Functional evidence for two distinct mechanisms of action of progesterone and selective progesterone receptor modulator on uterine leiomyomas

OBJECTIVE

To study the specific mechanisms through which progesterone and selective progesterone receptor modulators impact the growth, synthesis, and accumulation of the extracellular matrix in uterine leiomyomas.

DESIGN

Laboratory study.

SETTING

Academic Research Institutions.

PATIENTS (S)

This study involved reproductive-age women diagnosed with infertility associated uterine leiomyomas who underwent myomectomy either after selective progesterone receptor modulator ulipristal acetate (UA) treatment or without any pharmacological pretreatment. Control samples included healthy myometrium tissue (n = 100). Specimens were obtained from the Department of Reproduction and Gynecological Endocrinology and Biobank, Medical University of Bialystok, Poland.

INTERVENTIONS

Daily (5 mg/d) UA treated for 2 months (n = 100) and untreated (n = 150) patients with uterine leiomyomas or normal healthy myometrium (n = 100) tissue samples immediately after surgery were collected for transcriptional analysis and assessments.

MAIN OUTCOME MEASURES

Progesterone-induced activation of the signaling pathways related to uterine leiomyomas extracellular matrix synthesis, deposition, and growth, as well as the expression profile of progesterone receptors in uterine leiomyomas, were assessed.

RESULTS

The results indicated that progesterone activated the transforming growth factor-β and SMAD3 signaling pathways and promoted proliferation, growth, and extracellular matrix remodeling in uterine leiomyomas by up-regulating SMAD3, transforming growth factor-β (TGF-β) receptor type 1 and II, Ras homolog A, vascular endothelial growth factor, or increasing the fibrosis-related gene collagen, type I, ɑ-1, and procollagen, type I, ɑ-1 production. In contrast, UA had inhibitory effects on these processes. The study also showed that both nuclear and membrane progesterone receptors play distinct roles in uterine leiomyoma pathobiology.

CONCLUSIONS

We showed that both nuclear and membrane progesterone receptors were relevant in the treatment of uterine leiomyomas, especially when combined with selective progesterone receptor modulators. Novel therapeutic approaches combining selective progesterone receptor modulators with or without direct and indirect extracellular matrix targeting through selected specifically TGF-β and SMAD3 (SMAD3, TGF-β receptor types 1 and II, Ras homolog A, vascular endothelial growth factor, collagen, type I, ɑ-1) signaling pathways could therefore be a treatment option for uterine leiomyomas.

Serum irisin concentration in women with gestational diabetes

Irisin is a novel myokine and adipokine which induces an increase in total body energy expenditure, improving insulin sensitivity and glucose tolerance in experimental animals. In the present study, serum irisin concentration was measured by an enzyme immunoassay in 130 women with gestational diabetes mellitus (GDM) and 140 BMI-matched patients with normal glucose tolerance (NGT). Median irisin level was significantly lower in the patients with GDM than in the NGT subjects (1703.3 [1354.8-2097.9 ng/ml] versus 1873.8 [1519.8-2294.8 ng/ml], p = 0.01); however, 3 months after childbirth its concentrations did not differ markedly between the two groups (1165.9 [872.1-1497.5] ng/ml versus 1139.0 [984.0-1376.7] ng/ml). In the whole group, irisin concentration correlated negatively with 2 h glucose level (R = -0.14, p = 0.03). In the women with NGT, irisin concentration correlated positively with IS(OGTT) (R = 0.22, p = 0.04) and the disposition index (DI(120)) (R = 0.24, p = 0.03), as well as negatively with 2 h insulin level (R = -0.23, p = 0.03) and HOMA-IR (R = -0.24, p = 0.02). Multiple regression analysis revealed that 2 h glucose and DI(120) were the only variables significantly influencing serum irisin (β = 0.158, p = 0.03 and β = 0.159, p = 0.02, respectively). Our results suggest that serum irisin concentration increases markedly in pregnant women, but this increase seems to be significantly lower in patients with GDM.

The use of recombinant human LH (lutropin alfa) in the late stimulation phase of assisted reproduction cycles: a double-blind, randomized, prospective study

BACKGROUND

The effect of recombinant human LH (r-hLH; lutropin alfa) in women undergoing controlled ovarian stimulation with recombinant human FSH (r-hFSH) prior to IVF was investigated.

METHODS

After down-regulation with the GnRH agonist, buserelin, 114 normo-ovulatory women (aged 18-37 years) received r-hFSH alone until the lead follicle reached a diameter of 14 mm. Patients were then randomized in a double-blind fashion to receive r-hFSH in addition to r-hLH, 75 IU s.c., or placebo daily for a maximum of 10 days prior to oocyte retrieval and IVF. The primary end-point was the number of metaphase II oocytes.

RESULTS

There were no significant differences between treatment groups for the primary end-point. Serum estradiol concentrations on the day of HCG administration were significantly higher in the group receiving r-hLH plus r-hFSH than in the group receiving r-hFSH alone (P = 0.0001), but there were no significant differences between the groups in dose and duration of r-hFSH treatment required, oocyte maturation, fertilization rate, pregnancy rate and live birth rate.

