A human in vivo model for the luteoplacental shift

OBJECTIVE

To study the onset of early placental steroidogenesis in humans.

DESIGN

Ovarian failure patients who were administered a constant dosage of exogenous estradiol (E2) and progesterone (P) during the luteal phase and early gestation and who conceived after transfer of donated oocytes were used to assess serum hormonal changes throughout early pregnancy.

SETTING

Hormonally replaced ovarian failure patients undergoing an egg donation program in an academic research environment.

PATIENTS, PARTICIPANTS

Nine human volunteers desiring egg donation.

INTERVENTIONS

Replacement of E2 and P.

MAIN OUTCOME MEASURE

Serum E2 and P concentrations were measured weekly throughout the patients' gestations.

RESULTS

Serum E2 and P levels of these patients remained low in early gestation but significantly increased 25 +/- 1.6 and 34 +/- 1.6 days post embryo transfer, respectively. Regression lines of E2 (r = 0.99; P less than 0.01) and P (r = 0.95; P less than 0.005), intersected basal hormonal levels approximately 3 weeks after transfer.

CONCLUSION

This estimate of the onset of placental steroidogenesis is equal to the 5th gestational week as calculated by the patients' last menses, approximately 3 weeks earlier than previously reported.

Gonadotropin-releasing hormone agonist-induced ovarian hyperstimulation: low-dose side effects in women and monkeys

OBJECTIVE

To determine whether low (subtherapeutic) doses of gonadotropin-releasing hormone agonists (GnRH-a) can cause ovarian hyperstimulation.

DESIGN

The study is in two parts: a preliminary clinical trial of women and a follow-up study in laboratory primates.

SETTING

Normal human volunteers were studied in an academic research environment; primates were in a conventional laboratory setting.

PATIENTS, PARTICIPANTS

Human volunteers were selected on the basis of apparent normal health. The monkeys were believed to be of normal reproductive status.

INTERVENTIONS

Gonadotropin-releasing hormone agonists were administered at subtherapeutic doses.

MAIN OUTCOME MEASURES

After observing ovarian hyperstimulation in two of five women receiving low doses of GnRH-a, a study was specifically designed to test the hypothesis that at low (subtherapeutic) doses of GnRH-a the "flare-effect" can be sustained without achieving down regulation.

RESULTS

The data in women and monkeys suggest that a highly individualized response to low GnRH-a doses can be manifested as ovarian hyperstimulation.

CONCLUSION

Four points of interpretation are offered: (1) that subtherapeutic doses of GnRH-a can cause ovarian hyperstimulation and related sequelae; (2) this may be a unique observation in that, typically, lower doses of medications have a lower incidence of negative side effects; (3) the findings suggest that GnRH-a prescribed in self-administration regimens may be more prone to such problems in noncompliant patients; and (4) the hyperstimulation response of the ovaries to low GnRH-a doses may indicate a new approach to controlled ovulation induction, although wide individualism was found.

Early pregnancy wastage in IVF (in vitro fertilization) patients

Human in vitro fertilization is characterized by a low efficiency of implantation. Possible mechanisms for pregnancy loss are discussed. Embryo viability or quality, abnormal implantation, and delayed or absent corpus luteum rescue may all play a role in pregnancy wastage. Defining the possible mechanism for these losses may allow hormonal treatment to correct specific abnormalities.

Tumor necrosis factor is present in maternal sera and embryo culture fluids during in vitro fertilization

The incidence of tumor necrosis factor alpha (TNF) in sera of women undergoing in vitro fertilization (IVF) and in embryo culture fluids was evaluated using an enzyme-linked immunosorbent assay. Just prior to embryo transfer to the uterus, 24 of 49 maternal sera (49.0%) contained TNF. The incidence and range of TNF concentrations (84-920 pg/ml) did not differ between women with eventual successful pregnancies and women who subsequently suffered preclinical or clinical abortions. At 8 days post-embryo transfer, 24 of 56 sera (42.9%) contained TNF. Again, the occurrence of TNF was of no predictive value for the eventual outcome of the pregnancy. TNF was also detected in culture fluids from the in vitro fertilized eggs of 12 of 49 women (24.5%). In 9 women, TNF was detected in each of the embryo culture fluids tested. As was the case for sera, the presence or absence of TNF in the culture fluids was unrelated to pregnancy outcome. In 21 patients, paired sera and culture fluids were analyzed. In 9 of 10 women with TNF in their culture fluids, TNF was also present in the corresponding serum. Of 12 women with serum TNF, 9 also had TNF in their culture fluids. Since the culture fluids contained 10% maternal sera, it appeared that in most cases TNF in the culture fluids was derived, at least in part, from the serum. However, in 6 of 9 women TNF levels in the cultures exceeded levels in the corresponding sera. TNF was also identified in 2 of 10 culture fluids in which Plasmanate was substituted for serum.(ABSTRACT TRUNCATED AT 250 WORDS)

Radioimmunoassay of inhibin based on synthetic human inhibin alpha-chain peptide

Polyclonal rabbit antisera were produced against cyclic human inhibin [(Cys6, Tyr7) alpha-(6-30)NH2] peptide, covalently conjugated to bovine serum albumin. The tyrosine residue introduced at position 7 facilitated the oxidative incorporation of radiolabel (125I) to yield a tracer with specific activity of 73.9 Ci/g. These reagents were used to develop a homologous equilibrium radioimmunoassay for human inhibin, with polyethylene glycol, 200 g/L, serving as the separation phase. At a detection limit of 2 micrograms/L (n = 7), immunoactive inhibin was detectable in human pre-ovulatory follicular fluid (128 micrograms/L), seminal plasma (2374 micrograms/L), amniotic fluid (66 micrograms/L), and placental extract (347 micrograms/L). We also demonstrated inhibin immunoreactivity in biological fluids from other mammalian species: macaque, chimpanzee, porcine, and bovine, but not rodent (guinea pig). Although the antisera were raised against a nonbioactive inhibin peptide, immunoglobulins fractionated on Protein A-Sepharose neutralized the bioactivity of human ovarian inhibin. Further characterization of inhibin immuno- and bioactivity was undertaken with immobilized heparin, divalent metal cations, and dye ligands. Only heparin-Sepharose distinguished between immuno- and bioactive inhibin.

