Incomplete androgen and progesterone suppression following midluteal GnRHa prior to controlled ovarian hyperstimulation for IVF-ET.

PURPOSE: We aimed to determine if midluteal GnRH agonist (GnRHa) use prior to controlled ovarian hyperstimulation (COH) results in uniform progesterone and androgen suppression and whether elevations of these hormones occurring early in follicular development may adversely effect the outcome of IVF-ET. METHODS: Forty-four COH cycles using midluteal GnRHa were evaluated. Serum gonadotropins (LH and FSH) and gonadal steroids (E2, A, P4, and T) were measured after 10 days of GnRHa administration [cycle day 31 (CD 31)] and again on the day of hCG administration, following COH. Cycle outcomes evaluated were the number of oocytes retrieved, morphologic grade, fertilization, implantation, pregnancy, and spontaneous abortion rates. RESULTS: Endogenous serum FSH was uniformly suppressed (6.32 +/- 0.47 IU/L) on CD 31, however, LH was not (23.76 +/- 0.76 IU/L). Five and four tenths percent of cycles demonstrated low-level P4 elevations (> or = 0.9 ng/ml), 24.4% demonstrated serum androstenedione levels > or = 600 pg/ml, and 39% of cycles were characterized by serum T levels > or = 200 pg/ml despite evidence of E2 suppression (< or = 30 pg/ml) and the absence of follicular growth by sonography. LH levels were not predictive of incomplete P4 or androgen suppression. Elevations of either P4, A, or T occurring early in the follicular phase were not found to correlate with an impairment in clinical cycle outcome. CONCLUSIONS: Midluteal GnRHa use prior to COH may result in incomplete suppression of circulating progresterone and androgens. However, these relative elevations, occurring early in the development of the follicular cohort, did not appear to affect IVF cycle outcome adversely.

Prematurely condensed chromosomes and meiotic abnormalities in unfertilized human oocytes after ovarian stimulation with and without gonadotropin-releasing hormone agonist.

OBJECTIVE: To investigate the incidence of meiotic abnormalities, aneuploidy, and prematurely condensed sperm chromosomes in failed fertilized oocytes after controlled ovarian hyperstimulation (COH). DESIGN: Retrospective analysis of air-dried preparations of unfertilized oocytes. SETTING: University hospital-based infertility clinic. PATIENT(S): Thirty-three patients undergoing IVF having only tubal factor as the cause of infertility. Twelve patients (13 cycles) underwent treatment with hMG alone (-GnRH agonist [GnRH-a]), and 21 patients (24 cycles) underwent treatment with leuprolide acetate (LA) and hMG (+GnRH-a group). INTERVENTION(S): Standard IVF-ET treatment cycle for ovarian stimulation using hMG with or without LA. MAIN OUTCOME MEASURE(S): The meiotic stage, ploidy, and the presence of prematurely condensed sperm chromosomes were determined in 161 air-dried preparations of unfertilized oocytes. RESULT(S): Significantly more unfertilized oocytes were at metaphase II in the -GnRH-a group as compared with the +GnRH-a group, with significantly fewer exhibiting meiotic aberrations. Aneuploidy rates did not differ between groups. However, significantly more oocytes in the +GnRH-a group revealed prematurely condensed sperm chromosomes than in the -GnRH-a group. CONCLUSION(S): The use of GnRH-a for COH does not have an impact on aneuploidy rates in failed fertilized oocytes. However, the higher incidence of meiotic aberrations and prematurely condensed sperm chromosomes in the unfertilized population indicates that some retrieved oocytes exhibit incomplete nuclear and cytoplasmic maturation after the use of this agonist.

Ontogeny of steroidogenic enzyme gene expression in ovarian theca-interstitial cells in the rat: regulation by a paracrine theca-differentiating factor prior to achieving luteinizing hormone responsiveness.

The theca cells (TC) first become identifiable in preantral follicles after the granulosa cells (GC) begin to divide. It remains unknown when the TC first respond to LH and acquire the capacity to produce androgens. The signal initiating TC differentiation is also unknown since pre-theca cells do not contain LH receptors. Since the first wave of follicle development in the rat occurs postnatally, we correlated the function of dispersed ovarian cells from 4-, 5-, 6-, 7-, and 10-day-old rats with the morphological differentiation of TC. The largest follicles in ovaries from 4-day-old rats were primary follicles without associated TC. These cells were unable to produce cAMP or steroids in vitro in response to hCG. At 5 days, the first theca were associated with follicles containing 2-3 layers of GC. These cells were responsive to hCG, producing cAMP, progesterone, androstenedione, and androsterone. Responses to hCG increased progressively through 10 days of age. Cholesterol side-chain cleavage (P450scc), 3 beta-hydroxysteroid dehydrogenase (3 beta-HSD), and 17 alpha-hydroxylase/C17-20 lyase (P450(17 alpha)) enzymes were localized exclusively to the theca interna. Messenger RNAs for LH receptor, P450scc, 3 beta-HSD, and P450(17 alpha) were expressed prior to the time the TC become responsive to LH or morphologically differentiated. To determine the source of the signal regulating TC differentiation, dispersed cells from 4-day-old rat ovaries that were unresponsive to LH were treated with preantral follicle-conditioned medium containing thecal differentiating factor (TDF) activity. The TDF activity stimulated androgen production and expression of LH receptor, P450scc, 3 beta-HSD, and P450(17 alpha) mRNAs. These data demonstrate that a paracrine signal from the preantral follicle can initiate TC differentiation prior to expression of LH receptors. TC become responsive to LH and capable of producing androgens coincident with morphological differentiation.

