The effect of human menopausal gonadotropin and equine chorionic gonadotropin on the reproductive performance of treated ewes with short-term progesterone injections and sponge during the non-breeding season

This study investigated the effect of human menopausal gonadotropin (hMG) on reproductive efficiency of synchronized ewes with the sponge and progesterone (P4) injection-based protocols. In study 1, anoestrous ewes (n = 120) were used. Sixty ewes were treated with sponge (S) for 12 days. The injection of eCG (SeCG group, n = 30) or hMG (ShMG, n = 30) was given at the time of sponge removal. Thirty ewes received IM injection of P4, three times every 48 h and the injection of hMG was given 24 h after the third P4 injection (3PhMG group, n = 30), and 30 ewes were used as control group. Pregnancy was diagnosed on day 50 after the release of ram. In study 2, 60 ewes were randomly divided into two equal groups. In the treated group with antibiotics (n = 30), before inserting, the sponges were impregnated with the antibiotic penicillin G sodium (5,000,000 IU) and in the control group (n = 30), there was no added antibiotics. Before inserting and after removing sponges, a vaginal cytology sample was taken with a sterile cotton swab. The number of neutrophils in each sample was counted and analysed. The rate of oestrus and total pregnancy was greater in SeCG (96.7, 93.3%), ShMG (82.8, 93.1%) and 3PhMG (67.9, 89.3%) groups compared with the control group (13.8, 41.4%) (p < .05). No significant difference was found in single, twin and total lambing and pregnancy rates after injection of eCG and hMG during the non-breeding season (p > .05). A higher percentage of control ewes had the vaginal smear with neutrophils more than 50% (96.7% vs. 76.7%; p < .05). In conclusion, a single dose of hMG can induce fertile oestrus in synchronized ewes with P4 administered by either injection or intravaginally. Purulent discharge and percentage of neutrophils were significantly reduced in the synchronized ewes by the impregnated sponges with the antibiotic penicillin.

Follitropin delta combined with menotropin in patients at risk for poor ovarian response during in vitro fertilization cycles: a prospective controlled clinical study

BACKGROUND

The maximum daily dose of follitropin delta for ovarian stimulation in the first in vitro fertilization cycle is 12 μg (180 IU), according to the algorithm developed by the manufacturer, and based on patient's ovarian reserve and weight. This study aimed to assess whether 150 IU of menotropin combined with follitropin delta improves the response to stimulation in women with serum antimullerian hormone levels less than 2.1 ng/mL.

METHODS

This study involved a prospective intervention group of 44 women who received 12 μg of follitropin delta combined with 150 IU of menotropin from the beginning of stimulation and a retrospective control group of 297 women who received 12 μg of follitropin delta alone during the phase 3 study of this drug. The inclusion and exclusion criteria and other treatment and follow-up protocols in the two groups were similar. The pituitary suppression was achieved by administering a gonadotropin-releasing hormone (GnRH) antagonist. Ovulation triggering with human chorionic gonadotropin or GnRH agonist and the option of transferring fresh embryos or using freeze-all strategy were made according to the risk of developing ovarian hyperstimulation syndrome.

RESULTS

Women who received follitropin delta combined with menotropin had higher estradiol levels on trigger day (2150 pg/mL vs. 1373 pg/mL, p < 0.001), more blastocysts (3.1 vs. 2.4, p = 0.003) and more top-quality blastocysts (1.8 vs. 1.3, p = 0.017). No difference was observed in pregnancy, implantation, miscarriage, and live birth rates after the first embryo transfer. The incidence of ovarian hyperstimulation syndrome did not differ between the groups. However, preventive measures for the syndrome were more frequent in the group using both drugs than in the control group (13.6% vs. 0.6%, p < 0.001).

CONCLUSIONS

In women with serum antimullerian hormone levels less than 2.1 ng/mL, the administration of 150 IU of menotropin combined with 12 μg of follitropin delta improved the ovarian response, making it a valid therapeutic option in situations where ovulation triggering with a GnRH agonist and freeze-all embryos strategy can be used routinely.

TRIAL REGISTRATION

U1111-1247-3260 (Brazilian Register of Clinical Trials, available at https://ensaiosclinicos.gov.br/rg/RBR-2kmyfm ).

Letrozole use in vitrified single-blastocyst transfer cycles is associated with lower risk of large for gestational age infants in patients with polycystic ovary syndrome

PURPOSE

To evaluate the obstetric and perinatal outcomes of three routine endometrial preparation protocols in women with PCOS who underwent frozen embryo transfer (FET).

METHODS

This was a retrospective study in women with PCOS who underwent FET in an academic reproductive medical center. A total of 2710 cycles were enrolled and classified into three groups according to different endometrial preparation protocols; human menopausal gonadotropin (HMG), letrozole + HMG, or hormone replacement therapy (HRT).

RESULTS

The stimulation groups had reduced risks of hypertensive disorders of pregnancy (HDP), large for gestational age (LGA) infants, and cesarean delivery than the HRT group. After adjustment for different confounder combinations in the two models, the frequencies of LGA and HDP in the letrozole + HMG group and the HMG group were still significantly lower than those in the HRT group. The letrozole + HMG group exhibited a reduced risk of LGA than HMG group after adjustment of confounders. A trend toward risk reductions in HDP and LGA was observe in turns of HRT, HMG, and letrozole + HMG groups, and the trends were statistically significant (Ptrend = 0.031 and 0.001).

CONCLUSION

In patients with PCOS, ovarian stimulation protocols for endometrial preparation are associated with reduced risks of HDP and LGA compared to HRT cycles. The use of letrozole could further reduce risk of LGA compared to HMG only protocol. We propose that ovarian stimulation protocols can be used widely for endometrial preparation in FET cycles in women with PCOS, especially with the use of letrozole.

Optimal lead follicle size in letrozole human menopausal gonadotrophin intrauterine insemination cycles with and without spontaneous LH surge

RESEARCH QUESTION

What is the optimal lead follicle size in letrozole, human menopausal gonadotrophin and intrauterine insemination (IUI) cycles with and without spontaneous LH surges?

DESIGN

This retrospective cohort study included 3797 letrozole HMG IUI cycles between January 2010 and May 2021. All cycles were divided into two groups: the HCG trigger group (trigger day LH ≤15 mIU/ml) and the spontaneous LH surge group (trigger day LH >15 mIU/ml). These two groups were subdivided into smaller groups based on the diameter of the follicles. The primary outcome measure was clinical pregnancy rate. Logistic regression analysis was conducted to explore other risk factors.