CONCLUSION

In this patient population, the addition of r-hLH during the late follicular phase of a long GnRH agonist and r-hFSH stimulation cycle provides no further benefit in terms of oocyte maturation or other end-points.

Rescue ICSI of unfertilized oocytes after IVF

BACKGROUND

Failed fertilization after IVF occurs in 10-20% of cycles. Conflicting results of rescue fertilization by ICSI have been reported. We therefore compared the success rate in terms of fertilization and pregnancy of cycles in which rescue ICSI was performed with those from a matched control group of primarily ICSI cycles.

METHODS

Unfertilized oocytes from IVF cycles with total fertilization failure where at least four metaphase II oocytes were available were treated by ICSI (group I; n = 120). A matched control group was established with patients undergoing ICSI during the same period (group II; n = 280).

RESULTS

Both fertilization rate and the proportion of embryos with four blastomeres on day 2 after ICSI were significantly higher in the control group (P < 0.05). Embryo quality, however, was comparable in both groups. The pregnancy rate in the control group was 25.3% whereas in group I with rescue ICSI, no pregnancy was obtained.

CONCLUSIONS

Although unfertilized oocytes after IVF can be fertilized by ICSI, the developmental potential of the ensuing embryos is very poor. Therefore, rescue ICSI after total failure of fertilization is not recommended.

Chemokine growth-regulated-alpha: a possible role in the pathogenesis of endometriosis

Endometriosis is a common disease in women at reproductive age. We investigated the concentration of neutrophil-activating factor (growth-regulated gene-alpha; GRO-alpha) (a member of the chemokine family), in peritoneal fluid of infertile women with or without endometriosis. Peritoneal fluid was obtained laparoscopically from 22 women with and 21 without visible endometriotic lesions. GRO-alpha concentration was measured by the use of an ELISA kit. Median concentration of GRO-alpha was 87.65 +/- 56.19 pg/ml in the study group and 60.72 +/- 11.98 pg/ml in the control group. The distribution of data differed from normal, therefore logarithmic transformation of data was performed. Concentration of GRO-alpha was significantly higher in the peritoneal fluid of women with endometriosis when compared with controls (p = 0.05). No correlation between concentration of GRO-alpha, stage of endometriosis, duration of infertility or sex steroid hormone levels was found. The study shows that GRO-alpha may play a role in the pathogenesis of endometriosis, possibly by chemoattraction and activation of neutrophils present in higher numbers in the peritoneal fluid of women with endometriosis. It is also feasible that the angiogenic properties of GRO-alpha might prompt the progression of endometriotic lesions.

[Intracytoplasmic sperm injection (ICSI): the Białystok experience]

OBJECTIVE

To present a complete results of Intracytoplasmic Sperm Injection Program (ICSI) performed at IVF Unit in Bialystok, Poland.

DESIGN

Retrospective data analysis.

MATERIALS AND METHODS

A total of 2593 cycles of ICSI treatment were analyzed. The results of controlled ovarian hyperstimulation (COH), parameters of fertilization, early embryo development and clinical pregnancy rates were compared depending on the type of COH used.

RESULTS

Overall, for 16708 MII oocytes microinjected, the 2 pronuclear fertilization rate was 54%. Embryo transfer was performed in 94% of started cycles and 629 clinical pregnancies were recorded, giving a clinical pregnancy rate of 24% per cycle and 26% per transfer. No influence of COH on embryological and clinical results was noted.

CONCLUSION

Intracytoplasmic sperm injection can be used successfully to treat couples with male factor infertility and those who have failed standard IVF. Precisely adapted protocol of ovarian hyperstimulation for every patient could diminish the costs of treatment without negative influence on ICSI results.

The outcome of intracytoplasmic injection of fresh and cryopreserved ejaculated spermatozoa--a prospective randomized study

BACKGROUND

The overall aim of this prospective, randomized study was to compare the reproductive potential of fresh and frozen-thawed ejaculated spermatozoa from oligoasthenoteratozoospermic patients in an intracytoplasmic sperm injection (ICSI) procedure.

METHODS

All patients consenting to participate in this study had a sperm sample frozen prior to the start of a cycle. Patients were randomized using a random number table to undergo ICSI with either fresh (group A, n = 118) or frozen-thawed (group B, n = 122) spermatozoa. All prognostic variables were equally distributed among the two groups.

RESULTS

The pregnancy rate per started cycle was 29.7% in group A and 38.5% in group B, P > 0.05. A significant difference was observed in the rate of ongoing pregnancies between group A (23.7%) and group B (35.2%), P < 0.05.

CONCLUSION

From our data we can conclude that cryopreservation of spermatozoa from men with poor sperm quality does not negatively affect fertilization and pregnancy rates after ICSI. A larger study will be needed to investigate whether the use of cryopreserved spermatozoa can be helpful in selecting the most vital spermatozoa for ICSI.

