Circulating levels of free and total vascular endothelial growth factor (VEGF)-A, soluble VEGF receptors-1 and -2, and angiogenin during ovarian stimulation in non-human primates and women.

BACKGROUND: In a prospective study we measured circulating levels of vasoactive factors and their soluble receptors in women undergoing controlled ovarian stimulation (COS) for IVF who were at risk for ovarian hyperstimulation syndrome (OHSS), and compared them to those in a primate model, the rhesus monkey. METHODS: A total of 23 women were enrolled in the study and serum vascular endothelial growth factor (VEGF)-A (free and total), soluble (s)VEGF-R1 and -R2, and angiogenin levels were compared in pregnant and non-pregnant women, and in monkeys, during follicular stimulation, the luteal phase and early pregnancy. RESULTS: VEGF levels were similar during the period of follicular stimulation in pregnant and non-pregnant women, but a significant rise in both free and total VEGF occurred in pregnant women during the luteal phase (P < 0.05). The level of sVEGF-R1 (but not -R2) increased (P < 0.05) following implantation, and the rise in sVEGF-R1 corresponded to an abrupt fall in free (but not total) VEGF. In contrast, total VEGF levels remained similar to those observed on the day of hCG injection. Angiogenin levels tended to decline during follicular stimulation, then increased marginally during the luteal phase and were unchanged in early pregnancy. In contrast to women, free VEGF levels were non-detectable and total levels remained constant through the natural menstrual cycle and COS protocols in monkeys. CONCLUSIONS: The levels of circulating angiogenic factors and soluble receptors demonstrate significant changes during COS cycles and early pregnancy in women. Thus, the systemic effect of these agents is influenced by ligand-receptor protein-binding interactions, and these relationships may exhibit dynamic changes during COS cycles and early pregnancy, and could contribute to the development of OHSS.

Multiple gestations in assisted reproductive technology: can they be avoided with blastocyst transfers?

OBJECTIVE: Blastocysts are advanced-stage embryos with high implantation potential; theoretically, limited numbers of blastocysts can be used for embryo transfer to achieve good pregnancy rates with low multiple pregnancy rates. Clinical outcomes of a newly implemented blastocyst transfer program were evaluated. STUDY DESIGN: This study is a retrospective analysis of 553 blastocyst transfer cycles performed by a university-based in vitro fertilization program; risk factors associated with multiple gestations were analyzed. RESULTS: An average of 2.2 embryos were used for embryo transfer. The overall clinical pregnancy rate per embryo transfer was 45.1%; multiple gestation, twin, and triplet rates were 40.9%, 36.5%, and 4.3%, respectively. Multiple gestations increased significantly (1) when embryo transfer was done on day 5, (2) when > or =2 blastocysts were present on day 5, and (3) when maternal age was < or =30 years. CONCLUSION: In spite of a conservative approach to the number of blastocysts used for embryo transfer, the overall multiple pregnancy rate was high, and triplet pregnancies did occur.

Oocyte donor screening: the selection process and cost analysis.

OBJECTIVE: To evaluate the selection process and cost of screening oocyte donors. DESIGN: Retrospective analysis. SETTING: University-based IVF program. PATIENT(S): Potential oocyte donors. INTERVENTION(S): Outcomes of all inquiries by individuals responding to recruitment advertisements for oocyte donors over a 10-month period were assessed. Recruitment and screening costs to bring a single donor into the program were calculated. MAIN OUTCOME MEASURE(S): The attrition rate for each step of the oocyte donor screening process was determined. The costs assessed over the study period included the following: advertisement, administrative, professional, ultrasound, and blood screening. The total cost to bring a single donor into the program was calculated. RESULT(S): Advertisements led to 315 phone inquiries from potential oocyte donors. Of these, a total of 223 (71%) voluntarily withdrew from the screening process, 54 (17%) were screened out for medical or psychological reasons, and 38 (12%) entered the active donor pool. The total cost to bring a single donor into the program was approximately 1,869 dollars. CONCLUSION(S): There was significant attrition in the screening process for oocyte donation that needs to be taken into account in determining the costs of managing the program.

Development and integration of an extended embryo culture program.

