The need to step up the gonadotropin dosage in the stimulation phase of IVF treatment predicts a poor outcome.

PURPOSE: It is a common practice to increase the gonadotropin dose during ovarian stimulation when the estradiol (E2) rise is found to be inadequate. The prognostic impact of the use of this step-up regimen on the outcome of the affected in vitro fertilization (IVF) cycle is the subject of this study. METHODS: This is a retrospective analysis of IVF cycles in a series of consecutive patients who required an increase in the gonadotropin dosage during the stimulation phase because of inadequate E2 rise. Controls consisted of patients in whom the dose was not increased. After 4 days of stimulation, the gonadotropin dosage was increased if E2 levels failed to rise by 70% every 2 days. Outcome was defined in terms of maximum E2 level, number of follicles at aspiration, number of oocytes obtained, fertility rate, and pregnancy rate and was compared in study and control patients. Pregnancy was defined by sonographic demonstration of cardiovascular activity. RESULTS: One hundred forty-five patients were analyzed. A step-up regimen was used in 35 patients (24.1%). Patients who required the step-up dosing had significantly lower peak E2 levels (1373 vs 1828 pg/ml; P < 0.005), fewer follicles measuring greater than 16 mm (7.2 vs 9.7; P < 0.003), and fewer oocytes recovered (8.3 vs 11.2; P < 0.009). The fertilization rate (67.6 vs 64.2%) was not significantly different. The pregnancy rate (8.5 vs 32.7%; P < 0.004) was significantly lower in the group requiring the step-up regimen. CONCLUSIONS: The utilization of a step-up regimen during an IVF treatment cycle is a predictor of a poor outcome for the specific IVF cycle. As this information is available before retrieval, consideration of cycle cancellation may be appropriate.

Direct gamete uterine transfer in patients with tubal absence or occlusion.

PURPOSE: Our aim was to examine the potential of the uterine cavity to affect fertilization and early embryo development. DESIGN: A prospective IRB-approved protocol for patients fulfilling study eligibility criteria was used. METHODS: Patients studied included those with primary or secondary infertility, aged less than 38 years, with no history of severe male-factor infertility, and with hysterosalpingogram- and laparoscopic-confirmed bilateral proximal tubal occlusion. Superovulation induction was accomplished with a combination of GnRH agonist and menotropins, with serum hormonal and sonographic monitoring. Within 24 hr prior to, and again at the time of, ovulatory hCG administration, progesterone (P4) was given. Sonographic-guided transvaginal retrieval was performed 35 hr after hCG. Between four and six oocytes were returned to the uterine cavity, admixed with sperm, immediately following retrieval. Luteal support consisted of daily P4 administration. RESULTS: Of the 20 patients recruited for the study, all completed the retrieval and transfer procedure. A total of four clinical pregnancies was achieved, with one early first-trimester loss, one late first-trimester loss (Trisomy 14), and two healthy term infants delivered. IVF of surplus oocytes demonstrated a 82.5% fertilization rate and 66.7% cleavage following cryopreservation. CONCLUSIONS: Human fertilization can be achieved through direct uterine transfer of gametes. Furthermore, administration of P4 prior to the ovulatory dose of hCG is compatible with in vitro or in vivo fertilization and implantation.

Controlled ovarian hyperstimulation/intrauterine insemination cycles in subfertile couples. Effect of a six-day-only laboratory work week on cycle fecundity rates.

