Comparative effects of estrogens plus androgens and tibolone on bone, lipid pattern and sexuality in postmenopausal women

BACKGROUND

The main goals of estrogen replacement therapy (ERT) are the prevention of osteoporosis and cardioprotection and the improvement of quality of life (QL). Androgens and tibolone therapy may increase bone mineral density (BMD) to a greater extent than ERT and offer an increase in QL. Lipid and cardiovascular effects, however, are still a major concern.

AIM

To evaluate whether the addition of a weak androgen to ERT may improve postmenopausal bone loss and sexual activity without adverse effects on lipid pattern and to compare these effects with those observed after tibolone therapy.

SUBJECTS AND METHODS

This prospective study enrolled 120 surgical postmenopausal women; of these, 96 completed the 1-year follow-up. Patients were allocated to one of four groups. The first group (A; n = 23) received 4 mg of estradiol valerate plus 200 mg of enanthate of dihydroandrosterone im monthly. The second group (E; n = 26) received 50 microg/day of transdermal 17-b-estradiol continuously; the third (T; n = 23) received 2.5 mg of tibolone every day; and finally, the fourth group (C; n = 24) constituted a treatment-free control group. Bone mass (dual X-ray absorptiometry), serum total cholesterol, HDL, LDL, triglycerides, apolipoproteins A1 and B and sexual activity were evaluated before starting therapy and at the end of follow-up.

RESULTS

All active treatment groups showed an increase in BMD. This increase was higher in the A treatment group (4.08% P < 0.01). Sexuality improved significantly with therapy; however, tibolone and androgens increased scores to a greater extent than ERT. Androgen therapy was associated with significant increases in total cholesterol, LDL and triglycerides. Cholesterol and LDL fall into groups E and T, HDL into groups A and T and triglycerides in group T only.

CONCLUSION

The combined regimen of androgens and ERT increased vertebral bone mass and enhance sexual activity in postmenopausal women equal to that of tibolone and to a greater extent than ERT alone; its effects on lipids, however, are clearly adverse.

Follicular development and hormonal levels following highly purified or recombinant follicle-stimulating hormone administration in ovulatory women undergoing ovarian stimulation after pituitary suppression for in vitro fertilization: implications for implantation potential

PURPOSE

The main goal in the present study was to compare follicular development and estradiol levels after ovarian stimulation in pituitary suppressed normally ovulating women undergoing IVF, using highly purified urinary follicle stimulating hormone (FSH) (u-FSH-HP) and recombinant FSH (rec-FSH). A secondary variable in our study was embryo implantation potential, which is closely related to appropriate follicular development and oocyte competence.

METHODS

For the main purpose of this study, 30 IVF patients (group 1) were treated during IVF consecutive cycles, using the same stimulation protocol, with u-FSH-HP in the first treatment study cycle and rec-FSH in the second one. As a control group (group 2) for implantation rates obtained in cycles treated with rec-FSH, 30 additional IVF patients were included who underwent a second IVF attempt again with u-FSH-HP.

RESULTS

The total dose of FSH used and ovarian response obtained in terms of estradiol plasma levels and the total number of growing follicles on the day of human chronic gonadotropin (HCG) injection were similar in both treatment cycles in group 1 but better follicular dynamics and oocyte maturity were obtained with rec-FSH. The implantation rate was significantly higher in rec-FSH treated cycles in patients in group 1 than in control women (group 2).

CONCLUSIONS

rec-FSH is more efficacious than u-FSH-HP when used in the same patient in inducing multiple follicular development in down-regulated cycles as indicated by ovarian performance and oocyte maturity. In addition, rec-FSH yields significantly higher implantation rates than u-FSH-HP when used in patients undergoing their second IVF attempt.

Ovarian reserve test with human menopausal gonadotropin as a predictor of in vitro fertilization outcome

PURPOSE

Our purpose was to determine prospectively, using receiver-operating characteristic (ROC) analysis, whether the ovarian reserve test with hMG could improve the predictive value of a woman's age and basal levels of follicle stimulating hormone (FSH), E2, and inhibin or any combination of them regarding ovarian response and pregnancy rate in IVF treatment following pituitary desensitization.

METHODS

The hMG test was performed within 3 months of IVF treatment in 80 women undergoing the first cycle of IVF and consisted of 2 ampoules of hMG daily for 5 days starting on cycle days 2 to 3. Hormone and ultrasound evaluation was performed on cycle days 2 to 3 and 7 to 8.

RESULTS

The mean age and basal FSH levels were significantly higher in the canceled (n = 28) than in the control (n = 52) group, whereas the basal inhibin level was significantly higher in the latter. Regarding ovarian response, the combination FSH plus inhibin had the better diagnostic accuracy (predictive value of 70%) among basal variables. When post-hMG parameters (alone or in combination) were analyzed, E2 alone, with a 77% diagnostic accuracy, emerged as the best predictive variable of cancellation in IVF cycles. When ROC analysis was used, the area under the ROC curve for E2 post-hMG (diagnostic accuracy of 84.5%) was significantly higher than that for the estimates based on the combination of basal FSH and inhibin (diagnostic accuracy of 71.3%). However, woman's age was the only variable independently associated with pregnancy rate.

CONCLUSIONS

The predictive power of the hMG test of ovarian reserve is better than that of age and basal hormone values (FSH and inhibin) and it is based mainly on the E2 response to hMG treatment. However, given that age is the only predictor of pregnancy and considering the cost and discomfort of the hMG test, the usefulness, if any, of the test in predicting IVF performance in the daily clinical setting remains to be established.

Increasing the daily dose of recombinant follicle stimulating hormone (Puregon) does not compensate for the age-related decline in retrievable oocytes after ovarian stimulation

A prospective, randomized, double-blind, multicentre (n = 6) study was conducted to compare the influence of either a 150 or 250 IU daily fixed-dose regimen of recombinant follicle stimulating hormone (FSH, Puregon) on the number of oocytes retrieved and the total dose used in down-regulated women between 30 and 39 years of age undergoing ovarian stimulation. In all, 138 women were treated with recombinant FSH, 67 with 150 IU and 71 with 250 IU. The number of oocytes retrieved in the low-dose group was 9.1 compared to 10.6 in the high-dose group (not significant). In the 30-33 years of age class receiving the 250 IU dose, a surplus of 4.2 oocytes (14.8 versus 10.6) was found, whereas in the 37-39 age class nearly one oocyte more was retrieved in the 150 IU group (8.1 versus 7.4). The total dose used to reach the criterion for human chorionic gonadotrophin (HCG) administration was 1727 IU for the women treated with 150 IU daily and 2701 IU for the 250 IU treated women (P < 0. 001). No significant relationships were found between serum FSH concentrations as obtained in the early follicular phase and the number of oocytes collected, or the total dose. It is concluded that in women between 30 and 39 years of age, the decline in number of oocytes retrieved with increasing age cannot be overcome by augmenting the daily dose of recombinant FSH from 150 to 250 IU.

Long-term compliance with estrogen replacement therapy in surgical postmenopausal women: benefits to bone and analysis of factors associated with discontinuation

OBJECTIVE

To evaluate prospectively the effects of long-term estrogen replacement therapy (ERT) on bone density in surgical postmenopausal women treated for 5 years with two different modalities and to determine the factors associated with discontinuation of ERT.

DESIGN

We included in the present study 165 women (mean age, 46.8 +/- 4.6 years) who had undergone surgical menopause. ERT was prescribed immediately after surgery, and bone mineral density was measured at the lumbar spine before the women entered the study and at 12, 24, 36, 48, and 60 months after being included. Treated patients were assigned at random to one of two groups. The first group received conjugated equine estrogens 0.625 mg/day continuously, and the second group received transdermal 17beta-estradiol 50 mg/day continuously. Treated groups were compared with a nontreated control group.

RESULTS

Our data showed that although ERT clearly protected against bone loss in women who had experienced surgical menopause, only one third of the treated patients continued ERT at the end of follow-up. The main reason for discontinuation was fear of cancer (36.1 % of cases). In addition, no differences were observed between oral and transdermal groups of treatment.

CONCLUSIONS

Long-term ERT may have a protective effect against bone loss in surgically postmenopausal women; however, two thirds of treated patients discontinued therapy after 5 years and 43% of them presented a negative balance on bone mass in one or more bone density assessments. For this reason, enhancing compliance and monitoring treatment are mandatory.

Clinical study and follow-up of 100 patients with the antiphospholipid syndrome

OBJECTIVES

To study the clinical characteristics at diagnosis and during follow-up of patients with the antiphospholipid syndrome (APS) and to analyze the influence of treatment on their outcome.

PATIENTS

One hundred patients with APS were included (86% female and 14% male; mean age, 36 years). Sixty-two percent had primary APS and 38% had APS associated with systemic lupus erythematosus (SLE). The median length of follow-up was 49 months.

