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.     

Pregnancy: Corpus luteum failure in ectopic pregnancy

The endocrinology of ectopic pregnancy was studied in orderto investigate the origin of the discordance in the circulatingamounts of human chorionic gonadotrophin (HCG) and those ofoestradiol and progesterone. Serial maternal blood samples wereobtained at 4–9 weeks gestation from 93 patients who becamepregnant following in-vitro fertilization and embryo transferincluding 10 ectopic, 21 anembryonic and 62 normal singletonpregnancies. The samples were analysed for HCG, Schwangerschaftprotein-1 (SP-1), pregnancy-associated plasma protein-A (PAPP-A),progesterone and oestradiol. In ectopic pregnancies, concentrationsof all substances analysed were significantly reduced comparedto singleton pregnancies from 5 weeks gestation (P < 0.05–0.001)but they were not significantly different from those of anembryonicpregnancies. In ectopic pregnancies, associations were foundbetween the concentration of both HCG and SP-1 and those ofprogesterone and oestradiol. No associations were found betweenPAPP-A and any other substances analysed. This may be due toinsensitivity of the PAPP-A assay; alternatively PAPP-A concentrationsmay be differentially reduced in ectopic pregnancy. These findingssuggest that progesterone and oestradiol are derived from thecorpus luteum in early ectopic pregnancy but that the corpusluteum fails rapidly and the dominant source of both hormonesbecomes the trophoblast as early as 5 weeks.     

Pregnancy: Oocyte donation to women of advanced reproductive age: pregnancy results and obstetrical outcomes in patients 45 years and older

We analysed the results of oocyte donation to women of advancedreproductive age (45 years old) and followed their pregnanciesthrough to delivery in order to assess obstetrical outcomes.Patients (n = 162) aged 45–59 years (mean ± SD;47.3 ± 3.4 years) underwent 218 consecutive attemptsto achieve pregnancy. Oocytes (16.2 ± 7.2 per retrieval)were provided by donors 35 years old. Cleaving embryos (8.2± 4.8 zygotes/couple) were transferred trans-cervically(4.5 ± 1.1 per embryo transfer) to recipients prescribedoral micronized oestradiol and intramuscular progesterone. Followingoocyte aspiration there were six instances of non-fertilization(2.8%) and 212 embryo transfers. A total of 103 pregnancieswas established for an overall pregnancy rate (PR) of 48.6%,which included 17 preclinical pregnancies, 12 spontaneous abortions,and 74 delivered pregnancies (clinical PR 40.6%; delivered PR34.9%). Multiple gestations were frequent (n = 29; 39.2% ofpregnancies) and included 20 twins, seven triplets, and twoquadruplets. Two of the triplet and both of the quadruplet pregnanciesunderwent selective reduction to twins. Antenatal complicationsoccurred in 28 women (37.8% of deliveries) and included pretermlabour (n = 9), gestational hypertension (n = 8), gestationaldiabetes (n = 6), carpel tunnel syndrome (n = 2), pre-eclampsia(n = 2), HELLP syndrome (n = 2), and fetal growth retardation(n = 2). 48 (64.8%) deliveries were by Caesa-rean section. Thegestational age at delivery for singletons was 383 ±1.3 weeks (range 35–41 weeks), with birth weight 3218± 513 g (range 1870–4775 g); twins 35.9 ±2.0 weeks (range 32–39 weeks), birth weight 2558 ±497 g (range 1700-3450 g); and triplets 33.5 ± 0.7 weeks(range 32-34 weeks), birth weight 1775 ± 190 g (range1550-2100 g). Neonatal complications (4.6% of babies born) includedgrowth retardation (n = 2), trisomy 21 (n = 1), ventricularseptal defect (n = 1), and small bowel obstruction (n = 1).There were no maternal or neonatal deaths. We conclude thatoocyte donation to women of advanced reproductive age is highlysuccessful in establishing pregnancy. However, despite carefulantenatal screening, obstetrical complications are common, oftensecondary to multiple gestation.     

