HIRA contributes to zygote formation in mice and is implicated in human 1PN zygote phenotype

Elucidating the mechanisms underpinning fertilisation is essential to optimising IVF procedures. One of the critical steps involves paternal chromatin reprogramming, in which compacted sperm chromatin packed by protamines is removed by oocyte factors and new histones, including histone H3.3, are incorporated. HIRA is the main H3.3 chaperone governing this protamine-to-histone exchange. Failure of this step results in abnormally fertilised zygotes containing only one pronucleus (1PN), in contrast to normal two-pronuclei (2PN) zygotes. 1PN zygotes are frequently observed in IVF treatments, but the genotype-phenotype correlation remains elusive. We investigated the maternal functions of two other molecules of the HIRA complex, Cabin1 and Ubn1, in mouse. Loss-of-function Cabin1 and Ubn1 mouse models were developed: their zygotes displayed an abnormal 1PN zygote phenotype. We then studied human 1PN zygotes and found that the HIRA complex was absent in 1PN zygotes that lacked the male pronucleus. This shows that the role of the HIRA complex in male pronucleus formation potentially has coherence from mice to humans. Furthermore, rescue experiments in mouse showed that the abnormal 1PN phenotype derived from Hira mutants could be resolved by overexpression of HIRA. We have demonstrated that HIRA complex regulates male pronucleus formation in mice and is implicated in humans, that both CABIN1 and UBN1 components of the HIRA complex are equally essential for male pronucleus formation, and that rescue is feasible.

Clinical pregnancy is significantly associated with the blastocyst width and area: a time-lapse study

In order to maintain pregnancy rates following single embryo transfer, optimisation of embryo culture and selection is vital. Time-lapse monitoring (TLM) has the potential to play a crucial role by providing sequential images of embryo development and minimal disturbance. Therefore, in this study morphometric assessment of blastocyst area and maximum width was performed in order to evaluate if these parameters are associated with pregnancy outcomes in IVF/ICSI cycles. This is a retrospective study of 664 patients who had elective single blastocyst transfer (eSBT). The EmbryoScope drawing tools were used to measure specific variables such as the maximum blastocyst width and blastocyst area. Our results show that women who were pregnant had significantly (P < 0.01) larger blastocyst width [median (range) μm] 184 (125-239) versus non-pregnant, 160 (120-230)] and area [median (range) μm²] 26099 (12101-45,280) versus non-pregnant women, 22,251 (10992-37,931)]. A univariate logistic regression performed showed that blastocyst width [(OR = 1.026, 95% CI = (1.019, 1.033)] was significant (P < 0.01) and for every μm increase of blastocyst width, the odds of clinical pregnancy increase by 2.6%. A univariate logistic regression performed showed that blastocyst area [(OR = 1.00008, 95% CI = (1.00006, 1.00011)] was significant with P < 0.01. For every μm² increase of blastocyst area, our data showed the odds of clinical pregnancy increase by 0.008%. Hosmer-Lemeshow tests of calibrations were performed to verify calibration. Although our findings show a clear correlation between blastocyst dimensions and the clinical pregnancy rate, further studies are necessary to confirm these observations.

Spontaneous blastocyst collapse as an embryo marker of low pregnancy outcome: A Time-Lapse study

OBJECTIVE

In this study we investigate the correlation between spontaneous blastocyst collapse and pregnancy outcome.

METHODS

This is a retrospective study performed at Edinburgh Assisted Conception Programme, EFREC, Royal Infirmary of Edinburgh, UK. Embryos were cultured individually in 6.0% CO2, 5.0% O2, 89.0% N2, using single step medium (GTL™ Vitrolife, Göteborg, Sweden) and selected for transfer using standard morphological criteria. Using the EmbryoScope™ time-lapse monitoring (TLM), blastocysts collapse was analyzed by measuring the maximum volume reduction and defined as having collapsed if there was >50% volume reduction. Couples undergoing IVF/ICSI treatment and having an elective single embryo transfer (eSET) at blastocyst stage were included in this study. After the embryo transfer, retrospectively, each blastocyst was allocated to one of two groups (collapsed or not collapsed). 62 blastocysts collapsed once or more during development (17.4%), the remaining 294 showed no collapse (82.6%).

RESULTS

A significantly higher implantation rate (IR) of 61.2% and ongoing pregnancy rate (OPR) of 53.7% was observed when blastocysts which had not collapsed were replaced compared to cycles in which collapsed blastocysts were replaced (IR rate 22.6% and OPR 17.7%).

CONCLUSION

This study demonstrated that human blastocysts which collapse spontaneously during in vitro development are less likely to implant and generate a pregnancy compared with embryos which do not. Although this is a retrospective study, the results establish the utility of collapse episodes as new marker of embryo selection following eSET at blastocyst stage.

Fifteen year follow-up of embryos cryopreserved in cancer patients for fertility preservation

PURPOSE

Determine the outcome of embryo cryopreservation in female oncology patients

METHODS

The outcomes of IVF/ICSI cycles in oncology patients over 15 years in a University Teaching Hospital.

RESULTS

Forty-two oncology patients (mean 31.9 ± 3.9 years) underwent embryo cryopreservation treatment (n = 33 IVF, n = 6 ICSI). Controlled ovarian stimulation with GnRH antagonist protocol (n = 34; 81 %) yielded fewer oocytes than GnRH agonist protocol (n = 8; 19 %) (9.4 ± 6.3 vs. 15.3 ± 8.9; p = 0.04) respectively. There was no significant difference in mean (±SD) duration of ovarian stimulation (11.6 ± 2.6 vs.10.6 ± 2.7), median gonadotrophin dose (1950 vs. 1670 IU), median day 5-6 oestradiol level (1124 vs.1129 pmol/l) or embryo yield (6.2 ± 4.1 vs. 8.8 ± 4.3; p = 0.07) between GnRH antagonist and agonist treatment cycles respectively. Thirty-nine patients cryopreserved embryos and three had their cycle cancelled. During this study period, of those who cryopreserved embryos, 5 patients underwent 9 frozen-thaw cycles (13 %), resulting in 2 live births (1 twin, 1 singleton, live birth rate 22 %). Six patients died (15 %), 3 conceived naturally (8 %) and 2 couples separated (5 %). Fourteen patients discarded their embryos (36 %). Twenty-two patients' (56 %) have embryos remaining in storage.

