Anesthesia Management of a Patient With Familial Cold Autoinflammatory Syndrome: A Case Report

Familial cold autoinflammatory syndrome (FCAS) is a rare phenotype of cryopyrin-associated periodic syndrome (CAPS) and is characterized by repetitive systemic inflammation triggered by cold stimulation. Recently, we treated a 13-year-old female with FCAS/CAPS scheduled to undergo removal of an impacted tooth. To minimize perioperative heat loss, a forced-air warming system was utilized to prewarm the patient for 10 minutes before induction of general anesthesia. The patient's core and peripheral temperatures were monitored with axillary, superficial temporal artery, and rectal thermometers. The difference in temperatures at these 3 locations decreased to 0.4° C within 60 minutes as a result of the forced-air warming system before induction. Perioperative use of the warming system successfully prevented the occurrence any significant redistribution hypothermia and any symptoms of FCAS/CAPS.

Characteristics of bacterial populations responsible for uptake of amino acids in activated sludge acclimated to peptone

Amino acids (AAs) are produced from the hydrolysis of proteins, which are the major biodegradable organic compounds in municipal sewage. The characteristics of bacterial populations responsible for the assimilation of thirteen AAs into activated sludge (AS) acclimated to peptone are investigated. The results are as follows. (1) The bacterial populations responsible for the uptake of AAs were partly aggregated in AS flocs. (2) The amounts of the bacterial populations responsible for the uptake of leucine, valine, isoleucine, histidine, threonine, lysine and glycine are limited in AS acclimated to peptone. (3) The bacterial populations responsible for the uptake of phenylalanine, leucine and lysine were different. (4) The amounts of bacterial populations responsible for the uptake of aspartate, arginine, alanine, glutamate and phenylalanine are not limited. (5) The functions of the assimilation of these AAs were induced in many bacterial cells as a result of the BOD determination methods applied to these pure AAs.

A novel method of ovarian stimulation for in vitro fertilization: bromocriptine-rebound method

OBJECTIVE

To examine whether a new method of ovarian stimulation, bromocriptine-rebound method, improves IVF outcomes compared with the conventional long protocol of GnRH agonist and hMG regimen.

DESIGN

A prospective clinical trial.

SETTING

In vitro fertilization program at a university hospital.

PATIENTS

Endocrine-normal ovulatory women less than 40 years of age, with normal male partners and previous failed IVF-ET using long protocol.

INTERVENTIONS

Patients were assigned to either bromocriptine-rebound method (group 1) or long protocol (group 2). The bromocriptine-rebound method was the same as the long protocol, except that bromocriptine was administered daily from day 4 of the preceding cycle until 7 days before hMG stimulation.

MAIN OUTCOME MEASURES

The number of cleaved and morphologically superior embryos, pregnancy rate per oocyte pick-up, and serum PRL concentrations during administrations of hMG.

RESULTS

Significantly more embryos were cleaved and had superior morphology in group 1 than group 2. Clinical and ongoing pregnancy rates per oocyte pick-up were significantly higher in group 1 (42% and 38%, respectively) than group 2 (24% and 21%, respectively). The mean PRL concentration was significantly higher in the group 1 than group 2. A significant correlation between the number of superior embryos and PRL concentrations was observed in group 1, but not in group 2.

CONCLUSION

The bromocriptine-rebound method enhanced embryonic development, resulting in an increased pregnancy rate compared with the long protocol.

An improvement in the embryo quality and pregnancy rate by the pulsatile administration of human menopausal gonadotropin in patients with previous unsuccessful in vitro fertilization attempts

OBJECTIVE

To examine whether the pulsatile administration of hMG improves IVF outcomes in patients with previous unsuccessful attempts using IM injections of hMG.

DESIGN

A prospective randomized study.

SETTING

In vitro fertilization program at a university hospital.

PATIENTS

Eighty-eight endocrine-normal ovulatory women under 40 years of age, with normal male partners and a history of unsuccessful IVF treatment by the IM administration of hMG.

INTERVENTIONS

Patients were assigned randomly to receive either IM (bolus group) or pulsatile administration of hMG (pulsatile group) after pituitary desensitization by a GnRH agonist.

