Cost-effectiveness analysis of different embryo transfer strategies in England.

OBJECTIVE: The objective of this study was to assess the cost-effectiveness of different embryo transfer strategies for a single cycle when two embryos are available, and taking the NHS cost perspective. DESIGN: Cost-effectiveness model. SETTING: Five in vitro fertilisation (IVF) centres in England between 2003/04 and 2004/05. POPULATION: Women with two embryos available for transfer in three age groups (<30, 30-35 and 36-39 years). METHODS: A decision analytic model was constructed using observational data collected from a sample of fertility centres in England. Costs and adverse outcomes are estimated up to 5 years after the birth. Incremental cost per live birth was calculated for different embryo transfer strategies and for three separate age groups: less than 30, 30-35 and 36-39 years. MAIN OUTCOME MEASURES: Premature birth, neonatal intensive care unit admissions and days, cerebral palsy and incremental cost-effectiveness ratios. RESULTS: Single fresh embryo transfer (SET) plus frozen single embryo transfer (fzSET) is the more costly in terms of IVF costs, but the lower rates of multiple births mean that in terms of total costs, it is less costly than double embryo transfer (DET). Adverse events increase when moving from SET to SET+fzSET to DET. The probability of SET+fzSET being cost-effective decreases with age. When SET is included in the analysis, SET+fzSET no longer becomes a cost-effective option at any threshold value for all age groups studied. CONCLUSIONS: The analyses show that the choice of embryo transfer strategy is a function of four factors: the age of the mother, the relevance of the SET option, the value placed on a live birth and the relative importance placed on adverse outcomes. For each patient group, the choice of strategy is a trade-off between the value placed on a live birth and cost.

The impact of luteal supplement on pregnancy outcome following stimulated IVF cycles.

This is a prospeve randomised study designed to clarify the impact of various luteal support regimes (HCG and progesterone) on progesterone profiles and pregnancy outcomes. This study involved subjects undergone down regulated. stimulated IVF cycles using various types of luteal support, namely: Cyclogest (n=35). Crinone gel (n=36), various doses of Utrogestan (n=55) and HCG (n=35). Various doses of Utrogestan (administered vaginally), Crinone gel (progesterone administered vaginally) and Cyclogest (progesterone administered rectally) supplementation induced similar end plasma progesterone concentrations ranging from 26 to 32 mmnl/l. These progesterone regimes produced no significant differences. Hence, the impact of exogenous proge,terone supplement was relatively trivial and did not 'stabilise' the sub-optimal luteal phase. In contrast, two small HCG injections during the early and mid-luteal phase possessed a much greater ability to 'stabilise' progesterone profiles. Despite this additional advantage, implantation and pregnancy rates with either HCG or progesterone supplements were similar. Although none of these forms of luteal support adequately 'normalised' luteal progesterone profiles, this did not appear to be detrimental to the process of implantation.

Inhibition of progesterone secretion by oestradiol administered in the luteal phase of assisted conception cycles.

A prospective randomised study was done to assess the effect of supplemental oestradiol in addition to progesterone on the luteal steroid profiles and pregnancy outcome in stimulated cycles with and without pituitary down regulation. Women undergoing stimulated cycle IVF with GnRH-a and FSH (Group A, n = 63) or stimulated intrauterine insemination using CC and FSH (Group B, n = 55) were studied. These subjects were randomly allocated to receive either 400 mg daily of vaginally administrated Cyclogest (progesterone) alone or in combination with 2 mg daily of oral Oestradiol Valerate (E2V) during the luteal phase. Significant lower concentrations of plasma progesterone were observed in those subjects supplemented with both E2V and progesterone compared to those in whom progesterone only was given during the luteal phase (P < 0.05). Exogenous E2V had a minimal impact on plasma oestradiol concentrations and did not disguise the characterised mid luteal decline in oestradiol secretion. The suppressive effect of E2V on plasma progesterone was lost if implantation occurred normally because any small change in steroid concentrations was reversed by the rapidly increasing concentrations of HCG. Similar pregnancy rates were observed among subjects supplemented with or without oestradiol. The addition of oestradiol to the luteal supplement suppresses endogenous corpus luteum progesterone secretion irrespective of the type of assisted conception cycle and that its use is unlikely to be beneficial to the process of implantation.

