Investigation of tubal infertility by radionuclide migration.

Investigation of the tubal factor in infertility is limited to an assessment of anatomical structure and tubal patency. No test of ascendant tubal function is currently available. The migration of radionuclide (99mTc-labelled human albumin microspheres) through the genital tract in 96 infertile women was compared with pelvic findings at laparoscopy and chromopertubation. The radionuclide test correlated with laparoscopy in the diagnosis of patency or blockage in 83 cases (86%). In nine patients, where 'blockage' was diagnosed on the radionuclide test but patency found at laparoscopy, a higher prevalence of pelvic abnormality was found, compared to the 78 patients where both tests demonstrated patency (P less than 0.02). The radionuclide test may facilitate detection of diseased but patent tubes and, as an adjunct to laparoscopy and chromopertubation, may provide useful information about tubal function.

Ovarian sensitivity to gonadotrophins in patients with PCO is unaffected by suppression of LH.

Infertile women with oligomenorrhoea and elevated LH concentrations (presumed polycystic ovary disease, PCO) were treated with exogenous gonadotrophins, HMG and HCG, for induction of follicular growth and ovulation, respectively. This was effected in the absence or presence of a gonadotrophin releasing hormone analogue (GnRH-A) to suppress basal LH and the positive feedback surge of LH. Analyses of the duration of HMG therapy required to attain the degree of stimulation for HCG to be administered showed no difference between those with and without LH suppression. Analyses of the ultrasound estimations of rates of follicle growth and continued recruitment during the course of HMG also failed to show any effect of LH suppression. These data show that the high sensitivity of these patients to HMG is not related to the circulating LH concentrations.

Unilateral pleural effusion as the presenting feature of ovarian hyperstimulation syndrome.

Ovarian hyperstimulation syndrome occurred in a 32-year-old woman who presented with symptoms from a large unilateral pleural effusion which was the predominant feature in her case. The aetiology of the effusion was initially uncertain in view of the relative absence of ascites suggesting that the effusion arose because of a primary pleural abnormality.

Combined gonadotropin-releasing hormone analog and exogenous gonadotropins for ovulation induction in infertile women: efficacy related to ovarian function assessment.

The ovarian function of infertile women with normal menstrual rhythm was investigated by daily plasma hormone (estradiol, progesterone, luteinizing hormone, and follicle-stimulating hormone) analyses throughout the menstrual cycle, and patients were diagnosed as showing a subnormal profile of progesterone in the early luteal phase or as showing no abnormality. Women with oligomenorrhea and elevated luteinizing hormone levels were diagnosed as having polycystic ovary syndrome primarily on the basis of endocrinology. All patients were treated with a gonadotropin-releasing hormone analog to suppress endogenous luteinizing hormone and follicle-stimulating hormone so that ovulation induction with exogenous gonadotropins could be undertaken as in patients with hypogonadotropic hypogonadism. Interference in the process of ovulation by endogenous luteinizing hormone fluctuations was eliminated and pregnancies were achieved. The pregnancy rate in the group with polycystic ovary syndrome was 77% per treatment course (six cycles) while that in the group with subnormal progesterone profiles was 61.5%. Patients showing no abnormality achieved no pregnancy, demonstrating the redundancy of interference with normal ovarian function.

The use of GnRH analogues in combination with exogenous gonadotropins in infertile women.

GnRH analogues suppress LH fluctuations and produce a condition of hypogonadotropic hypogonadism. This action combined with treatment with human menopausal gonadotropins (hMG) has been exploited in programmes of induction of follicular growth in infertile women for both in vivo and in vitro fertilisation. There is improved clinical control over the process of ovulation and the phenomenon of premature luteinization in women with polycystic ovary disease has been eliminated.

'Unexplained infertility' results of secondary investigations in 95 couples.

Abnormalities of in-vitro sperm-mucus penetration, ovarian hormone deficiency, specifically poor progesterone surge, and luteal cyst formation were assessed prospectively in 95 couples with fully investigated primary infertility of greater than or equal to 3 years duration. Abnormal sperm-mucus penetration was found in 22, half of whom could have been identified on semen assessment alone. Ten other males had recurrent oligospermia but with normal motility and mucus penetration. Twenty-one patients had a poor progesterone surge and seven of them demonstrated retained luteal phase cysts. Endocrine and mucus penetration abnormalities did not coincide, demonstrating that they are distinct and unrelated phenomena. A significant number of couples were found for whom the term 'unexplained infertility' was no longer applicable and appropriate management could be considered.