RESULTS

In the HCG trigger group, the clinical pregnancy rate varied significantly, with rates of 20.8%, 14.9% and 11.8% for the 16.1-18.0, 18.1-20.0 and 20.1-22.0 mm groups, respectively (P = 0.005). In the spontaneous LH surge group, the pregnancy rate of follicles within 14.1-16.0 mm was significantly higher than that of follicles within 20.1-22.0 mm (adjusted OR 0.533, 95% CI 0.308 to 0.923, P = 0.025). Also, patients with two lead follicles were 2.569 times more likely to achieve a clinical pregnancy than those with only one lead follicle (adjusted OR 2.569, 95% CI 1.258 to 5.246, P = 0.010). The duration of infertility was also found to be a common influencing factor in both groups.

CONCLUSIONS

The optimal lead follicle size was between 16.1 and 18.0 mm in HCG-triggered letrozole HMG IUI cycles. If the lead follicle size is relatively small (14.1-18.0 mm) when a spontaneous LH surge occurs, there is no need to cancel the IUI cycle.

Agonist long protocol improves outcomes of vitrified-warmed embryo transfer in repeatedly thin endometrium

RESEARCH QUESTION

Does follicular stimulation using human menopausal gonadotrophin (HMG) after pituitary down-regulation by a GnRH agonist improve endometrial thickness (EMT) and clinical outcomes of frozen-thawed embryo transfer (FET; using vitrified-warmed embryos) in women with thin endometrium after intensified oestrogen administration (IOA)?

DESIGN

This was a retrospective study. A total of 627 patients attempted 683 FET cycles with at least one previous history of thin endometrium. None of the cycles reached over 7 mm EMT after using oral and vaginal oestradiol for more than 21 days (IOA protocol). A total of 129 cycles proceeded with FET, 305 cycles were cancelled, and 249 cycles involved administration of HMG following GnRH agonist pituitary down-regulation (GnRH agonist + HMG protocol) for further endometrial preparation.

RESULTS

EMT became significantly greater (7.18 ± 1.14 mm versus 6.13 ± 0.63 mm, P < 0.001) using GnRH agonist + HMG compared with previous IOA cycles, but this was not related to serum oestrogen concentrations. A total of 213 cycles after the GnRH agonist + HMG protocol proceeded with FET, showing a significantly increased clinical pregnancy rate, implantation rate and live birth rate compared with those after IOA.

CONCLUSIONS

The GnRH agonist + HMG protocol for endometrial preparation in FET cycles improves EMT in women with a thin endometrium after IOA and showed significantly better clinical outcomes than IOA. The authors suggest that the GnRH agonist + HMG protocol should be used for EMT that is less than 7 mm after there has been no optimal response to IOA.

Superovulation of high-producing Holstein lactating dairy cows with human recombinant FSH and hMG

Superovulation of high-producing dairy cows is a challenging subject in dairy farms with respect to the cost, dose and type of gonadotropin. The objectives of this study were to compare three gonadotropin products: Folltropin-V® (highly purified FSH with porcine origin), Cinnal-f® (recombinant human FSH) and Menotropins® (hMG) for superovulation in high-producing Holstein lactating dairy cows and to investigate the pregnancy outcomes achieved following transferring embryos recovered from donors treated with different gonadotropins. Healthy high-producing Holstein lactating dairy cows (n = 30; milk production: 46.35 ± 8.78 kg; parity: 2-4; days in milk: 80-130 days) without any puerperal problems were selected as donors. On Day 10 after estrus (Day 0 of superovulation), donors (10 cows in each experimental groups) received Folltropin-V® (400 mg NIH, dissolved in 20 ml), Cinnal-f® (20 vials; each vial of 1 ml contains 75 IU Follitropin alfa) and Menotropins ® (20 ampules; each ampule of 1 ml contains 75 IU FSH and 75 IU LH), administered twice daily, in decreasing doses (4,4; 3,3; 2,2; 1,1 ml), over 4 days. On Day 2 of superovulation, donors received 3 doses of prostaglandin F₂α analogue, 6 h apart. They were inseminated twice with a frozen semen at 12 and 24 h after standing estrus. Concurrent with the second insemination, donors received 2500 IU hCG (Karma Pharmatech GmbH, Germany). On Day 7 after standing estrus, superovulatory responses (number of CLs, total ova/embryos and transferable embryos) were recorded and Code 1 embryos, recovered from each treated donors, were transferred to synchronized heifers. Pregnancy was detected on Day 30 and 60 after AI. Gestation length, the number and weight of live births were recorded. Data were analyzed using Proc GLM, Proc Mixed and Proc Genmod of SAS. The respective number of corpora lutea, total number of ova/embryos and transferable embryos were not different among donors received Cinnal-f (25.5 ± 3.01, 11.2 ± 2.77, 5.1 ± 0.86), Menotropins (24.0 ± 3.21, 9.0 ± 2.04, 6.3 ± 1.74) and Folltropin-V (20.3 ± 3.21, 8.9 ± 1.90, 5.1 ± 1.16; P > 0.05). Pregnancy rates on Day 30 was similar among treatment groups (P > 0.05). However, pregnancy rates on Day 60 and the number of calves born healthy was less in heifers that received embryos from Cinnal-f treated donors (P < 0.05). In conclusion, Cinnal-f and Menotropins could provide similar superovulatory response to Folltropin-V for superovulation of high-producing Holstein lactating dairy cows.

Ovulation induction regimens are associated with a higher rate of livebirth after frozen single-blastocyst transfer among women with polycystic ovary syndrome

BACKGROUND

Hormone replacement therapy (HRT) regimen was suggested to be associated with a decreased rate of livebirth and a higher risk of hypertensive disorders of pregnancy (HDP) after frozen cleavage stage embryo transfer in women with polycystic ovary syndrome (PCOS). With the dramatically increased use of elective single embryo transfer, there is great need to explore the impacts of different endometrial preparation regimens on frozen single-blastocyst transfer in women with PCOS.

METHODS

In this study, a total of 3941 women who diagnosed with PCOS and underwent single-blastocyst transfer during their first cycles of frozen embryo transfer (FET) between March 2012 and December 2020 were included. We retrospectively compared the pregnancy and neonatal outcomes after frozen single-blastocyst transfer with endometrial preparation by HRT regimen (n = 3540), ovulation induction by human menopausal gonadotropin (hMG) regimen (n = 226), and ovulation induction by letrozole regimen (n = 175).

RESULTS

After adjustment for confounders with multivariable logistic regression, the hMG regimen group [(58.4% vs. 49.6%; adjusted odds ratio (aOR): 1.43; 95% confidence interval (CI): 1.09-1.89)] and letrozole regimen group (58.9% vs. 49.6%; aOR: 1.42; 95% CI: 1.04-1.93) were associated with a higher rate of livebirth (primary outcome), compared with the group with HRT regimen. As to the secondary outcomes, the rate of pregnancy loss in the hMG regimen group (22.8% vs. 30.3%; aOR: 0.69; 95% CI: 0.48-1.00) and letrozole regimen group (16.9% vs. 30.3%; aOR: 0.48; 95% CI: 0.30-0.78) was also lower than that in the HRT regimen group. The pregnancy outcomes between the hMG regimen group and the letrozole regimen group were similar. We did not observe significant difference in the incidences of maternal and neonatal complications among these three groups.

