Adjunctive GnRH-a treatment attenuates depletion of ovarian reserve associated with cyclophosphamide therapy in premenopausal SLE patients.

BACKGROUND: We measured antimullerian hormone (AMH), a marker of ovarian reserve, in women with lupus treated with cyclophosphamide (CYC) (group I), CYC plus gonadotropin-releasing hormone agonist (GnRH-a) (group II) or neither (group III). We hypothesized that AMH would be diminished in women exposed to CYC versus women receiving adjunctive GnRH-a treatment or no CYC exposure. METHODS: Forty-eight premenopausal lupus patients were retrospectively divided into three treatment groups: CYC alone (group I, n = 11), CYC + GnRH-a (group II, n = 10) and neither (group III, n = 27). Serum AMH levels between groups were compared using a nonparametric test (Wilcoxon rank-sum). Multiple linear regression adjusting for age was performed. RESULTS: AMH (ng/mL) levels at the last collection were significantly lower in group I versus group III (mean ± SD: 0.18 ± 0.20 group I vs 1.33 ± 1.59 group III; p = 0.015), and versus group II (mean ± SD: 0.86 ± 1.06; p = 0.018). When centered on age 30 years, average AMH levels for group I, group II and group III were 0.20, 0.44 and 1.00, respectively. When adjusted for age, AMH between all groups was significantly different (p<0.0001). CONCLUSION: Posttreatment AMH levels were significantly higher among patients receiving CYC + GnRH-a compared to CYC alone, suggesting that GnRH-a coadministration mitigates CYC-induced ovarian injury.

Electroejaculation and assisted reproductive technologies in the treatment of anejaculatory infertility.

OBJECTIVE: To determine the efficacy of electroejaculation in combination with assisted reproductive technology (ART). DESIGN: Case series. SETTING: University fertility program. PATIENT(S): One hundred twenty-one consecutive couples seeking treatment of anejaculatory infertility. INTERVENTION(S): Electroejaculation with IUI, or gamete intrafallopian transfer or IVF. MAIN OUTCOME MEASURE(S): Pregnancy and pregnancy outcome. RESULT(S): Fifty-two couples became pregnant (43%), 39 by IUI alone (32.2%). Cycle fecundity for IUI was 8.7%. No difference in cycle fecundity was seen among ovarian stimulation protocols (clomiphene citrate, 7.6%, hMG, 13.2%, and natural cycle, 11.2%). Pregnancy was unlikely when the inseminated motile sperm count was <4 million. Female management protocol and etiology of anejaculation did not affect results. Patients undergoing IVF had higher cycle fecundity (37.2%) than did those undergoing IUI. The rates of spontaneous abortion and multiple gestations were 23% and 12%, respectively. CONCLUSION(S): Electroejaculation with stepwise application of ART is effective in treating anejaculatory infertility. Intrauterine insemination with the least expensive monitoring protocol should be used for most couples, because use of more expensive monitoring did not improve results. It is cost-effective to bypass IUI and proceed directly to IVF in men who require anesthesia for electroejaculation and in those with a total inseminated motile sperm count < 4 million.

Dynamics of bioactive follicle-stimulating hormone secretion in women with polycystic ovary syndrome: effects of estradiol and progesterone.

OBJECTIVE: To determine the nature of bioactive FSH secretion in anovulatory women with polycystic ovary syndrome (PCOS) and its modulation by luteal levels of E2 and P. DESIGN: Interventional and observational study. SETTING: Academic clinical research center. PATIENT(S): Five patients with PCOS. INTERVENTION(S): Treatment for 21 days with luteal levels of E2 and P. MAIN OUTCOME MEASURES: Serum levels of immunoreactive LH, immunoreactive FSH, bioreactive FSH, and the FSH isoform distribution pattern. Blood was sampled frequently and GnRH testing was done on day 0 (before treatment), days 10 and 20 (during treatment), and day 28 (7 days after treatment). RESULT(S): Treatment with E2 and P suppressed circulating immunoreactive LH and immunoreactive FSH but not bioreactive FSH. Anovulatory women with PCOS showed a predominantly acidic pattern of FSH isoform distribution. Treatment with E2 and P shifted the distribution profile of FSH isoforms to the less acidic. After cessation of E2-P treatment, FSH reverted to its pretreatment pattern of distribution. CONCLUSION(S): Resumption of follicular growth after luteal replacement of E2 and P in anovulatory women with PCOS may be related to the reduction in the elevated LH/FSH ratio and accompanying changes in the FSH signal.