Radioimmunoassay of inhibin based on synthetic human inhibin alpha-chain peptide

Polyclonal rabbit antisera were produced against cyclic human inhibin [(Cys6, Tyr7) alpha-(6-30)NH2] peptide, covalently conjugated to bovine serum albumin. The tyrosine residue introduced at position 7 facilitated the oxidative incorporation of radiolabel (125I) to yield a tracer with specific activity of 73.9 Ci/g. These reagents were used to develop a homologous equilibrium radioimmunoassay for human inhibin, with polyethylene glycol, 200 g/L, serving as the separation phase. At a detection limit of 2 micrograms/L (n = 7), immunoactive inhibin was detectable in human pre-ovulatory follicular fluid (128 micrograms/L), seminal plasma (2374 micrograms/L), amniotic fluid (66 micrograms/L), and placental extract (347 micrograms/L). We also demonstrated inhibin immunoreactivity in biological fluids from other mammalian species: macaque, chimpanzee, porcine, and bovine, but not rodent (guinea pig). Although the antisera were raised against a nonbioactive inhibin peptide, immunoglobulins fractionated on Protein A-Sepharose neutralized the bioactivity of human ovarian inhibin. Further characterization of inhibin immuno- and bioactivity was undertaken with immobilized heparin, divalent metal cations, and dye ligands. Only heparin-Sepharose distinguished between immuno- and bioactive inhibin.

Relationship of follicular fluid prorenin to oocyte maturation, steroid levels, and outcome of in vitro fertilization

Prorenin (PR) is present in high concentrations in the follicular fluid (FF) of the preovulatory follicle. It is the predominant form of renin detected in FF. Its biosynthesis and secretion from the ovary are regulated by gonadotropins. In the present study we measured PR and steroid levels in FF from 136 follicles. Follicular fluids were obtained, 36 h after hCG injection, from 41 ovarian-stimulated patients who underwent follicle puncture and oocyte retrieval for in vitro fertilization. We related FF PR to steroid levels and to the stage of oocyte-cumulus complex maturation. PR levels in 62 FF containing mature healthy fertilized oocytes averaged 2620 +/- 157 (+/- SE) ng/mL.h (728 +/- 44 ng/L.s; range, 1020-6880 ng/mL.h, 283-1911 ng/L.s). A subgroup of 16 of these follicles containing mature oocytes were from 7 women who conceived, in which PR levels spanned only the lower range from 1030-2720 ng/mL.h (286-756 ng/L.s). No patient conceived with FF PR above 2800 ng/mL.h (778 ng/L.s), yet one third of all mature follicles were above this range. Lower levels of PR were detected in FF containing immature oocytes (germinal vesicle stage) associated with either compact (1665 +/- 480 ng/mL.h; 463 +/- 133 ng/L.s; n = 22; P less than 0.02) or expanded (1785 +/- 193 ng/mL.h; 496 +/- 54 ng/L.s; n = 24; P less than 0.005) cumulus mass; a subgroup (n = 5) of follicles with immature oocytes and compact cumulus had very high levels of FF PR, ranging from 3830-7520 ng/mL.h (1064-2089 ng/L.s), while the remainder had levels less than 1300 ng/mL.h (361 ng/L.s). Progesterone and estradiol (E2) were lower in FF surrounding immature oocytes associated with compact (P less than 0.005) or expanded (P less than 0.02) cumulus, than in those containing mature oocytes. Testosterone (T) and androstenedione were measured in only a fraction of the samples; there were no apparent differences between follicles containing mature and immature oocytes. However, T and androstenedione levels were high in the subgroup of follicles containing immature oocytes and very high levels of PR. Of the hormones measured, T revealed the most striking relationship with PR (r = 0.62; n = 49; P less than 0.001).(ABSTRACT TRUNCATED AT 400 WORDS)

Survival of the cornual pregnancy in a heterotopic gestation after in vitro fertilization and embryo transfer

We present a case of combined intrauterine and cornual (interstitial) pregnancy after IVF-ET, with survival of the infant after the cornual pregnancy. The diagnosis of this rare phenomenon is difficult; a high index of suspicion and frequently ultrasound monitoring may enable early diagnosis in other forms of heterotopic pregnancy. Although the benefits of IVF-ET far outweight the risks of ectopic pregnancy, it is imperative that physicians who care for these patients be fully aware of the possibility of such a complication in this high-risk population.

Estradiol and progesterone replacement regimens for the induction of endometrial receptivity

Initiation of pregnancy in premature ovarian failure patients by use of donated oocytes fertilized in vitro requires establishment of a normal endometrial environment. We compared administration of estradiol (E2) and progesterone (P) by polysiloxane vaginal rings versus oral micronized E2 and P vaginal suppositories in 10 such patients. Serum E2 levels were similar between groups and similar to normally-cycling controls. With vaginal administration of E2, a burst effect was noted, with marked elevation 1 hour after insertion. The pattern with oral administration was more consistent, although marked conversion to estrone occurred. The P cylinder and suppositories delivered similar levels, with diminution of P in some patients with the cylinder. Despite apparent limitations, endometrial histology was normal after each cycle; both groups achieved pregnancies. Administration of E2 and P by polysiloxane vaginal rings achieved hormonal levels similar to oral micronized E2 and P vaginal suppositories. Endometrial biopsies after the stimulated cycle were appropriately mature.