MAIN OUTCOME MEASURES

The proportion of retrieved oocytes with a polar body, the number of fertilized oocytes and embryos, the proportion of morphologically superior embryos, and the rate of pregnancy per initiated cycle were compared.

RESULTS

The proportion of retrieved oocytes with a polar body and the number of fertilized oocytes and embryos were similar in both groups. Significantly more embryos had superior morphology in the pulsatile group (77%) than the bolus group (52%). The rates of overall and clinical pregnancy per initiated cycle were significantly higher in the pulsatile group (39% and 30%, respectively, n = 44) than in the bolus group (18% and 11%, respectively, n = 44).

CONCLUSION

In women with failed IVF attempts using IM administration of hMG, the pulsatile administration of hMG produces superior embryos and, hence, a higher pregnancy rate.

[A novel method of ovarian stimulation for in vitro fertilization (bromocriptine-rebound method) increases developmental potential of oocytes and pregnancy rate]

A novel method of ovarian stimulation for IVF is reported. Endocrine-normal ovulatory women with a history of unsuccessful IVF attempts by means of a long protocol of a GnRH agonist/hMG regimen (L regimen) were studied. Ovaries were stimulated by the three regimens described below. The bromocriptine-rebound (BR) regimen consisted of bromocriptine (B) 2.5mg/day administered daily beginning on day 4 of the preceding cycle and buserelin acetate administered beginning in early high phase. Administration of B was discontinued in the low phase of the IVF cycle and daily administration of hMG was begun 7 days later. HCG was administered when dominant follicles reached 16-18 mm in diameter. The bromocriptine-continuous (BC) regimen was the same as the BR regimen, except that B was administered until the administration of hCG. The L regimen was the same as the BR regimen, except that no B was administered. The pregnancy rate per oocyte retrieval was significantly higher on the BR regimen (56% in 70 cycles) than the L regimen (33% in 46 cycles), and lowest on the BC regimen (29% in 7 cycles). The rate of fertilization and cleavage per oocyte and the proportion of morphologically-good embryos were significantly higher on the BR regimen (59.1% and 57.3%, respectively) than the L regimen (46.3% and 48.0%, respectively), and lowest on the BC regimen (49.0% and 41.7%, respectively). Serum PRL concentrations (ng/ml) at the time hMG was started were 14.9 +/- 1.5, 7.9 +/- 1.7 and 2.5 +/- 0.7 on the BR, L and BC regimens, respectively. The results of this study show that the BR regimen increases the developmental potential of oocytes and the pregnancy rate, probably because of increasing serum PRL levels to within the normal range.

[Effects of the maturity of human oocytes on fertilization and embryonic development: application of oocyte maturation in medium containing follicle-stimulating hormone]

A total of 2,145 oocytes from 355 IVF cycles were classified as overmature (O), mature (M), transitional (T), immature (I) and abnormal (A) according to the morphology of the corona radiata. The rates of fertilization (%F) and embryonic development (%D) per oocyte were the highest in the M group, and decreased significantly with the decreasing maturity of the oocytes (T and I) and were the lowest in the A group. Decreases in %F and %D were also observed in the O group. %F and %D were significantly higher in oocytes with a polar body (PB) than without a PB. Mature oocytes classified according to the morphology of the corona radiata had significantly higher %F and %D than those classified according to the morphology of the cumulus oophorus. %F and %D were increased when T-oocytes without a PB and I-oocytes were matured in vitro for 18-24 hours in medium supplemented with FSH. A normal female baby was delivered, following IVF-ET of two T-oocytes matured in vitro with FSH.

Administration of human chorionic gonadotropin for in vitro fertilization-embryo transfer based on the serum luteinizing hormone (LH) concentration: the importance of synchronization with endogenous LH rises

OBJECTIVE

To examine whether synchronized administration of hCG at the onset of the endogenous LH rise promotes successful IVF.

DESIGN

A prospective randomized study.

SETTING

In vitro fertilization program at a university hospital.

PATIENTS

A total of 208 IVF cycles in 148 patients.