Fertilization antigen-1 removes antisperm autoantibodies from spermatozoa of infertile men and results in increased rates of acrosome reaction.

OBJECTIVE: To determine if fertilization antigen (FA)-1 will remove autoantibodies from the surface of sperm cells of immunoinfertile men by immune adsorption and permit an increased acrosome reaction (AR). DESIGN: Prospective analytic study. SETTING: University medical center. PATIENT(S): Men from 18 infertile couples with autoantibodies present on their spermatozoa. INTERVENTION(S): Sperm samples after processing were examined for antibody binding and AR before and after adsorption with control medium or FA-1. MAIN OUTCOME MEASURE(S): Sperm-bound antibody was assessed by the immunobead assay (immunoglobulin [Ig] A and IgG) and the AR by induction with ionophore A23187. RESULT(S): Adsorption with FA-1 compared with control medium increased immunobead-free swimming sperm an average of 50% and 76% for IgA and IgG antisperm antibodies, respectively, with 78% and 100% of the 18 semen specimens increasing significantly. The AR rate increased an average of 10.3% compared with control medium and showed improvement in 78% of the sperm samples after FA-1 adsorption. CONCLUSION(S): The FA-1 sperm antigen appears to significantly free sperm cells coated with autoantibodies in the semen of most infertile men examined. Reducing sperm-bound antibodies that inhibited the AR allowed the sperm cells to undergo successful AR induction by calcium ionophore.

The use of propofol, nitrous oxide, or isoflurane does not affect the reproductive success rate following gamete intrafallopian transfer (GIFT): a multicenter pilot trial/survey.

BACKGROUND: Whether anesthetic agents administered during gamete intrafallopian transfer (GIFT) affect reproductive outcome is controversial. This multicenter pilot trial and survey had two purposes: to evaluate the effect of propofol, nitrous oxide, midazolam, and isoflurane on pregnancy outcome after GIFT, and to determine if a larger prospective, randomized study is warranted. METHODS: A written invitation was mailed to all 50 fertility programs in the United States that are members of the Society for Assisted Reproductive Technology and perform more than 30 GIFT procedures per year. They were invited to contribute information from the medical records of women who underwent GIFT during the calendar years 1993 and 1994. They were asked to document whether propofol, nitrous oxide, midazolam, a potent inhaled anesthetic agent was used during the GIFT procedure; if the woman became pregnant; and if she delivered at least one live neonate. RESULTS: Seven medical centers participated and contributed data from 455 women. The clinical pregnancy rate (number of pregnancies/total number of GIFT procedures) and the delivery rate (number of women who delivered at least one live baby/total number of GIFT procedures) were 35% and 32%, respectively. A statistically significant difference could not be found in the clinical pregnancy or delivery rates between those women who received propofol, nitrous oxide, midazolam, or isoflurane during GIFT and those who did not. CONCLUSIONS: No agent-related differences in pregnancy rates were found when propofol, nitrous oxide, isoflurane, or midazolam was used as part of the anesthetic technique for GIFT. Therefore, a more extensive prospective trial does not appear to be warranted.

Comparison of low-technology and high-technology monitoring of clomiphene citrate ovulation induction.

OBJECTIVE: To determine whether newer monitoring techniques, including urinary detection of the LH surge and vaginal ultrasound, offer an advantage over basal body temperature (BBT) charts alone in achieving pregnancy using clomiphene citrate (CC). DESIGN: Randomized clinical trial. SETTING: Infertility patients in an academic research environment. PATIENT(S): Forty-five women undergoing ovulation induction with CC. INTERVENTION(S): The women were assigned randomly to receive either low- or high-technology ovulation monitoring for a total of 3 ovulatory cycles. Both groups were followed with BBT charts. The high-technology group also was monitored with urinary LH kits and vaginal ultrasound. MAIN OUTCOME MEASURE(S): Cycle fecundity rates for each technique were compared statistically with use of life-table analysis. RESULT(S): Forty-five patients were studied during a total of 134 cycles. The overall cycle fecundity rate was 8%, 10% (8 of 81 cycles) for the low-technology monitoring group and 6% (3 of 53 cycles) for the high-technology monitoring group. These rates were not statistically significant when evaluated by Fisher's exact test (P = .53) or when using life-table analysis and a log-rank test (P = .48). CONCLUSION(S): These data suggest that, for initial attempts at ovulation induction with CC in unselected patients, high-technology monitoring of ovulation offers no increase in fecundity over low-technology monitoring.