CONCLUSION

Ovulation induction regimen with letrozole or hMG for endometrial preparation was associated with a higher livebirth rate and a lower pregnancy loss rate in frozen single-blastocyst transfer cycles among women with PCOS.

A retrospective, matched case-control study of recombinant LH versus hMG supplementation on FSH during controlled ovarian hyperstimulation in the GnRH-antagonist protocol

BACKGROUND

The role of luteinizing hormone (LH) in controlled ovarian hyperstimulation (COH) requires more evidence for its efficacy. Several studies compared recombinant human LH (r-hLH) or human menopausal gonadotropin (hMG) in combination with recombinant human follicle-stimulating hormone (r-hFSH) but lack the results with GnRH-antagonist protocol and in Asians.

METHODS

This is a retrospective, single-center study inspecting women receiving GnRH antagonist protocol and r-hFSH+hMG or r-hFSH+r-hLH regimen for over five days for COH in the in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycle in Taiwan from 2013 to 2018. The outcomes of IVF/ICSI cycles were analyzed after propensity score matching between the two groups. A subgroup analysis was conducted in cycles in which women underwent their first embryo transfer (ET), including fresh ET and frozen ET (FET).

RESULTS

With a total of 503 cycles, the results revealed that the r-hFSH+r-hLH group performed better in terms of numbers of oocytes retrieved (r-hFSH+hMG vs. r-hFSH+r-hLH, 11.7 vs. 13.7, p=0.014), mature oocytes (8.7 vs. 10.9, p=0.001), and fertilized oocytes (8.3 vs. 9.8, p=0.022), while other outcomes were comparable. The analysis of first ET cycles also showed similar trends. Although the implantation rate (39% vs. 43%, p=0.37), pregnancy rate (52% vs. 53%, p=0.90), and live birth rate (39% vs. 45%, p=0.19) were not significantly different, the miscarriage rate was higher in the r-hFSH+hMG group than the r-hFSH+r-hLH group (26% vs. 15%, p<0.05) in first ET cycles. The cumulative pregnancy rate was significantly higher in the r-hFSH+r-hLH group (53% vs. 64%, p=0.02). No significant difference in rates of ovarian hyperstimulation syndrome (OHSS) was observed.

CONCLUSION

The results support the hypothesis that the treatment of r-hLH+r-hFSH improves COH clinical outcomes in the IVF/ICSI cycle.

Comparative efficacy of Ovaprim and hMG (menotropin) to induce breeding in African catfish (Clarias gariepinus)

The applications of exogenous hormones in different species for the induction of oocyte production, final oocyte maturation (FOM), and spawning for their reproduction is getting more attention day by day. The current preliminary research work was carried out to induce breeding in Clarias gariepinus, commonly known as African catfish, imported from Thailand. Single doses of two hormones as Ovaprim and human menopausal gonadotropin (hMG) were used and the research work was carried out at Muzaffargarh Fish Hatchery Punjab, Pakistan. A total of twenty-four (n = 24) C. gariepinus were selected having body weight approximately 2 kg and divided into two main groups based on gender as male (n = 12) and female (n = 12). For milt collection, all males were treated with Ovaprim 0.5 mg/kg body weight (b.w.) and female fish were divided into three groups as A, B, and C with four (n = 4) fish in each group. Group A was injected with only normal saline (control group) while fish in group B and group C were treated with hMG at 0.5 mg/kg b.w. and Ovaprim 0.5 mg/kg b.w., respectively. Then, after 6 h of hormone injections until 48 h, spawned eggs, eggs' weight, fertilization rate, hatching rate, survival rate, fecundity, and deformed larvae were investigated. The results revealed that Ovaprim injection significantly (p < 0.05) modulate the reproductive parameters in group C while no breeding was induced in both control and hMG-treated groups. Hence, it could be concluded that Ovaprim has the potential to induce breeding in African catfish, while in the current study, hMG failed to induce breeding. However, trials at large scales are required to further explore the effect of different doses of both tested hormones by increasing the treated subjects particularly in Pakistani fish farms.

[Fort Lauderdale congress report: advances in infertility treatment - Florida, 24-26 January 2002]

The goal of the treatment of infertility is to apply therapeutic techniques to patients in a safe manner and at the same time increase the chances for conceiving and delivering healthy babies: basic and clinical research is more and more finalized directed to these goals. The conference "Advances in Infertility Treatment" held in Fort Lauderdale, Florida on January 24-26, 2002 covered many clinical and research aspects of this important therapeutic area. Important discussed issues included the impact of age, lifestyle, and the genetic set-up of patients in the pathogenesis and development of infertility-causing disorders such as male reproductive dysfunction, polycystic ovary syndrome, and ovarian failure. New ovulation induction regimens that may optimize, reduce complications, and lower costs of ovarian stimulation procedures and of assisted reproduction in general were presented. This was the 5th Ferring Pharmaceuticals Conference in the area of reproductive medicine held in Florida.

The use of LH activity to drive folliculogenesis: exploring uncharted territories in ovulation induction

LH plays critical roles in the control of folliculogenesis and ovarian function in humans. LH activity administration during gonadotrophin ovulation induction can enhance ovarian response and optimise treatment. More specifically, LH activity (both LH and low-dose hCG) can support the growth and stimulate the maturation of larger ovarian follicles as a result of specific granulosa cell receptors that develop after a few days of FSH priming. This action of LH is independent of FSH, and it has been shown recently that the last stages of follicular development can be supported by sole administration of LH activity in the form of low-dose hCG, without causing premature luteinization. Reproductively competent oocytes and pregnancy can be obtained with this regimen. Furthermore, LH activity is capable of reducing the development of small ovarian follicles (<10 mm) that may predispose patients to developing complications such as the ovarian hyperstimulation syndrome. Thus, better understanding of the dynamics and mechanisms that control human folliculogenesis and a more rational and selective use of LH activity administration may allow a reduction in cost and increased safety, while maintaining a high efficacy of the ovulation induction regimens used in assisted reproduction.