Comparison between laparoscopically and ultrasonographically guided transvaginal follicular aspiration methods in an in vitro fertilization program in the same patients using the same stimulation protocol

Oocyte recovery from 43 patients undergoing ultrasound-guided transvaginal oocyte retrieval was compared to a previous laparoscopic oocyte retrieval cycle from the same patient. Gonadotropin stimulation in both cycles was performed using the same protocol. There were no statistically significant differences in the mean day of oocyte retrieval or the mean daily estradiol level up to the day of oocyte retrieval between laparoscopic and transvaginal cycles. The total number of follicles aspirated per cycle, preovulatory oocytes aspirated per cycle, and number of concepti of preovulatory origin transferred per cycle were not statistically different. The number of immature oocytes aspirated per cycle was statistically decreased in transvaginal retrieval cycles, which resulted in an increased total number of concepti transferred per transfer in laparoscopic retrieval cycles. Twelve pregnancies resulted from the transvaginal retrieval cycles (27.9%), seven of which are ongoing or delivered. Ultrasound-guided transvaginal follicular aspiration yields results comparable to laparoscopic retrieval in the same patients and should be the method of choice for oocyte pickup because of its many advantages.

Serum follicle-stimulating hormone inhibition is a marker for preovulatory oocytes in in-vitro fertilization and embryo transfer

A retrospective analysis was performed on 64 cycles stimulated with human menopausal gonadotrophin and/or pure follicle-stimulating hormone (FSH) and oestrogen (E2) levels. The increase in serum E2 on the day of HCG administration did not correlate (r = 0.05) with the number of preovulatory oocytes (preovs) or with an increase or decrease in serum FSH (r = 0.31). However, the change in serum FSH showed a significant correlation with the number of preovs (r = -0.95, P = 0.013). The probability of obtaining two or more preovs was relatively greater (1.47x) than that of other IVF patients, when there was a drop in FSH of 5% on the day of human chorionic gonadotrophin administration.

A prospective randomized comparison of single- and double-lumen needles for transvaginal follicular aspiration

Patients undergoing ultrasound-directed transvaginal follicular aspiration in a large in vitro fertilization (IVF) program were randomized for retrieval with either a single-lumen needle (SLN; N = 22) or a double-lumen needle (DLN; N = 22) to compare recovery rates and the technical aspects of their use. Two hundred ten and two hundred two follicles were aspirated with each needle, respectively. Follicular diameters were measured ultrasonically at the time of aspiration and recorded. One or more washes were performed when using the DLN and the SLN was withdrawn each time to recover the fluid in the dead space of the needle. The distribution of follicular sizes was the same for both needles. Oocyte recovery rates (SLN = 65.7%; DLN = 63.9%) and the incidence of fractured zonae (SLN = 9.1%; DLN = 6.4%) were the same for both needles (alpha greater than 0.50; beta less than 0.01). Although there were no differences between the two needles in the number of oocytes provided for IVF, there were technical differences. The DLN needle was more flexible and frequently deviated from the projected path as observed by ultrasound. The SLN may be preferable because it is technically easier to use; however, there may remain specific indications for the use of the DLN.

Follicle-stimulating hormone levels on cycle day 3 are predictive of in vitro fertilization outcome

Cycle day 3 basal levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (E2) were measured in 441 patients in 758 consecutive cycles to determine their predictive value for stimulation quality and pregnancy rates in vitro fertilization (IVF). Patients with low basal FSH levels (less than 15 mIU/ml) had higher pregnancy rates per attempt than those with moderate levels (15 to 24.9 mIU/ml), both of which were higher than those with high FSH levels (greater than 25 mIU/ml). Basal LH and E2 values did not improve the predictive value beyond that provided by FSH. Ongoing pregnancy rates per attempt in the low, moderate, and high FSH groups were 17.0%, 9.3%, and 3.6%, respectively (P less than 0.01). The three groups differed significantly in the percentage of patients having two ovaries, the mean number of follicles aspirated per retrieval, the mean number of preovulatory oocytes obtained, and peak E2 values (P less than 0.01). Cycle day 3 FSH levels are predictive of pregnancy outcome and stimulation characteristics in IVF, and may be useful in counseling patients.

Correlation of follicular diameter with oocyte recovery and maturity at the time of transvaginal follicular aspiration

Forty-four consecutive patients undergoing transvaginal follicular aspiration for in vitro fertilization underwent ultrasonic measurement of follicular diameter at the time of oocyte retrieval to determine the correlation of follicular size with recovery rates and oocyte maturity. Based on the results of 412 follicles aspirated, the data were grouped by size (less than or equal to 11, 12-14, 15-17, 18-20, and greater than or equal to 21 mm) and oocyte maturity. Recovery rates were significantly higher in 18- to 20-mm follicles (P less than 0.01) and lower in those less than or equal to 11 mm (P less than 0.001). The probability of retrieving a metaphase I or II oocyte was significantly lower in follicles less than or equal to 11 mm (P less than 0.001), somewhat higher in 12- to 14-mm follicles (P less than 0.01), and equally high among the other groups. There were no differences in the incidence of fractured zonas. We conclude that follicles greater than or equal to 15 mm provide the highest probability of retrieving mature oocytes and the low recovery rates of mature oocytes from follicles less than or equal to 11 mm suggest that, in selected circumstances, the operating surgeon may choose not to aspirate them.

Hormonal manipulation of endometrial maturation

Three experimental protocols were devised to induce endometrial maturation in 12 women with ovarian failure. Each was planned to serve a dual purpose: to resolve a particular clinical situation related to synchronization between ovum donor and recipient and to answer a specific question about endometrial physiology. A fourth protocol of sequential estrace (2-6 mg/day) and progesterone (P4; 25-50 mg/day, im) simulating the 28-day natural cycle, served as a control protocol (18 cycles). A short follicular phase protocol consisted of only 6 days of estrogen (E) administration before addition of P4 (13 cycles). In the long follicular phase protocol (5 cycles), estrace was given for 3-5 weeks, and P4 administration was accordingly postponed. In 6 accelerated secretory transformation cycles, 150 mg/day P4 were administered, im, from day 15 onward. The adequacy of the induced endometrial cycles was evaluated by hormonal, morphological, and histochemical criteria relevant to endometrial normalcy and receptivity. Serum estradiol levels and the areas under the estradiol curves for the long and short follicular phase protocols differed significantly from those during the control cycles (P less than 0.005). Areas under the estradiol curves in the accelerated secretory transformation protocol yielded significantly higher P4 values than those in all other protocols (P less than 0.05). All biopsies in the 3 experimental protocols compared favorably with those of the control protocol. Glycocalyx intensity (periodic acid-Schiff) and the amount of galactose residues in the glycocalyx (Ricinus communis-I agglutinin) were greatest during the periimplantation interval. We conclude that a very short exposure of the human endometrium to E or, conversely, prolonged E stimulation will allow normal endometrial maturation with the addition of P4. Supraphysiological doses of P4 in the accelerated secretory transformation protocol significantly enhanced endometrial maturational processes.

