An oocyte donation protocol using the GnRH antagonist ganirelix acetate, does not compromise embryo quality and is associated with high pregnancy rates.

PURPOSE: To evaluate the effect of the GnRH antagonist, ganirelix acetate, on oocyte quality. METHODS: Stimulation characteristics, implantation rates and clinical pregnancy rates were compared between 29 oocyte donors 21-31 years of age who underwent 31 cycles of ovarian stimulation with gonadotropins and ganirelix acetate, and 36 infertile couples of similar age range who underwent 51 cycles of ovarian stimulation using the same protocol. RESULTS: A significantly lower number of embryos were transferred in the donor/recipient group as compared to the infertile group (2.32+/-0.54 vs. 2.82+/-0.71, P<0.05). In contrast, implantation and clinical pregnancy rates per transfer, were significantly higher in the donor/recipient group (38.1% vs. 10.4%, P<0.01) and (61.3% vs. 23.1%, P<0.05) respectively, as compared to the infertile group. CONCLUSIONS: Incorporation of ganirelix acetate for pituitary suppression in stimulation protocols for oocyte donation is associated with high pregnancy rates suggesting that ganirelix acetate does not exert an adverse effect on oocyte or embryo quality.

Successful management of infertility due to retrograde ejaculation using assisted reproductive technologies: a report of two cases.

Although retrograde ejaculation is a relatively uncommon cause of infertility, it is nonetheless the most common cause of ejaculatory dysfunction. Retrograde ejaculation is characterized by either all or part of the seminal fluid going into the bladder. The initial management of patients with ejaculatory dysfunction is medical therapy. In couples who have failed medical therapy, assisted reproductive techniques using sperm harvested from either the urine or the male reproductive tract would be the ultimate option. We report successful management of two couples, both men with advanced age and complete retrograde ejaculation, by intrauterine insemination in one and in vitro fertilization (IVF) using intracytoplasmic sperm injection (ICSI) in the other using sperm harvested from urine. The cases reported herein suggest that male infertility due to retrograde ejaculation may be successfully treated in men significantly older than the usual reproductive age and that traditional methods of hydration and urine alkalinization allow for the successful recovery of fertile sperm for ART. The selection of the method of ART must be individualized to the needs of each couple based upon both male and female factors.

The human pluripotent stem cell: impact on medicine and society.

OBJECTIVE: To discuss the current state of the science surrounding human pluripotent stem cells and to show that the derivation of such cells from donated preimplantation human embryos should be eligible for federal funding provided that certain protections are met. DESIGN: A literature search focusing on the scientific aspects of pluripotent stem-cell research and analyses of current and past legislation and federal panel recommendations. CONCLUSION(S): The current federal laws regulating the permission necessary to obtain fetal tissue from elective pregnancy terminations are intended to insulate the decision to terminate a pregnancy from the potential positive influence of fetal tissue transplantation. A similar situation can be created for the derivation of cells from excess preimplantation human embryos produced by IVF programs. If, as in fetal tissue research, assurances can be made that the research will have no influence on the decision to dispose of the embryo, the derivation of pluripotent stem cells from embryo should proceed with federal funding.

Clinical significance of the qualification of atypical squamous cells of undetermined significance: An analysis on the basis of histologic diagnoses.

OBJECTIVE: This study was undertaken to evaluate the significance of further qualification of atypical squamous cells of undetermined significance in routine Papanicolaou smears. STUDY DESIGN: A retrospective medical records review was conducted on 316 women whose Papanicolaou smears yielded diagnoses of either atypical squamous cells of undetermined significance suggestive of the presence of an intraepithelial lesion or atypical squamous cells of undetermined significance suggestive of a reactive process. RESULTS: The overall incidence of a squamous intraepithelial lesion (cervical intraepithelial neoplasia grades I, II, and III) was higher in the group with atypical squamous cells of undetermined significance suggestive of the presence of an intraepithelial lesion than in the group with results suggestive of a reactive process (41.1% vs 22.3%; P =.0344). Women with atypical squamous cells of undetermined significance suggestive of the presence of an intraepithelial lesion were 9.7 times more likely to have high-grade squamous intraepithelial lesion (cervical intraepithelial neoplasia III) develop than were women with atypical squamous cells of undetermined significance suggestive of a reactive process (95% confidence interval, 1.26-74.64). The incidence of high-grade squamous intraepithelial lesion was higher among women 35 years old (17.8% vs 6.3%; P =.0378). CONCLUSION: Women with a diagnosis of atypical squamous cells of undetermined significance suggestive of the presence of an intraepithelial lesion are more likely to have intraepithelial lesions develop than are those with atypical squamous cells of undetermined significance suggestive of a reactive process. Aggressive evaluation of cases of atypical squamous cells of undetermined significance suggestive of the presence of an intraepithelial lesion with colposcopy and cervical biopsies may be appropriate. Age should be considered as an independent factor in the plan of management.

