Midluteal serum progesterone levels and pregnancy following ovulation induction with human follicle-stimulating hormone: results of a combined-data analysis

OBJECTIVE

This retrospective analysis of combined data (one Phase II and three Phase III clinical trials) of patients with oligo- or anovulatory infertility aimed to evaluate the association between pregnancy and midluteal serum progesterone (P4) level following ovulation induction and hence the indicative value of P4 for ovulation and pregnancy achievement.

STUDY DESIGN

All patients (n = 913) were treated with human follicle-stimulating hormone. Cycles (n = 1,554) with one or two serum P4 levels in the luteal phase (days 5-12) following human chorionic gonadotropin administration and complete data on cycle outcome were included.

RESULTS

Clinical pregnancy was achieved in 295/1,554 (19.0%) cycles; 87.5% of these led to live births (16.6%/cycle). Including and excluding multiple pregnancy data, 88% and 86% of all live births had P4 values >10 ng/mL, respectively. Overall clinical pregnancy rate plateaued at midluteal P4 levels >25 ng/mL but, when multiple pregnancies were excluded, plateaued at 20-25 ng/mL and then decreased. Mean midluteal P4 levels were twice as high in multiple versus singleton pregnancies.

CONCLUSION

A midluteal P4 level >10 ng/mL may represent an appropriate threshold for indication of ovulation resulting in live birth. Multiple pregnancies were associated with higher mean midluteal P4 levels.

Effects of urinary gonadotrophin preparations on human in-vitro immune function

Among commercially available urinary human menopausal gonadotrophin (HMG) material, gonadotrophins comprise <5% of the total protein content. Thus, during a typical ovarian stimulation cycle with HMG, several milligrams of non-relevant proteins are administered that may lead to unwanted side effects, including allergic or other hypersensitivity reactions. The effects of two recombinant and four urinary gonadotrophin preparations of different purity upon the function of T cells from healthy blood donors were studied. Only one of the HMG preparations significantly enhanced the spontaneous proliferation of peripheral blood mononuclear cells. Phytohaemagglutinin-induced proliferation was not modified by any preparation, while two preparations significantly increased proliferation in the mixed lymphocyte reaction. Three of the HMG preparations induced the release of interleukin (IL)-1. Highly purified FSH, either urinary or recombinant, showed no effect. None of the preparations induced detectable IL-2 production, whereas only one HMG preparation tended to decrease IL-2 secretion. No major changes in CD25 expression were induced by any of the gonadotrophins. Cytokine measurement by immunoassays detected only IL-1beta in two commercially available preparations. The various effects exhibited by the crude urinary preparations were not a result of the gonadotrophin content and differed from product to product, suggesting that the contaminants present in these preparations are not identical. This could contribute to unpredictable clinical manifestations of allergic or other immune reactions.

Localization of human follicle-stimulating hormone in the testis

Localization of the follicle-stimulating hormone (FSH) molecule and its receptor (FSHR), as well as the role of FSH in Sertoli cell mitosis and maturation, has been demonstrated by several investigators in human and murine testis by detecting the localization of anti-FSH antibodies or [(131)I]-labeled FSH and by detecting FSH receptor (FSHR) mRNA by in situ hybridization, or FSHR by anti-FSHR antibodies. The presence of FSH in germinal cells is controversial or, in humans, excluded. We have investigated the distribution of the human FSH molecule and its receptor in human and mouse testicular cells under different experimental conditions, at the submicroscopical level, by using a better antigenicity conservative procedure. Thus, the distribution of FSH and of the messenger RNA for its receptor in Sertoli cells has now been clarified. In germinal cells, our observations demonstrate the presence of FSH and the FSHR mRNA: the first on the plasma membrane and in endocytotic vesicles, and the second scattered in the cytoplasm. The cells presenting the higher amount of positivity ranged from spermatogonia to spermatocytes, including round spermatids. Penetration was by the endocytosis via membrane vesicles in which the FSHR is present, whereas its messenger is largely present in the cytoplasm and is responsible for the binding and subsequent internalization of the FSH molecule. As a control, human FSH was administered in vitro to the Y1 mouse cell line, which was stably transfected with cDNA for FSHR and devoid of endogenous FSH. The FSH molecule has been localized by monoclonal antibodies on plasma membranes and vesicles, and the FSHR mRNA was found scattered in the cytoplasm after in situ hybridization. We can now conclude that FSH is present in Sertoli cells and in round germinal cells, both expressing the FSHR. FSH penetrates in a similar way in both kinds of cells via endocytosis, and is therefore subsequently localized in the same membranous organelles.

Composition of commercial gonadotrophin preparations extracted from human post-menopausal urine: characterization of non-gonadotrophin proteins

Gonadotrophin preparations extracted from post-menopausal urine are of low purity and the major protein components are not gonadotrophins. A study was undertaken to identify some of these non-gonadotrophin proteins present in the extracted human urinary gonadotrophin preparations that are commercially available, i.e. Humegon (Organon), HMG Massone (Massone), Metrodin (Serono), Metrodin HP (Serono), Pergonal (Serono) and Progonadyl (Elea). As revealed by sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE) with Coomassie blue staining and Western blotting analysis, these products had electrophoretic protein profiles which differed in the amounts and species of proteins present. With the exception of Metrodin HP, all the other preparations tested contained tumour necrosis factor binding protein-I, transferrin, and immunoglobulin-related proteins. Some of the products contained in addition: urokinase, Tamm-Horsfall glycoprotein and epidermal growth factor. Recently, a highly purified human urinary follicle stimulating hormone (FSH) preparation (Metrodin HP) became available. In this preparation human FSH represents > 95% of the total proteins (approximately 10,000 IU of FSH/mg of protein). Metrodin HP was demonstrated to be the purest preparation tested, with none of the above-mentioned contaminants detected.

