Sperm as a noninvasive gene delivery system for preimplantation embryos

OBJECTIVE

To determine if sperm could be manipulated to be a noninvasive transport carrier for the delivery of gene fragments to the blastocyst.

DESIGN

Sperm cells carrying foreign DNA fragments from human papillomavirus (HPV) types 16, 18, 31, and 33 were allowed to migrate from one end of an artificial reproductive tube and to come in contact with hatching mouse blastocysts at the other end of the tube. The blastocysts were then washed and analyzed for the presence of the foreign DNA fragments.

SETTING

Clinical and academic research environment.

MAIN OUTCOME MEASURE

Detection of amplified products from transferred foreign DNA using the polymerase chain reaction and primers targeted at the E6-E7 region for different HPV types.

RESULTS

Polymerase chain reaction analyses showed transference of DNA HPV type 18 to the blastocysts. Not all types of DNA fragments were transferred equally.

CONCLUSION

The results suggested the possibility of using sperm as a noninvasive gene delivery system for passing on gene fragments to preimplantation embryos. It was demonstrated that certain DNA fragments were easier to deliver than others, indicating the necessity for exploring all the factors involved in the mechanism of the transference process. The study also serves to highlight the possibility of unintentional transmission of viral or bacterial DNA to the developing embryo via the sperm.

A new concept for anastomosis of the fallopian tube: tissue reconstruction with nonpenetrating, arcuate, legged clips in the rat model

OBJECTIVE

To evaluate the titanium Kirsch-Zhu microclip microsurgical reanastomoses of the fallopian tubes.

DESIGN

Compare the reanastomoses of the rat uterine horn between Kirsch-Zhu clips (Cushman Engineering, Albuquerque, NM) (group A) and conventional suture microsurgical techniques (group B).

SETTING

Microsurgery Research Laboratory, Loma Linda University Medical Center, Loma Linda, California.

PATIENTS, PARTICIPANTS

Fifteen SD rats Harlan (Harlan Sprague-Dawley Corp., Indianapolis, IN) were done in groups A and B and six in control group (C).

MAIN OUTCOME MEASURE

Pregnancy rate, litter size, tissue of procedure, and histologic results.

RESULTS

The clip technique was shorter in procedure time and resulted in equal fertility rate and litter size. Histologically, there were less granulomatous formation and histiocytic inflammation, but muscularis thinning and fibrosis were noted with the clip.

CONCLUSIONS

The Kirsch-Zhu clip has potential for application to human fallopian tube reanastomoses.

Human papillomavirus gene sequences in washed human sperm deoxyribonucleic acid

The present study demonstrated the presence of HPV gene sequences in Percoll-washed sperm cells using polymerase chain reaction primers targeting smaller gene regions. Up to 64% of the sperm specimens were shown to contain gene sequences indicative of the presence of HPV. Human papillomavirus type 16 was detected about twice as often as HPV type 18. The results suggest the possible role of sperm as a vector for HPV.

White blood cells in semen affect hyperactivation but not sperm membrane integrity in the head and tail regions

The presence of high numbers of peroxidase-positive PML in ejaculated semen significantly reduced sperm HA, an important step leading to sperm capacitation. Sperm membranes at both the head and tail regions, as assessed by the hypo-osmotic viability parameter and the hypo-osmotic sperm swelling test, respectively, were not affected by peroxidase-containing leukocytes. Sperm motility was not affected, but sperm curvilinear and straight line velocity parameters were reduced in the presence of high concentrations of leukocytes in the ejaculate. The results suggested that the effect of leukocytes on sperm was through a reduction in sperm hyperactive motility but not through alterations in the sperm head and tail membranes.