Endocrinology: Luteal function following ovulation induction in polycystic ovary syndrome patients using exogenous gonadotrophins in combination with a gonadotrophin-releasing hormone agonist

The luteal phase was studied in 12 polycystic ovary syndrome(PCOS) patients following ovulation induction using exogenousgonadotrophins combined with a gonadotrophin-releasing hormoneagonist (GnRH-a). Human menopausal gonadotrophin (HMG) was precededby 3 weeks of treatment with GnRH-a (buserelin; 1200 µg/dayintra-nasally) and administered in a step-down dose regimenstarting with 225 IU/day i.m. GnRH-a was withheld the day beforeadministration of human chorionic gonadotrophin (HCG; 10 000IU i.m.). Blood sampling and ultrasound monitoring was performedevery 2–3 days until menses. The luteal phase was significantlyshorter in PCOS patients as compared to eight regularly cyclingcontrols: 8.8 (3.3–11.4) days [median(range)] versus 12.8(8.9–15.9) days (P = 0.01). Median peak values for progesteronedid not show significant differences comparing both groups:52.3 (17.1–510.3) nmol/l versus 43.0 (31.2–71.1)nmol/l, respectively (P = 0.8). The interval between the dayof the progesterone peak and return to baseline was significantlyshorter in the PCOS patients than in controls: 2.5 (0.3–4.9)days versus 4.2 (3.9–10.5) days (P < 0.005). Luteinizinghormone (LH) concentrations during the luteal phase as reflectedby area under the curve were significantly lower in PCOS ascompared to controls: 4.4 (1.6–21.0) IU/l x days and 49.0(27.8–79.6) IU/l x days, respectively (P < 0.001).In conclusion, patients with PCOS may suffer from insufficientluteal phases after ovulation induction using HMG/HCG in combinationwith a GnRH-a. The corpus luteum apparently lacks the supportof endogenous LH and may be stimulated only by the pre-ovulatoryinjection of HCG. Potential involvement of adjuvant GnRH-a medicationor HCG itself in luteal suppression of endogenous gonadotrophinsecretion, and the importance of luteal function for pregnancyrates following treatment, warrant further studies.     

Induction of final follicular maturation and early luteinization in women undergoing ovulation induction for assisted reproduction treatment--recombinant HCG versus urinary HCG. The European Recombinant Human Chorionic Gonadotrophin Study Group

This multicentre, double-blind, double-dummy, randomized, parallel-groupstudy compared the efficacy and safety of recombinant humanchorionic gonadotrophin (rHCG) (Ovidrel^®) and urinary HCG(uHCG) (Profasi^®) for inducing final follicular maturationand early luteinization in women undergoing ovulation inductionfor assisted reproduction treatment. Following long down-regulationand stimulation with recombinant human FSH (rFSH) (Gonal-F^®),a total of 190 women received a single, s.c. injection of either250 µg rHCG or 5000 IU uHCG. For evaluable patients (n= 172), the mean number of oocytes retrieved per patient (primaryefficacy endpoint) was 11.6 for rHCG and 10.6 for uHCG (notsignificant). The mean number of mature oocytes was statisticallyhigher (P = 0.027) for the rHCG group than the uHCG (9.4 versus7.1). Serum progesterone concentrations on day 1 and days 6–7post-HCG, and serum HCG concentrations at all post-HCG timepoints were statistically significantly in favour of rHCG. Theclinical pregnancy rate was somewhat higher (not significant)in the rHCG group (33 versus 25%) as was the live birth rate(27 versus 23%, not significant). Both treatments were welltolerated, though the incidence of adverse events was significantlyhigher in the uHCG group (45.1 versus 22.7%, P = 0.0004). Theincidence of injection-site reactions was significantly lowerin the rHCG group (P = 0.0001). In conclusion, for triggeringovulation, rHCG seems to have significant advantages comparedwith uHCG in terms of number of mature oocytes retrieved, lutealprogesterone and local tolerance.     