Progesterone Profiles in Pregnant, Non-Pregnant, Natural and Stimulated IVF Cycles with and Without Luteal Support.

OBJECTIVES: (1) To describe the progesterone profiles following pituitary down regulation in stimulated IVF cycles with the use of GnRH-a (2) To assess the impact of progesterone supplement and pregnancy on the subsequent luteal phase. STUDY DESIGN: A prospective observational study performed in a specialist infertility clinic based at a tertiary centre in the north of England. Subjects were divided into cohorts depending on their treatment (natural or stimulated IVF cycles), the type of luteal support (nil or Progesterone) and eventual outcome (successful pregnancy or failure to conceive). Saliva Progesterone concentrations were the only measuring outcome. RESULTS: Natural versus stimulated cycle (SIVF); As expected saliva progesterone concentrations were significantly higher in subjects undergoing SIVF than in the natural cycle from day 1 to day 6 of the cycle (P<0.001) but thereafter stimulated cycle concentrations declined prematurely to fall below those of the natural cycle group by day 7, becoming significantly lower than natural cycle concentrations by days 9 and 10 (P<0.01). With and without progesterone supplementation; Saliva progesterone concentrations in subjects undergoing NIVF and receiving progesterone supplement were 2.5-3 times greater than those concentrations seen in the unsupplementated natural cycle (P<0.001). Similarly in the SIVF-Progesterone supplemented group, saliva concentrations remained significantly higher (P<0.001) than in the unsupplemented cycle throughout luteal phase. Despite this, luteal supplementation did not prevent nor reverse the acute mid luteal (day 7) decline in progesterone seen in all stimulated cycles. CONCLUSION: Luteal phase following pituitary down regulation is grossly abnormal. The timing and degree of luteal support routinely provided following stimulated IVF is not effective in 'correcting' the progesterone profile.

Low-dose dexamethasone augments the ovarian response to exogenous gonadotrophins leading to a reduction in cycle cancellation rate in a standard IVF programme.

BACKGROUND: Cancellation of assisted conception cycles because of poor ovarian response to gonadotrophins is a significant problem in assisted reproduction. Various adjuvant treatments have been suggested to improve responsiveness. This study reports on the potential benefits of low dose dexamethasone. METHODS: Patients <40 years of age were invited to participate in a twin centre prospective double blind randomized placebo controlled study. A total of 290 patients were recruited and computer randomized using sealed envelopes to receive either 1 mg dexamethasone (n = 145) or placebo tablets (n = 145) in addition to a standard long protocol gonadotrophin-releasing hormone analogue with gonadotrophin stimulation regime. RESULTS: A significantly lower cancellation rate for poor ovarian response was observed in the dexamethasone group compared with controls (2.8 versus 12.4% respectively, P < 0.002). Further comparisons between the dexamethasone group and controls were made of median fertilization rates (60 versus 61% respectively, NS), implantation rates (16.3 versus 11.6% respectively, NS) and pregnancy rate per cycle started (26.9 versus 17.2%, NS). The benefit was apparent in patients both with polycystic and normal ovaries. CONCLUSION: Low dose dexamethasone co-treatment reduces the incidence of poor ovarian response. It may increase clinical pregnancy rates and should be considered for inclusion in stimulation regimes to optimize ovarian response.

Endocrinology of the peri-implantation period.