The relationship between human sperm fertilizing capacity and histocompatibility linked antigen (HLA) alleles gene sequences

Heterodimer membrane glycoproteins expressed from hypervariable genes located in the histocompatibility linked antigen (HLA) class II genes on chromosome 6 have been shown to induce activation of lymphocytes and are involved in human sperm binding processes. The objective was to identify an association between HLA-DQA1, -DRB1 or -DPB1 genes and sperm kinematic parameters and sperm penetration of oocytes. The results showed reduced sperm hyperactivation and decreased sperm penetration of zona-free oocytes when the HLA-DRB1 allele was present. The reduced hyperactive motility was not attributed to alterations in sperm kinematic parameters. In contrast, the HLA-DPB1 gene only affected sperm count, linearity of movement and sperm head dimensions. HLA-DQA1 had no effect on the sperm parameters. The data suggest a link between HLA-DRB1 and HLA-DPB1 genes and sperm concentration, sperm movement characteristics and fertilizing capacity.

Clinical pregnancy rate after the double method wash and intrauterine insemination

The protocol for intrauterine insemination (IUI) involves sperm processing using different methods that have produced varying results. These sperm wash methods do not take into consideration the problems of the exact timing of ovulation and the requirements of sperm cells at different stages of capacitation. The objectives of this study were 1) to use the double method wash previously reported to produce a mixture of different populations of sperm cells and determine the pregnancy outcome after IUI and 2) to compare the sperm kinematic parameters after the double method wash with those after the centrifuge (or whole-population) wash method. Patients were divided into either the double method group (n = 119) or the centrifuge method group (n = 76). The Hamilton-Thorn HTM-C automated sperm motility analyzer (Hamilton-Thorn Research, Danvers, MA) was used to analyze sperm motility parameters. Pregnancy outcomes were evaluated after controlled ovarian stimulation and IUI. An almost 2-fold increase was seen in the pregnancy rate with the double method wash compared with the centrifuge method wash. Sperm motility and velocity were also enhanced in the double method wash groups. The results support the usefulness of the double method wash for the preparation of sperm for IUI.

Uptake of exogenous human papilloma virus L1 DNA by oocytes and detection by the polymerase chain reaction

OBJECTIVE

The purpose of this study was to determine if oocytes were capable of taking up exogenous DNA such as human papillomaviral (HPV) DNA and evaluate the zona pellucida as a barrier to the entry of foreign DNA into the oocyte.

METHODS

The experiment consisted of four groups of hamster oocytes exposed to HPV DNA fragments: Group A, zona-free oocytes (n = 5); Group B, oocytes with an intact zona pellucida (n = 5); Group C, oocytes fixed in 4% buffered formalin solution for 20 min (n = 5); and Group D, zona-free oocytes (n = 4). Group C oocytes served as an internal control to ensure adequate washing of the oocytes after incubation.

RESULTS

The zona pellucida was not a barrier to foreign DNA molecules. The PCR did not detect L1-HPV and beta-globin gene sequences in the untreated hamster oocyte. Uptake of the smaller DNA fragments such as that amplified from the beta-globin region was independent of active oocyte cell processes.

CONCLUSION

Oocytes cultured in vitro can passively take up exogenous DNA fragments. The results suggest a possible role of oocytes as vectors for foreign DNA.

Assessment of sperm for cryopreservation using the hypoosmotic viability test

In summary, the hypoosmotic viability parameter was significantly correlated with the outcome of the thawed sperm motility. The prefreeze supravital staining for sperm viability and the hypoosmotic sperm swelling test were not predictive of the thawed sperm total motility. The hypoosmotic viability parameter was not correlated to the postwarmed sperm motility after refrigeration. The results indicated that the integrity of the sperm membranes at the head were more important than the tail membrane.

A double method sperm wash for artificial insemination

Recently, there have been concerns regarding the presence of reactive oxygen species (ROS) produced during sperm processing for insemination. However, the sperm wash methods that yielded low ROS levels also had low sperm recovery after processing. The objective of this study was to compare sperm recovery after swim-up from pellet, overlay, and 2-layer Percoll wash methods with the recovery after the double method wash. The latter method consisted of a combination of 2 sperm wash methods, namely, the overlay and the Percoll method. Motile sperm were first collected through the overlay method. The leftover semen was then processed through the 2-layer Percoll method to scavenge motile sperm and the resultant pellet combined with the pellet from the overlay method. In this manner, the level of ROS was kept to a minimal, sperm recovery was improved, and a mixture of sperm with different surface properties was produced as a result of using different processing methods. The results indicated an improvement in sperm recovery and in total sperm motility in noncryopreserved sperm after using the double method wash when compared with the other wash methods. The study suggests that the double method wash is a feasible method for processing sperm for insemination.

