Fractured zona oocytes in in-vitro fertilization cycles stimulated with gonadotrophin-releasing hormone analogue and human menopausal gonadotrophin

In order to assess the possible influence of gonadotrophinreleasinghormone analogue and human menopausal gonadotrophin on the occurrenceof fractured zona oocytes (FZOs) in in-vitro fertilization (IVF)treatment cycles, we analysed 267 consecutive cycles in 199patients. In 87 cycles, at least one fractured zona oocyte wasrecovered, and in 180 cycles only intact zona oocytes (IZOs)were recovered. FZOs represented 5.8% of all oocytes retrievedand 14.8% when only cycles with FZOs were considered. Serumoestradiol concentrations were significantly higher at day –3and day –2 (P < 0.02) in cycles yielding at least onefractured zona oocyte compared to IZO cycles (day 0 = retrievalday), and there was a higher incidence of G terminal patternof oestradiol curve (P < 0.01) in cycles with FZOs. The meannumbers of all oocytes retrieved and of mature oocytes weresignificantly higher in FZO than in IZO cycles (P < 0.001).The fertilization rate of mature oocytes was significantly reduced(P < 0.05) in cycles with one or more oocytes with fracturedzonae. There was no significant difference in the number ofembryos transferred, pregnancy and abortion rates in both groups.We conclude that although the occurrence of fractured zona oocytesis a frequent event, it does not affect the overall resultsof our IVF programme. Zona pellucida fragility may be the resultof over-maturation of some oocytes.     

Effect of gonadotrophin-releasing hormone and related analogue on human luteal cell function in vitro

The possible direct effect of gonadotrophin-releasing hormone(GnRH) and GnRH agonist (GnRH-A; buserelin) on basal and humanchorionic gonadotrophin (HCG)-stimulated progesterone (P) andcyclic AMP (cAMP) production by cultured human luteal cellswas examined. Luteal cells from the early or mid-luteal phasewere incubated in long-term cultures. They responded to HCGstimulation with a 2- to 3-fold increase in P production anda 2-fold increase in cAMP production. The addition of GnRH (10^–7and 10^–5 M) or GnRH-A (10^–7 and 10^–5 M) tothe medium had no effect on either basal or HCG-stimulated secretion.These results indicate that both GnRH and GnRH-A have no directeffect on human luteal steroidogenesis in vitro.     

The synergistic effects of clomiphene citrate and human menopausal gonadotrophin in the folliculogenesis of stimulated cycles as assessed by the gonadotrophin-releasing hormone antagonist Nal-Glu.

Clomiphene citrate (CC), alone or in combination with exogenous gonadotrophins, has been widely used in ovulation induction. CC promotes endogenous release of gonadotrophins, yet when used in combination with exogenous gonadotrophins, its contribution to folliculogenesis is difficult to assess. In order to determine the contribution of CC-induced endogenous gonadotrophin production to the overall ovarian stimulation in cycles treated with CC/human menopausal gonadotrophin (HMG), Nal-Glu, a gonadotrophin-releasing hormone (GnRH) antagonist was administered. Fertile women (n = 10) undergoing ovarian stimulation and oocyte aspiration for the sole purpose of gamete donation were studied. Five women received CC (100 mg daily for 5 days) in conjunction with pure follicle stimulating hormone (FSH) 150 IU daily. Five women received HMG alone. Nal-Glu (50 micrograms/kg/day) was administered intramuscularly to both groups when the leading follicles reached a mean diameter of 16 mm. Human chorionic gonadotrophin (HCG) 10,000 IU was given when the largest follicles reached a mean diameter of 20-22 mm. A significant fall in serum oestradiol levels was observed in women given CC/FSH (37.9 +/- 7.3%) within the first 24 h of Nal-Glu administration. Serum luteinizing hormone (LH) decreased greater than 20% within 24 h of Nal-Glu administration and remained low throughout the rest of the treatment. No decrease in oestradiol levels was noted in cycles receiving HMG alone. With supplemental FSH, falling oestradiol levels in CC/FSH cycles rebounded and continued to rise until the day after HCG administration. Despite a drop in oestradiol in CC/FSH cycles, the aspirated oocytes exhibited no untoward effects. The fertilization and cleavage rates were similar, and pregnancies occurred in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)     

