Phase III Prospectively Randomized Trial of Perioperative 5-FU After Curative Resection for Colon Cancer: An Intergroup Trial of the ECOG-ACRIN Cancer Research Group (E1292)

BACKGROUND

Studies suggest that adjuvant chemotherapy should be initiated at the earliest possible time. The Eastern Cooperative Oncology Group (ECOG) and Intergroup evaluated the effect of perioperative fluorouracil (5-FU) on overall survival (OS) for colon cancer.

PATIENTS AND METHODS

This phase III trial randomized patients to receive continuous infusional 5-FU for 7 days starting within 24 h after curative resection (arm A) or no perioperative 5-FU (arm B). Patients with Dukes' B3 and C disease received adjuvant chemotherapy per standard of care. The primary endpoint of the trial was overall survival in patients with Dukes' B3 and C disease. The secondary objective was to determine whether a week of perioperative infusion would affect survival in patients with Dukes' B2 colon cancer with no additional chemotherapy.

RESULTS

From August 1993 to May 2000, 859 patients were enrolled and 855 randomized (arm A: 427; arm B: 428). The trial was terminated early due to slow accrual. The median follow-up is 15.4 years (0.03-20.3 years). Among patients with Dukes' B3 and C disease, there was no statistically significant difference in OS [median 10.3 years (95% CI 8.4, 13.2) for perioperative chemotherapy and 9.3 years (95% CI 5.7, 12.3) for no perioperative therapy, one-sided log-rank p = 0.178, HR = 0.88 (95% CI 0.66, 1.16)] or disease-free survival (DFS). For patients with Dukes' B2 disease, there was also no significant difference in OS (median 16.1 versus 12.9 years) or DFS. There was no difference between treatment arms in operative complications. One week of continuous infusion of 5-FU was tolerable; 18% of arm A patients experienced grade 3 or greater toxicity.

Accuracy of prediction of genomic breeding values for residual feed intake and carcass and meat quality traits in Bos taurus, Bos indicus, and composite beef cattle

The aim of this study was to assess the accuracy of genomic predictions for 19 traits including feed efficiency, growth, and carcass and meat quality traits in beef cattle. The 10,181 cattle in our study had real or imputed genotypes for 729,068 SNP although not all cattle were measured for all traits. Animals included Bos taurus, Brahman, composite, and crossbred animals. Genomic EBV (GEBV) were calculated using 2 methods of genomic prediction [BayesR and genomic BLUP (GBLUP)] either using a common training dataset for all breeds or using a training dataset comprising only animals of the same breed. Accuracies of GEBV were assessed using 5-fold cross-validation. The accuracy of genomic prediction varied by trait and by method. Traits with a large number of recorded and genotyped animals and with high heritability gave the greatest accuracy of GEBV. Using GBLUP, the average accuracy was 0.27 across traits and breeds, but the accuracies between breeds and between traits varied widely. When the training population was restricted to animals from the same breed as the validation population, GBLUP accuracies declined by an average of 0.04. The greatest decline in accuracy was found for the 4 composite breeds. The BayesR accuracies were greater by an average of 0.03 than GBLUP accuracies, particularly for traits with known genes of moderate to large effect mutations segregating. The accuracies of 0.43 to 0.48 for IGF-I traits were among the greatest in the study. Although accuracies are low compared with those observed in dairy cattle, genomic selection would still be beneficial for traits that are hard to improve by conventional selection, such as tenderness and residual feed intake. BayesR identified many of the same quantitative trait loci as a genomewide association study but appeared to map them more precisely. All traits appear to be highly polygenic with thousands of SNP independently associated with each trait.

Improving accuracy of genomic predictions within and between dairy cattle breeds with imputed high-density single nucleotide polymorphism panels

Achieving accurate genomic estimated breeding values for dairy cattle requires a very large reference population of genotyped and phenotyped individuals. Assembling such reference populations has been achieved for breeds such as Holstein, but is challenging for breeds with fewer individuals. An alternative is to use a multi-breed reference population, such that smaller breeds gain some advantage in accuracy of genomic estimated breeding values (GEBV) from information from larger breeds. However, this requires that marker-quantitative trait loci associations persist across breeds. Here, we assessed the gain in accuracy of GEBV in Jersey cattle as a result of using a combined Holstein and Jersey reference population, with either 39,745 or 624,213 single nucleotide polymorphism (SNP) markers. The surrogate used for accuracy was the correlation of GEBV with daughter trait deviations in a validation population. Two methods were used to predict breeding values, either a genomic BLUP (GBLUP_mod), or a new method, BayesR, which used a mixture of normal distributions as the prior for SNP effects, including one distribution that set SNP effects to zero. The GBLUP_mod method scaled both the genomic relationship matrix and the additive relationship matrix to a base at the time the breeds diverged, and regressed the genomic relationship matrix to account for sampling errors in estimating relationship coefficients due to a finite number of markers, before combining the 2 matrices. Although these modifications did result in less biased breeding values for Jerseys compared with an unmodified genomic relationship matrix, BayesR gave the highest accuracies of GEBV for the 3 traits investigated (milk yield, fat yield, and protein yield), with an average increase in accuracy compared with GBLUP_mod across the 3 traits of 0.05 for both Jerseys and Holsteins. The advantage was limited for either Jerseys or Holsteins in using 624,213 SNP rather than 39,745 SNP (0.01 for Holsteins and 0.03 for Jerseys, averaged across traits). Even this limited and nonsignificant advantage was only observed when BayesR was used. An alternative panel, which extracted the SNP in the transcribed part of the bovine genome from the 624,213 SNP panel (to give 58,532 SNP), performed better, with an increase in accuracy of 0.03 for Jerseys across traits. This panel captures much of the increased genomic content of the 624,213 SNP panel, with the advantage of a greatly reduced number of SNP effects to estimate. Taken together, using this panel, a combined breed reference and using BayesR rather than GBLUP_mod increased the accuracy of GEBV in Jerseys from 0.43 to 0.52, averaged across the 3 traits.

Phase II Trial of Docetaxel and Carboplatin in Patients With Advanced Squamous Carcinoma of the Esophagus (E2298): A Trial of the Eastern Cooperative Oncology Group

BACKGROUND

Occasional complete responses have been reported in patients with squamous-cell carcinoma of the esophagus treated with carboplatin, and the inferior outcomes seen in early studies might have been the result of underdosing using BSA calculations. Docetaxel was reported to have single-agent activity in squamous-cell carcinoma of the esophagus, with a 50% response rate in a pilot study performed in South Africa. Thus, ECOG investigated the potential role of combination carboplatin using AUC-based dosing and docetaxel in patients with squamous-cell carcinoma of the esophagus.