Association of human sperm nuclear decondensation and in vitro penetration ability

Sperm nuclear decondensation is an integral step in fertilization which leads to the formation of the male pronucleus. The association between the in vitro spontaneous nuclear decondensation of human sperm and its fertilizing ability was studied in infertile male patients. The ability of sperm to fertilize an egg using the discontinuous two-layer Percoll method was significantly correlated to the percentage of decondensed swollen head (r = 0.43; P less than 0.005). The fertilizing ability of sperm processed with Test-Yolk buffer was correlated with the percentage of sperm at the fully decondensed stalk stage (r = 0.51; P less than 0.05). There were insignificant correlations for the whole-wash centrifugation, cryopreserved-thawed and swim-up methods. Samples of sperm that were positive (greater than 0% fertilization) in the sperm penetration assay had a higher percentage of decondensed sperm heads (66.7% vs. 20.6%) after Percoll wash or whole-wash centrifugation (60.5% vs. 44.3%) treatments compared with samples with no fertilization. Treatments that included Test-Yolk resulted in high percentages of decondensed swollen heads. The results suggest a positive association between sperm nuclear decondensation and the fertilizing ability of sperm, and affirm the importance of nuclear decondensation to the study of fertilization events.

Follicular phase hormonal profiles during administration of leuprolide for in vitro fertilization

Hormonal changes induced during short-term administration of leuprolide were evaluated during the follicular phase in 57 patients who completed an IVF cycle. They were compared with those of 14 patients who were placed on long-term suppression. There was an unexpected abnormal increase in serum progesterone during the first week of the cycle in nine of the 57, with no significant change in the fertilization and cleavage rate; however, no pregnancy was achieved in this group. Transient mild elevation of progesterone was also detected in 16 patients with no adverse effect on fertilization and the outcome of the IVF. In the long protocol, the tonic levels of LH, FSH, and progesterone remained low throughout the follicular phase. The total number of pregnancies was higher in the short suppression regimen, but the full-term pregnancy rates were similar in both protocols.

Sperm hyperactivation as quality control for sperm penetration assay

The sperm penetration assay (SPA) is subject to considerable variation, and controls are needed to verify the accuracy of the results. It is proposed that sperm hyperactivation (HA) can serve as a quality control check for the SPA. The objective was to determine if there was an association between the SPA outcome and sperm HA measured at various times during the SPA procedure. The data showed a significant correlation between percent sperm HA and percent zona-free oocyte penetration by sperm preincubated for three hours prior to sperm-oocyte interaction (short preincubation). Some sperm hyperactivity was observed in liquefied raw semen samples, but this was insignificantly related to SPA results. Low correlation was observed between SPA results and sperm HA determined immediately after centrifuge washing of sperm. The results suggest that it is possible to utilize sperm HA measured immediately after the sperm-oocyte interaction period as a quality control check of SPA results.

Diadenosine tetraphosphate (Ap4A) and triphosphate (Ap3A) signaling of human sperm motility

The ubiquitous dinucleotide polyphosphate, diadenosine tetraphosphate (Ap4A), has been shown to be a signal molecule for DNA replication in mammalian cells. In this study, Ap4A and a related compound, diadenosine triphosphate (Ap3A), were tested for possible signaling functions in human spermatozoa. A computerized automated semen analyzer was used to detect changes in spermatozoa motility parameters. Cryopreserved-thawed donor spermatozoa were washed and incubated in 0.1 mM Ap4A, 0.1 mM Ap3A, or control medium. The data indicated that both Ap4A and Ap3A decreased the percentage of motile spermatozoa after 4 or more hours of incubation in vitro. The two dinucleotide polyphosphates caused an increase in the amplitude of lateral spermatozoa head displacement parameter only at the start of incubation. The other spermatozoa kinematic parameters were unaffected. No opposing ying-yang dual actions of Ap4A to Ap3A were seen. From the results, Ap4A and Ap3A were observed to be potential inhibitory signals of spermatozoa motility after prolonged exposure.