INTERVENTIONS

Serum LH concentrations were measured daily and hMG was administered daily. Independent of follicle size and E2 concentration, hCG was administered as soon as the LH concentration exceeded the J level, defined as the minimum value + (the day 3 value-the minimum value) x 1/3(J group). Alternatively, hCG was administered when the serum LH concentration turned to increase but was still less than the J level, or 1 day after the serum LH concentration exceeded the J level (non-J group).

RESULTS

The rates of total and ongoing pregnancy per cycle were significantly higher in the J group (35.6% and 26.0%, respectively, n = 104) than in the non-J group (21.2% and 12.5%, respectively, n = 104). Pregnancies in the J group were achieved over a wide range of dominant follicle diameters (13 to 25 mm), E2 levels (198 to 1,700 pg/mL; conversion factor to SI units, 3.671), and E2 level per follicle > or = 12 mm (24 to 225 pg/mL per follicle) recorded on the day of hCG administration.

CONCLUSION

Synchronized administration of hCG in accordance with endogenous LH rises produces a high rate of pregnancy in IVF.

Hydatidiform mole with a surviving coexistent fetus following in-vitro fertilization

A case of a hydatidiform mole with a surviving coexistent fetus following in-vitro fertilization and embryo transfer is reported. The diagnosis was established at 12 weeks gestation and pregnancy was maintained until 31 weeks, during which time transient hyperthyroidism and lung metastasis developed. No difference was observed in pronucleus formation and early embryonic development between the two embryos, which resulted in a complete mole and a normal fetus. DNA finger-print analysis, karyotype analysis and histopathological examination confirmed that the pregnancy was a twin of a complete mole and a normal conception. DNA fingerprint analysis was performed with a single-locus probe cocktail. All DNA bands from the tumour were of paternal origin, and the bands from the placenta were of paternal and maternal origin.

Direct ovarian effect of growth hormone in the rabbit

PROBLEM

This study was undertaken to assess whether growth hormone (GH) can stimulate follicle growth and ovarian steroidogenesis via putative GH receptors.

METHOD

In vitro perfused rabbit ovary.

RESULTS

Ovulation occurred in neither the control ovaries nor experimental ovaries treated with 100 ng/ml of GH, whereas all ovaries exposed to 50 IU of human chorionic gonadotropin (hCG) ovulated. The addition of GH to the perfusate significantly stimulated the follicle growth in the absence of gonadotropin. The percent change in follicle diameter in GH-treated ovaries did not differ significantly from that in hCG-treated ovaries. Exposure to GH significantly stimulated the meiotic maturation in the follicular oocytes, as compared with the contralateral control ovaries. Although the concentration of progesterone in the perfusate did not differ significantly between GH-treated and control ovaries, GH stimulated estradiol production by the perfused rabbit ovaries. Rabbit ovary membranes exhibited high affinity binding sites of hGH (Kd = 6.1 x 10(-9) M).

CONCLUSION

GH acts on the rabbit ovary to stimulate the follicle growth, oocyte maturation, and ovarian estradiol production by interacting with the specific receptors located in ovarian plasma membranes.

Induction of meiotic maturation of follicle-enclosed oocytes of rabbits by a transient increase followed by an abrupt decrease in cyclic AMP concentration

The involvement of cyclic adenosine monophosphate (cAMP) in mammalian oocyte maturation was assessed using cultures of rabbit cumulus-oocyte complexes and perfused rabbit ovaries. Rabbit cumulus-oocyte complexes were cultured in Brackett's medium with or without forskolin at 10(-4), 10(-5) or 10(-6) mol l-1 for 3-6 h. At 3 or 4 h spontaneous meiotic maturation was significantly (P < 0.05) inhibited by forskolin at 10(-4) mol l-1. With prolonged incubation, spontaneous maturation progressed despite exposure to forskolin. In the second experiment ovaries were perfused for 12 h with forskolin (10(-4), 10(-5) or 10(-6) mol l-1) or medium alone. Neither ovulation nor degeneration of follicular oocytes occurred in any perfused ovary. The percentage of follicular oocytes achieving germinal vesicle breakdown was significantly (P < 0.001) increased in response to forskolin in a dose-related manner. In an additional experiment, ovaries were perfused with forskolin at 10(-4) mol l-1. A significant increase in the cAMP content in the follicle was observed within 30 min, but the ability to produce cAMP in response to forskolin decreased as the duration of perfusion was increased. Intraoocyte cAMP increased significantly within 30 min and reached its maximum 2 h after exposure to forskolin. Thereafter, cAMP levels in the oocytes decreased abruptly. This drop in intraoocyte cAMP concentration was followed by the resumption of meiosis. The alterations of intraoocyte cAMP contents following exposure to hCG in vivo paralleled those observed in the ovaries perfused with forskolin. These data suggest that a transient, but not continuous, increase in cAMP concentration after the gonadotrophin surge may be required to initiate oocyte maturation.