PATIENTS AND METHODS

ECOG 2298 was a multicenter, international, phase II clinical study of docetaxel and carboplatin in patients with histologically confirmed, measurable squamous-cell carcinoma of the esophagus. Docetaxel 75 mg/m(2) was infused over 1 hour on day 1 of each cycle. The carboplatin dose was calculated to an AUC of 6 and infused over 15-30 minutes immediately after the docetaxel. The regimen was repeated every 3 weeks for a total of 6 cycles or until disease progression occurred or unacceptable toxicity developed.

RESULTS

A total of 32 patients were accrued, mostly men (78%) with a median age of 64 (range, 41-86). Half the patients were black and half were white. Five patients were not evaluable due to protocol violations. Of the remaining 27 patients, one (3%) achieved a complete clinical response. Four others (13%) achieved partial responses. Thirteen (41%) had stable disease and 9 (28%) had progression of disease. Overall objective response rate was 15.6% (95% CI 5.9% to 36%). The most common grade 3 and 4 toxicities were leukopenia (25/32=78%) and neutropenia (27/32=84%). Most nonhematologic toxicities were infrequent and ≤ grade 3; however, two patients experienced grade 5 toxicities; one died of bowel obstruction and another died of infection with grade 4 neutropenia.

CONCLUSIONS

The high toxicity and poor efficacy shown in this study suggest that the combination of carboplatin and docetaxel in squamous-cell carcinoma of the esophagus should not be investigated further. Newer agents need to be investigated in this malignancy.

The relative contribution of point mutations and genomic rearrangements in BRCA1 and BRCA2 in high-risk breast cancer families

The demand for BRCA1 and BRCA2 mutation screening is increasing as their identification will affect medical management. However, both the contribution of different mutation types in BRCA1 and BRCA2 and whom should be offered testing for large genomic rearrangements have not been well established in the U.S. high-risk population. We define the prevalence and spectrum of point mutations and genomic rearrangements in BRCA genes in a large U.S. high-risk clinic population of both non-Ashkenazi and Ashkenazi Jewish descent, using a sample set representative of the U.S. genetic testing population. Two hundred fifty-one probands ascertained through the University of Pennsylvania high-risk clinic, all with commercial testing for BRCA1 and BRCA2, with an estimated prevalence of BRCA mutation >or=10% using the Myriad II model and a DNA sample available, were studied. Individuals without deleterious point mutations were screened for genomic rearrangements in BRCA1 and BRCA2. In the 136 non-Ashkenazi Jewish probands, 36 (26%) BRCA point mutations and 8 (6%) genomic rearrangements (7 in BRCA1 and 1 in BRCA2) were identified. Forty-seven of the 115 (40%) Ashkenazi Jewish probands had point mutations; no genomic rearrangements were identified in the group without mutations. In the non-Ashkenazi Jewish probands, genomic rearrangements constituted 18% of all identified BRCA mutations; estimated mutation prevalence (Myriad II model) was not predictive of their presence. Whereas these findings should be confirmed in larger sample sets, our data suggest that genomic rearrangement testing be considered in all non-Ashkenazi Jewish women with an estimated mutation prevalence >or=10%.

On the need for biopsy confirmation at suspected first recurrence of cancer

At the time of suspected first recurrence of cancer, it is unclear whether biopsy confirmation is routinely performed, although this is a very common clinical situation. First, 20 oncologists were surveyed to ascertain the pattern of practice in our community. A questionnaire with hypothetical typical cases suspected of having recurrent cancer was distributed. Second, eligibility criteria were reviewed from investigational protocols from the National Cancer Institute (NCI) and the Eastern Cooperative Oncology Group to see whether confirmation of recurrence was specifically required in these research studies. Third, 64 cases from our own practice were reviewed retrospectively to determine our patterns and results in performing biopsies to document suspected recurrence. Finally, criteria were developed that might suggest the need for biopsy confirmation of recurrence and then retrospectively tested against our cases. There was no clear consensus among oncologists regarding the need for tissue confirmation in patients with solid tumor with suspected recurrences, although rebiopsy was routinely requested for recurrent lymphoma. Published Eastern Cooperative Oncology Group and NCI protocols reviewed did not require biopsy proof specifically of recurrence. Retrospective review of our own cases suggested that, in the absence of one of the proposed indicators, the risk of making an erroneous diagnosis without biopsy confirmation is low. It is suggested that biopsy is not routinely necessary for confirmation of recurrence in all cases of suspected recurrent solid tumors, but criteria are proposed that would help to reduce the possibility of misdiagnosis when biopsy of suspected recurrence is not performed.

Breast cancer in the very young patient: a multidisciplinary case presentation

A case is presented that exemplifies many issues and controversies in the diagnosis and treatment of breast cancer in the very young. This woman was 22 years of age at diagnosis; she initially underwent breast-conservation therapy and adjuvant chemotherapy, retained fertility, had a subsequent uncomplicated pregnancy and delivery, and 7 years later developed a local recurrence in the breast. The discussion addresses risk factors, diagnosis, and treatment of breast cancer in the young; the impact of treatment on fertility; implications regarding pregnancy, and the management of local recurrence after breast conservation.

Postpartum hemorrhage and arterial embolization

Postpartum hemorrhage remains a major cause of morbidity and mortality for the obstetric patient. A timely, stepwise approach to management can reduce the negative impact of this complication. Improvements in pharmacotherapy and surgical techniques have also improved outcome. Uterine artery embolization is an especially promising approach to the management of severe or refractory obstetric hemorrhage which is generally underutilized but has several advantages over other more traditional techniques.

Serum ionized magnesium levels in normal and preeclamptic gestation

OBJECTIVE

To compare serum levels of ionized and total magnesium with those of ionized calcium, total calcium, sodium, and potassium over the course of pregnancy in normal women and in women who develop preeclampsia.

METHODS

We collected venous serum samples from 31 pregnant women during their first, second, and third trimesters. Gestational ages ranged from 6 to 37 weeks. Samples were analyzed for ionized and total magnesium, ionized and total calcium, sodium, and potassium using a biomedical chemistry analyzer. Data were analyzed with repeated-measures analysis of variance and two-way repeated-measured analysis of variance.

RESULTS

In 22 normal pregnant women, both serum ionized and total magnesium levels decreased significantly with increasing gestational age. No changes in sodium, potassium, or ionized or total calcium were observed. Nine of the 31 subjects developed preeclampsia by term; serum total magnesium levels decreased significantly by the second trimester in these women compared with those of normal pregnant women.

