Observations on preovulatory human ovarian follicles and their aspirates

Key to Life: Physiological Role and Clinical Implications of Progesterone

The most recent studies of progesterone research provide remarkable insights into the physiological role and clinical importance of this hormone. Although the name progesterone itself means “promoting gestation”, this steroid hormone is far more than a gestational agent. Progesterone is recognized as a key physiological component of not only the menstrual cycle and pregnancy but also as an essential steroidogenic precursor of other gonadal and non-gonadal hormones such as aldosterone, cortisol, estradiol, and testosterone. Based on current findings, progesterone and novel progesterone-based drugs have many important functions, including contraception, treatment of dysfunctional uterine bleeding, immune response, and prevention of cancer. Considering the above, reproduction and life are not possible without progesterone; thus, a better understanding of this essential molecule could enable safe and effective use of this hormone in many clinical conditions.

Nuclear maturation kinetics and in vitro fertilization of immature bovine oocytes injected into pre-ovulatory follicles

The maturation kinetics and in vitro fertilization of immature bovine oocytes injected by the intra-follicular oocyte injection (IFOT) technique into pre-ovulatory follicles of previously synchronized cows were evaluated. In Experiment 1, grade I, II and III cumulus-oocyte complexes (COCs) were randomly distributed to one of three Groups: Matvitro22 (COCs matured in vitro for 22 h), MatFol20 and MatFol28 (COCs matured in vivo after being injected into a pre-ovulatory follicle of previously synchronized cows for 19.8 ± 0.1 h and 28.3 ± 0.1 h, respectively). Cows received 12.5 mg of LH (Lutropin, Bioniche, Canada) at the time of IFOT in the MatFol20 Group or 10 h after IFOT in the MatFol28 Group. MatFol20 and MatFol28 COCs were aspirated approximately 20 h after the LH injection for nuclear maturation kinetics and recovery rate assessment. In Experiment 2, grade I, II, and III COCs were randomly distributed into two Groups: Matvitro22 Group, COCs were matured and fertilized in vitro, and MatFol20 Group, COCs were matured as in the MatFol20 Group in Experiment 1, but COCs were fertilized in vitro. Putative zygotes were classified as fertilized, unfertilized or polyspermic. In Experiment 1, the recovery rate was lower (P < 0.001) in the MatFol20 Group (52.9%, 91/172) compared with MatFol28 (72.9%, 113/155). Rate of oocytes in germinal vesicle stage, metaphase I, anaphase I and telophase I were similar among Groups. However, oocytes matured in vivo for 28.3 h had lower rate of metaphase II (P = 0.001) and greater rates of degenerated (P = 0.001) and parthenogenetically activated (P = 0.001) oocytes. In experiment 2, the rates of polyspermy and degenerated were similar between Groups. However, the rate of fertilized oocytes was greater (P = 0.05) in oocytes in the MatFol20 Group. It is concluded that oocyte in vivo maturation for 19.8 h after IFOT does not compromise the nuclear maturation kinetics and increases in vitro fertilization rates. However, the extra 10 h of intra-follicular incubation time decreased oocyte viability.

The curious case of premature luteinization

PURPOSE

Premature luteinization (PL) affects 12.3-46.7% of fresh in vitro fertilization cycles, and there is accumulating evidence confirming its negative effect on success rates. However, despite its clinical significance, PL is poorly understood and defined. This narrative review aims to provide a fresh look at the phenomenon of PL by summarizing the existing evidence and re-evaluating fundamental issues.

METHODS

A thorough electronic search was conducted covering the period from 1978 until January 2018 in PubMed, Embase, and Medline databases, and references of relevant studies were cross-checked. Meeting proceedings of the European Society of Human Reproduction and Embryology and the American Society for Reproductive Medicine were also hand searched.

RESULTS

In the curious case of PL, one should go back to the beginning and re-consider every step of the way. The pathogenesis, definition, measurement methods, clinical implications, and management strategies are discussed in detail, highlighting controversies and offering "food for thought" for future directions.

CONCLUSIONS

Authors need to speak the same language when studying PL in order to facilitate comparisons. The terminology, progesterone cut-off, measurement methods and days of measurement should be standardized and globally accepted; otherwise, there can be no scientific dialog. Future research should focus on specific patient profiles that may require a tailored approach. Progesterone measurements throughout the follicular phase possibly depict the progesterone exposure better than an isolated measurement on the day of hCG. Adequately powered randomized controlled trials should confirm which the best prevention and management plan of PL is, before introducing any strategy into clinical practice.

The Oldham Notebooks: an analysis of the development of IVF 1969-1978. III. Variations in procedures

A survey is presented of the various technical and scientific challenges that had to be met during the 10-year period before the first successful live birth after IVF and embryo transfer was achieved, and the approaches used to meet these challenges is discussed. Records dated from January 1969 to July 1978 indicate that a minimum of 282 women were involved in 495 cycles scheduled for laparoscopic oocyte recovery, of which 457 cycles (92%) proceeded to attempted egg collection. A total of 1361 eggs were recovered over 388 cycles, of which 1237 (91%) are recorded as having been inseminated in 331 (85%) of these cycles. Approximately 221 embryos were described in 165 (43%) of the 388 cycles. A total of 112 embryo transfers were attempted, which resulted in five clinical pregnancies with two live births. This paper discusses the ways in which hormonal stimulation of follicle growth to the pre-ovulatory stage was varied, and the endocrine monitoring of these variations in blood, urine and follicular fluid, as well as their influence on egg recovery and fertilization rates. Variations in media composition and preparation are also described. It is concluded that, whilst driven by scientific reasoning, the approach adopted in trying to achieve successful IVF was empirical rather than evidence-driven.