Effects of prolactin on ovarian plasmin generation in the process of ovulation

The present study was undertaken to assess the effects of prolactin (PRL) on gonadotropin-induced plasmin generation in the in vitro-perfused rabbit ovary. The ovarian plasmin activity was determined by measuring plasmin bound to its major inhibitor, alpha 2-plasmin inhibitor (alpha 2 PI-Plm). In the first experiment, exposure to hCG enhanced ovarian alpha 2 PI-Plm generation from 1.2 +/- 0.3 ng/min/ovary in unstimulated ovaries to 2.9 +/- 0.3 ng within 2 h. The concentration of alpha 2 PI-Plm reached a maximum at 4 h and then declined. A second peak occurred 8 h after hCG administration; however, the ovarian alpha 2 PI-Plm generation without hCG was very low throughout the entire perfusion period. In the subsequent experiment, the addition of PRL(10-10(3) ng/ml) to the perfusate inhibited hCG-induced ovulation in a dose-dependent manner. Exposure to PRL at 10(3) ng/ml significantly (p less than 0.05) inhibited hCG-induced alpha 2 PI-Plm generation in ovaries throughout the entire perfusion period. Furthermore, PRL inhibited hCG-stimulated alpha 2 PI-Plm generation at 4 h after hCG administration in the perfused rabbit ovaries in a dose-dependent manner. In conclusion, PRL directly inhibits hCG-induced ovulation in rabbit ovary, at least in part, by a mechanism depending upon inhibition of the plasmin-generating system in the preovulatory follicles.

Possible involvement of lipoxygenase products in human corpora lutea

The present study was undertaken to determine the ability of cultured luteal cells from human corpora lutea to secrete progesterone (P4) and prostaglandins (PGs), and to assess the effects of the products of the lipoxygenase pathway on luteal P4 production. Luteal cells responded to human chorionic gonadotropin (hCG) with a significant increase (2- to 7-fold) in P4 production. Arachidonic acid significantly stimulated PGE2 synthesis by luteal cells in a dose-dependent manner. Both basal PGE2 production and the responsiveness to arachidonic acid were maintained for 8 days. In contrast, both PGF2 alpha and 6-keto-PGF1 alpha production abruptly declined as the culture proceeded. However, the addition of hCG did not further stimulate the accumulation of the 3 PGs assayed. In the subsequent experiment, 5-hydroxyeicosatetraenoic acid (5-HETE) and the reaction products of soybean lipoxidase of arachidonic acid (AA-LIP) were utilized for evaluating the involvement of the lipoxygenase pathway in luteolysis. The addition of 5-HETE dose-dependently inhibited P4 production by the cultured luteal cells. Although treatment with either arachidonic acid or lipoxidase alone had no effect on P4 production, AA-LIP significantly reduced P4 production in the presence or absence of hCG. These results suggest that the products of the lipoxygenase as well as of the cyclo-oxygenase pathway may be important in regulating the life span and function of human corpora lutea.