OBJECTIVE: To study and evaluate a sequential, extended embryo culture system. DESIGN: Prospective study. SETTING: University-affiliated IVF clinic. PATIENT(S): All couples who were treated between October 1997 and July 1998. INTERVENTION(S): A standard human tubal fluid plus 10% serum substitute supplement (SSS) culture medium was used. The embryos were transferred to extended culture medium (S2 or G2) on day 3. MAIN OUTCOME MEASURE(S): Blastocyst formation and implantation and pregnancy rates. RESULT(S): Forty percent of the 20 donated cryopreserved embryos progressed to the blastocyst stage by day 6. Clinically, 7 (5.6%) of the 125 cycles did not result in a transfer. Blastocyst formation rates ranged from 33%-63% in the five study groups. Implantation rates ranged from 15%-52% and pregnancy rates ranged from 37%-75%. CONCLUSION(S): Extended culture to day 5 or 6 results in acceptable blastocyst formation rates, implantation rates, and pregnancy rates.

Initial experience with extended culture and blastocyst transfer of cryopreserved embryos.

OBJECTIVE: Our purpose was to evaluate the viability and transfer efficiency of cryopreserved embryos allowed to develop into blastocysts in extended culture for in vitro fertilization. STUDY DESIGN: The embryos for in vitro fertilization that had been cryopreserved at either 2 PN (pronuclear) or cleaving stage (day 1-3) were thawed and cultured for uterine transfer on day 5. Outcome for day 5 embryo transfer was prospectively compared with previous outcomes from embryos transferred on day 2 or 3. RESULTS: For embryos thawed and transferred on day 2 or 3 (n = 99), the pregnancy rate was 33%, the implantation rate per embryo transferred was 15.2%, and the rate of multiple gestations was 42.4% (14/33) with 35.7% of pregnancies having >/=3 gestational sacs. For extended culture embryos transferred on day 5 (n = 25), the pregnancy rate was 36%, the implantation rate per embryo transferred was 16.7%, and the rate of multiple gestations was 33.3% (3/9) with all of these being twins. For embryo transfers performed on day 5 in which only blastocysts were transferred (n = 9), the pregnancy rate was 66.7%, the implantation rate per blastocyst was 44.4% (greater than the rate for the day 2 or 3 embryos, P =.0043), and the rate of multiple gestations was 33.3% (2/6) with all of these being twins. In extended culture 29.8% of cryopreserved embryos progressed to the blastocyst stage. In this series 4 subjects (15.4%) did not have blastocysts by day 5. CONCLUSION: Acceptable pregnancy rates can be obtained from cryopreserved embryos cultured to the blastocyst stage with a significantly higher implantation rate. Transfer of embryos that have "self-selected" to blastocysts results in reduced risk of higher-order (>2) multiple gestations, because only 1 or 2 embryos are transferred.

Tubal obstruction after ligation reversal surgery: results of catheter recanalization.

PURPOSE: To evaluate the role of transcervical fallopian tube catheterization in restoring tubal patency after ligation reversal surgery. MATERIALS AND METHODS: Twenty-four women with tubal obstruction after ligation reversal surgery underwent selective salpingography and tubal recanalization. RESULTS: Patency was established in 26 (68%) of 38 anastomotic tubes without complication. In the 13 patients who were followed up and who could conceive only via a recanalized anastomotic tube, there were six (46%) pregnancies: two (15%) successful uterine pregnancies, two (15%) early spontaneous abortions, and two (15%) tubal pregnancies. The mean time from procedure to conception was 2 months. CONCLUSION: Patency of fallopian tubes not visualized at hysterosalpingography after ligation reversal surgery can be established 68% of the time with selective salpingography. In some patients, selective salpingography can be therapeutic. If subsequent conception occurs in these patients, it occurs shortly after the catheterization procedure.

Satellite in vitro fertilization: the Oregon experience.

