Clinical evaluation of luteal function.

OBJECTIVE: To determine the ability of luteal phase length determined by basal body temperature (BBT) pattern and a midluteal serum progesterone level to predict the result of an endometrial biopsy in a subsequent cycle. METHODS: We performed a retrospective analysis of 141 women with a history of infertility who were being evaluated for luteal function. The luteal phase length determined from a BBT chart of one menstrual cycle was compared to a single midluteal serum progesterone level from a second menstrual cycle. These findings were compared to a luteal phase endometrial biopsy performed in a third menstrual cycle. Subjects were divided into four groups depending upon luteal phase length (normal 11 or more days) and serum progesterone level (normal at least 10 ng/mL). The four groups were designated "normal," "short luteal phase," "low progesterone," and "abnormal," depending upon the results of the two tests. The frequency of in- and out-of-phase endometrial biopsy results in the four groups was compared. RESULTS: There was no difference in the occurrence of an in- or out-of-phase endometrial biopsy when the four groups were compared. CONCLUSION: Neither luteal phase length nor a single midluteal serum progesterone level was predictive of subsequent in-phase or out-of-phase endometrial biopsy.

The relationship between hCG and relaxin secretion in normal pregnancies vs peri-implantation spontaneous abortions.

OBJECTIVE: We determined the ovarian response to human chorionic gonadotrophin (hCG) in terms of relaxin and progesterone secretion during the peri-implantation period of normal and failing pregnancies. We wished to test the hypotheses that relaxin production in failing pregnancies is different from that in normal pregnancies, that relaxin is a reliable, quantitative indicator of the biological activity of endogenous hCG, and that relaxin is a useful predictor of peri-implantation spontaneous abortions. DESIGN: Daily blood samples were collected in a prospective longitudinal study from insemination patients. PATIENTS: Women undergoing artificial insemination in natural cycles with non-frozen donor semen at a University clinic. MEASUREMENTS: Serum LH, hCG, relaxin and progesterone were measured and the relationship between hCG and the ovarian hormones was evaluated in the peri-implantation period of normal pregnancies and spontaneous abortions. RESULTS: Nine of 23 conceptive cycles resulted in a spontaneous abortion between 16 and 70 days after the LH peak. In all normal and failing pregnancies there was a close qualitative relationship between hCG secretion and relaxin production. Six of nine failing pregnancies were associated with abnormally low hCG secretion. Six of the spontaneous abortions were associated with rates of relaxin secretion which were higher than the mean of 14 normal pregnancies. No such alterations in progesterone concentrations were observed. In cases where hCG was extremely low, the quantitative relationship between hCG and relaxin was different from that in cases of normal hCG concentrations. CONCLUSIONS: There is a close temporal relationship between the secretion of trophoblastic hCG and ovarian secretion of relaxin in the peri-implantation period of normal and failing pregnancies. In failing pregnancies there is substantial variability in the quantitative relationship between relaxin and hCG, indicating that relaxin is not a reliable quantitative indicator of hCG bioactivity. Contrary to previous reports, relaxin concentrations in failing pregnancies tended to be higher than or equal to concentrations in normal pregnancies until the loss was imminent. Because of this relaxin is not a useful predictor of peri-implantation spontaneous abortions.

Prevention of adhesion formation/reformation with the Gore-Tex Surgical Membrane.

Eighteen patients with extensive adhesions and 10 undergoing myomectomy had GORE-TEX Surgical Membranes placed in order to prevent adhesion formation/reformation. At the time of second-look laparoscopy the membranes were removed easily and the extent of adhesion was minimal. Preliminary data from 10 additional patients undergoing adhesiolysis demonstrated that the GSM resulted in significantly fewer adhesions than did oxidized regenerated cellulose. The number of patients in this group will be expanded to insure that this difference is maintained.

Prospective assessment of early fetal loss using an immunoenzymometric screening assay for detection of urinary human chorionic gonadotropin.