The impact of sperm morphology evaluated by strict criteria on intrauterine insemination success.

OBJECTIVE: To determine the relationship between IUI success and the level of morphologically normal sperm, evaluated using strict criteria, in the raw semen. DESIGN: Evaluation of semen quality characteristics and pregnancy results for 538 stimulated IUI cycles. SETTING: University medical center infertility clinic. PATIENT(S): Women undergoing IUI with their partner's semen as treatment for infertility (n = 193). INTERVENTION(S): Ovulation induction using clomiphene citrate, hMG, or both; preparation of raw semen using wash and swim-up or Percoll; deposition of prepared semen at the uterine fundus. MAIN OUTCOME MEASURE(S): Pregnancy status after IUI. Percentage morphologically normal sperm in raw semen, evaluated using strict criteria. Sperm concentration and percentage motile sperm in raw and prepared semen. RESULT(S): Pregnancy rates (PRs) per cycle were not different when the percentage of morphologically normal sperm in raw semen was < 5%, 5% to 9%, 10% to 19%, 20% to 29%, and > or = 30% (6.5% +/- 3.9%, 13.6% +/- 3.2%, 8.8% +/- 2.4%, 7.1% +/- 2.5%, and 9.7% +/- 3.3%, respectively). Pregnancy rates did not differ among age groups, infertility diagnoses, ovarian stimulation protocols, or semen preparation methods. CONCLUSION(S): The percentage of morphologically normal sperm in the raw semen, as judged by strict criteria, did not affect IUI PR. Intrauterine insemination appears to be a successful treatment modality for male factor infertility, even when the percentage of morphologically normal sperm in raw semen is very low.

Short-term endocrine response to gonadotropin-releasing hormone agonist initiated in the early follicular, midluteal, or late luteal phase in normally cycling women.

OBJECTIVE: To determine short-term pituitary and ovarian hormonal responses to GnRH agonist (GnRH-a) administered during various phases of the menstrual cycle, in the absence of controlled ovarian hyperstimulation (COH), to determine its independent effect on hormonal parameters previously demonstrated to influence assisted reproductive technology cycle outcome. DESIGN: Prospective, randomized, controlled crossover study of five regularly cycling women. The GnRH-a, leuprolide acetate (LA), was administered 1 mg SC daily for 5 days beginning on cycle day 3 (early follicular); 8 days post-LH surge (midluteal); or 13 days post-LH surge (late-luteal). SETTING: Clinical research unit at a tertiary care medical center. MAIN OUTCOME MEASURES: Serum gonadotropins (LH and FSH) and gonadal steroids (E2, estrone [E1], P, A, and T) measured daily during GnRH-a administration begun in the early follicular, midluteal, or late luteal phase of the menstrual cycle. Gonadotropin pulse amplitude and frequency were determined after frequent serum sampling on the 2nd day of GnRH-a administration in each treatment cycle. RESULTS: Serum LH elevations, 4- to 10-fold greater than observed for FSH, did not differ by cycle day of GnRH-a initiation. Initial increases in FSH did not differ by cycle day, however, early follicular initiation resulted in a more pronounced suppression of FSH. Mean LH pulse amplitude and frequency increased to a similar extent in all three groups, however, FSH pulse amplitude and frequency varied significantly by cycle day of GnRH-a initiation. Gonadotropin-releasing hormone agonist initiated in the early follicular phase resulted in significant increases in E2, E1, and P levels compared with both midluteal or late luteal. Increases in serum androgens were significantly greater after early follicular and late luteal initiation as compared with midluteal GnRH-a initiation. CONCLUSIONS: Relative FSH suppression and marked androgen elevations in both late luteal and early follicular groups, which may have potential detrimental effects on oocytes of the developing cohort, suggest little advantage of late luteal or early follicular over midluteal initiation of GnRH-a for COH.

The influence of supraphysiologic estradiol levels on human nidation.

