Medium-associated luteinization expressed as progesterone release in granulosa-luteal cells isolated from patients undergoing in-vitro fertilization.

The present study describes the effect of culture medium components on progesterone release from human granulosa-luteal cells isolated from patients undergoing in-vitro fertilization (IVF). Progesterone release was selectively measured as a central parameter of in-vitro luteinization, a process believed to decrease the success rate of IVF treatments. Ten different media of relevance to embryo culture were investigated for their effect on progesterone release in unstimulated granulosa cell cultures and in cultures stimulated with human chorionic gonadotrophin (HCG) (1 IU/ml) during 4 days in vitro. Culture media supplemented with human serum yielded the greatest secretion of progesterone. Supplementation with fetal calf serum caused an intermediate pattern of progesterone release. Substitution of serum with a synthetic replacement (Medi-CultR SSR 1 and 2), lacking hormones, cholesterol and growth factors, led to a minimal output of progesterone from granulosa-luteal cells. Complex media (RPMI 1640 and Ham's F10) generally caused a greater progesterone release than simple salt solution (EBSS). No effect of insulin was detected when added to serum-free media.     

Immunology: Repeat trials of oocyte donation to women with previous donor oocyte success

Oocyte donation has proven to be highly successful in establishingpregnancy in functionally agonadal women. Both implantationand ongoing pregnancy rates in women using this method havesurpassed those normally seen in standard in-vitro fertilization(IVF) patients. Over a 5 year period, seven women who had previouslyconceived using oocyte donation elected to attempt pregnancyand deliver a second child using the same donor. In each casethe paramount consideration was to provide a sibling of thesame genetic make-up as the child or children previously borne.Of the seven women studied, whose ages ranged from 24 to 44years, five became pregnant on subsequent cycles. The time toconception varied from one to a maximum of three attempts withthree of the five women becoming pregnant on the first cycleand two requiring three cycles to establish the subsequent pregnancy.The overall rate of success in this group was 12 pregnanciesin 20 cycles of embryo transfer (60%). An exaggerated implantationrate (25.6%) was also noted (23 individual embryo implantationsfrom 90 embryos transferred). Of the 12 pregnancies establishedin these seven women, four (33%) were multiple gestations (threetriplets, one twin). We conclude that women who have previouslyexperienced pregnancy following oocyte donation are highly likelyto conceive in a subsequent trial at a rate that may be higherthan that normally seen in the general population of women undergoingoocyte donation.     

Infertility: Altered responses to stress in women undergoing in-vitro fertilization and recipients of oocyte donation

Clinical impressions suggest the presence of considerable anxietyand depression in infertile couples. We utilized a psychologicalstress test to assess adaptations to provoked stress to improvethe psychological profile of infertile women. A psychologicalstress test was administered to four groups: normal menstruatingfemales (controls, n = 13); oocyte donors (n = 13); recipientsof oocyte donation (n = 7); and women undergoing standard in-vitrofertilization (IVF; mean age 38.0 years; n = 8). The psychologicalstress test consisted of three active coping tasks: (i) serialsubtraction, (ii) Stroop colour test, (iii) speech task and(iv) one passive coping task, the cold-pressor test. Haemo-dynamicresponses (HD) were monitored before, during and after the psychologicalstress test, and serum samples were drawn for catecholaminesand cortisol. Baseline blood pressures were similar among groups.The psychological stress test elicited different biophysicalresponses in controls compared with the other groups (P <0.001). Oocyte donors had different speech task responses frombaseline, although these and the other parameters of the psychologicalstress test were not different from either the recipient orIVF groups. Blood pressure responses from baseline were bluntedin both recipients and standard IVF patients following provokedstress. Baseline cortisol and norepi-nephrine were similar amongall groups, yet provoked stress elicited a significant increasein controls (142.0 ± 25.2%, P < 0.001) compared withoocyte donors (17.1 ± 19.7%), recipients and standardIVF patients (mean –15.5 ± 17.3% respectively).Norepinephrine responses were apparently greater in controls(60.1 ± 13.1%) compared with oocyte donors (41.8 ±27%) and recipient and IVF groups combined (21.7 ± 12.4%)but this result was not significant. These data suggest thatinfertile women have blunted biophysical and biochemical reactionsto provoked behavioural stressors. Oocyte donors demonstrateblunted passive coping responses similar to those of infertilewomen, yet still respond to active coping stressors in a mannersimilar to that of normal controls. Our data suggest that infertilitytherapy combined with the anticipation of success or failureresults in blunted patterns of response to passive coping stressors.However, blunted active coping responses are unique to infertilewomen.     

