The effect of age on the cyclical patterns of plasma LH, FSH, oestradiol and progesterone in women with regular menstrual cycles

Luteinizing hormone (LH), follicle-stimulating hormone (FSH),oestradiol and progesterone concentrations in plasma were obtaineddaily throughout the menstrual cycles of 94 regularly cyclingwomen, aged between 24 and 50 years. Although mean LH concentrationschanged little with advancing age, mean FSH concentrations weresignificantly (P< 0.001) elevated from the age of 39 years.FSH concentrations in the oldest women studied (48–50years) were 3-fold greater than in the younger controls (womenaged 23–35 years). LH concentrations rose slightly (P< 0.05) during the last 5 years only. The increase in FSHconcentration was not, however, uniform across the cycle, butwas confined predominantly to the mid-follicular and post-ovula-toryphases (i.e. those times in the normal menstrual cycle whencirculating inhibin concentrations appear to be minimal). Despitethe clear increases in FSH concentration, there was little alterationin the mean steroid profiles which remained within the normalfertile range throughout the last decade of reproductive life.The only exception to this was a small, transient, but significant(P< 0.05) decrease in pre-ovulatory oestradiol concentrationbetween the ages of 36 and 38 years, which was followed by atransient increase (P< 0.01) in oestradiol concentrationbetween 39 and 44 years. However, no corresponding significantchanges in mean progesterone concentrations were observed.     

Endocirnology: Comparison between prolactin, gonadotrophins and steroid hormones in serum and follicular fluid after stimulation with gonadotrophin-releasing hormone agonists and human menopausal gonadotrophin for an in-vitro fertilization programme

The inter-relationship between serum and follicular fluid prolactin,oestradiol, progesterone, follicle stimulating hormone (FSH),and luteinizing hormone (LH) in two groups of women was investigated.In group 1, 32 women were treated with gonadotrophin-releasinghormone agonist (GnRH-a) in a long term protocol and subsequentlystimulated with human menopausal gonadotrophin (HMG). In group2, 25 women were simultaneously stimulated with GnRH-a in ashort protocol with HMG. Follicular fluid was collected from54 follicles in group 1 and 47 follicles in group 2. Serum wasobtained on the day of human chorionic gonadotrophin (HCG) administration.Serum prolactin and oestradiol concentrations were significantlyhigher (P < 0.025 and P< 0.01, respectively) in group1 than in group 2. Serum LH (P < 0.005), FSH (P< 0.01)and progesterone (P < 0.025) were significantly lower ingroup 1 than in group 2. Follicular fluid prolactin was significantlyhigher (P < 0.005) in group 1. No differences were foundin follicular fluid progesterone and oestradiol. Follicularfluid LH was significantly lower (P < 0.005) in group 1.Serum prolactin correlated positively with oestradiol in bothgroups (P < 0.005 group 1; P < 0.02 group 2). No significantcorrelation was found between serum prolactin and LH in group1. We conclude that prolactin secretion is independent fromLH secretion. Hyperprolactinaemia, which is observed in womenstimulated with GnRH-a and HMG, is positively associated withincreased oestradiol.     

Melatonin and steroids in human pre-ovulatory follicular fluid: seasonal variations and granulosa cell steroid production