Correctly timed coasting reduces the risk of ovarian hyperstimulation syndrome and gives good cycle outcome in an in vitro fertilization program

One hundred and twelve severely overstimulated in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) patients were treated with coasting when estradiol concentration was > 3000 pg/ml and the leading follicles had attained > or = 18 mm in diameter. Gonadotropin withholding was offered to them as a promising method for the prevention of both cycle cancellation and complications associated with severe ovarian hyperstimulation syndrome (OHSS). The duration of prolonged coasting prior to human chorionic gonadotropin (hCG) administration ranged from 2 to 9 days (mean 3.5). hCG was administered when the serum estradiol dropped to < 3000 pg/ml and at least three growing follicles > or = 20 mm in diameter were present. Fertilization failure was noted in six couples and in another 10 cases freezing of all embryos was decided, therefore embryo transfer was performed on 96 patients. There were 31 clinical pregnancies (five twins) giving a pregnancy rate per patient and per embryo transfer of 30.4% and 32.3%, respectively, with an implantation rate of 18.1%. With regard to all 112 coasted patients, six developed moderate and two severe OHSS. This study shows that withholding gonadotropin administration in high-risk IVF patients results in a good cycle outcome and a very low risk of severe OHSS, and also demonstrates the importance of both the timing of coasting initiation and the timing of hCG administration.

Ammonia concentration in human preovulatory ovarian follicles

OBJECTIVES

To determine ammonia concentrations in both the direct environment of the oocyte, ovarian follicular fluid, and peripheral blood.

STUDY DESIGN

Samples of preovulatory follicular fluid and antecubital venous blood were obtained from 23 randomly selected women attending an in vitro fertilization program in an academic department. Ammonia concentrations were measured using the indophenol method.

RESULTS

In every patient examined, the ratio of ammonia concentration in follicular fluid to that in blood exceeded 1.0. Mean ammonia concentration in follicular fluid (38.01+/-2.61 microM) was significantly higher than that in blood (22.70+/-1.35 microM; P<0.001 paired Student's t test).

CONCLUSIONS

There is an ammonia gradient from follicular fluid to blood. The human preovulatory oocyte grows in an environment of a moderately increased ammonia concentration. This study suggests that the preovulatory follicle is a source of ammonia production.

[Enzymatic assisted hatching in the infertile couple after failed attempts of IVF ET]

The study was conducted on the patients who had attempted and failed previous IVF procedures. The aim of this study was to determinate effectiveness sequential culture of embryos to blastocyst and assisted hatching by zona pellucida digestation by pronase. In this group the pregnancy rate was 24.1% compared to control 17.8%. The implantation rate was higher in study group than control one. It suggests that the culture embryos to balstocyste stage and assisted hatching by digestation by pronase is safe and effective mode of treatment of infertile couple after failed attempts IVF ET.

[Reinsemination of oocytes by intracytoplasmic sperm injection after the failure of conventional fertilization. Early embryonal development]

OBJECTIVE

To analyze the influence of intracytoplasmic sperm injection (ICSI) on early embryo development used for reinsemination of unfertilized 1-day-old oocytes.

DESIGN

Prospective observational study.

MATERIALS AND METHODS

A total of 126 embryos resulted from reinsemination by ICSI were analyzed with regard for the time course of cleavage and the quality of embryos at 48 hours after injection. Results were compared with those obtained in 698 embryos obtained after routine ICSI program.

RESULTS

It has been shown that embryos derived from reinsemination developed slower in comparison with those obtained after regular ICSI program. At 48 hours after microinjection 50% of embryos achieved 4 blastomeres stage and 37% remained on 2 cells stage. 71% of regular ICSI embryos at this same time showed 4 blastomere or more, only 16% remained on 2 blastomeres stage. The quality of embryos was similar in two compared groups, however those obtained following reinsemination at 4 blastomere stage were significantly poorer quality.

CONCLUSION

Embryos derived from reinsemination of 1-day old oocytes unfertilized after conventional IVF developed slower and the quality of embryos at 4 blastomere stage was poorer comparing to regular ICSI embryos.

[Prolonged desensitization pretreatment for in vitro fertilization in women with polycystic ovary]

OBJECTIVE

To analyse the outcome of intracytoplasmic sperm injection (ICSI) in women with severe polycystic ovary disease (PCD), stimulated after prolonged pituitary desensitization in comparison with regular long protocol therapy.

MATERIALS AND METHODS

The results of controlled ovarian hyperstimulation (COH), fertilization rate, early embryo development parameters and clinical pregnancy rates were compared depending on the duration of pituitary desensitization before gonadotropin administration. A total of 60 patients with severe PCOD were desensitized with GnRH agonist up to 30 days before COH. The results were compared with the group of 213 patients with mild PCOD treated with regular long protocol (control).

RESULTS

We observed a slightly higher rate of mature oocytes MII as well as the number of embryos obtained in the control group, however the pregnancy rate in the group with prolonged desensitization was significantly higher (50%) in comparison to the control group (33.8%).

CONCLUSION

The prolonged pituitary desensitization before controlled ovarian hyperstimulation gives better chance for obtaining pregnancy in patients with severe PCOD. It could be recommended facing previous treatment failure.

[Pregnancy and delivery after the transfer of one blastocyst with enzymatically removed zona pellucida]

OBJECTIVES

The embryonic development up to the blastocyst stage and hatching from zona pellucida are prerequisites for implantation and successful pregnancy. It is suggested that one of the possibilities limiting the implantation rate is impaired hatching. To overcome this problem an artificial alteration of the zona pellucida have been carried out in many laboratories.

DESIGN

The report of the first pregnancy in Poland obtained after the transfer of enzymatically zona removed blastocyst.