Embryo transfer and luteal support in natural cycles

Embryo transfer policy and luteal supplementation was reviewed, comparing literature data and the results from the Maribor IVF Centre. A retrospective analysis of 1024 cycles in patients undergoing IVF, intracytoplasmic sperm injection (ICSI) or testicular sperm aspiration in unstimulated cycles was carried out using four different approaches for cycle monitoring. This showed that the most successful protocol for monitoring was administration of human chorionic gonadotrophin (HCG) when serum oestradiol was >0.49 nmol/l and follicle diameter was at least 15 mm. The implantation rate per transferred embryo was higher when a blastocyst was transferred (42.8%) rather than a day-2 embryo (23.5%) in the same monitoring protocol. Analysis of the influence of patient age on the success of oocyte retrieval, oocyte fertilization, embryo transfer rate and delivery rate demonstrates that patient age does not influence the rate of positive oocyte retrieval or fertilization rate as much as it influences pregnancy rate per embryo transfer. The delivery rate per cycle was dramatically influenced by age in patients over 38 years. There is no clear evidence in the literature as to whether luteal phase support is necessary in natural cycles for IVF/ICSI. Comparing the data, a higher pregnancy rate was observed if HCG was administered after embryo transfer.

IVF, IVM, natural cycle IVF, minimal stimulation IVF – time for a rethink

Considerable changes are afoot in the practice of assisted human conception. Doubts about its methods, especially over endocrinology, concern its complexity and its expense. IVF has spread worldwide since its beginnings in the UK, but its current practice, termed routine IVF, is being challenged by simpler routines. These include natural cycle IVF, which has been in the background for many years, minimal stimulation IVF, where doses of hormones are reduced, and the in-vitro maturation of human oocytes ready for fertilization in vitro (IVM). These three approaches are now practised in increasing numbers of IVF clinics, and may well replace routine IVF. The events leading to current interest in these methods will be discussed briefly in this review.

Mancozeb adversely affects meiotic spindle organization and fertilization in mouse oocytes

In this study the effects of mancozeb, a widely used ethylenebisdithiocarbamate fungicide, on mouse oocyte meiotic maturation and fertilization were analyzed. Oocyte cumulus cell-complexes were matured in vitro with or without increasing concentrations of the fungicide (from 0.001 to 1 microg/ml) that, due to its different stability in organic solvents and in water, was resuspended either in dimethyl sulfoxide or in culture medium. Although, about 95% of oocytes reached the metaphase II stage; mancozeb-exposed oocytes showed a dose-dependent increase of alterations in spindle morphology, and this negative effect was more evident when the fungicide was resuspended in culture medium. Under the latter culture condition, oocytes matured in the presence of 0.1 and 1 microg/ml mancozeb showed a significant reduction also in the formation of male and female pronuclei. These results indicate that mancozeb can adversely affect mammalian reproductive performance, likely by perturbing microtubular organization during meiotic maturation.

Relationship between follicle size and ultrasound-guided transvaginal oocyte recovery

We evaluated the relationship between follicle size and oocyte recovery (OR) using ultrasound-guided follicle aspiration. Thirty Holstein cows were subjected to OR without gonadotrophic therapy. Oocytes were recovered two to four times from each cow in a total of 67 aspiration sessions. Ovarian follicles with diameters < or =4 mm and >4 mm were aspirated in separated groups. Recovered oocytes from each group were kept separate and submitted to in vitro maturation, fertilization, and culture to the blastocyst stage. A total of 430 follicles were aspirated, of which 154 (35.8%) were from follicles >4 mm and 276 (64.2%) were from follicles < or =4 mm. Seventy-seven oocytes (50%) were recovered from follicles >4 mm and 200 (72.2%) were from follicles < or =4 mm. Nineteen blastocysts were obtained from follicles >4 mm, whereas 45 blastocysts were obtained from follicles < or =4 mm. Recovery rate was greater (P<0.01) in follicles < or =4 mm. Oocyte quality, cleavage rate and blastocyst development did not differ between different follicle sizes. Routine aspiration of small follicles (< or =4 mm) could increase the number of oocytes available for in vitro development.

Intrafollicular concentrations of steroids and steroidogenic enzymes in relation to follicular development in the mare

The objective of the present study was to determine the changes in follicular fluid steroid concentrations and in granulosa cell steroidogenic enzyme expression during the follicular phase, in relation to follicular size and physiological status in the mare. Follicular fluid and follicular cells were recovered by ultrasound-guided follicular punctures either around the time of emergence of the dominant follicle, at the end of the dominant follicle growth, or at the preovulatory stage, after injection of gonadotropin to induce ovulation. Cellular relative amounts of steroidogenic acute regulatory protein (StAR), P450-side chain cleavage (P450(scc)), 3beta-hydroxysteroid dehydrogenase (3betaHSD), 17alpha-hydroxylase, and aromatase were assessed by semiquantitative Western blot and densitometry. Follicular fluid was assayed for cholesterol concentrations by colorimetric assay and for progesterone, testosterone, and estradiol-17beta concentrations by RIA. Intrafollicular concentrations of progesterone and estradiol-17beta significantly increased in the dominant follicle during growth. After injection of gonadotropin, follicular maturation was characterized by a decrease in estradiol-17beta concentrations and a further increase in progesterone concentrations. Granulosa cells from dominant follicles had increased levels of StAR, P450(scc), 3betaHSD, and aromatase during growth, but decreased levels during maturation. Levels of StAR, P450(scc), 3betaHSD, and aromatase, as well as progesterone and estradiol-17beta, were lower in granulosa cells from subordinate than from dominant follicles. We did not observe a relationship between the steroidogenic activity of follicles and the capacity of their enclosed oocytes to complete meiosis in vitro.