Follicular fluid samples were obtained from the largest pre-ovulatoryfollicle of 120 women undergoing in-vitro fertilization andwere examined for melatonin by enzyme-linked immunosorbent assayand the steroids oestradiol and progesterone by radioimmunoassay.The concentrations (mean ± SE) of melatonin (213.4 ±18.9 pmol/1) and progesterone (20.1 ± 1.1 µmol/l)in follicular fluid during the autumn and winter (dark) monthswere significantly higher than during the spring and summer(light) months, melatonin (138.4 ± 12.5 pmol/1) and progesterone(11.6 ± 0.8 µmol/l). By contrast, oestradiol concentrationswere significantly lower during the dark months than duringthe light months (264.7 ± 44.1 and 661.8 ± 55.1nmol/l respectively). There was a positive correlation betweenfollicular fluid melatonin and progesterone concentrations (r= 0.271, P < 0.05, n = 120) and a negative relationship betweenmelatonin and oestradiol (r = –0.254, P < 0.05, n =120). The effects of melatonin alone and in combination withhuman chorionic gonadotrophin (HCG) or follicle stimulatinghormone (FSH) on steroidogenesis by human granulosa cell culturewere also investigated. Melatonin had minimal effects on oestradiolor progesterone production by granulosa cells. Interestingly,the oestradiol response in culture appeared to be differentaccording to the time of the year when harvested. During thelight period oestradiol production was enhanced. Melatonin alsosynergized with HCG in increasing progesterone production ondays 6 and 7 after treatment during both light and dark periods.FSH stimulated oestradiol production by the cells on day 2 ofculture. Melatonin had no effect on FSH stimulation of oestradiolproduction. The results of this study suggest that melatoninmay be involved in the regulation of steroidogenesis by thehuman ovaries.     

Early follicular rise of serum progesterone concentration in response to a flare-up effect of gonadotrophin-releasing hormone agonist impairs follicular recruitment for in-vitro fertilization

A retrospective study of 150 cycles of in-vitro fertilization(IVF) was undertaken to determine the impact of elevated serumprogesterone in the early follicular phase of IVF cycles utilizinggonadotrophin-releasing hormone agonist (GnRHa) initiated inthe follicular phase. A total of 127 patients identified asbeing at risk for poor response to stimulation were treatedwith a flare-up protocol of GnRHa combined with high dose folliclestimulating hormone (FSH). Patients were excluded for severemale factor requiring micromanipulation. Patients were stimulatedwith GnRHa beginning on cycle day 2, and high dose FSH beginningon cycle day 3. Some 85% of the cycles exhibited a rise of serumprogesterone to a peak concentration of > 1.0 ng/ml (range,1.2–4.2 ng/ml) during cycle days 2–6. When comparedto cycles with no demonstrable progesterone rise, cycles witha rise were associated with a significantly decreased ovarianresponse: more ampoules of gonadotrophin were required (mean26.8 versus 22.6, P < 0.05), lower peak oestradiol concentrationwas reached (mean 774 pg/ml versus 1030; P < 0.05), and fewermature oocytes were harvested (mean 4.6 versus 7.5; P < 0.01).Among the different pregnancy outcomes (clinical pregnancy,no pregnancy, ongoing pregnancy, and miscarrige), there wereno significant differences detected in the early follicularprogesterone concentrations as measured by peak progesterone,progesterone area undre the curve (days 2–6), and dayof peak progesterone. The follicular phase initiation of GnRHascan result in significant elevations of serum progesterone inthe early follicular phase, which may impair follicular recruitmentand overall ovarian response.     

Alternate day and daily administration of GnRH antagonist may prevent premature luteinization to a similar extent during FSH treatment

BACKGROUND: This randomized controlled trial was designed toevaluate whether a GnRH antagonist given every other day couldprevent premature luteinization in women undergoing IVF/ICSItreatment. METHODS: A total of 73 women receiving ovulationstimulation IVF cycles with recombinant FSH were allocated randomlyon cycle day 7 to GnRH antagonist ganirelix in multiple doses(0.25 mg each), either daily (n = 37 women, group 1) or everyother day (n = 36 women, group 2) until the day of HCG administration.RESULTS: Serum FSH, LH, estradiol and progesterone values showedsimilar trends in the two groups. During FSH stimulation, 13(35%) of the women in group 1 had premature LH rises (10 IU/l)of which eight (22%) were after the start of antagonist administration.In group 2 there were 14 (39%) LH rises during FSH stimulationof which 10 (28%) were after the start of antagonist administration.Luteinization (serum progesterone >2 ng/ml) occurred in onlyone woman in each group overall (3%). A significantly smallertotal dose of the antagonist was used in group 2 than in group1 (P < 0.001). The study did not have power to evaluate differencesin total dose of FSH, number of oocytes recovered and clinicalpregnancy rate, all of which appeared similar in the two groups.CONCLUSIONS: Whether alternate day is as effective as dailyadministration of ganirelix in preventing premature luteinizationshould be addressed in a non-inferiority trial powered to evaluatelive birth rate.     