Allergenic potential of gonadotrophic preparations in experimental animals: relevance of purity

Local reactions have been frequently reported following repeated injections of human menopausal gonadotrophins (HMG) for the treatment of infertility. Also immunoglobulin (Ig) E-mediated systemic reactions have sporadically been observed. Since most HMG preparations contain significant amounts of non-hormonal urine-derived proteins, it was suggested that these contaminating proteins are responsible for the various allergic reactions. In order to verify this hypothesis, different human follicle stimulating hormone (HFSH) and HMG preparations (Metrodin and Pergonal from Ares-Serono, and Humegon from Organon), were compared with a highly purified preparation (Metrodin HP from Ares-Serono) for the frequency and severity of allergic reactions induced in laboratory animals. The occurrence of anaphylactic shock or related symptoms was studied in sensitized guinea-pigs. The production of specific IgE was evaluated in serum from mice sensitized with the test drugs by the induction of passive cutaneous anaphylaxis in rats. In both models, two different schedules of sensitization were used. Severe allergic reactions were found in 20 of 7% of the guinea-pigs receiving highly purified FSH (Metrodin HP) in the two schedules, respectively, compared to 90 and 88% with the other preparations. Similarly significantly lower IgE titres were induced by highly purified FSH in respect to the other preparations. It can be concluded that the elimination of contaminating proteins significantly reduces the allergenicity of urine-derived HFSH preparations.

Binding kinetics of the long-acting gonadotropin-releasing hormone (GnRH) antagonist antide to rat pituitary GnRH receptors

The GnRH antagonist Antide has been shown to produce prolonged inhibition of gonadotropin secretion in ovariectomized monkeys and other animal models. The reasons for such a long duration of action have not yet been clarified. To understand the mode of action of this new antagonist, we have performed association and dissociation binding kinetics using either crude rat pituitary homogenates as source of GnRH receptors or dispersed pituitary cells in culture. The binding characteristics of the radioiodinated Antide analog 125I-labeled[D-Tyr0] Antide to GnRH receptors in rat pituitary homogenates were comparable to those of the first generation GnRH antagonist 125I-labeled [Ac(3)Pro1,pFD-Phe2,D-Trp3,6]GnRH or the GnRH agonist 125I-labeled [D-Trp6,(N-Et)Pro9,Des,Gly10]GnRH, with an affinity constant (Ka) in the 10(10) M-1 range. The maximum binding capacity was consistently higher with the antagonist tracers than with the [125I]GnRH agonist. Both antagonists dissociated at a slower rate at 4 C (approximately 4 times) than the [125I]GnRH agonist. Incubation at 23 C of 125I-labeled [D-Tyr0] Antide previously bound at 4 C resulted in complete dissociation within 8 h after the addition of an excess amount of any of the GnRH analogs; in addition, simple dilution of the incubation medium produced spontaneous dissociation at this temperature. Using rat pituitary cells, Antide was found to inhibit the LH response to native GnRH (10(-8) M) in a dose-related manner. To test whether the binding of Antide is normally reversible at 37 C, Antide (10(-7) M) was added to the culture medium 3 days after cell plating, and the initial preincubation was resumed for 24 h. Cells were then washed twice, and dissociation was allowed to take place. Bound Antide was shown to dissociate rapidly at 37 C, as cells previously treated with Antide produced a full LH response within 24 h if challenged with native GnRH. In conclusion, the binding kinetics of 125I-labeled [D-Tyr0]Antide to GnRH receptors, which should reflect those of Antide, did not present abnormal features. Although this antagonist, similar to other GnRH antagonists, dissociated from pituitary receptors at a slower rate than GnRH analogs, rapid and spontaneous dissociation was achieved at 23 C with simple dilution, and dissociation of unmodified Antide occurred at 37 C. Taken together, our results support the concept that the long duration of action of Antide is not due to any toxic effect of Antide at the receptor site and could derive only marginally from the slow dissociation rate of this antagonist.

Neural tube defects after infertility treatment: a review

OBJECTIVE

To investigate whether an association exists between ovulation induction and neural tube defects (NTDs).

MATERIALS AND METHODS

Risk estimations in the medical literature were identified through Medline, and validity and power were assessed. Large in vitro fertilization-embryo transfer (IVF-ET) registries represent another source of information. The total number of NTDs and the total number of fetuses were computed from five registries. These data were expressed as proportions and compared with data from the general population.

RESULTS

Only one study could be identified as both valid and powerful, through literature review. This case-control study concluded there was no association between ovulation induction and NTDs. The pool of IVF-ET registry data represents another powerful epidemiologic tool. Analysis of the registry data confirms the findings of the case-control study.

CONCLUSIONS

Ovulation induction does not seem to represent a risk factor for NTDs in the offspring.

Effects of uncomplicated acute myocardial infarction on biochemical parameters of stress and sexual function

The blood levels of several "stress indicators" (prolactin [PRL], growth hormone [hGH], total catecholamines, and adenosine 3',5'-cyclic monophosphate [cAMP]) were measured in men during the first 2 weeks of uncomplicated acute myocardial infarction (AMI) and during a 3-month follow-up period. PRL levels were significantly elevated during the first day, and hGH was elevated during the week after the AMI. The levels returned to the control baseline values thereafter. The levels of the total catecholamines and cAMP in blood remained normal throughout the study period. Sexual function during the 3-month follow-up was measured in 29 patients, using a specially designed questionnaire. Impotence was found in five patients and decreased libido in four. No correlation was noted between PRL values, the other stress indicators, and sexual dysfunction. A trend toward increased incidence of sexual dysfunction was found among patients with recurrent AMI.