RESULTS

Fifty-three percent of the patients had thromboses, 52% had thrombocytopenia, and 60% of the women had pregnancy losses. Patients with APS associated with SLE had a higher prevalence of hemolytic anemia (P = .02), thrombocytopenia (platelet count lower than 100 x 10(9)/L) (P = .004), antinuclear antibodies (P = .0002), and low complement levels. Fifty-three percent of the patients with thrombosis had recurrent episodes (86% in the same site as the previous thrombotic event). Recurrences were observed in 19% of the episodes treated with long-term oral anticoagulation, in 42% treated prophylactically with aspirin, and in 91% in which anticoagulant/antiaggregant treatment was discontinued (P = .0007). Multivariate analysis showed that prophylactic treatment and older age had an independent predictive value for rethrombosis. Prophylactic treatment during pregnancy (usually with aspirin) increased the live birth rate from 38% to 72% (P = .0002).

CONCLUSIONS

Patients with APS have a high risk of recurrent thromboses. Long-term oral anticoagulation seems to be the best prophylactic treatment to prevent recurrences. Prophylactic treatment with aspirin during pregnancy reduced the rate of miscarriages remarkably.

Type-1 and type-2 cytokines in human decidual tissue and trophoblasts from normal and abnormal pregnancies detected by reverse transcriptase polymerase chain reaction (RT-PCR)

PROBLEM

Cytokine expression at the maternal fetal interface has been well documented in rodents, but data in the human are scanty and controversial.

METHOD OF STUDY

We examined cytokine expression of human decidua and trophoblasts by semiquantitative visual grading of reverse transcriptase polymerase chain reaction (RT-PCR) products in five groups of patients: ten patients with uncomplicated term pregnancies undergoing elective cesarean section (Group 1); ten women having normal pregnancies at term and vaginal delivery (Group 2); ten patients having intrauterine growth-retarded infants of unknown cause after a spontaneous vaginal delivery at term (Group 3); ten childless women having their first, first-trimester spontaneous abortion (Group 4); and ten childless women with a history of one or more previous first-trimester spontaneous abortions and having a new miscarriage (Group 5).

RESULTS

Results favoring the T-helper 1 (Th1)/T-helper 2 (Th2) model during pregnancy were: significantly higher expression of interferon gamma (IFN-gamma) in trophoblast samples from Group 3 versus 2 and in decidual tissue from Group 5 versus 4; stronger positivity of interleukin (IL)-10 in decidual tissue samples from Group 1 versus Groups 2 and 5; and higher expression levels of tumor necrosis factor-beta (TNF)-beta by the trophoblast in Group 5 versus 1. Against the Th1/Th2 paradigm were the following findings: the significantly increased expression of IFN-gamma by decidual or trophoblast samples in Groups 1 versus 2, 2 versus 3, and 1 versus 5; and the significantly higher expression of TNF-alpha in decidual samples from patients in Group 1 (but also Group 4) as compared with Group 5. IL-2 mRNA and IL-4 mRNA could not be detected.

CONCLUSIONS

Overall, our findings suggest that there is a balance between type-1 and type-2 cytokines during pregnancy, which is mainly characterized by the expression of IFN-gamma (a type-1 cytokine) and IL-10 (a type-2 cytokine) at the maternal fetal interface.

Human reproductive failure is not a clinical feature associated with beta(2) glycoprotein-I antibodies in anticardiolipin and lupus anticoagulant seronegative patients (the antiphospholipid/cofactor syndrome)

It has been suggested that patients with clinical features suggestive of antiphospholipid syndrome but being lupus anticoagulant (LA) and anticardiolipin (aCL) negative, should be tested for antibodies to beta(2) glycoprotein-I (abeta(2)GP-I), a protein involved in the binding of antiphospholipid antibodies (aPL) to phospholipid surfaces. This was investigated in the present study where a total of 385 women aged </=40 years were included. Of these, 175 were experimental subjects and 210 were controls. The former comprised the following two study groups: 100 spontaneous recurrent aborters (group one), and 75 patients with repeated failure of embryo transfer (group two). Controls included three groups of women: 100 normal healthy parous women with no previous abortion (group three), 60 infertile patients achieving a live birth with their first in-vitro fertilization (IVF)/embryo transfer attempt (group four), and 50 patients with recurrent abortion who tested positive for aPL (LA and/or aCL) (positive controls, group five). Only one patient among recurrent aborters (group one) tested positive for abeta(2)GP-I. All women in groups two, three and four were negative for abeta(2)GP-I screening. As expected, prevalence of patients testing positive for abeta(2)GP-I was significantly higher in group five than among the other groups of patients (P < 0.001). No differences were observed regarding the prevalence of abeta(2)GP-I positive sera in the subgroup of patients having aCL and those having the LA in group five. It is concluded that abeta(2)GP-I screening in first-trimester recurrent abortion or in failure of implantation after IVF is not warranted in patients without aPL as detected by standard antiphospholipid assays.

Adrenomedullin and nitric oxide in menstrual and in vitro fertilization cycles. Relationship to estradiol

BACKGROUND

Estradiol has marked systemic vasodilator effects which may be partially mediated by nitric oxide. Recently, a new vasodilator peptide, adrenomedullin, having potent vasodilatory action which is mediated at least in part by nitric oxide, has been isolated. This study investigated whether a relationship exists between circulating levels of estradiol, adrenomedullin, and nitrite/nitrate (the two stable oxidation products of NO metabolism) both in the spontaneous menstrual cycle and IVF cycles.

METHODS

Ten normal ovulatory infertile patients were included in this prospective longitudinal study. Circulating levels of estradiol, adrenomedullin, and nitrite/nitrate were investigated. Follicular fluid concentrations of adrenomedullin and nitrite/nitrate, as well as estradiol, were also determined in IVF cycles.

RESULTS

Serum nitrite/nitrate levels were significantly elevated in the late follicular phase compared to cycle day 3 of the spontaneous menstrual cycle thus paralleling plasma estradiol. However, no significant change in serum nitrite/nitrate concentration was found associated to multifollicular development and supraphysiological levels of estradiol in IVF cycles. Adrenomedullin plasma levels did not show significant variation either in menstrual or IVF cycles. No correlation was found between plasma estradiol levels and nitrite/nitrate serum concentrations or adrenomedullin plasma levels nor between circulating adrenomedullin and nitrite/nitrate both in menstrual and IVF cycles. Follicular fluid concentrations of estradiol and adrenomedullin but not nitrite/nitrate were significantly higher than those found in plasma or serum. Neither estradiol follicular fluid concentration correlated with those of adrenomedullin or nitrite/nitrate nor a relationship was observed between adrenomedullin and nitrite/nitrate.

CONCLUSIONS

Circulating levels of nitrite/nitrate show a significant increase during the late follicular phase in the normal menstrual cycle which is unrelated to adrenomedullin. In addition, this does not necessarily indicate a cause and effect relationship between nitrite/nitrate and estradiol levels given that no increase in nitrite/nitrate was observed from a hypoestrogenic to a hyperestrogenic state during IVF cycles. Further studies are necessary to clarify this subject. Also, the biological and clinical significance of the presence of adrenomedullin in the human follicular fluid remains to be elucidated.

Recurrent empty follicle syndrome successfully treated with recombinant human chorionic gonadotrophin

We report a case of a patient with polycystic ovary syndrome and primary infertility who was admitted to our in-vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) programme because of her partner's severe oligozoospermia and asthenozoospermia. Ovarian stimulation was accomplished in the three treatment cycles using gonadotrophin therapy after a dual approach with ovarian suppression using oral contraceptive pills followed by gonadotrophin-releasing hormone agonist therapy. Oocyte retrieval was unsuccessful in the first two treated cycles despite the fact that human chorionic gonadotrophin (HCG) from three different batches was used. In the third treatment cycle, recombinant HCG was used and five oocytes were retrieved. This is the first report of recurrent empty follicle syndrome despite the use of different batches of commercially available urinary HCG, and of its successful treatment using recombinant HCG.

Two-year prospective and comparative study on the effects of tibolone on lipid pattern, behavior of apolipoproteins AI and B

OBJECTIVE

To investigate long-term lipid and lipoprotein changes in postmenopausal women treated with tibolone in a prospective study using appropriate control groups.

DESIGN

Seventy-six of 105 postmenopausal women initially selected for this study completed the 2-year follow-up. Patients were allocated into three groups. The first received 2.5 mg/day tibolone continuously (n = 27; group T), the second received 0.625 mg/day conjugated equine estrogen plus 2.5 mg/day of medroxyprogesterone (group E-P) continuously (n = 25), and a third group contained an additional 24 women who did not receive replacement therapy; these constituted the untreated control group (group C). Plasma lipids and lipoproteins were determined in all patients before joining the study and also at 12 and 24 months after being included.