OBJECTIVE: To develop an economical, nonradiometric immunoenzymometric assay (IEMA) for the detection of urinary human chorionic gonadotropin (hCG) in studies of early fetal loss. To be effective, the IEMA must have a sensitivity equal to the standard immunoradiometric assay (IRMA) and sufficient specificity to eliminate the need for screening most nonconceptive cycles with the expensive and labor-intensive IRMA. DESIGN: Two different assays were used to measure hCG in daily early morning urine samples from potential conceptive cycles. SETTING: Women undergoing donor artificial insemination (AI) were evaluated in a prospective study. PATIENTS, PARTICIPANTS: Ninety-two women volunteers were selected on the basis of apparent normal reproductive health. INTERVENTIONS: Artificial insemination with nonfrozen donor semen was performed by cervical cup twice each menstrual cycle at 48-hour intervals, and daily urine samples were self-collected throughout the menstrual cycle. MAIN OUTCOME MEASURES: An IEMA was developed to detect urinary hCG using the same antibodies as in the standard IRMA; a study was designed to determine whether this nonradiometric assay could successfully detect the early fetal loss that was detected by the IRMA. RESULTS: Of 224 menstrual cycles analyzed by both assays, a total of six early fetal losses were detected by the IRMA. When the tentative screening rule was set to allow all six of these losses and 95% of future losses to be detected by the IEMA, an additional 34 false-positive results were detected by the IEMA. The specificity of the IEMA with this rule was calculated to be 84%. CONCLUSION: An IEMA based on the same antibodies used for the standard IRMA can serve as an efficient screening assay for the detection of early fetal loss. When the IEMA is used in this manner, nearly 80% of screened menstrual cycles can be eliminated without further testing by the IRMA.

The role of digital image analysis in reproductive biology and medicine.

The use of high-speed computers, direct digitization of video images, and new methods to probe soft tissues has revolutionized our view of biology. Many of these new techniques are now commonly used in several areas of medicine, but their use in reproductive biology has just begun. At present, digital image processing is limited to a few applications in reproductive medicine, including digital colposcopy and the laboratory analysis of spermatozoon motility and cellular morphology. Early implementations of digital image processing experienced problems typical of any newly introduced high technology. Today, however, with careful attention to operational details, digital image processing instruments can be productively used in the clinical diagnosis of cervical cancer, in the laboratory diagnosis of male infertility, and in more basic cell biological research. Such instruments also promise to play a significant role in laboratory quality assurance and control and in technologist training and education. In the near future, digital image processing instruments will also be applied to other areas of reproductive laboratory medicine, such as oocyte evaluation and embryo monitoring in the in vitro fertilization laboratory.

Serum relaxin concentrations in patients with out-of-phase endometrial biopsies.

When luteal phase relaxin concentrations were summed to give an integrated measure (pg/mL per cycle), relaxin was found to be significantly lower in those cycles with an out-of-phase endometrial biopsy. In addition, peak relaxin concentrations were lower in out-of-phase cycles compared with normal cycles. These data indicate that relaxin secretion may be related to normal luteal function and suggest that shortening of the luteal phase results in reduced relaxin production. Measurement of circulating relaxin may prove to be useful in making the diagnosis of out-of-phase biopsy and needs to be assessed for its usefulness in diagnosing abnormal luteal function.

Operating room setup and instrumentation.

The emphasis of this chapter has been on the organization of an operating room for pelviscopic surgery--the major equipment and instrument components; their basic requirements for effective, safe function; and their logical arrangement and integration during surgery. Instrumentation for laparoscopic tubal sterilization has been omitted, having been widely discussed in the past. There are undoubtedly alternate plans to accomplish the same task. This is but one approach, based on the experience of a particular pelviscopy team. The important thing is that the room works, that the basic components are in place and in order, and that the individual members of the surgical team have a thorough understanding of the technical capabilities and limitation of each and every instrument they use.

Ovarian antibodies detected by immobilized antigen immunoassay in patients with premature ovarian failure.