Involvement of leukotriene B4 in ovulation in the rabbit

The present study was undertaken to assess the effects of lipoxygenase products on ovulation, oocyte maturation, and steroid production in the perfused rabbit ovary preparation. Ovulatory efficiency was significantly reduced when rabbit ovaries were perfused with human CG (hCG) plus nordihydroguaiaretic acid (NDGA) at 10(-5) or 10(-6) M, as compared to contralateral hCG-treated controls. The addition of NDGA to the perfusate inhibited hCG-induced ovulation in a dose-related manner. The percentage of ovulated ova and follicular oocytes achieving germinal vesicle breakdown did not differ significantly between NDGA-treated ovaries and contralateral controls. Leukotriene B4 (LTB4) production by the perfused rabbit ovaries reached its maximum 6 h after exposure to hCG and then declined. The addition of NDGA at 10(-5) M significantly inhibited hCG-stimulated LTB4 production by rabbit ovaries throughout the entire perfusion periods. The ovulatory efficiency in ovaries treated with hCG alone or with hCG plus NDGA correlated significantly with LTB4 production by perfused rabbit ovaries 6 h after exposure to hCG (alpha = 0.8893, P less than 0.01). Furthermore, the addition of LTB4 at 100 ng/ml to the perfusate reversed the inhibitory effects of NDGA on hCG-induced ovulation. However, exposure to NDGA affected neither progesterone nor estradiol production elicited by hCG administration. These results suggest that NDGA may block hCG-induced ovulation in vitro, probably via the inhibition of LTB4 production by rabbit ovaries.

Treatment of uterine leiomyomata with a luteinizing hormone-releasing hormone agonist: the possibility of nonsurgical management in selected perimenopausal women

OBJECTIVE

To evaluate the efficacy of luteinizing hormone-releasing hormone agonist (LH-RH-a) in the treatment of leiomyomata.

DESIGN

A retrospective randomized trial.

SETTING

Hospital department of obstetrics and gynecology.

PATIENTS

Twenty-five women, ages 36 to 54 years with symptomatic uterine leiomyomata, were divided into two groups according to the responsiveness to LH-RH-a: group A patients reached menopause after LH-RH-a, whereas resumption of menstruation occurred within 12 weeks after cessation of therapy in group B.

INTERVENTIONS

Luteinizing hormone-releasing hormone agonist was administered intranasally three times a day with 150 micrograms insufflation of one spray in each nostril (total dose: 900 micrograms/d).

MAIN OUTCOME MEASURES

Efficacies of treatment were assessed in terms of uterine volume, hemoglobin concentrations, serum levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol (E2), and bone density during and after treatment.

RESULTS

In both groups, hemoglobin concentrations increased significantly after 16 weeks of treatment. A significant reduction in uterine volume was observed in both groups. After completing therapy, there was no further significant change in uterine volume in group A, whereas uterine volume in group B returned to pretreatment values. Serum LH and FSH concentrations were suppressed during treatment, but those gonadotropins in group A increased significantly up to the menopausal levels after treatment. Serum E2 concentrations in both groups showed consistent suppression by the end of the first treatment cycle. After cessation of therapy, serum E2 levels on group A remained in the castrate range, whereas E2 in group B returned to pretreatment levels, concomitant with the return of normal ovulation.

CONCLUSIONS

Intranasal administration of LH-RH-a was successful in significantly decreasing uterine volume and increasing hemoglobin concentration in premenopausal women with leiomyomata.

Gonadotropin-releasing hormone agonists induce meiotic maturation and degeneration of oocytes in the in vitro perfused rabbit ovary

The present study was undertaken to assess the effects of gonadotropin-releasing hormone agonists (GnRH-a, buserelin and leuprolide acetate [LA]) on ovulation, oocyte maturation and degeneration, and steroid and prostaglandin production in the perfused rabbit ovary preparation. Ovulation did not occur in any of ovaries treated with buserelin or LA (10(2) to 10(4) ng/mL) in the absence of gonadotropin. Gonadotropin-releasing hormone agonists were associated with the resumption of meiosis in follicular oocytes in a dose-related manner. Furthermore, the addition of GnRH-a to the perfusate significantly increased the percentage of follicular oocytes that showed evidence of degeneration compared with contralateral untreated or human chorionic gonadotropin-treated controls. Prostaglandin E2 and prostaglandin F2 alpha production by the perfused rabbit ovaries were stimulated significantly by GnRH-a treatment. Exposure to GnRH-a failed to increase either progesterone or estradiol production by the perfused rabbit ovaries. These data demonstrate that GnRH-a act directly in the rabbit ovary to trigger meiotic maturation in oocytes within the follicles, concomitantly increasing oocyte degeneration.