Hydrosalpinges adversely affect implantation in donor oocyte cycles

Hydrosalpinges have been associated with poor in-vitro fertilization (IVF) outcome in some, but not all, studies, perhaps through endometrial effects. To determine whether hydrosalpinges affect IVF outcome via endometrial factors alone, we analysed the results of recipients of donor oocytes with hydrosalpinges, thereby controlling for confounding variables, while isolating the intrauterine environment. We retrospectively analysed 110 patients who underwent 121 donor oocyte cycles in a university-based assisted reproduction programme. Thirteen cycles involving recipients (n = 10) with hydrosalpinges were compared to 108 cycles involving recipients (n = 100) without hydrosalpinges. Pregnancy, implantation, miscarriage, and ectopic pregnancy rates were compared between women with and without hydrosalpinges. There were no significant differences between the hydrosalpinx and no hydrosalpinx groups with respect to donor age, recipient age, or number or grade of embryos transferred. Patients with a hydrosalpinx had significantly lower embryo implantation rates (7.1 versus 19.3%, P < 0.05) and significantly higher miscarriage (75.0 versus 14.9%, P < 0.05) and ectopic pregnancy rates (33.3 versus 0.0%, P < 0.05) than normal controls. We conclude that the presence of a hydrosalpinx adversely affects early pregnancy events by altering the intrauterine environment.     

Pregnancy: Endometrial ultrasonography as a predictor of pregnancy in an in-vitro fertilization programme

The endometrial pattern and thickness were analysed by ultrasonographyin 139 cycles stimulated for in-vitro fertilization (IVF) onthe day of administration of human chorionic gonadotrophin (HCG).A semi-programmed schedule based on the pill + clomiphene citrate+ human menopausal gonadotrophin (HMG) was used in all cycles.On the day of HCG administration, endometrial pattern and thicknesswere assessed with an Ultramark 4 (ATL) ultrasound equippedwith a 5 MHz vaginal probe. Endometrial pattern I (a ‘tripleline’multilayer) was observed in a total of 105 cycles (76%), andpattern II (fully homogeneous and hyperechogenic in relationto myometrial tissue) in 34 (24%). The incidence of clinicalpregnancy did not differ (P = 0.52) between the groups withendometrial patterns I (23.8%) and II (29.4%). Endometrial thicknesson the day of HCG administration in the group with pattern I(8.4 ± 1.9 mm) was similar (P = 0.96) to that observedin the group with pattern II (8.4 ± 2.0 mm). In addition,the endometrial thickness of the patients who became pregnant(8.0 ± 1.7 mm) did not differ (P = 0.15) from that ofwomen who did not achieve pregnancy (8.6 ± 2.0 mm). Theconclusion from the present data is that ultrasonographic analysisof endometrial thickness and refringency on the day of HCG administrationhad no predictive value for conception in IVF cycles.     

High fecundity rates in donor oocyte recipients and in-vitro fertilization surrogates using parenteral oestradiol valerate

Ovum donation and in-vitro fertilization (IVF) surrogacy canhelp couples with difficult infertility problems achieve pregnancy.Most centres using oral oestrogens and oestradiol patches reportpregnancy rates in the range of 30% per cycle. Parenteral oestradiolvalerate has pharmacological properties that make it an attractiveoption for preparing the endometrium in the recipients undergoingthese procedures. When the egg providers were under age 35 years,and using oestradiol valerate in the recipients, we achieveda 61% clinical pregnancy rate in 62 cycles. These improved resultssuggest that parenteral oestradiol valerate should be used toprepare the endometrium in recipients, and that the hormonalmilieu of the endometrium plays an important role in the higherimplantation rates obtainable in ovum donor and IVF surrogatecycles.     