Value of suppression with a gonadotropin-releasing hormone agonist prior to gonadotropin stimulation for in vitro fertilization

This study examined the use of gonadotropin-releasing hormone agonist (GnRHa) suppression before gonadotropin stimulation in 26 patients with failed prior in vitro fertilization (IVF) attempts and variable basal serum gonadotropin levels. Leuprolide, 1 mg subcutaneously per day, was administered from the midluteal phase of the cycle before IVF treatment. Concomitantly, stimulation was initiated on cycle day 3 with human menopausal gonadotropin (hMG) and follicle stimulating hormone (FSH). Based on their prior IVF attempts and serum gonadotropin levels on cycle day 3, 9 patients were high responders with elevated mean basal luteinizing hormone (LH)/FSH, 8 were low responders with elevated mean basal FSH/LH, 7 were intermediate responders with normal mean basal FSH/LH and a history of premature LH surge, and 2 had elevated (perimenopausal) mean FSH and LH. Leuprolide was discontinued on the day of human chorionic gonadotropin (hCG) administration. Prior IVF attempts in the same patients with the same protocol, but without GnRHa suppression, were used as controls. The mean number of ampules of hMG and FSH was significantly higher in leuprolide cycles than in controls. The mean day of hCG administration was also higher for leuprolide cycles than for controls. The mean LH and progesterone levels on the day of hCG were significantly lower in leuprolide cycles. The mean number of preovulatory oocytes aspirated and transferred was higher in leuprolide cycles. Cancellation and pregnancy rates were improved in leuprolide cycles. It is concluded that prior GnRHa suppression is beneficial for follicular recruitment for IVF. More patients with variable basal serum gonadotropin levels need to be studied before definite recommendations are made.

The hemizona assay (HZA): a predictor of human sperm fertilizing potential in in vitro fertilization (IVF) treatment

The hemizona assay (HZA) was developed to assess human sperm fertilizing potential. This blinded study investigated the relationship between sperm binding to the hemizona and in vitro fertilization (IVF) success (36 patients). Nonliving human oocytes were recovered from excised ovaries and stored. Each zona pellucida was cut into equal hemispheres by micromanipulation. For the HZA, one droplet exposed a hemizona to abnormal spermatozoa, while the control droplet contained the matching hemizona and spermatozoa from normal semen. After 4 hr, the number of tightly bound spermatozoa was counted. Binding to the hemizona was significantly higher for those having IVF success (mean of 36.1 +/- 7, versus 10.4 +/- 4 from the failure group; P less than 0.05). Fewer sperm from the failure group had a strictly normal morphology (3.2 versus 12.7%; P less than 0.05, Kruger method). Tight zona binding was significantly correlated with the percentage motile sperm, percentage normal morphology, and seminal sperm concentration. These results enhanced our confidence that the HZA is diagnostic for identification of patients at high risk of failing to achieve fertilization in vitro.

Hemizona assay using salt-stored human oocytes: evaluation of zona pellucida capacity for binding human spermatozoa

Human oocytes were stored (25 degrees C) in 1.5 M MgCl2 for 6-30 days, then utilized in the new hemizona assay (HZA) for tight binding of human spermatozoa [Burkman et al.: Fertil Steril 49:688-697, 1988]. We have compared 1) the ability of matching salt-treated hemizonae or dimethylsulfoxide (DMSO)-treated hemizonae to distinguish between sperm from semen having normal versus subnormal characteristics and, 2) the kinetics of fertile sperm binding to salt-treated or DMSO-treated hemizonae. After sperm preparation one salt-treated hemizona was incubated with normal spermatozoa and the matching hemizona was placed with sperm from the subnormal group. As a control, DMSO-treated hemizonae were incubated in additional sperm droplets. After 4 hours, the number of sperm tightly bound to each hemizona was counted. Within the normal semen group, there was equivalent binding to salt- or DMSO-treated hemizonae (54.0 +/- 12 and 49 +/- 14, respectively, mean +/- SEM). Similarly, tight binding of sperm from the subnormal group was not affected by the zona storage method (21 +/- 8 and 17 +/- 5, respectively). For either storage approach, binding of subnormal sperm was significantly less (P less than 0.01) compared with the number of normal sperm attached to the matching hemizona. For the kinetics study, the hemizona binding of proven fertile spermatozoa was followed throughout 8.5 hours. The shape of the binding curve was the same for zonae stored by either method and was consistent with our published kinetics data. Salt storage offers a simple and inexpensive means for accumulating and transporting human zonae pellucida; the resulting hemizonae function effectively in the HZA for estimating sperm binding potential.