OBJECTIVE: Controlled ovarian hyperstimulation (COH) combined with intrauterine insemination (IUI) is commonly used to improve fecundability in subfertile couples with tubal patency. Daily hormonal and/or sonographic monitoring is considered important to minimize risks and determine optimal timing of human chorionic gonadotropin (hCG) administration. No patient monitoring or IUI services are available on Sundays in our program. We sought to determine if lack of Sunday monitoring and IUI services adversely affected cycle fecundity (CF) in our COH-IUI program. STUDY DESIGN: We retrospectively analyzed 1,336 consecutive COH-IUI cycles and compared the CF rate for IUIs performed on either Saturday or Monday (group I) with those done on Tuesday through Friday (group II). Cycles where IUIs would have been ideally scheduled on Sunday, as determined by the patient's estradiol level and/or ultrasound, were performed on either Saturday or Monday by altering the day of hCG administration. RESULTS: No difference existed in patient age, diagnosis, treatment or number of total motile sperm inseminated between groups I and II. The CF rate for group I (13.8%/cycle) was not significantly different than that for group II (11.8%). CONCLUSION: We were unable to demonstrate any significant effect on pregnancy rates of suboptimal hCG timing in COH-IUI cycles resulting from the lack of Sunday services.

Does the absence or presence of seminal fluid matter in patients undergoing ovulation induction with intrauterine insemination?

Sperm preparations for intrauterine insemination (IUI) generally do not include seminal fluid, and it is not known whether the absence of this component affects pregnancy rates. Therefore we evaluated the effect of high intravaginal seminal fluid deposition on clinical pregnancy rates in patients undergoing ovulation induction and IUI therapy. A prospective, randomized, double-blind study was designed for an infertile population in a university-based infertility practice. Patients were randomized to receive high vaginal deposition of either seminal fluid separated from the husband's ejaculate (study group) or normal saline solution (control group). Intercourse was restricted. A comparison of clinical pregnancy rates per cycle between study and control groups showed no significant difference between them [22/164 (13.4%) and 19/155 (12.3%) respectively]. Furthermore, in non-participants with unregulated intercourse, the pregnancy rate per cycle was not significantly different (40/307; 13.0%). Miscarriage rates between the study and control groups were similar. As high intravaginal deposition of seminal fluid at the time of IUI does not improve the clinical pregnancy rate in patients undergoing ovulation induction and IUI therapy, our study suggests that, after ejaculation, clinically significant biological contributions of seminal fluid to the achievement of pregnancy are bypassed by well-timed IUI.

High-order oocyte transfer in gamete intrafallopian transfer patients 40 or more years of age.

OBJECTIVE: To analyze whether a policy of high-order oocyte transfer would be effective in women > or = 40 years of age who are undergoing GIFT, and further, whether a specific subgroup of these patients could be identified where clinical pregnancy was more likely to occur. DESIGN: Prospective descriptive study. SETTING: Patients in a university-based reproductive endocrinology and infertility practice. PATIENTS: Infertile women > or = 40 years of age who underwent GIFT cycles between January, 1990 and December, 1993 after not having achieved pregnancy with at least three previous cycles of superovulation and intrauterine insemination. INTERVENTIONS: Gamete intrafallopian transfer was performed after controlled ovarian hyperstimulation with hMGs. High-order oocyte transfer was employed. MAIN OUTCOME MEASURES: Clinical pregnancy rates (PRs). RESULTS: The overall clinical PR was 24.5% per retrieval (12/49) and 25.5% per transfer (12/47). A significantly higher number of oocytes were retrieved in patients who became pregnant than those who did not. Patient age, cycle day 3 FSH level, E2 level on the day of hCG administration, number of oocytes transferred, and total number of motile sperm transferred did not differ significantly between the two groups. The clinical PR per transfer was significantly higher in patients with more than five oocytes transferred (10/27, 37%) versus those with five or less oocytes transferred (2/20, 10%). No multiple gestations were obtained. CONCLUSION: The number of oocytes retrieved in women > or = 40 years of age undergoing GIFT is the main determinant predicting clinical pregnancy. High-order oocyte transfer seems to lead to a favorable PR while the risk of multiple gestation is limited.

The discriminatory human chorionic gonadotropin zone for endovaginal sonography: a prospective, randomized study.

