Oocyte matched follicular fluid anti-Müllerian hormone is an excellent predictor of live birth after fresh single embryo transfer.

STUDY QUESTION: What is the relationship between the anti-Müllerian hormone (AMH), gonadotropin and androgen concentrations within a single follicle and live birth after ICSI and a transfer of an embryo developed from the matched oocyte? SUMMARY ANSWER: Among the analysed markers on the day of oocyte retrieval, AMH concentration in follicular fluid (FF) is a predictor of live birth after single embryo transfer (SET). WHAT IS KNOWN ALREADY: High serum concentrations of AMH and low FSH concentrations have been associated with a high chance of pregnancy after ART. Whether there are differences in the hormonal milieu for individual follicles and whether this impacts the laboratory and clinical outcomes for the individual oocyte developing within that follicle are unknown. STUDY DESIGN, SIZE, DURATION: This prospective cohort study included 322 individual FF samples from 199 infertile women scheduled for ICSI/SET over an 18-month period. Of these women, 76 provided a single FF sample, while 123 women contributed two FF samples taken from two different follicles. PARTICIPANTS/MATERIALS, SETTING, METHODS: The first follicle aspirated in each ovary on the day of oocyte retrieval had the FF aspirated; the individual cumulus-oocyte complex (COC) was tracked, and the associated FF was stored at -80°C. FF AMH, FSH, LH, testosterone (T) and androstenedione (A2) levels were measured by mass spectrometry (androgens) and immunoassays. The laboratory and clinical outcomes for each individual oocyte were related to their unique follicle hormone concentrations. MAIN RESULTS AND THE ROLE OF CHANCE: Of the 322 oocytes with paired FF samples, 70 (21.7%) oocytes did not fertilise. From the remaining 252 2PN embryos, 88 (34.9%) were transferred as single embryos on Day 3; of the remaining 164, 78 developed into blastocysts, and 18 single blastocyst transfers were performed. Thus, a total of 106 transferred embryos had matching FF samples. An analysis of these individual FF concentrations revealed that AMH concentrations were higher in follicles in which the oocyte developed into a top quality (TQ) blastocyst (6.33 ± 5.52 ng/ml) and whose transfer led to live birth (7.49 ± 5.03 ng/ml) than those in which there was a failure of fertilisation (3.34 ± 2.21 ng/ml). In contrast, follicular FSH concentrations were the lower for oocytes that resulted in a TQ blastocyst (5.36 ± 2.20 mIU/ml) and live birth (5.60 ± 1.41 mIU/ml) than for oocytes that failed to fertilise (9.06 ± 3.36 mIU/ml). FF AMH was the only studied marker that increased the chance of live birth (odds ratio: 1.93 [95% CI: 1.40-2.67], P < 0.001). The receiver operating characteristic analysis showed that FF AMH levels predicted live birth with a very high sensitivity (91.2%), specificity (91.7%) and an excellent AUC value of 0.954, whereas serum AMH level only had a fair (AUC = 0.711) significance as a predictor for live birth after ICSI/SET. The predictive capabilities of the interfollicular markers were not limited to the TQ embryos or blastocysts; they applied to all SET cycles. LIMITATIONS, REASONS FOR CAUTION: Whether an altered intrafollicular hormonal environment reflects the developmental capacity of the oocyte or defines cannot be determined from this cross-sectional analysis. Inclusion of 21 subjects with polycystic ovary syndrome (PCOS) may have biased the findings due to a unique intrafollicular milieu associated with PCOS. WIDER IMPLICATIONS OF THE FINDINGS: Our results suggest that highly competent human oocytes have an FF composition of AMH, FSH, T and A2 that is close to that in a natural cycle. Also, the relationships between intrafollicular AMH, gonadotropin and androgen levels in the same follicle support the hypothesis that FF AMH concentration may reflect granulosa cell proliferation during gonadotropin-stimulated follicle growth. Finally, the serum AMH concentration is markedly lower than the FF AMH concentration, with a moderate correlation between serum and FF AMH, implying ovarian follicle autonomy with regards to its secretory products. STUDY FUNDING/COMPETING INTEREST(S): The National Science Centre of Poland supported this work (grant number: N N407 217 040). The authors declare that there is no conflict of interest regarding the publication of this article.