Successful pregnancy following gonadotropin therapy in a patient with hypogonadotropic hypogonadism resulting from craniopharyngioma

The authors report a rare case of a patient with panhypopituitarism who became pregnant by gonadotropin therapy and gave birth to a healthy baby. A brain tumour and/or the surgical resection of a brain tumour occasionally results in pituitary dysfunction. An 18-year-old Japanese patient developed hypogonadotropic secondary amenorrhoea because of a craniopharyngioma, which was surgically removed. The patient came to us, and peripheral blood was collected every 15 minutes for four hours. The levels of luteinising hormone (LH) and follicle-stimulating hormone (FSH) were measured. Results showed that LH and FSH levels were very low and did not fluctuate. Several years later, the patient complained of infertility, and treatment with human menopausal gonadotropin (hMG) and human chorionic gonadotropin (hCG) was started. The therapy was repeated for several cycles, but she did not conceive, so hMG-hCG therapy combined with conjugated oestrogen administration was started. The patient became pregnant at the seventh cycle of this combined therapy. She was not treated with supplementary growth hormone.

HMGN3a and HMGN3b, two protein isoforms with a tissue-specific expression pattern, expand the cellular repertoire of nucleosome-binding proteins

HMGN1 (HMG-14) and HMGN2 (HMG-17) are nuclear proteins that bind specifically to nucleosomes, reduce the compactness of the chromatin fiber, and enhance transcription from chromatin templates. Here we report that many vertebrates contain an additional type of HMGN protein named HMGN3 (Trip 7). The human HMGN3 gene is located on chromosome 6 and spans 32 kilobase pairs, which is nearly 10-fold longer than the closely related HMGN2 gene. However, the intron/exon boundaries of the HMGN3 gene are identical to those of HMGN1 and HMGN2. Unique within the HMGN family, the HMGN3 transcript undergoes alternative splicing and generates two different variants, HMGN3a and HMGN3b. The shorter variant, HMGN3b, arises from an additional splice site that truncates exon V and causes a frameshift. The resulting HMGN3b protein lacks the majority of the C-terminal chromatin-unfolding domain. Both splice variants are found in many vertebrates from frogs to man and are expressed in many tissues. The pattern of tissue-specific expression differs considerably from those of HMGN1 and HMGN2 at both the mRNA and the protein level. Our results expand the multiplicity of the HMGN protein family and raise the possibility that these nucleosome-binding proteins function as co-activators in tissue-specific gene expression.

[Purification of follicle-stimulating hormone by radial-flow chromatography]

By comparing the purification results of radial-flow chromatography with conventional chromatography, a new purification process of follicle-stimulating hormone (FSH) from crude sample of human menopausal gonadotrophin has been developed. The results showed that the specific activity, activity recovery, and purification factor of FSH purified by radial-flow chromatography were higher than those by conventional chromatography in large scale. The specific activity of FSH purified was 180 IU/mg protein, activity recovery 56%, purification factor 150. The purified product meets the quality requirement of the Standard of Chinese Pharmacopoeia.

Administration of recombinant follicle stimulating hormone in a woman with allergic reaction to menotropin: a case report

This report describes a patient who experienced a generalized allergic reaction to Pergonal during controlled ovarian hyperstimulation in preparation for an intracytoplasmic sperm injection procedure for treatment of severe male factor infertility. The report describes a successful desensitization protocol which allowed the patient to complete her treatment cycle despite the allergic reaction to Pergonal. Subsequently recombinant follicle stimulating hormone was used successfully in inducing follicular growth in the absence of any allergic reactions. Therefore, this report confirms other studies which have suggested that an allergic reaction to human menopausal gonadotropins is due to impurities in such urine-derived products.

Outcome of stimulated in vitro fertilisation (SIVF) using clomiphene citrate and human menopausal gonadotropin in different infertility groups

A prospective study was undertaken to evaluate the efficacy of stimulated in vitro fertilization (SIVF) using Clomiphene Citrate and hMG in different infertilities. The analysis was applied to the first 81 cycles over a period of 9 months in the years 1994-1996 in Sheffield Fertility Centre (SFC). The female patients included in this study were under 40 years of age, and their FSH and LH values were < 10IU/L. Mild and moderate male factor infertilities were included. For tubal factor infertility 16 cases were included with an implantation rate of 0%. The unexplained factor infertility included 33 cases with an implantation rate per embryo transfer (ET) of 41%. For male factor infertility there were 18 cases with an implantation rate per ET of 42%. Out of 3 cases in the ovulatory factor group none reached ET with 0% implantation. For multiple factor infertility 11 cases were included with a 0% implantation rate. The overall implantation per embryo transfer was 27%, while the implantation per cycle started was 15%. We conclude that there are certain infertility factors, i.e. unexplained infertility and mild male factor, which can have good results in IVF using CC/hMG only.

A reliable endocrine test with human menopausal gonadotropins for diagnosis of true hermaphroditism in early infancy

In true hermaphroditism diverse phenotypes and karyotypes are found; there are no distinctive laboratory features that can distinguish it from other intersex disorders, thus the diagnosis is made by the histological findings. Existence of Leydig cells is demonstrated by testosterone levels above the female range; however, presence of ovarian tissue cannot be ascertained because of the absence of a reliable functional test. Unless appropriate biopsies are performed or the whole gonad is removed, there is a risk of not diagnosing true hermaphroditism. To find a reliable test that can differentiate patients with true hermaphroditism from those with other intersex disorders, we investigated the estradiol (E2) response to human menopausal gonadotropins (hMG) in infants with genital ambiguity. These results were correlated with the histological findings. Eleven infants with genital ambiguity and four with a high scrotal testis were stimulated every 12 h with 2 IU/kg hMG. If E2 rose above 80 pg/mL (cut-off point), the test was discontinued; if after 7 days E2 remained below 80 pg/mL, the hMG dose was doubled and stimulation extended for 7 additional days. In five patients in whom true hermaphroditism was later histologically demonstrated, E2 rose above 80 pg/mL. In two of them, ovarian tissue was removed and hMG stimulation repeated; no response above our cut-off point was observed during the second test. The maximal E2 response to hMG in the remaining 10 individuals was 43 pg/mL; after laparotomy or gonadal biopsies no ovarian tissue was found. The hMG stimulation test can be considered a reliable and safe dynamic procedure for demonstrating the presence or absence of ovarian tissue in infants with genital ambiguity.