CONCLUSION

Our results provide evidence of decreases in ionized and total magnesium levels with increasing gestational age during normal pregnancy, as well as evidence of a magnesium disturbance in women who later develop preeclampsia. Future studies of magnesium balance in women at risk for developing complications of pregnancy are indicated.

Fetal ionized magnesium levels parallel maternal levels during magnesium sulfate therapy for preeclampsia

OBJECTIVE

Little is known about ion regulation in fetuses. Our aim was to determine the effects of magnesium sulfate therapy on ionized (bioactive) magnesium in the cord blood of pregnancies complicated by preeclampsia.

STUDY DESIGN

Seventy-four pregnant women were studied (37 preeclamptic and 37 controls matched for maternal age, gravidity, and gestational age). The preeclamptic women received intravenous magnesium sulfate 6 gm load followed by 2 gm/hour for > or = 4 hours; controls were not preeclamptic and received no magnesium. Maternal venous and fetal cord blood samples were obtained from study and control patients and were analyzed for sodium, potassium, total magnesium, ionized magnesium, total calcium, and ionized calcium. Comparisons between the groups were made and analyzed by the Mann-Whitney U test.

RESULTS

There were no significant differences between the treatment and control group cord samples with respect to sodium or potassium. However, total magnesium and ionized magnesium were significantly elevated (p < 0.001) in cord samples of the treated group. At the same time ionized calcium and total calcium were reduced. Interestingly, ionized calcium levels were lower in preeclamptic women before magnesium sulfate therapy was begun, whereas total calcium levels were not different. Importantly, there was no difference between maternal and fetal ionized magnesium levels in either treatment or control groups.

CONCLUSIONS

In preeclamptic women undergoing magnesium sulfate therapy, ionized magnesium levels in cord blood parallel maternal levels. Before magnesium therapy ionized calcium levels were lower in preeclamptic women than in matched controls. In the presence of elevated magnesium levels ionized calcium appears to be tightly regulated.

Differential regulation of seizure activity in the hippocampus of male and female rats

OBJECTIVE

The aim of the current study was to directly examine and compare the susceptibility to N-methyl-D-aspartate-induced seizures in male versus female rats. We also sought to compare the anticonvulsant effects of magnesium sulfate in these two groups.

STUDY DESIGN

Eighteen female and 10 male rats were stereotaxically implanted with a chronic bipolar recording electrode in the hippocampus and an injection cannula in the lateral cerebral ventricle. After 1 week rats randomly received an intravenous injection of 90 mg/kg magnesium sulfate or saline solution control. Fifteen minutes after the infusion rats were given the convulsant N-methyl-D-aspartate at a dose of 5 micrograms/microliters by direct intraventricular injection. Electrical seizure activity was thereafter assessed for 20 minutes. All data were analyzed by the Mann-Whitney U test and Student t test.

RESULTS

In saline solution-treated rats receiving the convulsant N-methyl-D-aspartate, females had significantly lower total duration (p < 0.01) and total number of seizures (p < 0.05) compared with the male rats. The initial seizure was not affected by gender. In the female animals magnesium sulfate significantly reduced first seizure duration (p < 0.01) compared with saline solution controls. In males magnesium sulfate reduced both total duration (p < 0.05) and total seizure number (p < 0.05) compared with saline solution-treated animals.

CONCLUSION

N-methyl-D-aspartate-induced seizure activity is more severe in males versus female rats. Magnesium sulfate's effect on N-methyl-D-aspartate-induced seizures is also dependent on gender. We speculate that seizure regulation may be hormonally influenced.

Adenosine modulates hypoxia-induced atrial natriuretic peptide release in fetal sheep

The effects of adenosine on atrial natriuretic peptide (ANP) secretion were determined in chronically catheterized fetal sheep (> 0.8 term). Adenosine was infused into the the right jugular vein for 1 h at 8 +/- 0.4 (5 fetuses), 160 +/- 8 (6 fetuses), and 344 +/- 18 micrograms.min-1.kg estimated fetal wt-1. Fetal arterial blood gases and pH were generally unaffected by adenosine, although mean arterial CO2 tension increased transiently by 2-5 Torr and pH fell progressively during the highest rate of infusion. During the intermediate and high infusion rates, fetal hemoglobin concentrations increased by 11-13% and mean fetal heart rate rose by 18% from a control value of approximately 167 beats/min. Mean arterial pressure was not affected during adenosine infusion. Adenosine significantly increased fetal plasma ANP levels, with maximum concentrations 1.80, 2.36, and 2.51 times greater than control means (142-166 pg/ml) for the respective infusion rates of 8, 160, and 344 micrograms.min-1.kg estimated fetal wt-1. In seven fetuses, reducing fetal arterial O2 tension by approximately 9-10 Torr from a control of 23 +/- 1.3 Torr increased plasma ANP concentrations approximately 2.4 times the control mean of 176 pg/min. Adenosine-receptor blockade with 8-(p-sulfophenyl)-theophylline reduced by 50% the maximum hypoxia-induced rise in plasma ANP concentrations. It is concluded that adenosine causes a dose-dependent rise in fetal plasma ANP concentrations and modulates fetal ANP release during hypoxia.

Pathologic response to induction chemotherapy in locally advanced carcinoma of the breast: a determinant of outcome

BACKGROUND

The prognosis for patients with locally advanced carcinoma of the breast remains poor. This study examines the pathologic evidence of response of the mammary tumor and axillary nodes after preoperative chemotherapy. We sought to determine if there was a relationship between the histologic response and clinical outcome.

STUDY DESIGN

Between 1987 and 1992, 36 patients with locally advanced carcinoma of the breast received three cycles of chemotherapy after incisional biopsy. Modified radical mastectomy was then performed. The breast and axillary nodes were examined pathologically for therapeutic effect and a grading scale was assigned. Postoperatively, patients received completion chemotherapy with the same agents used preoperatively followed by radiation therapy to the chest wall.

RESULTS

Fourteen tumors (39 percent) showed near total therapeutic effect, five (14 percent) showed greater than 50 percent but less than total effect, 12 (33 percent) showed less than 50 percent effect, and five (14 percent) showed no effect. Nodal positivity was seen in 61 percent of the patients. Overall clinical response to induction chemotherapy was seen in 86 percent of the patients. There was poor correlation between clinical and pathologic response. Only 50 percent of the patients with complete clinical response were pathologically free of disease. Patients with excellent pathologic therapeutic response had a 79 percent overall five-year survival rate compared with 34 percent for tumors with a lesser response. This was irrespective of nodal status. While pathologic response was critical in determining outcome, clinical response was not.