Relationship of biochemical pregnancy to pre-ovulatory endometrial thickness and pattern in patients undergoing ovulation induction

In order to assess the relationship between pre-ovulatory endometrialthickness and pattern and biochemical pregnancy, the pregnancyoutcome was retrospectively analysed in 81 patients undergoingovulation induction evaluated by vaginal ultrasound on the dayof human chorionic gonadotrophin (HCG) administration or luteinizinghormone (LH) surge. Biochemical pregnancies occurred in 7/32(21.9%) pregnancies when endometrial thickness was <9 mm,compared to 0/49 when endometrial thickness was 9 mm on theday of HCG administration or LH surge (P < 0.0025). Clinicalabortions occurred in 5/32 (15.6%) pregnancies when endometrialthickness was 6–8 mm, compared to 6/49 (12.2%) when endometrialthickness was 6–8 mm (NS). Endometrial thickness was relatedto the cycle day of HCG or LH surge (r = 0.37, P < 0.001)but was unrelated to oestradiol level on the day of HCG administrationor LH surge (r = 0.12). Biochemical pregnancies were relatedto endometrial pattern (r = – 0.22, P = 0.02) but wereunrelated to maternal age or previous abortions. Clinical abortionswere related to age (r = 0.26, P = 0.01) and to previous abortion(r = 0.25, P = 0.013) but were unrelated to endometrial pattern.Neither biochemical pregnancy nor clinical abortion was relatedto oestradiol or LH levels on the day of HCG administrationor LH surge. These findings suggest that the majority of biochemicalpregnancies do not result from karyotypically abnormal embryos,as do clinical abortions.     

Effect of insulin on human chorionic gonadotrophin secretion by placental explants

The effect of physiological concentrations of insulin (5–50µU/ml) was tested on human chorionic gonadotrophin (HCG)secretion by first trimester (7–9 weeks) and term placentalexplants using both static and dynamic culture models. In staticcultures, insulin exerted a significant biphasic inhibitoryeffect (80% at 5 µU/ml and 40% at 50 µU/ml) on HCGsecretion by placental explants. At approximate fasting plasmalevels, 25 µU/ml insulin added to superfused explantsfor 8 min also had a rapid inhibitory effect. A delayed inhibitoryeffect on HCG pulsatility was also observed using 25 µU/mlinsulin, with a 2-fold decrease in HCG pulse amplitude and a4-fold decrease in the area under the curve following overnightpre-incubation (P < 0.01). Insulin had no effect in staticcultures at term. The effect of insulin-like growth factor (IGF-I)and fibroblast growth factor (bFGF) on HCG secretion in staticcultures was not statistically significant. In conclusion, physiologicalconcentrations of insulin inhibit HCG secretion in first trimesterplacenta in vitro. This effect is gestational age dependentand specific since it is not mimicked by IGF-I or bFGF. Thus,insulin may be an important modulator of trophoblastic HCG secretionduring early pregnancy.     

Epidermal growth factor receptors in placentae and fetal membranes from hypertension-complicated pregnancies

Epidermal growth factor receptor concentrations (EGFR) in placentaeand fetal membranes from 25 normal and 25 hypertension-complicatedpregnancies were analysed by a radioreceptor technique. HigherEGFR concentrations were found in placentae from hypertension-complicatedpregnancies than in those from normal pregnancies (median 125.0fmol/mg protein, range: 33.4–190.7 versus median 50.3fmol/mg protein, range 21.4–184.0) (P = 0.0002). EGFRconcentrations were significantly lower in fetal membranes thanin placental tissue, both in normal membranes (median 31.7,range 4.8–92.0 versus median 50.3, range 21.4–184.0)(P = 0.0004) and in hypertension-complicated pregnancies (median65.0, range 16.8–125.0 versus median 125.0, range 33.4–190.7)(P = 0.0001). A statistically significant inverse correlationbetween EGFR concentrations and gestational age was found inplacentae (r = 0.53, P = 0.0061) and fetal membranes (r = 0.56,P = 0.0032) from hypertension-complicated pregnancies. Multipleregression analyses demonstrated that hypertensive disease ismore closely associated with EGFR concentrations than gestationalage and fetal weight in placental tissue and fetal membranes.Our findings suggest that hypertensive disorders in pregnancyare associated with elevated EGFR concentrations in both theplacenta and fetal membranes.     