RESULTS

Women treated with tibolone experienced the greatest decreases in cholesterol, both total and high density lipoprotein (HDL), and triglycerides (TG), whereas the highest increase in HDL was observed in the group E-P. A decrease in low density lipoprotein levels was detected in both therapy groups, whereas a significant increase was observed in the control group. TG were increased after E-P therapy. In all the groups, apolipoprotein AI showed parallel trends to HDL and apolipoprotein B to low density lipoprotein.

CONCLUSIONS

Both therapy groups, tibolone and E-P, induced changes in levels of plasma lipids, lipoproteins and apolipoproteins. Long-term tibolone treatment is associated with a marked and significant decrease in HDL apolipoprotein AI and TG, an effect that defines the major difference with standard HRT. Clearly, further studies are necessary to establish the definite risk/benefit ratio of tibolone with respect to its overall effect on lipid metabolism.

Ascites and liver test abnormalities during severe ovarian hyperstimulation syndrome

OBJECTIVE

Severe ovarian hyperstimulation syndrome is an uncommon cause of ascites that is being increasingly recognized because of the high number of women undergoing assisted reproductive techniques, mainly in vitro fertilization. This prospective study investigates the clinical and biochemical characteristics of a large series of patients with this syndrome and ascites, including renal and electrolyte abnormalities, activity of neurohormonal systems participating in the regulation of extracellular fluid volume, and liver function tests.

METHODS

This was a prospective longitudinal study including 50 consecutive patients with ascites due to severe ovarian hyperstimulation syndrome. Renal function, serum electrolytes, body weight, mean arterial pressure, pulse rate, plasma renin activity, plasma concentration of aldosterone, norepinephrine, antidiuretic hormone and atrial natriuretic peptide, and standard liver function tests were measured during the syndrome and 4-5 wk after recovery. A sample of ascitic fluid was obtained from eight patients for protein measurement and cell count.

RESULTS

At diagnosis, patients had ascites associated with low urinary sodium excretion, oliguria, and hyponatremia. They had also markedly low arterial pressure and increased pulse rate in association with marked activation of vasoconstrictor and antinatriuretic factors. The ascitic fluid was characterized by a high protein concentration, low leukocyte count, and relatively high number of red blood cells. Fifteen (30%) patients had abnormal liver tests characterized by mild to moderate increases in AST (mean 103 +/- 17.1 IU/L) and ALT (76 +/- 8.3 IU/L), which were associated in some cases with increases in gamma-glutamyl transpeptidase or alkaline phosphatase. All abnormalities reverted to normal after the resolution of the syndrome.

CONCLUSIONS

With the increasing use of assisted reproductive techniques, physicians should be aware of severe ovarian hyperstimulation syndrome as a cause of ascites. The syndrome is associated with sodium retention, hyponatremia, arterial hypotension, and marked activation of vasoconstrictor and antinatriuretic systems. In one third of patients, liver tests abnormalities are present.

Obstetrical outcome of pregnancy in patients with systemic Lupus erythematosus. A study of 60 cases

OBJECTIVE

To analyze the course of maternal diseases and the outcome of pregnancy in patients with systemic Lupus Erythematosus (SLE).

STUDY DESIGN

During a period of 11 years we prospectively followed 60 pregnancies in 46 SLE patients in a tertiary care center in Barcelona (Spain). The management protocol included: (1) planning of conception when disease was inactive; (2) frequent follow-up visits by an internist-obstetrician team; (3) use of sequential ultrasonographic, Doppler and fetal echocardiographic examinations; (4) serial evaluations of maternal immunological condition; and (5) low dose aspirin from 1 month before attempting conception and throughout pregnancy was added in women with antiphospholipid antibodies. From 1985 until 1994 prednisone prophylaxis was used in all lupus patients during the last month of pregnancy and during the first month of the puerperium; from 1995 onwards this regime was abandoned.

RESULTS

The mean (S.D.) age of patients was 28.6 (4.8) years (range 20 to 42) and the mean (S.D.) previous duration of SLE was 6.25 (4.8) years (range 0 to 17). SLE was diagnosed during the pregnancy in two cases (3.3%) and the disease was active at conception in four cases (6.7%); at that time nine patients (15%) were taking prednisone. Antiphospholipid antibodies were positive in 16 patients (30.4%) and there were 10 (16.7%) pregnancies in patients having lupus nephropathy. There were three first-trimester miscarriages (5%) and four (6.7%) voluntary abortions. Obstetric complications in the remaining 53 pregnancies included: preterm delivery, 11 cases (20.8%); intrauterine growth retardation, five cases (9.4%); hypertension, 10 patients (18.9%), five of them fulfilling the criteria of preeclampsia; premature rupture of membranes, four patients (7.5%); finally, 13 neonates had a birthweight lower than 2500 g. There were 15 lupus flares (28.3%), giving a flare rate of 0.044 per patient/month. There were five neonatal deaths (perinatal mortality rate, 94 per thousand): one because of complete heart block, three due to severe hyaline membrane disease resulting from extreme prematurity and one intrauterine death in a patient having the Leiden mutation.

CONCLUSION

Pregnancy in patients with SLE should not be regarded as an unacceptable high-risk condition for the mother or her baby provided that conception is accurately planned and patients are managed according to a careful multidisciplinary treatment schedule.

Human chorionic gonadotrophin luteal support overcomes luteal phase inadequacy after gonadotrophin-releasing hormone agonist-induced ovulation in gonadotrophin-stimulated cycles

Gonadotrophin-releasing hormone agonist (GnRHa)-induced ovulation after gonadotrophin ovarian stimulation is used to prevent ovarian hyperstimulation syndrome and multiple pregnancy in polyfollicular cycles. However, one of the major problems to be resolved is corpus luteum function after follicular maturation and ovulation by mid-cycle GnRHa administration. The present report investigated the luteal phase in non-conceptual polyfollicular cycles in 26 patients (group 1) receiving a single dose of 0.5 mg leuprolide acetate to induce ovulation and in a control group of patients (n = 26) (group 2) who were given human chorionic gonadotrophin (HCG) (10,000 IU i.m.) for ovulation induction. All of them were normal ovulatory women undergoing gonadotrophin ovarian stimulation because of unexplained infertility or male factor. In both groups of patients two doses of 2500 IU HCG i.m. were given 6 and 10 days after the ovulatory dose of HCG or GnRHa to support the luteal phase. All cycles were ovulatory as shown by mid-luteal serum progesterone concentrations >10 ng/ml. Mean serum progesterone concentrations were 62% higher in group 2 than in group 1, but this difference was not statistically significant. The mean length of the luteal phase was similar in groups 1 and 2. It is concluded that HCG luteal support is a useful tool to overcome the luteal phase inadequacy that characterizes GnRHa-triggered cycles after gonadotrophin stimulation.

Integrin expression in normal and out-of-phase endometria

Integrins have recently been proposed as having a major role in endometrial receptivity. Different patterns of integrin expression have been described during the normal endometrial cycle, and the co-expression of several integrins, mainly alpha1, alpha4 and beta3 has been considered as specific to the 'window of implantation'. In the present study 55 infertile patients underwent two endometrial biopsies during a single menstrual cycle. An early biopsy was done on postovulatory days 6-8, and a late biopsy was performed on postovulatory days 10 to 12. Histological dating as well as immunohistochemical evaluation of alpha1, alpha4, beta1, beta3, beta5, alpha(v)beta3 integrin expression and oestrogen and progesterone receptors were determined in all endometrial biopsies. Oestradiol and progesterone serum concentrations in serum were evaluated on the same days of the endometrial samplings. Nine out of the 55 midluteal biopsies (16.4%) showed out-of-phase endometria, but all biopsies were in phase in the late luteal phase. Differences in integrin expression between in- and out-of-phase biopsies were observed only for alpha(v)beta3 integrin glandular expression during the midluteal phase. Alpha(v)beta3 integrin glandular expression was found in all late luteal phase biopsies. Alpha(v)beta3 expression was closely correlated with histological maturation of the endometrium appearing suddenly at postovulatory day 6-7 and being expressed by all endometria dated as postovulatory day > or = 8, irrespective of midluteal endometrial biopsies being in phase or out of phase. No differences in integrin expression were detected between patients with or without endometriosis or between patients who became spontaneously pregnant and those who did not. In conclusion, further studies are necessary before patterns of integrin expression may offer an alternative to predict uterine receptivity and implantation potential.