CONCLUSIONS

These results indicate that patients whose tumors have the best pathologic response to induction chemotherapy experience the best outcome.

Vaginal color Doppler assessment of uterine artery impedance correlates with immunohistochemical markers of endometrial receptivity required for the implantation of an embryo

OBJECTIVE

To investigate the correlation between uterine artery impedance with immunohistochemical histologic, and ultrasonographic markers of uterine receptivity.

DESIGN

A prospective study of subfertile women undergoing a frozen embryo replacement cycle.

SETTING

A tertiary infertility clinic.

PATIENTS

The study was based on 86 patients who had failed to become pregnant during a standard IVF treatment cycle and who had at least two good quality embryos cryopreserved.

INTERVENTIONS

All patients had pituitary desensitization with the GnRH analogue buserelin acetate, followed by E2 and P replacement therapy. Vaginal color Doppler images of both uterine arteries were obtained on days 7, 14, and 21 of the first (trial) cycle. On day 21, an endometrial biopsy was taken for dating a 24-kd protein, placental protein 14, and E2 receptor assessment. After a menstrual bleed had been induced, administration of estrogen and P was reinstituted and embryos transferred to the uterus on the 3rd or 4th day of P administration.

MAIN OUTCOME MEASURES

The mean pulsatility index of the left and right uterine arteries, a semiquantitative score of endometrial 24-kd protein, PP14, and E2 receptor assessment, endometrial histologic dating, and pregnancy outcome.

RESULTS

Nineteen of 76 patients who had a successful ET became pregnant. The pulsatility index on day 14 of both the trial and ET cycles was significantly lower in those who achieved pregnancy as compared with those who did not conceive: 2.65 (range 1.3 to 3.4) versus 3.85 (1.8 to 6.8) and 2.85 (1.4 to 3.6) versus 4.15 (2.1 to 6.8), respectively. There were significant correlations between pulsatility index and 24-kd protein, E2 receptor, and endometrial histology but not with PP14 and endometrial thickness.

CONCLUSIONS

Uterine artery impedance has a significant correlation with biochemical markers of uterine receptivity and accurately predicts the probability of pregnancy in frozen embryo replacement cycles. It is a useful method for assessing uterine receptivity in assisted conception programs.

Hypoxic inhibition of breathing in fetal sheep: relationship to brain adenosine concentrations

Because hypoxic inhibition of fetal breathing may be caused by a rise in central adenosine levels, the effects of O2 deficiency on fetal brain adenosine concentrations were determined at levels of hypoxia that inhibited fetal breathing. Under halothane anesthesia, the brains of fetal sheep (0.8 term) were implanted with guide cannulas exteriorized through a Silastic rubber window in the uterus and flank of the ewe. At least 4 days after surgery, a microdialysis probe was inserted into a cannula with the membrane tip placed in the rostral brain stem. During 1 h of isocapnic hypoxia, mean fetal arterial PO2 was reduced from 24.0 +/- 0.9 Torr (control) to 13 +/- 0.6 Torr and arterial pH fell progressively from 7.354 +/- 0.007 to 7.273 +/- 0.023. Hypoxia decreased the incidence of fetal breathing movements from 33 +/- 5.2 to 5 +/- 2.2 min/h, with a normal incidence (29 +/- 3.5 min/h) during the hour after arterial PO2 returned to control values. Adenosine concentrations in microdialysis perfusate under control conditions averaged approximately 35 nM, increased up to 2.3-fold during the hour of O2 deficiency, and fell toward control values when normoxia was restored. We conclude that fetal brain adenosine levels are increased at levels of O2 deficiency that inhibit fetal breathing, which are results consistent with a role for adenosine in hypoxic inhibition of fetal breathing.

Magnesium is more efficacious than phenytoin in reducing N-methyl-D-aspartate seizures in rats

OBJECTIVE

Although magnesium sulfate is one of the most commonly used agents for seizure prophylaxis in preeclampsia, its efficacy relative to other anticonvulsants is incompletely investigated. The underlying mechanisms of eclamptic seizures are unknown, and there is currently no universally accepted animal model for eclampsia. However, one commonly used method for studying the relative efficacy of antiepileptic drugs is through their effect on N-methyl-D-aspartate-induced seizures. Our aim was to compare the anticonvulsant effects of phenytoin and magnesium sulfate in an N-methyl-D-aspartate-induced seizure model.

STUDY DESIGN

Twenty-one female rats were each stereotaxically implanted with a chronic indwelling bipolar recording electrode in the hippocampus and an injection cannula in the lateral cerebral ventricle. After 7 days animals were randomly given 90 mg/kg magnesium sulfate (n = 7), 50 mg/kg phenytoin, or saline solution (n = 7) intravenously. Fifteen minutes after the infusions animals were given 20 micrograms/microliters N-methyl-D-aspartate by direct intraventricular injection, and seizure activity was assessed for 20 minutes thereafter. All data were analyzed with the Mann-Whitney test.

RESULTS

When compared with saline solution controls, total duration of seizure activity in animals treated with magnesium sulfate was significantly decreased (p < 0.05) and time to onset of seizure activity was significantly increased (p < 0.05). However, rats that received phenytoin did not show significant changes in these parameters. The post-N-methyl-D-aspartate seizure mortality rate was 50% in the saline solution controls and 29% in the phenytoin group, whereas none of the rats that received magnesium sulfate died.

CONCLUSION

These results suggest that magnesium sulfate is a significantly more effective prophylactic agent than phenytoin for N-methyl-D-aspartate-induced seizures.

Comparison of natural with clomiphene citrate-stimulated cycles in in vitro fertilization: a prospective, randomized trial

OBJECTIVE

To compare the outcome of natural with clomiphene citrate (CC)-stimulated cycles in IVF.

DESIGN

Prospective, randomized study.

SETTING

Tertiary referral center for assisted conception.

SUBJECTS

Thirty patients randomized to receive either no treatment (n = 14) or CC, 100 mg, from days 2 to 6 (n = 16).

INTERVENTIONS

Daily ultrasound (US) scan and measurements of serum LH and E2. Ovarian morphology was assessed on baseline US scan. Human chorionic gonadotrophin was administered when the mean diameter of the dominant follicle reached 17 mm. Transvaginal US-directed oocyte recovery was performed 35 hours later.