Possible contribution of prolactin in the process of ovulation and oocyte maturation

The present study was undertaken to evaluate the effects of PRL in the process of ovulation and oocyte maturation. In the first experiment, using an in vitro perfused rabbit ovary model, the addition of PRL to the perfusate inhibited hCG-induced ovulation in a dose-related fashion, without any reduction in progesterone synthesis. In a subsequent experiment, PRL directly inhibited both the degeneration and decomposition of surface epithelial cells and the disruption of connective tissue at the apex of the follicle wall. Furthermore, PRL inhibited hCG-stimulated plasminogen activator (PA) activity in mature follicles in a dose-related fashion. In the final experiment, we demonstrated conditions in which rabbit oocytes matured in vitro acquire competence for early embryonic development. PRL, as well as gonadotropins and estradiol, was an important constituent in the process of oocyte maturation, promoting embryonic development. These results suggest that the preovulatory environment of PRL within the follicle may influence the process of ovulation and oocyte maturation.

Effects of gonadotropin-releasing hormone agonists on meiotic maturation of follicle-enclosed oocytes in rabbits

The effects of GnRH agonists on in vitro maturation of rabbit follicle-enclosed oocytes were studied. Rabbit preovulatory follicles were cultured with or without hCG (10(2) ng/ml), buserelin (10(2)-10(5) ng/ml), or leuprolide (10(2)-10(5) ng/ml) for 14 hours in vitro. GnRH agonists induced the resumption of meiosis in the follicle-enclosed oocytes in a dose-dependent manner. The percentage of oocytes achieving GVBD following treatment with 10(5) ng/ml buserelin (87.9 +/- 6.3%) or 10(5) ng/ml leuprolide (86.0 +/- 4.1%) did not differ significantly from hCG-treated control (87.3 +/- 3.8%). Mature oocytes initially were detected within 2 hours of GnRH agonist exposure. Concomitant addition of a GnRH antagonist at 10(4) ng/ml significantly blocked the stimulatory effect of GnRH agonist on oocyte maturation. GnRH agonists significantly stimulated both prostaglandin (PG) E2 (PGE2) and PGF2 alpha production by preovulatory follicles (p less than 0.01), but secreted prostanoid levels did not differ significantly among different concentrations of GnRH agonists. Meiotic maturation of follicle-enclosed oocytes following GnRH agonist exposure began 2 hours earlier than production of PGs. PG production stimulated by GnRH agonists was reduced significantly by indomethacin. However, oocyte maturity in the presence of GnRH agonist plus indomethacin did not differ significantly from that of GnRH agonist alone. GnRH agonistic analogues induce the resumption of meiosis in follicle-enclosed oocytes in rabbits by a mechanism other than PG stimulation.

[Treatment of leiomyomas with luteinizing hormone-releasing hormone agonist]

Twenty-five premenopausal women, 36-54 years of age, with uterine myomas were treated with 600-1,200 micrograms/day of luteinizing hormone-releasing hormone agonist (LHRHa) for 4 months. Eight patients reached menopause following the treatment with LHRHa (menopause group), while the resumption of menstruation occurred within 12 weeks after cessation of the therapy in 17 patients (menstruation group). Although the mean hemoglobin (Hb) concentration in the menopause group increased during treatment and was maintained within the normal range after cessation of the therapy, the Hb concentration in the menstruation group decreased after the resumption of menstruation. Both estradiol and CA125 in the menopause group were reduced during and after treatment. However, these parameters in the menstruation group increased concomitantly with the resumption of ovarian function. LH and FSH were suppressed during treatment, but these gonadotropins in the menopause group increased significantly to the levels of menopause. About a 50% reduction in uterine volume was observed in the menopause group. Three months after completing therapy, the restoration of uterine volume occurred in the menstruation group. Bone density findings in microdensitometry 12 weeks after cessation of the therapy did not differ significantly from those before the treatment. These results demonstrate that LHRHa therapy significantly reduces the uterine volume in patients with leiomyoma. It may be possible to treat selected patients with leiomyoma, including perimenopausal women and high surgical risk women with LHRHa, thus avoiding the need for surgery.