Elevated serum progesterone on the day of HCG administration in IVF is associated with a higher pregnancy rate in polycystic ovary syndrome

Our study compared 84 patients with polycystic ovary syndrome (PCOS) with 84 control patients who had normal ovaries and who were matched for the main determinants of success in in-vitro fertilization (IVF) and embryo transfer. Serum concentrations of oestradiol and progesterone on the day of human chorionic gonadotrophin (HCG) injection were significantly higher in PCOS than in normal patients (oestradiol 2016 +/- 1.8 pg/ml versus 1456 +/- 40.9 pg/ml, P < 0.01; progesterone 1.6 +/- 0.1 ng/ml versus 1.2 +/- 0.1 ng/ml, P = 0.03). Furthermore despite oocytes from PCOS patients having a reduced fertilization rate compared with normal patients (61.8 +/- 4.1% versus 73.5 +/- 4.3%, P = 0.03), the differences in pregnancy rate (22.6 versus 19%) and miscarriage (31.5 versus 18.7%) were not statistically significant. In PCOS patients, a critical breakpoint was identified at serum progesterone concentrations of 1.2 ng/ml on the day of HCG injection. The PCOS patients with progesterone > or = 1.2 ng/ml showed a higher pregnancy and miscarriage rate than PCOS patients with progesterone < 1.2 ng/ml (26.6 versus 17.9%, P < 0.01; and 41.7% versus 14.3%, P < 0.01 respectively). These findings suggest that premature progesterone production does not have an adverse effect on pregnancy rate in PCOS, but on the contrary, may be a predictor for success in IVF/embryo transfer.     

Twin pregnancy following embryo transfer on day 7 of the luteal phase in an oocyte donation programme

We report a case of a 42 year old female patient with hypergonadotrophichypogonadism requiring oocyte donation. Spontaneous ovulationoccurred during a hormonal replacement treatment cycle and threeembryos were transferred 7 days after documented ovulation.This resulted in a viable twin pregnancy. The twins were geneticallydistinct from the mother. To the best of our knowledge thisis the first reported case of a successful transfer of embryoson day 7 of the luteal phase leading to a viable pregnancy inan oocyte donation programme.     

Premature luteinization is not eliminated by pituitary desensitization with leuprolide acetate in women undergoing gonadotrophin stimulation who demonstrated premature luteinization in a prior gonadotrophin-only cycle

A total of 40 women who demonstrated premature luteinization(serum progesterone 3.5 nmol/1 (1.1 ng/ml) on or before theday of human chorionic gonadotrophin (HCG) administration) duringovarian stimulation with human menopausal gonadotrophins (HMG)were restimulated in 46 subsequent cycles after pituitary desensitizationwith the gonadotrophin-releasing hormone agonist (GnRHa, 1 mg),leuprolide acetate. Five women were treated with a double doseof agonist (2 mg) when premature luteinization was determinedon the single dose protocol. In HMG-only cycles, a frank luteinizinghormone (LH) surge was detected in 30 cycles; 15 cycles werecancelled because of premature ovulation. In agonist cyclesthere were no cancellations, although 25 cycles demonstratedpremature luteinization and in six cycles a frank LH surge wasdetected. Doubling the dose of the agonist did not prevent prematureluteinization. Agonist cycles with and without premature luteinizationdid not differ in any in-vitro fertilization (IVF) outcome parameters(ampoules of gonadotrophins, day of HCG administration, peakoestradiol concentration, number of oocytes retrieved, fertilized,transferred or cryopreserved). We conclude that in patientswho demonstrate premature luteinization in a gonadotrophin-onlycycle, pituitary desensitization may not completely eliminatesubtle luteinization or a frank LH surge.     