A historical perspective of the clinical evolution of the assisted reproductive technologies

The practice of assisted reproduction technology today is the result of the dedicated patient care, observation, research, and experimentation undertaken by previous generations of physicians. The building blocks of progress have been assembled over past decades, by scientists whose primary objective has been to push forward the frontiers of knowledge, in order to offer more effective methods of infertility treatment. And fortunately that process continues today. Amongst the many scientific developments that have led to the modern practice in assisted reproductive technology, a small number stand out as having had a unique importance. This historical review redraws the path through which in vitro fertilization went from an experimental to an accepted infertility treatment.

Ratio of oestradiol concentration on the day of human chorionic gonadotrophin administration to mid-luteal oestradiol concentration is predictive of in-vitro fertilization outcome

The role of luteal oestradiol for successful implantation in humans seems to be permissive rather than obligatory. Few studies have attempted to clarify the role of early luteal oestradiol in in-vitro fertilization (IVF) outcome, whether peri-implantation oestradiol is predictive of successful IVF outcome. We retrospectively analysed 106 women undergoing 106 IVF/embryo transfer cycles. Only the first treatment cycle per patient was analysed. Peak oestradiol denoted the concentration on the day of human chorionic gonadotrophin (HCG) administration. Mid-luteal oestradiol was obtained 3 days after embryo transfer (8 days after HCG administration). A total of 44 pregnancies were noted (41.51%). There were no differences in age, cycle day 3 follicle stimulating hormone (FSH), peak oestradiol, number of retrieved oocytes, number of embryo transfers, and mid-luteal oestradiol between pregnant and non-pregnant women. However, the ratio of day of HCG oestradiol to mid-luteal oestradiol was highly predictive of successful outcome: the ongoing pregnancy rate and implantation rate (sacs with fetal heart beat/embryo transfer) were 15.8 and 5.7% respectively if the above ratio exceeded 5.0 (n = 19), compared to 42.1 and 16.3%, and 53.3 and 26. 5% if the ratio was between 0.4 and 2.5 (n = 57), and between 2.5 and 5.0 (n = 30) respectively. Our study suggests that the magnitude of decline in oestradiol concentrations after oocyte retrieval may be important in predicting IVF success. We postulate that endometrial integrity may become compromised when a dramatic drop in oestradiol occurs by the mid-luteal period. Whether these women benefit from oestradiol supplementation after oocyte retrieval remains to be investigated.

In vivo oocyte recovery and in vitro embryo production from bovine donors aspirated at different frequencies or following FSH treatment

The effects of frequency of follicular aspiration and treatment of donor cattle with FSH on in vivo oocyte recovery and in vitro embryo production were studied. Simmental heifers (n = 24) formed 8 replicates of 3 treatments in which oocyte donors were aspirated 1) once a week, 2) twice a week, or 3) once a week following treatment with FSH for 3 d prior to aspiration. Oocytes were graded, washed, matured for 20 to 24 h and then inseminated with frozen/thawed semen from a single sire, followed by co-culture on granulosa cell layers. Embryo development was observed until Day 7 after insemination. Significantly fewer follicles per heifer per week were counted (14.7+/-2.3 vs. 27.4+/-3.1 vs. 23.1+/-2.8) and aspirated (12.0+/-2.0 vs. 21.8+/-2.7 vs. 20.1+/-2.6) in heifers on the once-weekly than twice-weekly aspiration treatment (P<0.01) or on the once-weekly aspiration after FSH treatment (P<0.05). There were no significant differences between treatments in the total number of oocytes recovered per week (5.6+/-1.2 vs. 8.9+/-1.5 vs. 6.1+/-1.2), but significantly more oocytes per heifer per week recovered from animals treated with FSH were graded Category 1 (2.8+/-0.4), i.e., >4 layers good cumulus with a clear, even cytoplasm, than from animals aspirated once (0.9+/-0.2; P<0.01) or twice a week (1.5+/-0.3; P<0.05). The number of transferable morulae plus blastocysts produced per heifer per week was higher from animals aspirated twice a week (2.4+/-0.4; P<0.05) or once a week following FSH treatment (2.1+/-0.4; P<0.05) than from animals aspirated once a week without FSH treatment (1.0+/-0.3). In conclusion, FSH treatment of bovine oocyte donors aspirated once a week enabled a similar number of transferable embryos to be produced per donor week as aspiration twice a week without FSH treatment. These 2 treatments produced twice as many transferable embryos per donor week as aspiration once a week without FSH treatment.

Estrogen biosynthesis--regulation, action, remote effects, and value of monitoring in ovarian stimulation cycles

OBJECTIVE

To review current knowledge regarding estrogen biosynthesis, its regulation and action, specifically concerning local as opposed to remote effects of this hormone, and to examine the effectiveness and prognostic value of monitoring hormone concentrations and endometrial response in cycles of controlled ovarian hyperstimulation.

DATA IDENTIFICATION AND SELECTION

Studied that relate specifically to estrogen biosynthesis, enzymatic pathways, estrogen receptor physiology, and the clinical aspects of estrogen monitoring were identified through literature and Medline searches.