Early rapid growth,early birth: Accelerated fetal growth and spontaneous late preterm birth

The past two decades in the United States have seen a 24% rise in spontaneous late preterm delivery (34–36 weeks) of unknown etiology. This study tested the hypothesis that fetal growth was identical prior to spontaneous preterm (n = 221, median gestational age at birth 35.6 weeks) and term (n = 3706) birth among pregnancies followed longitudinally in Santiago, Chile. The hypothesis was not supported: Preterm‐delivered fetuses were significantly larger than their term‐delivered peers by mid‐second trimester in estimated fetal weight, head, limb, and abdominal dimensions, and they followed different growth trajectories. Piecewise regression assessed time‐specific differences in growth rates at 4‐week intervals from 16 weeks. Estimated fetal weight and abdominal circumference growth rates slowed at 20 weeks among the preterm‐delivered, only to match and/or exceed their term‐delivered peers at 24–28 weeks. After an abrupt growth rate decline at 28 weeks, fetuses delivered preterm did so at greater population‐specific sex and age‐adjusted birth weight percentiles than their peers from uncomplicated pregnancies (P < 0.01). Growth rates predicted birth timing: one standard score of estimated fetal weight increased the odds ratio for late preterm birth from 2.8 prior to 23 weeks, to 3.6 (95% confidence interval, 1.82–7.11, P < 0.05) between 23 and 27 weeks. After 27 weeks, increasing size was protective (OR: 0.56, 95% confidence interval, 0.38–0.82, P = 0.003). These data document, for the first time, a distinctive fetal growth pattern across gestation preceding spontaneous late preterm birth, identify the importance of mid‐gestation for alterations in fetal growth, and add perspective on human fetal biological variability. Am. J. Hum. Biol., 2009. © 2008 Wiley‐Liss, Inc.     

Ultrasound evidence for variability in the size and development of normal human embryos before the tenth post-insemination week after assisted reproductive technologies

Differences in human chorionic gonadotrophin (HCG), averagechorionic sac diameter, embryo/fetus crown —rump lengthand biparietal diameter were determined in 107 singleton pregnanciesdelivered after 34 weeks, whose post-insemination age was preciselyknown as a result of in-vitro fertilization (n = 28) or gameteintra-Fallopian transfer (n = 79). Crown — rump lengthswere interpreted in relation to the developmental stage of theembryo. A 7-fold to 10-fold difference in HCG levels was observedon post-insemination days 13–16. A 2-fold to 3-fold differenceoccurred in average chorionic sac diameter on days 25–36.A 2-fold difference occurred in crown — rump length onseven of 10 days prior to day 44. Biparietal diameter differedby no more than 42% from day 57–68 and 20% after day 68.Chorionic sac diameter, crown -rump length, and biparietal diameterwere also related to newborn weight. The results suggest firstlythat marked differences occur in the rate of early human development,secondly, that the differences occur prior to day 27 when observablecardiac activity begins, and thirdly, that the differences areminimized after day 68 when the embryonic period of developmentis completed.     