Medical management of endometriosis: emerging evidence linking inflammation to disease pathophysiology.

Progesterone action normally mediates the balance between anti-inflammatory and proinflammatory processes throughout the female reproductive tract. However, in women with endometriosis, endometrial progesterone resistance, characterized by alterations in progesterone responsive gene and protein expression, is now considered a central element in disease pathophysiology. Recent studies additionally suggest that the peritoneal microenvironment of endometriosis patients exhibits altered physiological characteristics that may further promote inflammation-driven disease development and progression. Within this review, we summarize our current understanding of the pathogenesis of endometriosis with an emphasis on the role that inflammation plays in generating not only the progesterone-resistant eutopic endometrium but also a peritoneal microenvironment that may contribute significantly to disease establishment. Viewing endometriosis from the emerging perspective that a progesterone resistant endometrium and an immunologically compromised peritoneal microenvironment are biologically linked risk factors for disease development provides a novel mechanistic framework to identify new therapeutic targets for appropriate medical management.

Naltrexone treatment in clomiphene resistant women with polycystic ovary syndrome.

BACKGROUND: Endogenous opiates may affect various aspects of reproductive and metabolic function in patients with polycystic ovary syndrome (PCOS). This study evaluated long-term inhibition of the opioid system using naltrexone in clomiphene citrate (CC)-resistant women with PCOS. METHODS: A group of 30 infertile females with PCOS were evaluated; all subjects were obese, hyperandrogenic and hyperinsulinemic; 16 patients were amenorrhic and 14 were oligomenorrhic. All subjects received natrexone (50 mg p.o. daily) for 6 months. Patients who did not ovulate after 12 weeks of naltrexone monotherapy, also received CC (starting at 50 mg/day for 5 days and, for non-responders, increasing it up to 150 mg/day). RESULTS: Of the 30 women, 3 ovulated during naltrexone monotherapy and 19 of the remaining 27 ovulated during naltrexone + CC therapy. There were no conceptions during naltrexone monotherapy, but 9 of 27 women (33.3%) conceived during naltrexone + CC; there was one missed abortion at 9 weeks, one preterm delivery at 34 weeks and seven term live births. Naltrexone therapy was also followed by significant reductions in BMI, fasting serum insulin, luteinizing hormone (LH), LH/follicle-stimulating hormone ratio and testosterone. CONCLUSIONS: In this preliminary trial, naltrexone improved endocrine and metabolic function in women with CC-resistant PCOS. Furthermore, naltrexone restored CC sensitivity in the majority of subjects, resulting in a significant number of pregnancies.

Proliferation of ovarian theca-interstitial cells is modulated by antioxidants and oxidative stress.

BACKGROUND: Maintenance of ovarian homeostasis requires precise regulation of proliferation of thecal- interstitial (T-I) cells. Recent evidence indicates that oxidative stress and antioxidants modulate proliferation of various tissues under both physiological and pathological conditions. This study evaluated the effects of oxidative stress and antioxidants on T-I proliferation. METHODS: Rat T-I cells were cultured in serum-free medium and proliferation was assessed by determination of DNA synthesis using the thymidine incorporation assay, by 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide (MTT) assay and by direct counting of steroidogenically active cells and steroidogenically inactive cells. RESULTS: Antioxidants and reactive oxygen scavengers induced a dose-dependent decrease of T-I proliferation. Vitamin E succinate was inhibitory at 10-100 micro mol/l, ebselen was inhibitory at 0.3-30 micro mol/l, and superoxide dismutase was inhibitory at 300-1000 IU/ml. In contrast, oxidative stress resulted in a biphasic effect. Modest oxidative stress induced by 1 mmol/l hypoxanthine and xanthine oxidase (3-30 micro U/ml) stimulated proliferation of T-I cells, while greater oxidative stress induced by xanthine oxidase (1 mU/ml) profoundly inhibited proliferation. Direct cell counting demonstrated comparable effects on steroidogenically active and inactive cells. CONCLUSIONS: Reactive oxygen species may play a role in the regulation of growth of ovarian mesenchyme. Under pathological conditions, such as those encountered in polycystic ovary syndrome, excessive oxidative stress and depletion of antioxidants may contribute to ovarian mesenchymal hyperplasia.