An enzyme-linked immunosorbent assay (ELISA) was used to detect ovarian and oocyte antibodies in serum from 45 patients with premature ovarian failure (POF). Control sera were obtained from a similar group of normally cycling women without POF. A specific antibody reaction was found when POF sera were tested against human ovary (47%) or oocytes (47%). A combined total of 69% of the sera were positive for either ovary or oocytes. Fewer sera were positive for antibodies against human thyroid (18%) or human placenta (22%), and virtually no reaction with human liver (4%) was seen. LH antibodies were detected by ELISA against LH in only 3 POF sera that also contained ovarian antibodies. Therefore, gonadotropin antibodies alone do not appear to account for POF. In addition, 2 patients were treated by immunosuppression and became pregnant coincident with a decline in the serum concentration of ovarian antibodies. In summary, the results of this study are consistent with previous immunohistochemical data which indicate that ovarian and oocyte antibodies are common in patients with POF. This supports the concept that some forms of POF are associated with an autoimmune process. Furthermore, detection of ovarian and oocyte antibodies by ELISA may permit routine diagnosis of autoimmune POF and provide a basis for therapy.

Human chorionic gonadotropin, estradiol, and progesterone profiles in conception and nonconception cycles in an in vitro fertilization program.

In 22 consecutive in vitro fertilization cycles stimulated with purified follicle-stimulating hormone, human chorionic gonadotropin (hCG), estradiol (E2), and progesterone (P) were measured every 3 days during the luteal phase. All serum measurements were normalized to the day of hCG administration (day 0). There was a total of nine pregnancies; two were biochemical pregnancies, whereas 7 of the 22 women had clinical pregnancies (31.8%). Of these, two miscarried and five had term pregnancies (three singleton, two twin). Conception cycles could be differentiated from nonconception cycles by serum E2 levels on day 8 (P = 0.035), by hCG levels on day 11 (P = 0.03), and by P levels on day 14 (P = 0.001). From days 8 to 11, hCG levels plateaued in conception cycles and decreased in nonconception cycles. However, during that period, E2 and P fell in both groups of women. This decline in sex steroids, which was observed in both conception and nonconception cycles, may well negatively influence endometrial development during the peri-implantation period and compromise conception, resulting in failure to conceive, biochemical pregnancy, and early miscarriage.

Super high estradiol response to gonadotropin stimulation in patients undergoing in vitro fertilization.

The likelihood of establishment of a term pregnancy from in vitro fertilization (IVF) is related to the estradiol (E2) pattern and peak level. To examine the influence of super high E2 peak levels (greater than or equal to 2000 pg/ml), we reviewed the clinical outcomes of all IVF cycles with follicular phase E2 levels greater than 2000 pg/ml from May 1982 through June 1987. Among 1651 IVF cycles initiated during this time, 102 cycles (6.2%) had super high E2 levels. Twenty-seven of these cycles occurred in 34 IVF attempts in 12 women. Stimulation was performed with human menopausal gonadotropin (hMG) in 96 cycles and follicle-stimulating hormone (FSH) in 6 cycles. A mean of 9.3 +/- 0.7 oocytes per cycle was recovered, of which 5.5 +/- 0.5 fertilized and underwent cleavage. In 11 cycles, with a mean of 6.8 oocytes recovered, none fertilized. Polyploid fertilization occurred in 23 of 90 cycles (25.6%), and 40 of 558 fertilized oocytes (7.2%). From these cycles, 10 clinical pregnancies (9.8%) have resulted: 6 pregnancies in 59 cycles with luteal-phase progesterone support (10.2%) and 4 pregnancies in 31 cycles without luteal-phase progesterone support (12.9%). Among the 1549 cycles with peak E2 levels less than or equal to 2000 pg/ml, 143 (9.2%) resulted in clinical pregnancies. We conclude that there is a small subset of patients who will have super high E2 responses to gonadotropin stimulation and that there is a tendency to stimulate repetitively in this fashion.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyaluronidase removal of the cumulus oophorus increases in vitro fertilization.

