Humoral complementomics - exploration of noninvasive complement biomarkers as predictors of renal cancer progression

Despite the progress of anti-cancer treatment, the prognosis of many patients with solid tumors is still dismal. Reliable noninvasive biomarkers are needed to predict patient survival and therapy response. Here, we propose a Humoral Complementomics approach: a work-up of assays to comprehensively evaluate complement proteins, activation fragments, and autoantibodies targeting complement proteins in plasma, which we correlated with the intratumoral complement activation, and/or local production, focusing on localized and metastatic clear cell renal cell carcinoma (ccRCC). In two prospective ccRCC cohorts, plasma C2, C5, Factor D and properdin were elevated compared to healthy controls, reflecting an inflammatory phenotype that correlated with plasma calprotectin levels but did not associate with CRP or with patient prognosis. Conversely, autoantibodies against the complement C3 and the reduced form of FH (a tumor neo-epitope reported in lung cancer) correlated with a favorable outcome. Our findings pointed to a specific group of patients with elevated plasma C4d and C1s-C1INH complexes, indicating the initiation of the classical pathway, along with elevated Ba and Bb, indicating alternative pathway activation. Boostrapped Lasso regularized Cox regression revealed that the most predictive complement biomarkers were elevated plasma C4d and Bb levels at the time of surgery, which correlated with poor prognosis. In conclusion, we propose Humoral Complementomics as an unbiased approach to study the global state of the complement system in any pathological plasma sample and disease context. Its implementation for ccRCC revealed that elevated C4d and Bb in plasma are promising prognostic biomarkers, correlating with shorter progression-free survival.

Changes in volatile fatty acid production and microbiome during fermentation of food waste from hospitality sector

Due to the increasing demand for low carbon-footprint bioproducts in the markets, innovative processes technologies and products are needed. The objective of this study was to assess the quality and potential of food waste (FW) from the hospitality sector to produce volatile fatty acids (VFAs). A batch type acid fermentation system was used to study VFA production in different process conditions (a decreased pH and increased organic loading rate). The evolution of VFAs and long-chain fatty acids was followed. Amplicon sequencing of the 16S rRNA gene was used to investigate the bacterial and archaeal community, and elucidate microbial communities in different FW and process conditions. The results show that high VFA concentrations (of up to 18 g/L) were achieved in overloaded conditions, which were also affected by the activity and composition of the inoculum. FW played an important role in modulating microbial composition, especially the bacterial communities belonging to the lactic acid bacteria group.

Bio-based Algae Oil: an oxidation and structural analysis

OBJECTIVE

In search of natural components, vegetal oils are increasingly becoming more popular in cosmetics. However, high oxidation instability, presence of potential allergens and synthetic anti-oxidants have limited their applications so far. Therefore, a need exists for a natural emollient with high oxidation stability. In this work, we report on a novel sustainably produced triglyceride containing primarily three monounsaturated oleic acid chains, dubbed 'Bio-Based Algae Oil' hereafter, as a natural emollient for cosmetic formulations. To produce Bio-Based Algae Oil, simple sugars are converted into triglyceride oils using microalgae fermentation with minimal environmental impact.

METHODS

Bio-Based Algae Oil was compared to other commonly used triglyceride-based emollients in the skincare industry in terms of thermal/oxidation stability, composition and moisturizing properties. Oxidation stability of emollients was compared using Rancimat and pressurized differential scanning calorimetry (PDSC) techniques. Fatty acid composition of each oil was analysed using proton nuclear magnetic resonance (¹ H-NMR) and gas chromatography (GC) techniques to correlate unsaturation level of each oil to its oxidation stability. We also conducted an in vivo moisturizing study in which skin hydration level of human subjects was compared before and after application of emollient up to 24 h.

RESULTS

Results showed that Bio-Based Algae Oil was the most stable emollient in thermal and oxidation stability studies given its low unsaturation and high anti-oxidant content determined by ¹ H-NMR and GC techniques. It also provided the highest skin hydration level when applied on skin demonstrating its efficacy as a moisturizing emollient in cosmetic formulations.

CONCLUSIONS

Compositional analysis of Bio-Based Algae revealed that it is a triglyceride containing primarily three monounsaturated oleic acid chains with very low polyunsaturated fatty acid content resulting in high oxidation stability and consequently prolonged shelf-life. Given its sustainability, high oxidation stability and skin health benefits such as moisturization demonstrated during an in vivo study, we envision to utilize Bio-Based Algae Oil in many cosmetic formulations across skincare, suncare and bath and shower markets.

[Haemorrhage and morbidity associated with the use of tranexamic acid in cardiac surgery: a retrospective, multicentre cohort study]

INTRODUCTION

Postoperative bleeding is common complication, affecting up to 20% of patients, after cardiac bypass surgery. Fibrinolysis is one of the causes of this excessive bleeding, and for this reason the use of tranexamic acid is recommended. The problem with using this is that there are numerous guidelines and differences in the dose to be administered. Our aim was to evaluate whether there were any differences in postoperative bleeding and morbidity after cardiac surgery with the administering of different tranexamic acid doses in three university hospitals.