Activin stimulates proliferation of rat ovarian thecal-interstitial cells.

There is growing evidence that the function of ovarian theca-interstitial (T-I) cells may be modulated by paracrine actions of activin, inhibin, and follistatin. Furthermore, either dysregulation, dysfunction, or both, of these peptides may play a role in conditions associated with T-I hyperplasia, such as polycystic ovary syndrome (PCOS) and hyperthecosis. This study was designed to evaluate the role of activin, inhibin, and follistatin in the modulation of T-I cell proliferation. Interaction of these peptides with insulin-like growth factor-I (IGF-I), a known stimulator of T-I cell proliferation, was also assessed. Purified rat T-I cells were cultured for 48 h in chemically defined media and with or without activin (3-30 ng/ml), inhibin (3-30 ng/ml), follistatin (100 ng/ml), and/or IGF-I (10 nM). T-I cell proliferation was assessed using radiolabeled thymidine incorporation assay. Activin alone stimulated proliferation of T-I cells in a dose-dependent fashion (by up to 320% above control; P < 0.001), whereas inhibin alone or follistatin alone had no significant effect. Inhibin had also no effect on activin-induced proliferation. Follistatin significantly reduced the stimulatory effects of activin and decreased proliferation by up to 46% (P < 0.01) below the level attained in the presence of activin alone. IGF-I (10 nM), at a dose producing a near-maximal effect, increased proliferation by 175% above control (P < 0.001); insulin (10 nM) increased proliferation by 52% above control (P < 0.03). A combination of IGF-I (10 nM) and activin (30 ng/ml) resulted in a 1090% increase of proliferation above control (P < 0.001); this stimulatory effect was significantly greater than that achieved in the presence of either activin alone or IGF-I alone (P < 0.001). Similarly, a combination of insulin (10 nM) and activin (30 ng/ml) increased proliferation by 506% above control levels. Flow cytometry evaluation revealed that activin increased the proportion of actively dividing cells (in S or G2/M phase of the cell cycle) by 42% (P < 0.02), whereas IGF-I had no effect on the proportion of actively dividing cells. The present findings indicate that an activin-follistatin system may be involved in the regulation of the size of ovarian thecal-stromal compartment. In view of the synergy between activin and IGF-I, and the difference in the effects on the cell cycle distribution, stimulation of T-I proliferation by these agents is likely to be mediated via separate transduction pathways. Excess activin or insufficient follistatin may contribute to T-I hyperplasia.

Effects of transforming growth factors-alpha and -beta on proliferation and apoptosis of rat theca-interstitial cells.

Ovarian development, follicular growth and atresia require mechanisms regulating proliferation and death of ovarian cells including theca-interstitial (T-I) cells. Transforming growth factors-alpha and -beta (TGF-alpha and TGF-beta) are well recognized local modulators of T-I function. This study was performed to evaluate the effects of TGF-alpha and TGF-beta on ovarian T-I cell proliferation, differentiation and apoptosis. T-I cells from immature Sprague-Dawley rats were purified and incubated in chemically defined media. Proliferation was assessed by [3H]thymidine incorporation assay and by cell counting. Steroidogenically active cells were identified histochemically by detection of 3beta-hydroxysteroid dehydrogenase (3beta-HSD) activity. DNA was extracted and apoptosis was identified by detection of internucleosomal DNA cleavage producing the characteristic 'ladder pattern' of low-molecular weight (LMW) DNA following agarose gel electrophoresis. Quantification of apoptosis was carried out with the aid of 3'-end labeling of DNA fragments with [32P]-dideoxy-ATP. TGF-alpha and TGF-beta stimulated [3H]thymidine incorporation by 2.2- to 3.1-fold and 1.7- to 3.4-fold respectively (P<0.005). A combination of TGF-alpha and TGF-beta produced a synergistic increase in DNA synthesis by 6.7-fold (at 1 ng/ml of each TGF-alpha and TGF-beta; P<0.001) and tenfold (at 10 ng/ml of each TGF-alpha and TGF-beta; P<0.001). Cell counting revealed that TGF-alpha increased the total number of cells 2.8-fold and TGF-beta 2.8-fold. The combination of TGF-alpha and TGF-beta increased the total cell count 3.2-fold, compared with control (P<0.05). The percentage of the steroidogenically active cells was 37+/-9% (mean+/-s.e.m. ) in the control cultures, 50+/-5% in the presence of TGF-alpha, 42+/-8% in the presence of TGF-beta, and 47+/-13% in the presence of both TGF-alpha and TGF-beta. TGF-alpha decreased apoptosis by 63+/-14% (P=0.02) while TGF-beta had no statistically significant effect. TGF-alpha in combination with TGF-beta produced the greatest inhibition of apoptosis by 73+/-8% (P=0.01). These findings demonstrate that TGF-alpha and -beta stimulate proliferation of both steroidogenically active and inactive T-I cells. Furthermore, TGF-alpha alone and in combination with TGF-beta protects T-I cells from apoptotic death. These effects of TGFs may be important in physiologic maintenance of ovarian mesenchymal growth and homeostasis as well as in pathophysiologic conditions associated with excessive growth of the T-I compartment, such as polycystic ovary syndrome.