CONCLUSIONS

This study demonstrates that embryo cryopreservation in female oncology patients gives a satisfactory live birth rate. However, there are concerns regarding cost-effectiveness, resulting from high disposal/non-usage of embryos, and further studies are required.

Cumulus gene expression as a predictor of human oocyte fertilisation, embryo development and competence to establish a pregnancy

The close relationship between cumulus cell function and oocyte developmental competence indicates that analysis of cumulus gene expression is a potential non-invasive method to aid embryo selection and IVF outcome. Cumulus was isolated from 674 oocytes from 75 women undergoing ICSI and gene expression analysed by quantitative RT-PCR. Cumulus expression of cyclooxygenase 2 (PTGS2) was higher with mature oocytes, whereas brain-derived neurotrophic factor (BDNF) was lower when fertilisation was normal. Expression levels of gremlin (GREM1) and BDNF were weak positive and negative predictors of embryo quality respectively. Ranking of GREM1 expression within cohorts of oocytes showed that oocytes associated with the highest GREM1 expression were more likely to be transferred or cryopreserved than discarded (49 vs 33%, P<0.02), although the clinical pregnancy rate was not significantly different. This study demonstrates both the feasibility and difficulties of this method of analysis in the largest such group studied thus far. Novel relationships between BDNF expression and fertilisation were identified, and the potential value of GREM1 expression as a marker of embryo quality supports the further assessment of GREM1 analysis in the context of embryo selection.

A comparison of psychological functioning in couples undergoing frozen-thawed embryo replacement in various stages of treatment using the Mean Affect Adjective Check List (MAACL)

PURPOSE

The objectives were to identify the stage(s) of frozen embryo replacement cycle where the couples are most vulnerable to psychological dysfunction. Assessment was performed by using the Mean Affect Adjective Check-List (MAACL).

METHODS

Thirty couples completed the MAACL questionnaire at the following stages: (a) pretreatment (visit 1), (b) before embryo transfer (visit 2), and (c) before pregnancy test (visit 3). Each partner had to complete a separate questionnaire set.

RESULTS

For both partners, the depression score for visit 3 was significantly higher and the sensation seeking and positive affect scores were significantly lower than the corresponding scores for earlier visits. Anxiety scores were similar for all visits. For men, the hostility scores were significantly higher between visits 1 and 2 while in women the same was reported between visits 3 and 2.

CONCLUSIONS

Psychological counselling should be targeted at couples especially after embryo transfer. MAACL is a useful method for measuring psychological dysfunction in these couples.

The administration of the GnRH antagonist, cetrorelix, to ooctye donors simplifies oocyte donation

BACKGROUND

We report our experience on the efficacy of a new regimen of the GnRH antagonist, cetrorelix, and recombinant FSH, Gonal-F, for controlled ovarian stimulation in a donor oocyte programme.

METHODS AND RESULTS

Six oocyte donors were commenced on Gonal-F (150 IU) and two on Gonal-F 225 IU daily on day 4 together with cetrorelix 0.25 mg daily on day 8 until the day of administration of hCG. Six premenopausal recipients were down-regulated with intranasal Nafarelin 400 micro g twice daily; two women with premature menopause did not require down-regulation for synchronization between donor and recipient cycles. The median (range) of oocytes retrieved and the median (range) fertilization rates were 7 (3-13) and 50% (0-71%) respectively. With the exception of a recipient who had failed fertilization, seven recipients had two embryos transferred. The median (range) number of days of ovarian stimulation, cetrorelix administration and number of Gonal-F ampoules administered for ovarian stimulation were 9 (7-12) days, 5 (3-8) and 18 (14-24) respectively. The clinical pregnancy rate per cycle was 50% (4/8) and one of the latter women miscarried at eight weeks gestation. Three women (37.3%) had full term deliveries.

CONCLUSION

This preliminary study has shown that using a combination of cetrorelix and Gonal-F resulted in a high pregnancy rate, reduced the duration of treatment for the donor and simplified oocyte donation.

A prospective randomized clinical trial comparing 150 IU and 225 IU of recombinant follicle-stimulating hormone (Gonal-F*) in a fixed-dose regimen for controlled ovarian stimulation in in vitro fertilization treatment

OBJECTIVE

To compare fixed daily doses of the recombinant FSH (rFSH) Gonal-F (150 IU vs. 225 IU) for ovarian stimulation in IVF-ET.

DESIGN

Single-center prospective, randomized study. Assisted conception unit of a university hospital. One hundred twenty-four women aged 23-41 years participated in the study. Exclusion criteria were as follows: FSH of >10 IU/L, polycystic ovarian syndrome, one ovary or previous ovarian surgery, previous poor response to ovarian stimulation, or ovarian hyperstimulation syndrome (OHSS).

INTERVENTION(S)

Randomized to commence 150 IU or 225 IU of Gonal-F per day without dose alterations during treatment.

MAIN OUTCOME MEASURE(S)

Number of oocytes retrieved and total rFSH dose.

RESULT(S)

More oocytes were retrieved in women aged <or=32 years in the 225-IU compared with the 150-IU group (11.8 +/- 8.0 vs. 7.0 +/- 5.8). In older women (>or=33 years), the number of oocytes retrieved in the two groups were similar. No significant differences were found for fertilization rate, number of embryos formed and cryopreserved, and pregnancy rates between the two groups. The total rFSH dose used was higher in the 225-IU group (2,595.0 +/- 510.0 vs. 1,897.5 +/- 457.5 IU). The cancellation rate due to insufficient ovarian response was higher in the 150-IU group (15.0% vs. 3.3%). All cases of ovarian hyperstimulation syndrome (n = 4) occurred in the 225-IU group.