Effects of the severity of tubo-ovarian disease and previous tubal surgery on the results of in vitro fertilization and embryo transfer

The purpose of this study was to evaluate the ovarian response and in vitro fertilization/embryo transfer (IVF-ET) results in patients with tubal infertility and two ovaries, according to (1) the degree and extent of pelvic disease (isolated tubal or tubo-ovarian) and (2) previous adnexal surgical procedures. A total of 549 patients who underwent 1031 IVF-ET cycles were evaluated. Significant findings were as follows: (1) No differences were found in the number of preovulatory oocytes, fertilization rates, or serum estradiol levels in the follicular phase between any classes of tubo-ovarian disease. (2) Patients with a "frozen pelvis" had significantly fewer follicles aspirated than those in any other category, although they had equivalent numbers of preovulatory oocytes retrieved and pregnancy rates. (3) Patients with previous bilateral tubal ligation had higher pregnancy rates than patients with severe tubo-ovarian disease. (4) The type of prior pelvic surgical procedure had no effect on IVF-ET outcome. Although patients with no cause of infertility other than tubal ligation had better results, these patients had previously proven fertility. We conclude that neither the stage of tubo-ovarian disease nor any history of pelvic adhesions or tubal surgery has a significant impact on the efficiency of IVF-ET.

Ovulation induction for assisted reproduction

The goal of ovulation induction in assisted reproduction is the development of multiple follicles, allowing the recovery of multiple mature, high-quality oocytes. Normally ovulatory women may respond very differently to gonadotropin stimulation. Most patients respond best to regimens that provide the highest quantities of gonadotropins in the early follicular phase followed by tapering dosages as the gonadotropin requirements of the developing follicles are reduced. Others, particularly those with inverted luteinizing hormone:follicle-stimulating hormone ratios, respond better to constant, low-dose, pure follicle-stimulating hormone protocols. Patients with elevated basal follicle-stimulating hormone concentrations may require upwards of eight ampules of gonadotropins per day to obtain multifollicular development. Gonadotropin releasing hormone agonists are of value in patients with exaggerated multifollicular responses as well as in those who have premature luteinizing hormone surges. In all cases, optimization of ovulation induction through the customization of stimulation regimens results in improved stimulation quality and outcomes.

Follicular atresia associated with concurrent initiation of gonadotropin-releasing hormone agonist and follicle-stimulating hormone for oocyte recruitment

The ability of gonadotropin-releasing hormone agonist (GnRHa) to cause an initial stimulation of serum gonadotropins was used for follicular recruitment for in vitro fertilization (IVF) in 12 patients with a history of low estradiol (E2) response to conventional gonadotropin stimulation. Stimulation was initiated on cycle day 3 with concurrent administration of leuprolide (1 mg/day subcutaneously) and follicle stimulating hormone (FSH, 4 ampules/day intramuscularly). An 8-fold increase in basal serum luteinizing hormone (LH) and a 4-fold increase in basal serum FSH was seen on cycle day 4. Serum progesterone levels rose significantly by day 6. When compared to prior IVF attempts in these patients, the mean day of human chorionic gonadotropin administration and corresponding E2 levels were not significantly different. More atretic oocytes and fewer preovulatory oocytes were retrieved using GnRHa, and no increase was seen in total oocytes retrieved. One patient was canceled for poor E2 response, and one patient conceived, with a current viable pregnancy. It is concluded that concurrent initiation of leuprolide and FSH stimulation on cycle day 3 in patients with prior low response does not improve oocyte recruitment, and the high LH environment generated from initial stimulation of the agonist may be detrimental to normal oocyte development.

Implantation potential of each pre-embryo in multiple pregnancies obtained by in vitro fertilization seems to be different

Endometrial receptivity and pre-embryo quality are the main factors determining embryo implantation in in vitro fertilization. If one embryo implants normally and goes to term, the endometrium can be assumed to be normal. Eighty-one patients (March 1981 to 1987) had transfers of multiple pre-embryos, resulting in multiple pregnancies with at least one reaching term. The number of gestational sacs at 8 to 12 weeks of pregnancy, at 20 weeks, and the number of term pregnancies were studied longitudinally. Twelve patients (14.8%) had 2 pre-embryos transferred, 19 (23.5%) had 3, 21 (25.9%) had 4, 17 (21.0%) had 5, 9 (11.1%) had 6, and 3 (3.7%) had 7. At 20 weeks 18 patients (22.2%) had a single viable fetus, 56 (69.1%) had twins, 6 (7.4%) had triplets, and 1 (1.2%) had quadruplets. A total of 325 pre-embryos were transferred; 178 gestational sacs were observed at 8 to 12 weeks, but only 153 showed fetal heartbeat. Total embryo loss at 8 to 12 weeks was 53.0%; when the "index" embryo was excluded, it reached 61%. Regardless of the number of pre-embryos transferred, only 2.2 embryos on average were able to establish a normal pregnancy. (A)synchronism of the pre-embryos did not affect outcome. Results suggest that with normal endometrial receptivity, the implantation potential of each pre-embryo is different.

Transdermal estrogen replacement in ovarian failure for ovum donation

This study examined the efficacy of transdermal estradiol (TE2) replacement versus oral estradiol (OE2) through evaluation of peripheral steroid levels, endometrial morphology, and clinical outcome in six patients with ovarian failure. Patients were begun on sequential E2 and progesterone replacement with transdermal E2 patches. Endometrial biopsies were done on day 21 of the first replacement cycle and day 26 of the second cycle. Controls were 28 cycles on a regular 28-day micronized OE2 protocol. No significant difference was found between E2 levels throughout the cycle of the two respective stimulation protocols, except for days 12 to 14, when the OE2 protocol produced significantly lower E2 than did the TE2 protocol (P less than 0.01). A positive, highly significant correlation was found between estrone (E1) and E2 values in the OE2 group (r = 0.92) (P less than 0.003). During OE2 administration, E1 was significantly higher than E2 (P less than 0.01). E1 was not found to be higher than E2 in the TE2 group, resulting in a significant difference in the E2/E1 ratio of 1.59 +/- 1.6 for TE2 compared with 0.13 +/- .04 for OE2 (P less than 0.05). Early biopsies in patients on TE2 revealed glandular components that were dated as day 18.2 +/- 1.7, while the stroma was dated as day 21.8 +/- 0.8, a statistically significant disparity (P less than 0.01). In patients on OE2, the same significant 3-day glandular/stromal disparity was observed (P less than 0.05). Morphologic evaluation of late biopsy specimens revealed day 25.0 +/- 0.8 and 24.5 +/- 1.5 for TE2 and OE2 groups, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous and pharmacologically induced remissions in patients with premature ovarian failure