Pregnancy: Temporal relationship between the human chorionic gonadotrophin peak and the establishment of intervillous blood flow in early pregnancy

The purpose of this study was to investigate the temporal relationshipbetween the early pregnancy peak of circulating human chorionicgonadotrophin (HCG) concentration and the establishment of maternalblood flow in the placental intervillous space. The presenceof blood flow echoes within intervillous space was determinedby colour Doppler imaging from 44 women with clinically uncomplicatedpregnancy between 6 and 18 weeks gestation. Circulating HCG,free - and HCG subunits, oestradiol and progesterone concentrationswere immunoassayed in blood samples collected at the time ofDoppler examination. A continuous intervillous blood flow wasdetected in all cases with a gestational age 11.7 weeks (n =18) but never before this time. Circulating concentrations offree HCG, oestradiol and progesterone were linearly or exponentiallycorrelated with gestational age (r = 0.860, 0.903 and 0.538respectively, all with P < 0.001), indicating steady increaseof these hormones with advancing gestation. However, the bestfitted lines were found to be parabolic for HCG (r = 0.771,P < 0.001) and HCG (r = 0.695, P < 0.001), their highestpoints corresponding to 11.24 and 10.74 weeks gestational agerespectively. The close temporal relationship between the Doppleradvent of intervillous maternal blood flow and the HCG peaksuggests that the establishment of the intervillous blood flowis associated with the decline in circulating HCG concentrations.     

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.     

Maternal serum concentrations of pregnancy associated placental protein A and pregnancy specific {beta}-1-glycoprotein in multifetal pregnancies before and after fetal reduction

Placental function in multifetal pregnancies before and afterembryo reduction was investigated by measuring maternal serumconcentrations of pregnancy associated placental protein-A (PAPP-A)and pregnancy specific -1-glycoprotein (SP-1). Three groupsof pregnant women were studied following assisted reproduction;groups 1 and 2, were 12 singleton and 12 twin pregnancies respectively,and group 3 comprised 12 women with multifetal pregnancies undergoingembryo reduction. PAPP-A and SP-1 were measured serially at8–21 weeks gestation. In all pregnancies, maternal serumPAPP-A and SP-1 increased with gestation. In twin pregnanciesthe mean concentrations of SP-1 were significantly higher thanin singletons at all gestations, whereas for PAPP-A, concentrationswere similar between these groups. In multifetal pregnanciesbefore embryo reduction, the serum concentrations of both proteinswere significantly higher than in twin pregnancies. Followingreduction, the concentrations of PAPP-A remained significantlyhigher than for twins throughout, whereas the concentrationsof SP-1 gradually converged towards those of twins; by 19 weeksthere was no difference between the means of the two groups.These findings suggest that circulating concentrations of SP-1reflect total placenta mass, which is proportional to the numberof live fetuses, whereas the pattern of PAPP-A changes suggeststhat this protein is produced by the placenta, decidua and othertissues.     

Infertility: Predicting and optimizing success in an intra-uterine insemination programme

We analysed 381 consecutive cycles of homologous intra-uterineinsemination (IUI) in 215 infertile couples, resulting in 48pregnancies (12.6%/cycle, 22.3/patient). Cycle fecundity rangedfrom 0.11 to 0.14 in women aged 25–39 years, falling to0.04 beyond age 40 years. Of the 48 pregnancies, 43 occurredin the first three treatment cycles, in which fecundity was0.14, 0.16 and 0.10 respectively. Beyond three cycles, fecunditywas 0.07 (P = 0.05 versus first two cycles). The occurrenceof pregnancy varied with diagnosis (P = 0.04). Fecundity wassignificantly greater for women with ovulatory dysfunction (0.30)than for endometriosis, male factor, tubal factor, idiopathicinfertility or multifactorial (0.08–0.14). Ovulation inductionusing menopausal gonadotrophins offered significant advantageover natural cycles or cycles using clomiphene citrate withoutgonadotrophins (0.15 versus 0.03, P = 0.01). Cycles in whichpre-ovulatory surges were either induced or supported with humanchorionic gonadotrophin (HCG) were superior to spontaneous luteinizinghormone surges (0.13 versus 0.03, P = 0.05). Recruitment ofat least two mature (>1.6 cm) follicles was critical. Onlyone pregnancy occurred in 64 cycles characterized by one maturefollicle, compared with a pregnancy rate of 0.15 in cycles characterizedby two or more mature follicles (P = 0.006). IUI is not beneficialto women >40 years old, and has the best chance of successwithin three cycles. Multiple follicle recruitment using gonadotrophin-basedstimulation protocols and mid-cycle HCG are necessary to achievean acceptable pregnancy rate.     