Current research suggests that the appearance of endometrial integrins and pinopode appearance signal the opening of the receptive phase of the endometrium. These integrins may be activated by the interleukin-1 system (IL-1). IL-1beta, expressed by the blastocyst, induces vascular endothelial growth factor (VEGF) which, in turn, promotes angiogenesis and integrin expression in endometrial cells. The IL-1 system also triggers the expression of gamma interferon (IFN-gamma) from T lymphocytes. Decidual natural killer (NK) lymphocytes interact with invading trophoblast to generate leukaemia inhibitory factor (LIF). LIF induces uPA and gelatinase, enzymes which play a crucial role in trophoblastic invasion. Progesterone is a potent inhibitor of LIF, while oestrogen is a potent inducer. Oestrogen in serum reflects follicular IL-1beta level and correlates with the outcome of embryo transfer after in vitro fertilization (IVF). Progesterone induces nitric oxide (NO) synthesis in the decidua, and NO promotes local vasodilatation and uterine quiescenceMeasurement of placental protein 14 (PP14, glycodelin-A) in serum may be of value as a screening test for implantation potential. However, human chorionic gonadotrophin (hCG) remains the most reliable predictor of successful implantation and pregnancy viability. An ovulation + 14 hCG level < 50 IU/l is often predictive of a non-viable outcome, while an ovulation + 21 hCG of < 200 IU/l always indicates a non-viable pregnancy. hCG secretion by invading trophoblast appears to be negatively modulated by endothelin-1 (ET-1) and prostaglandin F(2alpha)(PGF2alpha), while tissue growth factors and collagenases are positive modulators of hCG expression.ProalphaC, an inhibin pro-monomer, may have some value in monitoring corpus luteum function. Inhibin A, activin A and follistatin all rises throughout pregnancy and peak at 36 weeks of gestation. Relaxin is another ovarian hormone that may have a role in predicting implantation. Relaxin induces placental protein 14 (PP14, glycodelin-A) expression in a receptive endometrium, and measurement of serum PP14 may be of value as a screening test for implantation potential.

Corpus luteum response to exogenous HCG during the mid-luteal phase of the menstrual cycle.

OBJECTIVE: To assess a range of exogenous HCG regimes designed to simulate the endocrine environment occurring in biochemical, single and multiple pregnancies and to study the response of the corpus luteum to those regimes. DESIGN: Prospective clinical study. PATIENTS: Twenty-five normally cycling women aged 24-35 years were given one of four regimes of HCG injections designed to mimic the HCG concentrations found following spontaneous implantation. Regimes A, B, C and D were designed with starting HCG doses of 60, 140, 250 and 1000 iu, respectively. The daily HCG injections were then increased to give a doubling concentration every 30 h for regime A, every 27 h for regime B, every 24 h for regimes C and D. HCG administration was started on either days 7 or 8 after the LH peak. MEASUREMENTS: Plasma HCG and progesterone concentrations. RESULTS: Subjects given regime A failed to demonstrate any rescue of the corpus luteum despite low-detectable amounts of HCG in the circulation equivalent to those seen in some biochemical pregnancies. In contrast, subjects given regimes B and C demonstrated prompt increases in progesterone secretion immediately after the first HCG injection achieving HCG and progesterone concentrations in plasma similar to those seen in normal singleton pregnancies. Subjects given regime D also showed rapid rescue of the corpus luteum but this time achieved plasma HCG concentrations in the range normally seen in multiple pregnancies. All subjects in regimes B, C and D secreted significantly higher amounts of progesterone than those in regime A (P<0.001). However, despite the greater amounts of HCG used in regime D, the amount of progesterone produced was not significantly different from regimes B or C. CONCLUSIONS: The exogenous HCG regimes used in this study successfully mimicked the hormonal environment found in biochemical, single and multiple pregnancies and elicited appropriate corpus luteum responses.

Predictive value of plasma human chorionic gonadotrophin following assisted conception treatment.

A total of 429 pregnancies after assisted conception treatment was analysed, using receiver operator characteristic curves. The best balance between sensitivity and specificity for predicting viable (single and multiple births) and non-viable (fetal heart positive abortions, ectopic and biochemical pregnancies) outcomes was human chorionic gonadotrophin (HCG) 50 IU/l on day 14 and 200 IU/l on day 21 after treatment. Utilizing these indices all pregnancies could be classified into one of four groups. In group A (day 14 HCG <50 IU/l and day 21 <200 IU/l), the probability of a birth was 0%, pregnancy loss 72% and ectopic pregnancy 28%. Conversely for group D (day 14 HCG >50 IU/l and day 21 >1000 IU/l), the likelihood of a birth was 90%, pregnancy loss 8% and ectopic pregnancy only 1%. Between groups A and D there was, as expected, a gradually shifting balance in favour of a reduction in ectopic (28, 13, 3, 1%) and biochemical pregnancies (70, 36, 33, 2%) and an increase in fetal heart positive pregnancy losses (2, 6, 13, 7%) and births (0, 44, 50, 90%). The majority of multiple pregnancies (98%) occurred in group D. Two accurately linked HCG measurements allowed a greater predictive accuracy of pregnancy outcome than could be obtained using either alone.