OBJECTIVE: Exogenous estradiol (E2) has a well-recognized interceptive action when administered shortly after ovulation. The influence of extremely elevated levels of endogenous E2 on human oocyte fertilization and implantation are unclear. The purpose of this study was to evaluate a potential antinidatory role of extremely high endogenous E2 concentrations on implantation and pregnancy during in vitro fertilization-embryo transfer (IVF-ET). METHODS: Twenty-five patients receiving human menopausal gonadotropins (hMG) following midluteal GnRHa administration for IVF-ET, in which the maximal E2 concentration was > 5000 pg/ml (range 5358-16,344 pg/ml) were studied. Cycle parameters including oocyte and embryo characteristics, fertilization, cleavage, and implantation rates as well as pregnancy outcomes were compared to those of 25 patients treated contemporaneously whose treatment cycles had peak E2 values < 3500 pg/ml. Patients groups were matched for age, infertility diagnoses, duration of infertility and stimulation protocol. RESULTS: Cycles characterized by very high endogenous E2 levels resulted in significantly more oocytes per retrieval (21.4 +/- 1.7 versus 8.4 +/- 0.6; P < 0.0001), fewer postmature oocytes (1.6% +/- 1.0% versus 14% +/- 5.0%; P < 0.03), and a decreased fertilization rate (63% +/- 4.0% versus 73% +/- 3.0%; P < 0.04) compared to control cycles. There were no differences in the overall mean morphologic grade or cleavage rates between groups. However, high E2 cycles were associated with a significantly increased implantation rate (14% +/- 4.0% versus 8.0% +/- 4.0%; P < 0.01) and pregnancy rate per embryo transfer (62% +/- 16% versus 36% +/- 16%; P < 0.01) compared to controls. The incidence of spontaneous abortion did not differ between groups. CONCLUSIONS; Extremely high endogenous E2 levels do not appear to adversely affect implantation or overall cycle pregnancy rates in IVF-ET cycles. However, impaired fertilization rates in such cycles support a potential adverse effect on oocyte quality.

Haemostatic mechanism in the endometrium: role of cyclo-oxygenase products and coagulation factors.

1. The primary mechanism of haemostasis in the endometrium of rat was studied and results were compared to that in the mesenteric artery. 2. The bleeding time of the rat endometrium as assessed by haemoglobin output was significantly decreased after pretreatment of the animals with either indomethacin (5 mg kg-1, i.v.) or meclofenamate (3 mg kg-1, i.v.) whereas the bleeding time was significantly increased in the rat mesenteric artery. 3. The bleeding time of the rat endometrium was unchanged from control values following treatment with prostacyclin (0.5 microgram kg-1 min-1, i.v.) or 1-benzylimidazole (50 mg kg-1, i.v.) whereas the bleeding times were increased in the rat mesentric artery. 4. Administration of heparin (100 units kg-1) increased the bleeding time in the rat mesenteric artery but had no effect on the bleeding time of the endometrium. 5. Superfusion of the endometrium with 16, 16-dimethyl PGE2 (1 microgram ml-1) a vasodilator, increased the bleeding time of the endometrium but superfusion of PGE2 over the mesenteric artery did not affect the bleeding time from this site. 6. Histological studies of the mesenteric artery and the endometrium following haemostatis revealed that the haemostatic plug in the mesenteric artery was mainly composed of platelets and fibrin whereas in the endometrium it was mainly composed of fibrin. 7. These findings suggest that haemostasis in the endometrium may be mediated by the vascular tone and fibrin whereas formation of the platelet plug may be primary mechanism for haemostasis in the mesenteric artery.

The effect of clomiphene citrate and menopausal gonadotropins on cervical mucus in ovulatory cycles.

OBJECTIVE: To determine the effect of clomiphene citrate (CC) and hMG on cervical mucus (CM), optimally sampled in the periovulatory period from confirmed ovulatory cycles, in the dosage range commonly employed for ovulation induction. DESIGN: Controlled, observational. SETTING: Infertility treatment center at a university medical center. PATIENTS: One hundred fifty-four infertile patients undergoing 161 treatment cycles in which postcoital test was performed in a documented ovulatory cycle. INTERVENTION: One hundred six patients received CC at dosages of 50 to 200 mg. Twenty patients received hMG at dosages of 75 to 225 IU. Thirty-seven patients sampled during spontaneous ovulatory cycles served as controls. MAIN OUTCOME MEASURE: Cervical mucus score using standardized scoring criteria. RESULTS: Subjects receiving CC at all dosages had significantly lower CM scores 8.6 +/- 0.5, compared with patients receiving hMG 11.0 +/- 0.6 or spontaneous cycles 12.1 +/- 0.5. The incidence of unfavorable CM (score < 10/15) was similar in patients receiving CC at dosages of 50 mg (48.1%), 100 mg (48.6%), and 150 to 200 mg (60%). CONCLUSIONS: Cervical mucus scores are reduced in ovulatory cycles after CC administration compared with both spontaneous ovulatory cycles and in patients undergoing superovulation with hMG. The reduction in CM scores was similar at all dosages of CC studied. The lack of adverse effects on CM during hMG therapy supports a local antiestrogenic effect of CC at the level of the cervix.