Endocrinology: Human chorionic gonadotrophin is a better luteal support than progesterone in ultrashort gonadotrophin-releasing hormone agonist/menotrophin in-vitro fertilization cycles

In an attempt to determine the best luteal support in in-vitrofertilization (IVF) cycles treated with gonadotrophin-releasinghormone agonist (GnRHa) and human menopausal gonadotrophin (HMG)by the ultrashort protocol, 60 patients were prospectively randomizedfor either i.m. progesterone or human chorionic gonadotrophin(HCG) luteal support. The two groups did not differ in the meannumber of oocytes retrieved and embryos replaced, nor in themean age of the patients and the amount of HMG used. HCG maintainedhigher levels of oestradiol and progesterone during the lutealphase. Conception rate was significantly higher in the HCG group.We conclude that HCG is superior to i.m. progesterone as lutealsupport in IVF cycles in which GnRHa is used in the ultrashortprotocol.     

Comparison of luteal phase profile in gonadotrophin stimulated cycles with or without a gonadotrophin-releasing hormone antagonist.

BACKGROUND: The aim of our study was to explore luteal phase hormone profiles in gonadotrophin-stimulated cycles with or without gonadotrophin-releasing hormone (GnRH) antagonist therapy during intrauterine insemination (IUI). Forty-one infertile couples were recruited in this randomized clinical study. METHODS: The 19 patients included in group A were treated for 21 cycles with recombinant FSH 150 IU/day starting from day 3 of the cycle and with the GnRH antagonist cetrorelix at the dose of 0.25 mg/day starting from the day in which a follicle with a mean diameter of > or =14 mm was seen at ultrasound scan. Cetrorelix was administered until human chorionic gonadotrophin (HCG) administration. The 22 patients included in group B were administered recombinant FSH alone at the same dosage for 27 cycles. RESULTS: The two treatment groups showed a similar increase in progesterone concentration during the luteal phase. In the mid-luteal phase (day 6 after HCG), oestradiol concentrations in group B were significantly higher compared with group A (P < 0.05) but the oestradiol:progesterone ratio was similar in the two groups. Serum LH was completely suppressed during the follicular phase only in group A, concomitantly with GnRH antagonist administration. A total of six pregnancies, all ongoing, were achieved (14.3% per patient and 12.2% per cycle), equally distributed in group A and in group B. CONCLUSION: GnRH antagonists can be safely administered in gonadotrophin-stimulated IUI cycles without luteal phase supplementation because no deleterious effects of GnRH antagonist administration were noted on luteal progesterone concentration or on the duration of the luteal phase.     

The effect of luteal support with human chorionic gonadotrophin or progesterone on the daily progesterone profile after different types of ovarian stimulation.

Attempts have been made to increase the low pregnancy rate in in-vitro fertilization (IVF) cycles by luteal phase support with progesterone or human chorionic gonadotrophin (HCG). Previously, this practice has been inconsistent and the results unclear. The detailed effect of support on the progesterone profile in the luteal phase was assessed by daily salivary progesterone measurements in non-conception IVF cycles. The comparison of HCG and progesterone support in two different stimulation protocols showed that the profile of luteal progesterone concentrations was similar in control cycles and those supported with a vaginal progesterone suppository, showing an early decrease by the fourth luteal day. In cycles supported with multiple doses of HCG, the progesterone profile was normal but slightly increased up to the 9th luteal day subsequently falling to basal levels by the fourteenth luteal day.     

