Oocyte donation by gamete intra-fallopian transfer to amenorrhoeic and cycling patients given replacement steroids

Customised Oocyte Donation Enhancement and New Findings Regarding the Role of Growth Hormone

In vitro fertilisation (IVF) with donated oocytes is the most effective assisted reproduction treatment currently available; however, repeated implantation failure (RIF) can occur with this treatment. The protocol of patient preparation for IVF with donated oocytes is relatively simple and works well in most cases; however, it can fail in a minority of women, which is what occurs in RIF patients. While the probability of RIF occuring is 20–35%, it is reasonable to take adequate measures in all patients in order to avoid procedural failure. The risk of oocyte donation failure can be minimised by applying a customised oocyte donation enhancement (CODE) protocol, in which pitfalls of the standard protocol are detected and corrected in the pretreatment phase, during the patient’s uterus preparation for embryo transfer, and after the transfer. Growth hormone, recently reported to improve pregnancy outcomes in women with RIF after oocyte donation, is a possible component of the CODE protocol, but it cannot be considered a unique solution to RIF. This article reviews possible causes of RIF and places growth hormone treatment in the context of other important measures to be followed in the CODE protocol.

Expression and modulation of progesterone induced blocking factor (PIBF) and innate immune factors in human leukemia cell lines by progesterone and mifepristone

Progesterone (P), required for successful pregnancy, influences autoimmune, infectious, and malignant diseases via adaptive and innate immune effects. P induces NK inhibitor progesterone induced blocking factor (PIBF) in CD8+ T cells. PIBF isoforms could permit solid tumor immune escape. Expression and modulation of PIBF and innate immune proteins by P in leukemia cells and leukocyte subpopulations have not been reported. Ten T, seven myeloid, six B, five epithelial, fibroblast BG9, G-CSF mobilized CD34+ stem cells, and peripheral blood mononuclear cells were screened for PIBF mRNA by RT-PCR, and protein by immunohistochemistry in SRIK-NKL, MOT, U937, HL60, R-CLL, MD-E, 729pH6neo, SRIH-B(ATL), SRIK-B(T-PLL), and MeWo. Cell lines expressing PIBF and exemplifying myeloid/monoblast, natural killer/T, and B lineages were cultured with and without 0.5 - 5 microM P or 0.5 - 0.05 microM mifepristone (RU486) for 24 h. Subsequently they were examined for changes in the expression of mRNA by RT-PCR and protein by immunohistochemistry for PIBF and some innate immune factors. All cells expressed PIBF mRNA; protein only in four (SRIK-NKL, U937, SRIK-B(T-PLL) and HL60) out of 10 cell lines tested. P increased and RU486 decreased PIBF in U937, SRIK-B(T-PLL) and SRIK-NKL. P upregulated TLR-4 in U937, and HNP1 - 3, LL-37, IRAK-2, and IRAK-4 in multiple lines and RU486 down regulated these. PIBF may be used by some leukemias to evade immune surveillance and is a potential therapeutic target. P may impact infection and autoimmunity via effects on LPS receptor, TLR signaling, and antimicrobial peptides.

First trimester endocrinology: consequences for diagnosis and treatment of pregnancy failure

First-trimester endocrinology is determined on the one hand by corpus luteum progesterone and estradiol biosynthesis and secretion and on the other hand by the time of onset and extent of progesterone and estradiol secretion by the placenta. This dual interplay is dominated by the corpus luteum placental shift, where a relative progesterone and estradiol deficiency can develop and may lead to early as well as late abortion. Measurements of serum progesterone and estradiol are mandatory in order to reveal such deficiencies and to treat them effectively with 17 alpha-hydroxyprogesterone caproate in combination with estradiol valerate or with progestins such as dydrogesterone.

A model for potential tumor immunotherapy based on knowledge of immune mechanisms responsible for spontaneous abortion

Attempts to treat various cancers by immunotherapy have been tried for about 50 years. Most studies have focused on improving cytotoxic T lymphocyte (CTL) responses against various tumors. Immunotherapy has been both active and passive, and results have been modest at best. Spontaneous abortion (SAB) of pregnancies could in some ways resemble remission of a tumor. Both tumors and conceptusses are faced with a similar problem -- how to grow in a host in a vascular rich area, and yet escape immune surveillance despite both entities being an allogenic stimulus. In general, the fetus is far more immunogenic than a spontaneous tumor, and yet abortuses seem to avoid CTL responses but are sometimes invaded by natural killer (NK) cells. There are data suggesting that SAB will occur if there is inhibition of production of an immunosuppressive protein called progesterone-induced blocking factor (PIBF). This protein inhibits NK cell cytolysis and influences TH2 cytokine dominance over TH1. If some tumors avoid NK cell destruction through a PIBF mechanism, perhaps an active rejection of these tumors could be achieved by inhibiting PIBF production by treating with a progesterone receptor antagonist. Passive immunization could also be considered by conjugative radionuclide or toxic chemical to a PIBF antibody which may be tumor specific since PIBF is not produced in normal tissue. The first step should be to see if PIBF can be detected in the peripheral circulation in patients with certain tumors.