Prostaglandins in the ovary and fallopian tube.

More than 20 years following the recognition of a possible role for eicosanoids in ovarian function a physiological role for prostaglandins and/or leukotrienes in human ovulation, corpus luteum function and tubal motility remains to be demonstrated. With respect to ovarian function, the well-characterized preovulatory rise in eicosanoid production in animal species and humans, in conjunction with the large body of experimental evidence employing inhibitors of prostaglandin synthesis and replacement of individual prostaglandins, has provided strong evidence for a role in follicular rupture independent of other LH-mediated ovulatory events. The possible mechanism of prostaglandin-induced follicle rupture may involve stimulation of proteolytic activity via substances such as plasmin and PA; however, this is controversial. A role for prostaglandins in ovarian luteal function is well established in laboratory animals and large ruminant species, where PGF2 alpha derived from the uterus has been demonstrated to be the luteolytic factor. In humans, luteal function may be influenced by local intraovarian eicosanoid production, which has been suggested to involve the paracrine interaction of local ovarian hormones such as oxytocin, noradrenaline, insulin and IGFs, to name but a few. Several lines of evidence have also implicated prostaglandins as an aetiological factor in ovarian pathological states such as seen in the OHSS. However, the bulk of clinical experimental evidence to date has failed to support this contention. Prostaglandin production has likewise been well characterized in the fallopian tube in both humans and animal species. Whereas a role for prostaglandins in tubal transport has been demonstrated with animal species such as the rabbit, several studies have failed to define a similar function in humans. More recently, direct injections of prostaglandin analogues into the fallopian tube and the corpus luteum have been shown to be efficacious as a treatment for ectopic pregnancy. Whether the primary mechanism of action involves effects on tubal musculature or corpus luteum function, or is simply a local vascular effect, remains to be demonstrated. Therefore, although the physiological role for eicosanoids in ovarian and tubal function remains unclear, particularly in the human, an increasing body of recent evidence has suggested an important paracrine function for this class of cellular mediators whose interaction with other more recently characterized local ovarian factors has only begun to be recognized.

Menopause: new indications and management strategies.

Postmenopausal women may benefit from estrogen replacement. In addition to the well-established treatment indications of vasomotor symptoms, genitourinary atrophy, and osteoporosis, studies also suggest improvement in psychologic well-being and prevention of coronary heart disease. The potential cardioprotective effects of estrogen do not appear to be solely from alterations in lipid metabolism. Major risks of estrogen replacement including breast cancer continue to be a concern. Strategies of management including continuous estrogen and progestin regimens are reviewed. There exists an increasing body of evidence that successful treatment for estrogen-dependent tumors including endometrial carcinoma is not a contraindication to estrogen replacement therapy. The potential use of tamoxifen to relieve symptoms and prevent bone loss in women with breast cancer is suggested.

Long-latency auditory event-related potentials in epilepsy.

Long latency auditory event-related potentials have been shown to change in patients with cerebral dysfunction. Some seizure patients with no evidence of brain damage or mental retardation show altered interictal cognitive and memory function. Long-latency auditory event-related potentials to tone stimulation were recorded in nineteen control subjects and seventeen patients with complex partial or partial and secondarily generalized seizures who had no evidence of brain damage, retardation, or drug intoxication, and whose seizures were controlled when studied. The latencies of N2 and P3 components were significantly longer in seizure patients than control subjects, and the P3 waveform was significantly greater in amplitude in epileptics. These findings suggest that cognitive event-related potentials are affected by partial epilepsy. The changes may be related to the recently reported involvement of the hippocampus in ERP generation, or to loss or alteration of modulatory functions, possibly cholinergic in nature, in the temporal lobe consequent upon epileptogenesis.

Computerized spectral analysis of the interictal EEG in epilepsy.

Eight seizure patients without encephalopathy, frequent seizures, brain lesion, or medication intoxication had significant slowing of alpha-frequency activity, as compared to nonepileptic controls, that was evident in compressed spectral analysis but not in standard EEG. Those patients with cognitive or behavioral problems or taking more than one antiepileptic medication had a greater degree of slowing. Differences between seizure patients with and without cognitive or behavioral symptoms, and between specific antiepileptic drugs, were suggested but could not be assigned significance due to small numbers. The findings suggest that interictal changes in brain function that are not revealed by standard EEG may relate to observed changes in interictal behavior and cognition, and that computerized spectral analysis of the interictal EEG may be of value in the assessment of seizure patients before and during therapy.