Metformin therapy decreases hyperandrogenism and hyperinsulinemia in women with polycystic ovary syndrome.

OBJECTIVE: To evaluate the effects of 12 weeks of metformin therapy on hormonal and clinical indices in polycystic ovary syndrome (PCOS). DESIGN: Prospective study. SETTING: University hospital. PATIENT(S): Thirty-nine women with PCOS and fasting hyperinsulinemia. INTERVENTION(S): Twelve weeks of therapy with oral metformin (500 mg three times per day). MAIN OUTCOME MEASURE(S): Levels of insulin, T, DHEAS, insulin-like growth factor-I (IGF-I), gonadotropins, and sex hormone-binding globulin (SHBG); and clinical symptoms including acne, hirsutism, and length of the menstrual cycle were assessed before and after treatment with metformin. RESULT(S): Metformin therapy resulted in a significant decrease in fasting insulin and total T and an increase in SHBG, leading to a decrease in the free T index. In addition, there was a significant decline in mean body mass index, waist-hip ratio, hirsutism, and acne, as well as an improvement in the menstrual cycle. No changes in LH and LH-FSH ratio were observed. Multiple regression analysis demonstrated that the greatest decline of T and free T index in response to metformin was observed among patients with the most pronounced hyperandrogenemia. Subjects with elevated DHEAS differed from those with normal DHEAS in their responses to metformin treatment. Women with high DHEAS exhibited less improvement of menstrual cycle regularity, no change in hirsutism, and an increase in levels of IGF-I after treatment. CONCLUSION(S): Metformin treatment of women with PCOS results in a decline of insulin as well as total and bioavailable T, leading to significant improvement of clinical manifestations of hyperandrogenism. Responses to metformin are related to the severity of hyperandrogenemia and to adrenal function.

Septate uterus associated with cervical duplication and vaginal septum.

A woman had an unusual müllerian anomaly with a septate uterus, cervical duplication, and longitudinal vaginal septum. Gynecologists should be aware of the possibility of cervical duplication associated with uterine septum and not didelphic uterus, as this disorder in a patient with infertility or recurrent miscarriages can be treated surgically by resection of the uterine and vaginal septum. Embryologic explanations may account for the occurrence of the anomaly.

Tumor necrosis factor-alpha stimulates proliferation of rat ovarian theca-interstitial cells.

