Individual versus standard dose of rFSH in a mild stimulation protocol for intrauterine insemination: a randomized study.

BACKGROUND: Controlled ovarian stimulation (COS) and intrauterine insemination (IUI) are often used as the first-line treatment for subfertile couples. To minimize the variability in ovarian response in patients' first treatment cycle, we recently developed a recombinant follicle-stimulating hormone (rFSH) dosage nomogram. The nomogram has now been tested. METHODS: Multicentre randomized controlled trial (RCT) including 228 ovulatory patients scheduled for COS and IUI. Patients were randomized to 'individual' (50-100 IU rFSH/day, n = 113) or 'standard' (75 IU rFSH/day, n = 115) dose. 'Individual' dose was prescribed according to the nomogram, which was based on patients' body weight and antral follicle count. The primary end-point was the proportion of patients with two to three follicles > or = 14 mm (maximum two follicles > or = 18 mm) on the day of hCG (leading follicle = 18 mm). Primary analysis was made by intention-to-treat. RESULTS: In the 'individual' group, 79/113 (70%) of the patients developed two to three follicles versus 64/115 (56%) in the 'standard' group [absolute difference = 14.3 percentage points; 95% confidence interval (CI) 2-26, P = 0.03; absolute difference = 14.4; 95% CI 2-27, P = 0.02, when adjusting for centre]. Among patients with two to three follicles, the proportion of patients with two follicles was 46/79 (58%) in the 'individual' group versus 34/64 (53%) in the 'standard' group, P = 0.54. Ongoing pregnancy rate was 23/113 (20%) in the 'individual' group and 21/115 (18%) in the 'standard' group and the rate of multiple gestations was 1/113 (1%) versus 5/115 (4%), P = 0.21. CONCLUSIONS: This RCT is the first to clinically test a dosage nomogram in ovulatory IUI patients' first rFSH treatment cycle. Dosing according to the nomogram was superior to standard dosing. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT00374634.

Predictors of ovarian response in intrauterine insemination patients and development of a dosage nomogram.

The objective of this prospective study was to identify predictors of ovarian response in ovulatory patients treated with low-dose recombinant FSH (rFSH), gonadotrophin-releasing hormone antagonist and intrauterine insemination (IUI), and to develop an rFSH dosage nomogram based on the findings. Patients (n = 159) were stimulated with a starting dose of 75 IU rFSH/day. Ten parameters were investigated as possible predictors of the number of mature follicles >or=15 mm: age, spontaneous cycle length, body weight, body mass index, smoking status, total ovarian volume, total number of antral follicles, total Doppler score of the ovarian stromal blood flow, baseline FSH and oestradiol. Simple and multiple linear regressions were used for the statistical analysis. Appropriate ovarian response was defined as two to three mature follicles. Body weight (P = 0.001) and the number of antral follicles (P = 0.004) were the strongest independent predictive factors of the number of mature follicles. In conclusion, body weight and antral follicle count may be used to achieve appropriate ovarian response for IUI in ovulatory patients. Based on this, a simple rFSH dosage nomogram was developed for individual ovarian stimulation prior to IUI.

Cryobiology in human assisted reproductive technology. Would Hippocrates approve?