Nonviral vector-mediated thymidine kinase gene transfer and ganciclovir treatment in leiomyoma cells.

OBJECTIVE: To test the hypotheses that ganciclovir is cytotoxic to leiomyoma cells transfected with herpes simplex virus thymidine kinase and that estrogen modulates the responsiveness of tumor cells to this gene therapy approach. METHODS: Human and rat cultured uterine leiomyoma cells were transfected with plasmids encoding the beta-galactosidase gene, thymidine kinase gene, or a control plasmid. Transfection efficiency was monitored by measuring beta-galactosidase enzyme activity. Ganciclovir cytotoxicity in thymidine kinase-transfected cells was assessed by monitoring cell viability using trypan blue exclusion. The "bystander effect," a phenomenon in which thymidine kinase-expressing cells exposed to ganciclovir are toxic to adjacent thymidine kinase-nonexpressing cells, was assessed when thymidine kinase vector-transfected cells were cocultured with control plasmid-transfected cells at various percentages before exposure to ganciclovir. The effect of estradiol on ganciclovir-thymidine kinase-mediated cytotoxicity was assessed in estrogen-responsive rat leiomyoma cells. RESULTS: A thymidine kinase-ganciclovir-mediated "bystander effect" was demonstrated, with 48.6% (human) and 65.6% (rat) cell death when 5% of the leiomyoma cells were transfected with the pNGVL1-tk vector, with 0.84% and 1.9% of the cells expected to express thymidine kinase as based on the 16.7% and 39.8% transfection efficiency determined by the reporter gene assay in human and rat leiomyoma cells, respectively. Estradiol promoted cell growth and enhanced the "bystander effect" in rat leiomyoma cells. CONCLUSION: These findings demonstrate the feasibility of using thymidine kinase gene therapy as a novel treatment for uterine leiomyomas. The effect of estrogen may provide a mechanism to enhance the tumor-suppressive effect of this approach.

IGF-I induces collagen and IGFBP-5 mRNA in rat intestinal smooth muscle.

Insulin-like growth factor (IGF) binding protein 5 (IGFBP-5) mRNA was studied in intestines of rats with peptidoglycan-polysaccharide enterocolitis by Northern analysis and in situ hybridization. IGFBP-5 mRNA was increased 2.4 +/- 0.5-fold in inflamed rat colon compared with controls and was highly expressed in smooth muscle. Cultured rat intestinal smooth muscle cells were used to study the regulation of IGFBP-5 and type I collagen synthesis. IGF-I (100 ng/ml) increased IGFBP-5 mRNA (1.9 +/- 0.1-fold) and collagen type alpha1(I) mRNA (1.6 +/- 0.2-fold) in cultured smooth muscle cells. IGF-I induced a dose- and time-dependent increase in IGFBP-5 in conditioned medium by Western ligand blot and by immunoblot. IGF-I did not affect the IGFBP-5 mRNA decay rate after transcriptional blockade. Cycloheximide abolished IGFBP-5 mRNA. In conclusion, IGFBP-5 mRNA is expressed by intestinal smooth muscle and is increased during chronic inflammation. IGF-I increases IGFBP-5 and collagen mRNAs in intestinal smooth muscle cells.

Transforming growth factor-beta negatively modulates proliferation and c-fos expression of the human endometrial adenocarcinoma cell line HEC-1-A.

Growth factor regulation of normal and cancerous cell proliferation has been well-documented and may be mediated by proto-oncogene activity. The purpose of this study was to assess changes in proliferation and mitogen-induced c-fos mRNA expression of an endometrial carcinoma cell line, HEC-1-A, in response to TGF-beta, a potent growth-inhibitory peptide. HEC-1-A cells were incubated in the presence or absence of TGF-beta. Mitogen-stimulated cells were additionally treated with epidermal growth factor (EGF). Changes in proliferation were measured by [3H]thymidine uptake assays. Alterations in EGF-induced c-fos expression following TGF-beta pretreatment were assessed by Northern blot using a 32P-labeled human c-fos probe. Finally, chloramphenicol acetyltransferase assays were performed to evaluate c-fos promoter activity in response to treatment conditions. Basal and EGF-stimulated proliferation was inhibited by TGF-beta in a dose- and time-dependent manner. TGF-beta also reversibly decreased EGF-induced c-fos mRNA expression in a dose- and time-dependent manner. Sequences in the c-fos promoter that were stimulated by EGF showed suppressed activity when preincubated with TGF-beta. These results show that TGF-beta negatively modulates EGF-induced c-fos expression, which may be related to the observed inhibition of carcinoma cell proliferation.