Combined supravital staining and hypoosmotic swelling test

The parameter of sperm viability in hypoosmotic solution (VHOS) provides information concerning the membrane integrity of the sperm head. The objective of this study was to determine the association between the VHOS parameter and the sperm penetration assay. The VHOS parameter correctly predicted 70.0-71.4% of the failed sperm penetration assay samples in the short duration preincubation groups. A combination of both the VHOS parameter and the hypoosomotic sperm swelling (HOS) test significantly reduced the number of false negative results. In general, a sperm sample with an abnormal VHOS result and an abnormal HOS test result would be associated with a negative sperm penetration assay. Washing by centrifugation appeared to weaken the sperm head membranes while the swim-up method selected for sperm with strong head and tail membranes. After the various processing methods unique changes in the integrity of the sperm head and tail membranes for each sperm sample may help to identify the optimal method of preparation for individual patients undergoing the newer assisted reproductive technologies such as sperm microinjection.

Identification of male-factor semen samples prior to insemination and in vitro fertilization

Semen analyses carried out as part of the clinical in vitro fertilization or intrauterine insemination protocols provide important information that determine the type of clinical treatment of the male partner and the sperm processing method. It is postulated that the sperm of male-factor patients cannot survive hypoosmotic stress conditions because of defective sperm membrane function. To test this, 0.1 ml of semen from each of 102 patients was placed in 1.0 ml of 150 mosmol/liter eosin citrate fructose solution and incubated for 30 min at 37 degrees C. The percentage viability of the sperm cells was then determined. The results indicated that patients with two or more abnormal semen parameters had a significantly lower percentage viability while in the hypoosmotic solution (40.6 +/- 4.7%), in contrast to non-male-factor patients (69.0 +/- 1.6%). Donor sperm (N = 32) serving as controls (73.3 +/- 2.1%) had a viability in hypoosmotic solution similar to that of non-male-factor patients. The data suggest that sperm of male-factor patients are less able to survive the hypoosmotic stress conditions as shown by the percentage viability in hypoosmotic solution and emphasize the importance of using less stressful sperm processing methods for in vitro fertilization or insemination in these patients.

Cyclic CMP (cytidine 3',5'-monophosphate) suppresses changes in human sperm amplitude of lateral head displacement and hyperactivation

The dibutyryl analog of cCMP suppressed sperm amplitude of lateral head displacement and hyperactivation. Sperm motility was inhibited by dibutyryl cCMP with a shift toward less linear trajectory sperm movements. The results suggest a role of cCMP as an inhibitory signal on sperm motility patterns related to sperm capacitation.

Inhibition of implantation in vitro of frozen-thawed mouse embryos by the signal molecule diadenosine tetraphosphate

The dinucleotide polyphosphate, diadenosine 5', 5'''-P(1), P(4)-tetraphosphate (Ap4A), has been identified in mammalian and non-mammalian cells as a signal molecule that initiates the process of DNA replication and cell division. The objective of this study was to determine the function of this messenger molecule in preimplantation mouse embryonic cells. Frozenthawed two-cell mouse embryos were incubated in the presence of 0, 0.1 and 1.0 mM Ap4A at 37 degrees C in moist 5% CO(2) in air mixture for 5 d. The developmental stages of the embryos in terms of hatching and implantation were evaluated. The data showed dose-dependent inhibition of blastocyst implantation; however, there were no differences observed in the number of embryos developing to the blastocyst stage. The results suggest that Ap4A neither promotes nor inhibits the development of early stage embryos except at the implantation stage, where it exerts inhibitory control.

