Predicting the luteinizing hormone surge: relationship between the duration of the follicular and luteal phases and the length of the human menstrual cycle

Injury Incidence, Severity, and Type Across the Menstrual Cycle in Female Footballers: A Prospective Three Season Cohort Study

PURPOSE

The aim of the study was to assess the influence of menstrual cycle phase on injury incidence, severity, and type in elite female professional footballers over three seasons.

METHODS

Time-loss injuries and menstrual cycle data were prospectively recorded for 26 elite female football players across three seasons. The menstrual cycle was categorized into four phases using a standardized model: menstruation (phase 1; P1), remainder of follicular phase (phase 2; P2), early luteal (phase 3; P3), and premenstrual phase (phase 4; P4). Injury incidence rates (IIR) and ratios (IIRR) were calculated for overall injuries, injury severity, type, contact vs noncontact, and game/training.

RESULTS

A total of 593 cycles across 13,390 d were tracked during the study, and 74 injuries from 26 players were eligible for analysis. When comparing IIR between phases (reference: P1), overall injury rates were highest in P4 (IIRR, 2.30 (95% confidence interval, 0.99-5.34; P = 0.05)). When examining rates by injury severity and type, IIR values were also highest in P4 for ≤7 d' time-loss (4.40 (0.93-20.76; P = 0.06)), muscle-specific (6.07 (1.34-27.43; P = 0.02)), and noncontact (3.05 (1.10-8.50; P = 0.03)) injuries. Muscle-specific (IIRR P3/P1, 5.07 (1.16-22.07; P = 0.03)) and ≤7 d' time-loss (4.47 (1.01-19.68; P = 0.05)) injury risk was also significantly higher in P3. Muscle injuries were the most prevalent subtype ( n = 41). No anterior cruciate ligament injuries were recorded across the monitoring period.

CONCLUSIONS

Injury risk was significantly elevated during the luteal phase of the menstrual cycle (P3 and P4) among elite female professional footballers. Further research is urgently needed to better understand the influence of the menstrual cycle on injury risk and to develop interventions to mitigate risk.

Attentional, anticipatory and spatial cognition fluctuate throughout the menstrual cycle: potential implications for female sport

Current research suggests that menstruating female athletes might be at greater risk of musculoskeletal injury in relation to hormonal changes throughout the menstrual cycle. A separate body of work suggests that spatial cognition might also fluctuate in a similar manner. Changes in spatial cognition could, in theory, be a contributing risk factor for injury, especially in fast-paced sports that require precise, millisecond accuracy in interactions with moving objects in the environment. However, existing theories surrounding causes for increased injury risk in menstruating females largely focus on biomechanical mechanisms, with little consideration of possible cognitive determinants of injury risk. Therefore, the aim of this proof-of-principle study was to explore whether menstruating females exhibit fluctuations in cognitive processes throughout their cycle on a novel sport-oriented cognitive test battery, designed to measure some of the mental processes putatively involved in these sporting situations. A total of 394 participants completed an online cognitive battery, a mood scale and a symptom questionnaire twice, 14 days apart. After exclusions, 241 eligible participants were included in the analyses (mean: 28 ± 6 years) (male = 96, female(menstruating) = 105, female(contraception) = 47). Cycle phase for menstruating females was based on self-reported information. The cognitive battery was designed to measure reaction times, attention, visuospatial functions (including 3D mental rotation) and timing anticipation. Three composite scores were generated using factor analysis with varimax rotation (Errors, Reaction Time, Intra-Individual Variability). Mixed model ANOVAs and repeated measures ANOVAs were performed to test for between and within-subject effects. There was no group difference in reaction times and accuracy between males and females (using contraception and not). However, within subject analyses revealed that regularly menstruating females performed better during menstruation compared to being in any other phase, with faster reaction times (10ms c.ca, p < .01), fewer errors (p < .05) and lower dispersion intra-individual variability (p < .05). In contrast they exhibited slower reaction times (10ms c.ca, p < .01) and poorer timing anticipation (p < .01) in the luteal phase, and more errors in the predicted ovulatory phase (p < .01). Self-reported mood, cognitive and physical symptoms were all worst during menstruation (p < .01), and a significant proportion of females felt that their symptoms were negatively affecting their cognitive performance during menstruation on testing day, which was incongruent with their actual performance. These findings suggest that visuospatial and anticipatory processes may fluctuate throughout the menstrual cycle in the general population, with better performance during the menstrual phase and poorer performance during the luteal phase. If these extend to associations between phase-specific cognitive performance and injury incidence, they would support a cognitive theory of determinants of injury risk in cycling female athletes, opening an opportunity to develop mitigation strategies where appropriate.

Patellar Tendon Adaptations to Downhill Running Training and Their Relationships With Changes in Mechanical Stress and Loading History

ABSTRACT

Bontemps, B, Gruet, M, Louis, J, Owens, DJ, Miríc, S, Vercruyssen, F, and Erskine, RM. Patellar tendon adaptations to downhill running training and their relationships with changes in mechanical stress and loading history. J Strength Cond Res 38(1): 21-29, 2024-It is unclear whether human tendon adapts to moderate-intensity, high-volume long-term eccentric exercise, e.g., downhill running (DR) training. This study aimed to investigate the time course of patellar tendon (PT) adaptation to short-term DR training and to determine whether changes in PT properties were related to changes in mechanical stress or loading history. Twelve untrained, young, healthy adults (5 women and 7 men) took part in 4 weeks' DR training, comprising 10 sessions. Running speed was equivalent to 60-65% V̇O2max, and session duration increased gradually (15-30 minutes) throughout training. Isometric knee extensor maximal voluntary torque (MVT), vastus lateralis (VL) muscle physiological cross-sectional area (PCSA) and volume, and PT CSA, stiffness, and Young's modulus were assessed at weeks 0, 2, and 4 using ultrasound and isokinetic dynamometry. Patellar tendon stiffness (+6.4 ± 7.4%), Young's modulus (+6.9 ± 8.8%), isometric MVT (+7.5 ± 12.3%), VL volume (+6.6 ± 3.2%), and PCSA (+3.8 ± 3.3%) increased after 4 weeks' DR (p < 0.05), with no change in PT CSA. Changes in VL PCSA correlated with changes in PT stiffness (r = 0.70; p = 0.02) and Young's modulus (r = 0.63; p = 0.04) from 0 to 4 weeks, whereas changes in MVT did not correlate with changes in PT stiffness and Young's modulus at any time point (p > 0.05). To conclude, 4 weeks' DR training promoted substantial changes in PT stiffness and Young's modulus that are typically observed after high-intensity, low-volume resistance training. These tendon adaptations seemed to be driven primarily by loading history (represented by VL muscle hypertrophy), whereas increased mechanical stress throughout the training period did not seem to contribute to changes in PT stiffness or Young's modulus.

Comparison of serum anti-Müllerian hormone between unilateral and bilateral ovarian endometriomas during follicular, luteal, and random menstrual phases: a retrospective study

BACKGROUND

Over the last two decades, serum levels of anti-Müllerian hormone (AMH) have been shown to be reliable markers of ovarian reserve. This study aimed to compare baseline serum AMH levels and well-controlled clinical factors between patients with unilateral and bilateral ovarian endometriomas during the menstrual phase.

METHODS

We conducted a retrospective study. We enrolled 136 patients aged 18 to 36 years who were diagnosed with unilateral or bilateral ovarian endometriomas. Serum AMH levels of all patients and their latest two to three menstrual cycles were measured before surgery for ovarian endometriomas. The latest menstrual cycle length ranged from 26 to 30 days. Patients with irregular menstruation, a recent medication history of hormonal drugs other than oral contraceptive pills, a previous history of ovarian surgery, or any medical history influencing ovarian function were excluded.