Pregnancy: Supraphysiological serum relaxin concentration during pregnancy achieved by in-vitro fertilization is strongly correlated to the number of growing follicles in the treatment cycle

In order to analyse the relationship between the ovarian responseto stimulation in in-vitro fertilization (IVF) treatment cyclesand relaxin concentrations during subsequent pregnancies, 31healthy women pregnant after IVF treat ment were studied prospectively.The maximum number of follicles observed from day –4 today –2 in relation to ovum retrieval and the number ofoocytes recovered were recorded. In addition, blood sampleswere drawn in the follicular phase, the luteal phase, earlypregnancy and at gestational weeks 12, 16, 20, 27 and 35 toassess oestradiol, progesterone, human choriomc gonadotrophinand relaxin. The maximum numbers (mean±SEM) of folliclesobserved and oocytes recovered were 9.0±0.6 and 6.1±0.5respectively. The supraphyslological mean relaxin values werestrongly correlated to the maximum number of follicles observed(r=0.72, P <0.0001) and the number of oocytes recovered (r=0.64,P <0.0001), indicating that the source of increased relaxinproduction during IVF pregnancy might be the ovary. These resultsare supported by experimental data. In the present study, theoccurrence of multiple pregnancy was not associated with higherrelaxin concentrations, which is further support for the hypothesisthat the ovary is the main source of serum relaxin.     

Pregnancy and birth after high serum progesterone concentrations during the follicular phase in an in-vitro fertilization cycle with gonadotrophin-releasing hormone agonist suppression

This case illustrates the possibility of achieving a pregnancyand birth when elevated progesterone concentrations (>4 ng/ml)are present during the follicular phase (from 6 days beforehuman chorionic gonadotrophin injection) of a gonadotrophin-releasinghormone agonist/menotrophin cycle for in-vitro fertilization(IVF). The present patient underwent three IVF/embryo transfercycles in which progesterone concentrations were repeatedlyincreased from the mid-follicular phase onwards. A pregnancywas achieved after the first IVF attempt but ended in a miscarriagein the 19th week of gestation. During the second IVF attemptan endometrial biopsy taken on the day of oocyte retrieval revealedan endometrial advancement of 2 days. A successful pregnancyand birth was again achieved after the third IVF attempt althoughprogesterone concentrations were considerably increased from6 days before the ovulatory stimulus.     

Pregnancy: Heterotopic abdominal pregnancy following in-vitro fertilization/embryo transfer presenting as massive lower gastrointestinal bleeding

We present a case that, as far as we know, is the first reportof lower gastrointestinal haemorrhage as a complication of heterotopicpregnancy induced by artificial reproductive technology. Theheterotopic abdominal pregnancy caused erosion of the intestinalwall and massive rectal bleeding, 8 weeks after in-vitro fertilization/embryotransfer. The source of the bleeding could not be identifieddespite comprehensive investigation including gastroscopy, ultra-sonography,sigmoidoscopy, ⁹⁹Tc (technetium) scanning and angiography. Tagged-erythrocyteisotope scanning revealed an abnormal concentration in the leftlower quadrant, compatible with active bleeding in the areaof the terminal ileum. Laparotomy disclosed a heterotopic abdominalpregnancy, causing erosion of the intestinal wall at this site.As assisted reproductive technologies become more and more commonthis rare complication of intestinal erosion should be keptin mind in cases of lower gastrointestinal bleeding.     