MATERIAL AND METHODS

A retrospective, multicentre cohort study was conducted. A total of 146 patients who were subjected to elective cardiac bypass surgery according to the anaesthetic-surgical protocol of each hospital were included in the study. The clinical histories were reviewed, and they were divided into two groups according to the tranexamic acid dose: Group A (high doses), initial dose of 20mg/kg and continuous infusion of 4 mg/kg/hour until closure of the sternotomy. A further 100mg was added to prime the bypass machine. Group B (low doses), initial dose of 10mg/kg followed by a continuous infusion of 2mg/kg/hour until closure of the sternotomy. A further 50mg was added to prime the bypass machine. Variables, such as age, sex, weight, height, type of surgical procedure (valvular, coronary or mixed), haematocrit, INR, and preoperative platelet count, time and temperature of the bypass machine, and haematocrit on sternum closure, were recorded. Among the post-operative variables collected were: debit due to drainage at 6, 12 and 24 hours after surgery, number and type of blood products transfused in the first 24 hours, need for further surgery due to haemorrhage, CVA, TIA, or a new acute myocardial infarction, convulsions, and mortality.

RESULTS

The incidence of increased bleeding (patients in the 90 percentile) was higher in Group B at all the study evaluation times (P<.05). The incidence of further surgery due to bleeding, and the need for transfusion of ≥ 3 units of packed red cells was lower in Group A (5.56%) than in Group B (13.89%). There were no significant differences in the requirements for blood products transfusions between the groups. As regards associated morbidity, there was one isolated case of convulsion and a perioperative AMI in another case in Group A, and three cases of perioperative AMI in Group B.

CONCLUSIONS

Elevated doses of tranexamic acid in cardiac bypass surgery appear to significantly reduce bleeding in the first hours after surgery compared to low doses. However, this decrease did not lead to a reduction in the needs for blood products.

Embryo reduction of multifetal pregnancies following assisted reproduction treatment: a modification of the transvaginal ultrasound-guided technique

First-trimester transvaginal embryo reduction is an effective alternative for the management of multifetal pregnancy in assisted reproduction. We have modified the transvaginal technique by performing an intracardiac embryo puncture until asystolia is verified, without the injection of any substances. Any aspiration of embryo tissues or amniotic fluid was avoided. A total of 149 multifetal pregnancies was reduced to twins (n = 134) or singletons (n = 15) at early gestational age (7.8 +/- 0.8 weeks). Eleven cases (7.3%) of miscarriage, two cases (1.3%) of chorioamnionitis, and 17 cases (11.4%) of transient spotting were recorded as postoperative complications. Vanishing of one embryo occurred in four cases (3.0%) of those reduced to twins. The baby take-home rate was 89.5% for twins and 80.0% for singletons. Pregnancy outcome was analysed and compared with a control group of women with non-reduced multiple pregnancies. The birth weight of singleton pregnancies after reduction was lower (2929 +/- 160 versus 3291 +/- 422 g; P < 0.02). These studies show that early transvaginal intracardiac embryo puncture is an effective and safe technique.

Impact of stage III-IV endometriosis on recipients of sibling oocytes: matched case-control study

OBJECTIVE

To evaluate the impact of severe endometriosis on IVF-ET outcome in women receiving oocytes from the-same donor.

DESIGN

A matched case-control study.

SETTING

Oocyte donation program at the Instituto Valenciano de Infertilidad.

PATIENT(S)

Fifty-eight recipients were included in a matched case-control study of IVF-ET in our oocyte donation program. Twenty-five patients were diagnosed by laparoscopy with stage III-IV endometriosis (group I), while the remaining 33 were free of the disease (group II). On the day of retrieval, oocytes from a single donor were donated to recipients from both groups. Some of the donors supplied oocytes for more than 2 patients. Recipients received steroid replacement therapy for endometrial preparation.

INTERVENTION(S)

Ovarian stimulation and oocyte retrieval in donors. Uterine embryo transfer (ET) in recipients after appropriate exogenous hormone replacement therapy (HRT).

MAIN OUTCOME MEASURE(S)

Pregnancy, implantation, miscarriage, and live birth rates.

RESULT(S)

The number of oocytes donated and fertilized, as well as the number of available and transferred embryos, was not statistically different between the two groups. Pregnancy, implantation, and miscarriage rates were not affected by stage III-IV endometriosis when compared with the control group. The live birth rate was 28.0% in the group with endometriosis and 27.2% in the control group.

CONCLUSION(S)

These results show that implantation is not affected by stage III-IV endometriosis. Given the contemporary methods of endometrial preparation for transfer of embryos derived from donor oocytes, any potential negative effect of severe endometriosis on the uterine environment is undetectable.

Nocturnal hypoglycaemia in IDDM patients younger than 18 years

The present multicentre study was undertaken to assess the prevalence of nocturnal hypoglycaemia and its determining factors in 117 diabetic children and adolescents, aged 2-18 years and diabetes duration > 1 year in Spain. Each child made 3 measurements of blood glucose (BG) at home at night (between 0000 h and 0600 h) on nine separate nights. A hypoglycaemic event occurred in 12-14% of children in any one night. This is lower than rates for nocturnal hypoglycaemia reported in literature, perhaps because of relatively late mealtimes and different meal content, in Spanish children. Children aged < 7 years were at higher risk of nocturnal hypoglycaemia than older children (p < 0.05). Mean HbA1c from the year before the study and mean HbA1c measured during the closest time to the study were significantly lower in those with nocturnal hypoglycaemia (p < 0.0001). Blood glucose concentrations 2 h before hypoglycaemia did not predict nocturnal hypoglycaemia. The occurrence of low or very low blood glucose concentrations before breakfast was related to a higher risk for nocturnal hypoglycaemia (chi 2 22.97; p < 0.001). No previous symptoms were detectable in 89% of cases.