Combination ultrafiltration and 6 M urea treatment of human growth hormone effectively minimizes risk from potential Creutzfeldt-Jakob disease virus contamination

Although genetically engineered human growth hormone (hGH) is now commercially available, native pituitary-derived hGH is still used by physicians in many countries for the treatment of hormone deficiency states. We describe a method using ultrafiltration and 6 M urea that reduced infectivity in human pituitary tissue that had been deliberately contaminated with scrapie virus (an animal analogue of human Creutzfeldt-Jakob disease virus) from an initial level of 10(9.7) infectious units to just 5 infectious units. Based on estimates of the frequency of contamination and infectivity levels in batches of human pituitaries, the use of this protocol to prepare GH from cadaveric human glands yields a calculated probability of exposure to a contaminated vial of not greater than 1 in 3.2 million recipients; therefore, native hormone prepared by this method may be considered to be essentially risk-free. The same methodology may be useful in the preparation of other hormones, such as prolactin, for which no synthetic substitutes are currently available, as well as biological products derived from sheep or cattle, that may be infected with scrapie or bovine spongiform encephalopathy.

Growth hormone (GH) deprivation induced by passive immunization against rat GH-releasing factor delays sexual maturation in the male rat

GH deprivation after passive immunization against rat GRF (rGRF) markedly affects somatic growth in male rats. Since it has been postulated that GH and probably insulin-like growth factor-I (IGF-I) might have a permissive role on sexual maturation, the effects of GH deprivation on the course of sexual maturation were tested. Male rats were treated with a potent anti-rGRF serum between 15 and 39 days of life (0.25 ml administered sc every second day). Body weight of treated rats averaged 62% of that of control (normal rabbit serum-treated) rats at 40 days of life (d), and 64% at 50 d after which age, treated rats started to grow normally. At 40 and 50 d, pituitary GH content was very much depressed (representing approximately 20% of control values at both ages), plasma GH was undetectable, and plasma IGF-I levels averaged 30% of those of control rats. At 70 d, 30 days after cessation of treatment, pituitary GH content, and IGF-I secretion were almost normal. At 40 d, testes and seminal vesicles of treated rats were small-for-age in agreement with significantly decreased plasma levels of FSH and delayed spermatogenesis characterized by the presence of only few or no spermatozoa. At 50 d, 10 days after cessation of anti-rGRF injections, progress of sexual maturation was found to be consistent with age and coincided with normalization of growth rate. At 40 and 50 d, pituitary contents of FSH and LH were severely decreased but became normal at 70 d. In conclusion, GH deprivation which markedly affected somatic growth induced a transient delay of sexual maturation. GH deficiency seems to have affected mostly the synthesis and secretion of FSH, thus producing a delay in testes growth and in the differentiation of the germinal cells. The low levels of IGF-I might also have been the cause for the delay of maturation at the pituitary and/or the gonadal levels.

Adrenal response to adrenocorticotropin stimulation in unexplained infertile women

The response to a rapid intravenous administration of adrenocorticotropin (ACTH, cortrosyn) was compared in 24 unexplained infertile women and 13 fertile women. There was no significant difference in the response to a rapid ACTH stimulation as expressed by the slope of testosterone (T) response in both groups. However, the individual and mean T values prior and following the stimulation were significantly higher in the infertile group (P less than 0.001; P less than 0.005, respectively). There was no significant difference in individual values as well as in mean basal values or in mean values of 17-hydroxyprogesterone (17-OHP) after the stimulation between the two study groups (P less than 0.3; P less than 0.9, respectively). There was no significant difference in individual values as well as in mean values of dehydroepiadnrosterone (DHEA) before or 90 min after the stimulation between the two study groups (P less than 0.1; P less than 0.2, respectively). It can therefore be concluded that the elevated basal testosterone values in the infertile group originated from the ovary. Despite the fact that no attempt was made to reduce androgen values 7 (46.66%) of 15 infertile women who were available for follow-up and treatment conceived following ovulation induction therapy.

Plasma growth hormone (GH) response to intravenous GH-releasing factor (GRF) in adult rats: evidence for transient pituitary desensitization after GRF stimulation

The ability of human (h)GRF-(1-29)NH2 to stimulate GH secretion was studied in cannulated adult rats. In order to suppress endogenous GRF secretion and the inhibitory action of hypothalamic somatostatin (SRIF), rats were anesthetized with sodium pentobarbital. Intravenous administration of hGRF-(1-29)NH2 elicited a dose-dependent response of plasma GH, with 250 ng/kg being the smallest effective dose in male rats. In female rats, for each dose tested (250 to 70,000 ng/kg), the GH response represented only about 60% that of male rats. Repeated iv stimulations with hGRF-(1-29)NH2 at short time intervals (45 min) produced transient desensitization of pituitary responsiveness to GRF: a blunted GH response to the second and third stimulations was observed both in male and in female rats and for each dose tested. Similar blunted responses were also obtained with repeated injections of native hGRF-(1-44)NH2. The possibility that these blunted responses could be due to incomplete suppression of hypothalamic SRIF secretion by sodium pentobarbital was excluded by the use of rats that were passively immunized against SRIF; in these rats, it was shown that at least 65% of the inhibition of the GH response after the second GRF stimulation was unrelated to SRIF action. Similar transient desensitization to repeated hGRF-(1-29)NH2 stimulations was also observed in conscious rats that were passively immunized against SRIF. This occurrence of blunted responses was shown to be related to the length of the time interval between GRF stimulations, with longer intervals resulting in less or no desensitization. It appears thus that modulation of pituitary responsiveness to the action of GRF is mediated by at least two independent mechanisms in the rat: in addition to the inhibitory action imposed by hypothalamic SRIF, which induces periods of refractoriness to the action of GRF, it was shown in this study that in the pituitary level each GRF stimulation also induces a transient desensitization of somatotrophs for about 1 h. This period of refractoriness might not be due to excessive stimulation with GRF, since it was also observed with the lowest dose of hGRF-(1-29)NH2 that gave a significant release of GH. Finally, a sex difference was confirmed for the response of anesthetized adult rats to stimulation with hGRF-(1-29)NH2, reflecting a sex steroid-induced modification of pituitary responsiveness to GRF stimulation.