Peripheral arterial vasodilation hypothesis: a new insight into the pathogenesis of ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is a serious complication of ovulation induction which, at present, is being studied increasingly because of its frequent occurrence as a result of the growing number of in-vitro fertilization (IVF) programmes. The anatomical changes involving enlargement of the ovaries and increased capillary permeability leading to acute fluid shift have been traditionally proposed to explain the different clinical features observed in OHSS. Recent work from our group, however, has shown that the pathogenesis of severe OHSS is more complex than currently understood and that marked peripheral arteriolar vasodilation is a major event in the development of the syndrome. Peripheral vasodilation may, in its turn, alter microvascular haemodynamics and permeability. This leads to a circulatory dysfunction with marked homeostatic activation of endogenous vasoactive systems having vasoconstrictor and sodium- and water-retaining activities. In this way, sodium and water retention would be a cause rather than a consequence of ascites formation in severe OHSS. This report analyses current concepts on body fluid regulation as well as neurohormonal and haemodynamic studies both in patients with severe OHSS and asymptomatic IVF women, integrating their findings into the present knowledge of the pathogenesis of the syndrome. Therapeutic implications are discussed.

Follicular development and hormonal levels following highly purified or recombinant follicle-stimulating hormone administration in ovulatory women and WHO group II anovulatory infertile patients

PURPOSE

Our purpose was to compare ovarian performance and hormonal levels, after ovulation induction, in both normal ovulatory women undergoing intrauterine insemination (group 1) and World Health Organization (WHO) group II anovulatory infertile patients (group 2), using two different gonadotropin drugs.

METHODS

Patients (n = 20 per group) were treated during consecutive cycles, using the same stimulation protocol, with highly purified urinary FSH (HP-FSH) in the first treatment study cycle and recombinant FSH (rFSH) in the second one. Patients in group 1 were treated according to a late low-dose technique, and WHO group II anovulatory patients (group 2) received chronic low-dose FSH therapy.

RESULTS

Compared with HP-FSH, treatment with rFSH in group 2 required significantly less ampules of drug to induce follicular development but resulted in significantly higher plasma levels of estradiol and inhibin A on the day of human chorionic gonadotropin injection. No differences were found when both treatment modalities were compared in group 1.

CONCLUSIONS

rFSH is more efficacious than urinary HP-FSH for ovulation induction in WHO group II anovulatory infertile patients as assessed by follicular development, hormonal levels, and the amount of FSH required.

Haematocrit, leukocyte and platelet counts and the severity of the ovarian hyperstimulation syndrome

Previous studies have shown that severe ovarian hyperstimulation syndrome (OHSS) is secondary to circulatory dysfunction due to the simultaneous occurrence of increased vascular permeability and marked arteriolar vasodilation which lead to an intense homeostatic stimulation of the renin-aldosterone and sympathetic nervous systems and antidiuretic hormone (ADH). In the present report, we have investigated the correlation between changes in haematocrit concentration, and white blood cell (WBC) and platelet counts and the severity of OHSS, as assessed by these markers of effective intra-arterial blood volume, in a series of 50 patients. In comparison with recovery values (4-5 weeks after hospital discharge), OHSS patients showed arterial hypotension, tachycardia, oliguria, very high plasma concentrations of renin, aldosterone, norepinephrine and ADH, and increased mean haematocrit values and WBC and platelet counts. The haematocrit concentration values were directly related to the plasma concentrations of vasoactive substances (plasma renin activity, aldosterone, norepinephrine and ADH) during OHSS (P < 0.001). In contrast, no correlation was evident between WBC or platelet counts and neurohormonal measurements during the syndrome. It is concluded that haematocrit, but not WBC or platelet counts, can act as a biological marker of the severity of OHSS as indicated by plasma measurement of volume-dependent endogenous vasoactive substances.

Long-term down-regulation does not improve pregnancy rates in an in vitro fertilization program

OBJECTIVE

To investigate the effects of long-term down-regulation (4 months) used in combination with gonadotropin ovarian stimulation for IVF-ET.

DESIGN

Prospective randomized study.

SETTING

Assisted Reproduction Unit of the Hospital Clinic i Provincial in Barcelona, a tertiary care setting.

PATIENT(S)

Thirty pairs of IVF patients who were matched for age, indication for IVF, and number of attempts.

INTERVENTION(S)

Women were randomized to receive a standard long protocol of SC leuprolide acetate (n = 30, group L) or a monthly injection of leuprolide acetate depot for 4 months (n = 30, group D) before gonadotropin stimulation.

MAIN OUTCOME MEASURE(S)

Ovarian response and IVF outcome.

RESULT(S)

Days of ovarian stimulation, follicular recruitment and growth during gonadotropin treatment, and the endometrial thickness on the day of hCG administration were similar for the 2 groups of IVF patients. However, the serum concentration of E2 was significantly higher in group L even though group D received a higher total dose of gonadotropins. The number of follicles punctured, the number of oocytes retrieved, the number of oocytes fertilized, the number of embryos suitable for replacement and cryopreservation, the number of patients with ET, and implantation and clinical pregnancy rates were similar for groups L and D. However, the percentage of metaphase II oocytes was significantly higher in group L than in group D.

CONCLUSION(S)

Long-term down-regulation does not improve pregnancy rates in a general IVF program.

Circulatory dysfunction in asymptomatic in vitro fertilization patients. Relationship with hyperestrogenemia and activity of endogenous vasodilators

Severe ovarian hyperstimulation syndrome (OHSS) is consistently associated with a circulatory dysfunction characterized by arterial hypotension, low peripheral vascular resistance, and increased activity of the renin-aldosterone system. To investigate whether circulatory dysfunction also occurs in asymptomatic patients undergoing controlled gonadotropin ovarian hyperstimulation under pituitary suppression for in vitro fertilization (IVF), 12 women without clinical manifestations of OHSS underwent sequential blood, urine, and hemodynamic measurements at five study points: the 7th day of the menstrual cycle preceding IVF (study point 1 or baseline), the day when pituitary suppression was shown (study point 2), the day of hCG ovulatory injection (study point 3), the day after hCG was injected (study point 4), and 7 days after hCG administration (study point 5). Mean arterial pressure, cardiac output, peripheral vascular resistance, plasma concentrations of estradiol (E2) and aldosterone, and plasma renin activity (PRA) were measured at each study point in all women. Serum levels of nitrite/nitrate, and plasma concentration of atrial natriuretic peptide, norepinephrine, adrenomedullin, and cyclic guanosine 3'5'-monophosphate were measured in samples obtained at study points 1 and 5. Multiple follicular development during ovarian stimulation associated with increased plasma E2 concentration (mean peak plasma E2 level, 2430 +/- 428 pg/mL, range 1630-3840 pg/mL) were observed in each woman. All patients developed a significant increase in cardiac output and decrease in arterial pressure and peripheral vascular resistance, and a marked elevation in PRA and aldosterone, all indicating the development of arteriolar vasodilation. Changes in circulatory measurements were temporarily related with the increase in E2 both being detected at study points 3-5. In contrast, there was a clear chronological dissociation between the increase in plasma E2 concentration and the stimulation of the renin-aldosterone system. PRA and aldosterone only reached abnormal levels at study point 5 in association with a significant increase in plasma norepinephrine concentration. Serum levels of nitrite/nitrate and plasma concentrations of atrial natriuretic peptide, adrenomedullin, and cyclic GMP were similar at study points 1 and 5. It is concluded that the circulatory dysfunction that characterizes severe OHSS is a universal event in patients undergoing controlled ovarian hyperstimulation for IVF. Although the increase in E2 levels during IVF cycles is associated with significant circulatory changes, the circulatory dysfunction that characterizes severe OHSS is clearly unrelated to the onset of hyperestrogenemia. Arteriolar vasodilation during IVF cycles was not associated with an increased activity of the vasodilator substances atrial natriuretic peptide, adrenomedullin, and nitric oxide.

Antiphospholipid antibodies and the outcome of pregnancy after the first in-vitro fertilization and embryo transfer cycle

Increased antiphospholipid antibody prevalence has been demonstrated by a number of recent studies in in-vitro fertilization (IVF) patients but the potential effects of antiphospholipid antibodies on the different components of the reproductive process and the consideration of whether to test IVF patients for antiphospholipid antibodies are controversial. The present study was undertaken to investigate the possible association between the presence of circulating antiphospholipid antibodies (namely the lupus anticoagulant and anticardiolipin antibodies), among a series of 21 consecutive IVF patients having a clinical spontaneous abortion after their first embryo transfer. As a control group (n=42), the nearest IVF cycle resulting in an ongoing pregnancy before and after each miscarried IVF cycle (i.e. the closest cycles in temporal relationship to the index cycle) was used. One patient (4.8%) in the study group and two women (4.8%) among controls were seropositive for antiphospholipid antibodies. These low and similar seropositivity rates found in the two groups studied lead us to conclude that antiphospholipid antibodies testing in IVF patients should be considered only in those women having repeated failures of implantation/clinical abortion after embryo transfer but not in an infertile general population reaching an IVF programme.

Recurrent in vitro fertilization failure evaluated by fluorescence in situ hybridization: a case report

OBJECTIVE

To present a case of IVF failure evaluated by fluorescence in situ hybridization (FISH).

DESIGN

Case report.