A comparison of three methods for detecting the acrosome reaction in human spermatozoa

This study was designed to compare three different fluorescent probes to assay the acrosome reaction in human spermatozoa: chlortetracycline (CTC), mannosylated bovine serum albumin (BSA) labelled with fluorescein (MAF), and quinacrine (QN). Normal human sperm ejaculates were washed and allowed to swim up for 30-60 min. Samples were examined under epifluorescence for the percentage of the acrosome reacted spermatozoa, as detected by the three probes. There was no significant differences between samples of fresh, uncapacitated spermatozoa evaluated with CTC, MAF or QN; all gave < 10% reacted. Following capacitation for 3 h, the percentage of spontaneously reacted spermatozoa was higher than in fresh spermatozoa; CTC and MAF gave the same percentage (12%), while QN indicated a higher percentage (18%) of reacted spermatozoa (P < 0.001). Following exposure to ionophore A23187 at 1 h, the percentage of acrosome reactions increased to a mean of 31% as detected with CTC or MAF; the mean percentage (45%) was significantly higher with QN (P < 0.0001). Further incubation up to 2 h with A23187 did not change these percentages. These results suggest that the QN probe detects the onset stage of the acrosome reaction, whereas the CTC and MAF probes detect the later stages in which the acrosomal cap is lost. Use of the two types of probe provides a means for finer resolution of the time course of the acrosome reaction in the human spermatozoa.

Can the immunobead assay for detecting sperm antibodies in fresh samples be reproduced in cryopreserved/thawed human spermatozoa?

PROBLEM

To evaluate the reproducibility of the Immunobead Assay (IBA) on sperm samples before and after cryopreservation.

METHOD

Sperm samples (fresh and post-thaw) from known antibody negative donors (N = 20) were evaluated for percent immunobead binding by IBA following incubation with known antibody-positive serum.

RESULTS

In both fresh and thawed negative samples, the mean sperm head binding was 0.5% +/- 0.5, the mean sperm tail binding was 2.0% +/- 2.0 and the mean sperm head-tail binding was 3.0% +/- 2.0 for IgG, IgA and IgM type antibodies, respectively. The same samples exposed to positive sera showed 40.0% +/- 10.0 mean head binding, 7.0% +/- 8.0 mean tail binding and 47.0% +/- 11.0 mean head-tail binding.

CONCLUSIONS

IBA is highly reproducible for detecting sperm antibodies in both fresh and cryopreserved/thawed samples of human spermatozoa.

Effect of follicular size on oocyte retrieval, fertilization, cleavage, and embryo quality in in vitro fertilization cycles: a 6-year data collection

OBJECTIVE

To determine the effect of follicular size, including the size of the leading follicle, on oocyte retrieval, fertilization, cleavage, and embryo quality in IVF cycles based on a large data collection.

DESIGN

Retrospective analysis of 1,109 IVF cycles between 1987 and 1993 at the Hospital of the University of Pennsylvania including 606 patients ranging in age from 23 to 49 years.

RESULTS

Follicles with a volume < or = 1 mL show a significantly lower oocyte recovery rate than follicles with a volume of > 1 mL. The highest recovery rate (83.5%) was found in follicles with a volume of 3 to 4 mL. Above a follicular volume of 7 mL, the oocyte recovery drops below that observed for follicles between 1 and 7 mL. Fertilization and cleavage rates were also higher in oocytes obtained from follicles > 1 mL compared with follicles < or = 1 mL. Although fertilization rates were fairly stable above volumes of 1 mL, cleavage rates continued to rise to a peak percentage of 92% with volumes between 6 and 7 mL. Leading follicle size did not have an effect on fertilization and cleavage rates of cohort oocytes. Embryo quality was not influenced significantly by follicular volume.

CONCLUSION

Based on this evaluation of a large number of follicles, follicular size is a useful indicator of oocyte recovery, fertilization, and cleavage in IVF cycles. For optimal results, the follicular fluid volume in gonadotropin- and hCG-stimulated cycles should be > 1 mL, which corresponds to a follicle diameter of > 12 mm, and not larger than 7 mL (24 mm). For timing of hCG administration, the number of adequate size follicles appears to be more important than the size of the leading follicle(s).