Association of early {beta}-human chorionic gonadotrophin values with pregnancy wastage and multiple implantation in a donor oocyte programme

An early marker predictive of a viable pregnancy would easethe anxiety associated with positive pregnancy tests after theuse of donor oocytes. We examined the predictive value of anearly serum quantitative human chorionic gonadotrophin (Q-HCG)concentration on pregnancy outcome following oocyte donation.Embryo transfers after oocyte donation resulting in a positiveserum -HCG were examined beginning 9 days after embryo transferfrom those samples assayed in our laboratory (n = 77). Q-HCGconcentrations were measured in our laboratory by an immunoradiometricassay utilizing the first International Reference Preparation.Implantations were defined as the number of gestational sacsvisualized by transvaginal ultrasound 21 days after embryo transfer.Biochemical pregnancies were those with transient elevationsin -HCG concentration but without implantation sites. Spontaneousabortions were characterized by an implantation site with theeventual arrest of development. Ongoing/delivered pregnanciesdeveloped appropriately and proceeded beyond the first trimester.Day 9 Q-HCG concentrations did not differentiate between biochemicalpregnancies/spontaneous abortions and ongoing/delivered pregnancies,although mean ± SD concentrations for biochemical pregnancieswere significantly lower than those for the other groups (P< 0.0001): biochemical pregnancies, n = 18, 5.8 ±8.9 mlU/ml, range 0–35; spontaneous abortions, n = 2,46.0 ± 10.0 mlU/ml, range 39–53; ongoing/deliveredpregnancies, n = 57, 41.5 ± 35.4 mlU/ml, range 0–214.In addition, day 9 Q-HCG concentrations did not differentiatebetween multiple implantations, although the implantation offour sacs had a significantly higher mean Q-HCG concentrationcompared with the implantation of fewer sacs (P > 0.0001):one sac, n = 22, 32.2 ± 21.5 mlU/ml, range 3–78;two sacs, n = 25, 35.8 ± 21.3, range 0–81; threesacs, n = 7, 47.1 ± 37.1 mlU/ml, range 22–126;four sacs, n = 4, 122.3 ± 62.4 mlU/ml, range 76–214.The positive predictive value of a Q-HCG >10 mlU/ml was 0.91(sensitivity 91%, specificity 75%). These initial data suggestthat early day 9 serum Q-HCG determinations do not accuratelyidentify viable pregnancies or multiple implantations. Evenan early negative pregnancy test should be repeated becauseit can be associated with a normal pregnancy.     

HCG concentration and receptor gene expression in placental tissue from trisomy 18 and 21

Trisomy 21 is associated with high maternal serum concentrationsof intact human chorionic gonadotrophin (HCG) and free ß-HCGwhereas these concentrations are markedly decreased in trisomy18. In this study, we investigated the effect of trisomy 21and 18 on endogenous HCG concentrations and luteinizing hormone(LH)/HCG receptor expression in placental villous tissue ineight trisomy 21, six trisomy 18 and 42 chromosomally normalsamples, collected at 12–16 weeks gestation. The tissueconcentrations of intact HCG, free -HCG and free ß-HCGsubunits were measured using solid-phase two-site immunoradiometricassay. LH/HCG receptor expression was evaluated with immunohistochemistryand in-situ hybridization. Villous tissue in trisomy 21 containedhigher ß-HCG concentrations than the controls (P <0.05). In trisomy 18 cases, the ß-HCG concentration waslower than in the control group (P < 0.01). Both immunocytochemistryand in-situ hybridization demonstrated a more intense stainingof the trophoblast in cases of trisomy 21 and 18, compared withcontrols with the strongest signal in cases of trisomy 18 (P< 0.01). We concluded that in trisomy 21 the high tissueHCG concentration and expression of LH/HCG receptor in the trophoblastmay reflect the relative immaturity of the trophoblastic tissuewhereas in trisomy 18, the very low concentration of endogenousHCG, associated with an over-expression of LH/HCG receptor inthe trophoblast, is probably secondary to the poor differentiationof the cytotrophoblast. HCG/placenta/pregnancy/receptors/trisomy Notes ⁴ To whom correspondence should be addressed at: Academic Departmentof Obstetrics and Gynaecology, University College London MedicalSchool, 86–96 Chenies Mews, London WC1E 6HX, UK     