Hyperinsulinemia--a link between glucose intolerance, obesity, hypertension, dyslipoproteinemia, elevated serum uric acid and internal cation imbalance

A representative sample (n = 1211) of the Jewish population in Israel age 40-70 (excluding known diabetics), underwent a glucose tolerance test. Insulin response was found to be independently and positively associated with the GOH conditions--glucose intolerance (p less than 0.001), obesity (p less than 0.001), and hypertension (p less than 0.01) and with elevated serum uric acid (p less than 0.001) after accounting for the effects of sex, age, serum creatinine and use of antihypertensive medications. In a representative subgroup of 542 individuals, total VLDL and LDL fractions were estimated by standardized values (based on the reference group--individuals free of the GOH conditions), of their cholesterol and triglyceride components. Hyperinsulinemia was characterized by jointly elevated VLDL and LDL with reduced HDL. The risk ratio for this pattern (adjusted for the effects of age, sex, smoking and presence of any of the GOH conditions) was 3.4 (p less than 0.001). There was no further association of this disturbed lipoprotein profile with the GOH conditions. Cation concentrations were determined in a stratified subsample (n = 89) of the study group. The subsample comprised 30 individuals in the reference group, and 59 representing each of the seven possible combinations of abnormal glucose tolerance, obesity and hypertension (GOH group). Rate of cation imbalance defined as presence of at least one of three cation concentration--red blood cell sodium greater than or equal to 7.0 mEq/l, red blood cell potassium less than 92.5 mEd/l or plasma potassium greater than or equal to 4.5 mEq/l was 88.1% in the GOH, compared to 40.0% in the reference group (p greater than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Excretion of total estrogens and estrone-3-glucuronide during treatment with human menopausal gonadotropins

HMG treatment is usually monitored by the evaluation of the cervical mucus, the determination of plasma 17 beta-estradiol, total urinary estrogens, ultrasonographic evaluation or a combination of these. We evaluated the daily validity of estrone-3-glucuronide excretion in urine as an indicator of follicular growth and maturation in 28 infertile women who were treated with HMG (Pergonal 500). Total urinary estrogens and estrone-3-glucuronide were measured in 24 h urine collections, and 11 of the women collected the early-morning urine separately. This allowed comparison of the concentrations and excretion of total estrogens and estrone-3-glucuronide of the 24 h urine with that found in the urine collected overnight. This comparison was made on 83 urine samples. The correlation between either the total excretion per 24 h or the concentration per liter in the 24 h urine collection of the two systems of determination was good in all determinations. Also in the urine collected on the day prior to HCG administration, total estrogens measurement was in good correlation with the estrone-3-glucuronide. However, there was statistically a significant difference in the concentrations of total estrogens and estrone-3-glucuronide between the women who ovulated and those who did not. Estrone-3-glucuronide, when calculated as a percentage of the total estrogens, was 60.86% in the women who ovulated and 33.15% in those who did not. These results demonstrate that although estrone-3-glucuronide reflects ovarian function in women treated with HMG, it may serve as a better predictor to ovulation.

Hyperinsulinemia. A link between hypertension obesity and glucose intolerance

Hypertension and glucose intolerance, determined in a random population sample (n = 2,475), showed a highly significant (P less than 0.001) association from the mildest levels of both conditions, independent of the confounding effects of age, sex, obesity, and antihypertensive medications. Summary rate ratios for hypertension were 1.48 (1.18-1.87) in abnormal tolerance and 2.26 (1.69-2.84) in diabetes compared with normal tolerance. Altogether, 83.4% of the hypertensives were either glucose-intolerant or obese--both established insulin-resistant conditions. Fasting and post-load insulin levels in a representative subgroup (n = 1,241) were significantly elevated in hypertension independent of obesity, glucose intolerance, age, and antihypertensive medications. The mean increment in summed 1- and 2-h insulin levels (milliunits per liter) compared with nonobese normotensives with normal tolerance was 12 for hypertension alone, 47 for obesity alone, 52 for abnormal tolerance alone, and 124 when all three conditions were present. The prevalence of concentrations (milliequivalents per liter) of erythrocyte Na+ greater than or equal to 7.0, K+ less than 92.5, and plasma K+ greater than or equal to 4.5 in a subsample of 59 individuals with all combinations of abnormal tolerance obesity and hypertension was compared with those in 30 individuals free of these conditions. Altogether, 88.1% of the former vs. 40.0% of the latter group presented at least one of these three markers of internal cation imbalance (P less than 0.001). We conclude that insulin resistance and/or hyperinsulinemia (a) are present in the majority of hypertensives, (b) constitute a common pathophysiologic feature of obesity, glucose intolerance, and hypertension, possibly explaining their ubiquitous association, and (c) may be linked to the increased peripheral vascular resistance of hypertension, which is putatively related to elevated intracellular sodium concentration.

Clinical, endocrine and ultrastructural study of XY gonadal dysgenesis. A case report

About 120 cases of XY gonadal dysgenesis have been reported on. We treated such a patient with bilateral gonadectomy. The gonadal tissue's capacity to respond to hormonal trophic stimulation was assessed. When the gonads were examined ultrastructurally, structures with the morphologic characteristics of stromal ovarian cells, Sertoli's cells and Leydig's cells were found. Because of the potential malignancy of the XY gonads, bilateral gonadectomy and hormonal substitution therapy are recommended for these patients. We prefer to use combined hormone replacement with sequential estrogen and progesterone rather than sequential unopposed estrogen because of the small but increased risk of endometrial hyperplasia and carcinoma after long-standing sequential therapy.