Centrifugation of human spermatozoa induces sublethal damage; separation of human spermatozoa from seminal plasma by a dextran swim-up procedure without centrifugation extends their motile lifetime

While washing of human sperm cells by centrifugation and resuspension is a procedure in widespread use, there have been indications that this procedure per se may be harmful to the cells. The objective of this study was to investigate this question. To this end, a method for the clean separation of motile human spermatozoa from seminal plasma in the absence of centrifugation was developed, using a modified swim-up procedure, in which liquefied semen was mixed with an equal volume of 30 mg/ml dextran in medium, and the mixture overlaid with medium containing 5 mg/ml bovine serum albumin, forming two discreet layers with stable interface. The percentage of motile cells in a given sample was consistently > 80% immediately after recovery. Damage to the cells was assessed by loss of motile cells during incubation up to 96 h post-recovery. Comparison of aliquots of spermatozoa obtained by the dextran swim-up procedure showed that the aliquot subjected to centrifugation had 4 +/- 3% motile cells after 48 h, while the untreated aliquot had 52 +/- 12%. The aliquots showed no difference 1 h post-recovery. Similar results were obtained with spermatozoa that had been centrifuged in seminal plasma and resuspended in fresh plasma, then recovered by dextran swim-up. The delayed onset of motility loss in the centrifuged samples implies that this treatment induces sublethal damage in the cells. Comparison of the standard swim-up and Percoll gradient methods for sperm recovery, both of which involve centrifugation steps, showed decline in motility of the samples similar to that seen with dextran swim-up of centrifuged cells. We conclude that centrifugation per se induces sublethal damage in human spermatozoa, independently of treatment method, and suggest that recovery methods for human spermatozoa which avoid centrifugation might partially alleviate the damage incurred by these cells during cryopreservation.

Perioperative complications arising after transvaginal oocyte retrieval

OBJECTIVE

To determine the incidence of perioperative morbidity in patients undergoing transvaginal oocyte retrieval and to identify those patients at greatest risk for complications.

METHODS

A retrospective analysis was performed on 674 patients of reproductive age who underwent transvaginal retrieval of oocytes for assisted reproduction technologies during a 3-year period. All procedures were performed by surgeons with extensive experience with transvaginal retrieval. Patients were entered into the program with a primary diagnosis of unexplained infertility (16%), endometriosis (32%), pelvic adhesions and/or tubal occlusion (38%), or infertility from male or immunologic factors (14%).

RESULTS

Of the 674 patients studied, ten (1.5%) required hospital admission because of perioperative complications. Nine of these patients needed intravenous antibiotics and one required admission and observation for an expanding broad-ligament hematoma. Six of nine women admitted for antibiotic therapy had a history of extensive pelvic adhesions with or without a history of salpingitis. Five of nine patients had a history of salpingitis. In addition, two patients experienced impressive vaginal arterial bleeding during the procedure.

CONCLUSION

This study suggests that transvaginal retrieval may not be as innocuous as is often expressed and that the primary factor predisposing to perioperative morbidity is a history of previous pelvic inflammatory disease and/or adnexal adhesions.

Comparison of different regimens of a gonadotropin-releasing hormone analog during ovarian stimulation for in vitro fertilization

Three treatment protocols were used in 156 in vitro fertilization cycles. Leuprolide acetate was begun on day 1 of the cycle in one group (n = 20), on day 3 in another (n = 48), and the third control group (n = 88) did not receive the gonadotropin-releasing hormone analog. Human menopausal gonadotropin was initiated on day 3 in all groups. Peak estradiol (E2) levels and the mean numbers of mature oocytes and embryos transferred per cycle were significantly greater in the day 3 group than in either the day 1 or control groups. Patients who received the day 3 protocol had significantly fewer cancelled cycles. A decline in E2 was observed on the third day of analog administration in certain patients, particularly those on the day 1 protocol. Follicle-stimulating hormone and luteinizing hormone (LH) levels increased two- to fivefold 24 hours after initiation of the analog. Thereafter the gonadotropin levels fell, but nevertheless remained above those of controls for most of the cycle. Hence, it appears that enhanced follicular growth attributed to the early transient rises in gonadotropins can be coupled to a suppression of endogenous LH surges in leuprolide-treated women. These beneficial effects seem to be more likely to occur if leuprolide is initiated on cycle day 3 rather than day 1.

Ovulation prediction by monitoring salivary and vaginal electrical resistance with the PEAK Ovulation Predictor

We investigated the ability of the PEAK Ovulation Predictor to predict the expected date of ovulation in 21 infertile, spontaneously ovulating women. A nonsignificant correlation (R = 0.15; P = .51) existed between the predicted date of ovulation and the day of the serum LH peak. A moderately strong correlation (R = 0.61; P less than .01) was observed between the day of the salivary electrical resistance peak and that of the serum LH peak. However, the serum LH peak occurred between 4-9 days after an identified peak in salivary electrical resistance. Twice-daily urine LH testing correlated strongly with both the serum LH peak (R = 0.93; P = .0001) and the ultrasound-detected day of ovulation (R = 0.81; P = .0001). A statistically significant peak in the mean salivary or vaginal electrical resistance on a particular day relative to the day of the serum LH peak could not be demonstrated. When identified, the nadir in vaginal electrical resistance occurred no earlier than 2 days before the serum LH peak and thus may mark the endpoint of the fertile period for natural family planning methods. We conclude that, whereas the PEAK Ovulation Predictor is of little value in accurately predicting ovulation, measurements of salivary and vaginal electrical resistance may be helpful in timing inseminations. However, for detection of the serum LH surge, twice-daily urine LH testing demonstrated a stronger correlation and narrower frequency distribution than did those determinations based on electrical resistance.

