An aggressive philosophy in controlled ovarian stimulation cycles increases pregnancy rates

To assess the effect of timing of human chorionic gonadotrophin(HCG) administration in ovarian stimulation cycles, the serumoestradiol concentration and follicle profile were comparedwith the clinical pregnancy rate in 582 ovarian stimulation— intra-uterine insemination (OS—IUI) cycles and3917 in-vitro fertilization—embryo transfer (IVF—ET)cycles. The pregnancy rates increased exponentially with increasingoestradiol in both OS—IUI and IVF—ET cycles (R²= 0.720, P < 0.001) but then decreased in OS-IUI cycles whenthe oestradiol concentration exceeded 5000 pmol/l (R² = 0.936,P < 0.004) at HCG administration. In OS—IUI cyclesthe percentage of cycles with three or more mature follicles( 18 mm diameter) increased up to an oestradiol concentrationof 5000 pmol/l then declined, mirroring the pregnancy rate (R²= 0.900, P = 0.01). The exponential increase in pregnancy ratewith increasing oestradiol concentration in IVF—ET cyclessuggests that high oestradiol concentration does not have adeleterious effect on endometrial receptivity. The decreasein pregnancy rate in OS-IUI cycles when oestradiol concentrationexceeded 5000 pmol/l reflected fewer mature follicles, resultingfrom premature administration of HCG to avoid severe ovarianhyperstimulation syndrome (OHSS). We recommend that HCG administrationbe delayed until multiple follicles have reached maturity, andreducing the risk of severe OHSS by converting high risk OS—IUIcycles to IVF—ET, or if funds or facilities are unavailable,transvaginally draining all but four or five mature follicles.     

Endocrinology: Efficacy of chronic therapy with the gonadotrophin releasing hormone agonist decapeptyl in patients with polycystic ovary syndrome

Our objective was to assess the endocrine and morphologicalresponse of polycystic ovary syndrome (PCOS) in patients receiving6 months of therapy with the long-acting gonadotrophin releasinghormone agonist (GnRH agonist) decapeptyl (3.75 mg monthly injections).Eighteen documented PCOS patients were basally evaluated forhirsutism, gonadotrophin and androgen concentrations and ovarianmorphology using trans-vaginal ultrasonography. Measurementswere repeated at 3 and 6 months. The results (values as x ±SD) showed a significant improvement in hirsutism (Ferrimanscore 11.0 ± 5.9 versus 6.6 ± 2.7, P < 0.01),acne and seborrhoea. A significant post-treatment decrease ingonadotrophins [follicle-stimulating hormone (FSH): 5.8 ±1.8 versus 3.8 ± 1.1 IU/I, P < 0.01; luteinizing hormone(LH): 10.8 ± 8.3 versus 3.4 ± 3.3 IU/1, P <0.01], LH/FSH ratio (1.8 ± 1.1 versus 0.8 ± 0.6,P < 0.01) and androgen concentrations (free testosterone:4.0 ± 1.9 versus 1.9 ± 0.7 pg/ml, P < 0.01,₄-androstenedione: 3.9 ± 1.2 versus 1.9 ± 0.6ng/ml, P < 0.001) was also found, while oestradiol approximatedcastration concentrations (68.4 ± 29.5 versus 29.1 ±6.7 pg/ml, P < 0.001). Finally, mean ovarian volume (19.7± 6.2 versus 10.9 ± 4.6 cm³, P < 0.001), capsulethickness (2.5 ± 0.8 versus 1.9 ± 0.7 mm, P <0.05) and stromal density dropped significantly, as did uterinevolume (34.2 ± 10.5 versus 19.9 ± 8.9 cm3, P <0.01). In conclusion, treatment of our PCOS patients for 6 monthswith the GnRH agonist decapeptyl proved efficient in inducingsignificant clinical, biochemical and ovarian morphologicalimprovement.     