MAIN OUTCOME MEASURES

The number of patients reaching oocyte recovery; numbers of oocytes collected, fertilized and embryos transferred; and clinical pregnancy and multiple pregnancy rates (PRs) were recorded.

RESULTS

Ten cycles in the natural cycle group were abandoned before oocyte recovery compared with none in the CC group. There were significantly more follicles > 14 mm (2.4 +/- 0.3 [SE] compared with 0.9 +/- 0.2) and higher peak levels of E2 (375 +/- 67 pg/mL (1,378 +/- 247 pmol/L) compared with 204 +/- 17 pg/mL (748 +/- 61 pmol/L)) in those receiving CC compared with those receiving no drug. All 16 patients treated with CC had oocyte retrieval (mean, 1.8 +/- 0.3 oocytes) compared with only 4 in the natural cycle group (1 oocyte each). The oocyte recovery rate was 95%. Two patients conceived in the CC group (PR per ET, 18%) compared with none in the natural cycle group. Patients with polycystic ovaries developed more large follicles than those with normal ovaries. No patient developed ovarian hyperstimulation syndrome.

CONCLUSIONS

Patients undergoing natural cycle IVF are more likely to have abandoned cycles, produce fewer follicles and oocytes, and are less likely to reach ET than patients treated with CC alone. Clomiphene citrate should be considered for use in the context of a conventionally organised IVF-ET program if a mild degree of ovarian stimulation is desired.

Midluteal-phase vaginal color Doppler assessment of uterine artery impedance in a subfertile population

OBJECTIVE

To compare the midluteal uterine artery impedance to blood flow as measured by the pulsatility index in women with different causes of infertility with that of women with normal fertility and to correlate this with endometrial thickness.

DESIGN

A prospective study of normal women undergoing insemination with donor semen and subfertile women with tubal damage, endometriosis, premature ovarian failure, anovulation, or unexplained infertility.

SETTING

A tertiary infertility center.

PATIENTS

One-hundred sixty-one women (25 to 40 years of age) who were attending the clinic for subfertility treatment and 23 normal women who were having artificial insemination with donor sperm because their partners were azoospermic.

INTERVENTIONS

All women were examined by transvaginal ultrasonography, with color flow imaging and blood flow analysis, on day 21 of an unstimulated ovarian cycle.

MAIN OUTCOME MEASURES

The mean pulsatility index of the left and right uterine arteries and the endometrial thickness.

RESULTS

The patients were grouped according to the causes of infertility and compared with normal women. There were 23 women in the normal group (median pulsatility index, 1.91; range, 0.84 to 2.95), 35 with unexplained infertility (median pulsatility index, 2.45; range, 1.0 to 7.0), 91 with tubal damage (median pulsatility index, 2.65; range, 1.25 to 8.0), 8 with endometriosis (median pulsatility index, 2.32; range, 2.05 to 5.7), and 22 with anovulatory infertility (median pulsatility index, 3.03; range, 1.6 to 7.0). All the infertile groups had significantly different median pulsatility indexes when compared with the normal group, and the pulsatility indexes correlated with endometrial thickness.

CONCLUSIONS

The impedance to uterine artery blood flow is significantly different in women with different causes of infertility as compared with women of normal fertility. Increased resistance to uterine blood flow in the midluteal phase may be an important contributing factor to some causes of infertility and the cause of some previously "unexplained" infertility.

Adenosine mediates hypoxic release of arginine vasopressin in fetal sheep

The effects of adenosine on plasma arginine vasopressin (AVP) concentrations were determined in chronically catheterized fetal sheep (> 0.8 term). Infusion of adenosine [0.35 +/- 0.01 (SE) mg.min-1.kg-1] into the inferior vena cava of six fetuses caused a transient fall in arterial PO2 (by approximately 3 Torr), a slight reduction in arterial pH, and a 5- to 6-mmHg decrease in diastolic pressure without significantly affecting systolic or mean arterial values. A lower rate of infusion (0.19 +/- 0.01 mg.min-1 x kg-1) in five fetuses had virtually no effect on arterial blood gases, pH, or arterial pressures. Both the low- and high-dose adenosine infusions significantly increased fetal plasma AVP concentrations (1.7 +/- 0.2 to 25 +/- 7 pg/ml and 1.6 +/- 0.1 to 54 +/- 8 pg/ml, respectively). Intravenous infusion of papaverine lowered fetal diastolic and mean arterial pressures by approximately 8 mmHg but had no significant effect on plasma levels of AVP. During an hour of isocapnic hypoxia (arterial PO2 12-13 Torr), fetal plasma AVP levels increased from 1.7 +/- 0.2 to 40 +/- 6 pg/ml. Intra-arterial infusion of the adenosine receptor antagonist 8-(p-sulfophenyl)-theophylline significantly blunted the hypoxia-induced rise in plasma AVP concentrations to a maximum mean level of 11 +/- 6 pg/ml. These results indicate that 1) adenosine causes a dose-dependent increase in plasma AVP concentrations and 2) a hypoxia-induced rise in fetal adenosine levels triggers vasopressin release.

Maternal and fetal cardiorespiratory responses to adenosine in sheep

OBJECTIVE

We determined the cardiorespiratory effects of maternal adenosine administration on the ewe and fetus.

STUDY DESIGN

Adenosine was infused intravenously to five pregnant ewes as graded (25 to 400 micrograms/min per kilogram) and constant (200 micrograms/min per kilogram) infusions and as a single injection (200 micrograms/kg). Heart rate, arterial pressure, and arterial blood gases and pH were monitored in the ewe and fetus; the data were analyzed with two-way analysis of variance with Duncan's test.

RESULTS

Graded adenosine infusion produced a dose-dependent rise in maternal heart rate and hemoglobin concentration and a fall in diastolic and mean arterial pressures, effects that were maintained during 1 hour of constant infusion. Single injections transiently lowered diastolic pressure and induced a biphasic change in heart rate consisting of a bradycardia followed by a tachycardia with a return to control values. Adenosine administration to the ewe did not affect maternal arterial blood gases and systolic pressure nor alter fetal heart rate, arterial pressure, or arterial blood gases.

CONCLUSION

Although adenosine causes cardiovascular changes in pregnant ewes, the effects are well tolerated and do not significantly affect the cardiorespiratory status of the fetus.