CONCLUSION(S)

Two hundred twenty-five IU is more effective than 150 IU in younger women but requires a higher total dose of Gonal-F. The use of 225 IU in older women did not result in a higher oocyte yield, suggesting that 225 IU of rFSH does not compensate for the age-related decline in the number of follicles available for stimulation.

Regulation of 11beta-hydroxysteroid dehydrogenase type 1 gene expression in human ovarian surface epithelial cells by interleukin-1

BACKGROUND

Local modulation of 11beta-hydroxysteroid dehydrogenase (11betaHSD) activity, to promote increased availability of anti-inflammatory glucocorticoids, is proposed as a compensatory response to inflammatory stimuli. Human 11betaHSD type 1 (11betaHSD1) is principally an 11-oxoreductase that reversibly reduces cortisone to cortisol.

METHODS

Since ovulation is an acute inflammatory process, we examined the influence of pro-inflammatory cytokines on expression of 11betaHSD1 mRNA and metabolism of cortisone to cortisol by human ovarian surface epithelium (HOSE) in vitro.

RESULTS

Northern analysis showed an approximately 1.5 kb-sized 11betaHSD1 mRNA transcript in total RNA that was up-regulated approximately 3-fold by interleukin (IL)-1alpha (0.5 ng/ml) at 24 h. By real-time RT-PCR, induction of 11betaHSD1 mRNA by IL-1alpha was measurable at 6 h and maximal at 12 h. Primary HOSE cell cultures also showed low-level 11-oxoreductase activity that was stimulated time- and dose-dependently by IL-1alpha and IL-1beta. The 11betaHSD1 mRNA and 11-oxoreductase responses to 0.5 ng/ILalpha were both suppressed by IL-1 receptor antagonist (25 ng/ml).

CONCLUSIONS

Cultured HOSE cells express IL-1-responsive 11betaHSD1 and 11-oxoreductase activity mRNA in vitro. An 11betaHSD1-catalysed increase in anti-inflammatory glucocorticoid activity caused by pro-inflammatory cytokines could contribute to the local resolution of inflammation during ovulation.

Second trimester medical abortion with mifepristone and gemeprost: a review of 956 cases

The treatment outcomes of 956 women undergoing second trimester termination of pregnancy with mifepristone and gemeprost were studied. The median gestational age was 16 weeks (range: 12-24 weeks). All women were treated with 200 mg mifepristone orally, followed 36 h later with 1 mg vaginal gemeprost administered every 6 h to a maximum of 4 doses in the first 24 h. A second course of 1 mg vaginal gemeprost was given 3-hourly in the next 12 h, if abortion had not occurred. Overall, 96.4% and 98.8% of the women aborted within 24 and 36 h, respectively. The median induction-to-abortion interval was 7.8 h (range: 0.5-109.9 h). The induction-abortion interval was longer in nulliparous women and women with a gestation age 17 weeks or above. Surgical evacuation of the uterus was performed in 11.5% of women for incomplete abortion or retained placenta. More multiparous women (16.7%) required surgical evacuation of uterus than did nulliparous women (7.3%; p <0.001). Ten (0.1%) women failed to abort with gemeprost and required other methods for abortion. In conclusion, a combination of mifepristone and gemeprost is a safe, effective, and noninvasive method of medical abortion for second trimester pregnancy.

Development-related increase in cortisol biosynthesis by human granulosa cells

Antiinflammatory mechanisms are important in ovulation and may be regulated by cortisol (F). We previously showed that after administration of human (h)CG for ovulation induction, luteinized granulosa cells (LGC) abundantly express 11beta-hydroxysteroid dehydrogenase type 1 (11betaHSD1) messenger RNA but not 11betaHSD type 2 (11betaHSD2) messenger RNA. 11ssHSD1 is responsible for the reversible formation of antiinflammatory F from its inactive precursor cortisone (E), whereas 11betaHSD2 unidirectionally converts F to E through 11-oxidation. This pattern of gene expression predicts that LGC from periovulatory follicles would show increased activation of E to F, compared with granulosa cells from immature follicles (IGC), and that follicular fluid concentrations of E and F would alter accordingly. To test this hypothesis, we isolated IGC, thecal cells (TC), and follicular fluid, from ovaries of cyclic women, removed during surgery for benign gynecological disease. LGC and follicular fluid were aspirated from periovulatory follicles, 35 h after hCG injection, in patients undergoing in vitro fertilization treatment. In an 11betaHSD assay based on interconversion of tritiated E and F by cell suspensions in vitro, IGC (% conversion, 0.6 +/- 0.4, mean +/- SEM) and collagenase-dispersed TC (0.2 +/- 0.1%) were unable to convert E to F, whereas LGC (36.3 +/- 3.7%) were highly efficient at this reaction. Immature granulosa cells, LGC, and (to a lesser extent) TC were all able to convert F to E. Correspondingly, follicular fluid concentrations of total F and F:E ratios were significantly higher in periovulatory follicles, compared with immature follicles. Culturing IGC for 48 h in the presence of hFSH resulted in increased 11betaHSD1 reductase activity, paralleling stimulation of estrogen (aromatase activity) and progesterone biosynthesis. Similar treatment with hLH did not influence 11betaHSD1 reductase activity, except in a patient with more mature IGC, which also showed a significant increase in E-to-F conversion, as well as progesterone synthesis in response to hLH. These data confirm that 11betaHSD activity in the human ovary is developmentally regulated and gonadotropin responsive, favoring metabolism of F to E in immature follicles and E to F in periovulatory follicles. Increased formation of F by LGC in periovulatory follicles is consistent with an antiinflammatory function for this glucocorticoid at ovulation.

Routine antenatal screening for syphilis in Lothian: a study of the results 1988 to 1994

A retrospective study was carried out of the cases of positive syphilis serology detected by routine antenatal screening within Edinburgh (and surrounding district) over the six years 1988 to 1994. The study demonstrated a low incidence of syphilis with only 15 pregnancies in 58,445 screened. In eight cases serology and history were suggestive of late latent syphilis and in the remainder of previous infection which had been treated. All women were delivered of liveborn infants at term without stigmata of congenital syphilis. Lack of identifiable risk factors in women with positive serology suggests that routine rather than selective screening should continue.