RESULTS

Of the 136 patients, 76 (55.9%) had unilateral ovarian endometriomas and 60 (44.1%) had bilateral ovarian endometriomas. Serum AMH levels were not significantly different between the two groups in the follicular phase, luteal phase, or at any random time point.

CONCLUSION

Serum AMH levels were not significantly different between unilateral and bilateral ovarian endometriomas in the follicular and luteal phases, or at any random time during the menstrual cycle when various confounding factors were excluded.

Collagen supplementation augments changes in patellar tendon properties in female soccer players

We investigated the effect of collagen hydrolysate supplementation on changes in patellar tendon (PT) properties after 10 weeks' training in female soccer players from a Football Association Women's Super League Under 21 s squad. We pair-matched n = 17 players (age: 17 ± 0.9 years; height: 1.66 ± 0.06 m; mass: 58.8 ± 8.1 kg) for baseline knee extension (KE) maximum isometric voluntary contraction (MIVC) torque, age, height, and body mass, and randomly assigned them to collagen (COL) or placebo (PLA) groups (COL n = 8, PLA n = 9). Participants consumed 30 g collagen hydrolysate supplementation or energy-matched PLA (36.5 g maltodextrin, 8.4 g fructose) and plus both groups consumed 500 mg vitamin C, after each training session, which comprised bodyweight strength-, plyometric- and/or pitch-based exercise 3 days/week for 10 weeks in-season. We assessed KE MIVC torque, vastus lateralis muscle thickness and PT properties using isokinetic dynamometry and ultrasonography before and after 10 weeks' soccer training. KE MIVC torque, muscle thickness and tendon cross-sectional area did not change after training in either group. However, COL increased PT stiffness [COL, +18.0 ± 12.2% (d = 1.11) vs. PLA, +5.1 ± 10.4% (d = 0.23), p = 0.049] and Young's modulus [COL, +17.3 ± 11.9% (d = 1.21) vs. PLA, +4.8 ± 10.3% (d = 0.23), p = 0.035] more than PLA. Thus, 10 weeks' in-season soccer training with COL increased PT mechanical and material properties more than soccer training alone in high-level female soccer players. Future studies should investigate if collagen hydrolysate supplementation can improve specific aspects of female soccer performance requiring rapid transference of force, and if it can help mitigate injury risk in this under-researched population.

How Lifestyle Changes during the COVID-19 Global Pandemic Affected the Pattern and Symptoms of the Menstrual Cycle

This research investigated the implications that the COVID-19 pandemic had on the menstrual cycle and any contributing factors to these changes. A questionnaire was completed by 559 eumenorrheic participants, capturing detail on menstrual cycle symptoms and characteristics prior to and during the COVID-19 pandemic lockdown period. Over half of all participants reported to have experienced lack of motivation (61.5%), focus (54.7%) and concentration (57.8%). 52.8% of participants reported an increase in cycle length. Specifically, there was an increase in the median cycle length reported of 5 days (minimum 2 days, maximum 32 days), with a median decrease of 3 days (minimum 2 days and maximum 17 days). A lack of focus was significantly associated with a change in menstrual cycle length (p = 0.038) reported to have increased by 61% of participants. Changes to eating patterns of white meat (increase p = 0.035, decrease p = 0.003) and processed meat (increase p = 0.002 and decrease p = 0.001) were significantly associated with a change in menstrual cycle length. It is important that females and practitioners become aware of implications of environmental stressors and the possible long-term effects on fertility. Future research should continue to investigate any long-lasting changes in symptoms, as well as providing education and support for females undergoing any life stressors that may implicate their menstrual cycle and/or symptoms.

Blood oxidative stress biomarkers in women: influence of oral contraception, exercise, and N-acetylcysteine

Purpose

To compare physiological responses to submaximal cycling and sprint cycling performance in women using oral contraceptives (WomenOC) and naturally cycling women (WomenNC) and to determine whether N-acetylcysteine (NAC) supplementation mediates these responses.

Methods

Twenty recreationally trained women completed five exercise trials (i.e., an incremental cycling test, a familiarisation trial, a baseline performance trial and two double-blind crossover intervention trials). During the intervention trials participants supplemented with NAC or a placebo 1 h before exercise. Cardiopulmonary parameters and blood biochemistry were assessed during 40 min of fixed-intensity cycling at 105% of gas-exchange threshold and after 1-km cycling time-trial.

Results

WomenOC had higher ventilation (β [95% CI] = 0.07 L·min⁻¹ [0.01, 0.14]), malondialdehydes (β = 12.00 mmol·L⁻¹ [6.82, 17.17]) and C-reactive protein (1.53 mg·L⁻¹ [0.76, 2.30]), whereas glutathione peroxidase was lower (β =  22.62 mU·mL⁻¹ [− 41.32, − 3.91]) compared to WomenNC during fixed-intensity cycling. Plasma thiols were higher at all timepoints after NAC ingestion compared to placebo, irrespective of group (all p < 0.001; d = 1.45 to 2.34). For WomenNC but not WomenOC, the exercise-induced increase in malondialdehyde observed in the placebo trial was blunted after NAC ingestion, with lower values at 40 min (p = 0.018; d = 0.73). NAC did not affect cycling time-trial performance.

Conclusions

Blood biomarkers relating to oxidative stress and inflammation are elevated in WomenOC during exercise. There may be an increased strain on the endogenous antioxidant system during exercise, since NAC supplementation in WomenOC did not dampen the exercise-induced increase in malondialdehyde. Future investigations should explore the impact of elevated oxidative stress on exercise adaptations or recovery from exercise in WomenOC.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00421-022-04964-w.

Alcohol Intake and Endogenous Hormones in Pre- and Postmenopausal Women: Findings from the UK Biobank

BACKGROUND

Alcohol intake may influence breast cancer risk in women through hormonal changes, but the evidence to date is inconclusive. We investigated cross-sectional associations between habitual alcohol intake and serum concentrations of testosterone, sex hormone binding globulin (SHBG), insulin-like growth factor-1 (IGF-1), and estradiol (premenopausal women only) in UK Biobank.

METHODS

We included 30,557 premenopausal and 134,029 postmenopausal women aged between 40 and 69 years when recruited between 2006 and 2010. At their initial assessment visit, habitual alcohol intake was assessed using a touchscreen questionnaire, and serum hormone concentrations were assayed. Multivariable linear regression analysis was performed.

RESULTS

Per 10 g/day increment in alcohol intake, testosterone concentration was 3.9% [95% confidence intervals (CI): 3.3%-4.5%] higher in premenopausal women and 2.3% (1.8%-2.7%) higher in postmenopausal women (P heterogeneity < 0.0001); SHBG concentration was 0.7% (0.2%-1.1%) higher in premenopausal women and 2.4% (2.2%-2.6%) lower in postmenopausal women (P heterogeneity < 0.0001); and IGF-1 concentration was 1.9% (1.7%-2.1%) lower in premenopausal women and 0.8% (0.6%-0.9%) lower in postmenopausal women (P heterogeneity < 0.0001). In premenopausal women, there was no significant overall association of alcohol with estradiol but a positive association was observed in the early and mid-luteal phases: 1.9% (95% CI: 0.2%-3.6%) and 2.4% (95% CI: 0.7%-4.2%) higher, respectively.

CONCLUSIONS

This study confirms significant but modest associations between alcohol intake and hormones, with evidence of heterogeneity by menopausal status.

IMPACT

The findings facilitate better understanding of whether alcohol intake influences hormone concentrations, but further work is necessary to fully understand the mechanisms linking alcohol with cancer risk.