Repetitive ovarian response to gonadotropin stimulation in an in vitro fertilization program

The temporal changes of estradiol levels in 19 women undergoing ovulation induction for in vitro fertilization (IVF) and embryo replacement were described by a mathematical model. The model was analyzed for differences between treatment cycles of an individual woman and between cycles of different women. This model was also used to evaluate the results of IVF treatment. The variation between cycles within individuals was found to be less than that between different women. The parameters that describe this model were found to correlate with follicular growth but not with number of oocytes retrieved, fertilized or cleaved.

An increased initial follicle-stimulating hormone/luteinizing hormone ratio does not affect ovarian responses and the outcomes of in vitro fertilization

The tenet that a combination of human follicle-stimulating hormone (hFSH)/human menopausal gonadotropin (hMG) improves follicular recruitment was assessed by randomly treating ovulatory women either with hFSH/hMG on days 3 and 4 of the cycle followed by two ampules of hMG daily or with a constant daily dose of 2 ampules of hMG. Estradiol (E2) levels on the day of human chorionic gonadotropin (hCG) and the mean number of mature, immature and atretic oocytes per cycle did not differ between the two groups. Likewise, fertilization, cleavage, and pregnancy rates were similar for the two treatments. When daily hormone levels were compared in 11 patients during two successive treatment cycles with both stimulation protocols, the temporal pattern of FSH accumulation was repeated in both cycles, but FSH levels were significantly higher when patients received hFSH/hMG. Nevertheless, during both cycles, E2 reached similar peak levels and the mean number of follicles per cycle on the day of hCG administration was not different. We conclude that routine use of hFSH/hMG does not improve the success of an in vitro fertilization (IVF) program and that higher FSH levels do not change the individuality of ovarian response in the same woman.

Ovarian response to human menopausal gonadotropin following suppression with oral contraceptives

The main conclusion of this study is that a profound suppression of the pituitary and ovary can be associated with an inadequate response which may require a longer or different regimen of stimulation to achieve the desired outcome for IVF. We suggest that a pretreatment determination of E2 and gonadotropins can be of value to predict the nature of ovarian response in women with suppressed pituitary-ovarian function.

Follicular aspiration and in vitro fertilization associated with pelvic reconstructive surgery

Between August 1982 and May 1987, 103 patients underwent in vitro fertilization-embryo transfer (IVF-ET) in association with pelvic reconstructive surgery for infertility. Follicular stimulation was induced with clomiphene citrate and laparotomy scheduled day 12 to 15 of the menstrual cycle. Ultrasound measurements of follicular diameter and number of follicles were obtained on the day of human chorionic gonadotropin (hCG) administration, and laparotomy and ovum retrieval performed 36 hours later. Embryo transfer was performed 48 to 72 hours after insemination. Patients were treated postoperatively with intramuscular progesterone. In addition to evaluating the overall pregnancy rate, the outcome of patients having one or more follicles greater than or equal to 1.4 cm in mean diameter (group A) were compared to those in group B (no follicles greater than or equal to 1.4 cm in diameter). The number of oocytes obtained and the fertilization rate and polyspermic fertilization rate were not significantly different between groups; 10.1% of patients in group A conceived but no patient conceived in group B, yielding an overall pregnancy rate of 8.7%. These data suggest that physicians having IVF-ET at their disposal offer patients IVF during pelvic reconstructive surgery.

Incidence of abortion in pregnancies after in vitro fertilization and embryo transfer

Our purpose was to assess factors that are associated with an increased rate of spontaneous abortion in pregnancies initiated by in vitro fertilization. Pregnancies were diagnosed by measurement of serum human chorionic gonadotropin (hCG) 15 days after embryo transfer. Of the 64 women who conceived, 47 delivered term infants, one patient delivered a stillborn at 22 weeks, 14 aborted in the first trimester, and two had pregnancies that implanted in the tube. Abortion rates were similar for women treated with human menopausal gonadotropin (24%; 12 of 54) and those who received clomiphene citrate (12.5%; one of eight). Two patients conceived after treatment with a combination of clomiphene citrate and human menopausal gonadotropin, neither of whom aborted. In 54 patients treated with human menopausal gonadotropin, there were no significant differences in mean maternal age, number of years of infertility before the pregnancy, history of previous pregnancies, amount of human menopausal gonadotropin used to induce ovulation, serum estradiol levels on the day of hCG administration, mean number of follicles, and the mean number of transferred embryos between the group who delivered and the group who aborted. We conclude that none of these factors are associated with increased tendency for fetal loss in our in vitro fertilization program. Beta-hCG levels on day 15 after embryo transfer were significantly lower in the group who aborted than in the group who delivered, and may be predictive of implantation failure.

Dose of human menopausal gonadotropin influences the outcome of an in vitro fertilization program

This study compares outcomes of in vitro fertilization (IVF) in two groups of 57 patients when either 2 (group 1) or 3 (group 2) ampules of human menopausal gonadotropin (hMG) were administered daily. Treatment began on day 3 of the cycle and was discontinued when at least 2 follicles attained diameters greater than or equal to 1.5 cm. Human chorionic gonadotropin (hCG) was given either 24 or 48 hours after the last dose of hMG. Although serum estradiol levels were lower in group 1, the average number of oocytes retrieved (3.2 versus 2.9), fertilized (1.9 versus 2.0), and cleaved (1.7 versus 1.8) per completed cycle did not differ between groups 1 and 2. Likewise, the number of oocytes that fertilized abnormally was similar in both groups (0.5 versus 0.3/cycle). However, the number of atretic oocytes (0.03 versus 0.5/cycle) and the percent of oocytes recovered from the cul-de-sac (0 versus 7.2%) were significantly (P less than 0.05) lower in group 1. In group 1, administration of hCG 48 hours after the last dose of hMG was associated with a higher number of cleaving embryos (2.1 versus 1.5/cycle) and a higher pregnancy rate (34.8 versus 14.7%; P less than 0.05) when compared with injection at 24 hours. In group 2, the interval between hMG and hCG did not influence these results. Together, the associations between fewer oocytes that were atretic or recovered from the cul-de-sac, and a trend toward a higher pregnancy rate, suggest that follicular recruitment with 2 ampules of hMG is more appropriate than 3 ampules in an IVF program.