Reproductive function in female mice lacking the gene for endothelial nitric oxide synthase.

Nitric oxide (NO) acts as a neuronal messenger in both the central and peripheral nervous systems and has been implicated in reproductive physiology and behavior. Pharmacological inhibition of nitric oxide synthase (NOS) with the nonspecific NOS inhibitor, l-N(G)-nitro-Arg-methyl ester (l-NAME), induced deficits in both the number of ovarian rupture sites and the number of oocytes recovered in the oviducts of mice. Female neuronal NOS knockout (nNOS-/-) mice have normal numbers of rupture sites, but reduced numbers of oocytes recovered following systemic injections of gonadotropins, suggesting that NO produced by nNOS accounts, in part, for deficits in ovulatory efficiency observed after l-NAME administration. Additionally, endothelial NOS knockout (eNOS-/-) mice have reduced numbers of ovulated oocytes after superovulation. Because endothelial NOS has been identified in ovarian follicles, and because of the noted reduced breeding efficiency of eNOS-/- mice, the present study sought to determine the role of NO from eNOS in mediating the number of rupture sites present after ovulation. Estrous cycle length and variability were consistently reduced in eNOS-/- females. The number of rupture sites was normal in eNOS-/- mice under natural conditions and after administration of exogenous GnRH. After exogenous gonadotropin administration, eNOS-/- females displayed a significant reduction in the number of ovarian rupture sites. Female eNOS-/- mice also produced fewer pups/litter compared to WT mice. These data suggest that NO from endothelial sources might play a role in mediating rodent ovulation and may be involved in regulation of the timing of the estrous cycle.

Impaired ovulation in mice with targeted deletion of the neuronal isoform of nitric oxide synthase.

BACKGROUND: Nitric oxide (NO) plays an important role in numerous reproductive processes. To date, most studies have assessed the role of NO by using nonspecific pharmacological inhibitors of the precursor to NO, nitric oxide synthase (NOS). These pharmacological NOS inhibitors suppress all isoforms of NOS; thus, the precise contribution of each isoform to female reproductive physiology is unknown. The purpose of this study was to determine the specific role of neuronal NOS (nNOS) in the regulation of ovulation in female mice lacking the gene that encodes for nNOS (nNOS-/-). MATERIALS AND METHODS: Ovulation was assessed in wild-type (WT) and nNOS-/- female mice by examining the number of ovarian rupture sites and number of oocytes recovered from the oviducts following mating or exposure to exogenous gonadotropins (i.e., 5 IU pregnant mares serum gonadotropin [PMSG] and 5 IU human chorionic gonadotropin [hCG]). Ovulatory efficiency was determined as the number of ovulated oocytes per number of ovarian rupture sites. To examine whether ovulatory deficits in nNOS-/- mice were due to alternations in central mechanisms, plasma luteinizing hormone (LH) concentrations were assessed in WT and nNOS-/- mice that were challenged with 25 ng of gonadotropin-releasing hormone (GnRH). To determine whether ovulatory deficits in nNOS-/- mice were due to local ovulation processes, nerves innervating the reproductive tract of WT and nNOS-/- females were examined for the presence of nNOS protein. RESULTS: There were substantial fertility deficits in nNOS-/- female mice; the nNOS-/- mice had fewer oocytes in their oviducts following spontaneous and gonadotropin-stimulated ovulation. Pituitary responsiveness to exogenous GnRH challenge was intact in nNOS-/- mice. Dense nNOS protein staining was observed in nerves innervating the reproductive tracts of WT mice. CONCLUSIONS: The reproductive deficits in nNOS-/- females are most likely due to alternations in the transfer of oocytes from the ovaries to the oviducts during ovulation. These results suggest that defects in neuronally derived NO production may contribute to female infertility.

Day 4 estradiol levels predict pregnancy success in women undergoing controlled ovarian hyperstimulation for IVF.