RESULTS

Folliculogenesis is the basic unit of ovarian activity, which has a dual purpose: oocyte maturation and steroid production. Steroidogenic granulosa and theca cells cooperate under gonadotropin control to produced estrogens by stimulating synthesis of steroidogenic enzyme messenger RNAs. Steroid synthesis is amplified further by local growth factors and follicular cell multiplication. Estrogen synthesis is directed by FSH, and only small amounts of LH are needed to amplify the follicular estrogenic potential. However, the growth of preovulatory follicles can proceed without LH, under FSH regulation only, even in the presence of low peripheral estrogen levels. Oocyte maturation and fertilization may proceed independently of ambient estrogen levels, leading to the assumption that estrogen exerts a minimal autocrine-paracrine function. The notable effect of follicular estrogen production is to promote adequate receptive endometrium for embryo implantation. Clinical treatment cycles may be monitored more effectively by evaluating end-organ response to estrogen rather than by evaluating absolute serum E2 concentrations or sonographic follicular measurements.

CONCLUSION

Follicular estrogen production is regulated by a complex set of signals that synergize to produce optimal steroidogenesis. Most importantly, the effect of estrogen is truly an endocrine effect, as it prepares the endometrium for implantation. Therefore, the goal of effective treatment and monitoring strategies should focus on direct assessment of the biologic activity of estrogen as it optimizes endometrial receptivity in anticipation of subsequent implantation.

Developmental failure in preimplantation human conceptuses

The majority of human conceptuses fertilized normally in vitro fail to establish a pregnancy following their replacement in utero. However, since conceptuses are usually transferred after only one or two cell divisions, their developmental outcome is not known. It has been found that a significant number of human oocytes which can be fertilized carry chromosomal abnormalities, even in the absence of ovarian stimulation. After fertilization, preimplantation-stage conceptuses developing in vitro display a high incidence of cellular abnormalities. Similar disruptions of cellular organization have also been noted in conceptuses fertilized in vivo. Thus, developmental abnormalities and the demise of the conceptus prior to the stage of implantation may stem from the poor quality of the oocyte. The conditions encountered in vitro have also been proposed to cause or contribute to the early demise of human conceptuses.

Androstenedione and progesterone concentrations in preovulatory follicular fluid correlate with successful fertilization and cleavage of human oocytes in vitro

OBJECTIVE

To determine if androstenedione (A) and progesterone (P) concentrations in preovulatory follicular fluid (FF) correlate with successful fertilization and cleavage of human oocytes in vitro.

DESIGN

A retrospective randomized trial.

SETTING

Hospital department of obstetrics and gynecology.

PATIENTS

Fifty-five patients, ages 24 to 39 years, with normal menstrual cycles undergoing in vitro fertilization (IVF) for tubal infertility.

INTERVENTIONS

Multiple follicular development was induced with clomiphene citrate and human menopausal gonadotropin.

MAIN OUTCOME MEASURES

Relationships among FF steroid hormone, morphological maturity of oocyte-corona-cumulus complexes, and fertilization and cleavage of oocytes.

RESULTS

Follicles with mature oocyte-corona-cumulus complexes and unfertilized oocytes contained significantly greater amounts of A (P less than 0.05) than those with mature oocyte-corona-cumulus complexes and fertilized ova, indicating the occurrence of atretic changes. Follicles yielding successfully fertilized and cleaved ova had significantly greater amounts of P (P less than 0.05) and A (P less than 0.01) but similar levels of 17 beta-estradiol compared with follicles yielding fertilized ova that failed to cleave.

CONCLUSIONS

Follicles yielding oocytes that cleaved as a result of IVF have both a shift in steroidogenesis from estrogen to progestin accumulation and declining aromatase activity, thus reflecting progressive luteinization of the follicles.

The luteal phase after oocyte recovery in a spontaneous cycle

There is disagreement as to whether follicular aspiration and oocyte recovery leads to a defective luteal phase. A group of 20 women with mild endometriosis was studied over two consecutive spontaneous cycles. Follicular aspiration and oocyte recovery was performed 32 hours after the onset of the endogenous luteinizing hormone surge during the second cycle. There was little disturbance of the luteal phase or in the pituitary gonadal relationship in the aspirated cycle. Although a significantly lower serum progesterone was noted on day 8 of post-oocyte recovery, all results were within the normal range seen in the control cycles.

Relationships between follicular fluid steroid hormone concentrations, oocyte maturity, in vitro fertilization and embryonic development in the rhesus monkey

Oocytes and matched samples of follicular fluid (FF) were obtained from 70 follicles of five rhesus monkeys stimulated with either pregnant mare serum gonadotropin or human menopausal gonadotropin. Follicular aspiration was performed 30-32 h after human chorionic gonadotropin administration. The concentrations of estradiol (E2), progesterone (P), testosterone (T), and dihydrotestosterone (DHT) in FF were measured. Twenty-six percent of oocytes were classified as mature (M), 41% matured in vitro (Miv), 13% were dysmature, and 20% atretic. M oocytes were associated with significantly higher levels of P and a higher P:E2 ratio. There were no differences in hormone levels associated with fertilized and nonfertilized oocytes. Thirty-five embryos developed to the six- to eight-cell stage in vitro, of which 13 exhibited optimal cleavage rates. Significantly lower levels of E2 and higher P:E2 ratios were associated with the more rapidly cleaving embryos. Proportionally more embryos showing optimal cleavage rates developed from M compared to Miv oocytes, and only embryos derived from M oocytes developed to blastocysts in culture. Optimal cleavage rates to the six- to eight-cell stage in vitro, rather than fertilization rates, are a better indicator of (subsequent) developmental capacity, and, in this study, embryonic development was closely associated with the maturity of the oocyte at recovery.