SETTING

Research university laboratory and clinical IVF laboratory.

PATIENT(S)

An infertile couple with recurrent IVF failure.

INTERVENTION(S)

Fluorescence in situ hybridization study of the complete cohort of "zygotes" obtained at the third IVF attempt.

MAIN OUTCOME MEASURE(S)

Fluorescence in situ hybridization studies of chromosomes X, Y, 13, 18, and 21.

RESULT(S)

All the recovered putative zygotes were abnormal for the expected ploidy, presumably as a result of abnormal oocytes.

CONCLUSION(S)

Fluorescence in situ hybridization techniques represent a promising approach to analyze zygotes that fail to divide normally in vitro and eggs that fail to become fertilized. In cases of recurrent IVF failure, the results of FISH could be used to counsel couples and thus to help them choose among methods other than IVF for assisted reproduction.

Parental human leukocyte antigens and implantation failure after in-vitro fertilization

At present, it is well accepted that maternal recognition of paternally derived fetal antigens occurs during normal pregnancy and may be beneficial for implantation and maintenance of gestation. Thus, we have investigated the compatibility of human leukocyte antigens (HLA) in couples with successive failed in-vitro fertilization (IVF) cycles. Study group 1 included 50 couples with prior primary infertility who had not achieved a pregnancy after > or = 3 (range 3-7, mean 3.7) IVF cycles where at least two embryos (mean 3.3, range 2-4) were transferred in each attempt. An infertile control group (group 2) included 50 infertile couples undergoing IVF with the same indications as couples in group 1, who achieved a viable pregnancy with their first IVF attempt. The results were compared with those found in a population sample including 100 men and 100 women from the local population (group 3). We found a statistically significant (P < 0.05) excess of HLA sharing (> or = 2 antigens) between partners in group 1 as compared to groups 2. There was a trend toward increased HLA sharing in group 1 when groups 1 and 3 were compared. We conclude that some cases of implantation failure after IVF and embryo transfer might be caused by underlying close histocompatibility between partners.

Short-term effects of transdermal estrogen replacement therapy on coronary vascular reactivity in postmenopausal women with angina pectoris and normal results on coronary angiograms

OBJECTIVES

This study sought to analyze the effect of short-term transdermal estradiol treatment on in vivo coronary endothelial function in postmenopausal women with angina and normal results on coronary arteriograms.

BACKGROUND

The incidence of coronary heart disease increases in women after menopause. Estrogen replacement therapy has been associated with a global reduction in cardiovascular disease incidence and mortality. In addition, coronary endothelial dysfunction has been demonstrated in a group of postmenopausal women. It has been shown that intravenous or intracoronary estrogens improve endothelial function in postmenopausal women with coronary atherosclerosis. However, the efficacy of this treatment is unknown in patients with angina and normal coronary arteries.

METHODS

Endothelium-dependent coronary reactivity was analyzed in 15 postmenopausal women with angina and normal coronary arteries at baseline and after 24 h of estradiol transdermal administration (100 microg).

RESULTS

Estradiol concentration increased from 22 +/- 8 pg/ml (mean +/- SEM) at baseline to 76 +/- 13 pg/ml (p < 0.01) at 24 h. At baseline, acetylcholine induced vasoconstriction, with a mean diameter reduction of -23 +/- 6% (p = 0.002). After estrogen treatment, there was no vasoconstriction with acetylcholine, with a mean diameter change of 0 +/- 4%, significantly different from the pretreatment diameter reduction observed (p = 0.003). Similarly, estimated coronary blood flow significantly increased in response to acetylcholine after estrogen treatment, with a mean change of 50 +/- 30% compared with 5 +/- 24% before estradiol administration (p = 0.04).

CONCLUSIONS

Early after transdermal estrogen administration, endothelium-dependent coronary vasomotion is improved in postmenopausal women with angina and normal coronary arteries.

Transferrin receptor (CD71) expression in peritoneal macrophages from fertile and infertile women with and without endometriosis

PROBLEM

Hyperactivated macrophages are implicated in the pathophysiology of endometriosis-associated infertility. This study investigates transferrin receptor expression (CD71) as a marker of hyperactivity in peritoneal macrophages of infertile patients with minimal to mild endometriosis (group 1, n = 25).

METHOD OF STUDY

Expression of the activation antigen CD71 on peritoneal fluid macrophages was determined by a specific monoclonal anti-CD71 antibody using indirect immunofluorescence technique and was analyzed by flow cytometry. Three different control groups of women were used: women with unexplained infertility (group 2, n = 25), fertile women with endometriosis (group 3, n = 10), and fertile women without endometriosis (group 4, n = 25).

RESULTS

The percentage of CD71 positive cells was significantly increased in infertile women with endometriosis as compared with the three control groups. There were no differences among groups 2, 3, and 4 with respect to the percentage of CD71 positive macrophages.

CONCLUSIONS

Our results favor the concept that hyperactivated macrophages play a role in the pathophysiology of endometriosis-associated subfertility, a feature which is lacking in patients with unexplained infertility.

Pentoxifylline versus placebo in the treatment of infertility associated with minimal or mild endometriosis: a pilot randomized clinical trial

The present study is the first prospective randomized controlled trial of the effect of pentoxifylline on future fertility in infertile women with asymptomatic minimal or mild endometriosis. After completion of a basic infertility workup and laparoscopy, patients were entered into the study and randomly allocated to receive either a 12 month course of oral pentoxifylline (800 mg/day) (n = 30) or an oral placebo (n = 30). Those patients with other infertility factors were included in the study only if the factors were correctable and ultimately determined to be non-contributory. Life-table analysis was used to compare pregnancy rates between the two groups over a 12 month period that started immediately after laparoscopy. The 12 month actuarial overall pregnancy rates were 31 and 18.5% in the pentoxifylline and placebo groups respectively. However, this difference was not statistically significant by the chi(2)-test. Similarly, the Cox regression method showed no differences between the hazard of pregnancy in the two groups studied (odds ratio, 0.56; 95% confidence interval, 0.18-1.67). Therefore, there is no evidence from this study that immunomodulation with pentoxifylline aids fertility in those women with minimal or mild endometriosis. Further studies including more infertile patients with endometriosis are desirable in order to confirm our results.

Immunological factors in endometriosis-associated reproductive failure: studies in fertile and infertile women with and without endometriosis

Immunopathophysiological mechanisms in endometriosis-associated reproductive failure were studied in appropriate populations: infertile and fertile women with and without endometriosis. The incidence of sera positive for any of the autoantibodies tested among infertile women with endometriosis (n = 25) was similar to that observed in the three control groups [unexplained infertility patients (n = 25) and fertile women with (n = 10) and without (n = 25) endometriosis]. The mean volume of peritoneal fluid was significantly elevated in women with endometriosis (both fertile and infertile) as compared with patients without endometriosis (fertile or infertile). The concentration of peritoneal fluid leukocytes and the percentage of cells positive for macrophage markers were significantly increased and the percentage of T lymphocytes significantly decreased in infertile women with endometriosis but not in patients with unexplained infertility and fertile women with endometriosis, as compared with fertile controls without endometriosis. Macrophages from infertile patients with endometriosis had higher sperm phagocytosis than did those from infertile women without endometriosis or fertile subjects with or without endometriosis. Incidences of serum and peritoneal fluid samples embryotoxic to the in-vitro development of 2-cell mouse embryos were significantly higher in infertile patients with endometriosis than in unexplained infertility patients and fertile women with or without endometriosis. It is concluded that immunological mechanisms of endometriosis-associated infertility exist but that these peritoneal immunological factors in infertile women with endometriosis are related to their subfertility rather than to the presence of ectopic endometrial implants. This is supported by the lack of immunological abnormalities observed among fertile women with endometriosis. These immunological abnormalities are lacking in patients with unexplained infertility.

First-trimester repeated abortion is not associated with activated protein C resistance

The present study was undertaken to investigate the possible association between activated protein C resistance and first-trimester repeated abortion. Fifty-five consecutive patients with unexplained first-trimester repeated abortion and 50 healthy control women having at least one child but no previous abortion were included. Activated protein C resistance was measured in all subjects and factor V Leiden genotype testing was performed in those individuals with phenotypic activated protein C resistance. One patient with first-trimester repeated abortion and one control subject had phenotypic activated protein C resistance. Genotype analysis confirmed that both subjects were heterozygous for factor V Leiden. Our results indicate that first-trimester repeated abortion is not associated with activated protein C resistance. Factor V Leiden screening in first-trimester repeated abortion is not warranted.