OBJECTIVE: To evaluate the usefulness of serum estradiol levels obtained on the fourth day of gonadotropin stimulation in predicting the likelihood of pregnancy during controlled ovarian hyperstimulation (COH) using luteal phase leuprolide acetate (LA). DESIGN: A 4-year retrospective analysis of day 4 estradiol levels and subsequent clinical pregnancy and delivery rates. SETTING: A university hospital tertiary referral center. PATIENT(S): Couples undergoing IVF treatment. MAIN OUTCOME MEASURE(S): Primary outcome measures included clinical pregnancy and delivery rates. Secondary outcome measures included the number of oocytes retrieved and the number of embryos available for transfer per COH cycle. RESULT(S): The clinical pregnancy and delivery rates for cycles with day 4 estradiol levels of >75 pg/mL were 42.3% (30/71) and 32.4% (23/71), respectively. These rates differed significantly from those for cycles with day 4 estradiol levels of < or = 75 pg/mL, which were only 9.1% (4/44) and 6.8% (3/44), respectively. The number of oocytes retrieved and the number of embryos available for transfer for cycles with day 4 estradiol levels of >75 pg/mL also differed significantly from those for cycles with day 4 estradiol levels of < or = 75 pg/mL (11.4 and 7.8 versus 6.8 and 4.3, respectively). CONCLUSION(S): Estradiol levels obtained on the fourth day of gonadotropin therapy are highly predictive of successful ovulation induction and pregnancy outcome in cycles using luteal phase LA.

Nitric oxide modulates human chorionic gonadotropin-induced ovulation in the rabbit.

OBJECTIVE: To examine the potential role of the L-arginine:nitric oxide pathway in hCG-induced ovulation in the rabbit. DESIGN: Randomized, controlled animal study. SETTING: University research laboratory. INTERVENTION(S): Nitric oxide synthase, the enzyme that produces nitric oxide (NO), was immunohistochemically localized in the ovary. NG-nitro-L-arginine methyl ester (L-NAME), an analogue of L-arginine, which inhibits the enzyme NO synthase, and the inactive D-enantiomer were administered in vivo and/or in vitro via an isolated, perfused ovary preparation during the periovulatory period. MAIN OUTCOME MEASURE(S): Rate of follicular rupture (ovulatory efficiency). RESULT(S): Immunohistochemical staining for NO synthase was localized specifically to the granulosa cell layer of the follicle and the endothelium and adventitia of ovarian blood vessels. In vivo administration of L-NAME significantly reduced the percentage of large follicles that ovulated in response to hCG (treated 24.6%, control 68.1%). Similarly, exposure of the in vitro-perfused ovary to L-NAME significantly reduced follicular rupture (treated 32.8%, control 64.2%). In contrast, addition of an equimolar concentration of D-NAME to the perfusion medium had no significant effect on the rate of ovulation (treated 83.3%, control 61.3%). CONCLUSION(S): The stereospecific inhibition of follicular rupture by the arginine analogue suggests that NO production by the ovary is an important feature of the normal physiologic processes of the periovulatory period.

Effects of a gonadotropin-releasing hormone analog on rabbit ovarian function.

This study was undertaken to elucidate the effects of a GnRH analog (GnRH-a) on rabbit ovulation, oocyte maturation, and steroidogenesis, and to verify whether treatment with a GnRH-a interferes with ovarian response to exogenous gonadotropin (hCG), both in vivo and in vitro. Three approaches were used. In the first, adult New Zealand White (NZW) rabbits were divided into two groups. Both received PMSG and hCG administered 72 h after PMSG. In the test group a GnRH-a, leuprolide acetate (LA; 20 microg/kg) was administered s.c. every 24 h. Treated rabbits showed a significant decrease in ovulatory efficiency (control = 88%; treated = 72%), and an increase in degeneration rate of preimplantation embryos (control = 30% vs. treated = 40%). For the second approach, in vitro perfusion experiments were designed to compare the direct effects of LA (10.000 ng/ml) and hCG (50 IU) on ovarian function and to verify whether the presence of a GnRH-a in the perfusate modifies the actions of hCG. LA reduced the ovulatory efficiency of hCG-treated ovaries perfused in vitro (hCG-treated = 87%; hCG-treated LA-perfused = 70%), reduced the potential for preimplantation development (morula stage: hCG-treated = 53%; hCG-treated LA-perfused = 31%; LA-perfused = 12%), and increased the degeneration rate of early embryos (21%, 48%, and 56% respectively). In the third approach, the direct effect of LA (Group I: control, Group II:1.000 ng/ml, and Group III:10.000 ng/ml) on the in vitro maturation of denuded rabbit oocytes was evaluated. LA induced meiotic maturation, but increased oocyte degeneration rate. The potential for preimplantation development was reduced (Morula stage: control = 16%, Group II = 8%, and Group III = 6%), and degeneration rate was increased (38%, 65%, 63% respectively). This study suggests that pharmacological doses of LA may exert a negative effect on oocyte function by direct action on the oocyte, indirectly via alteration of the intrafollicular environment and/or through interference with gonadotropin-induced biological effects within the ovary.