Endogenous hormones and risk of invasive breast cancer in pre- and post-menopausal women: findings from the UK Biobank

BACKGROUND

Some endogenous hormones have been associated with breast cancer risk, but the nature of these relationships is not fully understood.

METHODS

UK Biobank was used. Hormone concentrations were measured in serum collected in 2006-2010, and in a repeat subsample (N ~ 5000) in 2012-13. Incident cancers were identified through data linkage. Cox regression models were used, and hazard ratios (HRs) corrected for regression dilution bias.

RESULTS

Among 30,565 pre-menopausal and 133,294 post-menopausal women, 527 and 2,997, respectively, were diagnosed with invasive breast cancer during a median follow-up of 7.1 years. Cancer risk was positively associated with testosterone in post-menopausal women (HR per 0.5 nmol/L increment: 1.18; 95% CI: 1.14, 1.23) but not in pre-menopausal women (pheterogeneity = 0.03), and with IGF-1 (insulin-like growth factor-1) (HR per 5 nmol/L increment: 1.18; 1.02, 1.35 (pre-menopausal) and 1.07; 1.01, 1.12 (post-menopausal); pheterogeneity = 0.2), and inversely associated with SHBG (sex hormone-binding globulin) (HR per 30 nmol/L increment: 0.96; 0.79, 1.15 (pre-menopausal) and 0.89; 0.84, 0.94 (post-menopausal); pheterogeneity = 0.4). Oestradiol, assessed only in pre-menopausal women, was not associated with risk, but there were study limitations for this hormone.

CONCLUSIONS

This study confirms associations of testosterone, IGF-1 and SHBG with breast cancer risk, with heterogeneity by menopausal status for testosterone.

Temporal changes in blood oxidative stress biomarkers across the menstrual cycle and with oral contraceptive use in active women

PURPOSE

To examine the temporal changes in blood oxidative stress biomarkers in recreationally-trained women that were naturally-cycling (WomenNC) or using oral contraceptives (WomenOC) across one month.

METHODS

Blood samples were acquired at three timepoints of the menstrual cycle (1: early-follicular, 2: late-follicular and 3: mid-luteal) and oral contraceptive packet (1: InactiveOC, 2: Mid-activeOC and 3: Late-activeOC) for determination of estradiol, progesterone, oxidative stress, C-reactive protein (CRP) and other cardiometabolic biomarkers in plasma and serum.

RESULTS

There was a Group by Time effect on estradiol (p < 0.001, partial η² = 0.64) and progesterone (p < 0.001, partial η² = 0.77). Malondialdehyde, lipid hydroperoxides and CRP concentrations were higher in WomenOC during Late-activeOC compared to InactiveOC (+ 96%, + 23% and + 104%, respectively, p < 0.05). However, there were no changes in these biomarkers across the menstrual cycle in WomenNC (p > 0.05). At all timepoints (i.e., 1, 2 and 3), WomenOC had elevated lipid hydroperoxides (+ 28, + 48% and + 50%) and CRP (+ 71%, + 117% and + 130%) compared to WomenNC (p < 0.05, partial η² > 0.25). There was no Group by Time effect on non-enzymatic antioxidants or glutathione peroxidase; however, glutathione peroxidase was lower in WomenOC, i.e., main effect of group (p < 0.05, partial η² > 0.20).

CONCLUSION

These findings demonstrate that WomenOC not only have higher oxidative stress and CRP than WomenNC, but also a transient increase across one month of habitual oral contraceptive use. Since changes in oxidative stress and CRP often relate to training stress and recovery, these outcomes may have implications to workload monitoring practices in female athletes.

Injury Incidence Across the Menstrual Cycle in International Footballers

Objectives: This study aimed to assess how menstrual cycle phase and extended menstrual cycle length influence the incidence of injuries in international footballers.

Methods: Over a 4-year period, injuries from England international footballers at training camps or matches were recorded, alongside self-reported information on menstrual cycle characteristics at the point of injury. Injuries in eumenorrheic players were categorized into early follicular, late follicular, or luteal phase. Frequencies were also compared between injuries recorded during the typical cycle and those that occurred after the cycle would be expected to have finished. Injury incidence rates (per 1,000 person days) and injury incidence rate ratios were calculated for each phase for all injuries and injuries stratified by type.

Results: One hundred fifty-six injuries from 113 players were eligible for analysis. Injury incidence rates per 1,000 person-days were 31.9 in the follicular, 46.8 in the late follicular, and 35.4 in the luteal phase, resulting in injury incidence rate ratios of 1.47 (Late follicular:Follicular), 1.11 (Luteal:Follicular), and 0.76 (Luteal:Late follicular). Injury incident rate ratios showed that muscle and tendon injury rates were 88% greater in the late follicular phase compared to the follicular phase, with muscle rupture/tear/strain/cramps and tendon injuries/ruptures occurring over twice as often during the late follicular phase compared to other phases 20% of injuries were reported as occurring when athletes were “overdue” menses.

Conclusion: Muscle and tendon injuries occurred almost twice as often in the late follicular phase compared to the early follicular or luteal phase. Injury risk may be elevated in typically eumenorrheic women in the days after their next menstruation was expected to start.

Quantifying the intraindividual variation of antimüllerian hormone in the ovarian cycle

OBJECTIVE

To quantify intraindividual variability of antimüllerian hormone (AMH) as analytical and biological coefficients of variation and assess the effects of variation on clinical classification.

DESIGN

Retrospective cohort study.

SETTING

Not applicable.

PATIENT(S)

Thirty-eight women referred by general practitioners.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Total intraindividual variability (CV_W), analytical (CV_A) and biological variability (CV_I) for each woman and for AMH ranges: low (<5 pmol/L), reduced (5-10), moderate (>10-30) and high (>30 pmol/L), with calculation of proportion of women crossing clinical cutoffs and expected variability around each cutoff.

RESULT(S)

Cycling women (n = 38) contributed 238 blood samples (average 6 samples each). The average total intraindividual AMH variability was 20% (range: 2.1% to 73%). Biological variation was 19% (range: 0 to 71%) and at least twice the analytical variation of 6.9% (range: 4.5% to 16%). Reclassification rates were highest in women with low (33%) or reduced AMH (67%) levels. Expected variations around the 5, 10, and 30 pmol/L cutoffs were 3-7, 7-13, and 20-40 pmol/L, respectively. In a woman with mean AMH in the 10-30 pmol/L range, the span of results that could occur was 7-40 pmol/L.

CONCLUSION(S)

Total variation in AMH was 20%, and the majority of this was biological. Changes in AMH resulted in reclassification in 29% of women and occurred most frequently in those with low and reduced AMH. In cycling women, the variability in AMH should be considered by clinicians, especially if a result is close to a clinical cutoff.

Gene expression confirms a potentially receptive endometrium identified by histology in fertile women

BACKGROUND

To use contemporary biochemical markers to characterize mRNA/gene expression in the potentially fertile secretory endometrium to confirm its identification based on histological characteristics in order to develop a clinically applicable test.

METHODS

Nine, fertile, cycling Caucasian women were sampled from one IVF clinic. Endometrial samples were collected from them in two to four menstrual cycles at 2 and 7 days post first significant rise in blood LH. Separate endometrial glands and stroma populations were obtained by laser microdissection. Linear polymerase chain reaction amplified mRNAs which were hybridized to both Affymetrix U133 Plus2 and Agilent 4 × 44K microarrays followed by gene set analysis. Four histopathologists reviewed the sample set using the same histological criteria to date and characterize the non-receptive and potentially receptive samples.