Endocrinology: Pre-ovulatory progesterone growth rate in patients treated with gonadotrophin-releasing hormone agonist and outcome of in-vitro fertilization

The present study was undertaken to assess whether the increasein serum progesterone concentration following the administrationof human chorionic gonadotrophin (HCG) may have predictive valueon the in-vitro fertilization (IVF) success rate. Progesteroneconcentration on the day of HCG administration and the increasein progesterone concentration on the following day were evaluatedin 140 consecutive patients undergoing IVF with embryo transfer.Stimulation protocol in all study patients entailed intranasaladministration of short-acting gonadotrophin-releasing hormoneagonist (GnRHa) buserelin and human menopausal gonadotrophin.A pregnancy rate of 37.2% was achieved when at least three embryoswere transferred. The only significant difference between conceptionand non-conception cycles was found in serum progesterone concentrationsafter HCG administration (P < 0.01), whereas the mean progesteroneconcentration on the day of HCG did not differ. No differencein other hormonal or cycle parameters was observed. The increasein progesterone concentration was significantly greater in thegroup of patients who achieved pregnancy than in the group whodid not (2.2 ± 0.2 versus 1.6 ± 0.1 ng/ml, respectively;P < 0.01). A critical breakpoint in serum progesterone wasarbitrarily determined at 1 ng/ml. An increase in progesteroneconcentration 1 ng/ml when three or more embryos were transferredwas associated with a positive predictive value for pregnancyof 40.4% (sensitivity of 94.7%), whereas a negative predictivevalue of 86.7% was obtained when this value was <1 ng/ml.These findings indicate that an adequate rise in serum progesteronefollowing HCG administration provides useful information aboutthe possible outcome of the treated cycle.     

Pregnancy: The prediction of ectopic pregnancy after in-vitro fertilization and embryo transfer

Data from 135 patients who suffered ectopic pregnancies andfrom 135 patients who progressed to singleton deliveries afterin-vitro fertilization and embryo transfer have been analysedretrospectively. The ectopic pregnancies represent all suchcases observed at Bourn Hall Clinic between 1983 and 1993. Thedelivered group was randomly selected from the same time period.The ectopic pregnancies included 20 heterotopic, eight ovarianand six bilateral tubal pregnancies; the remainder were singletontubal pregnancies. The aim of this study was to identify thevariables which differed systematically for the two groups ofpatients and to explore whether such variables could be usedto predict ectopic pregnancy at an early stage. The mean plasmaconcentration of human chorionic gonadotrophin and progesteronefor the ectopic pregnancy group was significantly lower thanthat for the singleton delivery group (P < 0.001). However,there was such a degree of overlap that it was impossible todevise a cut-off concentration for either hormone which wouldoffer a clinically useful predictor of ectopic pregnancy. Nevertheless,using the discriminant function analysis of these data, togetherwith the history of pelvic inflammatory disease, we could predictup to 90% of cases of ectopic pregnancy by day 23 after embryotransfer, long before ultrasound imaging would be useful.     

Pregnancy: Oocyte donation in menopausal women

Oocyte donation was performed by in-vitro fertilization andembryo transfer in 82 women. The average age of the patientswas 48 years (range 26–60), and 71 were over 40 yearsold, with an average follicle stimulating hormone (FSH) valueof 74±14 IU and oestradiol concentration of 30 ±9 pg/ml. Overall 32 clinical pregnancies were achieved, of which21 reached term, three are ongoing, and eight were lost (sixmiscarriages, one abruptio placentae, and one severe gestationalproteinuria hypertension in the second trimester). The 21 termpregnancies produced 26 newborns; one patient who had had threeembryos replaced delivered triplets and three patients had twins.Before the embryo transfer was performed, the endometrium thicknesswas accurately determined by vaginal ultrasound probe. The highestnumber of implanted embryos was reached when the endometriumthickness was 9–12 mm.     

Pelvic abscess in the second half of pregnancy after oocyte retrieval for in-vitro fertilization: case report.

We describe a very late manifestation of pelvic abscesses after oocyte retrieval for in-vitro fertilization (IVF). In a twin pregnancy achieved after intracytoplasmic sperm injection, rupture of bilateral ovarian abscesses occurred at the end of the second trimester. An emergency laparotomy was necessary because of an acute abdomen. This complication led to severe maternal and neonatal morbidity, preterm birth and neonatal death. The rare occurrence of acute abdomen in pregnancy due to pelvic infection and the non-specific symptoms of a pelvic abscess after oocyte retrieval for IVF are discussed.     