Total ovarian volume before human chorionic gonadotrophin administration for ovulation induction may predict the hyperstimulation syndrome

Total ovarian volumes were measured before the administrationof HCG in 42 women undergoing treatment for infertility by in-vitrofertilization (IVF) and embryo transfer and considered to havean exaggerated response to stimulation (>20 follicles). Sevenwomen who subsequently developed moderate or severe ovarianhyperstimulation syndrome (OHSS) (n = 7; group 1) were comparedwith 35 matched controls (five matched controls per case; n= 35; group 2) of similar age, number of follicles and durationof infertility who underwent follicular stimulation, oocyterecovery, in-vitro fertilization and embryo transfer duringthe same period but did not develop moderate or severe OHSS.The mean age, duration of infertility and total number of follicleswere similar but the mean total ovarian volume was significantlyhigher in the group of women who developed moderate or severeOHSS compared with controls (271.00 ± 87.00 versus 157.30± 54.20 ml; P < 0.01). We conclude that total ovarianvolume measured before HCG administration is higher in womenwho develop moderate or severe OHSS compared with controls andmay therefore be used as an additional parameter in the preventativestrategy for the ovarian hyperstimulation syndrome.     

Pregnancy: Premature luteinization as detected by elevated serum progesterone is associated with a higher pregnancy rate in donor oocyte in-vitro fertilization

Premature luteinization has been reported to be associated withdecreased pregnancy rates in patients undergoing in-vitro fertilization.However, the detrimental effect created by a pre-aspirationrise in progesterone is difficult to assess since ovarian stimulationaffects both oocyte quality and endometrial receptivity. Therefore,the relationship between premature luteinization and pregnancyrates remains uncertain. To achieve improved control for confoundingvariables, we studied premature luteinization in ovum donorsof proven fertility. A total of 114 consecutive ovum donationcycles using pituitary suppression with a gonadotrophin-releasinghormone agonist followed by gonadotrophin stimulation were examined.Serum progesterone concentration on the day of administrationof human chorionic gonadotrophin (HCG) was > 1.2 ng/ml in29% of patients. Patients were divided into two groups basedon this value. There was a significant increase in clinicalpregnancy rates per embryo transfer in the group with higherprogesterone concentrations (53 versus 25%, P = 0.012), as wellas significantly more oocytes obtained at aspiration (19.6 ±10.4 versus 13.3 ± 5.4, P < 0.001), and significantlyhigher peak serum oestradiol values (3903 ± 1787 versus2453 ± 1232 pg/ml, P < 0.001). There were no significantdifferences between groups due to age, degree of stimulationor the number of embryos transferred. We conclude that prematureluteinization as based on elevated serum progesterone concentrationis a common occurrence in oocyte donors, reflects healthy folliculardevelopment, and is associated with increased pregnancy rates.     

Fertilization and early embryology: Embryo quality and pregnancy potential of fresh compared with frozen embryos--is freezing detrimental to high quality embryos?

To determine the effect of cryopreservation on embryo qualityand the pregnancy potential of embryos, donated oocytes fromthe same donor (n = 24) were randomly allocated, with subsequenttransfer to two or more different ovum recipients resultingin at least one fresh and one frozen embryo transfer cycle fromthe same cohort of oocytes. Endometrial receptivity was controlledin all ovum recipients, and male factor patients were excluded.The number of embryos transferred, mean embryo grade transferred,number of high quality embryos (grade 2.5, grade 1 being best)transferred and embryo implantation and live birth rates arereported. Significantly more embryos (4.4 ± 1.2 versus3.3 ± 1.2, P < 0.00003) of higher quality (1.9 ±0.5 versus 2.1 ± 0.5, P < 0.013) and of a more advancedcell stage (3.0 ± 0.6 versus 2.6 ± 0.7, P <0.019) were transferred fresh than after cryopreservation respectively.Implantation rates/embryo [19/151 (12.6%) and 9/111 (8.1%)]and live birth rates/transfer [11/42 (26.2%) and 6/45 (13.3%)],from fresh and frozen transfers respectively, were not significantlydifferent despite the larger number of high quality embryostransferred fresh. Embryo cryopreservation adversely affectsembryo quality, but does not have detrimental effects on theimplantation or pregnancy potential of high quality embryos.Because of the loss of embryos during freeze — thawingduring frozen embryo cycles, every effort should be made toattempt a fresh transfer.     