MATERIALS AND RESULTS

The patient was previously treated three times in in vitro fertilisation program without success. In the fourth program the embryos were cultured in co-culture of Vero cells to the blastocyst stadium. On the day 5 after insemination the zona of cavitating and expanding blastocyst was removed by pronase. The zona free blastocyst was transferred to the uterus. As a result of implanted blastocyst the ongoing pregnancy developed normally and the patient delivered healthy baby.

CONCLUSION

Enzymatic zona pellucida hatching probably increases the rate of implantation. It is simple, safe and economic techniques.

Good results of milder form of ovarian stimulation in an in vitro fertilization/intracytoplasmic sperm injection program

In a prospective study, we compared two protocols of ovulation stimulation, the clomiphene citrate and human menopausal gonadotropin (hMG) versus D-triptorelin, a long-acting gonadotropin-releasing hormone (GnRH) agonist and hMG in 324 couples having their first in vitro fertilization or intracytoplasmic sperm injection (IVF/ICSI) program, in terms of pregnancy rates and cost-effectiveness of drugs used. The GnRH agonist/hMG group was characterized by a greater mean number of ampoules of hMG used (31.7 versus 10.2), a larger number of oocytes collected (10.4 versus 4.2), and a larger number of embryos obtained (5.8 versus 2.9). With the policy of transferring only two of the best quality embryos, the mean number of embryos replaced were comparable (1.8 in clomiphene citrate/hMG and 1.9 in GnRH agonist/hMG group). The percentage of patients reaching embryo transfer was lower in the clomiphene citrate/hMG than in the GnRH agonist/hMG group (84.1% versus 93.1%, respectively). However, the combined results of the IVF and ICSI procedure in terms of pregnancy rate, both per patient and per embryo transfer were better, though not significantly in the clomiphene citrate/hMG than in GnRH agonist/hMG group (25.0% and 29.7% versus 23.7% and 25.5%, respectively). Similarly, the implantation rate was better (19.0% versus 13.5%, respectively). With the use of clomiphene citrate/hMG, a fivefold less costly drug regimen, we obtained pregnancy rates equivalent to those gained using GnRH agonist/hMG in our IVF/ICSI program.

[Deontological aspects of ovarian stimulation]

The physician and the infertile couple should be partners in the development of a treatment plan that optimally meets the couple's needs. The information about the benefits, side effects and costs of treatment is to be presented to the couple. Stimulation of the ovary has become the central component of rapidly developing assisted reproduction. The fundamental rule in ovulation induction is individual approach to each patient and close monitoring of the stimulation, because the dangers of ovarian hyperstimulation syndrome, multiple pregnancy and putative longer term risks. There is general agreement that multiple pregnancies, including twins, are still too common and must be avoided as they are the major causes of maternal and fetal morbidity. Since the advent of ICSI tens of oocytes are not necessary to achieve fertilization, and milder forms of ovarian stimulation should suffice in most IVF/ICSI cycles. Our target in infertility treatment should be the birth of healthy, singleton babies, with no health risks to their mothers.

[The effect of obesity on ovarian function. I. Serum insulin and insulin dependent protein concentrations in obese patients with polycystic ovary syndrome]

OBJECTIVES

The aim of the present study was to estimate the role of insulin in the pathogenesis of polycystic ovary syndrome.

DESIGN

The study was carried out in 21 obese women with PCO, 18 obese women without menstrual disturbances and 9 normal-weight healthy women.

MATERIALS AND METHODS

In all patients antropomethric parameters: weight, height, % of body fat, waist and hip girths were measured and than BMI and WHR were calculated. Oral glucose tolerance test after 75 g glucose was done after overnight fast. Plasma glucose and insulin were measured in 0 min, 60 min and 120 min of the test. The concentrations of IGF-I, IGFBP-1, SHBG, LH, FSH, testosterone, cortisol, PRL, estradiol, were estimated.

RESULTS

There was statistical significant difference between plasma insulin concentrations in obese patients with PCO in comparison to obese women with normal menstrual cycle (p < 0.05) and control group (p < 0.001). The concentrations of IGFBP-1 and SHBG were similar in both groups of obese patients and differ markedly in comparison to the control group. There were significant correlation between plasma insulin and % body fat, BMI and waist girth in all studied groups.

CONCLUSIONS

We conclude that in obese women with PCO insulin influence ovarian androgen production and decreases the serum SHBG and IGFBP-1 which could contribute in the augmentation of the symptoms of PCO.

[The influence of obesity on ovarian function. II. Plasma leptin concentration in women with polycystic ovary syndrome]

OBJECTIVES

The aim of the present study was to estimate the leptin role in the pathogenesis of polycystic ovary syndrome.

DESIGN

The study was carried out in 21 obese women with PCO, 18 obese women without menstrual disturbances and 9 normal-weight healthy women.

MATERIALS AND METHODS

In all patients antropomethric parameters: weight, height, % of body fat, waist and hip girths were measured and than BMI and WHR were calculated. Plasma concentrations of leptin, insulin, LH, FSH, testosterone, cortisol, PRL, estradiol were estimated.