OBJECTIVE: This study was designed to compare the results of preliminary evaluation, ovarian hyperstimulation, and monitoring of patients at a distant in vitro fertilization satellite center with those treated at the main campus of the program. STUDY DESIGN: Fifty-four patients completing oocyte retrieval cycles at the Eugene satellite Oregon Health Sciences University in vitro fertilization program for the period Jan. 1, 1991, through Dec. 31, 1993, were compared with 222 patients at the main campus for age, peak estradiol level, number of oocytes retrieved, number of embryos, clinical pregnancy rate, and pregnancy outcome. RESULTS: There were no statistically significant differences between the Eugene in vitro fertilization satellite center and the main campus for any of the factors analyzed with the exception of clinical pregnancy rate. The clinical pregnancy rate per cycle at the Eugene satellite center was 39% while the Portland main campus rate was 23% (p = 0.027), presumably because of a larger number of couples with severe male factor infertility at the central site. CONCLUSION: A distant in vitro fertilization satellite program was highly successful in the Oregon experience. In addition to greater convenience to the patients, the program was highly comparable to the main campus program in measured parameter of ovarian hyperstimulation, oocyte retrieval, number of embryos, and pregnancy rate.

Comparison of the hamster sperm motility assay to the mouse one-cell and two-cell embryo bioassays as quality control tests for in vitro fertilization.

The hamster sperm motility assay, mouse one-cell embryo, and mouse two-cell embryo bioassays were used to test modified Tyrode's solution and modified Ham's F-10 (Gibco, Grand Island, NY) medium prepared in tap water versus ultrapure water. Factors influencing the ability of each assay to discriminate water quality were evaluated to characterize these assays for quality control use in the in vitro fertilization laboratory. The hamster sperm motility assay reproducibly detected differences in treatment without significant interanimal, interanalyst, or interassay variation. Interanalyst and interanimal variation significantly affected the ability to detect treatment differences using the mouse bioassays. Sample sizes needed to predict clinically significant treatment effects were calculated using varying assay conditions. Ham's F-10 medium can be tested with the hamster sperm motility assay.

Attitudinal survey of sperm donors to an artificial insemination clinic.

Donors (n = 42) to an artificial-insemination-by-donor sperm clinic were surveyed to ascertain individual motivations and attitudes regarding participation. Responses were compared to those of a matched control group (n = 50) of nondonors. Donors were motivated by money, with the majority (69%) unwilling to participate if financial incentives were withdrawn. Anonymity was desired, and donors did not favor disclosure of information to a national registry tracking insemination outcomes. However, donors and controls did endorse providing sperm for an infertile brother. Donors and controls differed significantly in response to 2 of 15 questions asked, with differences due to perceptions of donor motivation. Although perceived as altruistic by peers, donors did not envision themselves as such, and most considered donating semen similar to donating blood or organs.

Reliability of ultrasound in predicting uterine leiomyoma volume.

Recently ultrasound has been used to size and track individual myoma volumes for patients undergoing medical therapy. However, little is known about the specific performance characteristics and limitations of this technique with respect to volume measurements. We performed and prospectively interpreted serial ultrasound examinations on myoma patients and confirmed the location, size and number of myomas in the surgical specimens. The smallest detectable tumor was 2.7 cm in diameter. The specificity was 94%; reproducibility had a 14% coefficient of variation for tumors with diameters greater than 6 cm. We conclude that ultrasound is suitable for imaging and sizing myomas provided that the diagnosis is otherwise certain and the tumors tracked are large.

Corpus luteum activity in tubal pregnancy.

Corpus luteum activity was monitored in 20 women undergoing nonsurgical management of ectopic pregnancy with methotrexate and citrovorum factor (N = 15) or observation (N = 5). The functional integrity of the corpus luteum was assessed by measuring progesterone and 17-hydroxyprogesterone. Trophoblastic viability was assessed by measuring the immunoreactive beta subunit of human chorionic gonadotropin. Ten of 15 methotrexate-treated patients demonstrated initial progesterone levels above 1.0 ng/mL, declining to levels below 1.0 ng/mL after treatment. Five of 15 methotrexate-treated patients and all five managed by observation alone demonstrated progesterone and 17-hydroxyprogesterone values below 1.0 ng/mL both initially and throughout the surveillance period, leading to resolution, indicating previous death of the corpus luteum. We conclude the following regarding ectopic pregnancy: 1) Corpus luteum function declines early in the biologic history of some gestations while persisting in others, and 2) corpus luteum function varies from active to inactive independent of serum levels of immunoreactive beta-human chorionic gonadotropin.