The aetiology of infertility in 1162 investigated couples.

The aetiological factors associated with 1162 couples who attended a single infertility clinic and who were assessed according to a fixed protocol over an eight-year period were analysed retrospectively. Male problems accounted for 17 per cent, ovulation disorders 31 per cent, tubal factors were present in 18 per cent and idiopathic infertility was observed in 32 per cent. Single factor infertility was present in 58.8 per cent and multiple factors were present in 9.8 per cent of all cases. Although results may be biased by sub-specialty interests, only by continuous updating with reference to the most modern accepted methods of investigation can the likely demand for specialised infertility services and in vitro fertilisation be determined with accuracy.

Effects of LH suppression in polycystic ovary syndrome.

A LH-releasing hormone (LHRH) analogue was administered to subjects with elevated circulating LH concentrations and elevated androgens (polycystic ovary syndrome, PCO) and also to a control group with normal menstrual rhythm and normal LH and androgens. In both groups circulating LH concentrations were reduced to low and indistinguishable concentrations. Oestradiol, oestrone, androstenedione and testosterone levels were all reduced by treatment in both groups. However, the reduction in androgen concentrations was less marked in the patients with PCO. The oestrogen/androgen ratios remained relatively unaltered, but the testosterone levels remained slightly elevated in the PCO patients after treatment. The results suggest that patients with PCO syndrome show a disorder of androgen metabolism independent of elevated LH concentrations.

Successful treatment of infertile women with oligomenorrhoea using a combination of an LHRH agonist and exogenous gonadotrophins.

Eight oligomenorrhoeic patients with increased luteinizing hormone (LH) and androgen levels who had failed to conceive during prolonged anti-oestrogen therapy received a new treatment. Large doses of an LH-releasing hormone (LHRH) analogue (HOE 766) were used to suppress circulating gonadotrophin concentrations and block the positive feedback gonadotrophin surge. Ovulation was induced during continued LHRH analogue treatment with exogenous gonadotrophins without interference from the patient's own pituitary. Seven of eight patients conceived rapidly without premature luteinization and without excessive ovarian enlargement. These complications had occurred in control treatment cycles using exogenous gonadotrophins in the absence of the LHRH analogue.

A new systematic treatment for infertile women with abnormal hormone profiles.

Five infertile women, with normal menstrual rhythm who had been investigated previously by daily hormone analyses throughout at least one complete menstrual cycle and had shown poor luteal-phase steroid-hormone profiles were treated by a new approach. They were rendered hypogonadotrophic with large doses of a luteinizing hormone releasing-hormone analogue (Hoe 766) and were then treated with exogenous gonadotrophins to induce follicular growth and ovulation. Progesterone production after ovulation in all cases was superior to that observed in the individual patients' without treatment. One patients conceived in her first conception cycle and another in her fourth. This regimen offers a systematic approach to the treatment of unexplained infertility in women with deficient luteal-phase steroid-hormone profiles.

Ovarian morphology in oligomenorrhea.

An account is given of the ovarian histology on 38 patients complaining of oligomenorrhea. The majority of these patients, 22, had polycystic ovaries, but in 11 the ovaries were comparatively normal in appearance. In another 3 they were small and inactive. The remaining 2 cases had chromosomal anomalies. The polycystic ovaries could be divided into two groups, one showing little follicular activity, the other a great deal. The maturation of most follicles in all ovaries appeared to be restricted and antral follicles rarely grew beyond a diameter of 4-5 mm. It is suggested that this degree of maturation is related to a low tonic secretion of FSH. An excessive production of luteinized thecal cells was found around most antral follicles. Polycystic change in these ovaries is mainly due to the presence of many atretic follicles. Luteinized thecal cells persist after atresia and it is suggested that this may be the result of a tonic secretion of LH. The lack of preantral and antral follicles in one group of polycystic ovaries may indicate a prolongation of the atretic process. Ovulation occurs with considerable frequency in these women. The mechanism is obscure.