RESULTS

There were no statistical significant difference between plasma leptin concentrations in obese patients with PCO in comparison to obese women with normal menstrual cycle. In both groups of obese patients plasma leptin concentrations was significantly higher than in control group (p < 0.001, p < 0.001). There were significant correlation between plasma leptin and % body fat, BMI and waist girth in all studied groups.

CONCLUSIONS

We conclude that leptin is not directly involved in observed hormonal disturbances in polycystic ovary syndrome. The main predictor of plasma leptin concentrations in patients with PCO is amount of body fat.

Oxidative stress markers in preovulatory follicular fluid in humans

Intensified peroxidation in the Graafian follicle may be a factor compromising the normal development of the oocyte. The aim of this study was to measure concentrations of three oxidative stress markers: conjugated dienes, lipid hydroperoxides and thiobarbituric acid-reactive substances, in preovulatory follicular fluids and sera of 145 women attending an in-vitro fertilization programme, and to correlate these concentrations with pregnancy outcome. Determinations were conducted either with or without an antioxidant (10 microM butylated hydroxytoluene) and an iron chelate (10 microM deferoxamine mesylate) to examine peroxidation associated with the methods used. Concentrations of conjugated dienes, lipid hydroperoxides and thiobarbituric acid-reactive substances in follicular fluid were all significantly lower than those in serum, both in the presence or absence of the antioxidant and iron chelate. These concentrations did not correlate with pregnancy outcome. In conclusion, the intensity of peroxidation in the Graafian follicle is much lower than that in serum. This gradient is the result of the lower rate of initiation of peroxidation in the follicular fluid, suggestive of the presence of efficient antioxidant defence systems in the direct milieu of the oocyte before ovulation. The concentrations of investigated oxidative stress markers in follicular fluid do not reflect the reproductive potential of oocytes.

[The comparison of efficiency of supplement of the second phase in the program IVF-ET by dydrogesterone and progesterone]

The retrospective study was carried out to compare effectiveness of progesteron and dydrogesteron luetal phase support following in vitro fertilisation and embryo transfer. Two hundred and fifty eight patients undergoing IVF ET received progesteron in itramuscular injections. Two hundred sixty patients received dydrogesteron three times daily p.o. There were no differences in stimulation protocols, indications for IVF and IVF procedures. Pregnancy rate, implantation rate and spontaneous abortion rate were similar in both groups. The effectiveness of luteal phase support in patients undergoing IVF ET program by dydrogesteron and progesteron is similar with significantly lower costs for the last one.

[Monozygotic pregnancy after the treatment for infertility by transfer of frozen-thawed embryos]

OBJECTIVES

It has been suggested that monozygotic pregnancies occur more frequently after in vitro fertilisation. This phenomenon is attributed to a number of factors including in vitro culture conditions, malformation of the zona pellucida due to manipulation on the oocytes and artificial opening of the zona pellucida.

DESIGN

Retrospective analysis of monozygotic pregnancies in an IVF-ET procedures and obstetrical these pregnancies outcome.

MATERIALS AND METHODS

A total of 2254 IVF-ET procedures were analysed. Three protocols were used for ovarian stimulation: short or long protocols with gonadotropins releasing hormone analogue or clomiphene citrate with hMG. In 811 cases male factor was diagnosed and intracitoplasmatic sperm injections were performed.

RESULTS

549 clinical pregnancies were achieved in analysed group. In six cases ultrasound examination 5 weeks after embryo transfer showed a greater number of foetus than the number of embryo transferred. In three of those cases the embryos were obtained after ICSI. Age and average thickness of zona pellucida were similar in group of patients with monozygotic pregnancies when compared with all pregnant patients after IVF treatment.

CONCLUSIONS

The incidence of monozygotic pregnancy is increased in group pregnancies resulting from IVF ET. No single risk factor can explain this phenomena. This type of pregnancy needs special obstetrical attention.

Fertility and infertility in aging women

Age is often a dominant factor for women wanting to conceive. The objective of this study was to examine the outcome of an in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) program in relation to a woman's age. Between January 1995 and June 1997 we stimulated 2511 cycles. The mean age of the women was 34 years, with 21.9% under 30, 45.9% between 30 and 35, 24.5% between 36 and 39, and 7.7% over 39 years. All patients aged > or = 40 years had day 3 serum follicle-stimulating hormone (FSH) concentrations < 20 IU/l. The stimulation regimen consisted of 150-450 IU of human menopausal gonadotropin (hMG) or FSH combined with either clomiphene citrate (CC) or gonadotropin-releasing hormone agonist (GnRHa) in a short or long protocol. Age had a significantly negative effect on the stimulation and fertilization failure rates. The clinical pregnancy rate per transfer and the embryo implantation rate declined significantly from 29.4% and 18.9% in women < 30 years to 19.8% and 14.3% in patients between 30 and 35 years, 17.1% and 9.0% between 36 and 39 years and to 12.8% and 7.4% in those aged > or = 40 years. The spontaneous abortion rate was 14.9%, 16.5%, 22.4% and 33.2%, respectively. The clinical pregnancy rate per transfer reflected only imperfectly the performance of the older women because the discharge rate during stimulation and spontaneous abortions reduced the 'take home baby' rate to about 7% per cycle in patients aged > or = 40 years. It is very important in fertility practice to recognize the major impact of advancing maternal age.