The optimum time for exogenous human chorionic gonadotropin to rescue the corpus luteum.

PURPOSE: Our purpose was to study the optimum time to administer exogenous human chorionic gonadotropin (hCG) to rescue the human corpus luteum during the luteal phase of normal menstrual cycles. METHODS: Groups of normally cycling women were given 4-day regimes of exogenous hCG by daily injection beginning 4 (Group A), 8 (Group B), and 12 (Group C) days after the midcycle luteinizing hormone surge. The hCG regime used was designed to mimic hCG levels following a spontaneous implantation. All subjects acted as their own controls in a preceding normal menstrual cycle. RESULTS: Group A subjects exhibited patterns and levels of salivary progesterone concentration similar to those seen in the control cycles throughout the normal luteal phase. In contrast, subjects in both Group B and Group C demonstrated a rapid and sustained increase in progesterone production following the hCG injections. Furthermore, subjects in Group B achieved the highest mean peak progesterone concentrations and the total amount of salivary progesterone secreted was significantly higher than in the control cycles (P < 0.05). Although the mean luteal-phase length was greatest in Group C, the response of the corpus luteum was suboptimal, with a delayed rise in salivary progesterone. CONCLUSIONS: These data show that the qualitative and quantitative response of corpus luteum to an early pregnancy-type hCG signal is maximal around the midluteal phase, coincident with the time of implantation.

Retrograde tubal embryo transfer in natural cycle in-vitro fertilization.

Two modes of embryo transfer, uterine and tubal, were compared following natural cycle in-vitro fertilization (IVF). Only patients with patent Fallopian tubes were included in the study. Tubal embryo transfer was performed by retrograde tubal cannulation without analgesia on an outpatient basis. Tubal transfer conferred no benefit compared with uterine transfer in male factor infertility with positive fertilization (pregnancy rates of 15.8% in both groups). Although tubal embryo transfer in the patients with unexplained infertility improved the pregnancy rates from 7.8% in uterine transfer (5/64) to 17.6% in the tubal transfer group (13/74), this improvement was not statistically significant.

Is subclinical ovarian failure an autoimmune disease?

Young women with unexplained infertility who exhibit elevated basal serum follicle stimulating hormone (FSH) concentrations (>10 IU/l) have poor outcomes in in-vitro fertilization. A subgroup of these women has regular menses, representing 'subclinical' ovarian failure, which may have an autoimmune basis and could potentially be treated by immunosuppression. To investigate this further, a range of immunological markers was used to assess autoimmune activity in 14 women aged <40 years with elevated FSH compared with 15 infertile women with normal FSH and 10 pre-menopausal, healthy controls. All samples were taken during natural menstrual cycles. Organ-specific antibodies against ovary, endometrium and thyroid, and non-organ-specific antibodies against histones and cardiolipin, were not significantly increased in elevated FSH patients compared with other control groups. Soluble CD23 and soluble intercellular adhesion molecule concentrations were not elevated in the sera of the women tested, and circulating T cell subsets remained unaltered. Significantly, increased concentrations of the complement breakdown product C3a and terminal complement complexes were detected in the elevated FSH group compared with the normal FSH group, although the latter also had significant complement activation compared with laboratory controls. Autoimmunity appears as an infrequent cause of 'subclinical' ovarian failure, but there is evidence of activation of complement in the sera of infertile women.

Natural cycle in-vitro fertilization in couples with unexplained infertility: impact of various factors on outcome.