Endocrine composition of follicular fluid comparing human chorionic gonadotrophin to a gonadotrophin-releasing hormone agonist for ovulation induction

Concentrations of inhibin, oestradiol and progesterone weredetermined in pre-ovulatory follicular fluid from 16 women undergoingin-vitro fertilization and embryo transfer treatment. A prospectiverandomized design was used such that ovulation was induced ineight women with human chorionic gonadotrophin (HCG) (9000 IU),and in eight women with an endogenous surge of luteinizing hormone(LH) and follicle stimulating hormone (FSH) caused by a singleinjection of gonadotrophin-releasing hormone agonist (GnRHa).Inhibin was measured by an enzyme-linked immunosorbent assay,and oestradiol and progesterone were measured by radioimmunoassay.Concentrations of inhibin and progesterone are significantlyhigher in follicular fluids collected after ovulation inductionwith HCG compared with ovulation induction with GnRHa (P <0.001, P < 0.02, respectively). Concentrations of oestradiolwere similar in the two groups. This study shows that the methodby which ovulation is triggered significantly affects the micro-environmentof the oocyte just prior to ovulation. The results indicatethat HCG causes a prolonged luteotrophic effect well beforeovulation, compared to an endogenous surge of gonadotrophinscaused by GnRHa, and suggest that follicular maturation withan endogenous surge of gonadotrophins may be closer to the naturalcycle than those cycles in which HCG is administered for ovulationinduction. In addition, this study shows that the concentrationsof inhibin and progesterone in follicular fluid may be valuableparameters in assessing the midcycle LH surge requirements forinduction of ovulation.     

Ovary and Ovulation: Contralateral selection of dominant follicle favours pre-embryo development

Ovulation was studied using vaginosonography in a total of 410natural cycles of 123 women undergoing infertility treatment[267 intrauterine insemination (IUI) cycles of 103 women and143 in-vitro fertilization (IVF) cycles of 50 women]. None ofthe women received ovarian stimulation. Each follicle was measureddaily from 14 mm in diameter until formation of corpus luteumor oocyte retrieval. Contralateral ovulation as compared withthe preceding cycle occurred in 57% of the 410 cycles. Contralateralovulations occurred in 72% of cycles with a follicular phase<13 days. In cycles with a follicular phase of >14 days,ovulations occurred at random. The length of follicular phasein contralateral ovulation cycles (15.2 ± 3.2 days) wassignificantly (P < 0.05) shorter than that of ipsilateralovulation cycles (15.8 ± 2.8). During the 57% contralateralovulations in 143 IVF cycles, the rates of oocyte retrieval(89%), fertilization (69%), cleavage (90%) and embryo transfer(56%) were significantly higher than those of ipsilateral ovulations(69, 51, 64 and 23% respectively). The pregnancy rate of contralateralovulations (9%) was also higher, though not significantly, thanthat of ipsilateral ovulations (3%), although the pregnancyrates per transfer were similar (16 and 14% respectively). Thetotal pregnancy rate of both IUI and IVF was higher in contralateralthan in ipsilateral ovulation cycles (8.1 and 4.0% respectively).The dominant follicles in contralateral ovulation cycles showedsignificantly higher oestradiol/androstenedlone ratio (P <0.025) and oestradlol/testosterone + androstenedione ratio (P< 0.025), and lower androstenedione (P < 0.05) than thoseof ipsilateral ovulation cycles. There was no significant differencein oestradiol, progesterone and testosterone. These resultsindicate that the dominant follicles in contralateral ovulationcycles are healthier than those of ipsilateral ones. Local intra-ovarianfactors, e.g. from the corpus luteum, may negatively affectthe health of the dominant follicle and the enclosed oocyte.Therefore contralateral selection of the dominant follicle inthe succeeding cycle may favour pre-embryo development. Thechance of conceiving during a natural cycle may be affectedby the site of ovulation in the preceding cycle.     