Pregnancy rate and ovarian hyperstimulation after luteal human chorionic gonadotropin in in vitro fertilization stimulated with gonadotropin-releasing hormone analog and menotropins

The value of luteal phase supplementation with human chorionic gonadotropin (hCG) was assessed after a combined protocol of ovarian stimulation, using a long acting gonadotropin releasing hormone analog (GnRH-a) and human menopausal gonadotropins (hMG), in a randomized prospective study of 36 consecutive cycles in an in vitro fertilization (IVF) program. The patients were allocated on the transfer day to either luteal phase supplementation with hCG (Group A, n = 18) or none (Group B, n = 18). Nine patients of Group A conceived as compared with 3 in Group B. Five patients, all in Group A, developed ovarian hyperstimulation syndrome (OHSS) (3 moderate and 2 severe forms). Analysis of the hormonal profiles disclosed similar progesterone (P), estradiol (E2), and E2/P ratio up to the 6th post ovum pick-up day. Then, E2 and mainly P levels decreased only in Group B resulting in a rising E2/P ratio. These findings stress the importance of luteal support in IVF cycles treated with GnRH-a. In light of the increased risk of OHSS among hCG treated patients, further studies are needed to assess the optimal preparation needed.

In-vitro steroid production by human granulosa lutein cells in long-term cultures

delta 4 and delta 5 pathway steroidogenesis by human granulosa lutein cells (GLC) in long-term cultures (6-8 days) was investigated under basal (10% serum + medium + GLC) and stimulated (human chorionic gonadotropins (hCG), 100 mIU/ml) conditions. In the delta 4 pathway, 17-hydroxyprogesterone (17-OHP) secretion increased from 160-fold at 48 hours of culture to 360-fold at 144 hours under basal conditions, when compared with the respective controls (concentrations in the 10% serum added to the medium) (p less than 0.005). HCG further augmented 17-OHP production significantly at 96, 144 and 192 hours of culture. Progesterone (P) secretion behaved similarly, and increased from 150-fold at 48 hours to 560-fold at 96 hours when compared with controls, being further stimulated by hCG. In contrast, androstenedione (A) secretion throughout the entire culture period increased only slightly (3-5-fold) under both basal and stimulated conditions, when compared with the respective controls. In the delta 5 pathway, the secretory pattern of 17-hydroxypregnenolone (17-OHPregn) and dehydroepiandrosterone (DHEA) was similar to that observed with A, and both steroids increased only slightly under basal and stimulated conditions, when compared with their respective controls. In conclusion, 17-OHP and P are secreted in very significant amounts during the entire culture period while 17-OHPregn, DHEA and A are secreted in extremely small amounts. These results demonstrate that the delta 5 pathway is inactive in long-term human GLC cultures while the delta 4 pathway is active in certain portions only.(ABSTRACT TRUNCATED AT 250 WORDS)

Endocrine profile of follicles containing oocytes with subsequent polyploid fertilization

In an attempt to identify oocytes at risk for polypronuclear fertilization, follicular fluids were obtained retrospectively that contained oocytes that fertilized normally and abnormally. Whenever possible, each patient served as her own control during the same stimulation cycle. Twenty-six of 169 patients had oocytes that became polypronuclear, and of those 26, 21 had oocytes that fertilized and cleaved normally. Follicular fluids were analyzed for estradiol, progesterone, androstenedione, transferrin, and insulin. Insulin levels were noted to be significantly elevated (P less than 0.05) in the polypronuclear group when compropose that insulin, a known growth factor for granulosa cells cultured in vitro, when present in excessive concentrations may predispose to polypronuclear fertilization.

A comparison of follicular fluid levels of insulin-like growth factor-1 in normal dominant and cohort follicles, polycystic and multicystic ovaries

Fourteen ovulatory patients undergoing diagnostic laparoscopy had at least two samples of clear follicular fluid (FF) collected in the late follicular phase. The cohort concentrations of Insulin-like Growth Factor-1 (IGF1) were significantly correlated with serum IGF1 and dominant follicles contained significantly higher concentrations of IGF1 and oestradiol (E2) than their cohorts. After the LH surge, a further significant increase in dominant FF-IGF1 occurred. FF-(log)E2 was significantly correlated with both FF-IGF1 and FF volume. Nine women with the polycystic ovary syndrome (PCOS) and one patient with multicystic ovaries (MCO) associated with weight-loss related amenorrhoea also had follicular aspiration performed. The mean (SD) FF-IGF1 in the PCOS group, 0.42 (0.15) U/ml, was not significantly different from that of the cohorts in the control group, 0.39 (0.13) U/ml. The patient with MCO had both serum and FF-IGF1 concentrations less than 10th centile. These results support the hypothesis that IGF1 has a paracrine (and possibly endocrine) role in the regulation of ovarian function in the human female.