To determine the fertility potential of patients with apparent ovarian failure, a retrospective analysis of 86 ovarian failure patients in the Norfolk oocyte donation program was performed. None of the 23 patients with primary ovarian failure ovulated. Seven of 63 (11.1%) with secondary ovarian failure did ovulate, and three of 63 (4.8%) conceived and delivered normal, healthy infants. Of patients whose etiology for ovarian failure was partial ovarian resection or chemotherapy, the ovulation rate and pregnancy rate were 30.8 and 15.4%, respectively, compared with 5.0 and 1.7%, respectively, for the other patients with secondary ovarian failure. Serum estradiol and FSH obtained during hormone replacement were not predictive of the resumption of normal reproductive functions. Therefore, it is recommended that patients with secondary ovarian failure, especially in the better-prognosis group, be treated with a trial of estradiol replacement and have close monitoring for ovulation before oocyte donation.

Spontaneous luteinizing hormone (LH) surges are associated with more rapidly increasing estradiol (E2) and follicle stimulating hormone (FSH) in in vitro fertilization and embryo transfer

In a retrospective analysis of 64 patients stimulated with human menopausal gonadotropin (hMG) and/or pure follicle stimulating hormone (FSH); 35 cycles with spontaneous luteinizing hormone (LH) surges were compared with 29 control cycles with respect to serum FSH and estradiol (E2) levels drawn on the day prior to and the day of human chorionic gonadotropin (hCG), approximately 16 hr after gonadotropin stimulation. FSH decreased significantly (P less than 0.05) in control cycles where two or more preovulatory oocytes (preovs) were obtained, in contrast to cycles with a spontaneous LH surge, where FSH increased irrespective of the number of preovs. The E2 increase in the LH surge cycles was significantly higher (P less than 0.05) than in the control cycles. However, the increase in E2 did not correlate with the change in FSH levels or with the number of preovs.

The ovarian prorenin-angiotensin system. Lessons from IVF

Recent evidence suggests that prorenin and other active components of the renin-angiotensin system may be linked to ovarian physiology. Prorenin, the inactive form of the enzymatically active renin, is present in the fluid of mature human ovarian follicles in concentrations more than 10 times higher than that found in the plasma of women undergoing ovarian stimulation. Only 1% of the renin in follicular fluid is in active form. Concentrations of prorenin in fluid of immature follicles are lower than levels detected in concomitantly aspirated mature follicles. Study of prorenin levels disclosed a positive correlation to testosterone and E2 in fluids of mature follicles. Plasma prorenin increases about twofold at midcycle at the time of the LH surge; the peak of prorenin is sustained for about 40 hours. In patients undergoing ovarian stimulation for IVF, hCG administration results in much higher plasma prorenin levels and the height of prorenin response is directly related to the number of mature follicles. It peaked 4 to 6 days after hCG injection and then fell, close to baseline, by about 12 days after hCG administration. Examination of the time course of hormonal changes in response to hCG revealed a temporal relationship between prorenin and both plasma E2 and progesterone. In women who conceived, prorenin began to rise again on days 8 to 12 after embryo transfer when endogenous hCG was detected in the blood. No such changes in prorenin occurred in women with ovarian failure who conceived after transfer of a donor egg. These findings indicate that prorenin is produced by the mature follicle and the corpus luteum in response to LH/hCG. Since angiotensin II affects intracellular calcium and phospholipase activity, there are many potential roles for prorenin via angiotensin II action. Putative actions of the ovarian renin system may include control of oocyte maturation, ovulation, ovarian blood flow, and ovarian steroid biosynthesis. Future work to elucidate the function of this new renin system may have relevance to many basic and clinical aspects of human reproduction.

Distribution of T cell subsets in follicular fluid

Examination of follicular fluid (FF) from in vitro fertilization patients revealed a significant difference in concentrations of lymphocytes and T cell subpopulations with increased oocyte maturation. A total of 111 follicles containing 82 oocytes were aspirated from 10 patients undergoing laparoscopic oocyte retrieval. FF from 61.3% of the follicles was classified as clear and 38.7% as bloody, based on gross and microscopic appearance. A mean of 1.78 X 10(6) lymphocytes/ml was obtained from peripheral blood (PB) as compared to 2.14 X 10(5) and 2.79 X 10(5) lymphocytes/ml for clear and bloody FF, respectively. There were 6.3 X 10(5) T4 and 3.7 X 10(5) T8 lymphocytes in PB, resulting in a T4/T8 ratio of 1.72, which is not significantly different from that of the general population. The mean concentration of FF T4 and T8 lymphocytes decreased with increased oocyte maturation; the T8 reduction was statistically significant (P less than 0.05). The proportion of T4 to T8 lymphocytes in FF remained unchanged and was unaffected by maturity of the oocyte. Although estradiol (E2) did not vary with oocyte maturity, progesterone (P) increased and E2/P decreased. There was no correlation between E2 or P levels and distribution of T cells. Fertilization rates were higher in more mature oocytes, but there was no correlation between fertilization and E2, P, E2/P, or T cell subpopulations. It remains to be determined what factors result in the decrease in lymphocytes with increased oocyte maturity and the observed difference in FF T4/T8 compared to PB.