Induction of ovulation with pulsatile subcutaneous administration of human menopausal gonadotropin in patients with polycystic ovary syndrome

The present study was undertaken to determine whether ovulation can be induced in patients with polycystic ovary syndrome (PCOS) by pulsatile subcutaneous administration of hMG after the pituitary secretion of LH and FSH was suppressed with a gonadotropin releasing hormone (GnRH) analogue. The results of the combined regimen cycles (group II) were compared with those of hMG (group I) or FSH (group III) pulsatile administration in the same PCOS patients. The ovulation rate (89.1% of 46 cycles) in group I was significantly greater (p less than 0.01) than that found in group II (65.9% of 41 cycles). In group III, ovulation occurred in 89.5% of the 19 treatment cycles. Ovarian hyperstimulation syndrome (OHSS) occurred in 28.3% of cycles in group I, 7.3% in group II, and 26.3% in group III, respectively. The incidence of OHSS in group II was significantly lower than that found in group I or III. The rates of pregnancy were 10.9% of cycles in group I, 4.9% in group II, and 21.1% in group III, respectively. All 10 fetuses were singleton conceptions, and the pregnancies continued successfully to term. The present data demonstrate that pulsatile subcutaneous administration of hMG or FSH is effective in the induction of successful ovulation and the establishment of singleton pregnancy in patients with PCOS.

Clinical experience in the induction of ovulation and pregnancy with pulsatile subcutaneous administration of human menopausal gonadotropin: a low incidence of multiple pregnancy

The pulsatile subcutaneous administration of human menopausal gonadotropin (hMG) or follicle-stimulating hormone (FSH) was used for induction of ovulation in 26 patients with hypothalamic/pituitary amenorrhea or polycystic ovary syndrome (PCO). Ovulation was observed in 116 (90.6%) of 128 treatment cycles, and 15 (16 treatment cycles) of 26 patients became pregnant. All 14 fetuses, excluding two pregnancies interrupted spontaneously at weeks 6 and 9, were singleton conceptions. Ovarian hyperstimulation was observed in 15.6% of treatment cycles. Five patients with PCO who failed to conceive on the hMG regimen also received pulsatile FSH administration. Although ovulation rates in PCO patients did not differ significantly between the hMG (88.1%) and FSH (88.2%) regimens, a significant reduction in the average dose of FSH (P less than 0.05) was observed with pulsatile FSH administration. Furthermore, the number of patients who conceived during the FSH regimen was significantly greater than that found with hMG treatment. The present data demonstrate that pulsatile subcutaneous administration of hMG or FSH is effective in induction of successful ovulation and establishment of singleton pregnancy in patients with various types of anovulatory infertility.

Treatment of polycystic ovarian disease by inducing ovulation with pulsatile subcutaneous administration of human menopausal gonadotrophin associated with luteinizing hormone-releasing hormone analogue

Treatment with a combination of luteinizing hormone-releasing analogue (GnRHa, Buserelin) and pulsatile administration of hMG (Group I) were used to induce ovulation in nine patients with polycystic ovary syndrome (PCO). The same patients were also treated with pulsatile hMG administration alone (Group II). Ovulation was observed in all twelve treatment cycles in Group I, and there were two pregnancies. In Group II, ovulation occurred in 22 of 26 treatment cycles. Ovarian hyperstimulation occurred in one cycle of Group I and in 5 of 26 cycles of Group II. The total dose per cycle of hMG to induce ovulation in Group I was significantly lower than that needed when only pulsatile hMG administration was used. In response to Buserelin administration, the concentrations of serum luteinizing hormone (LH) and follicle stimulating hormone (FSH) increased transiently and then declined to the normal range observed in the early follicular phase. The concentrations of FSH increased in response to hMG administration, resulting in a normal LH/FSH ratio. The present data demonstrated that pulsatile subcutaneous administration of hMG in addition to Buserelin was effective in inducing follicular maturation and ovulation in patients with PCO with a lower incidence of serious side-effects.