The effect of hyaluronidase removal of the cumulus oophorus on the in vitro fertilization rate of oocytes obtained from patients with poor oocyte fertilizability has been evaluated. Eighty-eight oocytes were obtained from 13 patients undergoing in vitro fertilization and embryo transfer (IVF-ET) for indications of male-factor, immunological, and idiopathic infertility. In addition, patients in whom fertilization did not occur on previous IVF cycles were evaluated in the study. The oocytes of each individual patient were randomly assigned into a treatment (removal of the cumulus; N = 40 oocytes) or nontreatment group (control; N = 48 oocytes). Hyaluronidase was used to remove the cumulus immediately following oocyte retrieval, and insemination was performed 6-8 hr later. The overall oocyte fertilization rate (both treated and untreated) was 42%. The treatment group demonstrated a higher rate of fertilization compared to the nontreatment group (55% vs 31%; P less than 0.05). Examination of various patient groups revealed a statistically significant difference in fertilization rates between the treated and the untreated oocytes only in the "no previous fertilization" group (60% vs 28%; P less than 0.05). A higher rate of fertilization of the treated oocytes was also seen in the immunologic infertility group, however, statistical significance was not achieved (50% vs 25%; P = 0.07). Only one clinical pregnancy was achieved in this group of 13 patients. We conclude that in this group of patients, removal of the cumulus prior to insemination may, in some cases, increase the fertilization potential of the oocyte.

Usefulness of serial measurements of serum follicle stimulating hormone, luteinizing hormone and estradiol in patients with premature ovarian failure.

This study tests the hypothesis that serial measurements of serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (E2) are useful in identifying a subset of patients with premature ovarian failure (POF) who may respond to high-dose human menopausal gonadotropin (hMG) therapy. Nineteen patients with POF were studied with weekly measurements of serum FSH, LH, and E2 for five consecutive weeks. Nine patients (group I) showed episodic increases in E2 (greater than 50 pg/ml), seven accompanied by decreases in FSH, and an FSH/LH ratio that was periodically less than 1.0. Ten patients (group II) displayed persistent, nonvarying low E2 and high FSH and LH levels. There was no significant difference in the E2 response to high-dose hMG (48 to 100 ampules hMG/trial) in the two groups, all patients failing to respond. In conclusion, serial assays for FSH, LH, and E2 in patients with POF fail to predict ovarian responsiveness to a trial of high-dose hMG.

Reduction of postoperative pelvic adhesions in the rabbit with Gore-Tex surgical membrane.

Gore-Tex (W.L. Gore and Associates, Inc., Flagstaff, AZ) surgical membrane (SM), a nonreactive expanded polytetrafluoroethylene (PTFE), was used in 24 mature New Zealand rabbits (2200 to 3000 gm) to cover 2-cm2 ischemic defects in the pelvic sidewall peritoneum to reduce adhesion formation in a rabbit pelvic sidewall/uterine horn injury model. SM was randomly assigned to cover one defect; the opposite defect remained uncovered, each animal serving as its own control. Rabbits were sacrificed 3 weeks later, and adhesions between uterine horn and pelvic sidewall or SM were scored for extent (0 to 4), type (0 to 4), and tenacity (0 to 3). Injury sites were removed en bloc for histologic study. The mean (+/- standard deviation [SD]) adhesion score for SM-covered lesions (4.3 +/- 1.8) was significantly lower than for controls (9.1 +/- 2.5) (P less than 0.001; Wilcoxon Signed Rank test). By histology, none of 24 SM-covered lesions demonstrated adhesions to the membrane itself, whereas 19 of the 24 control lesions showed dense adhesions to the injury site (P less than 0.001; chi-square test). By both gross and microscopic assessment, SM was nonadherent to the underlying sidewall defect in 100% of cases. In conclusion, Gore-Tex surgical membrane is an effective barrier for reducing primary adhesions in this pelvic injury model and offers promise for adhesion reduction in human pelvic surgery.

The effect of periovarian adhesions on follicular development in patients undergoing ovarian stimulation for in vitro fertilization-embryo transfer.

It has been suggested that the presence of periovarian adhesions might impair the ovarian response to gonadotropins. Periovarian adhesions were recorded in 49 women, and the total percentage of accessible ovarian cortex was described at the initiation of the operative procedure. Adhesiolysis was performed as needed for oocyte recovery. Ovarian access did not correlate with serum estradiol level on either the day of human chorionic gonadotropin (hCG) administration or the day after hCG administration. Similarly, neither the total number of follicles on the day of hCG or on the day after hCG, nor the number of follicles 1.0 to 1.4 cm or greater than or equal to 1.5 cm correlated with ovarian access. We conclude that periovarian adhesions are not a major determinant of the ovarian response to gonadotropin stimulation.