Cervical mucus changes in relationship to urinary luteinizing hormone

In order to evaluate the relationship between the urinary luteinizing hormone (LH) surge as detected by the OvuSTICK (Monoclonal Antibodies, Inc., Mountain View, CA) method and daily cervical mucus parameters, ten spontaneously ovulating women undergoing infertility evaluation were followed during their cycles with twice daily urinary LH testing as well as daily ultrasound, mucus evaluation, and hormonal assays of serum LH, progesterone (P), and estradiol (E2). Maximal cervical mucus scores, as determined using a modified Insler score, were noted to coincide consistently with the urinary LH surge as detected by twice daily testing and to precede ultrasound evidence of ovulation by 0 to 24 hours. Mucus scores rapidly declined in the 24-hour period following the urinary LH surge. Detection of the urinary LH surge may therefore help identify that period of time during which cervical mucus parameters are optimal and therefore facilitate the timing of artificial insemination, intercourse, or postcoital testing.

Capacitation and acrosome reactions in human spermatozoa monitored by a chlortetracycline fluorescence assay

Human spermatozoa were incubated in culture medium containing human serum albumin (HSA) to promote capacitation, which was monitored by a rapid chlortetracycline (CTC) fluorescence assay. Four CTC fluorescence patterns were readily distinguished, one of which appeared to be correlated with capacitated sperm. When capacitated sperm were treated with either ionophore A23187 or acid-solubilized mouse zonae pellucidae to induce the acrosome reaction, the CTC assay identified acrosome-reacted sperm by lack of fluorescence on the head. Fresh sperm would not undergo the induced acrosome reaction. The percentages of acrosome-reacted sperm identified by the CTC assay in induced and control populations were the same as those identified by the presently used indirect immunofluorescence and triple stain assays.

Spontaneous lipid peroxidation and production of hydrogen peroxide and superoxide in human spermatozoa. Superoxide dismutase as major enzyme protectant against oxygen toxicity

Spontaneous lipid peroxidation in washed human spermatozoa was induced by aerobic incubation at 32 C and measured by malonaldehyde production; loss of motility during the incubation was determined simultaneously. Malonaldehyde production at the point of complete loss of motility, defined as the lipoperoxidative lethal endpoint (LLE), was 0.10 +/- 0.03 nmol/10(8) cells (mean +/- SD, n = 40), and was independent of the time to complete loss of motility. Human spermatozoa produced both H2O2 and O2-. during aerobic incubation. Inhibition of superoxide dismutase in these cells with KCN showed that all the H2O2 production is due to action of the dismutase. The superoxide dismutase activity of individual human sperm samples varied between 1 and 10 U/10(8) cells, variations between samples from a single donor being nearly as great as those between different donors. The time to complete motility loss (tL) showed equal variation of 1 to 10 hours among samples. The rate of spontaneous lipid peroxidation, calculated as LLE/tL, for a given sperm sample and the superoxide dismutase activity of the same sample, determined prior to aerobic incubation, gave a good linear correlation (r = 0.97). Glutathione reductase, glutathione peroxidase, and glutathione were found to be present in human spermatozoa, but showed little variation among samples. These results suggest that superoxide dismutase plays the major role in protecting human spermatozoa against lipid peroxidation. In addition, the superoxide dismutase activity of a fresh sperm sample appears to be a good predictor of the lifetime (up to the complete loss of motility) of that particular sample, and so may prove useful in semen analysis.

Endometrial cytosolic and nuclear progesterone receptors in the luteal phase defect

Basal body temperature profiles, serial serum progesterone levels, and serial endometrial biopsies were studied in 15 infertile women during 21 ovulatory cycles. Ten cycles (in 9 women) demonstrated luteal phase defects (LPD), diagnosed by a histological lag in endometrial maturation, normal luteal phase length, and normal luteal phase serum progesterone levels. Both normal and LPD cycles had a maximum amount of endometrial cytosolic progesterone receptor (PgR) on days 13-15, with a significant decline thereafter. LPD cycles had significantly lower endometrial nuclear PgR concentrations than did normal cycles during the proliferative phase, but luteal phase endometrial nuclear PgR levels were similar in both groups. In 2 LPD women treated with dydrogesterone, normal endometrial maturation and a decline in endometrial cytosolic PgR concentrations in the late luteal phase were found. Therefore, with the exception of endometrial nuclear PgR concentrations during the proliferative phase, we found no evidence for a major abnormality in endometrial PgR levels in LPD cycles with a lag in endometrial histology.