In vitro fertilization and embryo transfer (IVF/ET): an established and successful therapy for endometriosis

The purpose of this report is to present a 6-year experience in the management of endometriosis with in vitro fertilization and embryo transfer (IVF/ET). We divided 136 patients who underwent 280 cycles into three groups: (1) previous history of endometriosis but normal pelvis at the time of oocyte retrieval, (2) stages I-II endometriosis (revised AFS classification), and (3) stages III-IV endometriosis. The stimulation protocols, estradiol (E2) responses, and distribution of terminal E2 patterns were similar in all groups. Group 3 had significantly fewer preovulatory and immature oocytes retrieved and fewer embryos transferred. The fertilization rate and the per cycle/per transfer pregnancy rates were similar in all groups. The miscarriage rate was higher in group 3, and the ongoing pregnancy rate per cycle was lower. Luteal phase E2 and progesterone levels were comparable in all groups. No differences were found when groups 2 and 3 were analyzed for the presence of one or two ovaries or the presence/absence of ovarian endometriosis. The overall fertilization rate, the per cycle/per transfer pregnancy rates, and the miscarriage rate were similar to those of tubal factor patients. We underscore the excellent outcome of patients with minimal or mild endometriosis in IVF/ET. We conclude that patients with moderate or severe endometriosis have a compromised reproductive potential, probably because of a reduced oocyte recovery rate and poor embryo quality.

Abdominal pregnancy after in vitro fertilization and embryo transfer

Ectopic pregnancy continues to be a major complication of in vitro fertilization (IVF) and embryo transfer. We report the first abdominal pregnancy occurring after this therapeutic approach. The patient, a 35-year-old female, presented a frozen pelvis with a history of severe endometriosis and a left salpingectomy. After the transfer of four concepti in her second IVF/embryo transfer attempt, she became pregnant. Unfortunately, ultrasound evaluation five weeks later showed an ectopic pregnancy in the cul-de-sac. During laparotomy, it was noticed that implantation had taken place near the mesentery of the sigmoid and rectosigmoid. A right cornual tubal ligation was performed. Although the benefit of IVF/embryo transfer far outweighs the risk of an ectopic pregnancy, it is imperative that physicians who care for patients after IVF/embryo transfer be fully aware of the possibility of this complication in this high-risk population.

Timing of oocyte retrieval in cycles with a spontaneous luteinizing hormone surge in a large in vitro fertilization program

Forty-four cycles with a spontaneous luteinizing hormone (LH) surge among 377 in vitro fertilization (IVF) patients were studied for outcome with different timing of oocyte retrieval. Mean number of preovulatory oocytes per retrieval and per transfer was significantly less in these cycles than in controls. Mean number of preovulatory oocytes per retrieval and per transfer was significantly higher when the human chorionic gonadotropin (hCG)-retrieval interval was greater than 35 hours, compared with less than 24 hours. In cycles with an hCG-retrieval interval of less than 24 hours, percentage of preovulatory oocytes was higher when serum estradiol (E2) decreased by greater than 15% on the morning after hCG administration compared with a plateau or an increase in serum E2. Timing oocyte retrieval after spontaneous LH surge should consider the hCG-retrieval interval and changes in E2 levels after hCG administration; this may avoid cancellation for many patients.

The value of basal and/or stimulated serum gonadotropin levels in prediction of stimulation response and in vitro fertilization outcome

The purpose of this study was to determine whether basal or stimulated (or both) serum follicle-stimulating hormone (FSH) and luteinizing hormone (LH) on day 3 of the cycle before administration of exogenous gonadotropins can predict stimulation response and in vitro fertilization (IVF) outcome. Eighty consecutive new patients underwent a gonadotropin-releasing hormone (GnRH) stimulation test on the morning of cycle day 3. All patients underwent the same stimulation protocol consisting of a combination of FSH and human menopausal gonadotropin (hMG). Paired discriminant analysis of FSH0 (at 0 minutes from GnRH injection) and LH0 revealed seven distinct groups of patients with statistically significant differences among the means: groups 1, 2, and 3 (26.25%) with higher means FSH0:LH0; group 4 (40%) with mean FSH0:LH0 (both levels less than 10 mIU/ml) of 1:1, and groups 5, 6, and 7 (33.75%) with higher mean LH0:FSH0. Canonical discriminant analysis of both basal and stimulated serum FSH and LH levels confirmed the seven groups and did not add to the information from analysis of FSH0 and LH0 only. Serum estradiol (E2) response during stimulation, as well as the number of preovulatory oocytes aspirated and transferred, was highest in the groups with a higher mean LH0:FSH0, intermediate in the group with mean FSH0:LH0 of 1:1, and lowest in the group with a higher mean FSH0:LH0. No pregnancy occurred in the higher FSH:LH groups. It is concluded that basal serum gonadotropin levels can distinguish different populations of IVF patients who tend to behave differently in terms of E2 response, oocytes obtained and transferred, and pregnancy rates and outcome.

Corrective measures and pregnancy outcome in in vitro fertilization in patients with severe sperm morphology abnormalities

Sperm morphology evaluated by new, strict criteria is a good predictor of outcome in in vitro fertilization (IVF). This study aimed (1) to determine whether the fertilization rate of preovulatory oocytes in patients with abnormal morphology can be improved by increasing insemination concentration at the time of IVF and (2) to evaluate the pregnancy outcome in patients with abnormal sperm morphology. Three groups were studied: (1) normal morphology, (2) good prognosis pattern, and (3) poor prognosis pattern. All other sperm parameters were normal. Group 3 had a lower overall fertilization rate, lower pregnancy rate/cycle, and lower ongoing pregnancy rate/cycle. Groups 2 and 3 showed a higher miscarriage rate, although not significantly different from group 1. By increasing insemination concentration from 2- to 10-fold, the fertilization rate in group 3 increased from 14.5% to 62.6%. However, pregnancy outcome did not improve. We conclude that patients with severe sperm head abnormalities have a lower ability to establish successful pregnancies, even though fertilization may be achieved.