Diet and weight loss: their effect on norepinephrine renin and aldosterone levels

The effect of low calorie diet on blood pressure, catecholamines, plasma renin activity (PRA) and aldosterone was examined in 22 obese subjects (19 hypertensives and 3 borderline hypertensives). A significant decrease in blood pressure (P less than 0.05) was observed in all patients after 10 days on the diet. Twenty subjects showed a significant decrease in norepinephrine (NE) levels (P less than 0.05) and two patients showed an extreme increase in NE level. On reexamination six months later these two patients presented with high NE levels and predict blood pressure levels despite having lost 15 and 18 kg respectively. The study group showed a significant decrease in mean PRA (P less than 0.05). A correlation was observed between changes in NE levels and PRA (r = 0.42, P less than 0.05) and between changes in PRA and aldosterone (r = 0.54, P less than 0.05). The reduction in blood pressure associated with caloric restriction in these obese patients may be a result of reduced sympathetic nervous system activity.

Enhanced response of plasma aldosterone to metoclopramide in essential hypertension

Aldosterone responses to posture and the dopamine antagonist, metoclopramide, were studied in seven normotensive controls and 12 patients with essential hypertension. Both groups had similar basal supine plasma renin activity and aldosterone levels. Aldosterone levels of the hypertensive patients were greater than those of the controls 10 min after assuming an upright posture but indistinguishable at 120 min. Metoclopramide induced a peak fourfold increase above basal aldosterone levels in the hypertensive group as compared to a peak twofold increase observed in the normotensive controls. Mean 120-min integrated aldosterone response area for the hypertensives (237 +/- 44 10(-10) mol min/l) was greater (P less than 0.05) than that for normotensive subjects (106 +/- 32 10(-10) mol min/l). Simultaneous cortisol, plasma renin activity, and serum potassium levels were unaffected by metoclopramide. It is concluded that dopaminergic modulation of aldosterone secretion may be altered in essential hypertension.

The renal effects of radiocontrast administration during cardioangiography in two different groups with congenital heart disease

Renal effects of the administration of contrast media during cardiac catheterisation were compared in two groups of patients with congenital heart diseases. Group A consisted of 21 patients with cardiac malformations, characterised primarily by left ventricular volume overload and known to be associated occasionally with left heart failure, such as: left to right shunts and left ventricular valvular defects. Group B consisted of 23 patients with lesions affecting the right ventricle which are rarely associated with left heart failure, such as: Tetralogy of Fallot and Pulmonic stenosis. Patients in Group A showed a significant increment in both plasma creatinine and uric acid levels in the 24 h following heart catheterisation. This observation was significantly more prominent in the older age group (above the age of 5 years). In Group B no changes in these parameters were encountered. Plasma renin activity and fractional sodium excretion increased and decreased respectively, by a similar degree in both groups in the 24 h following contrast media administration. No difference in renal tubular handling of uric acid was observed between both groups, nor did any of the patients studied demonstrate any degree of proteinuria or abnormality in the urine sediment, prior to or following heart catheterisation. We suggest that chronic pre-existing left ventricular overload should be considered a risk factor among the other known risk factors which promote the incidence of acute renal failure after contrast media administration.(ABSTRACT TRUNCATED AT 250 WORDS)

Sex reassignment in a girl with 11 beta-hydroxylase deficiency

A two-month-old infant was referred to our department because of a short penis (2 X 1.2 cm). No testes were palpable. Acceleration of growth and bone age were observed. Laboratory results showed that serum urea, nitrogen, electrolytes and urinary sodium excretion were all normal. However, levels of serum testosterone (2.1 ng/ml), 17-OH-progesterone (1.8 ng/ml), and 11-deoxycortisol (33 ng/ml) were all high. Urinary excretion of 17-ketosteroids and tetrahydro-s (tetrahydro-pregnane-3 alpha, 17 alpha, 21-triol-20-one) were also very high. Analysis revealed a 46 XX chromosome; laparoscopy revealed normal internal female genitalia. The abnormal concentrations of metabolites were corrected by cortisol acetate treatment. Thus, the diagnosis of virilizing congenital adrenal hyperplasia (11 beta-hydroxylase deficiency) was confirmed. Under our guidance the parents raised the infant as a girl. Reduction clitoroplasty and reconstruction of female external genitalia were performed at the age of 22 months. Early medical, psychological and surgical treatment of children with virilizing congenital adrenal hyperplasia should enable them to become normal adults.

Breast engorgement and galactorrhea after preventing premature contractions with ritodrine

Breast engorgement and galactorrhea were observed in many patients receiving ritodrine treatment to delay labor due to premature contractions. In an attempt to understand the causes for these phenomena, serum prolactin, progesterone, estradiol and estriol excretion were measured in 11 women. No statistical difference was found in these parameters after ritodrine administration. It can thus be assumed that breast engorgement and galactorrhea after ritodrine treatment are unrelated to changes in these hormones but might be mediated by some other factors or probably by the premature contractions themselves.

Aldosterone concentrations in dehydrated infants

The mean serum aldosterone concentration of 37 infants with acute gastroenteritis and dehydration was markedly elevated on admission (mean +/- SE 94.3 +/- 12.1 ng/ml) and approximated to normal values (18.2 +/- 3.7 ng/ml) following recovery from the acute disease (t=3.56 p less than 0.005). Serum aldosterone levels were significantly positively correlated with the percent weight loss (r=0.41, p less than 0.05) and with the blood urea nitrogen levels (r=0.55, p less than 0.001). There was no correlation between either serum sodium levels or blood osmolarity and aldosterone concentrations. Serum potassium levels were positively correlated with aldosterone levels (r=0.53, p less than 0.001). These findings indicate that small infants when dehydrated respond appropriately with elevated aldosterone levels. The amount of body fluid depletion and hyperkalemia are the major factors determining the amount of aldosterone response.