Cardiovascular responses to adenosine in fetal sheep: autonomic blockade

The mechanism by which adenosine increases heart rate was investigated in 21 chronically catheterized fetal sheep (> 0.8 term). Intra-arterial infusion of adenosine (0.16 mg.min-1.kg fetal wt-1) for 1 h significantly increased fetal heart rate within 5 min with maximum values of approximately 68 beats/min above the control mean of 163 +/- 8 beats/min. The average diastolic blood pressure was reduced only during the first 10 min of infusion, and the average systolic and mean arterial pressures were not significantly affected. Mean venous pressure rose by approximately 48% after 20 min of adenosine infusion, but all other measurements did not differ significantly from the control value. The mean hemoglobin concentration during the last 30 min of infusion was increased by approximately 8%. Plasma concentrations of norepinephrine and epinephrine were elevated only during the first 30 min of adenosine administration, to values as high as 2.3 and 5 times the respective control mean. Adenosine significantly increased mean fetal heart rate by about 15-20 beats/min in fetuses with autonomic ganglion blockade or combined cholinergic, alpha-, and beta-adrenergic receptor blockade. Intra-arterial infusion of CGS 21680C, an A2-adenosine receptor agonist, also produced a fetal tachycardia of approximately 86 beats/min above the control mean and increased intrinsic fetal heart rate by approximately 38 beats/min. It is concluded that approximately 75% of the positive chronotropic effects of adenosine are produced by A2-receptor stimulation of the autonomic nervous system and that approximately 25% of the rise in heart rate induced by adenosine may be caused by activation of A2-receptors in myocardium.

Adenosine in the treatment of maternal paroxysmal supraventricular tachycardia

Paroxysmal supraventricular tachycardia is the most common sustained cardiac arrhythmia in pregnant women. Because nearly 50% of these supraventricular tachyarrhythmias fail to respond to vagal maneuvers, other therapies are used, including electrocardioversion and pharmacologic agents. Propranolol, verapamil, and adenosine have Food and Drug Administration-approved labeling for acute termination of supraventricular tachycardia. Verapamil has been the most commonly used agent in the general population but it has several shortcomings, such as its potential to cause or exacerbate systemic hypotension, congestive heart failure, bradyarrhythmias, and ventricular fibrillation. In addition, verapamil readily crosses the placenta and has been shown to cause fetal bradycardia, heart block, depression of contractility, and hypotension. Adenosine has several advantages over verapamil, including rapid onset, brevity of side effects, theoretical safety, and probable lack of placental transfer. Adenosine ultimately may prove to be the preferred agent for termination of paroxysmal supraventricular tachycardia in the gravid woman.

The use of transvaginal color flow imaging after in vitro fertilization to identify optimum uterine conditions before embryo transfer

OBJECTIVE

To assess whether a measure of uterine blood flow impedance (the pulsatility index, PI) as determined by transvaginal ultrasonography with color blood flow imaging, may be used to assess endometrial receptivity immediately before the time of embryo transfer (ET) after assisted conception.

DESIGN

A prospective study of infertile women who had undergone treatment to induce multiple follicular development followed by ultrasound-guided oocyte retrieval. The oocytes were fertilized in vitro.

SETTING

The Hallam Medical Centre.

PATIENTS

Eight-two women (22 to 44 years of age) who all had three or four good quality embryos available for transfer to the uterus.

INTERVENTIONS

All women were examined by transvaginal ultrasonography, with color flow imaging and blood flow analysis, immediately before ET.

MAIN OUTCOME MEASURES

The mean PI of the left and right uterine arteries, the pregnancy rate (PR) (%), the embryo implantation rate (%), and the multiple PR (%).

RESULTS

The patients were grouped according to whether the PI was low (1.00 to 1.99), medium (2.00 to 2.99), or high (3+). There were 27 women in the low PI group, 36 in the medium, and 19 in the high. The PR (%), embryo implantation rate (%), and multiple PR (%) were 41%, 15.3%, and 27.3% for the low PI group and 47%, 22.2%, and 47.1% for the medium PI group. There were no pregnancies in the high PI group. Thus 35% (19/54) of women who failed to become pregnant had a PI value greater than 3.0.

CONCLUSIONS

These data suggest that the PI value on the day of ET could be used to: (1) increase the implantation rate by showing which embryos should be cryopreserved until the uterus is more receptive and (2) reduce the multiple PR by indicating that the number of embryos transferred should be limited when the uterus is most receptive.

Cotreatment with growth hormone, after pituitary suppression, for ovarian stimulation in in vitro fertilization: a randomized, double-blind, placebo-control trial

OBJECTIVE

To explore the effect of cotreatment with growth hormone (GH) for ovarian stimulation after pituitary suppression.

DESIGN

A randomized, double-blind, placebo-controlled study.

SETTING

Specialist Reproductive Endocrine and In Vitro Fertilization (IVF) Unit.

PATIENTS, PARTICIPANTS

Twenty-five IVF patients who had responded suboptimally in a previous treatment cycle. A subgroup of 18 patients were found to have ultrasound (US) findings of polycystic ovaries (PCO).

MAIN OUTCOME MEASURE

The amount of gonadotropin used, development of follicles greater than or equal to 14 mm, number of oocytes collected, fertilized, cleaved and replaced, serum and follicular fluid (FF) insulin-like growth factor I (IGF-I) concentrations.

RESULTS

Cotreatment with GH was associated with a significant reduction in gonadotropins requirement (P less than 0.05). In patients with US-diagnosed PCO more follicles developed (P less than 0.05), more oocytes were collected (P less than 0.03), fertilized (P less than 0.004), and cleaved (P less than 0.02). A significantly higher FF IGF-I concentrations were found in patients receiving cotreatment with GH compared with those who received placebo (P less than 0.04).

CONCLUSION

We believe that there may be a place for GH treatment in selected IVF cycles after pituitary suppression but what the role of IGF-I should further be investigated.

Serum and follicular fluid insulin like growth factors I and II during growth hormone co-treatment for in-vitro fertilization and embryo transfer

OBJECTIVE

We wished to assess the changes in serum IGF-I and IGF-II concentrations during gonadotrophin treatment alone or with additional GH treatment and to compare follicular fluid IGF-I and IGF-II concentrations in the two treatment groups.

DESIGN

We performed an open study of co-treatment with GH and subsequently a randomized double blind comparison of addition of placebo or GH to clomiphene citrate and gonadotrophins.

PATIENTS

We studied previously poor responders to superovulation regimens for in-vitro fertilization and embryo transfer, six women in an open study, four of whom had ultrasound diagnosed polycystic ovaries, and 17 women in a double blind study, 12 of whom had polycystic ovaries.

MEASUREMENTS

We measured serum IGF-I and IGF-II concentrations throughout treatment cycles. Follicular fluid concentrations were measured at the time of oocyte recovery.