Endocrinology: Inhibition of ovarian-derived prorenin to angiotensin cascade in the treatment of ovarian hyperstimulation syndrome

The purpose of this experiment was to determine whether useof the angiotensin-converting enzyme (ACE) inhibitor, enalapril,would prevent the occurrence of ovarian hyperstimulation syndrome(OHSS) in the rabbit model. A total of 20 adult female New Zealandwhite rabbits were studied. All rabbits received 75 IU of humanmenopausal gonadotrophin s.c. each day for 7 days. On day 8,all rabbits received 2500 IU of human chorionic gonadotrophin(HCG). Ten rabbits were randomly chosen to receive enalaprilorally. Five received 1 mg/kg of enalapril and five received2 mg/kg of enalapril twice daily. The remainder received placeboorally twice daily. On day 10, all rabbits underwent surgicalexploration. Total body weight was found to increase significantlyin the placebo group (by 293 g, P < 0.001) but not in eithergroup receiving enalapril. Haematocrit also increased significantlyin the placebo group (by 3%, P < 0.013) but not in the enalaprilgroups. Ovarian weights were highest for the 2 mg/kg enalaprilgroup (5.80 ± 0.52 g), followed by the 1 mg/kg enalaprilgroup (3.64 ± 0.45), and least for the placebo group(2.69 ± 0.17). All 10 placebo rabbits met criteria forsevere OHSS whereas only six in the enalapril groups did. Weconcluded that angiotensin II may play a significant role inthe development of weight gain, third space fluid accumulationand intravascular fluid depletion in OHSS. ACE inhibition resultedin a 40% decrease in the incidence of OHSS in the rabbit model.     

In-vitro fertilization and the ovarian hyperstimulation syndrome.

Eight patients who developed severe ovarian hyperstimulation syndrome (OHSS) were identified among 1302 patients undergoing in-vitro fertilization (IVF) over a 1 year period (prevalence of 0.6%); 63% had ultrasonically diagnosed polycystic ovaries (PCO) and 75% were undergoing their first attempt at IVF. Pretreatment with a superactive luteinizing hormone-releasing hormone (LHRH) analogue significantly increased the prevalence of severe OHSS (1.1% versus 0.2%, P less than 0.05) compared with ovarian stimulation with clomiphene citrate and human menopausal gonadotrophin (HMG). The mean serum oestradiol concentration on the day of human chorionic gonadotrophin (HCG) administration was 8200 +/- 2300 pmol/l. A mean of 19.6 +/- 6.8 follicles had been aspirated and 13.1 +/- 7.7 oocytes recovered at transvaginal ultrasound-directed oocyte recovery. All patients had an embryo transfer and luteal support in the form of HCG. The clinical pregnancy rate was 88%, multiple pregnancy rate 71% and implantation rate 63.5 +/- 41.3%. In a group of seven patients who were hospitalized for moderate OHSS during the same period, peak oestradiol levels were significantly lower than in those with severe OHSS (P less than 0.05). Of the group with moderate OHSS, 57% had PCO, the clinical pregnancy rate was 100% and multiple pregnancy rate 43%. Patients with ultrasound-diagnosed PCO have an increased risk of developing OHSS and the dose of HMG administered to them should be minimized. In patients at risk of developing OHSS, progesterone instead of HCG should be used for luteal support. Transfer of a maximum of two embryos or freezing all embryos for transfer in a subsequent cycle may reduce the likelihood of multiple pregnancy.     