RESULTS

mRNA expression of microdissected glands and stroma provided molecular signatures that characterized the two specific phases of the cycle with distinct clustering patterns. Cell proliferation and five other associated biological pathways were significantly down-regulated when the endometrium is considered potentially receptive accompanied by an increase in secreted glycoproteins mRNAs in the potentially receptive glands. Reported histological findings identified the presence of one histological feature characteristic of each phase: glandular mitoses indicated a non-receptive endometrium, whereas a potentially receptive endometrium was distinguished by supranuclear vacuolation.

CONCLUSIONS

This study defined a transcriptome characteristic of active cell proliferation in the non-receptive samples with a marked overall down-regulation of this pathway in potentially receptive samples-suggesting a transitional state associated with receptivity but not implantation. However, microarrays involve expensive, specialized testing and require significant post-data analysis. Sampling according to endocrinological and molecular prediction improved the consistency of histological assessment and allowed reliable histological markers of glandular mitosis in the non-receptive phase and supranuclear vacuolation of the potentially receptive endometrium to be identified. Thus, histology can provide an affordable, clinically applicable test in the context of reproduction.

Does the increase of endogenous steroid hormone levels also affect breast cancer risk in Chinese women? A case-control study in Chongqing, China

Accumulating epidemiological evidence suggests that sex steroid hormones are positively associated with the development of breast cancer. However, most of these studies were conducted among Caucasian women and few have been carried out in China. To determine whether the associations of sex steroid hormone levels with breast cancer risk observed by and large in Caucasian populations are also evident in Chinese women, we conducted a case-control study in Chongqing, China. The study included 367 incident breast cancer patients and 367 healthy controls matched on menstrual status, age and periods of blood collection in the menstrual cycle. Plasma concentrations of estradiol, progesterone, testosterone, dehydroepiandrosterone sulfate (DHEAS) and sex hormone binding globulin (SHBG) were determined by electrochemiluminescene immunoassay (ECLIA). Conditional logistic regression analysis was performed to examine their associations with breast cancer risk. From comparisons of upper and lower tertiles, we observed statistically significant positive associations with breast cancer risk for plasma estradiol levels in follicular phase (adjusted odds ratio [OR] = 5.48, 95% confidence interval [CI] = 1.58-18.97), luteal phase (OR = 4.23, CI = 1.65-10.87) and postmenopausal (OR = 2.67, CI = 1.20-5.93); for progesterone levels in luteal phase (OR = 3.11, CI = 1.28-7.56), and for testosterone levels in postmenopausal (OR = 2.83, CI = 1.26-6.35). No significant association was found with DHEAS or SHBG. Our study suggests that high circulating levels of estradiol and testosterone are positively associated with increased breast cancer risk in Chinese women, which are generally consistent with the observations in Caucasian populations.

Follicular growth pattern in normal-cycling Brazilian adolescents

OBJECTIVE

To examine the follicular growth characteristics in normal Brazilian adolescents.

DESIGN

Descriptive study.

SETTING

Adolescent clinic in a university hospital.

PATIENT(S)

Healthy normal cycling adolescents.

INTERVENTION(S)

Endovaginal ultrasound; blood samples for hormone measurement.

MAIN OUTCOME MEASURE(S)

Follicular-phase length, follicular growth rate.

RESULT(S)

The menstrual-cycle interval was 29.5 +/- 1.6 days. Sixty-five percent of adolescents had follicular-phase length of <or=16 days (group 1), and nearly 35% had follicular-phase length of >16 days (group 2). In the early follicular phase, the levels of FSH, LH, and E(2) were 5.1 mIU/mL, 3.0 mIU/mL, and 28.3 pg/mL, respectively. There was a mild negative correlation between FSH and follicular-phase length across the whole cohort (r = -0.464), but after analysis as a separate group, the correlation was present only in those adolescents with follicular phase lasting </=16 days. There was no correlation between LH or E(2) levels and the follicular-phase length in either group. There was good correlation between the follicular size and follicular-phase length in both groups of adolescents. The follicular growth rate was 1.11 +/- 0.05 mm/d across the whole cohort, 1.33 +/- 0.05 mm/d in the adolescents with follicular-phase length of <or=16 days, and 0.88 +/- 0.06 mm/d in those in whom the follicular phase lasted >16 days.

CONCLUSION(S)

A long follicular phase is common in normal-cycling, healthy adolescents as a consequence of slow follicular growth rate.

Menstrual profile and early menopause in women with Down syndrome aged 26-40 years

BACKGROUND

It is known that women with Down syndrome can be fertile, but it is not known whether all women with Down syndrome are fertile or sub-fertile. The age at menopause for women with Down syndrome is lower compared to women without Down syndrome.

METHOD

A cross-sectional study of 11 women was undertaken, in which the participating women had a blood sample taken and were also examined using transabdominal ultrasound scanning (ULS).

RESULTS

Definite signs of ovulation were evident in 2 women; hormone values in 5 women showed that they were in the luteal phase of the menstrual cycle; 1 woman was anovulatory; and in 1 woman it was not possible to judge the time of the menstrual cycle. Two of the women were postmenopausal according to medical information, ultrasound examination and hormone values.

CONCLUSIONS

Safe contraceptives should be considered and offered if women with Down syndrome are engaging in sexual relations. Early menopause (before the age of 40 years) and the possibility of hormonal replacement therapy should be kept in mind.

Further considerations on natural or mild hyperstimulation cycles for intrauterine insemination treatment: effects on pregnancy and multiple pregnancy rates

BACKGROUND

The high iatrogenic multiple pregnancy rate associated with intrauterine insemination (IUI) in hyperstimulated cycles is becoming less acceptable. Therefore we investigated data from an earlier prospective trial with regard to the specific question of whether the application of mild hyperstimulation in IUI cycles could be an alternative strategy for obtaining acceptable pregnancy rates while preventing a high multiple pregnancy rate, compared with natural cycles for IUI.

METHODS

Pregnancy outcome of 310 natural and 334 mildly hyperstimulated cycles for IUI in 171 couples with unexplained or mild male factor subfertility was analysed on a patient level with random coefficient models.

RESULTS

Pregnancy rates were similar: 35 and 39.8% per couple in the natural and mildly hyperstimulated cycles respectively (P = 0.60). Multiple pregnancies, all twin pregnancies, were conceived significantly more frequently in the mild hyperstimulation group (27% of the pregnancies) than in the natural cycle group (4% of the pregnancies) (P = 0.01). All multiple pregnancies in the hyperstimulation group were conceived in multifollicular cycles. Multifollicular development was strongly associated with the application of mild hyperstimulation only (odds ratio 21.14, 95% confidence interval 8.15-54.79).

CONCLUSION

The application of a mild hyperstimulation protocol as an alternative to a standard hyperstimulation protocol for IUI does not result in higher pregnancy rates than IUI in the natural cycle, while at the same time multiple pregnancies cannot be avoided. Therefore, there is no place for the use of gonadotrophins in IUI treatment.

The specific role of isoflavones on estrogen metabolism in premenopausal women

BACKGROUND

There is increasing evidence that dietary factors may play a role in the production, metabolism, and bioavailability of sex hormones and their impact on target tissues. The specific objective of this study was to evaluate the effectiveness of supplementing a group of premenopausal women who were free of breast carcinoma with a dietary supplement of isoflavones (40 mg per day) in producing a change in steroid hormones and menstrual cycle length.

METHODS

Sixty-eight consecutively recruited, premenopausal, omnivorous women of all races and ethnicities between the ages of 25 years and 55 years were admitted to the study and randomized to an experimental group supplemented with soy (40 mg genistein per day) or to a control group that consumed a placebo for a 12-week period. Changes in their anthropometric, nutritional, and hormonal biomarkers from early follicular phase were analyzed at baseline and post-intervention.