Rapid diagnosis of early ectopic pregnancy in an emergency gynaecology service--are measurements of progesterone, intact and free {beta} human chorionic gonadotrophin helpful?

The clinical usefulness of measuring serum concentrations ofprogesterone, human chorionic gonadotrophin (HCG) and the free-subunit of HCG in distinguishing between early viable and non-viablepregnancy, before an accurate ultrasound diagnosis is possible,was evaluated in a prospective study of patients presentingto our emergency gynaecology service with a clinical suspicionof ectopic pregnancy. Patients were selected on the basis ofinitial HCG concentrations; samples with HCG 25–10 000IU/I were later analysed for progesterone and free HCG. Of the181 patients studied, 38 (21%) had an ectopic pregnancy, 108(60%) had a spontaneous abortion and 35 (19%) had a viable intra-uterinepregnancy. Concentrations of HCG and free HCG in the group withviable pregnancies were significantly higher than in the groupwith ectopic pregnancy (P < 0.001) and than those destinedto miscarry (P < 0.01). Progesterone concentrations werealso significantly higher in the viable versus the ectopic andthe spontaneous abortion groups (P < 0.001 in each case).Despite these highly significant differences there was a degreeof overlap such that it was impossible to devise a cut-off levelfor any hormone analysed, either singly or in combination, whichwould offer a clinically useful predictor of outcome.     

Implantation: Endometrial and placental protein markers and ovarian steroids in serum during in-vitro fertilization cycles

The objective of this study was to find the earliest time atwhich it was possible to detect clinical pregnancy in an in-vitrofertilization (IVF) treatment cycle supported with human chorionicgonadotrophin (HCG), and also retrospectively to diagnose abnormalovarian- or endometrium-related situations in failure cycles.Serum samples were taken in 41 IVF cycles at frequent intervalsfrom the beginning of ovarian stimulation until menstrual bleedingoccurred or a pregnancy was established. Concentrations of oestradiol,progesterone, placental protein 14 (PP14), pregnancy-specific1-glycoprotein (SP₁), and pregnancy-associated plasma proteinA (PAPP-A) were determined in the serum samples using commerciallyavailable (steroid) or purpose-developed (protein) immunoassays.The cycles were retrospectively distributed into four outcomegroups: (i) fertilization failure (FF, n = 8); (ii) implantationfailure (IF, n = 10); (iii) ‘interaction’ (embryo-endometrium)cycle (IC, n = 14), and (iv) clinical pregnancy (CP, n = 9).The embryo-endometrium interaction was detected by a rise inSP₁ in 23 cycles (70% of embryo transfers) at a time when endogenousHCG was still masked by external support. Early (‘false’)positive SP₁ concentrations were observed in two out of eightand five out of 14 cases in groups FF and IC respectively, butnever amongst the ongoing pregnancies (CP). PAPP-A did not distinguishpregnancy from the other outcomes. The PP14/progesterone ratiowas lower, later in the cycle, in CP than in the other groups.We conclude that, while it is not possible to predict the outcomeof a given IVF cycle earlier than 2 weeks after embryo transfer,the hormonal patterns can be used to detect abnormalities (e.g.endometrial asynchrony) which may be useful for subsequent treatmentcycles in the same patient.     