Recent advances in human cryobiology have been substantially greater than the first slow step from freezing spermatozoa in animals in Italy, published in 1776 to observing motility in frozen-thawed human sperm in 1938(1). Reports on cryopreservation of rabbit oocytes (1947)(1) and births from fertilised frozen-thawed mice oocytes in 1977(1) were soon followed by the first human pregnancy (1983)(1) and birth (1984)1 following transfer of frozen-thawed embryos after in-vitro fertilisation (IVF). Whereas cryopreservation of human sperm and embryos in tertiary level fertility centres is now commonplace, the full clinical, scientific and sociological consequences of progress in this rapidly moving field are to be determined. These include pregnancy with frozen-thawed human mature, oocytes after conventional IVF (1986)4, intracytoplasmic sperm injection (ICSI)(5) (1996), pregnancies following use of frozen-thawed mature (1995)(5,6) and immature oocytes (1999)(7), ovarian tissue banking (8) and possible autografting (1999)(9) as well as repeated freeze-thawing of male gametes and of embryos (10,11). Cryopreservation of female and male gametes instead of embryos offer solutions of obvious religious, ethical, legal and clinical problems. In addition, there may be benefits in reducing the cost of infertility treatment, improving the safety of fertility treatment with respect to ovarian hyperstimulation syndrome and repeated treatment with controlled ovarian hyperstimulation, prevention of diseases such as sexually transmitted diseases and hereditary disorders and preventing infertility by possible long-term storage of gametes, gonadal tissue and even embryos. The benefits of cryopreservation of sperm, oocytes and embryos in the management of subfertile couples, many being self-evident to some, bear emphasis. Cryopreservation of sperm offers substantial organisational, cost and social advantages in IVF/ICSI treatment, in that it is no longer necessary for both partners to be present at the time of oocyte retrieval, or to have the sperm retrieval done simultaneously, as frozen-thawed sperm (ejaculatory, epididymal or testicular) can be used. This strategy permits men in the latter two categories to be able to support their partners at the time of oocyte retrieval, with the knowledge that their sperm surgically obtained some time previously, is available. It is now clear that, in men with obstructive azoospermia, the use of fresh or frozen-thawed sperm will yield equivalent fertilisation rates following ICSI. In men with non-obstructive azoospermia, with a 60% chance only of obtaining sperm from the testicular aspiration or biopsy, the option could be cryopreservation of the sperm harvested first and later controlled ovarian hyperstimulation of the female partner, to use thawed sperm which will lead to equivalent fertilisation rates using fresh sperm. Thus, one may avoid cost of treatment of the female in those couples who do not wish to use donor sperm as a back-up in the 40% of men from whom sperm is not obtained. Important consequences of cryopreservation of gametes and gonadal tissue are likely to be in the area of prevention of hereditary and familial diseases, as cryopreservation of oocytes, sperm, embryos and blastocysts is exploited fully in pre-implantation genetic diagnosis (PGD) strategies12. Embryo biopsy now permits screening to identify normal embryos from couples who are carriers of known single gene defects and hereditary disorders and the list of these conditions is expanding rapidly. PGD is feasible on frozen-thawed blastomeres even if cells have lysed after thawing, providing information relevant for surviving blastomeres or blastocysts. But what of the gene probes which will soon deluge us on the completion of the Human Genome Project? Can we anticipate benefits and consider proposing that couples with familial disorders, whether degenerative e.g. Type 2 Diabetes, or malignant conditions such as cancer of the ovary, breast and colon? Should we cryopreserve oocytes/sperm/embryos for the purposes of PGD once the markers are available? Cryobiology indeed provides hope now for women and men with neoplastic diseases, who are about to receive oncotherapy for malignancies which inevitably will render them sterile. Men may now freeze epididymal, testicular as well as ejaculatory sperm as ICSI has revolutionalised the treatment of male infertility. It might be likely that testicular tissue from prepubertal boys can be cryopreserved with a reasonable expectation that techniques will soon be developed to effect maturation of spermatogonia in-vivo or in-vitro13. The greatest advance is likely to be for women suffering from reproductive cancer, who may now consider mature and immature oocytes being frozen or vitrified with a reasonable chance of fertilisation by ICSI later, as well as the cryopreservation and storage of ovarian cortex tissue biopsies. Work is proceeding still to refine techniques of in-vitro maturation of frozen-thawed immature oocytes, and the frozen-thawed ovarian cortex tissue slices. The potential benefits will not only be to female fertility for the latter conditions but endocrine disorders as well as by autotransplantation (1999)9. Currently, ovarian tissue banking8 is being considered by women undergoing procedures or treatment which could destroy ovarian function with quite realistic but cautious expectations of preserving ovarian function, but tomorrow women may consider banking ovarian tissue as insurance against childlessness because of the risk of disorders in the reproductive tract (endometriosis, simple recurrent ovarian cysts) and even advancing years. For those who have conceived with surplus oocytes cryopreserved, anonymous oocyte donation is a possibility for the solution of ethical and legal problems. All over Europe, the age of women having their first child is dramatically increasing now being in their late twenties, with likely significant implications in the need to fertility treatment in the Millennium. Society has always been excited but understandably cautious about the prospect of whole body cryopreservation. Hippocrates would have argued that Society could separate medicine and its advances from religious views, dogma and prejudice and, on the present evidence, would probably have looked upon human cryobiology favourably. Human cryobiology is here to stay and society as well as the profession is addressing its relevance. There are clear signs that this technology can and will alleviate suffering by preventing genetic and familial diseases, infections and infertility as well as lowering the cost and social consequences of the treatment. For these reasons, further research in this field should be welcomed and supported.