Effectiveness of stimulated menstrual cycles and Percoll sperm preparation in intrauterine insemination

To examine the usefulness of intrauterine insemination in women with various fertility factors, we retrospectively analyzed data from women treated during 1986 and 1987. Ninety-three patients underwent 1-11 cycles of single or double procedures, for a total of 423 inseminations in 263 treatment cycles. Twenty-six patients (28%) conceived, for a 10% total pregnancy rate per cycle, with 58% of the pregnancies resulting from double inseminations per cycle. An average of two treatment cycles was required to achieve pregnancy. Eight pregnancies (31%) occurred in spontaneous cycles, while 18 (69%) occurred in stimulated cycles. While clomiphene citrate therapy was useful in anovulatory patients, it was of no benefit in ovulatory patients being treated with intrauterine insemination. Human menopausal gonadotropin therapy was of benefit in both ovulatory and anovulatory patients when combined with intrauterine insemination. The live birth rate was higher (75%) in spontaneous cycles than in stimulated cycles (44%). Semen preparation was accomplished by sperm washing in 61% of the pregnancies and by Percoll preparation in 39%. The effectiveness of the discontinuous Percoll gradient for semen preparation for insemination was suggested by a pregnancy rate of 9% per cycle. While the mean sperm count in the pregnant group was 44 million, successful pregnancy was accomplished with a double insemination of 880,000 and 1.16 million rapidly progressive sperm in the first and second inseminate, respectively. The data confirm the important role of intrauterine insemination for the treatment of infertility.

Evaluation of the Pipelle curette for endometrial biopsy

The Pipelle endometrial suction curette was evaluated, and its application and effectiveness were compared to those of the Novak curette for endometrial sampling during the midluteal phase. Fifty women underwent an endometrial biopsy with the Pipelle and Novak curettes. Ninety percent of the women preferred the biopsy with the Pipelle. Histologically, tissue obtained with the Pipelle was satisfactory and similar to that with the Novak. The Pipelle curette appears to be an excellent device for midluteal endometrial biopsy during an infertility evaluation.

Effectiveness of short pituitary suppression with gonadotropin-releasing hormone agonist leuprolide during induction of ovulation for in vitro fertilization

A short suppression regimen with daily 0.5 mg leuprolide commencing the first day of in vitro fertilization (IVF) cycles was evaluated in 10 women who previously underwent similar IVF cycle without suppression. Induction of ovulation, oocyte retrieval, incubation, and embryo transfer were similar in all the cycles. Assessment included the amount of human menopausal gonadotropin (hMG) used, length of stimulation, serum estradiol and luteinizing hormone (LH) levels, number of oocytes retrieved and their quality, cleavage rate, and number of embryos. The results showed that when leuprolide was used, no endogenous LH surge was detected, and there was a significant increase in hMG injected, from 19.0 +/- 5.8 to 34.4 +/- 17 ampoules, and in estradiol levels, from 1276 +/- 470 to 2618 +/- 1084 pg/ml (mean +/- SD). In addition, there was an increase in the total oocytes retrieved from 54 to 94, their cleavage rate from 59 to 86%, and the number of embryos from 24 to 70 in the suppressed cycle. No deleterious effects were observed and there were two pregnancies in this group.

Regulation of mouse trophoblast giant cell nucleus development in hatched mouse blastocysts by cyclic cytidine 3',5'-monophosphate (cCMP)

The dibutyryl analog of cCMP enlarged the nuclei of trophoblast giant cells and promoted blastocyst development. The result suggests that cCMP has a trophic effect on embryonic development, specifically by altering the size of the trophoblast cell nucleus but does not enhance trophoblast cell proliferation processes.