Effects of angiotensin converting enzyme inhibitor cilazapril and angiotensin II antagonist saralasin in ovarian hyperstimulation syndrome in the rabbit

We investigated the possible effects of the angiotensin converting enzyme (ACE) inhibitor cilazapril and angiotensin II antagonist saralasin on ovulation, ovarian steroidogenesis and ascites formation in the ovarian hyperstimulation syndrome (OHSS) in the rabbit model. OHSS was induced in rabbits by human menopausal gonadotropin (hMG) and intermittent human chorionic gonadotropin (hCG). In the cilazapril group (n = 10), animals also received cilazapril 2 mg/kg intraperitoneally daily for 7 days. In the saralasin group (n = 8), animals received saralasin intraperitoneally 1 h before or 1 h after hCG administration. Control animals (n = 8), received intraperitoneal saline solution. Serial blood samples were drawn on days 1, 5, 7 and 9 to measure serum estradiol and progesterone levels. On day 9, all rabbits underwent surgical exploration. Peritoneal and pleural fluid formation, ovarian weights and number of ovulations were determined. The volume of the ascitic and pleural fluids after hyperstimulation were not statistically different between the control, cilazapril and saralasin groups. The weight gains and ovarian weights of animals were similar between treatment and control groups. Saralasin significantly (p < 0.05) inhibited ovulation, but cilazapril did not. Cilazapril and saralasin did not affect progesterone production. Only cilazapril significantly decreased estradiol production (p < 0.05). In conclusion, the ACE inhibitor cilazapril and angiotensin II antagonist saralasin did not prevent ascites formation in OHSS. The ovarian renin-angiotensin system may not be the only factor acting in ascites formation in the OHSS.

Prediction of changes in levels of haemostatic variables during natural menstrual cycle and ovarian hyperstimulation

To find if there is a relation between levels of haemostatic variables at low and high hormonal levels (oestradiol and progesterone) in an individual, blood samples were drawn from 12 women repeatedly during one menstrual cycle (Study I) and from 14 women undergoing in vitro fertilization, before hormonal stimulation and daily during the periovulatory period (Study II). Regression coefficients were calculated between minimum (independent) and maximum (dependent) values in both studies. In Study II highly significant regression coefficients were found between oestradiol minimum (pretreatment) and maximum (median 105 and 4730 pmol/l, respectively) for coagulation factors FVIII, von Willebrand Factor (antigen), FVII (activity and antigen), fibrinogen, protein C, protein S (free), antithrombin, plasminogen and plasminogen activator inhibitor-1; furthermore, between progesterone-minimum at day -3 or -2 (related to ovum pick up) and maximum (median 4.7 and 98 nmol/l, respectively) for FVIII, von Willebrand Factor, FVII (activity and antigen), protein C, protein S (free), and plasminogen. In Study I, where much lower hormonal levels were obtained at maximum (oestradiol median 297 pmol/l and progesterone 47 nmol/l), the same pattern was observed especially for FVII, FX, fibrinogen, plasminogen and plasmin inhibitor. Thus, the concentration of a haemostatic variable at a low oestradiol or progesterone level can predict the level at a high hormonal level.

Comparison of the role of cervical and intrauterine insemination techniques on the incidence of multiple pregnancy after artificial insemination with donor sperm

PURPOSE

Our purpose was to investigate the role of the insemination technique used in an artificial insemination program with donor sperm (AID) in multiple pregnancy rates.

METHODS

We carried out a retrospective nonrandom analysis of 300 pregnancies corresponding to 300 cycles in women from our Artificial Insemination Donor Sperm Program. All cycles were stimulated with gonadotropins. Single and multiple pregnancy cycles and intracervical and intrauterine pregnant cycles were compared.

RESULTS

Intracervical insemination was performed in 173 cycles (58%), and intrauterine insemination in 127 (42%). Two hundred twenty-three pregnancies were single (74%), and 77 multiple (26%). In multiple pregnancy cycles, initial dose and mean total daily dose of gonadotropins, plasma estradiol levels, and number of follicles > or = 14 mm were significantly higher compared to those in single pregnancy cycles. Multiple pregnancy rte was significantly higher among pregnancies after intrauterine insemination (32%) than after intracervical insemination (21%).

CONCLUSIONS

The intrauterine technique of insemination in AID-stimulated cycles with gonadotropins is related to multiple pregnancy risk.

EFFECTS OF HUMAN MENOPAUSAL GONADOTROPHIN PREPARATIONS IN DIFFERENT BIOASSAY METHODS

Several gonadotrophin preparations, HMG (Human Menopausal Gonadotrophin), HPG (Human Pituitary Gonadotrophin) and NIH FSH S1 (a FSH preparation distributed by the National Institute of Health) were investigated for biological activity, using three methods of assay.

The rat augmentation test, specific for FSH, and the rat seminal vesicle weight test, specific for ICSH both gave statistically valid results. The potencies were expressed in terms of the IRP (International Reference Preparation for HMG), and the International HCG Standard respectively. The gonadotrophic activity as determined by the rat uterine weight method was expressed in terms of IRP and in terms of the International HCG Standard.

Good agreement was found between the results in the uterine weight method and the seminal vesicle test, suggesting a strong ICSH dependence for the former. On the other hand, the results of the uterine weight method and the augmentation test were not in agreement.

Consequently the rat uterine weight method must be regarded as completely unsuitable for the assay of FSH-activity.

Among the three test methods studied, the augmentation test appears to be the only one suitable for the assay of the FSH content of gonadotrophin preparations for clinical use.

Fractionation of HMG with ethanol led to preparations with high FSH activity, 200 to 300 times that of IRP, but with little ICSH activity.

Most of the ICSH was concentrated in other fractions, indicating that both hormones can be separated. In starch gel electrophoresis these fractions showed different patterns.

[Evaluation of ovarian sensitivity to gonadotrophins: role of ovarian reserve tests]

Among several parameters involved in the age-dependent reduction in conception rate, intra-ovarian factors, specially the follicular oocyte complex, play a major role. The aim of endocrine challenge tests is to assess ovarian follicular reserve. Basal serum FSH determination on day 3 of the cycle is easily measurable, inexpensive. Its sensitivity is increased with a clomiphene citrate challenge test. Both GnRH agonist stimulation test and exogenous FSH test allow to evaluate more directly the ovarian function. However they are more invasive, expensive and need further standardisation.

Elevated interleukin-6 levels in the ovarian hyperstimulation syndrome: ovarian immunohistochemical localization of interleukin-6 signal

OBJECTIVE

To examine the production and immunolocalization of interleukin-6 (IL-6) in patients with the ovarian hyperstimulation syndrome.

METHODS

The study group consisted of patients with ovarian hyperstimulation syndrome (n = 9) from whom serum and ascites samples were obtained. The control samples used were serum (n = 10) and peritoneal (n = 16) and follicular fluids (n = 8) from healthy individuals. Follicular fluid (n = 40) and serial serum samples were also obtained from patients undergoing menotropin stimulation for in vitro fertilization (IVF) before (n = 10) and after ovulation (n = 34). Interleukin-6 measurements were performed with a sensitive immunoassay and confirmed with a bioassay. Immunohistochemical localization of IL-6 was performed with a mouse monoclonal antibody in normal premenopausal (n = 5) and postmenopausal ovaries (n = 5), as well as with cells from stimulated follicular fluid aspirates (n = 3).