The efficacy of short-term gonadotrophin-releasing hormone agonists versus human chorionic gonadotrophin to enable oocyte release in gonadotrophin stimulated cycles

One of the reasons for failure to conceive following human menopausalgonadotrophin (HMG) therapy may be due to non-release of oocytesfrom the follicles. We hypothesized that by using a gonadotrophin-releasinghormone agonist (GnRHa) for a short duration, endogenous releaseof luteinizing hormone and follicle stimulating hormone mayenable oocyte release to occur, similar or superior to the effectof human chorionic gonadotrophin (HCG). This study attemptedto compare the efficacy of HCG versus the GnRHa leuprolide acetateto release oocytes and achieve pregnancies and to compare theeffectiveness of leuprolide acetate versus a combination ofHCG with HMG to release oocytes. Unfortunately due to lack ofprior data, many patients preferred to reject leuprolide acetatein favour of HCG, resulting in three times as many patientsbeing treated with HCG in cycle 1; 78.2% of oocytes were releasedfollowing leuprolide acetate versus only 55.7% with HCG. Interestingly,87.5% of those females in whom oocyte release failed in cycle1 with HCG did indeed release with leuprolide acetate in cycle2, but none of these previous failures released with HCG incycle 2. Pregnancy rates were equal in those women releasingoocytes, whether treated with HCG or leuprolide acetate. Thesepreliminary data justify a larger randomized study.     

Regression of endometrial hyperplasia after treatment with the gonadotrophin-releasing hormone analogue triptorelin: a prospective study

Endometrial hyperplasia is thought to be caused by the prolonged, unopposed oestrogenic stimulation of the endometrium. The regression of hyperplastic back to normal endometrium is the main purpose of any conservative treatment in order to prevent development of adenocarcinoma. The aim of this study was to evaluate the regression of hyperplastic to normal endometrium in patients with various forms of endometrial hyperplasia after treatment with the gonadotrophin-releasing hormone analogue (GnRHa) triptorelin for 6 months. Fifty-six patients with endometrial hyperplasia were enrolled in this trial; 39 patients (group I) presented simple hyperplasia, 14 (group II) complex hyperplasia and three (group III) atypical complex hyperplasia. All patients were treated with triptorelin for 6 months. Bleeding control during treatment was excellent. A post-treatment curettage for estimation of endometrial histology was performed on 54 out of 56 patients 100.1 +/- 44.7 days after the last triptorelin dose, following the restoration of pituitary function. Regression of hyperplastic to normal endometrium was observed in 32 (86.5%) out of 37 patients in group I and in 12 (85.7%) out of 14 in group II. Persistence of simple hyperplasia was found in five (14.5%) out of 37 patients in group I. Persistence of complex hyperplasia was found in 1 (7.1%) out of 14 patients and progression to atypical complex hyperplasia in another one (7.1%) woman in group II. In some of these cases, the presence of risk factors such as obesity, diabetes mellitus and ovulatory disturbances may contribute to the disease persistence despite therapy. On the other hand, in group III, none of the three patients had normal post-treatment endometrial histology. It seems, therefore, that in cases of endometrial hyperplasia without atypia, the administration of the GnRHa triptorelin is associated with high regression rates to normal endometrium. Conversely, the presence of atypia seems to be a poor prognostic factor. Treatment tolerance and bleeding control during therapy is excellent.     

EndocrinologyHormonal profile during the follicular phase in cycles stimulated with a combination of human menopausal gonadotrophin and gonadotrophin-releasing hormone antagonist (Cetrorelix)

A third-generation gonadotrophin-releasing hormone antagonist(Cetrorelix) was used during ovarian stimulation in 32 patientsundergoing assisted reproduction, in order to prevent the prematureluteinizing hormone (LH) surge. In all patients, ovarian stimulationwas carried out with two or three ampoules of human menopausalgonadotrophin (HMG), starting on day 2 of the menstrual cycle.In addition, 0.5 mg of Cetrorelix was administered daily fromday 6 of HMG treatment until the day of ovulation inductionby human chorionic gonadotrophin (HCG). A significant drop inplasma LH concentration was observed within a few hours of thefirst administration of Cetrorelix (P<0.005). Moreover, noLH surge was detected at any point in the treatment period inany of the 32 patients. A mean oestradiol concentration of 2122±935ng/1 was observed on the day of the HCG administration, indicatingnormal folliculogenesis. Like LH, progesterone concentrationalso dropped within a few hours of the first administrationof Cetrorelix (P< 0.005). A 0.5 mg daily dose of Cetrorelixprevented a premature LH surge in all the 32 patients treated.     