[Infertility in ethnic groups. Etiology and treatment]. / Infertilitet hos etniske par. Arsager og behandling.

In this retrospective case control study we analysed the causes and treatments of infertility in 100 ethnic couples consecutively discharged from the Fertility Clinic in the period October 1995 to March 1999. The mean age at referral was 28 years (19-37) for ethnic women and 31 years (24-39) for Danish women. Male infertility was the most frequent cause in ethnic couples compared to Danish couples (24% vs. 16%; NS). Tubal infertility was less frequent in ethnic than in Danish couples (19% vs. 45%; p < 0.01), ovulatory defects were more frequent in ethnic couples than in Danish (13% vs. 4%; p < 0.04). Among ethnic couples 57 (118 cycles) underwent IVF and ICSI treatment vs. 85 (198 cycles) Danish couples (p < 0.01). The ongoing pregnancy rate per initiated cycle was 29.6% in ethnic couples vs. 24.2% in Danish couples (NS). Forty four percent of the ethnic couples did not complete the whole treatment program vs. 29% of Danish couples (p < 0.04). This may be due to cultural differences and difficult communication.

Delivery rates after in-vitro fertilization following bilateral salpingectomy due to hydrosalpinges: a case control study.

This retrospective case-control study assessed the impact of bilateral salpingectomy due to uni- or bilateral hydrosalpinges on the outcome of in-vitro fertilization (IVF) in a large consecutive series of patients. The effect of bilateral salpingectomy due to hydrosalpinges on pregnancy outcome was compared in 139 patients (263 cycles) and 139 age-matched controls with tubal infertility without hydrosalpinges (296 cycles). The delivery rates per initiated cycle as well as the implantation rates were equal in the two groups (21.7 versus 21.6% and 19 versus 21%). The number of embryos, the cleavage stage, and the embryo morphology score were equal in the two groups. Among 92 patients treated with 182 IVF cycles who underwent salpingectomy between 1.5 and 5 years prior to their first IVF cycle, the delivery and the implantation rates were 22.5 and 20.5% respectively. Of the patients with salpingectomy after an average of 1.7 failed IVF cycles and who re-entered the IVF programme 3 and 6 months subsequent to surgery, 47 were treated with 83 IVF cycles. The live birth and the implantation rates after surgery in this group were 20.5 and 20% respectively. It is concluded that bilateral salpingectomy due to hydrosalpinges restores a normal delivery as well as implantation rate after IVF treatment compared to controls. A favourable outcome is also found in patients operated on after repeated IVF failures. Furthermore, a normal live birth rate as well as a high implantation rate is maintained for at least three IVF cycles subsequent to surgical treatment.

Expression and characterization of preproVIP derived peptides in the human male urogenital tract.

Expression of the gene sequence encoding vasoactive intestinal polypeptide (VIP) leads to the synthesis of a 170 amino acid precursor molecule which can be processed to five fragments: preproVIP 22-79, peptide histidine methionine (PHM), or peptide histidine valine (PHV), preproVIP 111-122, VIP and preproVIP 156-170. Using region specific radioimmunoassays and antisera against the functional domains of the VIP precursor in combination with immunocytochemistry and chromatography, the localization, distribution and identity of the preproVIP derived peptides within the human male urogenital tract were investigated. Postmortem as well as fresh tissue specimens were used. All the preproVIP derived peptides were expressed and could be demonstrated in nerve fibres throughout the urogenital tract in close relation to the epithelial lining and in vascular as well as non-vascular smooth muscle. The VIP-related peptide containing fibres were most abundant in the prostate parenchyma and the seminal vesicle. Using double immunostaining, co-localization of the various preproVIP derived peptides could be evidenced. The fact that all preproVIP derived peptides are present in the urogenital tract, should be taken into consideration when the regulatory aspects of neuropeptides in physiological and pathophysiological functions are discussed.

Location of PHM/VIP mRNA in human gastrointestinal tract detected by in situ hybridization.