RESULTS

We found significantly higher serum and ascites IL-6 levels in ovarian hyperstimulation syndrome (mean 18.8 +/- 1.1 and 810.8 +/- 60.7 pg/mL, respectively) compared with postovulatory serum and peritoneal fluid from normal controls (mean 4.4 +/- .69 and 44.7 +/- 7.5 pg/mL, respectively) (P < .001) or serum after menotropin stimulation (13.1 +/- 1.1 pg/mL) (P < .001). At the time of ovulation, follicular fluid IL-6 levels (normal controls, mean 9 +/- 2.1 pg/mL; menotropin stimulation, mean 10.1 +/- 4 pg/mL) were higher than in preovulatory serum (normal controls, mean 4.5 +/- .8 pg/mL; menotropin stimulation, mean 6.3 +/- 1.4 pg/mL) (P < .001). Immunohistochemical localization of IL-6 revealed intense staining in corpora lutea and theca cells from large antral follicles and luteinized granulosa cells in follicular aspirates after menotropin stimulation.

CONCLUSION

Interleukin-6 levels are markedly elevated in the ovarian hyperstimulation syndrome when compared with controls. The higher follicular fluid IL-6 levels seen suggest local secretion of this cytokine. Immunohistochemical correlation demonstrated IL-6 within ovarian theca cells. These findings suggest a local role for IL-6 both in normal and stimulated ovarian function. Whether IL-6 is directly responsible for the clinical manifestations of this syndrome is unclear. However, when produced in massive amounts, the pro-inflammatory effects of IL-6 may contribute to its pathogenesis and perhaps serve as a marker for the disease.

Sonographically monitored ovarian stimulation for assisted reproduction: a prospective, blind study

OBJECTIVE

To assess prospectively the appropriateness of follicular sonography alone for monitoring ovarian stimulation and to compare it to ovarian monitoring with both follicular sonography and hormone level determinations.

STUDY DESIGN

Prospective, blind, clinical study in which the investigator made cycle management decisions based on follicular sonography only.

RESULTS

Follicular sonography alone predicted 88% of the decisions made by the combination of follicular sonography, luteinizing hormone (LH), estradiol (E2) and progesterone measurements. Follicular sonography was unable to predict abnormal E2 patterns in eight (8%) of the patients' scans. Follicular sonography did not detect three (3%) patients with a premature LH surge.

CONCLUSION

Follicular sonograms alone performed during ovarian stimulation predicted 88% of cycle decisions. One could argue that hormone measurements could be either reduced or eliminated during ovarian stimulation for assisted reproductive technology and that follicular sonography only would be a cost-effective compromise. The effect of such simplified monitoring on pregnancy rates would require further prospective evaluation.

Prorenin is elevated in polycystic ovary syndrome and may reflect hyperandrogenism

OBJECTIVE

To examine the null hypothesis that women with polycystic ovary syndrome (PCOS) produce similar levels of prorenin and other components of the ovarian-derived prorenin to angiotensin cascade (ODPAC) at baseline and after stimulation with clomiphene citrate (CC) or hMG when compared with normal age- and weight-matched ovulatory controls.

DESIGN

Prospective controlled clinical trial.

SETTING

Infertility clinic in a university-based county hospital and a hospital-based private infertility practice.

PATIENTS

Twenty-eight infertile women aged 18 to 35 years. Thirteen patients were diagnosed with PCOS. Fifteen normal ovulatory patients who were matched for age and weight served as controls.

INTERVENTIONS

Twenty patients were stimulated with CC and eight were stimulated with hMG.

MAIN OUTCOME MEASURES

Serum E2, P, T, androstenedione (A), DHEAS, LH, FSH, and plasma prorenin, active renin, and angiotensin II (Ang II) were measured at baseline and during the preovulatory and midluteal phases of the stimulation cycles.

RESULTS

Baseline plasma prorenin in PCOS was higher than that of follicular phase controls. Plasma prorenin correlated significantly with peripheral androgen levels. Prorenin, active renin, and Ang II increased in response to gonadotropins with the largest increases occurring in control patients receiving CC. An association was seen between ovulation with CC and lower baseline levels of active renin.

CONCLUSIONS

The null hypothesis was rejected. Infertile women with PCOS have higher baseline prorenin levels when compared with age- and weight-matched ovulatory controls. There is a significant correlation between prorenin and the peripheral levels of androgens produced during ovarian stimulation. Baseline active renin levels may be predictive of ovulation with CC.

Extended induction of ovulation by human menopausal gonadotropins and a gonadotropin-releasing hormone analog in high responders for in vitro fertilization and oocyte donation

OBJECTIVE

To examine the efficacy of extending ovulation induction for the in vivo maturation of oocytes.

STUDY DESIGN

Fifty-nine high responders underwent 72 in vitro fertilization (IVF) cycles with a conventional protocol of human menopausal gonadotropin and a gonadotropin-releasing hormone analog. These patients donated oocytes to 81 recipients. The same 59 patients underwent 90 subsequent cycles in which the duration of induction was extended by two to three days. The oocytes were also donated to 138 patients.

RESULTS

With the extended protocol, significantly more oocytes were retrieved (29.1 vs. 20.6), and a greater proportion of them were mature. Fertilization rates were significantly higher for both donors (67.7% vs. 36.2%) and recipients (67.5% vs. 47.1%). Conception rates were also significantly higher for both donors (24.4% vs. 11.1%) and recipients (38.4% vs. 24.7%).

CONCLUSION

Extending the duration of ovulation induction in high responders is associated with in vivo maturation of oocytes and improved success rates in IVF and ovum-donation programs.

The effect of multifetal pregnancy reduction on serum relaxin

OBJECTIVE

To determine the effect of multifetal pregnancy reduction on circulating relaxin levels.

METHODS

Patients with multifetal pregnancies had relaxin levels determined on the day of multifetal pregnancy reduction, after the procedure, and late in pregnancy.

RESULTS

Forty-eight women (26 presenting with three fetuses and 22 with four or more) were studied. All pregnancies followed some form of ovulation induction. All pregnancies (except for one, which was reduced to a singleton) were reduced to twins. Pre-procedure, post-procedure and late-pregnancy relaxin levels were significantly higher in the in vitro fertilization (IVF)-gamete intrafallopian transfer (GIFT) group compared with the human menopausal gonadotropin (hMG)-alone group (P < .05). The initial number of fetuses had no significant effect on relaxin levels. Although post-procedure relaxin levels were significantly lower than pre-procedure levels (P = .002), relaxin levels continued to decrease throughout pregnancy, as evidenced by even lower levels later on (P = .0001).