This study evaluated outcome in 117 couples with unexplained infertility who underwent 162 attempts at natural cycle in-vitro fertilization (NIVF) between 1991 and 1993. An egg was obtained in 138 cycles and a single embryo was transferred in 89 cycles. There were 16 implantations (four biochemical pregnancies, three clinical abortions and nine live births). The implantation rate per embryo was 16/89 (18.0%), which translated into a live birth rate per egg collection of 9/138 (6.5%). The impact factors that were assessed included oocyte quality, sperm quality, embryo quality and woman's age. The outcome measures used were fertilization/inseminated egg and implantation/replaced embryo. All embryo transfers were of single embryos. We conclude that, in couples with unexplained infertility, outcome following NIVF is affected by both egg and sperm quality and by the age of the woman. Embryo quality was independent of the above factors but was also critical for successful implantation.

Comparison between stimulated in-vitro fertilization and stimulated intrauterine insemination for the treatment of unexplained and mild male factor infertility.

A prospective trial was undertaken to evaluate the efficacy of stimulated in-vitro fertilization (SIVF) and stimulated intrauterine insemination (SIUI) in couples with unexplained and mild male factor infertility. In all, 80 couples were allocated to treatment with SIVF or SIUI, both treatments following the same protocol [clomiphene citrate and follicle stimulating hormone (FSH) injection], except that higher doses of FSH were used in the SIVF treatment cycles. Initially, 41 couples were allocated to and started treatment with SIVF but eight cases were eventually converted to SIUI because of under-response. Similarly, although 39 couples were initially allocated to SIUI treatment, five of these converted to SIVF because of over-response. The treatment cycles that were converted either to SIUI or to SIVF were not considered as treatment failures but as treatment changes and so were included in the analyses. Of the final 38 SIVF cycles, four were cancelled (dysfunctional response), failed fertilization occurred in five cycles and 29 subjects reached embryo transfer. There were two biochemical pregnancies [positive human chorionic gonadotrophin (HCG) only], two clinical abortions and seven live births. Of the final 42 SIUI cycles, only two were cancelled, insemination being performed in the remaining 40 cases. The result was one clinical abortion, three ectopics and eight live births. The proportion of cycles with positive HCG was identical (28.9% per cycle treated for SIVF and 28.6% for SIUI) and the livebirth rates were also not different (18.4% per cycle treated for SIVF and 19.0% for SIUI). The cost per maternity of SIUI was approximately half that of SIVF (Pounds Sterling 1923 versus Pounds Sterling 4611) and so we conclude that, as SIUI had an efficacy that was not significantly different from SIVF (using similar protocols) but was more cost-effective, it must be considered the more appropriate form of management for the treatment of unexplained and mild male factor infertility. Indeed, it is hard to justify the routine use of IVF, as a first approach, in unexplained infertility.

The influence of Vero cell culture on human embryo development and chorionic gonadotrophin production in vitro.

Co-culture of human embryos with cell layers has generally shown that blastocyst formation rates are improved compared to routine culture in medium alone. In order to assess this further, we have additionally classified resulting blastocysts according to their morphology and secretion of human chorionic gonadotrophin (HCG). A total of 70 supernumerary human embryos from 15 patients were divided equally and randomly between two culture conditions: (i) co-culture with Vero cells; and (ii) culture in our routine medium. Embryo development and morphology were recorded for up to 14 days in culture. The results showed that embryos on Vero cells had a significantly higher blastocyst formation rate (P < 0.02) by or on day 6 of development than those in routine culture medium alone (77 and 46% respectively). For HCG analysis, the culture medium was changed in both culture systems on days 5, 7, 9, 12 and 14 of embryo development and analysed. Most embryos began to produce HCG between days 7 and 9, with HCG secretion being significantly higher from embryos on Vero cells between days 9 and 12 than from embryos in routine culture (P < 0.03). The morphology of the blastocysts obtained was related to their ability to hatch and produce HCG but was not significantly better for one type of culture system than for the other.

The human ovarian granulosa cell: a stereological approach.