OBJECTIVE: To determine the probability of detecting the gestational sac of a normal intrauterine pregnancy by vaginal ultrasound at different gestational ages and serum hCG concentrations. DESIGN: Prospective, randomized study. SETTING: Pregnant human volunteers in a university-based clinical research environment. PATIENTS: Women with viable pregnancies who conceived spontaneously or after ovulation induction. INTERVENTIONS: Vaginal ultrasound and serum hCG determinations were performed between 20 and 30 days after conception. The timing of the tests was determined randomly. MAIN OUTCOME MEASURE: Detection of gestational sac. RESULTS: The probability of detecting a gestational sac increased significantly with both gestational age and serum hCG concentration, but the regression on gestational age fitted the data much better than the regression on loge (hCG). The probability of detecting a sac was similar in multiple and singleton pregnancies of the same gestational age but, for a given hCG concentration, the probability of detecting a sac was lower for multiple than for singleton pregnancies because multiple gestations were associated with higher serum hCG concentrations than singleton pregnancies of the same gestational age. CONCLUSION: If it is known, gestational age rather than the serum hCG concentration should be used to determine whether the gestational sac of an intrauterine pregnancy should be detectable by vaginal ultrasound. Failure to image a gestational sac > or = 24 days after conception is presumptive evidence of an ectopic pregnancy. Reliance on serum hCG rather than gestational age may lead to an erroneous diagnosis of ectopic pregnancy in women with multiple pregnancies.

A prospective, randomized study of the chorionic gonadotropin-time relationship in early gestation: clinical implications.

OBJECTIVE: To investigate the hCG-time relationship in early pregnancy. DESIGN: Prospective, randomized study. SETTING: Pregnant human volunteers in a university-based clinical research environment. PATIENTS: Normal pregnant women with viable singleton pregnancies, conceived spontaneously or after ovulation induction. INTERVENTIONS: Vaginal ultrasound was performed, and blood samples were obtained for hormone parameters between 20 and 30 days after conception. The timing of the tests was determined by random assignment using sealed envelopes. MAIN OUTCOME MEASURE: Serum hCG. RESULTS: The log hCG-time relationship was linear, both during the first 20 days and between 20 and 30 days after conception. The inclusion of a quadratic term in either regression was not statistically significant. The slopes of the two regression lines were also not statistically different. CONCLUSION: For practical purposes, the hCG-time relationship in early pregnancy can be treated as log-linear, but short sampling intervals should be used if doubling times are to be calculated from paired samples.

The utility of a home urinary LH immunoassay in timing the postcoital test.

OBJECTIVE: To evaluate whether a urinary LH immunoassay improves timing of the postcoital test compared to traditional timing methods in normally ovulating women. METHODS: Subjects included 37 infertile couples evaluated in a tertiary care setting. A randomized, prospective trial was performed of two methods of postcoital test timing: urinary LH assay or the traditional timing by cycle-averaging and/or review of basal body temperature graphs. RESULTS: Similar serum estradiol, progesterone, LH, number of motile sperm per high-power field, cervical mucus scores, and postcoital test scores were identified in both groups. CONCLUSION: Urinary LH immunoassays do not appear to improve timing of the postcoital test as compared with traditional timing methods.

Use of urinary luteinizing hormone immunoassays in the assessment of luteal function in infertile women.

It has been suggested that the chronologic date of an endometrial biopsy performed to evaluate luteal adequacy should be based on the date of the luteinizing hormone surge rather than the date of the next menstrual period. Sixty-four infertile women used a urinary luteinizing hormone immunoassay to identify the luteinizing hormone surge; timed serum progesterone level tests and an endometrial biopsy were then performed. An out-of-phase endometrium was identified in 26.6% of cycles dated traditionally and 28.1% of cycles dated from the luteinizing hormone surge. No relationship was identified between progesterone levels and endometrial biopsy results when the next menstrual period was used. When the luteinizing hormone surge was used no progesterone cutoff value could be identified that would reliably distinguish between in-phase and out-of-phase cycles. Use of a urinary luteinizing hormone immunoassay offers no advantage over the next menstrual period and does not lead to better agreement between histologic and chronologic dating.