Endocrine profile in patients with Klinefelter's syndrome

Twenty-seven patients with Klinefelter's Syndrome, aged 19-38 years were divided according to the basal testosterone (T) levels into sub-eugonadal (less than or equal to 3 ng/ml) and eugonadal (greater than 3ng/ml) groups. The pretreatment T level was 3.21 +/- 1.59 ng/ml. The LH and FSH levels, 14.54 +/- 6.68 mIU/ml and 21.51 +/- 10.74 mIU/ml respectively, were above the upper eugonadal range. Short-term hCG treatment stimulated T production significantly and a further increase was observed following long-term hCG treatment. In patients with sub-eugonadal levels of basal T, a greater relative increment of the T level was observed following the hCG stimulation but not in the absolute T increase. Thus, the assumption that in Klinefelter's patients, the low basal T levels and the relative refractoriness to hCG stimulation are secondary to chronic exposure to elevated LH levels, could not be supported. Higher FSH levels were associated with elevated plasma T levels (p less than 0.025). No such association was established with the LH.

Inability of round acrosomeless human spermatozoa to penetrate zona-free hamster ova

The spermatozoa from five healthy men of proved fertility and five infertile men with a single abnormal semen parameter associated with high proportion of round acrosomeless heads were evaluated for their ability to bind to and to penetrate zona-free hamster ova. Sperm from five men of proved fertility penetrated a high proportion of the eggs (16-80%) while sperm from men of the infertile group failed to bind and to penetrate any of the ova. Round acrosomeless sperm do not have the ability to bind to or to fuse with the vitellus of zona-free hamster eggs.

Idiopathic hypercalciuria: a familial generalized renal hyperexcretory state

Twenty-two children with idiopathic hypercalciuria (IH) as well as their parents and siblings were compared to 29 control children and their parents and siblings. Urinary calcium excretion following calcium deprivation or calcium loading was significantly higher in parents and siblings of the IH children than in the corresponding controls. Significantly higher rates of glomerular filtration and increased urinary excretion of sodium potassium and phosphate were found in all family members in the IH group as compared to controls. Significant positive correlations of the five variables studied (glomerular filtration and urinary excretion of calcium, phosphate, sodium, and potassium) were noted within individuals and also within families, both in the IH and the control groups, notwithstanding the lower mean levels in the latter. Serum concentrations of calcium, phosphate, potassium, and sodium were similar in the IH and controls. The distributions of all urinary variables in both the IH and control groups were unimodal with considerable overlap of the two groups, suggesting that IH may be a single entity, possibly representing the upper end of normality. Our data seem to indicate that IH is more likely to be due to nutritional than to genetic factors, since maintenance of sodium potassium homeostatis in the face of increased excretion necessitates increased ingestion of these electrolytes, while increased sodium ingestion is known to be associated with increased urinary excretion of calcium, potassium, and phosphate.

Microphallic hypospadias: testosterone therapy prior to surgical repair

The surgical repair of hypospadias may be more difficult in boys with microphallus than in those with a penis of normal size. Temporary enlargement of the abnormally small penis can be achieved by local application or systemic administration of testosterone. We have studied the effect of local application of testosterone cream in seven boys with microphallic hypospadias. Serum testosterone levels and penile size were measured before, during and after treatment. The relative advantages and disadvantages of local testosterone application in comparison with injection are discussed.

Hemoglobin A1 and pancreatic beta cell function in cystic fibrosis

Hemoglobin A1 (HbA1) blood levels were examined in 34 cystic fibrosis (CF) patients aged 1 1/2 to 20 1/2 yr. The mean (+/- SD) HbA1 concentration in the 34 patients was 7.97 +/- 1.16--significantly higher than that in 150 normal children (6.8 +/- 0.8). Oral glucose tolerance tests (OGTT) were performed in 11 patients and blood glucose and insulin concentrations were measured. There was no difference in the fasting blood glucose values between the two groups. Eight children had a normal OGTT, and three showed an impaired OGTT with a delayed peak response in insulin levels. There was a decreased insulin response in all the CF patients. No correlation was found between HbA1 concentration and the age of the patients, nor between HbA1 and the clinical status (Shwachman score). We conclude that insulinopenia in children with CF is not always accompanied by an increment in HbA1, although serial determinations of its level may reveal deterioration in glucose tolerance.

Prolactin secretion in essential hypertension

This study was designed to evaluate prolactin (PRL) secretion in patients with essential hypertension. PRL secretory pattern was assessed by hourly blood sampling between 2200 and 0800 hours. Additional samples were collected at 0810 and 1000 hours (10 and 120 minutes after assumption of upright posture), as well as at 1200, 1400, and 1800 hours under normal simulated activities. No difference could be detected between the two study groups at any of the sampling times, and the number of secretory episodes were similar. Basal plasma renin activity levels were inversely related to simultaneous PRL levels in the hypertensive patients (r= -0.60, p less than 0.05). In the normal subjects mean overnight PRL levels were inversely related (r= -0.78, p less than 0.05) to the overnight urinary Na/K excretion. There was no PRL response to posture in either group. Hypertensive patients had a greater early response to the dopamine antagonist, metoclopramide than did normal subjects. Our data do not support the previously introduced concept of enhanced PRL responses to normal physiologic stimuli in essential hypertensives. However, it appears that dopaminergic control of PRL secretion may be altered in this disease state.

Hormonal dependence of the first spermatogenic wave in the mouse

Antiserum to rat gonadotropins (arG) has been proved capable of binding homologous luteinizing hormone (LH) and follicle stimulating hormone (FSH) in vitro and mouse LH and FSH in vivo. The administration of arG did not evoke antibody production. The physiological role of endogenous gonadotrophins during neonatal life was studied by administration of this antiserum to groups of newborn male mice. Daily injection of arG from birth up to the age of 100 days inhibited markedly weight increase of testes and accessory glands. Histological evaluation of the testes of such treated animals revealed that spermatogenesis up to the stage of pachytene spermatocytes can proceed in the absence of endogenous gonadotropins; however, no spermatids were formed and the number of cells that developed in the hormone-deprived animals was significantly lower than in the normal animal. Substitution treatment with exogenous FSH permitted the formation of a small number of spermatids, but completion of spermatogenesis was obtained only with combined LH and FSH treatment.