Effect of oocyte quality and sperm characteristics on the number of spermatozoa bound to the zona pellucida of human oocytes inseminated in vitro

Sperm characteristics and oocyte quality may play a role in in vitro fertilization. The objective of this paper is to analyze the effect of the quality of oocytes, the husband's semen characteristics, and category of the couple's infertility on the number of spermatozoa bound to the zona pellucida. One hundred eighty-one oocytes which failed to fertilize or failed to cleave were fixed in 2.5% glutaraldehyde 40 to 60 hr after insemination in vitro and examined under interference microscopy and the number of sperm bound to the zone pellucida was determined. The means +/- SD of sperm bound to mature, immature, and atretic oocytes were 51.0 +/- 50.7, 7.3 +/- 12.1 10.4 +/- 17.8, respectively. Fertilized mature oocytes (81.0 +/- 53.3) had a significantly higher number of sperm bound to zonae compared to unfertilized oocytes (41.8 +/- 47.3). It is concluded that the number of sperm bound to zonae is functionally important. The sperm motility and the number of motile sperm used to inseminate oocytes were significantly correlated with the number of sperm bound to zonae, whereas sperm morphology and sperm concentration did not correlate. This study supports the notion that sperm motility is the single most important factor influencing fertilization of human oocytes in vitro.

Luteal phase after ovarian hyperstimulation

The luteal phase was investigated in 17 women with normal menstrual cycles and tubal infertility who were superovulated with clomiphene (9 cycles), clomiphene plus pulsatile human menopausal gonadotrophin (hMG) (12 cycles) and clomiphene plus pulsatile follicle stimulating hormone (FSH) (11 cycles) during an in-vitro fertilization programme. Follicles were aspirated 34-36 h after the onset of the endogenous LH surge. Urinary total oestrogen levels during the first 6 days of the luteal phase were significantly higher, the duration of the luteal phase was significantly shorter and the luteal levels of urinary pregnanediol were significantly lower in the two combination treatment cycles than in the clomiphene only cycles. When the three treatment groups were combined the mid-luteal peak pregnanediol levels and the duration of the luteal phase showed significant negative correlations with plasma or urinary oestrogen levels during the follicular and the luteal phase. It is suggested that the luteal function in cycles superovulated with clomiphene/hMG or clomiphene/FSH is disrupted and this is related to the high amounts of circulating oestrogen.

Serum progesterone levels in women treated with human menopausal gonadotropin and human chorionic gonadotropin for in vitro fertilization

For evaluation of the adequacy of luteal function after in vitro fertilization-embryo transfer (IVF-ET), serum progesterone (P) levels were measured on days 3, 7, and 10 after laparoscopic follicle aspiration. Fifty-six infertile patients were treated during 86 cycles with human menopausal gonadotropin-human chorionic gonadotropin (hMG-hCG) for stimulation of follicular development. Serum estradiol (E2) levels were measured daily during hMG-hCG treatment. P levels were determined in 67 cycles. The mean (+/- standard deviation [SD]) of the sums of 3 P levels was 55.63 +/- 24.13 ng/ml. There were 11 pregnancies. The mean of the sums of 3 P levels of pregnant patients was 64.45 +/- 26.23 ng/ml and of 56 nonpregnant cycles was 53.90 +/- 23.35 ng/ml. The duration of luteal phase varied from 9 days to 15 days. The mean of the sums of 3 P values of patients with different luteal phase lengths ranged from 28.8 ng/ml to 60.51 +/- 25.68 ng/ml. The mean of the sums of 3 P levels of women with normal luteal phase and that of women with luteal phase defect by endometrial biopsy study were used as controls for comparison. There was poor correlation (r = 0.3441) between E2 peak levels and P levels; the sum of 3 P levels did not indicate luteal phase inadequacy in IVF-ET patients; and the majority of the nonpregnant cycles (32/56) showed a luteal phase of 11 days or less, in spite of adequate P levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Ultrastructural characterization of human granulosa cells in stimulated cycles: correlation with oocyte fertilizability

The fine structure of human granulosa cells (GC) obtained in the course of an in vitro fertilization procedure was correlated with oocyte fertilizability. The investigation was performed by light-microscopic and electron-microscopic examination of ultrathin sections and replicas of freeze-fractured material. GC associated with nonfertilizable oocytes (group I) had significantly smaller cell areas, tended to be tightly packed, and exhibited abundant intercellular gap junctions and adherence junctions. Multiple structural variations of cytoplasmic organelles were observed in comparison to cells associated with fertilizable oocytes (group II). Cells in group II tended to be widely dispersed, frequently contained interiorized gap junctional elements (annular junctions), and showed morphologic correlates of high steroidogenic activity. Structural dissimilarities between groups I and II were not consistently related to follicle size, as determined by volume of aspirated follicular fluid. In view of the sequential ultrastructural changes known to occur during follicular maturation and ovulation, it is concluded that GCs related to nonfertilizable oocytes were lacking structural correlates of luteinizing hormone/human chorionic gonadotropin responsiveness.

Plasma progesterone and prolactin changes in superovulated women before, during, and immediately after laparoscopy for in vitro fertilization and their relation to pregnancy

To define changes in peripheral plasma progesterone (P) and prolactin (PRL) levels in relation to oocyte recovery for in vitro fertilization (IVF), the authors studied these hormones in 20 women before, during, and after oocyte recovery for IVF. The patients were superovulated with clomiphene citrate and human menopausal gonadotropin and underwent general anesthesia (19 women) or epidural anesthesia (1 woman) and laparoscopy for follicular aspiration. One half of the women were given bromocriptine to control PRL levels during anesthesia. There was a marked drop in P levels (mean decrease of 76%) within the 2 hours after induction of anesthesia and follicular aspiration. PRL levels rapidly rose in patients not treated with bromocriptine. Four of the 20 patients became pregnant after embryo transfer, and in these women P levels were significantly higher than in nonpregnant patients before and during oocyte recovery. Changes in PRL levels and P levels during oocyte retrieval were not related to the occurrence of pregnancy.

