Programmed follicular stimulation reduces cycle cost and stress with no compromise in cycle quality: use of a modified programmed protocol.

To reduce cycle cost and patient/staff stress in an ongoing in vitro fertilization (IVF) program, we have utilized a modified "programmed" (PP) follicle stimulation protocol with limited monitoring. We have compared our PP results with those using a conventional, individualized, and fully monitored protocol (OP) in order to show that PP does not compromise the quality of care. Hormonal presuppression made possible an arbitrary starting day for the cycle. In 80% of the cycles, oocyte retrieval (OR) was performed on the planned day or 1 day later. There was no statistically significant difference between the two regimens in oocyte/embryo numbers, quality or pregnancy rates. The cycle cost was significantly reduced. In addition, patient stress was lessened because of the reasonable predictability of cycle timing. We conclude that PP has significant financial and emotional advantages for the patient over OP but does not appear to diminish the chance for pregnancy in an IVF cycle. PP also allows program staff to manage time more effectively, thereby reducing staff stress.

Prolactin synthesis and release during pregnancy and puerperium.

Prolactin (PRL) synthesis and its release following thyrotropin-releasing hormone (TRH) administration during pregnancy and puerperium was studied in 45 women. Mean baseline E2 increased from 1,900 +/- 384 (SEM) pg/ml in the first trimester to 3,520 +/- 849 in the second trimester (P less than 0.05) and 43,057 +/- 5,765 pg/ml in the third trimester (P less than 0.001) of pregnancy. Mean baseline progesterone increased from 27.6 +/- 3.2 ng/ml in the first trimester to 41.9 +/- 6.6 in the second trimester (P less than 0.01) and 109.3 +/- 11.2 ng/ml in the third trimester (P less than 0.001) of pregnancy. Ten days after delivery, mean E2 dropped to 13 +/- 2.9 pg/ml and progesterone dropped to 0.56 +/- 0.07 ng/ml in the lactating women; in the nonlactating women, mean E2 level was 100 +/- 44 pg/ml and mean progesterone was 0.63 +/- 0.09 ng/ml. Baseline PRL increased from 27 +/- 15 ng/ml in the third trimester (P less than 0.002). The increased synthesis of PRL with increasing gestation was thought to be due to the stimulatory effects of E2 and progesterone, resulting in hyperplasia of the lactotrophs. In response to TRH, PRL demonstrated a significant increase from the first trimester to the second, with no further increase in the third. Therefore, it appears that the PRL reserve increases only during the first and second trimesters of pregnancy. Ten days after delivery, baseline PRL in response to TRH decreased to levels found in the first and second trimesters. However, the lactating women released less PRL than the nonlactating subjects (P less than 0.01), since PRL is released with each lactating episode which in turn probably reduces the PRL reserve.

Disappearance of human chorionic gonadotropin and resumption of ovulation following abortion.

The disappearance of human chorionic gonadotropin (hCG) and resumption of pituitary ovarian function was investigated in 13 patients following first- and second-trimester abortions. First-trimester abortion patients (with suction curettage) had a mean time of 37.5 +/- 6.4 days for the clearance of hCG to a level of 2 mlU/ml. Second trimester abortions (with prostaglandin) had a mean time of 27.4 +/- 4.8 days. Patients undergoing second-trimester hysterectomy had a mean disappearance time of 39.7 +/- 5.3 days and only 12 days if the hysterectomy was initiated with ligation of the uterine and ovarian vessels. No significant difference in clearance time was found when it was compared on the basis of the baseline hCG levels. Based on a concomitant luteinizing hormone (LH) and follicle-stimulating hormone (FSH) peak, nine of 12 patients resumed normal pituitary function. These LH and FSH peaks were seen even though the serum hCG levels were as high as 35 mlU/ml. Based on serum progesterone levels of greater than 3 ng/ml, all these nine patients ovulated as early as 21 days after abortion. In view of these results, the clearance of hCG after pregnancy termination depends mainly upon the type of procedure used. Moreover, in view of the early time of ovulatory recovery, contraception should be instituted within the first 2 weeks following pregnancy termination.

PIP: The disappearance of human chorionic gonadotropin (hCG) and resumption of pituitary ovearian function was investigated in 13 patients following 1st- and 2nd-trimester abortions. The patients were selected on the basis of previous good health and an uneventful pregnancy. Baseline blood samples were obtained within 24 hours of the initiation of the abortion. Daily blood samples were then obtained for 507 days in all patients. Subsequently, serum samples were obtained twice weekly for 42-55 days after abortion. The serum was separated by centrifugation and stored at -20 degrees C until assays were performed. Serum levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), the beta subunit of hCG, and progesterone were measured by radioammunoassay procedures. 1st trimester abortion patients (with suction curettage) had a mean time of 37.5 + or - 6.4 days for the clearance of hCG to a level of 2mlU/ml. 2nd trimester abortions (with prostaglandin) had a mean time of 27.4 + or - 5.3 days and only 12 days if the hysterectomy was initiated with ligation of the uterine and ovarian vessels. No significant difference in clearance time was found when comparison was on the basis of the baseline hCG levels. Based on a concomitant LH and FSH peak, 9 of 23 patients resumed normal pituitary function. These LH and FSH peaks were observed even though the serum hCG levels were as high as 35 mlU/ml. Based on serum progesterone levels of greater than 3 ng/ml, all 9 patients ovulated as early as 21 days following the abortion. In terms of these results, the clearance of hCG after abortion is dependent primarily on the type of procedure used.