Correlation of postcoital evaluation with in vitro sperm cervical mucus determinations and ureaplasma cultures

Fifteen trials were completed in 14 couples during an infertility evaluation. The postcoital test (PCT) was accomplished in a standardized manner. Also, standardized determinations of the sperm-cervical mucus penetration test (SCMPT) with the addition of cross-testing (X-test) utilizing bovine cervical mucus (BCM) and normal donor semen (NDS) were done. Male and female samples were also cultured for Ureaplasma urealyticum using U9-B indicator broth and A-7 agar. The PCT and SCMPT agreed in 87% (13/15) of the cases. Utilizing BCM and NDS, where possible, the causative factor was the cervical mucus in 54% (7/13); semen factor in 15% (2/13); both factors in 8% (1/13); and undetermined in 23% (3/13). U. urealyticum cultures were positive in 40% (6/15) of the cases. Analysis of the results revealed: (1) significant correlation between PCT and SCMPT (P less than 0.01); (2) no significant difference among the PCT, SCMPT, and X-test, indicating that the cervical mucus was the causative factor; and (3) no U. urealyticum correlation with the PCT or the SCMPT. Thus, laboratory SCMPT and X-test correlated with the PCT, providing additional information concerning the causative factor in infertility. The U. urealyticum status in cervical mucus and semen cannot be determined from the PCT nor the SCMPT.

Pituitary response to LHRH in hypothyroid women

This study was designed to characterize pituitary function in premenopausal women during hypothyroid and euthyroid periods. Six subjects with basal thyroid-stimulating hormone (TSH) levels above 10 microU/ml were studied. Estradiol (E2), prolactin (PRL), follicle-stimulating hormone (FSH), and luteinizing hormone (LH) levels were measured by radioimmunoassay at 30, 15, and 0 minutes before infusion. Pituitary function was evaluated by rapid infusion of 10 micrograms of luteinizing hormone-releasing hormone (LHRH) every 2 hours for a total of 6 hours. Samples were then obtained for FSH and LH every 30 minutes for the duration of the 6-hour study. A significant elevation in basal gonadotropins was observed during the hypothyroid period regardless of basal E2 levels in all 6 subjects (P < .01). Basal PRL levels were not significahtly different during the 2 periods (P > .05). In all 6 patients pituitary sensitivity and reserve correlated significantly with basal E2 levels (P < .05), but were not altered by the hypothyroid condition. It is concluded that pituitary responsiveness to LHRH is not altered in hypothyroid women, but that chronic elevation of basal gonadotropins may in part explain the anovulation that so often accompanies this disorder.

A reciprocal translocation (X;11) in a female with gonadal dysgenesis

A 24-year-old female patient was referred for evaluation of primary amenorrhea. Endocrine studies showed elevated gonadotropins, consistent with gonadal failure. At laparoscopy, a normal nulligravid uterus, normal fallopian tubes, and bilateral streak gonads were observed. Histologic studies showed that the left gonad consisted entirely of fibrous tissue, confirming the presence of streak gonads. Chromosome banding studies of peripheral blood and cultures of tissue from the left gonad demonstrated a 46,X,rcp(X;11)(q22;q13) karyotype. A review of reports of X-autosome reciprocal translocations indicated that abnormal gonadal development is associated with break-points in the mid-region of the long arm of the X chromosome.

Hypothalamic-pituitary responses to high concentrations of gonadal steroids in a three-month-old infant with a feminizing gonadal stromal tumor

A 3-month-old female infant feminized by an ovarian stromal tumor is presented. Clinicopathologic aspects of such tumors occurring in infancy are discussed. In addition, the evaluation of hypothalamic-pituitary function preoperatively and postoperatively are presented. In the preoperative, high-steroid environment, both basal and stimulated secretion of follicle-stimulating hormone (FSH) was suppressed. Secretion of luteinizing hormone (LH) was normal. Following surgical castration, stimulated secretion of both gonadotropins clearly increased. These findings suggest an active but less sensitive negative feedback mechanism for FSH than for LH during infancy, i.e., high concentrations of gonadal steroids are necessary to maximally suppress FSH secretion while normal steroid concentrations appear to maximally suppress LH secretion. Developmental changes in hypothalamic-pituitary sensitivity to negative feedback controls are discussed in light of these findings.