Endocrinology: Daily measurements and in-vitro effects of human chorionic gonadotrophin in the early luteal phase

The purpose of the present study was to analyse daily measurementsof human chorionic gonadotrophin (HCG) in in-vitro fertilization(IVF) cycles and to reproduce the effects of HCG in vitro usinghuman granulosa—luteinized cells from the same patients.The study population consisted of nine women undergoing IVFbecause of tubal infertility in whom blood was drawn every 24h from the day of the ovulatory dose of HCG (10 000 IU) until6 days after ovum pick-up. Granulosa—luteal cells fromthe follicular aspirates were collected and cultured in vitroup to 6 days in the presence of increasing concentrations (0,0.01, 0.1, 1.0 and 100.0 IU/ml) of HCG. Serum progesterone andHCG in vivo as well as progesterone accumulation in vitro ondays 2, 4 and 6, were the main outcome measures. Maximum HCGconcentrations (0.25 IU/ml) were reached the day before ovumpick-up, and continuously decreased until day 6 after ovum retrieval.HCG did not stimulate progesterone production in vitro at anydose tested until day 6 after ovum pick-up. Then, 0.01 IU/mlresulted significantly (P < 0.05) stimulatory compared tocontrols, while 1.0 IU/ml was inhibitory (P < 0.05). It isconcluded that HCG supplementation in an IVF cycle is unnecessaryuntil day 6 after ovum pick-up. On day 6, progesterone productionis stimulated with very low concentrations of HCG.     

Serum luteinzing hormone pulsatility and intratesticular testosterone and oestradiol concentrations in idiopathic infertile men with high and normal fofficle stimulating hormone serum concentrations

The purpose of the study was to evaluate pulsatile luteinizinghormone (L release and intratesticular concentrations of testosteroneand oestradlol in infertile men, to determine if alterationsin gonadotrophin secretion are associated with changes in thetesticular concentrations of steroids. Patients with idiopathicoligo/azoospermia were divided into a high follicle stimulatinghormone (FSH) group (n=5) and a normal FSH group (n = 6). Bloodsamples were taken every 15 mm for 6 h to determine LH, FSH,testosterone, oestradiol, sex hormone binding globulin, bioactiveLH and bioavailable testosterone. The patients underwent a bilateraltesticular biopsy for histological assessment and to determinetestosterone and oestradiol concentrations. Serum measure mentswere compared with those of seven fertile men. The high FSHgroup had a higher concentration of serum UI and oestradiolthan normal men (P < 0.01) and showed a lower frequency ofLII pulses than the normal FSH group and control men (P <0.01). Intratesticular oestradiol was higher in the high FSHgroup (P < 0.001), with a lower testosterone/oestradlol ratio(P < 0.01). Patients showed a negative correlation betweenthe serum testosterone/LH ratio and FSH (r = -–0.75; P< 0.01) and a positive correlation between the testicularoestradiol concentration and serum FSH (r=0.86; P<0.01).The histopathological examination only showed a smaller tubediameter in the high FSll group (P < 0.05). These data seemto indicate that a higher intratesticular concentration of oestradiolwith a lower testosterone/oestradiol ratio in the high FSH groupcould have a deleterious effect on spermatogenesis.     

Implantation: Variations in concentrations of the major endometrial secretory proteins (placental protein 14 and insulin-like growth factor binding protein-1) in assisted conception regimes