[The effectiveness of hysteroscopic intrauterine septum resection in terms of reproductive outcome]

Uterine septum is the major intrauterine disorder associated with infertility and recurrent abortions. The aim of the study was to find out what is the effectiveness of hysteroscopic intrauterine septum resection in terms of reproductive outcome and in comparison with conventional procedure. The mean follow up period was 18 +/- 8.3 months. The pregnancy wastage before operation in study group was 79% and decreased to 45% after hysteroscopic treatment. Hysteroscopic resection of intrauterine septum is the treatment of choice for patients suffering from infertility or recurrent pregnancy wastage.

[The case of intrauterine pregnancy coexisting with extrauterine pregnancy which was surgically removed]

The case of simultaneous intrauterine and ruptured ectopic pregnancy was presented. The diagnosis of coexisting intrauterine and ectopic pregnancies is difficult. The patient was admitted to the clinic because of abdominal pain and vaginal bleeding in the 10th week of pregnancy has been treated by laparotomy. The intrauterine pregnancy was continued successfully to term. The importance of careful sonographic examination of adnexal region was stressed in all symptomatic patients with first trimester pregnancy.

[Surgical treatment of uterine leiomyomas in infertile patients]

Retrospective analysis of the results of operative treatment for uterine leiomyomas was carried out. Our screening included the total of 186 patients. One hundred and eight women responded to the questionnaire /58%/. Respondens were treated for sterility in the period between 1990-1995. Successful operative treatment, expressed as pregnancy rate reached 29.7%.

Prevention of high-order multiple gestations in an in vitro fertilization program

The aim of this study was to assess the benefits of the transfer of only two of the best quality embryos, three if a woman was over 35 years of age, in terms of pregnancy rate and the incidence of multiple gestations. In 1993-94, when we were replacing three embryos when available and up to five when the woman was over 35 years of age, 217 clinical pregnancies were obtained (25% per embryo transfer). Among them there were 34 (15.6%) twins and 8 (3.7%) triplet pregnancies. Eighty-one patients had surplus embryos cryopreserved. In 1995, with the new policy of transferring only two embryos and three when the woman was over 35 years of age, 170 patients became pregnant (23.9% per embryo transfer). There were 31 (18.2%) twins and no triplet pregnancies. One hundred and forty-four patients had surplus embryos cryopreserved. Although limiting the number of transferred embryos slightly decreases the pregnancy rate, this small reduction can be considered acceptable if the social, health and financial problems associated with high-order multiple gestations are taken into account.

The outcome of an in vitro fertilization program in women with polycystic ovary syndrome

The objective of this study was to examine the efficacy of D-triptorelin in the long protocol and follicle-stimulating hormone (FSH) in an IVF-embryo transfer program in a group of patients with polycystic ovary syndrome (PCOS) who had earlier failed to respond or did not conceive after clomiphene citrate (CC)/human menopausal gonadotropin (hMG) or 'flare up' gonadotropin-releasing hormone agonist (GnRHa)/hMG stimulation. Eighty-nine women with PCOS (based on typical ultrasound criteria) had 1-3 treatment cycles without success. The stimulation protocol was changed to D-triptorelin given in midluteal phase and when pituitary desensitization was achieved, FSH administration was started. The clinical pregnancy rate per transfer in this 'negatively selected' group of PCOS patients was 29%. This was the same as the rate for a group of women with tubal factor, as was the spontaneous miscarriage rate. Although the use of GnRH agonists in the long protocol increases the costs of treatment, the number of cancelled cycles is reduced. The pregnancy rate increased in this group of women with PCOS.

Nonenzymatic antioxidant activity of human seminal plasma

OBJECTIVE

To examine the nonenzymatic antioxidant properties of human seminal plasma.

DESIGN

Determination of total (peroxyl) radical-trapping antioxidant parameter and malondialdehyde concentration in seminal plasma of 112 men attending IVF-ET or intracytoplasmic sperm injection (ICSI) programs.

SETTING

University-based center for reproductive medicine.

PATIENT(S)

Normozoospermic men, ages 25 to 50 years, of fertility proved by a pregnancy resulting from IVF-ET, and men ages 25 to 50 years with negative IVF-ET or ICSI outcome, distinguished by their smoking status.

INTERVENTION(S)

Seminal plasma was obtained from ejaculates collected for IVF-ET or ICSI procedures.

MAIN OUTCOME MEASURE(S)

Total (peroxyl) radical-trapping antioxidant parameter and malondialdehyde concentrations.

RESULT(S)

No significant differences for total (peroxyl)-radical-trapping antioxidant parameter were observed between normozoospermic IVF-ET or asthenozoospermic ICSI patients; neither was a difference revealed for pregnancy-positive or -negative couples within those groups. Age, smoking status, or increased leukocyte count had no effect on total (peroxyl) radical-trapping antioxidant parameter or malondialdehyde concentrations in seminal plasma.

CONCLUSION(S)

Nonenzymatic antioxidant activity in seminal plasma does not reflect sperm fecundity ability.