Ultrasonically guided percutaneous and laparoscopic oocyte aspiration: a comparative study

Oocyte collection for in vitro fertilization was performed in 105 cycles (65 patients) by ultrasonically guided percutaneous puncture (63 cycles) or laparoscopy (42 cycles). During the ultrasonically guided approach an open or closed needle system was used. During both ultrasonically guided and laparoscopic follicle aspiration, all visible follicles were punctured. The mean number of punctured follicles per cycle was comparable for both techniques. Despite a significantly higher mean number of oocytes per cycle harvested during laparoscopy, the mean number of embryos per cycle was not essentially different with the two techniques. Also no difference could be established between the ultrasonically guided open and closed needle systems.

Follicular development: lessons learned from human in vitro fertilization

In vitro fertilization has offered new insights into our understanding of ovulation induction, folliculogenesis, and luteal phase events. This new information is provided by the ability to precisely study these cycles in a frequent and sequential fashion through the use of peripheral blood markers, ultrasound evaluation, and follicular fluid constituents and cell culture techniques, as well as direct observation of the oocyte, fertilization, and cleavage. In these stimulated cycles the follicular phase serum estradiol levels in conjunction with ultrasound were evaluated; a poor correlation was shown between follicle size and number and estrogen production. This distinct dyssynchrony suggests the recruitment of a number of cohorts of follicles in each stimulated cycle. From the biochemical markers in follicular fluid, cyclic adenosine monophosphate has a distinct predictive value in regard to pregnancy in in vitro fertilization-embryo transfer cycles. In the luteal phase, the mass effect of aspiration of great numbers of granulosa cells, the effect of supplemental progesterone, and the influence of high follicular phase estradiol levels remain controversial and, therefore, a less clear cut pattern emerges. Variations in the protocol have not greatly improved the major problems of folliculogenesis associated with ovulation induction and an in vitro fertilization-embryo transfer program, that is, follicular asynchrony and luteal phase deficiency.

Altered follicular development in clomiphene citrate versus human menopausal gonadotropin-stimulated cycles for in vitro fertilization

The pattern of periovulatory and luteal phase serum estradiol (E2) and progesterone (P) as well as follicular fluid (FF) E2, P, androgen, gonadotropin, and prolactin concentrations of eight women undergoing clomiphene citrate (CC)/human chorionic gonadotropin (hCG) stimulation and eight women undergoing human menopausal gonadotropin (hMG)/hCG stimulation of follicular development for the purpose of in vitro fertilization were compared. Ovulation was induced with either a 5-day course of CC (100 mg/day beginning on day 5 of the cycle) or an individualized hMG regimen, and laparoscopy was performed 36 hours after hCG administration. The length of the luteal phase was significantly longer (P less than 0.05) in the CC-treated group as compared with the hMG-treated group. The pattern of serum E2 levels differed significantly (P less than 0.01) in that E2 levels were lower in the early and midluteal phase in CC-stimulated cycles; in addition, a delayed second E2 peak was observed in the late luteal phase in these women. Serum P levels, however, were lower in the hMG-stimulated group. Analysis of FF hormone concentrations revealed significantly (P less than 0.05) higher concentrations of E2 and androsterone in the FF of hMG-treated patients. It is concluded that follicular development in CC-stimulated cycles differs markedly from that in hMG-stimulated cycles. These differences may reflect either an altered follicular maturational process or may represent a direct inhibitory effect of CC on follicular steroidogenesis.

Sequential use of clomiphene citrate, human menopausal gonadotropin, and human chorionic gonadotropin in human in vitro fertilization. II. Study of luteal phase adequacy following aspiration of the preovulatory follicles

The 88 patients included in the in vitro fertilization program during 113 cycles were submitted to superovulation by sequential use of clomiphene citrate, human menopausal gonadotropin, and human chorionic gonadotropin. No correlation was found between estradiol and progesterone levels during the luteal phase and estradiol on the days preceding administration of human chorionic gonadotropin. Nineteen biopsies of the endometrium were carried out. The importance of the increase of estradiol between the day before and the day of administration of human chorionic gonadotropin is positively correlated with the quality of the endometrium.

Analysis of 25 infertile patients treated consecutively by in vitro fertilization at Bourn Hall

Twenty-five infertile women suffering from tubal disorders were treated consecutively by in vitro fertilization over a 14-day period. Follicular growth in 24 of them was stimulated with clomiphene citrate, ovulation being induced by an endogenous surge of luteinizing hormone or an injection of human chorionic gonadotropin. One patient was given tamoxifen and had an endogenous luteinizing hormone surge. One or more oocytes were fertilized, and at least one embryo was replaced in 19 patients. Nine pregnancies were established, and eight infants have been delivered, a pregnancy rate of 36% per laparoscopy and 47% per replacement. A detailed analysis of each patient is presented.