CONCLUSIONS

Serum relaxin levels were significantly higher in the IVF-GIFT group than in the hMG-alone group, which probably reflects more aggressive ovulation induction in the former. Because relaxin levels continued to decrease throughout pregnancy, the difference observed between pre- and post-procedure levels are not considered to be due to the procedure itself.

Comparison of efficacy of high-dose pure follicle-stimulating hormone versus human menopausal gonadotropins for in vitro fertilization

The advent of recombinant DNA technology will soon produce for the market a product that has pure follicle-stimulating hormone (pFSH) but no luteinizing hormone. A prospective randomized study was performed to see if pFSH (Metrodin) was able to stimulate the same in vitro fertilization parameters as human menopausal gonadotropin when preceded by gonadotropin suppression by leuprolide acetate. The results showed similar parameters between the two drugs, i.e., number of oocytes, number of embryos, endometrial thickness at time of human chorionic gonadotropin, fertilization rates and pregnancy rates in a protocol purposely designed to stimulate as many follicles as safely as possible because of a shared oocyte and successful cryopreservation program.

Sperm binding capacity of human zona pellucida derived from oocytes obtained from different sources

The important contributions of sperm-oocyte interaction to infertility diagnostics is well established. Scientists are urged to search for methods to improve the assessment of gamete interaction. Sperm binding and penetration assays have frequented the literature, reporting on various aspects of sperm-oocyte interaction using either microbisected or whole human oocytes during the assay procedure. The objective of the study was to evaluate additional zona pellucida sources which can be used during zona binding studies. Hemizonae were obtained from the following oocytes: 1) experiment 1, prophase I oocytes from post-mortem ovarian tissue from different age groups namely, 7 months, 5 years, 7 years, 12 years and 30 years; 2) experiment 2 used donated immature Prophase I oocytes from the IVF treatment program and 3) experiment 3 evaluated zona binding for hemizonae which were previously used in hemizona assays. Results indicated that, in experiment 1, ovarian age does not have any influence on the zona pellucida's capacity to bind spermatozoa. The mean number of bound sperm among the different age groups did not differ significantly, namely 38.9 +/- 17 (7 months), 31.0 +/- 27 (5 years), 49.3 +/- 21 (7 years), 32.8 +/- 18 (12 years) and 39.5 +/- 17 (30 years). The pooled mean +/- SD binding for all the age groups in experiment 1 was 37.7 +/- 7. Likewise, the mean number of sperm bound (experiment 2) to zonae collected from oocytes using different ovulation induction regimes were 31.1 +/- 20 (unstimulated), 54.4 +/- 12 (HMG/HCG) and 15.3 +/- 9 (HMG alone).(ABSTRACT TRUNCATED AT 250 WORDS)

Regulation of testicular infiltration in acute lymphoblastic leukaemia of the rat

The testis is a common site of relapse in childhood acute lymphoblastic leukaemia (ALL). In adults, testicular relapses of ALL are very rare. A similar age-difference in the frequency of the testicular infiltration exists also in the rat T-cell leukaemia. In the present investigation, the effect of various hormonal treatments and unilateral cryptorchidism on the form of testicular infiltrates by the rat T-cell leukaemia was studied. Inhibition of testicular activity by estradiol treatment (E2) of early pubertal rats injected i.p. with rat T-leukaemic lymphoblasts significantly decreased the proportion of the testis occupied by leukaemic infiltrates. The proportion of the testis occupied by leukaemic infiltrates was significantly higher in the abdominal testes of both early and late pubertal unilaterally cryptorchid rats, than in the scrotal testes of leukaemic control rats. Daily treatment of early pubertal rats with human chorionic gonadotrophin (hCG), or human menopausal gonadotrophin (hMG), did not have an effect on testicular leukaemic infiltration. These studies demonstrate that the leukaemic infiltration of the testis is influenced by the changes in the physiological activity of the testes.

Carbohydrate-deficient glycoprotein syndrome in a girl with hypogonadism due to inactive follicle stimulating hormone

We report a very rare case of a girl with hypogonadism probably due to inactive FSH. She had been diagnosed as carbohydrate-deficient glycoprotein syndrome. The 14-year-old patient had no secondary sexual characteristics with the 46,XX karyotype and estradiol (E2) levels were undetectable. Follicle stimulating hormone (FSH) levels were extremely high and responded exaggeratedly to luteinizing hormone-releasing hormone (LH-RH). The E2 levels, on the other hand, were elevated after stimulation with human menopausal gonadotropin (75 units/day) for 5 days, suggesting biologically inactive FSH in the circulation. Abnormal structure in the glycoprotein may be possibly related with hypogonadism.

Ovulation induction

Induction of ovulation is indicated for anovulatory and amenorrheic women as well as for women who have an inadequate luteal phase. It is also indicated as a strategy for recruiting multiple follicles for women with unexplained infertility and those who are undergoing assisted reproductive technologies. The use of various agents and detection of ovulation are described. This includes a discussion of clomiphene citrate, bromocriptine, human menopausal gonadotropins, urinary follicle stimulating hormone and pulsatile gonadotropin releasing hormone therapy. Regimens, success rates and potential complications of each form of therapy are reviewed. Also discussed is the use of combination therapy and partial ovarian destruction.

The effect of estrogen level on glucose-induced changes in serum insulin-like growth factor binding protein-1 concentration

OBJECTIVE

To investigate the regulation of insulin-like growth factor binding protein-1 (IGFBP-1) concentration during ovarian stimulation.

DESIGN

A prospective study of patients undergoing in vitro fertilization treatment.

SETTING

Infertility unit at the University Central Hospital of Oulu, a tertiary referral center.

PATIENTS

Sixteen healthy, regularly menstruating lean tubal infertility patients.

INTERVENTIONS

Oral glucose tolerance test was performed first in a hypoestrogenic state after suppression by long-term gonadotropin-releasing hormone (GnRH) agonist and, second, in a hyperestrogenic state after stimulation by human menopausal gonadotropins.

MAIN OUTCOME MEASURES

Serum concentrations of IGFBP-1, insulin-like growth factor I (IGF-I), insulin and sex hormone-binding globulin were measured before and 2 hours after glucose administration.

RESULTS

Before and after glucose administration, the serum IGFBP-1 concentrations were significantly higher in the hyperestrogenic state (estradiol [E2] level 3.5 +/- 0.57 nmol/L) after ovarian stimulation than in the GnRH-analogue-induced hypoestrogenic state before the gonadotropin treatment (E2 level 0.10 +/- 0.02 nmol/L). On both occasions glucose-induced hyperinsulinemia caused a significant decrease in the circulating IGFBP-1 levels, whereas the IGF-I levels remained unchanged. There was a significant correlation between E2 and the insulin-suppressed IGFBP-1 level. The sum of follicular diameters correlated positively with the serum IGFBP-1 concentration.