Effects of daily low dose mifepristone on endometrial maturation and proliferation

Following an ovulatory control cycle, six women took 2 mg of mifepristone daily for 30 days. Endometrial biopsies were collected in the control cycle between 7 and 11 days after the plasma luteinizing hormone (LH) surge and on the corresponding day of the treatment cycle (days 19-28). In order to investigate the effects of unopposed oestrogen on the endometrium, persistent proliferative endometrium was obtained from six women with anovulatory infertility due to polycystic ovarian syndrome (PCOS) on a similar cycle day (days 21-23) following a progestogen-induced withdrawal bleed. Endometrium was evaluated for histology and immunolocalization of oestrogen receptors (ER), progesterone receptors (PR) and the cell proliferation markers [proliferating cell nuclear antigen (PCNA) and Ki67]. Treatment with mifepristone inhibited ovulation in four of the six subjects. In the two subjects in whom ovulation did occur, secretory transformation was delayed, suggesting that successful implantation of a blastocyst would be unlikely. In subjects who remained anovulatory during treatment, the histology and pattern of steroid receptor expression was similar to proliferative phase endometrium. In women with PCOS, mitoses and intense immunostaining for ER, PR and cell proliferation markers were observed in both glands and stroma. Although PCNA and Ki67 immunostaining were also present in mifepristone-treated endometrium from subjects who did not ovulate, there were no mitoses and significantly less ER immunostaining in spite of exposure to unopposed oestrogen for a similar duration. Since PCNA and Ki67 detect cells throughout all stages of the cell cycle this would suggest that mifepristone might affect the entry of cells into the mitotic phase of the cell cycle and, therefore, might prevent endometrial hyperplasia. These findings add further evidence to support the contraceptive potential and antiproliferative activity of daily low dose mifepristone.

A randomised study of two doses of gemeprost in combination with mifepristone for induction of abortion in the second trimester of pregnancy

Two regimens of the prostaglandin E1 analogue, gemeprost, in combination with mifepristone were compared in a randomised trial for termination of pregnancy between 12-19 weeks. Thirty-six hours after treatment with 200 mg mifepristone, women were allocated at random to receive either 4 x 1 mg (Group I) or 4 x 0.5 mg (Group II) gemeprost by vaginal pessary every 6 hours (n = 50 in each group). If abortion had not occurred after 24 h, 5 x 1 mg of gemeprost was administered every 3 h to both groups of women. Although the median abortion interval was slightly shorter in the 1 mg group (7.8 h vs. 8.4 h, p = 0.5), the cumulative abortion rates at 24 h were similar (98% vs. 96%). Women in Group I required significantly more gemeprost to induce abortion than Group II (p < 0.0001). Parous women in both groups required significantly less of the prostaglandin to induce abortion. In Group II, the median abortion interval was significantly longer in primigravidae than multigravidae (9.5 h vs. 6.1 h; p < 0.02). There were no significant differences between the groups in the incidence of vomiting, diarrhoea or the request for analgesia. The results suggest that in parous women, the dose of gemeprost can be reduced to 0.5 mg every 6 h within the first 24 h without loss of clinical efficacy.

Effect of daily low dose mifepristone on the ovarian cycle and on dynamics of follicle growth

BACKGROUND AND OBJECTIVE

The antiprogestin mifepristone has been shown to disrupt folliculogenesis and endometrial maturation and, therefore, has the potential to be used as a novel form of contraception. The purpose of this study was to investigate further the effects of daily administration of a low dose of mifepristone (2mg) on the ovarian cycle and on the dynamics of follicle growth.

SUBJECTS

Six healthy female volunteers were given 2mg mifepristone daily for 30 days following an ovulatory control cycle.

MEASUREMENTS

Follicle growth was monitored with transvaginal ultrasonography and hormonal measurements in blood and urine were used to monitor effects on the ovarian cycle. In addition, concentrations of cortisol and ACTH in serum were measured to assess the effects of mifepristone on the pituitary-adrenal axis.

RESULTS

Treatment with mifepristone retarded the follicular growth rate in all women (P = 0.01). Ovulation was inhibited in 4 of 6 subjects and appeared to be mediated through an effect on the hypothalamo-pituitary axis, as no surge of FSH or LH occurred. In these subjects the dominant follicle continued to grow and developed into a persistent follicle. In two cases the persistent follicle remained functional and ovulation occurred soon after stopping treatment. In the remaining two subjects, the dominant follicle developed into a non-functioning cyst ( > 30 mm) which persisted for one month after the end of the post-treatment cycle. In the two subjects who ovulated, the LH surge was delayed by 6 and 7 days but was followed by a luteal phase of normal length. There was no significant change in the concentration of ACTH or cortisol suggesting that treatment with mifepristone in this dose has little if any effect on the pituitary-adrenal axis.

CONCLUSION

These findings add further evidence to support the contraceptive potential of mifepristone through effects on follicular development and on the menstrual cycle.

Failure of oestrogen induced luteinizing hormone surge in women treated with mifepristone (RU 486) every day for 30 days

