a short 'flare' regimen or as a 'long' regimen to induce pituitary desensitization. There were 282 spontaneous abortions (26.6%) and 54 ectopic pregnancies (5.1%). The mean age of women with ongoing pregnancies was 32.2 (SD 3.9) years compared with 33.2 (SD 4.1) years in those who miscarried, which were significantly different (P = 0.008). There was no relation between the miscarriage rate and the indication for IVF. The miscarriage rate was 23.6% in women with normal ovaries compared with 35.8% in those with polycystic ovaries [P = 0.0038, 95% confidence interval (CI) 4.68-23.10%]. There was no difference in the miscarriage rate between treatment with HMG or FSH. Women whose ovaries were normal on ultrasound were just as likely to miscarry if they were treated with clomiphene or with the long buserelin protocol. Those with polycystic ovaries, however, had a significant reduction in the rate of miscarriage when treated with the long buserelin protocol, 20.3% (15/74), compared with clomiphene citrate, 47.2% (51/108) (P = 0.0003, 95% CI 13.82-40.09%).

This inductive study proposes a model for medical teacher development that attempts to explain how doctors learn to teach and train. More research is needed to clarify the findings. There are implications for faculty development.

OBJECTIVE -We investigated the effects of normal variations in maternal glycemia on birth size and other birth outcomes.RESEARCH DESIGN AND METHODS -Women in two unselected birth cohorts, one retrospective (n ϭ 3,158) and one prospective (n ϭ 668), underwent an oral glucose challenge at 28 weeks of gestation. In the retrospective study, glycemia was linked to routine birth records. In the prospective study, offspring adiposity was assessed by skinfold thickness from birth to age 24 months.RESULTS -In the retrospective study, within the nondiabetic range (2.1-7.8 mmol/l), each 1 mmol/l rise in the mother's 60-min glucose level was associated with a (mean Ϯ SEM) 2.1 Ϯ 0.8% (P ϭ 0.006) rise in absolute risk of assisted vaginal delivery, a 3.4 Ϯ 0.8% (P Ͻ 0.0001) rise in emergency cesarean delivery, a 3.1 Ϯ 0.7% (P Ͻ 0.0001) rise in elective cesarean delivery, and a 46 Ϯ 8 g (P Ͻ 0.0001) increase in offspring birth weight. In the prospective study, fetal macrosomia (birth weight Ͼ90th centile) was independently related to the mother's fasting glucose (odds ratio 2.61 per ϩ1 mmol/l [95% CI 1.15-5.93]) and prepregnancy BMI (1.10 per ϩ1 kg/m 2 [1.04 -1.18]). The mother's higher fasting glycemia (P ϭ 0.004), lower insulin sensitivity (P ϭ 0.01), and lower insulin secretion (P ϭ 0.02) were independently related to greater offspring adiposity at birth. During postnatal follow-up, the correlation between the mother's glycemia and offspring adiposity disappeared by 3 months, whereas prepregnancy BMI was associated with offspring adiposity that was only apparent at 12 and 24 months (both P Ͻ 0.05).CONCLUSIONS -Prepregnancy BMI, pregnancy glycemia, insulin sensitivity, and insulin secretion all contribute to offspring adiposity and macrosomia and may be separate targets for intervention to optimize birth outcomes and later offspring health.

Objective-To assess the efficacy of emergency cervical cerclage. Design-Retrospective review of patients who underwent emergency cervical cerclage between August 1986 and August 1989. Setting-University College and the Middlesex Hospitals obstetric unit, a neonatal referral centre. Subjects-19 women between 16 and 28 weeks gestation with a cervical dilatation between 3 and 10 cm. There were two twin pregnancies. Interventions-Amniocentesis and bacteriological assessments were performed prior to cerclage and prophylactic antibiotics were given. Insertion of sutures was aided by a combination of techniques described previously. Main outcome measures-Prolongation of gestation and pregnancy outcome. Bacteriological findings at delivery and maternal and fetal morbidity were also recorded. Results-Membranes remained intact in all the women after cerclage. Fifteen live babies were born and 13 of them survived (survival rate 63%). Gestation was prolonged from between 1 and 19 weeks in these patients and the gestational age at delivery ranged from 25 to 41 wecks. All eight intrauterine or neonatal deaths were associated with infection. Infecting organisms included Escherichia coli, Gardnerella vaginalis, Mycoplasma hominis, Trichomonas vaginalis and Fusobacterium spp. Pregnancy was prolonged for S5 weeks in these infected pregnancies. A cervical laceration occurred in a patient who had the suture inserted at full dilatation and subsequently laboured, but there were no other maternal complications. Conclusion.-Emergency cervical cerclage can prolong pregnancy and influence the outcome favourably.