RESULTS

Serum-free estradiol and estrone levels decreased moderately in the experimental group. Serum hormone-binding globulin levels increased in 41.4% of women in the experimental group compared with 37.5% of women in the placebo group. Free estradiol decreased in 53.85% of women in the experimental group compared with 37.5% of women in the placebo group. Estrone decreased in 55.56% of women in the experimental group compared with 42.86% in the placebo group. Those women in the experimental group who were consuming soy had their mean menstrual cycle length increased by 3.52 days compared with a mean decrease of 0.06 days for women in the placebo group (P = 0.04) from baseline to the third menstrual cycle. In addition, women who were taking soy had their mean follicular phase increase by 1.46 days compared with a mean increase of 0.14 days for women who were taking the placebo (P = 0.08).

CONCLUSIONS

These data suggest that increased isoflavone intake affects estrogen metabolism by altering the steroid hormone concentrations and menstrual cycle length, thereby demonstrating a potential to reduce the risk for breast carcinoma.

Comparison between two hCG-to-oocyte aspiration intervals on the outcome of in vitro fertilization

PURPOSE

To determine whether there was any difference in the outcome of in vitro fertilization when retrieval of oocytes was done 34 hr (group A) or 38 hr (group B) after hCG injection.

METHODS

A total of 170 patients with tubal failure were randomized into either group A (83 patients) or group B (87 patients). They underwent in vitro fertilization according to described protocols and were compared with regard to the frequency of spontaneous ovulation, number of oocytes retrieved, oocyte cumulus complex quality, embryo quality, and implantation and pregnancy rates.

RESULTS

There was no significant difference for any of the parameters tested for in group A and group B.

CONCLUSIONS

HCG can be administered at any time within the time interval of 34 to 38 hr before retrieval of oocytes without affecting the results of in vitro fertilization.

The relationship between menstrual cycle phases and suicide attempts

OBJECTIVE

The validity of prior studies on the menstrual cycle and suicide attempts assumes that suicidal women accurately describe their cycles. The three objectives of this study were 1) to explore whether prior inconsistencies are due to the effects of sample selection and method of assessment of the menstrual cycle, 2) to assess the relationship between the menstrual cycle phase and suicide attempts, and 3) to establish the role of sexual hormones in suicide attempts.

METHODS

The original sample included 134 women who came to the emergency room of a general hospital after a suicide attempt. One hundred eight female blood donors were recruited as control subjects. The menstrual cycle was divided into follicular, midcycle, and luteal phases using two clinical methods and serum hormonal assessment. Dividing the follicular phase into menstrual and nonmenstrual phases was also considered.

RESULTS

Two of 11 previously used sampling methods produced a sample size similar to that of the hormonal assessment. kappa values between the two clinical and the endocrinological methods were low (0.40-0.50). The number of suicide attempts during the follicular phase (particularly during the menstrual phase) was significantly higher than expected.

CONCLUSIONS

Despite the inability to control for other variables and limitations, the results of this study suggest that sample selection could introduce biases and that studies relating psychiatric symptomatology and menstrual cycle phases need to use hormonal determinations. New studies are needed to verify that suicide attempts are more frequent during the follicular phase (particularly during the menstrual phase).

Intrauterine insemination or in-vitro fertilisation in idiopathic subfertility and male subfertility: a randomised trial and cost-effectiveness analysis

BACKGROUND

Couples affected by idiopathic subfertility or male subfertility have an estimated spontaneous conception rate of about 2% per cycle. Although various infertility treatments are available, counselling of a couple in their choice of treatment is difficult because of the lack of consistent data from good-quality comparative studies. We compared the results of treatment with intrauterine insemination (IUI) with those of in-vitro fertilisation (IVF), and did a cost-effectiveness analysis.

METHODS

In a prospective, randomised, parallel trial, 258 couples with idiopathic subfertility or male subfertility were treated for a maximum of six cycles of either IUI in the spontaneous cycle (IUI alone), IUI after mild ovarian hyperstimulation, or IVF. The primary endpoint was a pregnancy resulting in at least one livebirth after treatment. Cost-effectiveness based on real costs was studied by Markov chain analysis.

FINDINGS

86 couples were assigned IUI alone, 85 IUI plus ovarian hyperstimulation, and 87 IVF. Ten couples dropped out before treatment began. Although the pregnancy rate per cycle was higher in the IVF group than in the IUI groups (12.2% vs 7.4% and 8.7%, respectively; p=0.09), the cumulative pregnancy rate for IVF was not significantly better than that for IUI. Couples in the IVF group were more likely than those in the IUI groups to give up treatment before their maximum of six attempts (37 [42%] drop-outs vs 13 [15%] and 14 [16%], respectively; p<0.01). The woman's age was the only factor that influenced a couple's chance of success. IUI was a more cost-effective treatment than IVF (costs per pregnancy resulting in at least one livebirth 8423-10661 Dutch guilders [US$4511-5710] for IUI vs 27409 Dutch guilders [US$14679] for IVF).

INTERPRETATION

Couples with idiopathic or male subfertility should be counselled that IUI offers the same likelihood of successful pregnancy as IVF, and is a more cost-effective approach. IUI in the spontaneous cycle carries fewer health risks than does IUI after mild hormonal stimulation and is therefore the first-choice treatment.

Bone mass and the risk of breast cancer among postmenopausal women

BACKGROUND

Recent studies have shown a direct relation between serum estrogen levels assessed at a single point in time and the risk of breast cancer, but no evidence links estrogen levels assessed repeatedly over an extended interval to the risk of breast cancer. Bone mass has been proposed as a marker of cumulative exposure to estrogen in women. We therefore studied the association between bone mass and the incidence of breast cancer.

METHODS

Between 1967 and 1970, 1373 women who were 47 to 80 years old and had no history of breast cancer underwent posteroanterior hand radiography in the Framingham Study. We used radiogrametry to measure the cortical width of each woman's second metacarpal. Participants were followed until the end of 1993. All incident cases of breast cancer were confirmed by pathological reports. We used a Cox proportional-hazards model to examine the relation of metacarpal bone mass to the risk of postmenopausal breast cancer.

RESULTS

Postmenopausal breast cancer developed in 91 subjects. Incidence rates per 1000 person-years increased from 2.0 among the women in the lowest age-specific quartile of metacarpal bone mass to 2.6, 2.7, and 7.0 among the women in the second, third, and highest quartiles, respectively. After adjustments for age and other potential confounding factors, the rate ratios for the risk of breast cancer were 1.0, 1.3, 1.3, and 3.5 from the lowest quartile to the highest (P for trend, <0.001).

CONCLUSIONS

Women in the highest quartile of bone mass are at higher risk for postmenopausal breast cancer than those in the lowest quartile. The mechanisms underlying this relation are not understood, but cumulative exposure to estrogen may play a part.

Relative influence of serum follicle stimulating hormone, age and other factors on ovarian response to gonadotrophin stimulation

OBJECTIVE

To determine the relative value of the woman's age, basal follicle stimulating hormone (FSH), basal luteinising hormone (LH) and menstrual cycle pattern (all defined prior to treatment) in predicting the ovarian response to gonadotrophin stimulation for in vitro fertilisation.

DESIGN

Open, descriptive cohort study.

PATIENTS

One hundred and seventy-one consecutive ovulatory women undergoing their first cycle of in vitro fertilisation with ovarian stimulation after pituitary desensitisation.

INTERVENTIONS

Measurement of basal (early follicular phase) and down-regulated concentrations of serum FSH and LH, and calculation of age at treatment and of median length of menstrual cycles and range of variation prior to treatment.