Evidence for an extrarenal action of chlorothiazide on serum potassium

The effects of chlorothiazide and furosemide on serum potassium were studied in fasting anuric patients maintained by chronic hemodialysis and compared to a control period when no drug was administered. Serum potassium levels were significantly lower following oral chlorothiazide (15 mg/kg body weight) than during the control period. After intravenous furosemide (1 mg/kg body weight), potassium levels were midway between those of the chlorothiazide and control periods, but statistical significance was not attained. Comparing the three study periods, there were no significant differences in the changes in body weight, blood pressure, blood pH, hematocrit, urea, glucose, sodium, albumin, insulin, plasma renin activity and aldosterone. This suggests that an extrarenal action of chlorothiazide on the cell membrane promotes cellular uptake of potassium.

Comparison of pituitary response to regular GnRH, analogue (D-TRP6) and placebo

Pituitary response to synthetic regular GnRH, to a potent analogue (D-TRp6) and to placebo were compared in ten azoospermic males. FSH and LH were measured prior to and at given intervals following administration of each substance. In addition, plasma levels of testosterone and prolactin were measured. There was no significant difference in the magnitude of FSH and LH release following injection of their the regular or the analogue form of GnRH. However, plasma gonadotrophins remained elevated for significantly longer time periods following the administration of the analogue GnRH. In those patients in whom LH levels remained elevated for at least 24 hours the observation of elevated testosterone levels permitted the inference of adequate biological activity of endogenously produced LH. Patients who did not respond to the regular GnRH were also non-responsive to D-TRp6 GnRH. A surprising finding ws elevated prolactin levels 4-6 hours following GnRH administration. Placebo had no influence on gonadotrophins, testosterone and prolactin.

Treatment of cryptorchidism with a potent analog of gonadotropin-releasing hormone

Pernasal therapy of cryptorchidism with D-Leu6-des-Gly10-gonadotropin-releasing hormone ethylamide (D-Leu6-des-Gly10-GnRH-EA), a potent, long-acting GnRH analog, was attempted. Eleven prepubertal cryptorchid boys received between 25 microgram once daily and 25 to 50 microgram twice daily for 5 to 12 weeks. Complete testicular descent was achieved in 4 of the 11 boys. GnRH tests (1.5 microgram/kg intravenously), conducted in six boys before treatment, after 4 weeks of treatment, and in 2 boys 3 months after treatment, did not reveal changes in gonadotropin secretion indicative of precocious puberty or of decreased hypophyseal sensitivity to GnRH. Antibodies to the GnRH analog or to GnRH could not be detected.

Hormonal and clinical responses in amenorrhetic patients treated with gonadotropins and a nasal form of synthetic gonadotropin-releasing hormone

Synthetic gonadotropin-releasing hormone (GnRH) in the form of nasal drops was self-administered by five amenorrheic patients in an attempt to assess its therapeutic value in anovulatory infertility. After follicular maturation had been induced with human menopausal gonadotropins (HMG), a total daily dose of 7.5 mg of GnRH in the form of nasal drops was self-administered at 2-hour intervals for 6 hours on 3 consecutive days. In four patients, plasma luteinizing hormone (LH) levels were significantly elevated over a period of at least 8 hours. In three of these patients, in addition, there was a definite upward shift in the basal body temperature (BBT) curve, and uterine bleeding occurred 6 to 9 days after the first dose of GnRH. In the fourth patient, ovulation was induced as indicated by a biphasic BBT curve, a plasma progesterone level of 13 ng/ml, and a luteal phase of 15 days. In the remaining patient, there was a borderline LH response and no clinical response. It is concluded that GnRH, in the form of nasal drops, is effective in eliciting and maintaining elevated plasma LH levels in patients in whom follicular maturation has been induced with HMG. By obtaining ovulatory LH levels, such a regimen can lead to ovulation. In addition, intranasal self-administration of GnRH is convenient and may provide an alternative route of administration for long-term therapy with this hormone.

The ovary learns to ovulate

Sensory stimuli from the external environment (e.g. visual and olfactory stimuli, stress) or internal stimuli cause brain nerve fibres to release neurotransmitters (catecholamines, indolamines and cholinergic agents). These neurotransmitters regulate the secretion of gonadotrophin-releasing hormone (GnRH) from neurosecretory cells of the hypothalamus (Kamberi, 1975). It would seem that under the proper steroid environment, catecholamines (dopamine, norepinephrine or epinephrine) and the cholinergic agent acetylcholine exert a stimulatory influence, whereas indolamines (serotonin or its metabolic product, melatonin) have an opposite effect. In turn, GnRH reaches the anterior pituitary via the hypophyseal portal system, and, through the mediation of cAMP [though may be not as an obligatory intermediate (Naor et al., 1975)], controls gonadotrophin secretion (Labrie et al., 1974).

Ovarian biochemical competence following gonadotrophic deprivation from birth

Normal ovarian morphogenesis is impaired by the absence of gonadotrophic hormones from birth. In the present study, the following question was asked: Does gonadotrophic deprivation also affect ovarian biochemical competence? Newborn mice were treated daily with an antiserum neutralizing endogenous circulating gonadotrophins. At the age of 14 days, ovaries from these mice and control littermates were incubated in the presence and absence of gonadotrophic preparations; cAMP and lactic acid levels were then measured in tissue and incubation medium. Ovaries from anti-gonadotrophin treated and control mice had the same basal levels, per mg tissue, of cAMP and lactic acid. Moreover, the levels increased to approximately the same extent following in vitro gonadotrophic stimulation: an increase in cAMP of 8-10-fold (using a preparation with an hLH:hFSH ratio of 1:1) or 2 1/2-fold (using a preparation with an hLH:hFSH ratio of 1:5), and about a 2-fold increase in lactic acid (using oLH). The acute effect of gonadotrophins on ovarian glycolysis, reported up till now only in the rat ovary, is the first such demonstration in mice. The results also indicate that despite impaired morphogenesis, the enzymatic systems necessary for ovarian glycolysis (as measured by lactic acid production) and cAMP formation can develop without gonadotrophic participation. Furthermore, ovarian capacity to respond to hormonal stimulation is acquired post-natally, as shown by refractoriness to gonadotrophic stimulation during the first week of life. Finally, post-natal gonadotrophic exposure does not seem an essential requirement, at least as measured by the above parameters, for acquiring ovarian competence to respond to hormonal stimulation.