Endocrinology: Ultrasonic control without hormone determination for ovulation induction in in-vitro fertilization/embryo transfer with gonadotrophin-releasing hormone analogue and human menopausal gonadotrophin

A total of 114 patients admitted to an in-vitro fertilization-embryotransfer programme for the first time, were randomly assignedto the study group or controls. Gonadotrophinreleasing hormoneanalogue (GnRHa) and human menopausal gonadotrophin (HMG) wereused for ovulation induction. The study patients were followedup merely by ultrasonography and the controls by ultrasonographyand serum determinations of oestradiol, progesterone and luteinizinghormone (LH). There was no significant difference in the durationand total amount of HMG used for ovulation induction (10.9 versus11.5 days and 34.8 versus 37.9 ampoules, respectively). Thenumber of oocytes retrieved (11.7 versus 13.4) and the numbersof embryos replaced (2.6 versus 2.8) and cryopreserved (1.9versus 3.3) were also similar. Pregnancy rates were similar.Pregnancy rate per ovum retrieval was 22.2 versus 25% and perembryo transfer 27.2 versus 26.5%. Oestradiol patterns werealso similar. The rate and severity of ovarian hyperstimulationsyndrome were virtually identical. We conclude that ‘ultrasound-only’monitoring of ovulation induction in IVF cycles treated by GnRHa-HMGin the long protocol is as effective and safe as the conventionalultrasound and hormone determination, but far simpler, swifterand more cost-effective     

Triggering of ovulation in human menopausal gonadotrophin-stimulated cycles: comparison between intravenously administered gonadotrophin-releasing hormone (100 and 500 {micro}g), GnRH agonist (buserelin, 500 {micro}g) and human chorionic gonadotrophin (10 000 IU)

We studied the peri-ovulatory and luteal phases in 38 humanmenopausal gonadotrophin (HMG)-stimulated cycles, in which ovulationwas triggered with four different i.v. bolus ovulation triggers:100 µg gonadotrophin-releasing hormone (GnRH; group A,n = 9), 500 µg GnRH agonist (GnRHa; group B, n = 10),10 000IU human chorionic gonadotrophin (HCG; group C, n = 10)and 500 µg GnRH (group D, n = 9). Endogenous luteinizinghormone (LH) surges occurred in all cycles of groups A, B andD. The rise was slowest but highest in group B (P < 0.0001)and lowest in group A. Although the t₀ serum oestradiol valueswere similar in all groups, day +8 oestradiol and day +4 and+8 progesterone concentrations were higher in group C (P <0.05). At day +4 and +8, serum LH concentrations were lowest(P < 0.01) but follicle stimulating hormone (FSH) concentrationswere higher. Clinically, day +8 luteal scores showed a moreconspicuous degree of ovarian hyperstimulation in the HCG group(P = 0.0292). Luteal insufficiency, defined as cycles with progesteroneconcentrations of <8 ng/ml, occurred much more frequentlyin groups A, B and D than in group C (day +4: P < 0.0003;day +8: P < 0.0001), despite progesterone supplementation.Three pregnancies (one in group C and two in group D) and onemoderate case of ovarian hyperstimulation syndrome (OHSS) (ina non-conceptional group D cycle) occurred. These findings showthat (i) ovulation occurs and pregnancy can be achieved followingan endogenous LH surge induced by GnRH and its agonists, (ii)a high frequency of luteal insufficiency occurs in such cycleseven with luteal supplementation and (iii) OHSS cannot be totallyprevented by this approach, although cycles with an endogenousLH surge in general result in fewer subclinical signs of ovarianhyperstimulation.     

Human menopausal gonadotrophin increases pregnancy rate in comparison with clomiphene citrate during replacement cycles of frozen/thawed pronucleate ova