MAIN OUTCOME MEASURES

Duration and amount of gonadotrophin stimulation to achieve follicular maturity, number of mature follicles, peak serum oestradiol concentration and number of mature oocytes, were compared between banded values of variables studied.

RESULTS

Increasing basal FSH concentrations were significantly associated with reducing oestradiol levels, numbers of mature follicles and oocyte yield even when the FSH levels were still within the normal range though above average (6 to 8.9 i.u./l). There were similar but weaker associations with FSH levels after down-regulation. There were also significant differences between women over and under 40 years old in their oestradiol levels, numbers of follicles and of oocytes. Analysis of variance showed significant independent association of basal FSH with both oestradiol and numbers of oocytes, but not of age, menstrual pattern, or serum LH concentrations.

CONCLUSION

Serum FSH is more sensitive than the woman's age in determining her ovarian responsiveness to stimulation. LH concentrations and menstrual cycle patterns are unhelpful.

Time schedules of intrauterine insemination after urinary luteinizing hormone surge detection and pregnancy results

A urinary luteinizing hormone (LH) test (LH Color, Organon, Oss, The Netherlands), was used to time intrauterine insemination in 177 cycles. Morning and evening urine samples were tested. In 58 women (33%) the test was positive in the morning urine sample. Fifteen of these patients were inseminated 8-10 h thereafter and one patient (6.7%) conceived. The remaining 43 women were inseminated the following day, 25-31 h after LH detection, and seven pregnancies (16.3%) ensued. In 119 cycles showing a positive urinary test in the evening sample, insemination was performed the next day, between 17 and 23 h after the LH surge, and 18 patients (15.1%) became pregnant. Statistical analysis showed no significant differences in pregnancy rates between the three different schedules, or in the time of insemination between conceptional and non-conceptional cycles within each group. Most ovulations occurred between 16 and 28 h after the positive test was observed. These findings suggest that while the lifespan of the gametes allows a relatively long period for fertilization, from 8 to 31 h after urinary LH surge detection, better results may be expected when inseminating about 24 (+/- 6) h after the positive test.

Ultrasound evaluation of ovarian activity under oral contraceptives

The trend towards changing the composition of the contraceptive pill in order to decrease side effects might lead to increased ovarian activity. This may decrease reliability. Therefore, a non-invasive method for monitoring the suppressive effect of the pill on ovarian function is warranted. The aim of the present study was to investigate whether or not diagnostic ultrasound might be the method of choice for studying residual ovarian activity during pill use. In 89 women on a low-dose oral contraceptive (30 mcg ethinyl-estradiol (EE)/75 mcg gestodene), the first two months of pill-intake were monitored extensively with diagnostic ultrasound. The study revealed that only one ultrasound investigation was needed during the first week of pill intake to discover all relevant cases of residual ovarian activity. Follow-up investigations are needed to quantify this activity more specifically.

Effect of cortisol on the secretion of testosterone and estradiol-17 beta by human granulosa-luteal cell cultures. A model system for analyzing hormonal alterations in female athletes

The combination of hypercortisolism and usually low androgen and estrogen levels is frequently observed in female long distance athletes. In order to find a useful model system for studying the underlying mechanisms, the following studies were performed. The effect of cortisol on the secretion of testosterone (T) and estradiol-17 beta (E2) by human granulosa-luteal cells was studied in vitro in cultures of cells recovered from mature follicles of gonadotrophin stimulated women (participating in the IVF program). Following 24 hours of culture in tissue culture medium without hormonal additives, the granulosa-luteal cells were incubated for 6 hours in media with addition of 4-androstene-3,17-dione (A-4) as precursor and hMG and cortisol in different combinations. The secretion of T was significantly stimulated by cortisol but not by human menopausal gonadotrophin (hMG). Cortisol, but not hMG, also increased the secretion of E2, although this effect was not statistically significant. These in vitro findings make a direct effect of cortisol upon ovarian sex steroid secretion less likely as the mechanism behind the subnormal sex steroid levels in female long distance athletes. Instead, inadequate gonadotrophic stimulation, related to hypothalamic amenorrhea, and/or a selective decrease in the adrenal secretion of precursor steroids, may be an explanation.

Pattern of gastrointestinal and somatic symptoms across the menstrual cycle

The pattern of gastrointestinal symptoms and select mood and somatic symptoms was examined across two menstrual cycles in women with (n = 19) and without (n = 39) functional bowel distress (FBD). The women (a) rated their gastrointestinal, perimenstrual, mood, and other symptoms and stool frequency and consistency daily; (b) completed the Menstrual Distress Questionnaire-T; and (c) had serum levels of estrogen and progesterone measured during the menses, follicular, and luteal phases. Stomach pain, nausea, and diarrhea were rated higher at menses in the group with FBD than in the group without FBD. Stomach pain was higher during the remaining days as well. The group with FBD reported higher levels of perimenstrual symptoms also on six of the eight Menstrual Distress Questionnaire-T subscales (P less than 0.01). Other complaints, e.g., poor work/school performance, were higher in women with FBD, but somatic symptoms that were expected to vary over the cycle did not differ between groups, except cramping pain. There were no significant group differences in ovarian hormone levels or stool consistency/frequency scores.

Reliability of urinary LH testing for planning of endometrial biopsies

A rapid urinary luteinizing hormone (LH) test was used to plan a late luteal phase endometrial biopsy from 20 women undergoing an infertility evaluation. Histologic dating was correlated with the day of urinary LH surge detection, the day of the basal body temperature (BBT) nadir, and the onset of the next menstrual period (NMP). From 17 interpretable specimens, histologic dating correlated well with the day of the biopsy as determined following a positive LH test detection (P = 0.079). No correlation was found following the BBT shift (P = 0.65), and it was significantly correlated with the NMP (P = 0.016). Moreover, the urinary LH test showed to be the best method to predict the onset of the NMP. These findings confirm urinary LH testing as a valuable adjunct in the investigation of luteal phase disorders.

Intrauterine insemination does and clomiphene citrate does not improve fecundity in couples with infertility due to male or idiopathic factors: a prospective, randomized, controlled study

In the present prospective study we compared, in terms of pregnancy rates, the differences between intrauterine insemination (IUI) of in vitro capacitated husband's semen and timed natural intercourse in spontaneous or clomiphene citrate (CC) stimulated cycles. A rapid urinary luteinizing hormone peak detection test was used for timing of ovulation. Forty patients suffering from longstanding infertility of male (n = 17), cervical (n = 2), and idiopathic (n = 21) origin were randomly assigned into four distinct treatment modalities during 4 consecutive cycles. A total of 132 cycles were analyzed. In 35 cycles treated with CC plus IUI, five conceptions were achieved, whereas three pregnancies occurred in 32 inseminated spontaneous cycles. Only 1 patient conceived after timed intercourse in 31 CC stimulated cycles, and no pregnancy resulted from 34 spontaneous cycles combined with timed intercourse. There was a statistically significant higher conception rate in cycles in which IUI was performed, whereas the use of CC does not seem to improve the pregnancy rate. Analysis of results for other modifying factors did not substantially affect the relative risk (odds ratio) of pregnancy.

Do raised serum luteinizing hormone levels during stimulation for in-vitro fertilization predict outcome?

Previous reports associating raised LH concentrations with reduced fertilization and pregnancy rates in women undergoing in-vitro fertilization (IVF) have assumed a Gaussian distribution of LH values with IVF treatment. We have determined the serum LH range during ovarian stimulation for IVF with a single regimen of clomiphene citrate/hMG from 102 consecutive IVF conception cycles. The results show a non-Gaussian distribution of LH values. Application of this LH range to a consecutive series of 596 women undergoing IVF treated with this single regimen showed no difference in pregnancy rates, fertilization rates, median number of oocytes fertilized or retrieved when analysed with respect to serum LH concentrations above the 75th or 95th centile for greater than or equal to 3 days of an IVF treatment cycle. We conclude that follicular-phase LH concentrations do not predict IVF fertilization rates or clinical outcome and are not clinically useful in individual patient management.