Relationships between polypronuclear fertilization and follicular fluid hormones in gonadotropin-treated women

Similar incidences of congenital abnormalities in in vitro fertilization and embryo transfer (IVF-ET) pregnancies and births in the general population have not supported earlier concerns that IVF may increase chromosomal aberrations. Nevertheless, polypronuclear fertilization is a common, undesirable, and poorly understood outcome of IVF. We evaluated hormone levels in 20 follicular fluids that were associated with mature oocytes that have fertilized abnormally (greater than or equal to pronuclei) and compared them to follicles with mature oocytes that cleaved normally, fertilized but failed to cleave, or did not fertilize. Progesterone (P), androstenedione, estradiol, percent free estradiol, sex hormone-binding globulin, insulin, and prolactin were measured. P levels were significantly higher in follicular fluids associated with oocytes that fertilized abnormally than in the other groups. Levels of the other hormones were similar in all the study groups. We conclude that IVF of oocytes from highly luteinized follicles as judged by P levels may result in polypronuclear fertilization.

Comparison of ultrasonographic transurethral and laparoscopic guided oocytes retrieval

Fifty-eight patients who underwent in vitro fertilization (IVF) treatment were divided into two groups. In 28 patients, ultrasonically guided transurethral follicular aspiration was performed under light general anesthesia. In 30 patients, laparoscopic follicular aspiration was performed under general anesthesia. The mean age for both groups was similar. Follicular recruitment was achieved with human menopausal gonadotropin (hMG) or a combination of clomiphene citrate and hMG. In the ultrasonically guided aspiration group, 128 follicles were aspirated, with a 64% recovery rate (83 oocytes) and an 88.1% embryo transfer (ET) rate (67 embryos). Three (10.7%) intrauterine pregnancies were established in this group. In the laparoscopic group, 153 follicles were aspirated, with a 68.6% recovery rate (105 oocytes) and an 86.3% ET rate (82 embryos), with 4 (13.3%) intrauterine pregnancies established. Three patients had both procedures done; however, none conceived. There were no statistically significant differences between the two groups. Ultrasonically guided transurethral follicular aspiration should be considered as an alternative route for oocyte retrieval, especially when laparoscopy is contraindicated or when the ovaries are not accessible.

Polycystic ovaries: MR imaging

To determine the characteristic appearance of polycystic ovaries on magnetic resonance (MR) images, seven women with polycystic ovarian disease (PCOD) underwent MR examination of the pelvis. These MR images were compared with sonograms. Histologic material was available in two patients. Six of the seven women had characteristic, small peripheral cysts, best seen on T2-weighted MR images; these cysts were seen sonographically in only one case. The centers of nine of 14 ovaries were of low intensity with all MR pulse sequences; this low intensity corresponded with low echogenicity in six cases. Histologically, these areas correlated with hypertrophic cellular stroma. Coexisting central teratomas were seen in three ovaries. The ability of MR to display the findings of PCOD better than ultrasound and its ability to demonstrate coexisting pathologic conditions are valuable in imaging the female pelvis.

Follicular maturation parameters associated with the failure of oocyte retrieval, fertilization, and cleavage in vitro

Follicular maturation parameters predictive of decreased success in human in vitro fertilization were evaluated in 104 gonadotropin-stimulated cycles. Falling estradiol (E2) levels correlated with decreased fertilization (1.9 oocyte/cycle) and cleavage (1.4 oocyte/cycle), when compared with cycles with increasing E2 (2.4 and 2.1 oocyte/cycle, respectively). Likewise, polyspermic fertilization was higher in the former group. Falling E2 levels after human chorionic gonadotropin (hCG) administration correlated with similar trends. Delaying hCG (24 to 96 hours) relative to the last dose of gonadotropin did not affect the total number of oocytes fertilized per cycle. However, polyspermic fertilization and cancellation rates were higher. Leading follicles growing beyond 2.3 cm (determined by ultrasound examination) were associated with decreased recovery, fertilization, and cleavage, and increased polyspermic fertilization. We conclude that ultrasonography and E2 monitoring can predict decreased fertilization and cleavage and should also be monitored after hCG administration.

Fertilization and cleavage after reinsemination of human oocytes in vitro

The results of reinsemination of 150 morphologically mature oocytes that failed to fertilize within 15 to 20 hours after initial insemination were evaluated. Only 41 oocytes (27.3%) were fertilized after reinsemination, which is significantly lower than the percentage obtained after initial insemination (74%). However, the cleavage rate was not impaired significantly. Polyspermic fertilization was common (17 oocytes, 29.3%). A total of 64 oocytes were transferred. In 18 patients, all of the oocytes that were transferred had been reinseminated; none of these patients conceived. However, of 28 patients who received embryos arising from both initial insemination and reinsemination protocols, 7 conceived (25%). We suggest that the percentage of fertilization is impaired after 22 hours of incubation in vitro and that those oocytes that have fertilized after reinsemination might partly reflect a misjudgment of initial oocyte maturity. Nevertheless, reinsemination is a relatively simple procedure, with no known attributed risk. Therefore, we recommend reinsemination to increase the overall fertilization percentage. Additional studies are needed to establish better methods for assessment of oocyte maturity to evaluate properly the benefit of such reinsemination procedures.