Sequential danazol/leuprolide acetate therapy for ovarian suppression in an in vitro fertilization patient unresponsive to leuprolide acetate

We report a case of pituitary-ovarian suppression obtained with sequential danazol/leuprolide acetate administration in a patient undergoing in vitro fertilization and unresponsive to leuprolide acetate alone and sequential oral contraceptive-leuprolide acetate therapy. Leuprolide acetate (1 mg daily subcutaneously) was administered after 5 weeks of danazol treatment (800 mg daily) while the latter was maintained for 1 additional week. Ovarian activity was assessed by transvaginal ultrasonography and serum estradiol determination. After 5 weeks of danazol therapy, ovarian arrest was obtained despite the fact that gonadotropin serum levels did not change relative to basal values. Leuprolide acetate injection for 14 days was associated with a decrease in serum concentrations of follicle-stimulating hormone and luteinizing hormone and a further decrease of the estradiol level. We conclude that sequential danazol/leuprolide acetate therapy is a useful alternative for obtaining ovarian arrest in patients unresponsive to leuprolide acetate alone.

Neonatal outcome in women treated for the antiphospholipid syndrome during pregnancy

The aim of this study was to determine the neonatal outcome in women with well-characterized antiphospholipid syndrome treated during pregnancy with low-dose aspirin. We compared 38 babies born after 36 pregnancies of 33 women diagnosed as having antiphospholipid syndrome with a group of 38 control infants matched for the same gestational age at birth. In all 76 newborns we studied the maternal events associated with the antiphospholipid syndrome, mothers' treatment and neonatal data. All mothers with antiphospholipid syndrome were treated with low-dense aspirin. Prednisone was only prescribed due to maternal complications and heparin in a case of thrombosis. No significant relation was found between maternal treatment and neonatal complications. The prematurity rate in these newborns was high 14% and the neonatal mortality (5.8%) was only associated with extreme prematurity (p < 0.001). In our population the overall rate of neonatal complications was higher than in the general population, but when compared with a similar group of newborns no significant differences were found. Our results suggest that primary antiphospholipid syndrome appears to be improved by low-dose aspirin treatment, with a high rate of neonatal survival (95%). Except for prematurity and its potential associated complications, fetal and neonatal outcome is very favourable and no significant relation between maternal treatment and neonatal pathology has been detected.

Midluteal immunoreactive alpha-inhibin serum concentrations as markers of luteal phase deficiency

The present prospective clinical study was undertaken to determine the usefulness of midluteal phase serum immunoreactive alpha-inhibin concentrations as markers of luteal phase deficiency and whether they are better indicators of biopsy confirmed luteal phase defect than serum progesterone. Consecutive patients (n = 138) with regular menstrual cycles attending our Infertility Clinic (experimental group) and 15 fertile women who were requesting contraception and had regular menstrual patterns (control group) were included. In all women (patients and controls), basal body temperature, midluteal serum concentrations of oestradiol, prolactin, progesterone and immunoreactive alpha-inhibin, and premenstrual endometrial biopsy were used in the same cycle to assess luteal function. Out-of-phase secretory endometria were detected in 15 of the 138 patients. Thus, hormonal concentrations were compared between the following three groups of women: group 1 (n = 15), infertile patients with defective secretory endometria; group 2 (n = 123), infertile patients with normal secretory endometria; and controls (n = 15), fertile women with normal secretory endometria. Midluteal serum concentrations of progesterone, immunoreactive alpha-inhibin, oestradiol, and prolactin of the two groups studied were similar to those of the control group of fertile women. Our results indicate that midluteal serum inhibin determination does not accurately reflect histological maturation of the endometrium and it is not a better indicator of endometrial luteal phase deficiency than midluteal serum progesterone concentration.

Analysis of compliance with oral contraception in Spain

OBJECTIVE

The study was designed to analyze factors related to compliance in oral hormonal contraception in Spain.

METHOD

A review study and a multicenter analysis of experience of compliance by 300 doctors, by means of a questionnaire and discussion about the determinants of contraceptive use.

RESULTS

Compliance is a major problem in Spain, being influenced mainly by side-effects, the general perception of the method and personal factors. The different factors involved in non-compliance in Spain were analyzed, with regard to the perspective of the professionals.

CONCLUSIONS

Strategies to improve compliance in Spain aim mainly at improving the general perception of the method and the accessibility of family planning centers. Factors associated with compliance are still not well known in our country. Better knowledge of the determinants of non-compliance in Spain is needed. For this purpose, another research group was formed to conduct a national study among women.

Further data favoring the hypothesis of the uterine first-pass effect of vaginally administered micronized progesterone

Ten infertile women, 28 to 36 years of age, with regular menstrual cycles were treated with oral estradiol valerate and intravaginally administered micronized progesterone under pituitary suppression with leuprolide acetate. Patients underwent endometrial biopsies on cycle days 17 and 28 (luteal phase days 3 and 14) and blood sampling for plasma progesterone and estradiol determinations on cycle days 17, 21 and 26 (luteal phase days 3, 7 and 12). All ten endometrial biopsies on cycle day 17 were in-phase and only two out of ten (20%) were out-of-phase on cycle day 28. This produced an incidence of endometrial luteal phase deficiency that was not different from the 14% found among an infertile general population of 300 women. Midluteal estradiol plasma levels in the study group were similar to those found in a control group of fertile women, but progesterone levels were significantly lower on cycle day 21 in the treatment group. As much as 75% (six out of eight patients) of treated women having in-phase late luteal endometrial biopsies had low midluteal plasma progesterone levels, a situation that is found in only 3% of infertile patients (9/300) or 3.5% (9/258) of those infertile women with normal endometria (p = 0.03). Thus, the present study adds further evidence favoring the current postulate that vaginal micronized progesterone enhances hormone delivery to the uterus and this explains the marked discrepancy between the strong uterine effect and the relatively low plasma progesterone levels.

Ethinyl oestradiol plus dl-norgestrel or levonorgestrel in the Yuzpe method for post-coital contraception: results of an observational study

This observational study compares the efficacy and incidence of side-effects between dl-norgestrel (2 mg) and levonorgestrel (1 mg) associated with ethinyl oestradiol (200 micrograms) given in two doses 12 h apart for emergency post-coital contraception. A total of 117 consecutive women were given dl-norgestrel in combination with the oestrogen (dl-norgestrel group) while 423 consecutive subjects received the combination ethinyl oestradiol/levonorgestrel (levonorgestrel group). Overall, four (0.8%) pregnancies occurred in the 540 treated women, one (0.9%) in the dl-norgestrel group and three (0.7%) in the levonorgestrel group. In addition to this similar high contraceptive efficacy between both study groups, women in the levonorgestrel group had a significantly lower incidence of side-effects (23.5%) and better timing of the next menstruation after treatment (75% had bleeding on time) than those in the dl-norgestrel group (corresponding figures were 50.5 and 62.6% respectively). It is concluded that levonorgestrel should be used in preference to dl-norgestrel for post-coital contraception in the Yuzpe regimen.

Pure and highly purified follicle-stimulating hormone alone or in combination with human menopausal gonadotrophin for ovarian stimulation after pituitary suppression in in-vitro fertilization

The use of pure follicle stimulating hormone (pFSH) and highly purified FSH (FSH-HP) versus the combinations pFSH/human menopausal gonadotrophin (HMG) and FSH HP/HMG, respectively, was compared for stimulating follicular development after gonadotrophin-releasing hormone agonist (GnRHa) suppression in women undergoing in vitro fertilization (IVF)-embryo transfer. Two consecutive prospective, randomized studies were carried out at the Assisted Reproduction Unit of the Hospital Clínic i Provincial in Barcelona, a tertiary care setting. Two groups of 188 (study 1) and 252 (study 2) consecutive infertile patients respectively, scheduled for IVF-embryo transfer were included. Pretreatment with leuprolide acetate (long protocol) was followed by gonadotrophin treatment in all patients. In study 1, 92 patients received i.m. pFSH alone (group pFSH) and 96 were treated with the combination of i.m. pFSH and i.m. HMG (group HMG-1). In study 2, 123 patients received s.c. FSH-HP alone (group FSH-HP) and 129 patients were given the combination of s.c. FSH-HP and i.m. HMG (group HMG-2). Main outcome measures included follicular development, oocyte retrieval, fertilized oocytes, duration and dose of gonadotrophin therapy, and clinical pregnancy. There were no significant differences between pFSH and pFSH/HMG nor between FSH-HP and FSH-HP/HMG cycles with regard to the number of ampoules of medication used, day of human chorionic gonadotrophin (HCG) administration, mean peak serum oestradiol concentrations, number of follicles punctured, and number of oocytes aspirated, embryos transferred, or pregnancies. We conclude that urinary FSH (either purified of highly purified) alone is as effective as the conventional combination of urinary FSH/HMG for ovarian stimulation under pituitary suppression in IVF cycles. Therefore, they can be used interchangeably in IVF programmes.

Inhibin, follicle-stimulating hormone, and age as predictors of ovarian response in in vitro fertilization cycles stimulated with gonadotropin-releasing hormone agonist-gonadotropin treatment

OBJECTIVE

Our purpose was to determine the relative power of basal inhibin and follicle-stimulating hormone (defined before treatment) and the woman's age both as single and combined predictors of ovarian response in an in vitro fertilization program where pituitary desensitization was routinely used.