The relationship between follicular fluid steroid concentration and successful fertilization of human oocytes in vitro

Follicular fluids (FF) and their matched oocytes were obtained from 64 follicles of 28 women who failed to conceive after in vitro fertilization ( IVF ) and 33 follicles of 8 women who successfully conceived after the procedure. Ovulation was induced with human menopausal gonadotropin, and follicular aspiration was performed 36 hours after human chorionic gonadotropin administration. The concentration of 17 beta-estradiol, progesterone, testosterone, dihydrotestosterone, and androsterone was correlated with the morphology of the oocyte-corona-cumulus complex ( OCCC ), oocyte fertilization, the rate of cleavage, and the incidence of pregnancy after embryo transfer. In both groups of women, FF progesterone was lowest in follicles containing immature OCCCs . However, follicles aspirated from women who conceived after IVF which contained intermediate and mature OCCCs had significantly higher FF estradiol levels than similar follicles from women who failed to conceive after the procedure. Fertilized oocytes and 4- to 6-cell stage embryos which were obtained from follicles of pregnant women contained significantly higher FF estradiol levels than fertilized oocytes and similar embryos from nonpregnant women. It appears that higher FF estradiol levels correlate well with successful fertilization and an enhanced cleavage rate of oocytes associated with pregnancy following IVF .

Clinical validation of enzymeimmunoassay of human luteinizing hormone (hLH) in the detection of the preovulatory luteinizing hormone (LH) surge in urine

The preovulatory luteinizing hormone (LH) surge (mean, 60.7 standard error +/- 4.7 mIU/ml) as determined by a solid-phase enzymeimmunoassay in urine has been correlated with clinical parameters in 24 women. In group A, of seven women, the preovulatory LH surge correlated with basal body temperature and cervical mucus. In one of the women in group A, serum levels of pituitary and gonadal hormones confirmed ovulation. In group B, of 17 women, the urinary estrone-3-glucuronide (E1-3-G) peak was either coincident with or preceded the LH surge. The LH surge in all cases occurred 12 to 24 hours prior to follicular rupture, as visualized by real-time sonography. The enzymeimmunoassay for the detection of the preovulatory LH surge is useful in patients for artificial insemination and for aspiration of mature oocytes for in vitro fertilization.

The recovery of pre-ovulatory oocytes using a fixed schedule of ovulation induction and follicle aspiration

Thirty-two volunteer women, scheduled for laparoscopy, were subjected to a fixed regimen of ovulation induction and ovarian follicle aspiration, following manipulation of the previous menstrual cycle with oral contraceptive pills or norethisterone. This allowed the time of oocyte recovery to be planned several weeks in advance. The recovery rate of mature oocytes (loosely dispersed cumulus) in the patients who had their cycles adjusted with norethisterone was comparable to that in a group of women treated in an embryo-transfer programme who were being individually monitored, although there was evidence from cleavage rates and concentration of sex steroids in follicular fluid that further follicular maturation could have occurred. It is suggested that a modification of this schedule could provide an acceptable recovery rate of pre-ovulatory oocytes for research purposes, and possibly by simplifying the monitoring technique could be applicable to a wider range of patients seeking embryo transfer.

Vital initiation of pregnancy (VIP) using human menopausal gonadotropin and human chorionic gonadotropin ovulation induction: Phase I--1981

Laparoscopies for oocyte aspiration in 31 cycles were performed on 25 patients receiving human menopausal gonadotropin and human chorionic gonadotropin. Sixty oocytes were aspirated, of which 48 were considered preovulatory. Ninety-seven percent (58 of 60) of the oocytes were found in the original aspirate, and the remaining oocytes were found in either the first or second follicle wash. The fertilization rate per preovulatory oocyte was 33% (16 of 48), whereas on a per cycle basis it was 39% (12 of 31). A total of 15 conceptuses (2-cell = 5; 3-cell = 3; 4-cell = 7) were transferred to 12 patients, and two pregnancies were established. These pregnancies were established by transfers of 3-cell and 4-cell conceptuses at approximately 47 hours after insemination. Both pregnancies resulted in term deliveries of normal infants.

Ultrasonically guided percutaneous aspiration of human follicles under local anesthesia: a new method of collecting oocytes for in vitro fertilization

Follicular aspiration was performed in 30 infertile patients by ultrasonically guided percutaneous puncture. In 18 cases the procedure was carried out under local anesthesia and in the remaining 12 under general anesthesia. The follicles were located with a dynamic sector scanner, and a needle was introduced through the abdominal wall and bladder into the follicles. Fifty follicles with a mean diameter of 19.6 mm were aspirated, and 26 oocytes were collected, giving an average recovery rate of 52%. Oocytes were obtained in 17 (57%) of the cases. Extensive pelvic adhesions did not impede the procedure, and the only complication was a transient hematuria in four patients. The technique was found to be atraumatic and inexpensive and therefore considered valuable for harvesting oocytes for in vitro fertilization.

Hormonal and histological study of the luteal phase in women following aspiration of the preovulatory follicle

A hormonal and histologic study of 60 luteal phases was carried out in 40 patients during spontaneous and stimulated cycles before and after follicle puncture for oocyte recovery. The duration of the luteal phase was modified neither by follicle rupture nor by hormonal stimulation. The aspiration of a spontaneous preovulatory follicle caused a temporary deficiency in plasma progesterone (P) (P less than 0.01) on the third day following aspiration, and a higher prolactin (PRL) level (P less than 0.02) on the ninth day. Dystrophia of the endometrium was observed in one-third of the cases, whereas the P level was normal. In cycles stimulated by clomiphene citrate, no P deficiency was observed. When luteinizing hormone (LH) discharge occurred spontaneously, biopsies carried out 3 days following follicle aspiration indicated a normal secretory state of the endometrium, and the P level was higher from, the sixth day following aspiration (P less than 0.05), as compared with the control cycles. This phenomenon was not observed when human chorionic gonadotropin (hCG) was administered.