Human follicular fluid contains a follicle-stimulating hormone (FSH) receptor binding inhibitor which has FSH agonist activity, is immunologically similar to FSH, but can be distinguished from FSH.

We have previously reported the presence in human follicular fluid (hFF) of a high (greater than 5000) mol wt FSH receptor binding inhibitor (FSH-BI). This hFF FSH-BI was further purified by removal of material insoluble in acidified acetone (pH 4.1) but soluble in diethyl ether (pH 10.5), followed by molecular sieving through Sephacryl S-100. FSH-BI activity eluted from S-100 with an elution volume similar to that of hFSH, but could be distinguished from hFSH on the basis of a differential sensitivity to acid inactivation. Human FSH was inactivated in acetone at pH 4.1 (1 h, 25 C), whereas hFF FSH-BI retained activity under these conditions. Human FF FSH-BI also demonstrated FSH-like agonist activity, defined as the ability to stimulate basal levels of estradiol synthesis in cultured rat Sertoli cells. Human FSH-BI strongly cross-reacted to a commercially available monoclonal antibody used to measure serum hFSH. Indeed, recovery of FSH immunologic activity was significantly greater (134-fold on a mass basis) after partial purification, indicating that antibody recognition sites were apparently masked in unfractionated hFF. In summary, large mol wt hFSH-BI has been partially purified from hFF and found to be similar in size to pituitary hFSH and to have FSH-like agonist activity in vitro. Although distinguishable from pituitary hFSH on the basis of stability to acid, hFSH-BI appears immunologically related to pituitary hFSH so that measurements of hFSH levels in hFF using immunologic techniques should be interpreted with caution.

Identification of low and high molecular weight follicle-stimulating hormone receptor-binding inhibitors in human follicular fluid.

Various fractions of human follicular fluid (FF) were tested for follicle-stimulating hormone (FSH) receptor-binding inhibitory activity, as well as for their ability to form a dansyl derivative previously reported to be associated with FSH receptor-binding inhibitory activity in bovine FF. Pooled human FF was found to inhibit binding of radioiodinated human FSH (125I-hFSH) to its receptor in a concentration-related manner. Fractionation of human FF by sequential ultrafiltration through membranes of calibrated pore size resulted in human FF components of low (500 to 5,000) and high (greater than 5,000) molecular weight, (Mr) respectively. Each of these inhibited 125I-hFSH binding to receptor in a concentration-related manner. Dansylation of the above components revealed the Rf = 0.15 dansyl derivative to be present in unfractionated human FF and in the low (500 to 5,000 Mr), but not the high (greater than 5,000 Mr), component of human FF. These findings are consistent with those previously reported for bovine FF and porcine FF and indicate that human FF contains FSH receptor-binding inhibitors with properties similar to those observed in animal species.

The relationship of sperm parameters to cycle fecundity in superovulated women undergoing intrauterine insemination.

Semen parameters of raw and prepared (post-swim-up) specimens from 451 cycles of intrauterine insemination (IUI) were analyzed in relation to cycle fecundity in 232 patients undergoing ovarian stimulation with sequential clomiphene citrate/menotropin therapy. Pregnancy occurred in 42 cycles, resulting in an overall pregnancy rate of 17.7%, and a cycle fecundity of 9.3%. Cycle fecundity was positively correlated with the parameters of post-swim-up log sperm density (r = 0.994), and with log total motile sperm inseminated (r = 0.964; inseminates were limited to a maximum of 20 million total motile sperm). Post-swim-up motility did not correlate (r = 0.308) with cycle fecundity; however, most specimens had a motility of greater than 40% post-swim-up. Only one pregnancy occurred when less than 1 million motile sperm were inseminated (38 cycles), which resulted in a cycle fecundity of 2.6% for these cycles. This may represent the threshold of effectiveness for IUI in this setting. Highest cycle fecundity was obtained with an inseminate containing approximately 10 million or more motile sperm. Parameters of raw samples correlated less well with cycle fecundity than did prepared specimens. Analysis of post-swim-up semen parameters can provide useful prognostic information for women undergoing IUI with ovarian stimulation; this information is helpful in counseling patients regarding their chances of success with this therapy.