RESULTS

Neither serum IGF-I nor IGF-II concentrations were altered by gonadotrophin treatment alone. However, co-treatment with GH led to a significant rise in serum IGF-I concentrations in women with ultrasound diagnosed polycystic ovaries. Concentrations of IGF-I and IGF-II in follicular fluid were lower than in serum, although follicular fluid IGF-I concentrations were higher in women receiving GH than in those receiving placebo.

CONCLUSIONS

Poor responders to superovulation regimens may have an abnormality of growth factor response. GH co-treatment leads to an increase in circulating IGF-I concentrations in women with polycystic ovaries but our results do not support the hypothesis that GH stimulates IGF-I production in the human ovary.

Co-treatment with growth hormone of sub-optimal responders in IVF-ET

Several growth factors augment the ovarian response to gonadotrophins and growth hormone is known to regulate the production of insulin-like growth factor-1. With this in mind, 20 women who had previously responded sub-optimally to standard ovarian stimulation regimens for in-vitro fertilization and embryo transfer (IVF-ET) were recruited into a randomized trial to study the effect of co-treatment with growth hormone (Norditropin, Novo Nordisk Gentofte A/S). Intramuscular injections of growth hormone (24 IU) or placebo were given on alternate days concurrently with the same daily dosage of gonadotrophin as administered in the patient's pretreatment cycle. Overall, there was no improvement in the ovarian response to the growth hormone-augmented regimen of stimulation although there was a tendency for the development of more follicles (P = 0.06). When the results from the patients with ultrasound-diagnosed polycystic ovaries were analysed separately, however, more follicles developed (P = 0.04), more oocytes were collected (P = 0.03) and there was a trend towards higher urinary oestrogen production following growth hormone therapy. There was no improvement in the ovarian response in patients with normal ovaries. The treatment was not associated with any adverse effects. We conclude, therefore, that in a subgroup of patients who respond sub-optimally to standard ovarian stimulation regimens for IVF-ET and who have ultrasound-diagnosed polycystic ovaries, systemic growth hormone is an effective adjunctive therapy.

Experience with peritoneal oocyte and sperm transfer as an outpatient-based treatment for infertility

Fifty-nine patients underwent 74 peritoneal oocyte and sperm transfer procedures. Forty-nine had previously failed treatment with inseminated frozen donor sperm and 10 had unexplained infertility. All procedures were carried out under ultrasound direction on an outpatient basis without general anesthetic by the transabdominal or vaginal route. Eighteen (24%) procedures resulted in pregnancy. Of these patients, 16 have delivered live infants (1 set of triplets, 2 twins, and 13 singletons) and 2 miscarried. Peritoneal oocyte and sperm transfer offers an outpatient-based alternative to gamete intrafallopian transfer (GIFT) for in vivo conception. It can also be used in patients scheduled for intrauterine insemination where stimulation is excessive because the number of oocytes replaced can be limited.

The use of an amniotic membrane graft to prevent postoperative adhesions

Grafts of trypsin-treated, gamma-irradiated human amniotic membranes were used to cover injured uterine horns of nulliparous female rabbits to prevent adhesions. In this study, the gradual integration of the membranes into the serosal layer of the uterus, together with marked neovascularization, was observed. By the 30th postoperative day, the grafts had been completely integrated, with little evidence of rejection and no evidence of infection at the graft sites. Of 30 uterine horns treated with membrane grafts, only 4 (13.4%) showed any adhesion formation at or among the graft sites. All of the 24 untreated controls showed adhesion formation at the site of injury. Furthermore, whatever adhesions were found in membrane-treated horns could be graded as thin and filmy, accounting for less than 10% of the surface area of the graft, whereas the controls showed dense, thick adhesions covering 50% to 100% of the injured areas. We conclude that these specially prepared amniotic membranes are safe and effective in dramatically reducing postoperative adhesion formation in this animal model.

Ovarian cyst aspiration and the outcome of in vitro fertilization

This study was designed to ascertain whether any benefit would be derived from aspirating ovarian cysts identified before ovarian stimulation in patients undergoing in vitro fertilization. Thirty-seven patients who had ovarian cysts were categorized into two groups: group A (n = 14) with baseline ovarian cysts and group B (n = 23) with ovarian cysts that developed during pituitary suppression with the gonadotropin-releasing hormone analog. Each group was prospectively randomized into two subgroups depending on whether the ovarian cysts were aspirated or not. In group A, there was a significantly greater number of follicles and oocytes in the ovaries in which cysts were aspirated. However, there was no significant difference in the total number of follicles, oocytes retrieved and fertilized, or in the final outcome. In group B, there was no significant difference in folliculogenesis between the aspirated and nonaspirated subgroups. These observations suggest that the presence of a baseline ovarian cyst may reduce folliculogenesis but do not support routine cyst aspiration if the patient has two functional ovaries.

Oocyte donation: the role of endometrial receptivity

Sixteen patients, 15 with primary ovarian failure and one carrier of chromosomal abnormality, received 21 embryo transfers following in-vitro fertilization of donated oocytes. Hormone replacement therapy was given to mimic a natural menstrual cycle. Five pregnancies were achieved (four infants delivered and one early pregnancy loss). All patients had endometrial biopsies taken in a preceding cycle of hormone replacement therapy. The majority (61%) showed delayed maturation compared with the expected appearances for the day of the cycle as assessed on light microscopy. Patients who conceived had a significantly better endometrial response than those who did not. Five out of seven patients (71%) conceived when the endometrium was 'in phase' (less than 2 days' delay). This suggests that endometrial receptivity is a key factor in conception. The implications for improving outcome from in-vitro fertilization treatment are discussed.

Outcome of pregnancies resulting from assisted conception

With the increasing practice of assisted conception, the health of the resulting children is becoming an increasingly important issue. Experience with four thousand children conceived by IVF or GIFT indicates that multiple pregnancy, which frequently results from assisted conception, is the main determinant of complications during pregnancy and of the health of the children at the time of birth. Overall malformation rates are similar to those in the country as a whole. There are, however, still insufficient numbers of children studied to draw firm conclusions about the risk of specific types of malformations. This will require the continued monitoring of children resulting from assisted conception, and the continued co-operation of many individuals and centres practising assisted conception.