Tumor necrosis factor-alpha (TNF-alpha) is a potent modulator of ovarian function, affecting steroidogenesis of both granulosa and theca-interstitial (T-I) cells. Women with polycystic ovary syndrome (PCOS) have increased levels of serum TNF-alpha. The present study evaluated the effects of TNF-alpha on T-I cell proliferation. Purified rat T-I cells were cultured for 48 h with or without TNF-alpha (0.001-1 nM), insulin-like growth factor I (IGF-I; 10 nM), and/or insulin (10 nM). Proliferation was measured by [(3)H]thymidine incorporation assay and by counting the steroidogenically active (stained positive for 3beta-hydroxysteroid dehydrogenase; 3beta-HSD) and inactive (3beta-HSD negative) cells. TNF-alpha stimulated thymidine incorporation in a dose-dependent fashion (up to 3.2-fold; P < 0.01). Insulin and IGF-I stimulated T-I proliferation (respectively, by up to 2.4- and 3.1-fold; P < 0.001). TNF-alpha potentiated effects of insulin and IGF-I in a dose-dependent and additive fashion (up to 6.7-fold; P < 0.001). TNF-alpha (1 nM) increased total cell count (by 80%, P < 0.05) and the proportion of 3beta-HSD-positive cells (by 19%, P < 0.05). Flow cytometry DNA analysis revealed that TNF-alpha (1 nM) increased the proliferative index by up to 16% (P = 0.05). The present findings demonstrate that TNF-alpha stimulates mitotic activity of T-I cells by increasing the proportion of actively dividing cells and preferentially increasing the number of steroidogenically active cells. The effects of TNF-alpha appear to be independent of those induced by insulin and IGF-I. We postulate that TNF-alpha may play a pathophysiologic role in disorders of the T-I compartment, such as PCOS.

Divergent mechanisms regulate proliferation/survival and steroidogenesis of theca-interstitial cells.

Luteinizing hormone (LH) and insulin-like growth factor I (IGF-I) are recognized as major regulators of ovarian theca-interstitial (T-I) function. This study was designed to compare the effects of LH and IGF-I on T-I proliferation and steroidogenesis. Purified rat T-I cells were cultured in chemically-defined media. DNA synthesis was evaluated by a radiolabelled thymidine incorporation assay. The cells were also directly counted. Progesterone production was assessed using a specific radioimmunoassay. DNA synthesis of T-I cells was stimulated by IGF-I (10 nM) but modestly inhibited by LH (100 ng/ml). The inhibitory effect of LH was mimicked by 8Br-cAMP (10(-4) to 10(-3) M); forskolin (10(-5) M), cholera toxin (10 ng/ml) and 3-isobutyl-methylxanthine (10(-5) M). Stimulation of protein kinase C with phorbol 12-myristate 13-acetate (10(-7) M) had no significant effect on DNA synthesis. Furthermore, DNA synthesis was not affected by testosterone (10(-10) to 10(-9) M) or progesterone (10(-9) to 10(-8) M). Accumulation of progesterone was co-operatively stimulated by LH and IGF-I. These results suggest that LH-induced inhibition of T-I proliferation and/or survival is mediated via the cAMP system. IGF-I may be viewed as a co-gonadotrophin with respect to steroidogenesis but not with respect to proliferation/survival. The divergence of the effects on proliferation/survival versus steroidogenesis underscores the complexity of the interactions between LH and IGF-I signalling pathways.

Proliferation and differentiation of rat theca-interstitial cells: comparison of effects induced by platelet-derived growth factor and insulin-like growth factor-I.

This study was designed to evaluate mechanisms regulating proliferation of steroidogenically active and steroidogenically inactive theca-interstitial (T-I) cells, and, specifically, to evaluate the effects of platelet-derived growth factor (PDGF) and insulin-like growth factor-I (IGF-I). T-I cells obtained from immature Sprague-Dawley rats were cultured in chemically defined media. Proliferation was assayed by thymidine incorporation and cell counting. Steroidogenically active cells were identified by the presence of 3beta-hydroxysteroid dehydrogenase activity. Flow cytometry facilitated separation of dividing cells (in S and G2/M phases of the cell cycle) from nondividing cells (in G0 and G1 phases of the cell cycle). PDGF alone (0.1-1 nM) produced a dose-dependent increase in DNA synthesis by up to 136%. IGF-I alone (10 nM) increased DNA synthesis by 56%. In the presence of both IGF-I (10 nM) and PDGF (0.1-1 nM), DNA synthesis increased by 108-214%. PDGF (1 nM) increased the total number of T-I cells by 43%; this effect was due to an increase in the number of steroidogenically inactive cells (47%). In contrast, the stimulatory effect of IGF-I (10 nM) was predominantly due to an increase in the number of steroidogenically active cells (163%). Separation of dividing cells from nondividing cells was accomplished with the aid of flow cytometry. In the absence of growth factors, the proportion of steroidogenically active cells was 35% lower among proliferating than resting cells. PDGF (1 nM) decreased the proportion of steroidogenically active cells among both proliferating and resting cells (by 43% and 16%, respectively). In contrast, IGF-I (10 nM) increased the proportion of steroidogenically active cells among proliferating cells by 56%. These findings indicate that differentiated/steroidogenically active cells divide; furthermore, PDGF and IGF-I may selectively stimulate proliferation of individual subpopulations of T-I cells, thereby providing a mechanism for development of structural and steroidogenically active components of the T-I compartment.