Endocrinology: Ovarian hyperstimulation syndrome: pre-ovulatory serum concentrations of interleukin-6, interleukin-1 receptor antagonist and tumour necrosis factor-{alpha} cannot predict its occurrence

The pathogenesis of the ovarian hyperstimulation syndrome (OHSS)is poorly understood. Since significant elevations in cytokinesare found in 01155, our objective was to conduct a prospectivecase-controlled study to assess if preovulatory cytokine serumconcentrations can predict its occurrence. The study group wasselected from in-vitro fertilization patients who subsequentlydeveloped severe OHSS, along with a matched group who did notdevelop this complication (n = 20), and a healthy normal controlgroup (n = 10). Interleukin-6 (IL-6), interleukin-1 receptorantagonist (IL-1RA) and tumour necrosis factor- (TNF) measurementswere performed with sensitive immune-assays and confirmed withbioassays. Serum IL-6 (mean concentration ± SEM: 4.38± 0.36 pg/ml), IL-1RA (829 ± 292 pg/ml) and TNF(15.5 ± 132 pg/ml) concentrations did not show differencesthroughout the normal menstrual cycle group. Cytokine variabilityand pre-ovulatory values were similar in OHSS compared to controlledovarian hyperstiinulation (COH) patients. However, average follicularphase serum 1L-6 concentrations were higher in OHSS (8.71 ±0.41 pg/ml) and COH (7.66 ± 0.38 pg/ml) patients thanin normally menstruating women (4.34 ± 0.99 pg/ml) (P< 0.0001). Pre-ovulatory serum 1L-6 concentrations were alsohigher in OHSS (9 ± 0.94 pg/ml) and COH (73 ±0.97 pg/ml) patients than in controls (4.57 ± 1.1 pg/ml)(P < 0.01 and P < 0.04 respectively). IL-1RA and TNF concentrationswere comparable in all the groups. This study suggests thatcytokine measurements cannot be used to predict the occurrenceof OHSS prior to the administration of human chorionic gonadotrophin.     

Pregnancy: Adverse effect of a homogeneous hyperechogenic endometrial sonographic pattern, despite adequate endometrial thickness on pregnancy rates following in-vitro fertilization

We have previously presented data to show that in patients whohad in-vitro fertilization (IVF)—embryo transfer usingovarian stimulation involving the luteal phase leuprolide acetate—humanmenopausal gonadotrophin (HMG) regimen, poor pregnancy resultsensued if either the endometrial thickness was < 10 mm ora homogeneous hyperechogenic sonograpic pattern was presentimmediately prior to taking a human chorionic gonadotrophin(HCG) injection. There were only 15 cases with this hyperechogenictype endometrium (and no pregnancies). The purpose of the presentstudy was to evaluate the influence of a hyperechogenic endometriumwhen the endometrial thickess was 10 mm, in a more extensiveseries, in women having IVF—embryo transfer using thesame ovarian stimulation regimen. A total of 273 consecutivecycles, where endometrial thickness was 10 mm, were evaluated(not including the 85 cycles previously reported). Of 22 patientswith the hyperechogenic pattern, one achieved a chemical pregnancy(-HCG >500 mIU/ml) and none achieved clinical pregnancies(ultrasound confirmation). In contrast, 67 of 251 (26.7%) patientsconceived with other echo patterns (x² analysis = 5.9, df =1, P = 0.01). These data thus confirm, in a larger series, thenegative influence of this type of echo pattern on subsequentpregnancy rates following the luteal phase leuprolide acetate—HMGovarian stimulation regimen.     