Luteal support with both estradiol and progesterone after clomiphene citrate stimulation for in vitro fertilization.

OBJECTIVE: To determine if pregnancy rates (PRs) for clomiphene citrate (CC)-stimulated IVF-ET can be increased by luteal support with E2 and P. DESIGN: Prospective randomized crossover clinical study. SETTING: Infertile women volunteers in an academic research environment. PATIENTS: Ninety-three infertile women underwent a total of 143 IVF-ET cycle using CC for ovulation induction. INTERVENTIONS: Each woman received either no luteal support (control group) or luteal support with both oral E2 (2 mg three times daily) starting on the day of retrieval and vaginal P suppositories (100 mg twice daily) starting on the day of ET. MAIN OUTCOME MEASURE: Clinical PR. RESULTS: In 79 of 143 (55%) of the cycles, at least one embryo was transferred. Compared with the control group (n = 35 cycles), the luteal support group (n = 44 cycles) had a significantly higher PR per retrieval (control: 2% versus luteal support: 16%) and were older (control: 33 +/- 4 versus luteal support: 35 +/- 4 years; mean +/- SEM). They did not differ in terms of E2 or P levels, endometrial thickness on the day of hCG, number of follicles > 16 mm in diameter, mature oocytes retrieved, or embryos transferred. CONCLUSIONS: Luteal support with both E2 and P significantly increase the clinical PRs for CC-stimulated IVF-ET.

Kallmann's syndrome: pregnancy achieved through gamete intrafallopian transfer.

This case report describes the use of GIFT to achieve pregnancy for a man with Kallmann's syndrome who obtained only marginal sperm counts with both the pulsatile GnRH infusion pump and gonadotropin injections. Failure of this man to achieve a pregnancy with hormonal therapy alone and in combination with IUI suggests that assisted reproductive technologies should be considered in male patients with Kallmann's syndrome when suboptimal sperm concentrations are achieved despite exogenous hormonal stimulation.

Spontaneous vaginal expulsion of Hulka clips.

BACKGROUND: Laparoscopic Hulka clip application is a common method of outpatient sterilization in women. We present a patient who experienced spontaneous expulsion of two Hulka clips. CASE: A 21-year-old woman was seen 17 months after sterilization because of spontaneous, asymptomatic passage of two Hulka clips into the vagina. The passage of one clip went unnoticed by the patient. Radiographic studies confirmed the migration and absence of two Hulka clips previously placed on the left fallopian tube. CONCLUSION: In rare circumstances, Hulka clips can migrate from the abdominal cavity and be expelled spontaneously, possibly by transuterine passage. This migration may occur without the patient's knowledge.

Abnormal findings on hysterosalpingography: effects on fecundity in a donor insemination program using frozen semen.

OBJECTIVE: We sought to evaluate the effect of abnormal baseline hysterosalpingography (HSG) on subsequent fecundity during the first six cycles of treatment. METHODS: Hysterosalpingography was performed on 208 asymptomatic ovulatory women with no history of pelvic disease who were referred for donor insemination. The findings were categorized into five groups: 1) normal study, 2) uterine anomaly or filling defect with bilateral tubal patency, 3) normal uterine anatomy with unilateral tubal patency, 4) normal uterine anatomy with bilateral tubal blockage, and 5) normal uterine anatomy with hydrosalpinx. Subjects in groups 4 and 5 received inseminations only if patency of at least one fallopian tube was demonstrated with laparoscopy. Life-table analysis was performed to calculate the average monthly fecundity and cumulative conception rates for each group. The Mantel-Haenszel test was used to compare group fecundities. RESULTS: A total of 1460 donor insemination cycles were performed. The number of cycles in each group were as follows: group 1, 1173 (80%); group 2, 153 (10%); group 3, 90 (6.2%); group 4, 16 (1.1%); and group 5, 28 (1.9%). None of the patients in group 4 or 5 conceived. The cumulative conception rates in the first three groups were 46, 34, and 40%, respectively, and were not significantly different from one another (P greater than .05). Although a high incidence of uterine filling defects and unilateral tubal blockage was observed (19.2%), the incidence of an abnormal HSG finding that significantly decreased fecundity was only 2.8%. CONCLUSION: In women with no history of tubal or uterine disease, routine HSG before initiation of donor insemination is of limited value for identifying decreased treatment fecundity.