We have previously shown that placental protein 14 (PP14) concentrationswere depressed in two pregnancies that followed down-regulationof the anterior pituitary and exogenous hormone support priorto a frozen—thawed embryo transfer. We now report on amore comprehensive series of pregnancies following this formof treatment, in-vitro fertilization (IVF) and natural cyclefrozen—thawed embryo transfer. Serum specimens were analysedfor PP14 and insulin-like growth factor binding protein-1 12days after embryo transfer and at 7 weeks gestation. At 12 daysafter embryo transfer, the mean serum PP14 concentrations inthe IVF and natural cycle were significantly higher in thosewho conceived than those who did not (82 versus 23 and 107 versus39 µg/l respectively, P < 0.001). Although the meanPP14 concentration in the hormone-supported pregnant patientswas higher than in the non-pregnant patients, this had not reachedstatistical significance 12 days after embryo transfer (49 versus31 µg/1). By 7 weeks gestation the PP14 concentrationsin the hormone-supported pregnant patients were significantlyhigher than in the non-pregnant patients (152 versus 31 µg/1,P < 0.001). However, the PP14 concentrations for hormone-supportedpregnant patients were significantly lower (P < 0.001) thanthose for pregnant IVF or natural cycle patients at 7 weeksgestation (152, 777 and 660 µg/l respectively). The PP14concentrations in the pregnant patients, although lower thanthose in IVF and natural cycle pregnancies, were higher thanthose previously reported in ovarian failure and Turner's syndromeovum donation cycles. Patients treated by down-regulation andexogenous hormones had significantly higher serum IGFBP-1 concentrationsthan IVF and natural cycle patients at 7 weeks gestation (P0.01); mean concentrations 107, 58 and 43 µg/l respectively).Elevated IGFBP-1 concentrations may influence the rise in PP14concentrations in these patients.     

Endocrinology: The development of functional ovarian cysts during pituitary down-regulation

This study investigated the development of functional ovariancysts during pituitary down-regulation prior to in-vitro fertilization(IVF), and identified 16 cases of cysts in 288 IVF cycles studied.Comparing the patients with functional ovarian cysts to theother 272 IVF cycles, there was no significant difference inage or incidence of endometriosis but significantly (P <0.01) more patients with cysts had ovulatory dysfunction. Theserum progesterone was <5.7 nmol/l in all 16 patients withcysts on day 4 of the IVF cycle, and in eight of these patientsthe serum progesterone was <5.7 nmol/l on the day buserelinwas commenced. In 10 of the 16 patients with cysts, serum oestradiolconcentrations remained elevated despite the prolonged use ofbuserelin, and the cysts were aspirated. The aspirate in allcases was clear without any suggestion of endometriosis. Thecyst aspirates had significantly lower progesterone (P <0.001), higher androstenedione (P < 0.01) and similar oestradiolconcentrations to 10 follicular fluid samples collected at thetime of oocyte retrieval. This study suggests that functionalovarian cysts may develop during pituitary down-regulation,and these cysts are follicular cysts rather than persistentcorpora lutea or endometriomata.     

Improved treatment for anovulation in polycystic ovarian disease utilizing the effect of progesterone on the inappropriate gonadotrophin release and clomiphene response

The treatment of anovulatory, clomiphene-resistant patientswith polycystic ovarian disease (PCOD) is difficult. Ten suchwomen were given progesterone, 50 mg/day i.m. for 5 days toachieve luteal phase concentrations. Immediately following progesteronetreatment, plasma concentrations of FSH were reduced in allpatients (P = 0.001) and seven of the 10 had reduced plasmaLH concentrations. Following the withdrawal bleeding these sevenall became responsive to clomiphene as shown by ovulation, andthree conceived after a single progesterone/clomiphene cycle.LH pulsatility, studied in five women over 4 h, before and immediatelyfollowing progesterone treatment, showed a slowing of the pulsefrequency (62 ± 26 min to 105 ± 51 min, P <0.05) and an increase in pulse amplitude (6 ± 1.9 IU/lto 16.7 ± 20 IU/l). The LH and FSH response to GnRH wasblunted by progesterone. It would thus appear that progesteronemodulates LH pulsatility and reduces pituitary sensitivity toGnRH, reducing LH levels and possibly inducing more FSH synthesisand storage, similar to its action in the normal ovulatory cycle.These changes provide a more favourable environment for ovulationinduction by clomiphene and we suggest that short-term progesteronetreatment may be utilized to improve the efficiency and resultsof clomiphene treatment in PCOD.     