The effects of the somatostatin analogue octreotide on ovulatory performance in women with polycystic ovaries

The elevated luteinizing hormone (LH) and androgen concentrationscharacteristic of women with polycystic ovaries (PCO) are consideredcrucial factors in their infertility. The somatostatin analogueoctreotide lowers LH and androgen concentrations in women withPCO. The effects of octreotide given concurrently with humanmenopausal gonadotrophin (HMG) were therefore compared withthat of HMG alone in 28 infertile women with PCO resistant toclomiphene. In 56 cycles of combined HMG and octreotide therapythere was more orderly follicular growth compared with the multiplefollicular development observed in 29 cycles in which HMG wasgiven alone (mean number of follicles > 15 mm diameter onthe day of human chorionic gonadotrophin (HCG) administration:2.5 ± 0.2 and 3.6 ± 0.4 respectively; P = 0.026).There was a significantly reduced number of cycles abandoned(>4 follicles > 15 mm diameter on day of HCG) in patientstreated with octreotide + HMG, so that HCG had to be withheldin only 5.4% of cycles compared to 24.1% with HMG alone (P <0.05). The incidence of hyperstimulation was also lower on combinedtreatment. Octreotide therapy resulted in a more ‘appropriate’hormonal milieu at the time of HCG injection, with lower LH,oestradiol, androstenedione and insulin concentrations. Althoughgrowth hormone concentration was similar on both regimens, significantlyhigher insulin growth factor-I concentrations were observedon the day of HCG in women on combined therapy than on HMG alone.     

A combination of norethindrone acetate and leuprolide acetate blocks the gonadotrophin-releasing hormone agonistic response and minimizes cyst formation during ovarian stimulation

A protocol utilizing both leuprolide acetate (LA) and norethindroneacetate (NETA) in subjects undergoing ovarian suppression priorto follicle aspiration proved more effective than LA alone inreducing the incidence of ovarian cyst formation without affectingclinical outcome. Patients (n = 105) undergoing ovarian stimulationfollowed by follicle aspiration and in-vitro fertilization (IVF)were prospectively randomized and studied. Study measures includedovarian suppression days, days of human meno-pausal gonadotrophin(HMG) stimulation, serum oestradiol concentrations, number ofcycles developing de novo cysts (>15 mm), number of inducedflare responses (day 8 oestradiol 5=50 pg/ml), number of officevisits, total dose exogenous gonadotrophins, number oocytesretrieved, and clinical pregnancy and delivery rates per retrieval.Patients undergoing FVF received either LA alone (n = 58; controls)or LA and NETA (n = 47; study group) for the first 8 days oftheir cycle. Results comparing NETA/LA versus LA demonstrated:serum oestradiol 20.7 ± 3.9 versus 573 ± 9.4 pg/mlrespectively on day 8 of ovarian suppression (P < 0.01);8.6 ± 2.74 days required for ovarian suppression versus123 ± 6.09 days (P < 0.01); and only three individuals(6.4%) using NETA/LA developed ovarian cysts >15 mm comparedto 15 (25.9%) controls (P < 0.01). No differences were observedfor days of stimulation, peak oestradiol attained, total dosageof exogenous gonadotrophins, or number of aspirated oocytes.Neither were there differences in the clinical pregnancy (26.8versus 22.6%) nor in delivery rates (19.5 versus 20.8%). Weconclude that the addition of NETA to LA enhances ovarian suppressionand lessens ovarian cyst formation, thereby significantly decreasingthe overall cost per cycle.     

Subcutaneous low dose leuprolide acetate depot versus leuprolide acetate for women undergoing ovarian stimulation for in-vitro fertilization