Changes in personality profile associated with laparoscopic surgery for chronic pelvic pain.

STUDY OBJECTIVE: To determine whether surgical treatment of chronic pelvic pain is associated with changes in personality profile. DESIGN: Prospective clinical trial (Canadian Task Force classification II-2). SETTING: University-affiliated tertiary referral center. PATIENTS: Sixteen women undergoing laparoscopic surgery for evaluation and treatment of chronic pelvic pain. INTERVENTION: Before and 3 months after surgery all subjects completed the Minnesota multiphasic personality inventory-2 and the West Haven-Yale multidimensional pain inventory. MEASUREMENTS AND MAIN RESULTS: Laparoscopic surgery for chronic pelvic pain was associated with a postoperative decrease in pain severity score by 53% (p <0.001), increase in activity level score by 24% (p <0.001), decrease in hypochondriasis score by 6% (p = 0.049), decrease in depression score by 12% (p = 0.007), and decrease in conversion hysteria score by 7% (p = 0.02). Improvements in pain severity and activity level were comparable in women with abnormal and normal preoperative scores of hypochondriasis, depression, and conversion hysteria. CONCLUSION: Improvement in chronic pelvic pain is associated with an improvement in personality profile. Abnormal versus normal preoperative scores for hypochondriasis, depression, or conversion hysteria scales are not predictive of change in pain or activity level after surgery.

The effect of a pure antiandrogen receptor blocker, flutamide, on the lipid profile in the polycystic ovary syndrome.

Polycystic ovary syndrome (PCOS) is one of the most common endocrinopathies affecting women of reproductive age; it is associated with hyperandrogenism, hyperinsulinemia, and dyslipidemia. This study was designed to assess the long term effects of a pure androgen receptor blocker, flutamide, on the lipid profile in women with PCOS and to examine the possible mechanisms by which androgens may exert their influence. Seventeen women with PCOS (10 obese and 7 lean) were studied. All subjects received a 12-week course of oral flutamide (500 mg/day). The baseline and posttreatment evaluations included lipid profile, androgen levels, insulin sensitivity, and serum catecholamine determinations. The primary outcome was the change in the ratio of low density lipoproteins (LDL) to high density lipoproteins (HDL). Treatment with flutamide was associated with a significant decrease in the LDL/HDL ratio by 23% (P = 0.005), in total cholesterol by 18% (P < 0.0001), in LDL by 13% (P = 0.002), and in triglycerides by 23% (P = 0.002). Flutamide treatment was also associated with a trend toward an increase in HDL (by 14%; P = 0.14). The effects on lipid profile were found regardless of obesity and were not associated with a change in weight. Furthermore, actions of flutamide on lipid metabolism were not associated with significant changes in circulating adrenaline or noradrenaline, glucose metabolism, or insulin sensitivity. This report has demonstrated for the first time that treatment with the pure antiandrogen, flutamide, may improve the lipid profile and that this effect may be due to direct inhibition of androgenic actions.

The window for embryo transfer in oocyte donation cycles depends on the duration of progesterone therapy.