A prospective study on the lack of development of antisperm antibodies in women undergoing intrauterine insemination.

To test the hypothesis that intrauterine insemination with washed spermatozoa induces antisperm antibody formation, we measured serum antisperm antibody levels by the Immunobead technique in a population of women receiving exogenous gonadotropins. Antibody levels were measured before therapy (baseline) and then serially during subsequent stimulation cycles, for a maximum of six cycles. Twenty-eight patients underwent intrauterine insemination; each patient served as her own control. An additional 25 patients were treated with exogenous gonadotropins but did not undergo intrauterine insemination; they served as external controls. Antisperm antibody levels in women who underwent concomitant intrauterine insemination were compared with levels in those who did not. Of the 53 enrolled patients, 18 completed six treatment cycles, and 35 achieved pregnancy before six cycles. Forty-five patients (85%) had less than 10% Immunobead binding, six (11%) had binding between 10% and 25% (mean 16%, range 14% to 20%), and two had binding greater than 25% (28% and 42%, respectively). Mean binding was similar (less than 10%) in the intrauterine insemination and external control groups. Eighteen patients conceived in the intrauterine insemination group and seventeen in the control group. Of patients who conceived, all but one had less than 10% Immunobead binding at the time of conception (mean 1.6 months). In patients who did not conceive, there was no difference in Immunobead binding between control and intrauterine insemination groups after 6 months of therapy. Our data do not support the hypothesis that serum antisperm antibody levels, as detected by Immunobead binding, will increase in menotropin-stimulated women undergoing intrauterine insemination over a prolonged treatment period.

Multiple gestation is associated with the use of high sperm numbers in the intrauterine insemination specimen in women undergoing gonadotropin stimulation.

Over a 27-month period, the authors observed 70 pregnancies in 66 women following intrauterine insemination (IUI) in conjunction with human menopausal gonadotropins/human chorionic gonadotropin (hMG/hCG) stimulation. Excluding ectopic pregnancies (n = 3) and spontaneous miscarriages (n = 15) during the first 10 weeks of gestation, 14 of the 52 pregnancies (27%) included multiple fetuses: nine twins, four triplets, and one quadruplet. Analysis of patient characteristics and clinical management, as well as semen characteristics of the conception cycle, revealed a significant correlation between gestation type (multiple versus singleton) and the total number of motile sperm in the IUI inseminate (P less than 0.01, Fisher's exact test). General linear models procedures did not identify additional significant relationships between various combinations of parameters examined and the gestation type. The authors conclude that IUI with high numbers of motile sperm constitutes a risk factor in the genesis of multiple gestation. The risk of multiple gestation rises significantly when the inseminate contains more than 20 million motile sperm.

Exogenous gonadotropin requirements are increased in leuprolide suppressed women undergoing ovarian stimulation.

We used a subcutaneously administered GnRHa for 21 to 26 days prior to menotropin stimulation, to suppress endogenous LH surges in four patients participating in IVF. GnRHa-pretreated cycles were compared with previous menotropin treatment cycles. Endogenous LH surges were successfully suppressed in all patients. Peak E2 levels and ultrasonographic parameters of follicular development were comparable in the two treatment groups. Exogenous gonadotropin requirements were increased 2- to 4-fold in GnRHa pretreated cycles (P less than 0.05). Ovum recovery rates were not improved by adjuvant LA. These studies indicate that there was an increased ovarian requirement for exogenous gonadotropins as a result of GnRHa therapy. It has to be considered that this may be a direct effect of GnRHa upon the ovary. Alternatively, the absence of endogenous pituitary support in GnRHa-treated patients may account for the increased gonadotropin requirement. Finally, it is possible that this effect is indigenous to this select patient population of poor responders to menotropin stimulation, or to a specific effect of subcutaneously (as opposed to intranasally) administered GnRHa on the ovary. Further studies are needed to clarify the extent to which any or all of these postulated mechanisms may be influencing ovarian response to exogenous gonadotropins after subcutaneous GnRHa pretreatment.