The role of oocyte donation in women who are unsuccessful with in-vitro fertilization treatment.

Oocyte donation improves the chances of becoming pregnant in some women who are unsuccessful with in-vitro fertilization (IVF) treatment. A total of 119 IVF cycles achieved a pregnancy rate per cycle of 2.5% whereas the same women, when treated with 45 cycles of oocyte donation, achieved a 24.5% pregnancy rate per cycle. To ascertain which women may be helped by oocyte donation, IVF data were analysed according to the outcome of oocyte donation. There was a difference in the number of previous natural conceptions and live births, and in the IVF fertilization rate. There was no difference in the age of the women and the numbers of oocytes collected per cycle of IVF. New criteria are therefore suggested for recommending oocyte donation to women who have previously failed to become pregnant with IVF treatment.     

Pregnancy: Apparent lack of seasonal variation in implantation rates after in-vitro fertilization

It has been suggested that seasonal variation in endometrialreceptivity may occur in women, which could affect the likelysuccess of in-vitro fertilization (IVF) treatment. We thereforestudied implantation rates (fetal sacs as a proportion of embryostransferred) as an indirect index of receptivity in a narrowlydefined population of women under 40 years old with normal ovulatorycycles and normal uterus and men with normal sperm function.A total of 577 cycles of IVF treatment were undertaken usinga standard protocol of pituitary desensitization and ovarianstimulation during the 3 years 1990–1992. Results werecompared between calendar months and 3-month seasons. The overallimplantation rate was 14.9% of embryos, and the clinical pregnancyrate was 30.3% of cycles reaching egg collection. There wereno significant differences in the monthly rates of eggs collected,fertilization and cleavage, or embryos transferred. Implantationrates varied to a greater extent but analysis of variance showedno seasonal variation. These findings do not support a seasonalvariation in ovarian responsiveness or endometrial receptivitywhen stimulated for IVF treatment, but larger studies are neededfor firm conclusions to be drawn.     

Pregnancy: Heterotopic pregnancy obtained after in-vitro fertilization and embryo transfer following bilateral total salpingectomy: case report

Heterotopic (coexistent ectopic and intra-uterine) pregnancyis common following in-vitro fertilization and multiple embryotransfer. Total bilateral salpingectomy is generally consideredto eliminate the risk of ectopic, and hence heterotopic pregnancy.This is, however, not strictly correct as it does not eliminatethe risk of interstitial tubal pregnancy. This is the firstreported case of a heterotopic pregnancy following total bilateralsalpingectomy. The diagnostic pitfalls and a suggested methodof avoiding them are discussed.     

Effect of in-utero diethylstilboestrol exposure on human oocyte quality and fertilization in a programme of in-vitro fertilization.

Genital tract abnormalities and adverse pregnancy outcome are well known in women exposed in utero to diethylstilboestrol (DES). Data about adverse reproductive performance in women exposed to DES have been published, including controversial reports of menstrual dysfunction, poor responses after ovarian stimulation, oocyte maturation and fertilization abnormalities. We compared oocyte quality, in-vitro fertilization results and embryo quality for women exposed in utero to DES with a control group. Between 1989 and 1996, 56 DES-exposed women who had 125 in-vitro fertilization (IVF) attempts were retrospectively compared to a control group of 45 women with tubal disease, who underwent 73 IVF attempts. Couples suffering from male infertility were excluded. The parameters compared were oocyte quality (maturation abnormalities, immature oocyte, mature oocyte), fertilization and cleavage rate (per treated and metaphase II oocytes), and embryo quality (number and grade). We found no significant difference in oocyte maturational status, fertilization rates, cleavage rates, embryo quality and development between DES-exposed subjects and control subjects. These results suggest that in-utero exposure to DES has no significant influence on oocyte quality and fertilization ability as judged during IVF attempts.