The use of luteinising hormone releasing hormone and its analogues for induction of ovulation and ovarian stimulation for in-vitro fertilisation

The use of subcutaneous pulsatile luteinising hormone releasing hormone (LHRH) for induction of ovulation in patients with hypogonadotrophic hypogonadism is efficacious and safer compared to human menopausal gonadotrophin (hMG) because of the lower risk of ovarian hyperstimulation and multiple pregnancy. In clomiphene citrate (CC) nonresponsive cases of polycystic ovarian disease (PCOD), the major advantage of pulsatile LHRH is that when ovulation occurs, it is usually uni-follicular. In cases of PCOD, we have found that if pulsatile LHRH alone fails to induce ovulation, addition of clomiphene citrate or a small dose of follicle stimulating hormone (FSH) will augment its action and allow, in the majority of cases, the threshold of stimulation to be reached that would be sufficient to induce ovulation but not produce clinical hyperstimulation or multiple pregnancy. LHRH analogues to desensitise the pituitary prior to ovarian stimulation with hMG have been recently used in in-vitro fertilisation (IVF). We have compared the use of the LHRH analogue, buserelin (Hoechst, UK) + hMG with clomiphene + hMG for ovarian stimulation in IVF in a number of prospective studies. In this review, the role of pituitary desensitisation in IVF is discussed in the light of our results. We have found that although the mean number of oocytes, the implantation rate and pregnancy rate per embryo transfer are higher in patients who receive buserelin + hMG, the differences are not statistically significant. The length of time taken to achieve pituitary desensitisation is increased in patients who have PCOD or who form ovarian cysts in response to the administration of buserelin.(ABSTRACT TRUNCATED AT 250 WORDS)

Transvaginal colour flow imaging of the uterine arteries during the ovarian and menstrual cycles

Uterine arterial blood flow was studied at defined times during the ovarian or menstrual cycles. Transvaginal colour pulsed ultrasound was used to identify the vessels in 23 healthy women. Blood flow impedance as reflected by the pulsatility index (PI) was determined for both arteries on 132 occasions. There was no significant difference in the PI values between the right and left arteries. The average PI value was used for subsequent analysis (range 0.5-5.6; mean 2.8). Peak mean PI values occurred on day 1 of menses (4.6), the day of the plasma oestradiol peak (3.7) and the day of the LH peak plus 3 (2.9). The lowest mean PI values (indicating the least impedance to blood flow) occurred on the day of the LH peak minus 6 (2.6), and the day of the LH peak plus 9 (1.9). There are complex temporal relationships between uterine blood flow, ovarian morphology, the concentrations of plasma oestradiol and progesterone and the thickness of the endometrium.

An evaluation of the hypo-osmotic sperm swelling test as a predictor of fertilizing capacity in vitro

The ability of sperm to swell in hypo-osmotic conditions was examined in 211 semen samples from the partners of patients about to undergo oocyte retrieval for in-vitro fertilization (IVF). The test was performed using aliquots of semen, the remainder of which was then prepared for IVF. No significant difference was found, in either the percentage of swollen sperm or the type of swelling response, between samples that achieved fertilization in vitro and those that did not, or between any of the diagnostic categories of infertility (tubal damage, unexplained infertility, oligospermia). In samples which achieved fertilization in vitro there were correlations between sperm swelling and sperm motility (r = -0.51) and abnormal morphology (r = 0.33), but no such correlations were demonstrated in samples that failed to achieve fertilization. Moreover, there was no significant difference between the percentage of swollen sperm in semen (mean motility 64%), in samples immediately after preparation for IVF (mean motility 96%) or in capacitated sperm 24 h after preparation (mean motility 91%). These results demonstrate that the hypo-osmotic sperm swelling test does not assist in the prediction of the fertilizing capacity of human sperm in vitro.

Outcome of triplet pregnancies resulting from IVF at Bourn Hallam 1984-1987

43 consecutive sets of triplet pregnancies progressing beyond 16 weeks and conceived following in vitro fertilisation at the Bourn Hallam Centre between 1984-1987 were included in the study. Follow-up information was available in the 31 sets born to United Kingdom residents. 91 live births resulted at an average gestation of 33 weeks and 2 days (range 26-38 weeks). All but one of the deliveries was by Caesarean section. The average birth weight was 1.85 kg and was significantly higher in the first-born triplet than in the third (1.93 kg versus 1.74 kg, respectively). The perinatal mortality rate amongst the triplets was 32.26 per thousand births, and the neonatal death rate was 21.98 per thousand live births. This compares favourably with the latest published data on perinatal mortality rates in triplets.

The clinical outcome of reinsemination of human oocytes fertilized in vitro

To assess the value of reinseminating human oocytes, the results of 1,662 embryo transfers were analyzed. In 1,460 transfers embryos arose from oocytes that had fertilized and cleaved after initial insemination. The pregnancy rate was significantly higher than in transfers of embryos (n = 76) resulting solely from reinseminated oocytes (27% versus 3%). Adding reinseminated embryos to those fertilizing on initial insemination at transfer failed to raise the pregnancy rate. Only 2 of 158 (1.3%) reinseminated embryos implanted compared with 540 of 4,181 (12.9%) fertilized and cleaved on initial insemination (P less than 0.001). Reinseminated embryos do occasionally produce viable pregnancies. It is therefore worth considering replacement of these embryos if initial fertilization has entirely failed. Patients should be counseled as to the low chance of implantation with these embryos.

The use of a short regimen of buserelin, a gonadotrophin-releasing hormone agonist, and human menopausal gonadotrophin in assisted conception cycles

The outcome of in-vitro fertilization treatment using buserelin, an agonist of luteinizing hormone releasing hormone, given in a short stimulation regimen with human menopausal gonadotrophin (HMG), was compared with a conventional regimen including clomiphene citrate (CC). A total of 94 infertile women underwent cycles of treatment with intranasal buserelin, 500 micrograms daily from the first day of menstruation and also HMG daily from the third day. The same patients had previously undergone unsuccessful treatment cycles with CC and HMG. Overall, addition of buserelin resulted in fewer cycles being abandoned (10 versus 34%) and none of the patients ovulated prior to collection. The mean total dose of HMG required was increased by 74% in buserelin cycles. Significantly more oocytes were collected with buserelin treatment (mean 5.9 versus 4.4, P less than 0.01) and, thus, significantly more embryos were transferred (mean 2.3 versus 1.2, P less than 0.0001) although fertilization and cleavage rates were unchanged. Fifteen pregnancies were achieved, giving a clinical pregnancy rate of 22% per embryo transfer. These pregnancies resulted in 16 live births (7 singletons, 3 twins, 1 triplets). Four pregnancies failed before 14 weeks gestation. We conclude, therefore, that the substitution of buserelin for CC for ovarian stimulation in poor responders results in an improved outcome, both in terms of the number of oocytes collected and the pregnancy rate per treatment cycle.