The human ovarian granulosa cell is perhaps the most widely studied endocrine cell, but little quantitative structural information exists for this cell. In the present study new and traditional stereological probes have been employed to provide quantitative structural information on these functionally important cells. Granulosa cells were obtained from follicular aspirations from 10 women during in vitro fertilisation procedures. Initially 2 methods were used to estimate the mean nuclear volume of these cells: the mean number weighted nuclear volume was estimated by the Selector and the mean volume weighted nuclear volume by the point sampled intercept method. It was found that the difference between the 2 volume estimates was only 8.5%. The volume weighted mean nuclear volume was used as an estimate of nuclear volume. This was subsequently corrected (taking the percentage difference as the empirical bias) and combined with fractional cell volumes (Vv) to produce estimates of cell, mitochondrial, lipid and nucleolar volume. The proportion of the cell occupied by the nucleus had a remarkably low interindividual variation (CV = 7.6%). The proportion of the nucleus occupied by euchromatin also had a striking low variation (CV < 6%). All other cellular parameters had CVs of less than 35%. The lipid composition of these cells showed the greatest interindividual variability, with a CV of 42% for relative and 54% for absolute volume. The present study outlines a simple protocol for the quantitation of granulosa cell structure using new unbiased stereological probes and providing baseline structural information.

Folliculocentesis: a novel research technique to investigate the intrafollicular endocrine microenvironment.

During development of the dominant follicle, the avascular granulosa cells and oocyte are exposed to the follicular fluid endocrine microenvironment. An alteration in the endocrine characteristics of follicular fluid affects follicular steroidogenesis, oocyte maturation, ovulation and subsequent corpus luteum function. In-vitro studies on pooled follicular fluid from ovarian specimens lacked temporal precision between menstrual and follicular endocrine events. We have established a new technique, termed folliculocentesis (FC), to sample follicular fluid from the dominant ovarian follicle without compromising its growth or function during the mid- to late follicular phase. A total of 38 subjects with regular ovulatory cycles each underwent two identical cycles of hormone and follicle growth monitoring: one cycle served as the control, and FC was performed during the second cycle. During all cycles, plasma luteinizing hormone (LH), oestradiol and ultrasound monitoring of follicle growth were commenced on day 7 and continued until after ovulation. During FC cycles, 200 microliters of follicular fluid were aspirated from the dominant follicle using transvaginal ultrasound guidance when the follicle diameter reached > or = 10 mm. Six subjects were excluded from the study because of incomplete or invalid endocrine data. In all, 32 subjects completed both the FC and control cycles. The follicle growth pattern, maximum follicle diameter, plasma oestradiol, oestradiol peak, plasma LH, LH surge and follicular phase length were similar during FC and control cycles. A total of 50 valid follicular fluid samples were obtained when the dominant follicle was sampled once, twice or three times during the same cycle and from the same follicle in 15, 16 and one subjects respectively. The follicular fluid samples contained steroid concentrations consistent with those of the mid- to late follicular phase. We conclude that the FC procedure is safe, easy to perform and does not affect follicle growth or hormone dynamics. Analysis of the follicular fluid samples is expected to provide us with valuable in-vivo information about ovarian endocrinology.

Comparison of pyruvate uptake by embryos derived from conception and non-conception natural cycles.

The uptake of pyruvate by human embryos derived from natural cycles in the first 24 h following fertilization was examined. Since only one egg was obtained and therefore only one embryo transferred to the woman, it was possible to relate pyruvate consumption by a particular embryo to the outcome of that cycle (pregnancy or no pregnancy). The results showed that embryos have a wide range of pyruvate uptake values (2-53 pmol/embryo/h) but that this variation was reduced significantly to an intermediate range of values in those embryos that were able to implant (10-30 pmol/embryo/h). An association was found between embryo morphology and pyruvate consumption. Morphologically good embryos were more likely to implant if they demonstrated an intermediate pyruvate uptake. However, poor embryos did not implant even if they had a pyruvate uptake of 10-30 pmol/embryo/h. No relationship was found between the type of infertility and pyruvate consumption of individual embryos. It is suggested that the ability of an embryo to implant is multifactorial and that both morphology and pyruvate uptake may be factors.