An instrument for the recovery of preimplantation uterine ova.

This report describes an instrument to recover fertilized ova from the human uterus without anesthesia. Two hundred sixty-five lavages were performed on 20 normal and presumed fertile women and on seven infertile women. Using 60 mL of fluid, median fluid recovery was 97% (range 65-100%). In the fertile women, ova were recovered in 40 of 90 insemination cycles (44%). Complications were rare (3%), but included two retained pregnancies, three minor pelvic infections, three occurrences of catheter kinking on insertion, and one failure to obtain insertion. Reproductive function in the subjects after repeated use does not appear to be impaired.

Nonsurgical management of unruptured isthmic ectopic pregnancy: preliminary experience.

Five unruptured isthmic tubal pregnancies diagnosed at laparoscopy were treated with either methotrexate/citrovorum factor rescue (MTX/CF) (n = 4) or observation alone (n = 1). Entry criteria required that the ectopic be fully visualized, no greater than 3 cm in diameter, with intact serosa, and without active bleeding. Treatment selection was based upon preoperative levels of beta-hCG with MTX/CF given to subjects exhibiting a plateaued or rising pattern and observation alone given those with falling levels. Subjects were followed with serial measurements of beta-hCG, complete blood counts, and liver function tests. In all subjects the ectopic pregnancy resolved without further surgery. Time to resolution (first day of treatment to undetectable beta-hCG) ranged from 12 to 55 days. Of the five subjects studied, follow-up hysterosalpingograms in four demonstrated tubal patency on the side of the ectopic gestation.

Timely diagnosis of early ectopic pregnancy using a single blood progesterone measurement.

We obtained a single serum P measurement in 70 subjects at risk for an EP. Retrospectively, a P less than 15 ng/ml was 100% predictive of either an EP or otherwise nonviable IUP, while P greater than 15 ng/ml would have ruled out an EP in all cases. Because of this high degree of diagnostic accuracy, we speculated on the clinical utility of an outpatient D and C for those patients in our series having a P less than 15 ng/ml. Laparoscopy would be reserved for those cases without identifiable chorionic villi on frozen section of curettings. Following this course of management could have potentially diagnosed all EPs at the first ER visit without disruption of a single normal IUP in our series. This sequence could have expedited the diagnosis of EP by up to 14 days compared with a standard hCG/US protocol. This report describes a promising new test for the early detection of EP. The findings, however, require confirmation in a prospective trial before widespread clinical implementation.

Nonsurgical management of unruptured ectopic pregnancy: an extended clinical trial.

Unruptured tubal pregnancies diagnosed at laparoscopy were treated with either methotrexate/citrovorum factor (MTX/CF) (n = 21) or observation (n = 5). Entry criteria required that the ectopic pregnancy be visualized, less than or equal to 3 cm in diameter, with intact serosa and no active bleeding. Treatment selection was based upon preoperative levels of beta-human chorionic gonadotropin (beta-hCG), with MTX/CF given to subjects exhibiting a plateaued or rising pattern and observation alone given to those with falling levels. Twenty-five of 26 ectopic pregnancies resolved without need of laparotomy. Two subjects received blood transfusions and one required a second operation for intra-abdominal bleeding. In both cases, fetal cardiac activity was noted pretreatment on ultrasound. The authors conclude the following: (1) MTX/CF may be safely used to treat selected unruptured ectopic pregnancy; (2) many ectopic pregnancies resolve spontaneously; and (3) ectopic pregnancies that form fetal elements, as evidenced on ultrasound, should not be managed medically.

In-vivo blastocyst production and ovum yield among fertile women.

We evaluated ova recovered from 13 fertile women undergoing uterine lavage for purposes of embryo donation, and assessed differences in blastocyst production and ovum yield among subjects. Six women produced 10 blastocysts during 31 insemination cycles (32%). Yet, despite undergoing at least four insemination cycles apiece, seven women produced no blastocysts in 52 lavage attempts. Comparing the ovum recovery rates between the blastocyst-producing and non-blastocyst-producing groups, we found the former more likely to yield ova (P less than or equal to 0.05), and more importantly 10 to 20 recovered ova were blastocysts. We conclude that donor fecundity is highly variable among fertile women, and that reproductive history alone does not predict ovum donor efficiency.