Monitoring gonadotropin-stimulated cycles for in vitro fertilization and embryo transfer

One hundred fifty-one cycles stimulated with human menopausal gonadotropin (hMG) and/or follicle-stimulating hormone (FSH) were analyzed retrospectively to determine the relationship of the monitoring parameters used: serum estradiol (E2), transvaginal sonographic follicular size, and peripheral biologic estrogen response, with harvests and pregnancies resulting from in vitro fertilization and embryo transfer. Mean +/- SE serum E2 levels were higher on the day of human chorionic gonadotropin (hCG) administration in the miscarriage group (689.4 +/- 27.5 pg/ml) than in the nonpregnant group (527.7 +/- 25.8 pg/ml) (P = 0.018) and highest in the ongoing pregnancy group (734.6 +/- 66.5 pg/ml) (P = 0.003). When two or more preovulatory oocytes (preovs) were retrieved, the mean E2 levels were higher (622.3 +/- 27.3 pg/ml) than if zero or one preov was retrieved (378.4 +/- 43.5 pg/ml) (P = 0.001). The mean diameter of the two largest follicles at the time of hCG administration was significantly greater (14.7 mm) in the group with two or more preovs retrieved than in the group with zero or one preov (13.3 mm) (P = 0.001). The relative probability of achieving a pregnancy was best predicted by the presence of two follicles greater than or equal to 16 mm in diameter on transvaginal ultrasound examination and was 1.63 times greater than that of all patients in this series.

Beta-human chorionic gonadotropin as a monitor of pregnancy outcome in in vitro fertilization-embryo transfer patients

Serum human chorionic gonadotropin (hCG) was studied to test its predictability of pregnancy outcome in in vitro fertilization (IVF) patients. The mean +/- standard deviation of serum hCG concentration related to the day complete clearance of exogenous hCG was derived from 47 single term pregnancies as a normal range. This range can be used to predict spontaneous abortion (77%), multiple pregnancy (60%), and abortion in multiple-sac pregnancies terminating in the birth of fewer infants than the initial number of sacs (80%). The results also showed that our stimulation protocol did not affect the clearance rate and doubling time of endogenous hCG or implantation time as suggested by the time of endogenous hCG detection and that spontaneous abortion may be due to late implantation.

Mechanisms and factors of early pregnancy wastage in in vitro fertilization-embryo transfer patients

Although the pregnancy rate per transfer of the Norfolk In Vitro Fertilization-Embryo Transfer (IVF-ET) program has been reported as between 25% and 35%, the viable pregnancy rate per transfer is only 15% to 20%. An understanding of the mechanism(s) and etiologic factors of miscarriage among IVF patients might suggest changes that could prevent some early pregnancy wastage. Forty-seven consecutive single pregnancies and 26 miscarriages (October 1985 to November 1986) were included in this study. Factors such as implantation time, date of corpus luteum rescue (CLR), embryo quality, and corpus luteum activity after rescue were studied and compared between term pregnancy and miscarriage groups. Results are discussed in detail in this paper.

The value of in vitro fertilization for the treatment of unexplained infertility

In 54 patients referred with the diagnosis of unexplained infertility (UI), the diagnosis was confirmed in 26 (strict UI) (48%). Minimal abnormalities (MA) were found in 19 (35%); 9 (17%) had gross abnormalities and were excluded from analysis. Fifty patients with tubal infertility were randomly assigned to form a control group. Mean age and type of stimulation did not differ in the two groups. Peak follicular estradiol (E2) and terminal follicular E2 patterns were comparable. There was no difference in the mean number of oocytes retrieved per cycle. However, the control group had significantly more preovulatory oocytes: 3.6 +/- 2.0 standard deviations versus 2.8 +/- 2.1 in the overall UI group (strict UI + MA groups) and 2.7 +/- 2.2 in the strict UI group. Significantly more fertilized oocytes per cycle were obtained in the control group (P less than 0.05). The per-cycle and per-embryo transfer (ET) pregnancy rates were 32.4 and 37.3% in the overall UI group and 24 and 24.5% in the control group. The miscarriage rate was 12% in the strict UI group, 22% in the overall UI group, and 25% in the control group. It is concluded that patients with UI constitute a favorable group for in vitro fertilization and ET.

A preclinical evaluation of pronuclear formation by microinjection of human spermatozoa into human oocytes

In vitro fertilization (IVF) is recognized as an accepted treatment for male infertility. However, the fertilization rate is significantly lower than the fertilization rate of other IVF patient groups. Some male factor infertility patients still have a basic semen quality too poor for treatment by IVF. Microinjection of a spermatozoon directly into ooplasm has been recommended to assist fertilization in this subfertile population. This study found that oocytes from 5 of 11 patients microinjected with human spermatozoa demonstrated successful pronuclear formation and correlated with the incidence of pregnancy in these patients transferred with same-source oocytes inseminated by standard protocols. This initial evidence promotes the supposition of clinical feasibility of assisted fertilization by sperm microinjection.

The efficiency of human reproduction after in vitro fertilization and embryo transfer

Two hundred ninety-seven nonpregnant patients were used to study the possibility of early transient implantation as a parameter of the efficiency of in vitro fertilization (IVF) procedures. Ten patients without embryo transfer (ET) were used as controls. The luteal estradiol, progesterone, and human chorionic gonadotropin were measured by radioimmunoassay (RIA). In 31 cases, a transient elevation of hCG occurred after complete serum clearance of exogenous hCG, suggesting that the transient increase in hCG was of embryonic origin. In addition, five patients were found to have prolonged clearance of hCG, which was due not to individual variation in clearance, but to a minimal production of hCG by trophoblastic tissue. These data suggest that implantations occurred in 12.1% of our so-called "nonpregnant" patients.

The hemizona assay (HZA): development of a diagnostic test for the binding of human spermatozoa to the human hemizona pellucida to predict fertilization potential

The authors present their initial results with the hemizona assay (HZA), which was developed to predict the fertilizing potential of spermatozoa. The HZA uses the matching halves of a human zona pellucida from a nonfertilizable and nonliving oocyte, providing an internal control on zona-to-zona variability. Maximal binding of human sperm to the hemizona usually occurred after 4 to 5 hours of coincubation. Sperm from fertile men exhibited significantly higher binding capacity to hemizonae compared with sperm from men who had fertilization failure during in vitro fertilization (IVF) treatment. The HZA index is calculated as follows: (bound sperm from subfertile male) divided by (bound sperm from fertile male) X 100. These findings demonstrate that the HZA may be a useful diagnostic tool in male infertility evaluations.