Intrauterine insemination with washed capacitated sperm cells in the treatment of male factor, cervical factor and unexplained infertility

One hundred and fourteen couples with long standing infertility due to male factor, cervical factor and unexplained infertility were admitted for therapeutic trials with intrauterine insemination of washed, capacitated husband's sperm cells between May 1986 to October 1987 at The Egyptian IVF-ET Center, Cairo, Egypt. Three hundred and sixty-four trials were done (an average of 3.19 trial per patient). Fifty-eight patients got pregnant (16% pregnancy rate per trial). This simple and noninvasive procedure can be considered as an alternative treatment for infertility due to male factor, cervical factor, and unexplained infertility.

A prospective study of prognostic factors in in vitro fertilization and embryo transfer

Multiple factors influence the outcome of in vitro fertilization and embryo transfer (IVF-ET). This prospective study was designed to assess their relative importance, in order to improve prognostic ability and treatment success. Prior to IVF-ET, couples were divided into "good" (GP) and "poor" (PP) prognosis groups according to female age, semen quality, previous response to stimulation, and embryo quality. The data obtained from 716 consecutive treatment cycles then were evaluated using univariate statistics and logistic regression, a technique designed to assess the relative contribution of significant factors. The pregnancy rate per GP cycle was 14.7%, compared with 5.4% per PP cycle (chi 1(2) = 12.7, P less than 0.001). The most important prognostic factors were female age, the pregnancy rate showing a linear decline after the age of 25, and previous failed fertilization due to abnormal sperm. The rate of pregnancy also declined after 14 or more follicles were aspirated and/or nine oocytes were retrieved. A formula for the probability of pregnancy, derived from the logistic regression, provides patients with a more accurate prognosis before treatment.

Sister-sister in vitro fertilization surrogate pregnancy with donor sperm: the case for surrogate gestational pregnancy

A case of surrogate pregnancy is described in the sister of a 40-year-old hysterectomized woman where two oocytes of the latter were fertilized in vitro with known donor sperm and transferred into the surrogate. A normal singleton pregnancy developed which was complicated after 24 weeks of gestation with recurrent antepartum hemorrhages due to grade 3 placenta praevia. A healthy female baby was delivered by elective cesarean section at 36 weeks of gestation. The legal, social, psychological, and ethical issues of surrogacy remain unsettled and are discussed in this case report.

The effect of cycle length on the outcome of in vitro fertilization

In order to study the effect of cycle length on the pregnancy rate in an in vitro fertilization and embryo transfer (IVF-ET) program, 173 consecutive patients were divided into short menstrual cycle (mode 26 days or less) and normal cycle (mode 27 days or more) groups. Patients were randomly allocated to one of two treatments, commencing ovarian stimulation with human menopausal gonadotropin (hMG) on either day 2 or day 4 of their cycle. The number of oocytes retrieved and embryos transferred did not differ significantly. The amount of hMG used and day of human chorionic gonadotrophin administration both differed significantly (P less than 0.01) between regimens but was independent of cycle length. Both the clinical pregnancy rate (30.2% versus 9.4%, P less than 0.05) and the number of cleaved embryos giving rise to gestation sacs (16% versus 3.4%, P less than 0.02) was significantly higher in patients with a normal cycle length. Mode cycle length has a significant bearing on the outcome of IVF-ET cycles.

Improvement of in vitro fertilisation after treatment with buserelin, an agonist of luteinising hormone releasing hormone

Treatment with buserelin, an agonist of luteinising hormone releasing hormone, and human menopausal gonadotrophin was compared with the conventional treatment of clomiphene citrate and human menopausal gonadotrophin in the outcome of in vitro fertilisation. Seventy seven infertile women had 83 cycles of treatment with buserelin and human menopausal gonadotrophin, and concurrently another 328 infertile women were treated with clomiphene citrate and human menopausal gonadotrophin. Seven (8%) cycles were cancelled owing to inadequate super-ovulation or ovarian hyperstimulation in the women receiving buserelin and 103 (31%) were cancelled because of poor follicular development in those receiving clomiphene citrate. The mean number of oocytes recovered was significantly higher with buserelin (9.5 (SD 4.5) v 5.5 (2.2)) as was the mean number of embryos obtained (4.3 (2.4) v 2.9 (1.7)). Significantly more women who had an embryo transfer became clinically pregnant after treatment with buserelin (53% (30/57) v 30% (48/159), or 36% v 14% of treatment cycles). Altogether 33% (10) of pregnancies in women treated with buserelin were multiple compared with 23% (11) in those treated conventionally. Of the 17 completed pregnancies in women treated with buserelin, 11 resulted in the birth of live babies (eight singletons, two sets of twins, and one set of triplets) and six failed, five before 12 weeks' gestation and one at 22 weeks. The 13 continuing pregnancies (32 weeks) were eight singletons, two sets of twins, and three sets of triplets. Of the 48 completed pregnancies in women treated with clomiphene citrate, 35 resulted in the birth of live babies (26 singletons, five sets of twins and four sets of triplets) and 13 failed, eleven before 12 weeks' gestation and two by 27 weeks. Buserelin increased the chance of pregnancy after in vitro fertilisation compared with conventional treatment, but the risk of multiple pregnancy may be increased.

Midcycle changes of 17-OH-progesterone levels in women superovulated with clomiphene citrate and human menopausal gonadotropin for in vitro fertilization

The dynamics of 17-alpha-hydroxy-progesterone (17-OHP) production during the onset of the luteinizing hormone (LH) surge were evaluated at 8-hour intervals and correlated with plasma estradiol (E2), LH, and progesterone (P) in 22 women superovulated for in vitro fertilization. Plasma 17-OHP levels rose 8 to 16 hours before the earliest rise in LH and P in 18% of patients, but had risen significantly in 82% of patients by the onset of the LH surge. In the late follicular phase, 17-OHP levels correlated significantly with E2 and LH levels, and the number of follicles greater than 10 mm. Because rising 17-OHP levels preceded the LH surge in only a few patients, it has no clinical value as a marker for human chorionic gonadotropin administration for timed oocyte recovery. Plasma 17-OHP levels, however, may complement LH levels better than P levels in determining the most appropriate stage for surge-timed oocyte retrieval.

Successful pregnancy in an ovulating recipient following the transfer of two frozen-thawed embryos obtained from anonymously donated oocytes

A fertile woman suffering from mild dystrophia myotonica had undergone sterilization because of the 50% genetic risk of this disease developing in her offspring. In her second treatment cycle on the donor oocyte program, four anonymously donated oocytes were inseminated with frozen-thawed sperm of her husband. Three embryos were obtained and two surviving embryos were deep-frozen at the eight-cell stage and kept in storage for 9 months. These embryos were successfully thawed and transferred to the recipient 97 hr after the onset of her luteinizing hormone surge. A normal singleton pregnancy developed and a healthy male infant was delivered by cesarean section at 36 weeks of gestation.