A reassessment of the fractional postcoital test

The present investigation was designed to reassess the fractional postcoital test (PCT). Specifically, the study addressed the question of whether the internal cervical mucus sperm count is significantly different from the sperm counts at other cervical levels. By means of standardized methodology, 25 normal postcoital tests were perfoemed on 22 couples. Cervical mucus from three different levels within the endocervical canal was examined for total count, motility, and sperm morphology. No significant difference could be found in these three parameters among any of the cervical levels (p greater than 0.05). Significantly fewer abnormal sperm were found in the cervical mucus when compared to the total abnormal forms in the semen (p less than 0.001). Therefore, while the fractional PCT is a reflection of cervical sperm, this study indicates that the three different cervical levels in the fractional PCT (internal-mid-external) are equally effective in the interpretation of the postcoital test.

Continued clinical experience with an increasing dosage regimen of clomiphene citrate administration

Between August 1, 1975, and July 31, 1977, 60 patients with infertility and ovulatory dysfunction were evaluated at the Naval Regional Medical Center, Oakland. Of these, 15 had incomplete work-ups or were lost to follow-up. Of the remaining 45 patients, 2 (4.5%) failed to ovulate at a maximal dose of 250 mg of clomiphene for 5 days with 10,000 units of human chorionic gonadotropin. Of the 43 (95.5%) who did ovulate, 33 conceived. Of these 33 patients, 9 (27%) required greater than 100 mg of clomiphene and/or longer than three ovulatory cycles to conceive. Of the 10 patients who did not become pregnant, additional infertility factors were present in 5. When these 5 were eliminated, the corrected pregnancy rate was 87% (33 of 38). The spontaneous abortion rate was 12.2% and there were no multiple gestations. These results would further emphasize that clomiphene can be used safely and effectively at doses greater than 100 mg or for longer than three ovulatory cycles.

Spontaneous pregnancy during the infertility evaluation

Of 299 patients evaluated for infertility between July 1, 1974, and December 31, 1976, 21 (7.2%) became pregnant during the initial evaluation prior to any recognized therapy. A comparative analysis was made between these 21 couples and the 223 completely evaluated infertility couples. No significant difference in sexual, psychiatric, or menstrual history was found. There was a significantly increased incidence of low coital frequency in the pregnancy group (P less than 0.01). The mean duration of infertility was also significantly less (1.6 years versus 2.9 years) in the pregnancy group. It is concluded that the majority of patients who become pregnant during an evaluation for infertility do so because of prior low coital exposure. There was no evidence in this study to support the concept that psychophysiologic factors were altered in these 21 couples during the initial clinical visits.

Gonadotropin secretion and hypothyroidism

Hypothyroidism is generally associated with hypogonadotropism. Occasionally, however, increased gonadotropin concentrations are encountered. The mechanisms, presumably hypothalamic, which determine the gonadotropin shift are unclear. A case report of hyperprolactinemic hypothyroidism with associated hypergonadotropism is presented. The previous literature is reviewed. It appears that hypothyroidism is generally associated with a decrease in the gonadogropin secretion. However, hypothyroidism with exxagerated hTSH secretin and hyperprolactinemia can be associated with increased gonadotropin secretion.

Effect of intramuscular triamcinolone acetonide on the human ovulatory cycle

The effect of intramuscular triamcinolone acetonide (TCA-A) on pituitary gonadotropins and ovarian hormones was studied in a normally menstruating woman. Serum levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), as well estradiol 17-beta (E2) and progesterone (P), were determined daily in a normal "ovulatory" pretreatment cycle. A total of 160 mg of TCA-A was then administered in four injections over two and a half months. Daily serum levels of LH, FHS, E2, and P were again measured during a period beginning thirty days after the last injection of TCA-A. Cyclicity of all these hormones was absent after treatment. Both LH and FSH were suppressed in the first half of the post-treatment period when compared with the pretreatment ovulatory cycle. A potent corticosteroid such as TCA-A is apparently capable of producing anovulatory cycles in humans by disruption of cyclic pituitary gonadotropin secretion.