Atrial natriuretic peptide, oestradiol and progesterone in women undergoing spontaneous and gonadotrophin-stimulated ovulatory cycles

The objective of this study was to examine the relationshipbetween the concentrations of oestradiol and progesterone onthe one hand and atrial natriuretic peptide (ANP) concentrationson the other, during the follicular and luteal phases of spontaneousand gonadotrophin-stimulated ovulatory menstrual cycles. A totalof 27 ovulatory women undergoing either a spontaneous (n = 9)or a gonadotrophin-stimulated (n = 18) cycle were selected forinclusion in this study. In comparison with spontaneous cycles,gonadotrophin-stimulated cycles had increased peak follicularoestradiol (mean ± SE; 937 ± 150 versus 195 ±18 pg/ml; P < 0.05) and midluteal progesterone (mean ± SE; 44.0 ± 7.4 versus 14.1 ± 2.4 ng/ml; P <0.05) concentrations. There were no differences in the circulatingANP concentrations between the follicular and luteal phasesof the menstrual cycle. Despite the increased oestradiol andprogesterone concentrations following gonadotrophin stimulation,no difference in ANP concentrations was seen between stimulatedand spontaneous cycles. There was no correlation between circulatingconcentrations of oestradiol, progesterone (at physiologicaland supraphysiological concentrations) and ANP throughout themenstrual cycle.     

Suppression of prolactin secretion during ovarian hyperstimulation is followed by elevated serum levels of endometrial protein PP14 in the late luteal phase

A double-blind placebo-controlled study on bromocriptine administrationduring days 2-12 of ovarian hyperstimulation for in-vitrofertilization(IVF) showed that, in bromocriptine cycles, levels of the endometrialprotein PP14 were higher in the late luteal phase. This wasverified both by calculating forward from the day of human chorionicgonadotrophin (HCG) administration and backward from the onsetof the next period. Bromocriptine had no effect on IVF performance.During bromocriptine treatment the serum prolactin levels declinedand serum oestradiol levels were higher on day 9 of the cycle.There was a positive correlation (r =0.55; P = 0.012) betweenthe serum oestradiol levels on day 9 and the PP14 levels ondays 22-23 of the cycle. No difference was found in the lutealphase progesterone levels between bromocriptine-and placebo-treatedcycles. These results suggest that low prolactin and/or highoestradiol levels during the follicular phase have an influenceon the subsequent secretory capacity of the endometrium as reflectedby secretion of a specific endometrial protein     

Placental and ovarian hormones in anembryonic pregnancy

The circulating levels of human chorionic gonadotrophin (HCG),pregnancy-associated plasma protein-A (PAPP-A), Schwangerschaftprotein 1 (SP-1), oestradiol and progesterone were measuredin 81 pregnant patients between 4 and 11 weeks gestation, followingin-vitro fertilization and embryo transfer. The patients weredivided as follows: singleton anembryonic pregnancies, n = 22;singleton pregnancies which spontaneously aborted followingthe demonstration of fetal heart activity, n = 7; and normalsingleton pregnancies, n = 52. The levels of all substancesmeasured were significantly reduced in women with anembryoniccompared to those with singleton pregnancies which proceededto term. The serum levels of SP-1, weeks 6–8 (P < 0.01);HCG, weeks 6–8 (P < 0.05); oestradiol, weeks 5–8(P < 0.05) and progesterone, weeks 6–8 (P < 0.05),were lower in anembryonic pregnancies than in those of pregnancieswhich spontaneously aborted. These differences may be a reflectionof the fact that miscarriage, after the demonstration of fetalheart activity, represents fetal demise at a later stage inpregnancy. In anembryonic pregnancies, significant associationswere found between HCG and both oestradiol and progesteronelevels from weeks 6 and 8, suggesting that in the absence ofan embryo, HCG is the prime determinant of steroid synthesisby the corpus luteum.     