Effects of acetylsalicylic acid (aspirin) and naproxen sodium (naproxen) on ovulation, prostaglandin, and progesterone production in the rabbit.

OBJECTIVE: To determine the effects of acetylsalicylic acid (aspirin) and naproxen sodium (naproxen) on ovulation, ovarian prostaglandins (PG), and P production in the rabbit via in vivo and in vitro studies. DESIGN: Aspirin and naproxen were administered i.v. 6.5 and 7 hours, respectively, after hCG administration to New Zealand White adult female rabbits. Laparotomy was performed 24 hours after hCG administration. For in vitro experiments, control animals underwent laparotomy 6.5 (aspirin) and 7 hours (naproxen) after hCG administration. The treated animal received aspirin and naproxen; laparotomy was performed 1 hour later. One ovary was perfused for 6 hours with aspirin or naproxen whereas the contralateral ovary served as a control and was perfused with control medium (M199; GIBCO, Grand Island, New York). Perfusate samples were collected at 1-hour intervals for PG and P determination. SETTING: A conventional laboratory setting. INTERVENTIONS: In vivo experiments used i.v. administration of 100 mg/kg aspirin and 10 and 50 mg/kg naproxen. In vitro perfusion was also carried out with 100 micrograms/mL aspirin and 10 and 50 micrograms/mL naproxen added to the perfusate. MAIN OUTCOME MEASURES: Ovulatory efficiency (no. of ovulations/no mature follicles) and ovarian vein PG and P concentration were determined. RESULTS: Ovulatory efficiency was 88% for control, 41% for in vivo aspirin-treated, and 40% (10 mg/kg) and 0% (50 mg/kg) for naproxen-treated rabbits. Aspirin and naproxen were associated with decreased ovulatory efficiency when administered in vitro to both in vivo control and in vivo treated ovaries (control-medium = 70%; control-aspirin = 14%; aspirin-medium = 34%; aspirin-aspirin = 0%; control-naproxen = 25%; naproxen-medium = 38%; naproxen = 0% with 10 microgram/mL, and control-naproxen = 13%; naproxen-medium = 0%; naproxen = 0% with 50 micrograms/mL). Prostaglandin F2 alpha was undetectable in the perfusate of those ovaries perfused of those ovaries perfused either with aspirin or naproxen. Ovarian venous concentration of P in the perfusate was similar in all groups. CONCLUSIONS: Aspirin and naproxen significantly reduced ovulatory efficiency and PG production both in vivo and in vitro in hCG-treated rabbits. A critical period of 6.5 and 7 hours after hCG administration was established.

RU486 inhibits ovulation, fertilization and early embryonic development in rabbits: in vivo and in vitro studies.

OBJECTIVE: To clarify the role of P in ovulation, fertilization, and early embryonic development using RU486, a potent P receptor blocker. DESIGN: Ovulatory efficiency, IVF, and early embryonic development were evaluated after RU486 administration in vivo and in vitro. SETTING: Research laboratory of a university hospital. PARTICIPANTS: Mature male and female New Zealand white rabbits. INTERVENTIONS: Animals were treated with RU486 or vehicle for 3 days before hCG-induced ovulation. Ovaries treated with hCG to induce ovulation were perfused for 6 hours in vitro with RU486 or vehicle. In vitro fertilization was performed in the presence or absence of RU486. MAIN OUTCOME MEASURES: The percentage of mature follicles ovulating (ovulatory efficiency) was determined after in vivo and in vitro treatment. Fertilization, morula, and blastocyst development were evaluated every 24 hours for 120 hours. RESULTS: RU486 significantly inhibited ovulation, fertilization, and early embryonic development. CONCLUSIONS: Progesterone plays a significant role in ovulation, fertilization, and preimplantation embryonic development.

Role of calcium/calmodulin-dependent protein kinase II in gonadotrophin-induced ovulation in in vitro perfused rabbit ovaries.