In 192 oocyte donation cycles performed between January 1993 and July 1996, we examined the width of 'the window for embryo transfer' using standard hormonal replacement methods. All transfers were performed within 48 h of insemination. We varied the day of embryo transfer with regard to the initiation of progesterone therapy and, thus, the duration of endometrial exposure to progesterone and analysed the resulting pregnancy rates. Patients were divided into five groups (I-V) and embryo transfers were performed 2, 3, 4, 5 or 6 days following initiation of progesterone therapy. The number of pregnancies per transfer cycle achieved in groups I-V were 0 (0%), 3 (12%), 16 (40%), 29 (48.3%), and 10 (20.4%) respectively. The increased pregnancy rate in group III in comparison to group II is statistically significant (P < 0.03). Furthermore, the pregnancy rate in group IV (5 days of progesterone administration before embryo transfer) was significantly higher than in group V (6 days of progesterone administration before embryo transfer; P < 0.005). We also noted that, when embryos were transferred 4 or 5 days after initiation of progesterone therapy, the pregnancy rates were not significantly different between menopausal and cycling recipients (50% vs 43.7%). Our results indicate that the window for embryo transfer is dependent on duration of treatment with progesterone; it begins approximately 48 h after starting progesterone administration and lasts for approximately 4 days. The optimum period for transferring embryos at the 4- to 8-cell stage corresponds to cycle days 18 and 19. Transfers performed on the 17th and 20th days of the cycle can result in successful implantation, although the rates of implantation are highest when transfers are done on days 18 and 19.

Comparison of intrauterine insemination with timed intercourse in superovulated cycles with gonadotropins: a meta-analysis.

OBJECTIVE: To compare timed intercourse and IUI with the husband's sperm in patients with unexplained infertility who are undergoing superovulation with gonadotropins. DESIGN: Meta-analysis. All published reports of randomized, prospective studies with an English-language abstract extracted from MEDLINE were analyzed. A crossover search was done from the papers obtained. SETTING: Academic center. PATIENT(S): Couples with unexplained infertility. INTERVENTION(S): Meta-analysis of studies evaluating patients superovulated with gonadotropins and randomized for timed intercourse or IUI. MAIN OUTCOME MEASURE(S): Pregnancy rates (PRs) were obtained. The common odds ratio (OR) and 95% confidence intervals (95% CI) were calculated. RESULT(S): There were 49 pregnancies in 431 cycles of timed intercourse (11.37%), whereas there were 110 pregnancies in 549 cycles of IUI (20.04%). The PRs for IUI were significantly increased compared with those for timed intercourse in superovulation cycles (common OR = 1.84; 95% CI = 1.30-2.62). CONCLUSION(S): On the basis of the meta-analysis of 980 cycles in randomized and prospective studies, a patient's chances of becoming pregnant are greater with IUI with her husband's sperm than with timed intercourse in cycles superovulated with gonadotropins.

Insulin and insulin-like growth factor I stimulate the proliferation of human ovarian theca-interstitial cells.

OBJECTIVE: To determine whether insulin and insulin-like growth factor I (IGF-I) affect the proliferation of human theca-interstitial cells. DESIGN: In vitro assays. SETTING: University laboratory. PATIENT(S): Premenopausal women undergoing oophorectomy for benign conditions. INTERVENTION(S): Purified theca-interstitial cells were cultured in chemically defined media with or without insulin and IGF-I. MAIN OUTCOME MEASURE(S): The proliferation of cells was evaluated by determination of [3H] thymidine incorporation and cell counting. RESULT(S): Insulin and IGF-I stimulated DNA synthesis by theca-interstitial cells in a dose-dependent fashion. Insulin-like growth factor I had a greater potency than did insulin. The effects of both approached, but did not reach, the level of DNA synthesis observed in cultures exposed to 10% fetal bovine serum. Direct counting of theca-interstitial cells revealed that IGF-I significantly increased the total number of cells (36% above control), whereas insulin induced a modest and statistically nonsignificant increase in the cell number (14% above control). CONCLUSION(S): The present results support the hypothesis that insulin and IGF-I promote the mitotic activity of theca-interstitial cells. These effects may represent mechanisms that lead to hyperplasia of the thecal/stromal compartment in polycystic ovary syndrome.

Diagnosis of endometriosis.

Diagnosis of endometriosis requires careful interpretation of objective surgical and pathologic findings in the context of the patient's clinical presentation. Clinical assessment helps to identify patients at high risk of endometriosis and selects those who warrant further testing. Determination of the serum level of CA-125, and to a lesser extent, other proteins, may be helpful in evaluating selected population at risk and following the course of the disease. Selective use of imaging studies, especially ultrasound and magnetic resonance imaging, may also be helpful. Ultimately, the diagnosis of endometriosis is usually confirmed or refuted by laparoscopy, preferably performed in conjunction with histologic evaluation of excised lesions.