Active ovulation management increases the monthly probability of pregnancy occurrence in ovulatory women who receive intrauterine insemination.

The authors examined the hypothesis that active ovulation management would increase the monthly probability of pregnancy occurrence (MPO) in ovulatory women who require intrauterine insemination (IUI). All patients were initially treated during spontaneous ovulatory cycles with IUI performed after the detection of an endogenous lutenizing hormone (LH) surge (phase 1). For phase 2, those patients who had not conceived were offered treatment with fertility medication and IUIs were scheduled accordingly. Four of 76 (5.3%) patients conceived during 180 treatment cycles in phase 1; 9 of 44 (20.5%) patients conceived during 105 treatment cycles in phase 2. The average MPO was 0.022 in phase 1, and 0.085 in phase 2: the difference is significant (P less than 0.02). The authors conclude that fertility medication improves MPO in ovulatory women who undergo IUI for certain infertility situations.

Pixe analysis of reproductive fluids.

An external 3.8-MeV proton beam was employed to induce X-rays in 100-mg pellets of human follicular fluids and in 4-8 mg pellets of spermatozoa. The elements Cl, K, Ca, Fe, Cu, Zn, and Br were quantitatively determined in follicular fluids, whereas the elements, S, Cl, K, Ca, Ti, V, Cr, Mn, Fe, Ni, Cu, and Zn were determined in the spermatozoa. Both samples had high interelement Spearman correlation coefficients. Correlations of elements in the samples were observed with several clinical parameters. The multielemental analysis of spermatozoa can be used to approximate quantities of trace elements inserted into the egg ooplasm at the time of fertilization. These elemental quantities appear to be in the femtogram (10(-15)) range.

A prospective study of intrauterine insemination of processed sperm from men with oligoasthenospermia in superovulated women.

The effectiveness of intrauterine insemination (IUI) was compared with that of intracervical insemination (ICI) in 49 infertile couples, in whom the major cause for infertility was oligoasthenospermia. All women had ovulation stimulated with either a clomiphene citrate (CC)-human gonadotropin combination or human gonadotropins alone. The ovulatory dose of human chorionic gonadotropin (hCG) was given after adequate estradiol levels were reached. The timing of inseminations was standardized--IUI was 28 hours after hCG and ICI was immediately after hCG administration. Only one insemination per month was performed with either IUI or ICI. The first treatment cycle was assigned randomly to be either IUI or ICI, and subsequent inseminations were alternated. A total of 182 cycles were completed, with 96 IUIs and 86 ICIs. Pregnancy occurred in eight patients, seven with IUI (14.3%) and one with ICI (2.0%); the difference is significant at P less than 0.05. The pregnancy rate per treatment cycle was 7.3% versus 1.2% (P less than 0.001). This study supports the use of IUI with processed sperm in the treatment of infertility due to oligoasthenospermia.

Correlates of sexual desire in post-menopausal women.

Sexual desire was studied in 22 post-menopausal women (absence of menses for at least 12 mth) without complaints of sexual dysfunction, not receiving estrogen replacement therapy, and in good physical health. Psychosexual evaluation, medical history, physical and pelvic examinations, and blood samples for the determination of estradiol, androstenedione, FSH and LH were obtained. In addition, the effects of a formal exercise program on sexual desire was investigated. It was found that approximately 50% of the women in this study experienced no decline in sexual interests with menopause, and less than 20% reported a significant decrease. Results indicated a positive relationship between desire and a measure of marital adjustments which women with loss of sex desire had on the Locke-Wallace Marital Adjustment Test. There was no correlation between gonadotropins and loss of sexual desire.