Establishing early pregnancy levels of serum progesterone in functionally agonadal women using polysiloxane vaginal rings and cylinders.

Using a polysiloxane cylinder impregnated with crystalline progesterone (P4), combined with a 17 beta-oestradiol (E2) and P4 vaginal ring, we produced first trimester pregnancy levels of serum P4 in six functionally agonadal women scheduled for transfer of donated embryos. With this 4 g P4 cylinder worn from cycle day 15 to day 30, overall mean serum P4 concentrations were 15.03 +/- 1.56 ng/ml, with a mean peak level of 21.34 +/- 1.85 ng/ml. These levels were significantly higher than those obtained by us previously in five subjects using a 2 g P4 cylinder [P = 0.007]. The cylinder produced minor but significant complications including small vulvovaginal lacerations, difficulty in removing the device, and vaginal discharge. We conclude that the steroid impregnated polysiloxane vaginal ring and cylinder system provides: continuous and sustained hormone release, and levels of serum P4 in the normal range for early pregnancy. Side effects however, may limit its clinical usefulness.

The medical treatment of unruptured ectopic pregnancy with methotrexate and citrovorum rescue: preliminary experience.

Seven women with unruptured tubal pregnancies diagnosed on laparoscopy were treated with methotrexate and citrovorum rescue. Criteria for inclusion in the study were that the level of human chorionic gonadotropin (hCG) be plateaued or rising, that the ectopic pregnancy not exceed 3 X 3 cm, that the tubal serosa be intact, and that there be no active bleeding. The women were followed with serial measurements of hCG, complete blood counts, and liver function tests. All women responded to a single course of therapy. The median time to resolution (from the first day of treatment to when the hCG was undetectable) was 31 days (range, 5 to 50 days). Follow-up hysterosalpingograms were available for five women. Four women demonstrated tubal patency, and one showed a unilateral occlusion on the side of the ectopic. One woman was found to have an intrauterine pregnancy prior to the scheduled time of hysterosalpingogram.

Pharmacology of estrogens and estrogen-induced effects on nonreproductive organs and systems.

The classification of estrogens based on chemical structure and origin is presented. The metabolism of endogenous estrogens and the postulated mechanism of action of steroid hormones are reviewed. Specific effects of estrogen on bone, kidney and coagulation are also discussed.

PIP: This article reviews the effects of estrogens on protein production by the liver, lipid metabolism, bone maturation and structure, and mineral metabolism. Also presented is a comparison of natural steroidal estrogens (estradiol, estrone, conjugated estrogens, and equine estrogens), synthetic steroidal estrogens (esters and 17-alpha-ethinyl estradiol), and nonsteroidal estrogens (diethylstilbestrol, dienestrol, and chlorotrianisene). Delivery of estrogens by different routes produces different effects. However, the metabolic changes that occur from enzyme induction within hepatic tissue are probably related to the type and dosage of estrogen rather than to the route of administration. Preparations containing estrogens that occur naturally in humans have the least exaggerated potency in the hepatic system relative to their estrogenicity, while conjugated estrogens that contain a mixture of equine estrogens are 2-3 times more potent in the hepatic system and ethinyl estradiol and diethylstilbestrol demonstrate a hepatic potency that is 4-18 fold greater than their estrogen potency. Estrogen is believed to induce a hypercoagulation state associated with both oral contraceptive (OC) use and pregnancy, but the clinical significance of increased levels of clotting factors remains undetermined. Estrogen appears to inhibit bone resorption in postmenopausal women and improve calcium balance. Although estrogen receptors are present in the kidney, their physiologic significance remains unknown. Estrogen does cause an increase in levels of plasma renin substrate, plasma renin activity, and angiotensin. Estrogen-induced increases in angiotensin, leading to renal sodium retention, appear to be the mechanism underlying the association of OCs with hypertension.