Pregnancy: Gestational-age-dependent effects of retinoids on HCG secretion by placental explants

Vitamin A (VITA) is considered to be an essential nutrient inboth pregnant and non-pregnant states. It has been suggestedthat VITA, among others, is involved in the process of morphogenesis.In contrast, synthetic derivatives of VITA, specifically Tigasone(etretinate, TIG) and Roaccutane (isotretinoin, ROA), are regardedas major teratogens. Therefore, in the present study we haveexamined the effect of VITA and other retinoids on human chorionicgonado-trophin (HCG) secretion by placental explants in thefirst trimester. Results show that, at 7–9 gestationalweeks, all three compounds had a significant inhibitory effecton HCG secretion. In the case of VITA, this inhibition was time-dependent.A biphasic maximal inhibition was present at 1 µM concentrationswhen the retinoids VITA, TIG and ROA were added for 16 h (52,58 and 57%, respectively; P < 0.01 by one-way analysis ofvariance). In contrast, the addition of the three retinoidsat 1 µM concentrations for 16 h had no significant effecton HCG secretion by placental explants of 11–13 weeksgestational age. In conclusion, both natural and synthetic retinoidsdemonstrate a significant inhibitory effect on HCG secretionby the early placenta (pre-HCG peak). VITA may be involved incausing a plateau and the later decline in HCG secretion. Inhibitionof HCG secretion by retinoids may contribute either directlyor indirectly to their teratogenicity.     

Supplementary growth hormone treatment of women with poor ovarian response to exogenous gonadotrophins: changes in serum and follicular fluid insulin-like growth factor-1 (IGF-1) and IGF binding protein-3 (IGFBP-3)

The effects of supplementary growth hormone (GH) treatment uponinsulin-like growth factor-1 (IGF-1), IGF binding protein-3(IGFBP-3) concentrations in serum and ovarian follicular fluidwere investigated in women undergoing buserelin human menopausalgonadotrophin (HMG) ovulation induction for in-vitro fertilization.Women (n = 40), aged 24–39 (mean 35 years), who showedpoor ovarian responses to HMG, were recruited and randomly dividedinto two groups. Each patient received two cycles of ovulationinduction, one with GH (12 IU/day x 12 days/HMG/buserelin) andanother with placebo/HMG. Serum IGF-1 increased substantiallyduring the GH treatment and remained significantly higher thanthe control 2 days after the last GH injection. Serum IGFBP-3fell steadily during the placebo/HMG treatment and to a nadiron the day of oocyte retrieval (P <0.05 compared to serumbefore any treatment). In contrast, IGFBP-3 was increased (P<0.01) during the GH administration and returned to the controllevel 2 days after GH injection. Serum oestradiol concentrationson the eighth day of HMG and the day of human chorionic gonadotrophin(HCG) were not significantly different between the two groups.Serum IGF-1 was highly correlated with IGFBP-3 before any treatment(r = 0.433, P < 0.001). This correlation disappeared afterbuserelin, placebo/HMG treatment in the control group, but itwas maintained during GH/HMG treatment (r = 0.343, P = 0.04).Follicular fluid concentrations of GH and IGF-1, not IGFBP-3or oestradiol, were significantly elevated in the GH-treatedwomen. Serum IGF-1 on the day of oocyte retrieval was highlycorrelated to the follicular fluid IGF-1 in both groups. Therelationships between the follicular fluid GH and IGF-1 werecompletely opposite in the two groups, being positive in thecontrol group and negative in the GH-treated group. In the controlgroup, significant correlations were found between follicularfluid concentrations of IGF-1 and IGFBP-3, and GH and IGFBP-3which were not found in the GH-treated group. There were nocorrelations found between follicular fluid concentrations ofGH or IGF-1 or IGFBP-3 and oestradiol. The results clearly demonstratethat the normal GH, IGF-1, IGFBP-3 relationships can be alteredby treatments which influence the ovarian—pituitary axis;the significance of such changes to ovulation remains to bediscovered.