It has been demonstrated previously that administration of the antiprogestin mifepristone (RU 486; 1-5 mg daily) inhibits or delays both the pre-ovulatory luteinizing hormone (LH) surge and ovulation. To investigate this mechanism, dynamic tests of pituitary ovarian function were performed in six healthy women before and during the administration of mifepristone (2 mg daily for 30 days). On day 9 of the control and treatment cycles, samples of blood were collected every 15 min over 12 h for measurement of LH concentration. After 10 h, the responsiveness of the pituitary was tested by the i.v. injection of 10 micrograms of gonadotrophin-releasing hormone (GnRH). On day 10 of the control and treatment cycles, two patches releasing 200 micrograms/day of oestradiol were applied to skin on the abdomen for 3 days. Blood was collected at 24, 48, 59, 72, 81 and 96 h after application of the oestrogen patches for the measurement of gonadotrophin and ovarian hormone concentrations. Follicular development continued in all women during their treatment with mifepristone, and ovulation was suppressed (four women) or delayed (two women). There was no significant difference in the basal concentration of LH between the control and treatment cycles (mean +/- SE; 5.5 +/- 0.4 versus 7.7 +/- 0.4 IU/l respectively), or in the frequency (interpulse interval, 101 +/- 12 versus 105 +/- 13 min respectively) and the amplitude (2.1 +/- 0.4 versus 2.6 +/- 0.4 IU/l respectively) of LH pulses. The response to GnRH was similar. On day 10, the basal concentrations of LH, follicle-stimulating hormone (FSH), prolactin, oestradiol and progesterone and the diameter of the dominant follicle (15.7 +/- 1.8 versus 13.3 +/- 1.9 mm) were similar during control and treatment cycles. In control cycles, there were significant increases in the concentrations of LH and FSH within 72 h of application of the oestrogen patches. During treatment cycles, concentrations of FSH and LH remained low, and were significantly lower than the values observed during control cycles (P < 0.006). We conclude that the antiprogestin mifepristone disrupts ovulation by inhibiting the positive feedback effect of oestrogens and, hence, prevents or delays the generation of a pre-ovulatory LH surge.

Randomized trial of misoprostol and cervagem in combination with a reduced dose of mifepristone for induction of abortion

Mifepristone (600 mg) in combination with a prostaglandin has been demonstrated to be a safe, acceptable alternative to vacuum aspiration for induction of abortion in the first 9 weeks of pregnancy. However, the efficacy and side-effects of different prostaglandins used in combination with mifepristone have not been assessed in a randomized trial. In this study, 800 women seeking an abortion at gestational age < or = 63 days amenorrhoea were randomized to receive either 0.5 mg gemeprost by vaginal pessary (group I) or 600 micrograms misoprostol (group II) by mouth approximately 48 h after taking 200 mg mifepristone by mouth. The side-effects and number of complete abortions were used as measures of efficacy. There was no significant difference in the rate of complete abortion between group I [96.7%; 95% confidence interval (CI) 94.9-98.5%, n = 391] and group II (94.6%; 95% CI 92.3-96.9, n = 386). It was not possible to assess the outcome with certainty in the remaining 23 women. However, there were significantly more ongoing pregnancies in the women who received misoprostol than in those who received gemeprost (nine versus one, P < 0.01) and in eight of these 10 women the gestation was > 49 days. Fewer women in group II required analgesia than in group I (48 versus 60%, P < 0.001) although the number requesting opiate was similar in each group (6.9 versus 5.2%, P > 0.4). The incidence of nausea and vomiting after misoprostol (47.8 and 21.9% respectively) was higher (P < 0.001) than after gemeprost (33.9 and 12% respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Metabolic regulation of androgen production by human thecal cells in vitro

The association between hyperinsulinaemia and hyperandrogenism in many women with polycystic ovarian syndrome (PCOS) implies roles for insulin and insulin-like growth factors (IGFs) in the regulation of ovarian androgen production. The aim of the present study was to compare the abilities of insulin, IGF-I and IGF-II to stimulate androgen production by human thecal cells in vitro. Serum-free monolayer cell cultures were established from the ovaries of euandrogenic women undergoing hysterectomy with oophorectomy for non-ovarian indications. Androgen (androstenedione) production was determined after 4 days of culture in the presence of insulin or either of the IGFs (10-100 ng/ml), with and without a maximal stimulatory dose of luteinizing hormone (LH; 10 ng/ml). Interactions with inhibin (30 ng/ml), a putative paracrine regulator of ovarian androgen synthesis, were also tested. The three metabolic hormones exerted similar dose-related effects on androgen production (ED50 < or = 10 ng/ml), which were augmented 2- to 3-fold in the presence of LH and further increased several-fold by the additional presence of inhibin. No treatment with insulin or either IGF stimulated thecal cell growth, but all treatments caused striking morphological changes consistent with enhanced steroidogenesis. These results reveal potent regulatory effects of metabolic hormones on human thecal androgen synthesis, which imply (i) 'progonadotrophic' roles for insulin and IGF-I in regulating normal ovarian androgen production, (ii) a role for insulin in the aetiology of hyperandrogenism (both with and without hyperinsulinism) in PCOS and (iii) paracrine roles for granulosa-derived IGF-II and inhibin in regulating ovarian androgen production.

Decrease in human plasma gravidin levels after medical abortion

The aim of this study was to determine if loss of pregnancy is associated with a decrease in plasma levels of gravidin, a phospholipase inhibitor thought to maintain pregnancy. Blood was taken from 28 women in the first trimester of pregnancy who had requested an abortion. The progesterone receptor antagonist, RU-486 was given on Day 0 for termination of pregnancy. Plasma gravidin levels were measured on day 0 and on day 2 just before the patients were given misoprostol, a prostaglandin E1 analogue (600 micrograms). In a small group of patients, plasma measurements were continued up to 42 days. By day 2, plasma gravidin levels had fallen significantly (100% to 94%, p = 0.010 in a paired t-test). Following treatment with prostaglandins and pregnancy loss, plasma gravidin levels continued to fall until day 14 when the non pregnant level was reached at 80% of the pregnant level. We conclude that a decrease in plasma gravidin levels is associated with loss of pregnancy. This may occur because progesterone action is blocked.

Lymphocyte subpopulations in early human pregnancy

OBJECTIVE

To examine changes in lymphocyte subpopulations in early pregnancy using a methodologically appropriate study design that addresses previous sources of bias.

METHODS

Thirty-seven healthy women without risk factors for human immunodeficiency virus (HIV) were reviewed when less than 9 weeks pregnant (median 51 days, range 44-61) and again at least 4 weeks following termination of pregnancy. No woman took the oral contraceptive pill. Blood was taken on each occasion at the same time of day under the same conditions of rest and food intake, transported immediately to the laboratory, and directly prepared for analysis. Lymphocyte surface markers were determined by staining with dual-colored, isotype-matched monoclonal antibody fluorescent conjugates, followed by whole blood lysis and subsequent flow cytometric analysis.