Embryonic human chorionic gonadotropin secretion and hatching: poor correlation with cleavage rate and morphological assessment during preimplantation development in vitro.

Of 593 bipronucleate eggs allowed to develop in vitro, 275 (46%) achieved the blastocyst stage and beyond, 124 (21%) initiated hatching, but only 49 (8%) fully hatched. About half of the pre-embryos (48%) which developed to these more advanced stages were incapable of secreting significant amounts (> 200 microIU) of cumulative human chorionic gonadotropin (HCG) up to day 14. HCG production does not appear to begin until the expanded stage and is independent of hatching. Assessing cleavage rate through successive stages and morphological grades up to the 8-cell stage had little bearing on the ability of a pre-embryo to hatch or secrete HCG. Progression through the stages of preimplantation development in vitro does not always appear to be accompanied by the necessary biochemical stages. If only 46% of pre-embryos with two pronuclei are capable of achieving the blastocyst stage, and of these only 52% are capable of secreting HCG, then it follows that only 24% of the original bipronucleate pre-embryos in vitro can be considered anatomically and biochemically competent. However, this is only applicable for pre-embryos not transferred or frozen, and is thus subject to a selection bias. Inability to detect HCG in vitro is not conclusive proof that a pre-embryo is developmentally incompetent. Similarly failure to hatch in vitro may not be taken as definitive evidence that hatching would have failed had fertilization and development been completed in vivo. Nevertheless, if pre-embryonic development in vitro is similar to that in vivo, this may be a contributory factor in the low pregnancy rates following in-vitro fertilization treatment.

Hypothalamic-pituitary ageing: progressive increase in FSH and LH concentrations throughout the reproductive life in regularly menstruating women.

OBJECTIVE: Reproductive ageing is associated with reduced fertility and endocrine changes that become more pronounced during the perimenopausal period. We aimed to assess changes in gonadotrophin concentrations and the onset of these changes during the reproductive life prior to the perimenopause. SUBJECTS: Ovarian and pituitary hormones were measured and follicle growth monitored in 500 regularly cycling infertile women aged 20-44 years. MEASUREMENTS: Serum levels of FSH and LH were determined during the follicular phase and ultrasonography was used to monitor follicle growth and ovulation. The luteal phase was assessed by salivary progesterone measurements. Changes in basal FSH and LH with age during ovulatory cycles were assessed. RESULTS: There was a significant progressive increase in FSH levels as early as age 29-30 years which was continued throughout the 30s and became more marked in the early 40s. LH levels showed significant increase at the age of 35-36 years which was maintained till the age of 40 years and followed by a further increase in women aged > 40 years. CONCLUSION: An increase in FSH and LH concentrations can be detected in women with regular ovulatory cycles quite early during the reproductive life. The increase in basal FSH (and later LH) may represent the earliest endocrine marker of reproductive ageing. These age-related increases in FSH and LH can be used as hormonal markers to counsel patients as to the likelihood of their reproductive potential.

Folliculogenesis--the natural way.

Natural cycle IVF (NIVF) arose from a wish to understand intrafollicular events in couples with unexplained infertility. Single follicle aspiration required unusual technical skill and a precise understanding of the endocrinology in the ostensibly normal cycle. The application of NIVF to all candidates for assisted conception resulted in a low delivery rate. However once data had accumulated it became apparent that age, follicular phase FSH concentrations and other endocrine abnormalities were associated with high failure rates. The concept of using NIVF as a preliminary screening cycle arose. By early elimination of some candidates and selective inclusion of others a highly cost effective regime can be developed. Taking delivery rates into account the cost per maternity is only half that of stimulated IVF. Using clear cut algorithms for the investigation of different categories of infertility the place of NIVF can be defined. Current UK discussions relate to exclusions from access to IVF. Biological exclusions such as age could further enhance the cost effectiveness of NIVF. When NIVF can contribute to at least 50% of cycles in an assisted conception programme it has the potential to have a major economic impact.