The expression of the gene for vasoactive intestinal polypeptide (VIP) and peptide histidine methionine (PHM) in the human gastrointestinal tract was studied by in situ hybridization and Northern blotting for PHM/VIP mRNA and immunocytochemistry using specific antisera against the bioactive peptides PHM and VIP. In the colon sigmoideum, antisera against all five putative processing products of the VIP precursor (prepro-VIP) were used, namely prepro-VIP 22-79, PHM, prepro-VIP 111-122, VIP and prepro-VIP 156-170. Furthermore, RNA extracted from various regions of the gastrointestinal tract was examined by Northern blots and hybridization to a VIP-cDNA probe. Throughout the gastrointestinal tract, PHM/VIP mRNA was found in neurons only. Using single- or double-staining methods, we demonstrated both PHM/VIP mRNA and the corresponding peptides PHM and VIP in the neurons. In the sigmoideum, the single-staining methods were extended to investigate whether the neurons simultaneously contained PHM/VIP mRNA and each of the five prepro-VIP-derived peptides. Only one major band of PHM/VIP mRNA (1.9 kb) was found by Northern blotting in the tissue of the gastrointestinal tract.

Expression of preproVIP-derived peptides in the human gastrointestinal tract: a biochemical and immunocytochemical study.

In order to study biosynthetic processing of the precursor for vasoactive intestinal peptide (preproVIP) in the human gut we have developed antisera against the five functional domains of the precursor molecule: preproVIP 22-79, peptide histidine methionine (PHM), preproVIP 111-122, VIP and preproVIP 156-170. The antisera were used to quantify and characterize VIP-precursor peptides by radioimmunoassay (RIA) together with high-pressure liquid Uchromatography (HPLC) and to examine their cellular localization and colocalization by immunocytochemistry. All five peptides were expressed but not in equimolar amounts as expected from the amino acid sequence of the precursor. However, the ratios between them were fairly constant throughout the gastrointestinal tract. The only exceptions were the lower concentrations of PHM and preproVIP 111-122 in the gastric antrum which could be explained by the presence of PHV (the C-terminally extended form of PHM which includes preproVIP 111-122) in large concentrations in this region. It was also found that the C-terminal lysine residue of preproVIP is not removed during processing. Immunocytochemically all preproVIP-derived peptides were shown in neuronal elements. They had a similar distribution throughout the gut suggesting coexistence, a finding which was supported by doublestaining. The findings indicate that differences in the posttranslational processing of preproVIP exist in subpopulations of neurons in the human gut.

Vasoactive intestinal polypeptide loses its ability to increase vaginal blood flow after menopause.

The effect of vasoactive intestinal polypeptide on vaginal blood flow was investigated in postmenopausal women. In women who were receiving hormonal replacement therapy the vasodilatory response induced by vasoactive intestinal polypeptide was identical to that of young women, whereas in postmenopausal women who were receiving no replacement therapy, the response induced by vasoactive intestinal polypeptide was absent. Plasma levels of vasoactive intestinal polypeptide and systemic cardiovascular effects were identical in the two groups.

Peptide histidine methionine (PHM) increases vaginal blood flow in normal women.

The effect of increasing doses of PHM given subepithelially or intravenously on vaginal blood flow was studied. Vaginal blood flow was measured by a heated oxygen electrode, and the concentration of PHM in peripheral plasma was monitored radioimmunochemically. Injection of PHM induced a significant dose-dependent increase in vaginal blood flow. The flow values correlated with the plasma concentrations independent of the way of administration. The efficacy was the same as previously found for VIP but the potency of subepithelially injected PHM was found to be 10-fold lower than that of VIP. In conclusion, PHM and VIP seem to have similar vasodilatory effects upon vaginal blood flow.

Vasoactive intestinal polypeptide and human vaginal blood flow: comparison between transvaginal and intravenous administration.

1. The present study was performed to examine and compare the effect of increasing doses of vasoactive intestinal polypeptide (VIP) on vaginal blood flow following vaginal subepithelial and intravenous injection in normal women. 2. Local vaginal blood flow was measured by a heated oxygen electrode. 3. Peripheral blood samples were collected throughout the experiments for VIP analysis by radioimmunoassay. 4. Both subepithelial and intravenous injections induced a significant and dose-dependent increase in vaginal blood flow (P less than 0.05), displaying the same efficacy, potency and sensitivity. 5. The vaginal flow values correlated with the corresponding plasma VIP concentrations after both routes of administration. 6. The systemic vascular side effects; that is, flushing, hypotension and tachycardia, were observed following both subepithelial and intravenous injection. 7. The findings indicate that the effect of VIP on vaginal blood flow irrespective of route of administration is part of a systemic vasodilatory effect rather than a local response.