In a prospective randomized study, the effect of two ovulationinduction regimens on implantation rate of frozen/thawed pronucleateova was investigated. Patients received either human menopausalgonadotrophin (HMG) or clomiphene/HMG. Ovulation induction wasdone on an individual basis using ultrasound and plasma 17-oestradiolconcentrations. Ovulation was induced with human chorionic gonadotrophin(HCG) when the leading follicle reached a diameter of 18 mm.Pronucleate ova had been frozen using the slow-freezing methodof Lassalle et al. (1985) (Fertil. Steril., 44, 645–651)and were thawed in synchrony with the age of the endometrium.Both groups of patients were comparable for age, indicationfor in-vitro fertilization, pre-ovulatory 17-oestradiol concentration,number of large follicles and number and quality of embryostransferred. The only difference found was that HCG was administered1 day earlier in the HMG group compared to the clomiphene/HMGgroup (P< 0.01). Using univariate analysis, the pregnancyrate was higher in patients stimulated with HMG alone comparedto those stimulated with clomipheneöHMG (27 versus 15%respectively; P < 0.03), when HCG was administered laterin the menstrual cycle (P < 0.01) and when more and betterquality embryos were transferred (P < 0.01). Using multivariateregression analysis, the influence of the stimulation on pregnancyrate was even more pronounced (P < 0.01) when the day ofHCG administration and the number and quality embryos transferredwere taken into account. Therefore, we conclude that HMG aloneincreases pregnancy rate compared to clomiphene/HMG during replacementcycles of frozen/thawed pronucleate ova. These data suggestthat HMG results in a better endometrium receptivity for embryos.This could be important not only for embryo replacement cyclesbut also for ovulation induction in general.     

Steroid receptor expression in late follicular phase endometrium in GnRH antagonist IVF cycles is already altered, indicating initiation of early luteal phase transformation in the absence of secretory changes

BACKGROUND: Ovarian stimulation for IVF profoundly alters the early luteal phase endometrial development. It has been hypothesized that this process has already started in the late follicular phase, as the endometrium has already been exposed to high steroid concentrations since that phase. The aim of the present study was to prospectively investigate the effect of multi-follicular ovarian stimulation for IVF on the late follicular phase endometrium histology and the expression of estrogen receptor (ER) and progesterone receptor (PR). METHODS: In a cross-over study, 11 infertile women with normal ovulatory function, participating in an IVF programme and treated with GnRH antagonist/recombinant FSH ovarian stimulation, were enrolled in the study. Endometrial biopsies were taken in a natural cycle on the day of the onset of the surge of the LH, and in a subsequent stimulation cycle on the day of hCG administration for final oocyte maturation. Endometrial histological dating was carried out according to Noyes' criteria. Immunohistochemistry was performed, using commercially available antibodies for ER and PR endometrial expression. The immunohistochemical signal was recorded in 1000 epithelial cells in each compartment (glands and stroma). Endometrial expression for each of the two receptors was graded on a scale of 0-3, based on the intensity of nuclear staining. Then a score range between 0 and 3000 was recorded, and expressed as a mean score per 1000 stroma or glandular cells per sample (range: 0-3). RESULTS: Histological examination of biopsies both in natural and stimulated cycles showed no secretory changes. However, in stimulated cycles, PR expression was significantly up-regulated compared to natural cycles in both glands (1.67 versus 1.34, P < 0.05) and stroma (1.98 versus 1.62, P < 0.05), whereas ER was down-regulated in glands (1.15 versus 1.43, P < 0.05). In IVF cycles, the progesterone measurements, although within normal values (range 0.8-1.4 microg/l), were significantly higher than in natural cycles (0.99 vs 0.63 microg/l, respectively, P = 0.008). An ongoing pregnancy rate of 37.5% was achieved in the stimulated cycles. DISCUSSION: Although the current study found no early secretory transformation in stimulated endometria before hCG administration, the ER and PR expression in these endometria is similar to the one described during the first days of the luteal phase in natural cycles. Supraphysiological concentrations of estradiol and subtle progesterone rises in the late follicular phase might be responsible for this modulated steroid receptor profile. This phenomenon indicates accentuated maturation of the endometrium in IVF cycles from the pre-ovulatory phase onwards.     