RESULTS

Pregnancy was associated with a significant reduction in total lymphocytes (P < .0001) and also in CD4+ cells, whether expressed as a percentage of lymphocytes (P = .004), an absolute count (P = .0006), or a ratio (P = .01). Change was independent of the basal level except for lymphocytes, and almost all indices had significant correlations between pregnant and nonpregnant values.

CONCLUSIONS

In this study design, each woman served as her own control and all factors remained constant except the pregnancy state. Early pregnancy causes a reduction in total lymphocytes of about 6% expressed as a percentage of total white cell count, and in CD4+ cells by 3% as a percentage of lymphocytes, or 100/mm3. We believe this fall can be accepted as definitive.

Changes in the concentration of alpha-fetoprotein and placental hormones following two methods of medical abortion in early pregnancy

OBJECTIVE

Measurement of alpha-fetoprotein (AFP) was used to investigate the occurrence of feto-maternal haemorrhage in women undergoing medical abortion.

DESIGN

Three groups of women with amenorrhoea of 56 or less days were studied. A control and a mifepristone group had two blood samples taken 48 h apart. Women undergoing medical abortion with gemeprost had two blood samples taken 24 h apart.

SETTING

Medical Termination Unit, Simpson Memorial Maternity Pavilion, Edinburgh.

SUBJECTS

Three hundred and thirty-five women requesting abortion.

INTERVENTIONS

Blood samples taken at 24 h or 48 h apart.

MEASUREMENTS AND MAIN RESULTS

The rise in concentration of AFP in plasma was much higher (P = 0.01) in the two groups of women in whom abortion was induced by gemeprost or mifepristone than in control women. Whereas only 5% of women in the control group had a significant rise in AFP, 27% and 33% of women in the mifepristone and gemeprost groups, respectively, had a rise in AFP level which exceeded the 95th centile (> or = 38%). The concentration of hCG rose by 48 h in both control and mifepristone groups. Progesterone remained unchanged, and oestradiol decreased (P < 0.02) in the mifepristone group. By 24 h, there was a significant fall in the concentrations of hCG, progesterone and oestradiol in the group who had aborted after being given gemeprost.

CONCLUSIONS

Anti-D prophylaxis must be administered to rhesus negative women to avoid rhesus iso-immunisation.

The effect of mifepristone (RU486) on the immunohistochemical distribution of prostaglandin E and its metabolite in decidual and chorionic tissue in early pregnancy

The widespread tissue distribution of prostaglandin dehydrogenase (PGDH), the main enzyme for the metabolism and deactivation of prostaglandin (PG), suggests that local effective levels of PG are controlled by catabolism. Previous reports have suggested that after the administration of mifepristone (RU486) in vivo, the levels of PGDH in uterine tissues fall, such results support earlier suggestions that PGDH is under progesterone control in reproductive tissues. In this study we have used immunohistochemistry to assess tissue concentrations of PGE and its main metabolite 13,14-dihydro-15-keto-PGE in chorionic villi and decidua from women treated with RU486 12, 24, and 36 h previously. In control villous tissue, PGE and 13,14-dihydro-15-keto-PGE2 (PGEM) are prominent in the syncytiotrophoblastic layer, whereas PGE stains only weakly in cytotrophoblasts, due to the presence of PGDH in this region; treatment with RU486 in vivo causes little change in distribution or intensity in villi. However, in decidua, staining for PGE2 was intense in the glands after RU486 and localized in the supranuclear region of the cells. Small blood vessels that were PGE negative and PGEM positive in the controls were PGE positive and PGEM negative in treated tissue. These findings show that PG stimulation by antiprogestin is by means of a direct effect on PGDH, and secondly, that the prominent rise in PGE in blood vessels may be a major mode of action of this steroid in causing abortion, as PGs may synergize with leukocyte chemotactic agents to stimulate neutrophil ingress and tissue destruction.

The effect of dose of mifepristone and gestation on the efficacy of medical abortion with mifepristone and misoprostol

Although it has been demonstrated that a combination of mifepristone and a prostaglandin is an effective method of inducing abortion in early pregnancy, the optimum dose of the antigestogen is unknown. Women (n = 220) requesting abortion in early pregnancy (< or = 63 days amenorrhoea) were randomized to receive a single dose of either 600 or 200 mg mifepristone followed 48 h later by a single dose of 600 micrograms misoprostol by mouth. The percentage of women who had a complete abortion (93.6% confidence interval 90.4-95.5%) was identical in the two groups. There was no significant difference in the number of women who passed the fetus within 4 h of receiving the prostaglandin (64 versus 74%), the days of bleeding (14.6 +/- 1.1 versus 15.3 +/- 0.9) nor in the onset of the next period (39.7 +/- 1.3 versus 36.7 +/- 1.3) respectively between the groups receiving 200 or 600 mg mifepristone. However, the complete abortion rate was significantly higher in women < or = 49 days compared to women 50-63 days amenorrhoea (97.5 versus 89.1% respectively; P < 0.02). There was no difference in any of the other parameters at different weeks of gestation. We conclude: (i) that the recommended dose of mifepristone could be reduced from 600 to 200 mg without loss of clinical efficacy, (ii) that the combination of mifepristone and 600 micrograms misoprostol is a highly effective alternative to vacuum aspiration for inducing abortion in women < 50 days amenorrhoea and (iii) at gestation > 56 days, this combination may result in too many incomplete abortions to be clinically acceptable.

Induction of second trimester abortion with mifepristone and gemeprost

OBJECTIVE

To determine the efficacy of a new regimen of the antiprogestogen mifepristone and gemeprost for midtrimester abortion.

DESIGN

Prospective study.

SETTING

Medical Termination Unit, Simpson Memorial Maternity Pavilion, Edinburgh.

SUBJECTS

One hundred women undergoing midtrimester abortion.

INTERVENTIONS

Women were pretreated with 200 mg mifepristone 36 h before prostaglandin; 1 mg gemeprost was administered every 6 h for the first 24 h. If abortion had not occurred, 1 mg gemeprost was administered 3 hourly over the next 12 h.