CONCLUSIONS

Gonadotropin-induced hyperestrogenism is related to elevated serum IGFBP-1 levels, either via estrogen-stimulated synthesis or via increased contribution from multiple follicles. Glucose-induced hyperinsulinemia suppresses serum IBFBP-1 concentration equally both in the hypoestrogenic and hyperestrogenic states. Because of similar IGF-I levels, it is likely that the biological activity of IGF-I is different before and after gonadotropin stimulations.

An indirect ELISA for urinary gonadotropins using immobilized human menopausal gonadotropin

An indirect ELISA for the estimation of urinary gonadotropins is described. Human menopausal gonadotropin is adsorbed on a microtitre plate, where it serves as an immunosorbent. The residual antigonadotropin antibody is captured by the immunosorbent after reaction with the sample or standard and detected with enzyme-labelled antispecies antibody (antirabbit gamma-globulin-horse radish peroxidase). The assay developed here is rapid and satisfies usual validatory criteria expected from an immunoassay. Moreover, it obviates the need for extraction of samples with acetone, as shown by the close agreement between the respective lutropin or follitropin concentrations in extracted and unextracted urine samples.

Localization and detection of ovarian follicular fluid protein in follicles of human ovaries

Human ovarian follicular fluid protein has been partially purified and the active fraction designated as hGF2. Using specific polyclonal antiserum to hGF2, it was observed to be localized immunohistochemically in the granulosa cells of medium but not large follicles of human ovary. The hGF2 levels were estimated by ELISA in serum and follicular fluid of 10 gonadotropin-stimulated women recruited for IVF-ET programme. The results revealed a 3-fold increase in the concentration of hGF2 in follicular fluid compared to that in serum of these patients. These data indicate that the protein is secreted by granulosa cells and plays an important role in the regulation of follicular maturation and ovulation.

True hermaphroditism: pre- and postoperative evaluation of gonadal function and the necessity of endoscopic examination for the search of cervix uteri at an early stage of diagnosis

Three previously unreported cases of true hermaphroditism are described and discussed with regard to their gonadal function and the value of endoscopic examination. All three patients showed a good response of serum testosterone to stimulation with human chorionic gonadotropin before gonadal biopsy. The third patient showed significant elevation of serum oestradiol level on stimulation with human menopausal gonadotropin at two years of age before operation. Endoscopic examination to search for cervix uteri at an early stage of diagnosis, and pre- and postoperative functional evaluation of the gonads by hormonal stimulation are emphasized.

Early miscarriage and fetal malformations after induction of ovulation (by clomiphene citrate and/or human menotropins), in vitro fertilization, and gamete intrafallopian transfer

From the reviewed data, it appears that CC, hMG-hCG, or the association of these drugs with IVF-ET and GIFT programs do not carry an increased risk for congenital malformations as a whole, nor is there any specific malformation that has an increased incidence or is related in any way with the use of these drugs. Table 7 represents the specific malformation rate per 1,000 births in the general population and in newborns delivered after treatment with CC, hMG-hCG, or IVF-ET and GIFT. The malformation rate in the treated groups does not differ from that of the general population. However, as shown by McIntosh et al., the incidence of congenital malformations often rises with a longer follow-up. Most of the reports about babies born after ovulation induction are based on the initial examination done shortly after birth. Thus, studies including examination of these infants up to at least 12 months of age will be undoubtedly of value. Also, data concerning the reproductive capability of women born after ovulation induction is lacking. With regard to the abortion rate in pregnancies achieved after such treatments and procedures, it can be concluded that it does not appear to be higher than that of the general population, particularly when early pregnancy loss, advanced maternal age, the infertility status, and the increased incidence of multiple pregnancies occurring in these patients are taken into consideration.

Ovarian response patterns to human menopausal gonadotropin in mixed hyperandrogenemia

Twenty-eight hyperandrogenemic women suffering from infertility owing to chronic anovulation were treated with hMG. Only 7 patients exhibited the typical polycystic ovarian appearance of multiple subcortical cysts, however, a wide range (6-15 cm3) of ovarian volume was observed. The LH/FSH ratio was consistently lower than 2.5 and circulating androgens of both ovarian and adrenal origin were elevated. The 4 days dexamethasone suppression test showed more than 80% suppression of dehydroepiandrosterone-sulphate and a variable (40-60%) reduction of testosterone and androstenedione levels. Two different patterns of follicular development were observed in response to hMG. Sixteen patients exhibited polycystic ovarian reaction, whereas 12 women had a follicular growth pattern similar to that seen in hMG-stimulated normo-ovulatory subjects. Patients with polycystic ovarian reaction showed a significantly increased androstenedione response to hMG when compared with the other group. Moreover, the non-stimulated ovarian volume was found to be markedly greater than in subjects without polycystic reaction. Thus, ovarian stimulation of patients with mixed hyperandrogenemia may elucidate the presence of borderline polycystic ovaries; furthermore the increased accumulation of androstenedione may suggest an inherent ovarian failure.

In vitro fertilization in unstimulated cycles: a new application

After four unsuccessful attempts at multiple follicular induction with exogenous gonadotropins, a patient underwent two attempts at IVF in spontaneous cycles triggered with hCG. The second attempt resulted in the transfer of three embryos and a successful singleton intrauterine pregnancy. We believe that unstimulated IVF is a viable option for patients with ovulatory cycles. It should be considered in cases of failed hyperstimulation, and may become a primary treatment option in the future.

Hypothalamic-pituitary-gonadal axis in thalassemic patients with secondary amenorrhea

Eight thalassemic patients, aged 24-35 years, who developed amenorrhea 2-15 years after menarche, were studied. Mean basal serum LH and FSH levels and the peak levels after gonadotropin-releasing hormone were significantly less than corresponding values in normal controls. All patients showed low basal serum levels of estradiol and six had a poor or absent response to human menopausal gonadotropin. One subject had intact pituitary-gonadal function and one patient had an impaired LH and FSH response to gonadotropin-releasing hormone in the presence of a significant increase of estradiol after human menopausal gonadotropin stimulation. The findings regarding pituitary hormones other than gonadotropins suggest that iron overload damages tropic cells unequally and inconsistently. We conclude that both pituitary and gonadal damage may be responsible for the secondary amenorrhea in thalassemic patients.

The first reported case of Down syndrome in the Southern California Fertility Institute's in vitro fertilization and embryo transfer program

The first case of a genetic abnormality in a 3-year in vitro fertilization and embryo transfer program was diagnosed after routine amniocentesis of a 38-year-old patient. The G-banded karyotype analysis gave 47, XY, +21, which constitutes an abnormal chromosome pattern consistent with Down syndrome.