The use of a short regimen of buserelin, a gonadotrophin-releasing hormone agonist, and human menopausal gonadotrophin in assisted conception cycles

The outcome of in-vitro fertilization treatment using buserelin, an agonist of luteinizing hormone releasing hormone, given in a short stimulation regimen with human menopausal gonadotrophin (HMG), was compared with a conventional regimen including clomiphene citrate (CC). A total of 94 infertile women underwent cycles of treatment with intranasal buserelin, 500 micrograms daily from the first day of menstruation and also HMG daily from the third day. The same patients had previously undergone unsuccessful treatment cycles with CC and HMG. Overall, addition of buserelin resulted in fewer cycles being abandoned (10 versus 34%) and none of the patients ovulated prior to collection. The mean total dose of HMG required was increased by 74% in buserelin cycles. Significantly more oocytes were collected with buserelin treatment (mean 5.9 versus 4.4, P less than 0.01) and, thus, significantly more embryos were transferred (mean 2.3 versus 1.2, P less than 0.0001) although fertilization and cleavage rates were unchanged. Fifteen pregnancies were achieved, giving a clinical pregnancy rate of 22% per embryo transfer. These pregnancies resulted in 16 live births (7 singletons, 3 twins, 1 triplets). Four pregnancies failed before 14 weeks gestation. We conclude, therefore, that the substitution of buserelin for CC for ovarian stimulation in poor responders results in an improved outcome, both in terms of the number of oocytes collected and the pregnancy rate per treatment cycle.     

Endocrinology: Reduced implantation rate associated with a subtle rise in serum progesterone concentration during the follicular phase of cycles stimulated with a combination of a gonadotrophin-releasing hormone agonist and gonadotrophin

Our objective was to assess the effects of subtle increasesin serum progesterone concentration (1.0–2.0 ng/ml) onthe outcome of in-vitro fertilization (IVF), particularly onthe quality of embryos, during the follicular phase of cyclesstimulated with gonadotrophin-releasing hormone agonist (GnRHa)and human menopausal gonadotrophin (HMG). A total of 97 patientsunderwent 116 cycles of IVF and were stimulated with a combinationof HMG and GnRHa. They were divided into two groups: those witha subtle progesterone rise and those with no progesterone rise.The two groups were compared with respect to serum oestradiol,progesterone, immunoreactive luteinizing hormone (I-LH), bioactiveLH (B-LH), and results of IVF. The groups did not differ significantlyin mean age or in total dose of HMG received. On the day thathuman chorionic gonadotrophin was administered, concentrationsof oestradiol and progesterone were significantly higher inthe subtle progesterone rise cycles than in the no progesteronerise cycles. In the no progesterone rise cycles, the percentagesfor embryos beyond the 4-cell stage, grade 1 embryos, and implantationrates were significantly higher than those in subtle progesteronerise cycles. The combination of GnRHa and HMG eliminated anysignificant rise in serum I-LH or B-LH concentration duringthe follicular phase, but did not suppress the subtle rise inprogesterone. These results confirm our previous finding thata subtle progesterone rise adversely affects the outcome ofIVF. It is also suggested that a reduction in embryo qualitymay influence the lower rate of implantation in subtle progesteronerise cycles.     

Luteal phase and clinical outcome after human menopausal gonadotrophin/gonadotrophin releasing hormone antagonist treatment for ovarian stimulation in in-vitro fertilization/intracytoplasmic sperm injection cycles.

The luteal phase hormonal profile and the clinical outcome of 69 patients undergoing in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) after ovarian stimulation with human menopausal gonadotrophin (HMG) and the gonadotrophin-releasing hormone (GnRH) antagonist Cetrorelix were analysed. Twenty-four patients received Cetrorelix 0.5 mg (group I) while in 45 patients Cetrorelix 0.25 mg was administered (group II). Human chorionic gonadotrophin (HCG) was used as luteal support. Nine clinical pregnancies were obtained in group I (37.5%) and 12 in group II (26. 6%). These results were not significantly different. Serum progesterone and oestradiol concentrations did not differ between the two groups either in pregnant or non-pregnant patients. An expected decrease of the same hormones was observed 8 days after the pre-ovulatory HCG injection in non-pregnant women. With regard to serum luteinizing hormone concentrations, a decrease was observed 2 days after the pre-ovulatory HCG injection and was maintained at almost undetectable levels throughout the entire luteal phase in both conception and non-conception cycles of group I and group II. This study demonstrates that different doses of GnRH antagonist do not have any impact on the luteal phase of IVF/ICSI cycles when hormonal support is given.