FERTILITY AND STERILITY Copyright<> 1991 The American Fertility Society Vol. 56, No.2, August 1991 Printed on acid-free paper in U.S.A. Facial and neck paresthesia associated with nafarelin administration Alan S. Penzias, M.D.* Jacqueline N. Gutmann, M.D. David B. Seifer, M.D.t Alan H. DeCherney, M.D. Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Yale University School of Medicine, New Haven, Connecticut Reported is a case of transient facial and neck paresthesia associated with the use of nafarelin ac- etate (Synarel; Syntex, Palo Alto, CA). Initial onset and eventual resolution of paresthesia were tem- porally related to the administration and discontin- uation of the medication. CASE REPORT A 26-year-old nulligravida woman with a 2! year history of primary infertility and severe dysmen- orrhea presented for evaluation. At age 21, the pa- tient had a diagnostic laparoscopy for progressively worsening dysmenorrhea that revealed stage I en- dometriosis.1 She was treated with cyclic oral con- traceptives. Repeat laparoscopy at age 23 revealed persistent pelvic endometriosis, with implants in- volving the appendix as well as the intestine. All sites were treated by laser vaporization. The remainder of her infertility evaluation re- vealed cyclic menses with an in phase endometrial biopsy and normal semen analysis. Past medical history was unremarkable. The patient underwent four cycles of controlled ovarian hyperstimulation with human menopausal gonadotropin (Pergonal; Serono, Randolph, MA). Two of these cycles were complicated by extreme ovarian response, and human chorionic gonadotro- Received January 29, 1991; revised and accepted April16, 1991. *Reprint requests: Alan S. Penzias, M.D., Yale University School of Medicine, Department of Obstetrics and Gynecology, 333 Cedar Street, New Haven, Connecticut 06510. t American Fertility Society-Ortho Distinguished Fellowship in Reproduction. Vol. 56, No.2, August 1991 pin was withheld to avoid inducing the ovarian hy- perstimulation syndrome. She continued to have severe dysmenorrhea throughout the course of gonadotropin therapy, and a third laparoscopy revealed stage II endometriosis 1 involving the cul-de-sac and left uterosacral liga- ment. These implants were treated by laser vapor- ization. No endometriosis was noted on the appendix or bowel. The fallopian tubes were noted to be patent and free of adhesions. The patient's dysmenorrhea persisted after sur- gical treatment. Physical examination was remark- able for uterine retroflexion with significant cul-de- sac tenderness but without fixation or nodularity. Pelvic ultrasound examination showed no uterine or adnexal pathology. After lengthy discussion with the patient and her husband, it was elected to begin suppressive therapy with nafarelin acetate. Medication was begun at a dose of 400 Jlg two times daily (2 sprays of 200 Jlg each to the left nostril each morning and 2 sprays of 200 Jlg each to the right nostril each evening) with the onset of menses. On medication day 23, the patient noted worsening hot flushes and left breast pain. In addition, she noted the onset of lower facial and neck tingling and numb- ness on the side contralateral to drug administration. This occurred approximately 15 minutes after in- halation and persisted for several hours. The symp- toms appeared consistently on the side of the face and neck contralateral to drug administration. On medication day 27, the patient reported these symp- toms, and the medication was discontinued. The pa- tient denied palpitations, headaches, visual distur- bances, weakness, or a previous history of having had such a sensation. She reported that the local sensory Penzias et al. Communications-in-brief 357