Histochemical demonstration of delta5-3beta-hydroxysteroid dehydrogenase activity in ovaries of intact infant mice and mice treated with anti-rat gonadotropin

The localization of delta5-3beta-hydroxysteroid dehydrogenase activity was demonstrated histochemically in the neonatal mouse ovary. Histochemical studies were also undertaken in an attempt to investigate the effects of gonadotropic deprivation from birth to age 7 or 14 days on the distribution of enzymatic activity. Between birth and the age of 2 weeks, delta5-3beta-hydroxysteroid dehydrogenase activity was observed in virtually all follicles. In the newborn mouse ovary, the activity was found in granulosa cells of follicles developing in the center of the organ. On the 14th day, the granulosa cells of some apparently normal follicles histochemically were relatively inert, while others, obviously atretic, demonstrated extensive, localized, diformazan granules. Deprivation of endogenous circulating gonadotropin by daily injections of anti-rat gonadotropin had specific effects on follicular development and histochemical patterns in animals deprived of gonadotropins for 14 days but not for only 7 days.

The function of the growing follicle

The follicle plays a major role in the dual function of the ovary--oocyte maturation and release and steroidogenesis required for regulating its own growth and providing the proper environment in reproductive organs for the transport of gametes and nidation. Some aspects of how follicles attain their functional competence following a series of developmental changes are discussed. The presentation is based on data obtained mainly in rodents in which follicular development occurs postnatally. The peak activity of follicular growth occurs during the 1st week of life, but not until the 5th day is follicular development clearly dependent upon gonadotrophin stimulation. The formation of the theca layer and zona pellucida, differentiation of the vascular system and competence to respond to gonadotrophins are acquired during the 2nd week. FSH alone is primarily responsible for granulosa cell proliferation and the integrity of the granulosa cell membrane, but has little differential effect on steroidogenic enzymes. Synergism of FSH and LH promotes an enrichment of the theca layer, enhancement of vascular development and antrum formation, and induces a marked differential stimulation of 20alpha-hydroxysteroid dehydrogenase, aromatizing and cholesterol side-chain cleavage systems. The number of gonadotrophin receptors on granulosa and theca cells increases with follicular development. Steroids secreted by the ovary seem to modulate follicular growth, not only by effects upon FSH and LH release but also by a local influence within the ovary. A number of physiological events related to follicular function are explained according to these observations.

Biological effects of antibodies to gonadotropins

Some of the contradictory postulates regarding gonadotropin action in infancy were reexamined. For the deprivation of newborn animals of endogenous gonadotropins, antiserum neutralizing theese hormones was administered from birth on. Using this approach it was elucidated that, even during the first week of life, gonadotropins stimulate development of ovarian somatic elements and are indispensable for this process. In the absence of the stimulatory action of endogenous gonadotropins, the normal ovarian development taking place during the first and second week of life was markedly altered and retarded. This was mainly evident from the reduction in the number of follicles which developed, the change in the appearance and ultrastructure of granulosa cells, the deficiency of thecal and of vascular development. That the observed alterations were due specifically to gonadotropin deprivation was proven by the fact that these alterations were prevented by the administration of human gonadotropins to mice deprived of endogenous gonadotropins. Substitution with human gonadotropins permitted the elucidation of the respective role of follicle-stimulating hormone (FSH) and FSH plus luteinizing hormone (LH) in the development of the infantile ovary. This was achieved by the use of HMG and of a biologically &#8216;pure FSH&#8217; which was obtained by the neutralization of the LH activity present in HMG. FSH was found to be primarily responsible for the stimulation of granulosa cell proliferation, organization and structure. FSH plus LH, in addition to the FSH effects, initiated secretory activity of granulosa cells, increase in intrafollicular spaces, antrum formation, enrichment and maintenance of the theca layer and development of the vascular system. At the age of 14 days, the administration of HMG to gonadotropin-deprived animals even enhanced some of the developmental phases beyond that observed in ovaries of control animals at the same age. Oocyte growth seems to be independent of gonadotropins since it was similar in all experimental groups. The functional integrity of the growing oocytes in gonadotropin-deprived animals could not be assessed in this study.

Labelling of antigens by various isotopes

Isotopically labelled protein or polypeptide hormones are chemically and/or structurally different from the native material. This may be a major handicap when biological studies or radioimmunoassays are performed. Labelling procedures with 131I, 125I or by introduction of 3H (exchange, acetylation, alanylation) are described, and the advantages and disadvantages of the different methods are outlined. The specific activity and biological and immunological properties of the labelled end products are discussed. The review presented should enable the individual investigator to choose the appropriate method of labelling according to his specific requirements.

Preparation and characterization of antiserum to purified gonadotrophins from rat pituitary glands

Antiserum to a gonadotrophic extract of rat pituitary glands was prepared and investigated:

The response of antiserum treated immature mice and rats to human gonadotrophins is described. Interpretation of these findings is based on previous observations in hypophysectomized animals.

The possible use of animals immunologically deprived of endogenous gonadotrophins for the study of the response to specific human gonadotrophins is discussed.

The significance of substituting hypophysectomized animals for antiserum treated rodents is outlined.