Effects of insulin and insulin-like growth factors on proliferation of rat ovarian theca-interstitial cells.

Hyperplasia of the theca-interstitial (T-I) compartment, such as observed in polycystic ovary syndrome, is associated with ovarian dysfunction. Yet the mechanisms regulating proliferation of T-I cells are virtually unknown. This study was an investigation of the effects of insulin and insulin-like growth factors (IGF-I and IGF-II) on proliferation of rat T-I cells. Purified T-I cells were incubated in chemically defined media. Insulin (1-100 nM) and both IGFs (0.3-30 nM) dose-dependently stimulated DNA synthesis as determined by radiolabeled thymidine incorporation assay. IGF-I was most potent with EC50 = 1.4 +/- 0.4 nM, while IGF-II had EC50 = 4.3 +/- 0.18 nM and insulin had EC50 = 8.4 +/- 3.9 nM. The maximal effects of all three treatments were comparable. A combination of IGF-I at 10 nM (a concentration producing a near-maximal effect) with insulin or IGF-II resulted in DNA synthesis comparable to that achieved by IGF-I alone. IGF-I mutants with decreased affinity to IGF-binding proteins (IGFBPs)-long R3-IGF-I and des(1-3)IGF-I-produced greater effects on DNA synthesis than did IGF-I. The effects of insulin and IGFs on cell proliferation were confirmed by counting the steroidogenically active cells (stained positive for 3 beta-hydroxysteroid dehydrogenase [3 beta-HSD]) and steroidogenically inactive cells (3 beta-HSD negative). The number of steroidogenically active T-I cells was increased by insulin (by 3.7-fold, p < 0.001), IGF-I (by 3.2-fold, p < 0.001), and IGF-II (by 2.1-fold, p < 0.001). The number of steroidogenically inactive cells was not significantly altered. These findings indicate that 1) insulin- and IGF-dependent synthesis of DNA by T-I cells is stimulated via a common pathway, probably via type I IGF receptors; 2) endogenous IGFBPs may modify the effects of IGF-I; and 3) the increased DNA synthesis is reflected by an increase in the number of steroidogenically active cells. Insulin and the IGFs may play a role in the regulation of proliferation and differentiation of T-I cells under physiological and pathological conditions. In particular, the present observations may explain thecal and stromal hyperplasia accompanying hyperinsulinemic conditions such as polycystic ovary syndrome or hyperthecosis.

Preretrieval predictors of pregnancy in IVF.

PURPOSE: This study was designed to evaluate the predictive value of preretrieval parameters of ovarian stimulation in patients undergoing IVF-ET. METHODS: Women diagnosed with infertility due to tubal factor were compared to women with other and/or multiple diagnoses. Stepwise logistic regression evaluated 389 cycles to identify the best predictors of pregnancy among the following variables: age, primary or secondary infertility, cycle number, type and dose of gonadotropin, duration of gonadotropin administration, serum estradiol level, and number and size of follicles. RESULTS: In the tubal disease group, probability of pregnancy was greater in cycles with serum estradiol levels below 1100 pg/ml on the day of hCG (odds ratio, 4.7) and with administration of gonadotropins for less than 10 days (odds ratio, 3.7). In contrast, in the other/mixed diagnoses group, a serum estradiol below 1100 pg/ml was associated with a decreased probability of pregnancy (odds ratio, 0.6). CONCLUSIONS: Optimal parameters of ovarian stimulation may vary according to the etiology of infertility. In patients with tubal disease, the beneficial effects of greater stimulation, and thus the greater number of available oocytes, may be offset by adverse effects on the endometrium and on the quality of oocytes and embryos. In contrast, in other diagnostic groups, the advantage of an increased number of oocytes may outweigh the potential adverse effects of prolonged stimulation and higher estradiol levels.

Regression analysis and multivariate analysis.

Proper evaluation of data does not necessarily require the use of advanced statistical methods; however, such advanced tools offer the researcher the freedom to evaluate more complex hypotheses. This overview of regression analysis and multivariate statistics describes general concepts. Basic definitions and conventions are reviewed. The types of regression analysis are then discussed, including simple regression, multiple regression, multivariate multiple regression, and logistic regression. The various steps required to perform these analyses are described, and the advantages and disadvantages of each is detailed.