Hormone levels of follicular fluids with and without oocytes in patients who received gonadotropin-releasing hormone analogues and gonadotropins in an in vitro fertilization program

Empty follicle syndrome: successful treatment in a recurrent case and review of the literature

Empty follicle syndrome is a condition in which no oocytes are retrieved after an apparently adequate ovarian response to stimulation and meticulous follicular aspiration. It is a rare condition of obscure etiology. A patient with primary infertility who underwent seven assisted reproductive technique cycles is described. In spite of a satisfactory ovarian response, aspiration yielded no oocytes in four cycles and 1-4 low quality oocytes in three cycles. In the index treatment cycle, ovulation was triggered using GnRH agonist 40 h prior to ovum pickup and hCG was added 6 h after the first trigger. Eighteen oocytes were recovered, of which 16 were mature and were inseminated by ICSI. Two embryos were transferred 48 h after aspiration and nine embryos were cryopreserved. The patient conceived and delivered a healthy boy at 38 weeks of gestation. The literature is reviewed and possible etiologies and treatment options of this enigmatic syndrome are suggested.

The variation of serum cortisol during ovarian stimulation for in vitro fertilization

AIM

As there is no consensus concerning the variation of serum cortisol level during in vitro fertilization (IVF), we studied it prospectively by frequent evaluation throughout the course of an IVF cycle and compared the value, as control, of cortisol concentration obtained in the previous month (M-1) with the concentration obtained on the first day (D1) of ovarian stimulation.

METHODS

In 23 IVF cycles using gonadotropin-releasing hormone agonist/human menopausal gonadotropins (hMG)/human chorionic gonadotropin, cortisol and estradiol were measured at M-1, D1, day 14 (D14, before beginning hMG), day 16 (D16), day 19 (D19), day 22 (D22), day 24 (D24), the day before (T-1) and the day after triggering ovulation (T+1), the day of oocyte retrieval (OR), 15 days after embryo transfer (ET+15) and the next month (M2). Statistical analysis used tests of linear tendency, the Pearson chi(2) test, analysis of variance, Student's t test and Spearman correlation.

RESULTS

Cortisol was non-significantly lower at M-1 compared with D1; although remaining in the normal range, mean cortisol increased progressively after D1, in a manner unrelated to estradiol, with non-significant differences between different time points but a significant linear tendency and a maximum value at T+1. All mean cortisol values were significantly higher than that at M-1 and, except for D19 and T-1, D1. Mean cortisol decreased at ET+15 and significantly at M2, the value at M2 being lower than that at M-1.

CONCLUSION

Cortisol showed a progressive increase beginning from D1, especially after ovulation triggering, and returned to pre-treatment level next month. Cortisol variation was not related to the changes in the E(2) values. Cortisol values at both M-1 and D1 could be used as controls.

Unsuccessful oocyte retrieval: technical artefact or genuine 'empty follicle syndrome'?

Unsuccessful oocyte retrieval after apparently successful ovarian stimulation (also referred to as 'empty follicle syndrome') occurs in 1-7% of women undergoing assisted reproductive techniques. A literature review was performed, as individual studies have reached differing conclusions on the aetiology and treatment or management of the phenomenon. The aetiology is not clear, but probably multifactorial, and occurs in natural and stimulated cycles. In many cases, technical problems such as errors in human chorionic gonadotrophin (HCG) administration or defects in HCG batches can be identified, but this is not sufficient to account for all reported cases. The term empty follicle syndrome is inappropriate in cases in which such procedural factors can be identified. In many patients, however, unsuccessful oocyte retrieval appears to be due to an underlying ovarian dysfunction, and some may have a genuine empty follicle syndrome. Appropriate measures, such as monitoring of serum beta-HCG, should be taken to minimize the risk of unsuccessful oocyte retrieval. This review discusses the potential causes of unsuccessful oocyte retrieval, its clinical implications, and potential solutions to this clinical problem.

Controlled ovarian hyperstimulation and transvaginal intratubal insemination as an alternative to gamete intrafallopian transfer

OBJECTIVE

To evaluate the efficacy of controlled ovarian hyperstimulation (COH) followed by intratubal insemination in the treatment of infertility.

DESIGN

Retrospective analysis of 179 intratubal insemination trials in 78 women over a 48-month period.

SETTING

Reproductive endocrinology practice.

PATIENTS

Seventy-eight women, 26 to 44 years old (34 +/- 4.3 years; mean +/- SD), classified into subgroups according to diagnosis and age (< 40 or > or = 40 years).

INTERVENTIONS

Patients underwent COH and intratubal insemination.

MAIN OUTCOME MEASURES

The rates of pregnancy, delivery, spontaneous abortion, ectopic and multiple gestation, and complications were studied and analyzed statistically.

RESULTS

Overall, there were 36 pregnancies (20.1% of 179 trials), 29 deliveries (16.2%), 5 of 36 first trimester abortions (13.9%), 2 of 36 ectopic pregnancies (5.6%), and 4 twin gestations. There were no serious complications. In 43 women < 40 years without male factor the first trial resulted in 15 pregnancies (34.9%); in 27 women < 40 years with male factor the first trial resulted in 4 pregnancies (14.8%). Male factor reduced significantly the probability of conception. In 19 women < 40 years of age with either ovarian dysfunction or infertility of unknown cause, the first trial resulted in 9 pregnancies (47.4%), which was significantly better than the 10 pregnancies achieved in the first trial in the remaining 51 women < 40 years of age. Peak serum E2 levels and number of mature follicles had a significant effect on pregnancy rates.

CONCLUSIONS

Intratubal insemination yielded pregnancy rates comparable to those published for GIFT at reduced cost and with fewer complications.

Spectrophotometric analysis of human follicular fluid with regard to in vitro fertilization (IVF) parameters, follicular protein, and hormone content

PURPOSE

Our purpose was to investigate possible relationships with spectrophotometric absorbance (458-nm region) and biochemical variables in follicular fluid (FF) as well as in vitro fertilization (IVF) outcome.

METHODS

This study included 227 normal ovulatory women undergoing oocyte retrieval for IVF. Blood-uncontaminated fluid samples, identified by spectrophotometry, were investigated. Spectrophotometric absorbance of FF at 458 nm (n = 426), as well as hLH, FSH, PRL, hCG, testosterone, sialic acid, alpha 1-antitrypsin and plasminogen of selected fluids, was analyzed.

RESULTS

Small-volume follicles (< or = 2 ml) were associated with higher absorbance profiles (P < 0.05), when compared to volumes greater than 2 ml. Our data suggest that the presence or absence of an oocyte, the potential of an oocyte to fertilize or cleave, failed to show any relationship with maximum FF absorbance at 458 nm. Maximum absorbances were significantly lower in FF from patients who subsequently became clinically pregnant (P = 0.039). No correlation between FF absorbances and biochemical parameters (P > 0.15) were established.

CONCLUSIONS

Absorbance of clear FF at 458 nm should not be viewed as the single parameter to predict oocyte development in vitro.