[Cryopreservation of embryos in an in vitro fertilization program(IVN-ET)--preliminary results]

The authors present preliminary results of cryopreservation of embryos in IVF-ET programme in the Institute of Obstetrics and Gynecology in Białystok. The method of slow cooling embryos with 1, 2 propanediol and saccharose were used. In the group of 136 patients with excess embryos after the transfer of two fresh embryos 29 pregnancies (21.3%) were obtained. After the transfer of frozen/thawed embryos up till now 5 pregnancies have been obtained (one child born, 3 pregnancies ongoing, 1 abortion).

["Long protocol" for ovarian stimulation using D-Trp6 LHRH (Triptorelin Depot) and menopausal gonadotropin in the IVF-ET program]

39 patients (age 35-40, anovulation, previous failures in the IVF-ET programme) were superovulated using GnRH analogue (Decapeptyl-Depot) in the long protocol and hMG 97 embryos were transferred and 109 were cryopreserved. The clinical pregnancy and implantation rates were 31.6% and 13.4%. The long protocol gives better results in the IVF-ET programme but increases the costs of treatment.

Use of GnRH analog for induction of the ovulatory surge of gonadotropins in patients at risk of the ovarian hyperstimulation syndrome

A total of 32 patients undergoing in vitro fertilization (IVF) and 16 treated for ovulatory disturbances were stimulated with clomiphene citrate and human menopausal gonadotropin. Gonadotropin releasing hormone (GnRH) analog was used for induction of the ovulatory surge of gonadotropins, because of the risk of ovarian hyperstimulation syndrome. In four patients after IVF-embryo transfer and four patients after ovulation induction, single pregnancies were obtained. None suffered from ovarian hyperstimulation syndrome. The authors suggest that the use of GnRH analog for induction of the gonadotropin ovulatory surge prevents the development of ovarian hyperstimulation syndrome.

The results of an in vitro fertilization program: two regimens of superovulation

Gonadotropin-releasing hormone (GnRH) agonists are increasingly used in ovarian hyperstimulation protocols in in vitro fertilization (IVF) programs. From March 1992 to June 1993, 565 patients attending our Institute underwent superovulation in 1104 IVF program cycles. Of these cycles, 650 were stimulated with clomiphene citrate and gonadotropins (human menopausal gonadotropin/hMG), and 454 with the GnRH agonist buserelin and hMG in a group of patients who had earlier failed to respond or did not conceive after clomiphene citrate/hMG stimulation. The ovarian response was similar in both groups, however, with the use of buserelin more oocytes were recovered -4.9 +/- 3.2 and 3.5 +/- 2.3 oocytes, respectively. The clinical pregnancy rate per transfer in the group of patients superovulated with buserelin/hMG was twice that of the clomiphene citrate/hMG group (21.0% vs. 10.4%). The relatively high pregnancy rate with the buserelin/hMG regimen in the group of 'poor responders' may be connected with GnRH agonist-induced pharmacological hypophysectomy and the sequelae thereof: normalization of some endocrinopathies, absence of an endogenous luteinizing hormone (LH) surge and better endometrium receptivity, oocytes and embryo quality.

[Use of an GnRH analogue for induction of gonadotrophin ovulatory surge in cycles stimulated with clomiphene citrate and menopausal gonadotropin in an in vitro fertilization program]

In 23 women treated for sterility by the in vitro fertilization method the gonadotropins ovulatory surge was stimulated by applying a GnRH analogue (Buserelin). The authors showed that a single injection of GnRH analogue in the cycles stimulated with clomiphene citrate and menopausal gonadotropin causes pituitary output of both LH and FSH which is sufficient for morphological and functional maturity of the oocytes. After such treatment two patients conceived and delivered healthy babies.

[Triploidy as a cause of failure in human reproduction]

Triploidy is a frequent chromosomal abnormality found in 12% of all spontaneous first trimester abortions. Triploidy can result from various mechanisms: failure of segregation during meiosis I or II leads to the formation of gametes with an extra haploid set of chromosomes or abnormally fertilization by two spermatozoa. The authors presents physiological mechanism which prevent polyspermic fertilization, the morphological pictures of triploid early embryos. After implantation of triploid embryos partial embryonal hydatidiform moles develops. Now the possibility of the prevention and treatment of triploid in humans are very limited.

[Diagnostic laparoscopy in the gynecology clinic at the academy of medicine in Białystok during the years 1989-91]

The authors present the results of 1056 diagnostic laparoscopies carried out from 1989 to 1991 in the Clinic of Gynecology of Medical School in Białystok. Sterility was the leading indication for diagnostic laparoscopies in 92.7% of patients. Suspicion of ectopic pregnancy was the reason of 44 laparoscopies. 46.5% of diagnosed infertile women had adhesions in pelvis post inflammation or surgery. 10.6% of them had massive pelvic adhesions and the tubes were damaged without any chance for surgical correction. The endometriosis was found in 15% of infertile women, and 17% of patients had no pelvic pathology.

[Use of GnRH analog for induction of gonadotropin ovulatory surge in cycles stimulated by clomiphene citrate and menopausal gonadotropin in an in vitro fertilization program]

In 23 women treated for sterility by the in vitro fertilization method the gonadotropins ovulatory surge was stimulated by applying a GnRH analogue (Busereline). The authors showed that a single injection of GnRH analogue in the cycles stimulated with clomiphene citrate and menopausal gonadotropin causes pituitary output of both LH and FSH which is sufficient for morphological and functional maturity of the oocytes. After such treatment two patients conceived and delivered healthy babies.