STUDY DESIGN

The study was a retrospective analytic investigation of 120 women undergoing the first cycle of in vitro fertilization. Forty consecutive cycles canceled because of poor follicular response were initially selected. As a control group, the nearest completed in vitro fertilization cycles before and after each canceled cycle (i.e., the closest cycles in temporal relationship to the index cycle) were used.

RESULTS

The mean age and basal follicle-stimulating hormone level were significantly higher in the canceled than in the control group, whereas the basal inhibin level was significantly higher in the latter. Follicle-stimulating hormone and inhibin alone, with an accuracy (predictive value of ovarian response) of 70%, were better predictors of cancellation than age was. Any two or all three of these variables studied did not improve the predictive value of follicle-stimulating hormone or inhibin alone.

CONCLUSION

Age is a poorer predictor than pretreatment basal follicle-stimulating hormone and inhibin levels for ovarian response in in vitro fertilization cycles stimulated with gonadotropin-releasing hormone agonist-gonadotropin treatment. Basal follicle-stimulating hormone and inhibin have similar predictive properties and could therefore be used interchangeably.

Antiphospholipid antibodies and human reproductive failure

Routine screening for circulating antiphospholipid antibodies (aPL), namely the lupus anticoagulant (LA) and anticardiolipin antibodies (aCL), was carried out in a total of 1273 women aged < 45 years. Of them, 822 were experimental subjects and 451 were controls. The former comprised the following three study groups: 498 infertile patients (group 1), 284 spontaneous recurrent aborters (group 2), and 40 patients with repeated failure of embryo transfer (group 3). Controls included five groups of women: 125 normal healthy women who had never been pregnant (group 4), 125 normal healthy parous women with no previous abortion (group 5), 52 women in labour after normal pregnancies at term (group 6), 49 infertile patients achieving a livebirth with their first in-vitro fertilization (IVF) and embryo transfer (group 7), and 100 female patients with systemic lupus erythematosus (positive controls, group 8). aPL positivity in the eight groups studied was as follows: 24, 9.2, 10, 0.8, 0, 0, 0 and 42% respectively for groups 1 to 8. There were no differences within groups 1 and 3 regarding incidence of aPL when patients were grouped according to infertility aetiological factors and indications of IVF respectively. Twenty-six out of 284 recurrent aborters (9.2%) tested positive for aPL, and the LA and/or a CL were identified as the aetiological factor in 12% of patients (24/199) with supposedly unexplained recurrent abortion. Incidence of positive sera for aPL in group 1 was similar to that observed in control groups 4, 5 and 6. On the contrary, incidence of aPL positivity in groups 2 and 3 was significantly higher than in control groups 4, 5 and 6 and among infertile women (group 1). The difference between groups 3 and 7 almost reached statistical significance. Interestingly, there was no difference between groups 2 and 3, but groups 2 and 7 resulted probably different regarding incidence of aPL positive sera. As expected, the highest incidence of patients testing positive for aPL was found in group 8. Seven infertile patients having circulating aPL and becoming pregnant spontaneously or after specific infertility treatment, successfully carried to term in spite of the fact that they did not receive immunotherapy. Among recurrent aborters, the live-born baby rate was significantly higher after treatment with low-dose aspirin than prior therapy. It is concluded that the presence of circulating aPL may be associated with recurrent abortion but with infertility. In addition, our results favour a possible role of aPL in failure of implantation after IVF embryo transfer.

Increased induced monocyte tissue factor expression by plasma from patients with severe ovarian hyperstimulation syndrome

OBJECTIVE

To investigate whether monocyte expression of tissue factor is increased by plasma from patients with severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

Prospective longitudinal study.

SETTING

Assisted Reproduction Unit of the Hospital Clínic i Provincial in Barcelona, a tertiary care setting.

PATIENTS

Nine IVF patients with severe OHSS.

INTERVENTIONS

Pretreatment with leuprolide acetate was followed by gonadotropin treatment for ovarian follicular stimulation. After administration of hCG, a standard IVF-ET procedure was performed.

MAIN OUTCOME MEASURES

Measurement during the syndrome and 4 to 5 weeks after recovery of induced monocyte tissue factor expression.

RESULTS

In each of the nine patients, plasma obtained during the syndrome induced a significantly higher proportion of monocytes expressing tissue factor and a significantly higher intensity of tissue factor expression on monocytes than plasma obtained after recovery and control plasma.

CONCLUSIONS

Procoagulant activity of blood monocytes, which is mediated principally by tissue factor expression, is increased in patients with severe OHSS. This fact may be important in thrombotic events associated with the syndrome.

Treatment of severe ovarian hyperstimulation syndrome by a conservative medical approach

OBJECTIVE

To assess the value of a conservative medical therapeutic approach in the management of severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

Prospective longitudinal study.

SETTING

Assisted Reproduction Unit of the Hospital Clínic i Provincial de Barcelona, a tertiary care setting.

PATIENTS

Twenty-five women with ascites because of OHSS.

INTERVENTIONS

Patients were treated by strict bed rest, low-sodium diet (60 mEq/day), plasma volume expansion with albumin (50 g/day of salt-poor albumin) and diuretics (20 mg of furosemide given intravenously every 8-12 hours).

MAIN OUTCOME MEASURES

Measurement at admission and 48 hours after commencement of treatment of the following: body weight, mean arterial pressure, heart rate, hematocrit, hemoglobin concentration, leukocyte and platelet counts, urine volume, sodium excretion, serum sodium, serum creatinine, plasma renin activity, and plasma aldosterone, norepinephrine, antidiuretic hormone, and atrial natriuretic peptide concentrations.

RESULTS

After 2 days of therapy there was marked improvement in clinical symptoms, standard laboratory parameters, diuresis and urinary sodium excretion in all patients. There was also a significant decrease in the plasma levels of volume-dependent endogenous vasoactive substances in the five patients in whom these measurements were repeated during treatment. The length of treatment with albumin plus furosemide ranged between 2 and 6 days with an average of 3.3 and it correlated directly with the severity of the syndrome. The hospital stay ranged from 4 to 10 days (mean 6.5 days). All patients recovered without any complication.

CONCLUSIONS

Severe ovarian hyperstimulation syndrome can be managed using the proposed conservative medical approach.

The safety and effectiveness of stepwise and low-dose administration of follicle stimulating hormone in WHO group II anovulatory infertile women: evidence from a large multicenter study in Spain

PURPOSE

Our goal was to investigate the safety, effectiveness, and feasibility for the practicing physician of stepwise and low-dose administration of FSH in WHO group II anovulatory infertile women.

METHODS

Infertile female patients (n = 234) suffering from WHO group II anovulation, and who failed to became pregnant with clomiphene citrate, were included in a multicenter, prospective, clinical study of treatment with a protocol of chronic low-dose and small incremental rises with urinary purified or highly purified FSH. Follicular development was monitored with ultrasonographic scans.

RESULTS

The 234 patients received a total of 534 cycles of treatment, for a mean number of 2.3 treated cycles per patient. hCG was withheld in 65 (12.2%) cyles because of no response and in 28 (5.2%) cycles because of hyperresponse. Of the remaining 441 cycles, 419 (95%) were ovulatory, and in 198 (47.3%) of these cycles a single dominant follicle developed. There were 93 pregnancies (39.7% per patient), for a cycle fecundity rate of 17.4%. Cumulative conception rate after two treated cycles was 33.5%. There were 14 (15%) pairs of twins and 10 (10.8%) spontaneous miscarriages. The prevalence of complications was low with no cases of severe OHSS. Basal LH/FSH ratio was significantly higher in the pregnant group of patients than in nonpregnant women.

CONCLUSIONS

Stepwise and chronic low-dose administration of FSH is a safe and effective method for treatment of WHO group II anovulatory infertility, mainly in those patients having high LH/FSH ratios.

In-vitro fertilization treatment for unexplained recurrent abortion: a pilot study

To determine the effectiveness of in-vitro fertilization (IVF) and embryo transfer for patients with unexplained habitual abortion, we carried out a prospective observational study using a historical comparison group. A total of 12 couples with three or more (mean 4. 91, range 3-10 miscarriages) first trimester spontaneous abortions of unknown aetiology were treated with IVF and embryo transfer (group 1). Patients underwent IVF after combined gonadotrophin-releasing hormone agonist/gonadotrophin treatment for ovarian stimulation, and three to four embryos were replaced into the uterus in all women. Eight of the 12 women (66.6%) in group 1 became pregnant (one patient after a frozen-thawed embryo transfer), and all of them had viable pregnancies. A patient with 10 previous abortions became pregnant and carried to term after IVF and embryo transfer, and subsequently miscarried two new spontaneous gestations. A historical comparison group (group 2) included the last eight women with unexplained recurrent abortion (mean 4, range 3-8 miscarriages) who underwent the same investigations for the condition and received identical early supportive care in their next spontaneous pregnancy as patients in group 1. Three of the eight pregnancies in group 2 ended in an abortion. Our results suggest that IVF and embryo transfer may be a new therapeutic approach for unexplained recurrent miscarriage.