MEASUREMENT AND MAIN RESULTS

Ninety-six percent and 99% women aborted within 24 h and 48 h, respectively. The median prostaglandin-abortion interval was significantly shorter in multigravidae compared to primigravida (6.6 vs 8.2 h, P < 0.01). The median number of gemeprost pessaries to induce abortion was only two and 47% of women required one pessary. The incidence of vomiting and diarrhoea was 31% and 5%, respectively. Eighty-four percent of women required intramuscular diamorphine for analgesia. Thirty-three percent of women required an evacuation of the uterus following abortion.

CONCLUSIONS

The shortened induction-delivery interval following pretreatment with mifepristone makes it possible to conduct midtrimester abortion on a daycare basis.

The effects of mifepristone (RU486) on prostaglandin dehydrogenase in decidual and chorionic tissue in early pregnancy

Prostaglandin dehydrogenase is the main inactivating enzyme for prostaglandins and therefore controls local levels of prostaglandins. Since there is some evidence that the expression of this enzyme is under progesterone control it is reasonable that one of the effects of antiprogestin is to reduce the concentration of this enzyme and thus increase the effective concentration of prostaglandin within tissue. We have investigated the amount of enzyme activity within decidua and chorionic villi from women receiving the antigestagen mifepristone (RU486) 12, 24 and 36 h prior to surgical abortion, and examined the effect on tissue concentrations of prostaglandin dehydrogenase. Women receiving mifepristone in all groups had a significant reduction in concentration of prostaglandin dehydrogenase enzyme in decidual tissue. There was also a marked reduction in prostaglandin dehydrogenase in decidual cells following RU486, as demonstrated by immunochemical methods. At this stage of pregnancy, prostaglandin dehydrogenase was present in abundance in cytotrophoblast cells of chorionic villi but virtually absent from syncytiotrophoblast. In chorionic villi after RU486 administration in vivo, there were no obvious differences in prostaglandin dehydrogenase distribution or reactivity in the majority of cases.

Induction of abortion with mifepristone and misoprostol in early pregnancy

OBJECTIVE

To investigate the clinical efficacy of the combination of mifepristone and an orally active prostaglandin, misoprostol, for early medical termination.

DESIGN

Women with amenorrhoea < or = 56 days were given 200 mg mifepristone. 48 h later, 600 micrograms misoprostol was given orally.

SETTING

Medical Termination Unit, Simpson Memorial Maternity Pavilion, Edinburgh.

SUBJECTS

100 women requesting medical termination of pregnancy.

INTERVENTIONS

Evacuation of uterus for incomplete abortion or on-going pregnancies.

RESULTS

One woman had an incomplete abortion prior to administration of misoprostol. 92 (93%) out of 99 women had complete abortion following administration of misoprostol. There were three on-going pregnancies (3.0%, 95% confidence limits (CL) 0.6-8.6) and four incomplete abortions with this regimen (4.0%, 95% CL 1.1-10.0). 24% women vomited and 7% had diarrhoea following administration of misoprostol. 62% did not require any analgesia.

CONCLUSIONS

The combination of misoprostol with mifepristone is inexpensive, simple, effective, noninvasive and an acceptable alternative to current regimens for medical termination.

What do women want during medical abortion?

A questionnaire study was carried out to investigate the needs of women undergoing a medical abortion induced by mifepristone in combination with either gemeprost pessaries or oral misoprostol. One-hundred-and-eighty women undergoing medical abortion of pregnancy of up to 63 days amenorrhoea were randomised to treatment in the sitting-room (treatment room) or in the ward. Overall, 77% and 69% treated in the sitting-room and ward, respectively, would have preferred treatment in the sitting-room. Fifty-four per cent did not wish their partner or friend to be present and 76% would prefer to stay in hospital following administration of prostaglandin. Ninety-five per cent of the patients would recommend this method of abortion to their friends. Women who received misoprostol required significantly less analgesia than women who were given 1 mg gemeprost as a vaginal pessary. The requirement for opiate analgesia was not influenced by parity, gestation of pregnancy, history of dysmenorrhoea or the dose of mifepristone. Almost 100% of the patients were satisfied with this method of treatment. This study indicates that the majority of women undergoing medical abortion prefer to be treated in a group, a method which is highly cost-effective.

Mifepristone (RU 486) compared with high-dose estrogen and progestogen for emergency postcoital contraception

BACKGROUND

Mifepristone (RU 486) is a synthetic steroid with potent antiprogestational and antiglucocorticoid properties that provides an effective medical method of inducing abortion in early pregnancy. Since progesterone is essential for implantation, we tested the use of mifepristone for emergency postcoital contraception.

METHODS

We studied 800 women and adolescents requesting emergency postcoital contraception who had had unprotected intercourse within the preceding 72 hours. A total of 398 women and adolescents were randomly assigned to treatment with 100 micrograms of ethinyl estradiol and 1 mg of norgestrel, each given twice 12 hours apart (standard therapy), and 402 women and adolescents were randomly assigned to receive 600 mg of mifepristone.

RESULTS

None of the women and adolescents who received mifepristone became pregnant, as compared with four of those who received standard therapy; the difference in failure rates between the two regimens was not statistically significant. The number of pregnancies in each group was significantly lower than the number expected according to calculations based on the day of the cycle during which intercourse had taken place (P less than 0.001). In many subjects the stage of the cycle as calculated by menstrual history was inconsistent with measurements of plasma progesterone or urinary pregnanediol excretion. The subjects treated with mifepristone reported less nausea (40 percent vs. 60 percent) and vomiting (3 percent vs. 17 percent) on the day of treatment, as well as lower rates of other side effects, than the subjects treated with the standard regimen, but they were more likely to have a delay in the onset of the next menstrual period (42 percent vs. 13 percent).

CONCLUSIONS

Mifepristone is a highly effective postcoital contraceptive agent that, if used more widely, could help reduce the number of unplanned and unwanted pregnancies.