[Treatment of infertility by in vitro fertilization (IVF-ET)]

The authors survey available publications dealing with the indications for in vitro fertilization, ovary stimulation technique, control of the ovary stimulation, oocytes collection, and transfer of the embryo in human. The authors personal experience with in vitro fertilization is also discussed.

[In vitro culture of fibroblasts from pubic skin of women in diagnosis of androgen hypersensitivity]

Intracellular metabolism of testosterone was studied in in vitro cultured skin fibroblasts obtained from women with idiopathic hirsutism. A significantly higher rate of conversion of testosterone into 5-alpha-dihydrotestosterone was found in these women (4.78 +/- 2.08 fmol/microgram DNA/hour) as compared to that obtained for skin cultures of women without symptoms of androgenization (0.98 +/- 0.37 fmol/microgram DNA/hour). These results demonstrate that fibroblast culture may be useful in diagnosing the causes of hyperandrogenization in women with normal androgen secretion.

[The role of gonadotropins, cyclic AMP, 22-R-hydroxycholesterol and cofactors in regulating endocrine functions of the Leydig cells in rats. I. Effect of cofactors on the synthesis of steroid hormones in the interstitial gland of rats]

The authors evaluated the influence of NAD, NADP, G-6-P and G-6-PDH on the synthesis of steroid hormones in the interstitial gland of the rat. The animals were killed by decapitation, and sections of the nucleus weighing altogether 20 mg were incubated with NAD (0.4 mM), NADP (0.4 mM), G-6-P (3.5 mM) and G-6-PDH (2 j.m./ml) for 4 hours in CO2 incubator. Then the tissue was homogenized, removed by centrifugation and then from the homogenous supernatant the authors extracted steroids which were in the incubating medium and in the tissue. Steroid hormones examined were marked radioimmunologically, they were: pregnenolon as the first and testosterone as the second stage of synthesis of nucleus androgens. The search carried out shows that the strongest stimulator in biosynthesis of pregnenolon was NADP together with the reducing system (G-6-P and G-6-PDH). On the other hand, in case of testosterone the highest effectiveness was achieved by simultaneous use of the cofactors examined. Applying cofactors separately the authors were able to find that both NAD and NADP together with the reducing system were responsible for testosterone synthesis and their simultaneous applying in the incubating medium leads to a synergistic effect.

[The role of gonadotropins, cyclic AMP, 22-R-OH-cholesterol and cofactors in regulating endocrine functions of the Leydig cells in rats. III. Mechanisms responsible for "desensitization" of the Leydig cells of rats caused by high doses of hCG]

Two groups of rats (a control group and the group examined) were administered intraperitoneally supraphysiological doses of hCG in order to induce a "down regulation" effect on the level of receptors LH and to achieve the desensibilization of Leydig cells. The authors tried to find out at which stage of sequence of changes from receptor stimulation to hormone production there appears a state of cellular resistance to further stimulation. Sections of the nucleus were incubated with various substances influencing steridogenesis (LH, hCG, dbcAMP, 22-R-OH-cholesterol, NAD + NADP + G-6-P + G-6-PDH). An index of the influence of the above substances on the synthesis of androgens were amounts of pregnenolon as the first and testosterone as the final stage of hormonal changes marked radioimmunologically in nucleus homogenates and incubating media. It was shown that the resistance of Leydig cells to further stimulation in the group of animals that were given high doses of hCG is the result of enzymatic blocks in testosterone synthesis. The first block is "late" block of 17 alpha-hydroxylase and 17-20 desmolase, disturbing transforming of 21-carbon steriods into 19-carbon androgens. When the dose of hCG increases, there appears the second block, the so called "early" block, disturbing mitochondrial synthesis of pregnenolon. It was found that exogenic cofactors are in a position, at least partially, to restore the activity of blocked enzymes.(ABSTRACT TRUNCATED AT 250 WORDS)

[The role of gonadotropins, cyclic AMP, 22-R-hydroxycholesterol and cofactors in regulating endocrine functions of the Leydig cells in rats. II. Effects of LH, hCG, dbcAMP, 22-R-OH-cholesterol and cofactors on the synthesis of pregnenolone and testosterone in the interstitial gland of rats]

The authors examined in vitro the influence of gonadotrophins, cAMP, 22-R-OH-cholesterol and cofactors on the synthesis of pregnenolon and testosterone in the interstitial gland of the rat. Sections of the nucleus were incubated with LH (100 ng/ml), hCG (1.0 j.m./ml), dbcAMP (1 mM), 22-R-OH-cholesterol (30 microM) and cofactors (NAD + NADP + G-6-P + G-6-PDH). It was found that an increase in concentrations of hCG above physiological values was not accompanied by an increase in secreting steroid hormones. LH, hCG and dbcAMP increased the synthesis of pregnenolon twice, and testosterone--three times. 22-R-OH-cholesterol as a substrate increased the synthesis three and four times respectively, and added cofactors five times and four and a half times respectively. Joining 22-R-OH-cholesterol or a cofactor with LH does not intensify a stimulating effect.