Improved glucose control in nonhospitalized pregnant diabetic patients

Methods for management of diabetic pregnancy in the outpatient setting require strict glucose control. To assess the effect of diet and injection of short and intermediate acting insulin on glucose, diabetic patients tested their urine daily for glucose and had biweekly serum glucose tests. A brief metabolic ward study in 9 diabetic patients during the third trimester yielded hourly glucose determinations. These results defined the range of serum glucose over a 24-hour period. Glucose data on 6 normal third trimester women also came from hourly glucose values. Glucose results of normal and diabetic subjects were similar. A 16th subject with diabetic eye, renal, and foot complications is included as a case report to illustrate management technics. Infants of the diabetic women had no perinatal mortality, morbidity, or macrosomia and thus differ from an earlier study where glucose was not strictly controlled. The data suggest hospitalization can be short and low perinatal morbidity and mortality are possible with this outpatient method of management of the pregnant diabetic patient.

Effect of clomiphene citrate upon amount and duration of human menopausal gonadotropin therapy

Human menopausal gonadotropin (HMG) was given to 10 patients who failed to ovulate after treatment with clomiphene citrate. Prior to one or more treatment courses, 200 mg. of clomiphene were administered daily for 5 days; at least one other treatment course was not preceded by clomiphene. Before therapy, progesterone in oil was administered and serum FSH, LH, and estrogen were measured. Those patients who had normal serum FSH levels and had withdrawal bleeding following progesterone had a reduction in amount and duration of HMG requirements for those patients with low serum FSH who did not withdraw. Thus, sequential clomiphene-HMG therapy is of benefit only for those women with normal serum FSH levels and is the treatment of choice.

The interpretation and significance of the fractional postcoital test

The investigation was designed to objectively determine the clinical usefulness of the fractional postcoital test. Forty-three normal subjects had midcycle cervical mucus collection at various times after insemination. There was a significant correlation between the number of motile sperm at the internal os level and the total sperm count within the cervical mucus. The median internal os count was 15 motile sperm per high-power field with a lower 95% confidence limit of five motile sperm per high-power field. Therefore, the fractional postcoital test is useful clinically as it is a physiologic indication of sperm transport in cervical mucus.

Effect of intrauterine devices on sperm transport in the human being: preliminary report

This investigation was designed to determine the effect of the intrauterine contraceptive device (IUD) on the early phase of sperm transport. Previously we have shown that in normal midcyle subjects the maximal number of sperm recovered from the oviducts occurred between ten and 45 minutes after vaginal insemination. Four normal subjects, three of whom had IUD's in situ for at least eight months (copper T, Dalkon shield, and loop) and one a loop for one month, were studied in a similar manner. All subjects were inseminated at midcycle and had bilateral abdominal salpingectomies 15 to 30 minutes after insemination. No sperm were present in the oviducts of any of the subjects. The results of this study indicate that the IUD interferes with sperm transport in the human being. Additional subjects are now being studied at different time intervals after insemination in order to determine the entire effect of the IUD upon sperm transport.

Significance of timing for the postcoital evaluation of cervical mucus

This investigation was designed to determine the role of cervical mucus in the dynamic in vivo distirbution of transported spermatozia in the human reproductive tract. Forty-two normal subjects had midcycle cervical mucus collection at various times after insemination. Sperm were identified in the cervical mucus at the level of the internal as shortly after insemination. The numbers of sperm in cervical mucus were directly related to the numbers of sperm in the inseminate and were related to time from insemenation. In order to obtain optimal information, the postcoital examination for the presence of sperm should be performed within two and one-half hours after semen exposure. It was also determined that cervical mucus does serve as a reservoir for those sperm which are transported to the Fallopian tubes.