A retrospective study of 932 second trimester terminations using gemeprost (16,16 dimethyl-trans delta 2 PGE1 methyl ester)

A retrospective study of 932 second trimester terminations between 12-27 weeks gestation was carried out to determine the efficacy of gemeprost for second trimester termination. A single course of 5 x 1 mg gemeprost pessaries was administered every three hours. If abortion had not occurred after the first course of pessaries, a further course of 5 x 1 mg pessaries was administered. Intravenous oxytocin was administered after 36 hours if abortion had not occurred. Eighty per cent and ninety five per cent of patients aborted within 24 and 48 hours respectively. Of the remaining 5 per cent of women, 3 per cent aborted with escalating doses of oxytocin. In the remaining 18 (2 per cent) women, the pregnancies were electively terminated with an alternative method. The median induction-abortion interval was 18.0 hours and 15.0 hours in nulliparous and parous women respectively (P less than 0.0001). The number of pessaries required to induce abortion was not influenced by parity. Significantly more parous women bled more than 500 ml. The incidence of pelvic sepsis (0.1 per cent) and cervical tear (0.1 per cent) was low. Twenty six per cent of women had diarrhoea and 23 per cent vomited following administration of prostaglandin. This study confirmed the efficacy of gemeprost for second trimester termination of pregnancy. This method of termination is safe, non-invasive, simple and has a low complication rate.

A study of gemeprost alone, dilapan or mifepristone in combination with gemeprost for the termination of second trimester pregnancy

It is well established that abortion can be induced successfully in midtrimester of pregnancy by gemeprost vaginal pessaries. A randomised study was carried out to determine the efficacy of mifepristone and dilapan in combination with gemeprost for second trimester termination between 12-18 weeks' gestation. A contemporary group of women treated with gemeprost alone was used as a control group. A single course of 4 x 1 mg gemeprost pessaries was administered every six hours. If abortion had not occurred after 24 hours, a further course of 5 x 1 mg pessaries was administered every three hours over the next 24 hours. In the first twenty hours after administration of gemeprost, 95%, 85% and 72% of women aborted in the mifepristone, dilapan and the control group, respectively. The median induction-abortion interval in the mifepristone group (6.6h) was significantly shorter than the other two groups and fewer pessaries were required to induce abortion. The incidence of diarrhoea and vomiting was lower in the mifepristone than the other two study groups. This study demonstrated the efficacy of mifepristone in combination with gemeprost and this regimen is associated with fewer gastrointestinal side effects.

Medical abortion in women of less than or equal to 56 days amenorrhoea: a comparison between gemeprost (a PGE1 analogue) alone and mifepristone and gemeprost

OBJECTIVE

To determine the efficacy of a new dose regimen of vaginal gemeprost (1 mg every 6 h up to three doses) in induction of abortion in women less than or equal to 56 days gestation, and to compare this regimen with mifepristone (200-600 mg) followed 48 h later by a single dose of gemeprost (1 mg).

DESIGN

Two separate protocols, with 50% of the subjects randomized to one or other protocol.

SETTING

The Royal Infirmary of Edinburgh, Scotland, UK.

SUBJECTS

301 referred by their general practitioner or local family planning clinic, requesting termination of pregnancy at less than or equal to 56 days amenorrhoea.

INTERVENTIONS

Ongoing pregnancies and incomplete abortions were terminated surgically.

MAIN OUTCOME MEASURES

Number of complete abortions, analgesic requirements and bleeding pattern following treatment.

RESULTS

Complete abortion occurred in 87% of women treated with gemeprost alone and 98% of women treated with mifepristone and gemeprost (P = 0.0004). Analgesic requirements were greater in the group treated with gemeprost alone, compared with the group treated with mifepristone and gemeprost (P = 0.0001).

CONCLUSION

The new dose regimen of gemeprost can be used for early induced abortion, but the use of mifepristone and gemeprost has several advantages over the use of gemeprost alone.

An open study comparing two regimens of gemeprost for the termination of pregnancy in the second trimester

Two regimens of the prostaglandin E1 analogue, gemeprost, were compared in an open trial for termination of pregnancy between 12 and 18 weeks. Fifty women received 5 x 1 mg of gemeprost every 3 h and in another 50 cases, 4 x 1 mg of gemeprost was administered every 6 h. Although the median abortion interval was slightly shorter in the 3-hourly group (15.9 h vs. 16.9 h; p = 0.5), the cumulative abortion rates at 24 h were similar (88% vs. 82%; p less than 0.5). In women who aborted within the first 24 h, significantly fewer pessaries (p less than 0.01) were required to induce abortion in the 6-h treatment group (median 3, range 1-4) than the 3-h group (median 5, 2-5). Parous women in both treatment groups required fewer pessaries to induce abortion than did nulliparous women (not significant; p = 0.5). Significantly (p less than 0.01) fewer pessaries were required to induce abortion in the 6-h gemeprost group. The were no significant differences between the groups regarding incidences of diarrhea, vomiting, or the request for analgesia. These results suggest that in many women the number of pessaries used to induce mid-trimester abortion could be reduced by lengthening the interval between insertion of pessaries within the first 24 h, without loss of clinical efficacy.

Uterine contractility and induction of abortion in early pregnancy by misoprostol and mifepristone

A combination of the antiprogestagen mifepristone and an exogenous prostaglandin given by intramuscular injection or intravaginal pessary is a highly effective means of inducing abortion in early pregnancy. However, the search for a stable oral prostaglandin preparation has been largely unsuccessful. The effect of misoprostol, an orally active prostaglandin used to treat peptic ulcer, on uterine contractility was investigated in 33 women in early pregnancy (under 56 days' amenorrhoea). After administration of misoprostol in doses ranging from 200 micrograms to 600 micrograms, there was a significant increase in uterine pressure. In a second group of women who were given 200-1000 micrograms misoprostol 48 h after the administration of 200 mg mifepristone, there was a significant increase in the amplitude and frequency of uterine contractions. Complete abortion took place in 18 of the 21 women who received misoprostol after mifepristone, but in only 2 of 40 women given misoprostol alone. Our findings show that misoprostol increases uterine activity in early pregnancy and suggest that, in combination with mifepristone, it may be a highly effective method of inducing therapeutic abortion.