Endocrinology: Progesterone alone versus progesterone combined with HCG as luteal support in GnRHa/HMG induced IVF cycles: a randomized clinical trial

Two different regimens of luteal support in gonadotrophin hormone-releasinghormone (GnRH) analoguefhuman menopausal gonadotrophin (GnRHa/HMG)-inducedin-vitro fertilization cycles (IVF) were compared in a randomizedclinical trial. After embryo transfer, either vaginal progesteronealone was administered (n=89, P group), or a combination ofvaginal progesterone and human chorionic gonadotrophin (n=87,P/HCG group). The primary aim of this study was to assess theeffect of the different regimens of luteal support on the pregnancyrate. The secondary aim was to compare oestradiol and progesteroneconcentrations in the luteal phase between the two groups, andassess their effect on the pregnancy rate. A clinical pregnancyrate of 15% was found in the P/HCG group in comparison with26% in the P group (odds ratio 0.49; 99% confidence interval:0.18–1.3). The luteal serum oestradiol and progesteronevalues in the P/HCG group were significantly higher when comparedwith the P group on the 6th, 9th and 12th day after oocyte retrieval(Wilcoxon P<0.001). In accordance with the high oestradiolconcentrations, more cases of ovarian hyperstimulation syndrome(OHSS) were found in the P/HCG group. Oestradiol values on the9th day after oocyte retrieval, presumably the day of implantation,appeared to be higher in women who did not become clinicallypregnant. We conclude that vaginal progesterone alone providessufficient luteal support in GnRHa/HMG induced IVF cycles. Thecombination of vaginal progesterone and HCG as luteal supportleads to significant high luteal oestradiol and progesteroneconcentrations. But a high concentration of oestradiol seemsto have a deleterious effect on the implantation process, resultingin a low pregnancy rate.     

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.     

Endocrinology: Growth hormone, oestradiol, progesterone and testosterone concentrations in follicular fluid after ovarian stimulation with various regimes for assisted reproduction

Follicular fluid samples and oocytes were obtained from 75 women(87 cycles), who participated in an assisted conception programme.Determinations of the concentration of oestradiol, progesterone,testosterone and growth hormone were performed in all follicularfluid samples. Patients were stimulated with the following regimes:group A (24 cycles, 94 samples), human menopausal gonadotrophin(HMG) (three ampoules/day) and human chorionic gonadotrophin(HCG); group B (23 cycles, 53 samples), HMG/HCG with prednisolone(7.5 mg/day) after cycle programming with oral contraceptives;group C (40 cycles, 60 samples), buserelin with HMG/HCG. Oestradiolconcentrations (mean ± SEM) were significantly higher(P < 0.05) in group A (320.1 ± 27.3 ng/ ml) and thoseof growth hormone in both groups A and C (3.8 ± 0.2 and3.2 ± 0.15 ng/ml, respectively), as compared to the othergroups, whereas progesterone and testosterone concentrationswere similar in all groups. The mean concentrations of oestradiol,progesterone, testosterone and growth hormone were significantlyhigher (P < 0.01) in follicular fluid with oocytes of intermediatematurity than with mature oocytes (382.5 ng/ml, 7847.5 ng/ml,1704.5 ng/dl and 3.7 ng/ml versus 217.8 ng/ml, 5488.4 ng/ml,1313.6 ng/dl and 2.7 ng/ml, respectively). On the other hand,only oestradiol concentrations were significantly higher infollicular fluid of fertilized compared to non-fertilized oocytes.Concentrations of the other hormones analysed, except growthhormone, were similar in follicular fluid from pregnant andnon-pregnant women after assisted reproduction. Growth hormone,on the other hand, was significantly lower (P < 0.05) infollicular fluid from pregnant compared to non-pregnant women(2.8 versus 3.5 ng/ml). It is concluded that intermediate maturityoocytes and oocytes which will be subsequently fertilized arefound in follicles with higher follicular fluid concentrationsof growth hormone and steroids. Moreover, oocytes leading topregnancy after in-vitro fertilization and embryo transfer arederived from follicles with lower growth hormone concentrationsin follicular fluid.     