Septate uterus with cervical duplication and longitudinal vaginal septum: a report of three new cases

The first case of a rare mullerian anomaly characterized by the presence of a complete uterine septum with duplication of the cervix and a longitudinal vaginal septum has been reported very recently. We present here three new cases of such an anomaly in an attempt to alert gynaecologists to the possible occurrence of such a malformation. The cases challenge the classical views of unidirectional (caudad to cranial) mullerian development and support the alternative embryologic hypothesis of Muller et al. according to which fusion and resorption begins at the isthmus and proceeds simultaneously in both the cranial and caudal directions.

The effect of hormone replacement therapy on bone mass in patients with ovarian failure due to bone marrow transplantation

BACKGROUND

Long permanent remissions in malignant hematopoietic disorders can often be achieved by autologous bone marrow transplantation (ABMT) or by allogenic bone marrow transplantation (BMT). Previous studies have shown that such therapies may induce osteoporosis due to iatrogenic ovarian failure. The administration of hormone replacement therapy (HRT) in these women could prevent the adverse effects of long-term ovarian failure without remarkable side effects. The aim of this study was to evaluate how the bone mass is affected by HRT in patients undergoing ABMT or BMT adjusting the results for age, weight, and height.

SUBJECTS AND METHODS

Thirteen women with previous ABMT/BMT were treated with a standard dose (0.625 mg/day) of conjugated equine estrogen (CEE) or with 50 micrograms/day of 17-beta-estradiol in transdermal therapeutic systems (TTS) plus 5 mg/day of medroxyprogesterone acetate sequentially added to the last 12 days of estrogen therapy. Bone mass was measured prior to and 12 months following HRT. Blood samples were collected before therapy and during the 6th and 12th treatment months.

RESULTS

The mean time elapsed between bone transplantation and HRT initiation was 13.0 months (range 3-26 months). Before treatment nine patients were osteopenic and after HRT bone mass increased in all cases. Following ABMT/BMT, hepatic hyperenzymemia was detected in three patients. After 6 and 12 months of treatment no significant changes were observed in hepatic enzymes.

CONCLUSION

Although hepatic hyperenzymemia is commonly considered as a contraindication for HRT, our results suggest that HRT is safe for these patients and that such therapy should be initiated after transplantation in women to prevent adverse effects of long-term ovarian failure.

Intravenous immunoglobulin preceding in vitro fertilization-embryo transfer for patients with repeated failure of embryo transfer

OBJECTIVE

To determine the effectiveness of immunotherapy with high-dose IV immunoglobulin preceding IVF-ET for patients with repeated failure of ET.

DESIGN

Prospective, observational.

SETTING

Assisted Reproduction Unit of the Hospital Clínic i Provincial in Barcelona, a tertiary care setting.

PATIENTS

Twelve consecutive tubal infertility patients experiencing repeated unexplained IVF-ET failure including at least three ETs replacing three to four fresh embryos each. Two women shared three or more human leukocyte antigens (HLA) with the husband.

INTERVENTION

During the subsequent new IVF-ET cycle, each patient received 400 mg/kg IV immunoglobulin daily for 5 days during ovarian stimulation, that is, 5 to 7 days before ET.

MAIN OUTCOME MEASURES

Clinical pregnancies.

RESULTS

No implantation occurred. There were no side effects.

CONCLUSIONS

High-dose IV immunoglobulin is not a useful tool for IVF-ET failure.

Visible and non-visible endometriosis at laparoscopy in fertile and infertile women and in patients with chronic pelvic pain: a prospective study

In 100 consecutive patients who were undergoing laparoscopy for infertility (group 1, n = 52), chronic pelvic pain (group 2, n = 18) or tubal sterilization (group 3, n = 30, asymptomatic fertile women), peritoneal biopsies were taken from areas of visually normal peritoneum of uterosacral ligaments. Twenty-six patients in group 1 (50%), eight patients in group 2 (44.4%) and 13 patients in group 3 (43.3%), were found to have laparoscopic evidence of endometriosis elsewhere in the pelvis. The majority of women (80.7% in group 1, 87.5% in group 2, and 100% in group 3) had stage I disease. The incidence of the distinctive appearances of the lesions was similar in the three groups of patients and 7% of all women or 15% (7/47) of those patients having endometriosis at laparoscopy had only subtle (non-¿typical') endometriotic peritoneal lesions. Uterosacral biopsies showed the presence of endometriotic tissue in three cases (5.7%), two cases (11%) and three cases (10%) in groups 1, 2, and 3 respectively. One of the two patients in group 2 and two of the three patients in group 3 had no evidence of endometriosis at laparoscopy; thus histological study revealed the presence of endometriosis in normal peritoneum in 11% (5/47) of patients having macroscopic endometriosis and in 6% (3/53) of patients without endometriosis at laparoscopy. Previous oral contraceptive users were significantly higher among women having macroscopic and/or microscopic endometriosis than among women without the condition. In conclusion, our prospective study shows a high prevalence (45-50%) of endometriosis (including microscopic forms) in both patients with chronic pelvic pain and asymptomatic women (fertile and infertile), thus supporting the modern concept that in many women endometriosis may be a paraphysiological condition while probably only in some patients small amounts of endometriosis are an ¿annoyance' with implications to their reproductive health and may produce symptoms (e.g. pelvic pain) and therefore should be defined as a ¿dis-ease'. Previous use of oral contraceptives may increase the risk of developing endometriosis.

Trial of routine gonadotropin releasing hormone agonist treatment before abdominal hysterectomy for leiomyoma

OBJECTIVE

To investigate the usefulness of a routine short term treatment with gonadotropin releasing hormone agonist (D-Trp-6-LHRH depot) before abdominal hysterectomy for leiomyoma.

STUDY DESIGN

Prospective, comparative, randomized study.

SETTING

A teaching hospital of Barcelona University.

PATIENTS

Fifty premenopausal women requiring hysterectomy as treatment for symptomatic leiomyomas. Twenty-three patients were randomized to receive gonadotropin releasing hormone agonist treatment before hysterectomy (cases), and 27 patients were randomized to immediate hysterectomy (controls).

MAIN OUTCOME MEASURES

Type of abdominal incision, operating time, operative hemoglobin and hematocrit decrease, postoperative morbidity, and days in hospital.

RESULTS

In the agonist treated group mean uterine volume decreased and mean hemoglobin and hematocrit significantly rose after 8 weeks of treatment. Operative time was similar in both groups of patients but the number of women having Pfannenstiel incision was significantly higher in the cases. Mean operative hemoglobin and hematocrit decrease and postoperative morbidity were lower in the cases. There was a trend for shorter postoperative hospital stays in the agonist treated group.

CONCLUSIONS

Our results favor the routine use of a short term gonadotropin releasing hormone agonist treatment before abdominal hysterectomy for leiomyoma in order to decrease operative blood loss and postoperative morbidity.

The role of luteinizing hormone in human follicle development and oocyte fertility: evidence from in-vitro fertilization in a woman with long-standing hypogonadotrophic hypogonadism and using recombinant human follicle stimulating hormone

To evaluate the relative importance of follicle stimulating hormone (FSH) and luteinizing hormone (LH) in follicular development and oocyte fertility in the human species, the use of recombinant human FSH, human menopausal gonadotrophin (HMG), and very highly purified urinary human FSH (FSH-HP) plus oestradiol valerate for ovarian stimulation and in-vitro fertilization (IVF) were compared in three cycles in a woman with isolated congenital gonadotrophin deficiency who had never been treated with ovarian stimulating agents. The total number of ampoules of gonadotrophins used was lower in the HMG treatment cycle. Ovarian response and IVF outcome in the three treatment cycles were as follows: (i) HMG cycle: normal follicular growth, normal pattern of oestradiol and inhibin through the menstrual cycle, high fertilization rate (93%); (ii) recombinant FSH cycle: normal follicular growth, low oestradiol and abnormal inhibin, finally poor rate of fertilization (28%); (iii) FSH-HP plus oestradiol valerate cycle: normal follicular growth, normal pattern of inhibin and poor fertilization rate (27%). Luteal plasma progesterone concentrations were much higher in the HMG treatment cycle. This case shows that FSH is the only factor required in order to induce follicular growth in the human, although LH or a product derived from its action may assist in order to achieve full follicular maturity and oocytes capable of fertilization. Though oestradiol might have a mediatory role in the process of follicular maturation, our results favour a direct primary role of LH in complete maturation of the follicle.