Immunology and progestins in pregnancy

The relationship between corpus luteum progesterone and rate of abortion is well known. Measurements of progesterone and clinical observations can demonstrate that low serum progesterone levels indicate, even better than human chorionic gonadotropin (hCG) measurements, an abnormal course of pregnancy. Early substitution seems to be the decisive therapeutic step. In relation to the concentration at the fetomaternal interphase progesterone leads to direct and indirect suppression of T-cell reactions. Progesterone acts synergistically with prostaglandin E2 immunosuppressive. Interleukin-2-induced cellular cytotoxicity is suppressed. Progesterone induces a number of proteins such as PP14, which inhibit the activity of T-cells and natural killer cells. Mitogenic lymphocyte reactivity is lowered. To date, results of immunological therapies do not prove the effectiveness of immunological treatment modalities.

Expression of an immunomodulatory protein known as progesterone induced blocking factor (PIBF) does not correlate with first trimester spontaneous abortions in progesterone supplemented women

PROBLEM

An immunomodulatory protein known as the progesterone induced blocking factor (PIBF) has been found to positively correlate with early pregnancy beta human chorionic gonadotropin (B-hCG) levels. The study presented herein evaluated PIBF levels from conception to the end of the first trimester to determine if lower levels will correlate with first trimester spontaneous abortions (SAB).

METHOD

Progesterone induced blocking factor expression by lymphocytes measured using an immunocytochemistry method was compared in pregnant women with ongoing vs. failed pregnancies.

RESULTS

There were no differences in the proportion of women having lymphocytes expressing PIBF or in the median numbers when comparing ongoing vs. failed pregnancies. There was no B-hCG interval where failed pregnancies were found to have lower frequency of PIBF expressing lymphocytes.

CONCLUSION

Inadequate PIBF expression independent of low P levels does not appear to be an etiologic factor for first trimester SABs; thus measuring this protein in pregnant women lacks practical usefulness.

Artificial hormonal replacement cycles have no advantage over hyperstimulated cycles in a gamete intrafallopian transfer oocyte donation program

OBJECTIVE

To evaluate if the previously reported increased implantation rates in hormonally replaced egg donation cycles relative to hyperstimulated IVF-ET cycles apply when GIFT is used. The increased implantation rates in the recipients have been attributed to the absence of the negative effects of hyperstimulation on endometrial receptivity.

DESIGN

A prospective comparison of implantation rates in hyperstimulated and hormonally replaced cycles when GIFT was used in both the egg donors and their corresponding recipients.

PATIENTS

Excess mature oocytes from 35 women undergoing GIFT after controlled ovarian hyperstimulation (COH) were transferred into the fallopian tubes of 35 hormonally replaced women.

RESULTS

The male partners of all donors and recipients had normal semen parameters. The two groups did not differ significantly in the mean age, duration of infertility, and quality of eggs transferred. There was no statistically significant difference in the mean number of oocytes transferred per cycle between the donors and the recipients. The mean implantation rate per mature oocyte transferred was significantly higher in the donors (19.3%) than in the recipients (6.6%).

CONCLUSION

Our results with GIFT show higher implantation rates in hyperstimulated cycles than in hormonally replaced cycles. These results differ from those reported in IVF-ET that suggest an adverse effect of COH on implantation rates.

Donation of oocytes as treatment for infertility in patients with premature ovarian failure. Awarded the "Nicolau de Moraes Barros" prize for gynecology

A total of 7 cycles of embryo transfer by oocyte donation were performed on 5 patients with premature ovary failure (POF). All donors were under 35 of age and the recipients average age was 38.6 years. For synchronization between donor and recipient a semi programmed menstrual cycle was used by means of oral contraceptive followed by ovarian stimulation of donor with clomiphene citrate and human menopausal gonadotrophin. The recipients were easily adjusted to the donors by a flexible model of gradually increasing doses of estradiol valerianate. The average number of oocytes donated was 3.14 and average embryo cleavage rate was 80.2%. The average number of embryos transferred was 2.57. Embryo implantation rate was 22.2%. Clinical gestations occurred in 57.1% of the cycles. This series is probably the first one in Brazilian literature on oocyte donation as treatment for infertility in patients with premature ovarian failure.

Ovum donation--an overview

Ovum donation is now an integral part of the management of infertility, providing a solution for patients previously considered permanently infertile. The indications now include not only patients with premature ovarian failure, but also patients who are carriers of genetic disorders, patients with repeated failures in IVF, and patients after surgical castration and after X-ray therapy or chemotherapy. OD is simpler than IVF and has better pregnancy and delivery rates per transfer. Yet this modality of treatment raises serious legal, social, religious, and ethical issues such as the maximal age for treatment and donor selection; these aspects are discussed elsewhere (70).