A paired analysis of in vitro fertilization and cleavage rates of first- versus last-recovered preovulatory human oocytes exposed to varying intervals of 100% CO2 pneumoperitoneum and general anesthesia.

This study compares the in vitro fertilization and cleavage rates of paired first- and last-recovered preovulatory human oocytes that were exposed to a 100% CO2 pneumoperitoneum and general anesthesia. In 305 consecutive cycles of laparoscopy, 1741 oocytes (5.7/cycle) were recovered. The exact time of aspiration (T) was recorded for each oocyte. The time interval (T1 to T2) between recovery of first and last oocytes ranged from 0 to 38 minutes and represented differences in the exposure time of first and last oocytes to the CO2 pneumoperitoneum and to general anesthesia. For all cycles (n = 305) without regard for T1 to T2, last-recovered oocytes fertilized less often than first-recovered eggs (P = 0.06; McNemar's test). When T1 to T2 was short (less than or equal to 5 minutes), first- and last-recovered oocytes fertilized at comparable rates (70.8% and 74.0%). When only cycles with T1 to T2 greater than 5 minutes were considered (n = 209), the difference in fertilization rates between first and last oocytes (68.5% versus 56.4%) was highly significant (P less than 0.01; McNemar's test). Pairing negated differences due to patient, cycle, or semen variables and first- and last-recovered oocytes had comparable maturity scores (4.0 +/- 0.5 versus 4.3 +/- 0.8). There were no significant differences in cleavage rates for first- and last-recovered oocytes that fertilized, regardless of the exposure interval (T1 to T2). We conclude that exposure to a 100% CO2 pneumoperitoneum and/or general anesthesia may adversely affect oocyte quality.

Weight of babies conceived in vitro.

Recent studies suggested that infants delivered after in vitro fertilization and embryo transfer IVF-ET had low birth weights. To assess further the relationship between birth weight and EGA in these offspring, a review was made of all infants delivered at our institution from May 1, 1983 to July 15, 1986. Forty-five infants in 39 deliveries were identified. Seventeen of 37 (46%) were delivered vaginally, 20 by cesarean section. Forty-two infants were delivered at term (after 36 weeks). The six sets of twins delivered at 254 +/- 7 days (mean, 36 weeks). Eighteen of 39 deliveries (46%) delivered at or beyond 40 weeks EGA. The mean weight at delivery for the term infants was 3225 +/- 90 g. Thirty-eight infants were size appropriate for dates as assessed by the Lubchenco scale, while the weight in the remaining seven infants exceeded the 90th percentile for their gestational age. We conclude that infants conceived through IVF-ET are not predisposed per se to a low birth weight or delivery at an early gestational age. However, prior studies suggesting lower birth weights for IVF infants may have resulted in part from early delivery due to patient pressure and anxiety.

The effect of polyploidy on embryo cleavage after in vitro fertilization in humans.

The effect of polyploidy on the early development of human embryos is unknown. This study compares the early development of 90 polyploid and 275 diploid human embryos conceived in vitro. Between May 1983 and January 1986, 3081 oocytes were recovered during 631 cycles of laparoscopy for in vitro fertilization (4.9 oocytes/cycle); 1924 oocytes (62.4%) fertilized. There were 90 oocytes with more than two pronuclei (4.7% of fertilized oocytes), identified in 72 cycles (11.4% of cycles). In these cycles, the proportion of diploid oocytes (n = 275) that cleaved (cleavage rate) (92.7%) was significantly greater than the proportion of polyploid oocytes (n = 90) that cleaved (65.5%) (P less than 0.001). The cleavage rate for all diploid oocytes (n = 1834) was 90.4%. There was no significant difference in the stage of development (number of blastomeres; mean +/- standard deviation [SD]) on the day of embryo transfer between diploid (4.3 +/- 2.1) and polyploid (4.1 +/- 2.1) embryos that cleaved, but a plot of the frequency distribution of cleavage stages revealed that significantly more polyploid than diploid embryos had an uneven number of blastomeres at that time (33% versus 8%, respectively; P less than 0.001). Polyploidy confers an immediate developmental disadvantage; one third of polyploid embryos fail to cleave, and those that do divide demonstrate more asynchronous divisions.