The effect of human menopausal gonadotrophin and highly purified, urine-derived follicle stimulating hormone on the outcome of in-vitro fertilization in down-regulated normogonadotrophic women

It has been suggested that the luteinizing hormone (LH) activityof human menopausal gonadotrophin (HMG) preparations used forovarian stimulation in in-vitro fertilization (IVF) may haveadverse effects on reproductive outcome. In the present prospective,randomized trial of 218 infertile couples this notion was investigated.A total of 114 women were treated with Pergonal (HMG group)and 104 with Fertinorm HP (HP-FSH group). The two groups werecomparable with regard to duration of infertility, cause ofinfertility, age and number of previous IVF attempts and allhad normal basal gonadotrophin concentrations before treatmentwas started. A standard hormonal treatment consisting of pituitarydown-regulation with gonadotrophin-releasing hormone analogue(GnRHa) for 14 days starting on cycle day 21, followed by eitherHMG or highly purified follicle stimulating hormone (HP-FSH),three ampoules (225 IU) per day for 7 days, was used in allcases. The daily hormone dose was thereafter individualizedaccording to the ovarian response. A maximum of two pre-embryoswere transferred after 3 days of culture. Luteal support withprogesterone (300 mg per day intravaginally) was used in allcases. Serum concentrations of oestradiol, FSH and LH were measuredon days 1 and 8 of stimulation and on the day of oocyte retrieval.The mean number of days of stimulation, mean number of ampoulesof HMG or HP-FSH used, mean total motile sperm count on theday of oocyte retrieval and mean numbers of oocytes retrieved(13.4 versus 13.7) or pre-embryos transferred (1.8 versus 1.8)were similar for both groups. Significantly (P < 0.05) morecycles in the HP-FSH group (17 = 16%) were cancelled due tocomplete failure of fertilization than in the HMG group (7 =6%). The mean fertilization rate was significantly (P < 0.05)higher in the HMG group (56%) than in the HP-FSH group (50%),and significantly more transferable pre-embryos were obtainedin the HMG than in the HP-FSH group (mean: 4.0 versus 3.2; P< 0.01). Serum hormone concentrations were similar in thetwo groups on stimulation day 1, but differed significantlywith regard to FSH, LH and oestradiol on stimulation day 8.The clinical outcome was similar in the two groups, with anongoing pregnancy rate (>12 weeks of gestation) per startedcycle of 33% in the HMG group and 29% in the HP-FSH group. Theclinical abortion rates were similar(10 and 14%), and the implantationrate was 30% in each group. In conclusion, no detrimental effectof the LH activity of HMG on the clinical outcome of IVF inGnRHa down-regulated normogonadotrophic women was found. Tothe contrary, some beneficial effects of HMG on fertilizationrates and pre-embryo development as compared with HP-FSH weredemonstrated. These effects, as well as the differences in serumhormone concentrations during ovarian stimulation, may be causedby differences in LH content and/or in the composition of FSHisoforms of the HMG and HP-FSH preparations.     

Physiology: Enhanced sensitivity of the extrinsic coagulation system during ovarian stimulation for in-vitro fertilization

The tissue factor activity in blood monocytes was investigatedduring ovarian stimulation for in-vitro fertilization (IVF)in 13 women. Blood samples were taken prior to hormonal stimulation(days 2–3 of the menstrual cycle, median serum oestradiolconcentration 70 pmol/1) and the day after ovulation inductionwith human chorionic gonadotrophin (days 11–13, medianserum oestradiol concentration 6270 pmol/l). The tissue factoractivity in unstimulated monocytes and factor VII concentrationwere unchanged during the treatment. However, the tissue factoractivity in lipopolysaccharide-stimulated monocytes was on averagemore than twice as high after stimulation (P < 0.02). A positivecorrelation was found between the tissue factor activity andthe serum concentration of oestradiol (r = 0.514, P < 0.02).The tumour necrosis factor (TNF)- increased during ovarian stimulation(P = 0.05), and there was a positive correlation between thechange in TNF- and the change in tissue factor activity (r =0.663, P < 0.05). Our results indicate an enhanced sensitivityof the extrinsic coagulation system during IVF treatment sincemore tissue factor is available upon stimulation. It is suggestedthat this may be important in thrombotic situations. Furtherstudies are necessary to elucidate the mechanism behind thisresponse.