The objectives of these experiments were to determine (i) the role of calcium/calmodulin-dependent protein kinase II-mediated signal transduction in hCG-induced ovulation and (ii) whether there is an association between arachidonic acid metabolites, nitric oxide and calcium/calmodulin-dependent protein kinase II in the overall scheme of ovulation induction. Ovarian arteries were cannulated in situ, and the ovaries were excised and perfused in vitro. Ovulatory efficiency ([number of ovulated follicles/number of mature follicles > 1.5 mm] x 100) was calculated for each experiment. Calcium/calmodulin-dependent protein kinase II substrate induced ovulation in the absence of gonadotrophin (calcium/calmodulin-dependent protein kinase II substrate: 66.3%; control: 0%). In the next experiment, perfusion medium of the experimental ovary was supplemented with KN 62, a potent inhibitor of calcium/calmodulin-dependent protein kinase II, while the contralateral ovary served as control. Ovulations were induced in both ovaries with hCG (50 iu (150 ml)-1) and perfusion was continued for 8 h. In the third experiment, ovaries were perfused with prostaglandin F2 alpha (PGF2 alpha) with and without KN 62, while the contralateral ovary was perfused with medium alone. KN 62 reduced the ovulatory efficiency of hCG-treated ovaries in vitro during perfusion (hCG + 10(-7) mol KN 62 l-1: 32.9%; hCG: 80.9%). Furthermore, it significantly reduced the ovulatory efficiency of PGF2 alpha-treated ovaries (PGF2 alpha + KN 62 = 21.5%; PGF2 alpha = 59.9%).(ABSTRACT TRUNCATED AT 250 WORDS)

Five decades of progress in management of the infertile couple.

OBJECTIVE: To review milestones in the care of the infertile couple over the past five decades. DATA RESOURCES: All issues of Fertility and Sterility were reviewed beginning with the first issue published in 1950 through volume 61, number 1 (January 1994). Other significant articles from the literature were reviewed as identified by directed Medline searches. RESULTS: This historical review gives the reader a sense of the evolution of modern reproductive technology--how the past has shaped the present--through the development of modern surgical techniques, methods of ovulation induction, laparoscopy, ultrasound, endocrine assays, in vitro fertilization, cryopreservation of sperm and preembryos, and microscopic procedures on gametes and preembryos. CONCLUSIONS: The remarkable capabilities of modern reproductive technologies are only possible because of the culmination of decades of innovative research.

Lipoprotein alterations from a triphasic oral contraceptive containing ethinyl estradiol and gestodene. A 12-month trial.

To evaluate the lipid and lipoprotein changes induced by a triphasic oral contraceptive (OC) containing ethinyl estradiol and gestodene, 25 healthy women from the Baltimore metropolitan area were enrolled in an open-label, noncomparative study. Serum lipids were measured prior to starting the OCs and again during the 3rd, 6th and 12th treatment cycles. Mean lipid concentrations in each treatment cycle were compared to baseline levels using the t test for paired samples. Small but statistically significant (P < or = .05) increases in the mean concentrations of total cholesterol, total triglycerides, total high density lipoprotein (HDL) cholesterol, HDL3 cholesterol, apolipoprotein A1 and apolipoprotein B were noted. Although the increases were statistically significant, the mean lipid concentrations were still within the normal range. The mean HDL2 and low density lipoprotein cholesterol concentrations were unchanged, as was the mean total cholesterol/HDL ratio. Healthy women taking a triphasic OC containing ethinyl estradiol and gestodene have minimal changes in lipids and should not be at increased risk of atherosclerosis due to OC-induced lipid alterations.

Inhibition of gonadotrophin-induced ovulation in rabbits by perfusion with dibutyryl cAMP via reduction of ovarian prostaglandin production.

The role of cAMP in ovulation, oocyte maturation and prostaglandin production was assessed using a rabbit ovary preparation perfused in vitro. Dibutyryl cAMP (10(-3), 10(-4) or 10(-5) mol l-1) was added to the perfusate of one ovary. The contralateral, control ovary was perfused with medium alone. Thirty minutes after the onset of perfusion, 50 iu hCG was added to the perfusate of all ovaries. Dibutyryl cAMP inhibited hCG-induced ovulation in a dose-related fashion. No difference in ovum maturity or degeneration was found between control ovaries and ovaries treated with dibutyryl cAMP. Ovarian progesterone production was not affected by exposure to dibutyryl cAMP. The concentrations of 6-keto PGF1 alpha (the stable metabolite of prostacyclin) and PGF2 alpha in the perfusate of ovaries treated with dibutyryl cAMP were 49.6% and 32.0% of the control values, respectively, 12 h after hCG administration. Inhibition of 6-keto PGF1 alpha production by dibutyryl cAMP was dose related. Production of PGE2 was unaffected by dibutyryl cAMP. These data raise the possibility that continuous exposure to dibutyryl cAMP may inhibit hCG-induced ovulation in the perfused rabbit ovary via a reduction in PGF2 alpha and prostacyclin production.