Outcome of patients with one ovary in an in vitro fertilization program

To determine whether the absence of one ovary would influence adversely the outcome of in vitro fertilization, the results of 60 laparoscopic oocyte retrieval procedures in 34 single-ovary patients were compared with the outcome for all laparoscopic retrieval cycles during the same period (January 1984-August 1986) in patients with tubal infertility and two accessible ovaries (559 cycles in 335 patients). The median age was younger in the one-ovary group (31 vs 32) (P less than 0.05). The group with two accessible ovaries had significantly more follicles aspirated (median, 7 vs 5; P less than 0.001) and more oocytes obtained (median, 5 vs 4; P less than 0.001) per retrieval compared with the single-ovary group. However, the single-ovary group had a higher percentage fertilization (69 vs 62%; P less than 0.05) so that the number of embryos transferred per transfer patient (median, 3 vs 3) and pregnancy rate per cycle (9.7 vs 15.6%) did not differ significantly between groups. We conclude that patients with a single ovary have a compensatory increase in the ability to produce oocytes which may have greater potential for fertilization and subsequent development.

The effect of the day of initiation of ovarian stimulation in the day of luteinizing hormone surge and outcome of in vitro fertilization

It was hypothesized that the day of initiation of ovarian stimulation may influence the day of the luteinizing hormone (LH) surge onset and follicular development. Two groups of 52 patients were randomly selected to commence ovarian stimulation on either day 2 or day 4. The mean +/- standard deviation day of the LH surge was 11.0 +/- 0.9 for day 2 and 12.2 +/- 0.9 for day 4 (P less than 0.001), and the day of human chorionic gonadotropin (hCG) administration was 10.7 +/- 1.2 for day 2 and 11.4 +/- 0.9 for day 4 (P less than 0.02). The two groups also differed significantly in the mean number of days of human menopausal gonadotropin (hMG) administration (day 2, 7.4 +/- 2.7, versus day 4, 6.3 +/- 2.5), and the mean number of vials of hMG administered (day 2, 10.4 +/- 3.2, versus day 4, 8.1 +/- 2.9). However, the mean estradiol level on the day of the LH surge or hCG administration, the number of oocytes collected and fertilized, the number of embryos transferred, and the pregnancy rates were not significantly different. In conclusion, the day of the LH surge or hCG administration can be influenced by the day of initiation of ovarian stimulation, and the initiation of ovarian stimulation around day 4 of the menstrual cycle is clinically more efficient than initiation of follicular development early in the follicular phase.

A laparoscopic approach to a program of gamete intrafallopian transfer

Gamete intrafallopian transfer (GIFT) provides an effective method of achieving pregnancy in infertile women with normal fallopian tubes. Laparoscopic approach to ovum pickup and tubal catheterization provides a simple and rapid means of performing the operation. Equipment used to facilitate this process is described, and techniques of tubal catheterization are discussed. A clinical pregnancy rate of 27% is reported in a series of 71 treatment cycles. The application of GIFT in conjunction with in vitro fertilization is discussed, especially the use of excess gametes to provide embryos for freezing. The use of GIFT as a research and investigative tool may provide further insight into the causes for idiopathic infertility.

Contributions of in vitro fertilization to knowledge of the reproductive endocrinology of the menstrual cycle

The administration of ovarian stimulants to endocrine-normal women in IVF programmes gives the clinical endocrinologist an opportunity to modify natural folliculogenesis. Use of antioestrogens and/or gonadotrophins at the correct time has demonstrated that follicular atresia can be prevented and that multiple pregnancy-potent haploid ova can be obtained. Scrutiny of spontaneous menstrual cycles in patients who show unsatisfactory IVF responses has identified two new syndromes, premature follicle selection and occult ovarian failure, in these patients. The incidence of these disorders in fertile women is still unclear. Early results suggest that endocrine manipulations may overcome premature follicle selection and induce codominant folliculogenesis. Inhibin is a recently characterized ovarian protein which is increased in peripheral blood during IVF treatment. Results from IVF cycles suggest that plasma inhibin may be a new index of follicular function. Other potential indices of ovarian function, such as the luteal protein relaxin, may also develop from the application of basic research to IVF and advance knowledge of the human ovarian and menstrual cycles.

Pregnancy established in an infertile patient after transfer of an embryo fertilized in vitro where the oocyte was donated by the sister of the recipient

A successful pregnancy in a patient suffering from infertility due to severe tubal disease has been achieved following the transfer of embryos fertilized in vitro following the donation of oocytes by the sister of the recipient. Both sisters ovulated irregularly and asynchronously. The donor's menstrual cycle varied from 24 to 30 days and the recipient's cycle varied from 23 to 26 days. Synchronization of ovulation was achieved by matching the onset of their menstrual cycles prior to treatment by in vitro fertilization and by manipulating the follicular phase of both the donor and the recipient during the cycle of treatment. Ten oocytes were collected from the donor and all were inseminated with spermatozoa from the recipient's husband. Nine normal embryos developed and three were transferred to the uterus of the recipient sister, 55 hr after laparoscopic egg collection. A normal singleton pregnancy resulted.

Cross-over trial of superovulation protocols from two major in vitro fertilization centers

A study was undertaken as a controlled comparison of two different superovulation induction protocols currently in use in major Australian in vitro fertilization (IVF) clinics. Thirty patients each from the Monash University and the Royal Women's Hospital (RWH) IVF programs were stimulated for ovulation induction by the other program. Once timing for oocyte retrieval was scheduled, all care reverted to the program from which the patient first came. Results given as pregnancies per patient commencing stimulation were: RWH patients on Monash protocol, 27%; RWH control patients, 15%; Monash patients on RWH protocol, 7%; Monash control patients, 13%. In the year preceding the trial pregnancy rates were 16.9% at Monash and 10.6% at RWH. Stimulation protocols were also compared with respect to each of administration, cost, and patient stress. The results of this cross-over trial demonstrated major differences between the two ovulation induction protocols studied, although it was not possible to conclude that differences in pregnancy rate were due to stimulation alone.

The effect of progesterone supplementation around the time of oocyte recovery in patients superovulated for in vitro fertilization

A randomized control trial involving 42 superovulated in vitro fertilization (IVF) patients was carried out to investigate the effects of providing supplementary progesterone (P) around the time of laparoscopy. P was given 12 to 15 hours and 1 hour before and 24 hours after laparoscopy in one group (group B); human chorionic gonadotropin was given 12 hours before laparoscopy in another group (group C); and the remainder received no treatment in addition to normal IVF procedures (group A). There was no difference in fertilization rate, the proportion of normally developing embryos, pregnancy rate, or birth rate between the treatment groups, We conclude that in the superovulation schedule used, P supplementation around the time of laparoscopy does not affect success rate of IVF.

Cryopreservation of human embryos: progress on the clinical use of the technique in human in vitro fertilization

Embryo cryopreservation has been studied at Monash University since 1981 and has been available to patients since mid-1983. Of approximately 1200 patients' cycles of in vitro fertilization (IVF), 445 have had excess embryos which they requested to be frozen. To date 205 patients have requested thawing of their embryos and 144 have had frozen-thawed embryos replaced in utero, resulting in 16 pregnancies. Four of these pregnancies aborted, four are ongoing, and eight deliveries have resulted, including one stillbirth at 26 weeks and one set of twins. Analysis of the data collected to date shows that patients with three or more embryos frozen have a significantly higher pregnancy rate than patients with one or two embryos frozen (23 versus 4%, respectively). Embryo viability, but not embryo survival, following freeze-thawing is related to the degree of embryonic fragmentation and the cell stage at freezing. Eight-cell embryos had a significantly higher viability than other cleavage stages. Those resulting in pregnancy tended to be the faster-dividing eight-cell embryos and were undamaged after freezing and thawing. However, when considering all cleavage stages, there was little effect of freezing damage on embryo viability, providing that at least 50% of the cell complement of embryos were intact and the zona pellucida was undamaged. Nor was there any marked effect of the age of embryos postinsemination. It is also possible that patients who were pregnant following the initial embryo replacement on the cycle of IVF treatment are more likely to conceive following replacement of their frozen-thawed embryos.