Reduction of gonadotropin-releasing hormone pulse frequency is associated with subsequent selective follicle-stimulating hormone secretion in women with polycystic ovarian disease.

Polycystic ovarian disease (PCO) is characterized by hyperandrogenism, ovulatory dysfunction, and altered gonadotropin secretion. Mean plasma FSH concentrations are low, while LH is elevated in a majority of patients. LH pulsatile secretion has been shown to occur at rapid follicular phase frequencies (approximately one pulse per h) in PCO, suggesting persistent rapid frequency GnRH secretion in this disorder. Anovulatory women with PCO were given estradiol (E2; Estraderm skin patches) and progesterone (P; vaginal suppositories) to produce midluteal concentrations for 21 days. The aim was to determine if E2 and P would slow LH (GnRH) pulse frequency and if this would result in augmented FSH secretion and follicular development after withdrawal of E2 and P. Plasma LH was measured every 10 min for 8 h before, during (days 10 and 20), and 7 days after withdrawal of E2 and P (day 28). On each of these study days FSH was measured hourly, and E2 and P were measured every 2 h. After sampling, GnRH (25 and 250 ng/kg, iv) was given to assess pituitary responsiveness. Follicular development was monitored by vaginal ultrasound through day 34 of the study. Basal LH frequency was 8.5 +/- 0.5 pulses/8 h (mean +/- SEM). During E2 and P, LH pulse frequency fell to 3.3 +/- 1.0 (10 days) and 2.3 +/- 0.8 (20 days), 39% and 27% of the basal value, respectively, and subsequently increased to 5.6 +/- 0.7 (66% of basal) 7 days after withdrawal of E2 and P. LH pulse amplitude (basal, 7.2 +/- 1.5 IU/L) was not reduced until day 20, but remained suppressed (3.9 +/- 1.1 IU/L) on day 28. As a result, mean LH (basal, 21.0 +/- 3.5 IU/L) fell progressively during E2 and P, to 3.8 +/- 1.2 IU/L on day 20, and remained low (39% of basal) 7 days after steroid withdrawal. Mean plasma FSH (basal, 7.1 +/- 0.9 IU/L) also fell during steroid administration, but in contrast to LH, had risen to 93% of the basal value by 7 days after E2 and P. LH release in response to exogenous GnRH revealed marked initial responses which did not decrease until day 20, but remained suppressed (8% of basal) after withdrawal of E2 and P. FSH responses were also suppressed on day 20, but had increased to 75% of the basal value by day 28. Initiation of follicular development occurred in all patients, and the lead follicle measured 12.3 +/- 0.8 mm 13 days post-E2 and P. Ovulation occurred in one patient.(ABSTRACT TRUNCATED AT 400 WORDS)

Differential responsiveness of luteinized human granulosa cells to gonadotropins and insulin-like growth factor I for induction of aromatase activity.

OBJECTIVE: To examine the in vitro responsiveness of cultured luteinized human granulosa cells over time to insulin-like growth factor 1 (IGF-1), human follicle-stimulating hormone (FSH), and human chorionic gonadotropin (hCG) for the induction of aromatase activity. DESIGN: Granulosa cells were retrieved from preovulatory follicles in patients undergoing in vitro fertilization. Cells were cultured for a period of 72 hours or 10 days. The ability of hCG, human FSH, and/or IGF-I to induce aromatase activity was assayed by the stereospecific release of tritium from [1B-3H]androstenedione. RESULTS: Short-term cultures (72 hours) demonstrated a marked rise in aromatase activity in response to human FSH and IGF-I, whereas a smaller response to hCG was observed. In contrast, 10-day cultures demonstrated responsiveness predominantly to hCG rather than human FSH for the induction of aromatase activity with no remarkable effect of IGF-I. CONCLUSION: Luteinized human granulosa cells undergo a transformation from an initial human FSH and IGF-I responsive state to an hCG responsive state in long-term cultures.