Detection of the ovulatory luteinizing hormone (LH) surge with a semiquantitative urinary LH assay

We examined blood concentrations of ovarian steroid hormones (E2, P) and serum LH concentrations to establish that the Ovu-STICK assay reliably reflects endocrine events in the periovulatory period. In all 16 cycles studied, which included 2 cycles in which the women received CC, the ovulatory surge of LH was detected with the use of the Ovu-STICK assay. In contrast, BBT monitoring correctly predicted the ovulatory event in only half the cycles.

Assessment of the cause of infertility

The different causes of infertility and evaluation of the infertile couple are reviewed in this paper. Forty to 50 percent of cases are due to male factors, and special emphasis is placed in describing techniques to diagnosis this type of infertility. Five to ten percent of infertile couples have infertility of unknown etiology even after a complete, appropriate evaluation. Special instruction in how to diagnose and treat these types of patients is described. A step by step evaluation of peritoneal factors, ovulation factors, and male and cervical mucus interaction is presented for the clinicians' use.

Human in vitro fertilization

Human in vitro fertilization has become a widely accepted method of treatment for infertile couples. The list of indications for this technique is rapidly growing and includes oligospermia, endometriosis, and unexplained infertility. The techniques of follicular recruitment, ovum maturation, and follicular aspiration, as well as laboratory culture techniques, are described. The various factors to be taken into consideration when trying to assess possible success of in vitro fertilization and embryo transfer are discussed in this paper.

The effect of immunoglobulin occurring on human sperm in vivo on the human sperm/hamster ova penetration assay

We selected 91 infertile men who were tested for increased sperm-associated immunoglobulin and also tested in the human sperm/hamster ova penetration assay. There was a statistically significant association between the presence of increased sperm-associated IgG alone (p = 0.0218) and both sperm-associated IgG and A (p = 0.0187) when correlated with the failure to penetrate any hamster ova. There was a trend but no statistical significance when sperm-associated immunoglobulin A alone was present. There was a trend but no statistical relationship between the presence of sperm-associated immunoglobulin and the sperm penetration assay when the criteria for normality of the sperm penetration assay was a 15% or greater ovum penetration rate.

The zona-free hamster egg penetration assay as a prognostic indicator in a human in vitro fertilization program

The present study was designed to test the validity of the hamster egg penetration assay as a prognostic indicator of male fertility in 54 patients undergoing in vitro fertilization. Human oocyte fertilization, cleavage, and pregnancy were compared with the results of this bioassay. Good correlation was found between hamster egg penetration and oocyte fertilization. Conversely, a definite lower limit of hamster egg penetration to define absolute male infertility could not be established because human oocyte fertilization, cleavage, and even pregnancy occurred in spite of low hamster egg penetration.

Simultaneous ectopic pregnancy with intrauterine twin gestations after in vitro fertilization and embryo transfer

A simultaneous ectopic tubal pregnancy with viable intrauterine twin gestations after IVF-ET of five fertilized eggs is presented. Pelvic ultrasound and serial quantitative hCG levels were not helpful in the diagnosis of the tubal pregnancy. The risk of multiple pregnancies and of concomitant intrauterine and extrauterine gestations increases with transfer of a greater number of embryos. Karyotype of the tubal pregnancy was normal (46,XX).

Serum hormones and their receptors in women with normal and inadequate corpus luteum function

The purpose of this study was to attempt to characterize women with a luteal phase defect (LPD) by cytosol estrogen and progesterone (P) levels and peroxidase activity in endometrial biopsy samples. These values were correlated with circulating serum estradiol, P, testosterone, and dehydroepiandrosterone sulfate measurements. Similar data were obtained from women during the proliferative phase of the cycle. Midluteal phase P values were significantly greater in women with normal luteal function than in those with LPD; however, some overlap of values existed. Furthermore, because no significant differences between this group and normal women were seen, we were unable to characterize women with LPD by estrogen or P receptor levels or endometrial peroxidase activity.

Human sperm velocity and postinsemination cervical mucus test in the evaluation of the infertile couple

Homologous artificial insemination (AIH) followed by postinsemination cervical mucus test (PIT) was performed in 100 couples in a prospective study to evaluate suspected cervical or male factor infertility. A portion of the ejaculate was submitted for standard semen analysis as well as turbidimetric analysis of sperm velocity. In a review of 333 cases evaluated for infertility, the average sperm velocity in a normal semen analysis was 96.5 mu/sec, for those with normal postcoital test (PCT) 96.6 mu/sec, and in those that established a pregnancy 91.6 mu/sec. These are significantly higher than the values obtained for abnormal semen analysis and abnormal PCT (64.6 and 63.6 mu/sec, respectively; p less than 0.001). Patients with normal PIT (WHO criteria for normal PCT consisting of greater than or equal to 7 motile sperm/hpf) had sperm velocity of 87 mu/sec compared to velocities of 46 mu/sec for abnormal PIT (p less than 0.001). Four of the five patients with abnormal PIT (in spite of normal semen analysis and normal cervical mucus) had sperm velocities less than 75 mu/sec. Likewise, all 8 patients who had normal PIT in spite of abnormal semen analysis had sperm velocities greater than 75 mu/sec, even though the sperm motility was below normal in 5 of them. Sperm velocity is a more sensitive indicator of sperm function when compared to standard semen analysis results.