A total of 100 women undergoing ovarian stimulation with gonadotrophin-releasinghormone agonist (GnRHa) and a human menopausal gonadotrophin(HMG) for in-vitro fertilization (IVF) participated in thisrandomized comparative study. Leuprolide acetate at a dose of0.5 mg/day s.c. (n = 52, group I), or low-dose leuprolide acetatedepot at a dose of 1.88 nig s.c. (n = 48, group II), was startedon days 21–23 of the cycle. Stimulation with 225 IU/dayHMG was started after pituitary desensitization had been achieved.The luteal phase was supported by human chorionic gonadotrophin(HCG) i.m. injection. There were nostatistical differences inbaseline oestradiol (24.5 ± 4.8 versus 21.9 ±4.5 pg/ml) and follicle stimulating hormone (FSH) concentrations(3.9 ± 1.9 versus 3.2 $ 1.8 mlU/ml), and concentrationson the day of HCG administration of oestradiol (1657 ±245 versus 1512$165 pg/ml), luteinizing hormone (LH; 6.2 ±4.8 versus 5.6 ± 4.3 mlU/ml) and FSH (10.6 ± 2.8versus 10.8 ± 3.6 mIU/ml). There were also no statisticaldifferences in the HMG dosage (26.8 ± 1.8 versus 28.5± 1.5), the number of oocytes retrieved (7.6 ±3.0 versus 8.1 ± 4.3), the number of oocytes fertilized(5.3 ± 2.1 versus 5.6 ± 3.0) and the number ofembryos transferred (3.5 ± 1.3 versus 3.4 ± 1.6).There was no evidence of a premature LH surge in either group,but two patients appeared to have a poor response in the leuprolideacetate group (group I). There were 11 pregnancies (21.2%) afterthe use of leuprolide acetate and 12 pregnancies (25.0%) inthose given leuprolide acetate depot; no statistical differenceexisted between these two groups. Thus, an s.c. low-dose leuprolideacetate depot injection may offer a useful alternative for pituitarysuppression in ovarian stimulation for IVF.     

Endocrinology: Isolated polycystic morphology in ovum donors predicts response to ovarian stimulation

The isolated finding of polycystic-appearing ovaries on ultrasoundexamination of normal women is not uncommon. The purpose ofthis study was to determine the clinical significance of polycysticovaries in a population of healthy, non-hirsute, fertile womenpreparing to undergo ovarian stimulation. We evaluated whetherthe finding of polycystic ovaries in oocyte donors predictsa different response to ovarian stimulation when compared todonors with normal-appearing ovaries. Furthermore, we examinedwhether oocytes from polycystic ovaries had the same capacityfor fertilization and development as those retrieved from normalovaries. In all, 11 donors with polycysticappearing ovarieswere compared prospectively to 13 donors with normal-appearingovaries who were undergoing ovarian stimulation during the sametime interval. The two groups were similar in age and baselineandrogen concentrations. Significantly more oocytes were producedby the polycystic group for the amount of human menopausal gonadotrophin(HMG) administered (P < 0.05). In addition, all previouscycles completed by these 24 donors were compared (polycysticgroup: total of 31 cycles; normal group: total of 37 cycles).The donors with polycystic ovaries required less HMG to obtainoptimal stimulation (P < 0.05), attained a greater peak oestradiolconcentration (P < 0.05), produced a greater number of follicles(P < 0.05) and oocytes (P < 0.01) and a higher percentageof mature oocytes (P < 0.05). Furthermore, they achieveda higher peak oestradiol/HMG (P < 0.01) and oocytes/HMG ratio(P < 0.01). Also, the oocytes from donors with polycystic-appearingovaries, in contrast to reports of oocytes from women with polycysticovary syndrome, demonstrated superior maturity (P < 0.05)and similar fertilization, clinical pregnancy and miscarriagerates as oocytes from normal-appearing ovaries. In conclusion,visualizing polycystic ovaries in normal women predicts a heightenedsensitivity to HMG. Nonetheless, women with polycystic-appearingovaries are excellent oocyte donors, producing significantlymore oocytes than donors with normal-appearing ovaries. Furthermore,the oocytes collected are of normal quality and have the samecapacity for fertilization and embryo development.     

Miscarriage rates following in-vitro fertilization are increased in women with polycystic ovaries and reduced by pituitary desensitization with buserelin

To assess the risk of miscarriage after in-vitro fertilization(IVF) with respect to age, cause of infertility, ovarian morphologyand treatment regimen, a retrospective analysis was performedof the first 1060 pregnancies conceived between June 1984 andJuly 1990 as a result of 7623 IVF cycles. Superovulation inductionwas achieved with human menopausal gonadotrophin (HMG) and/orpurified follicle stimulating hormone (FSH) together with eitherclomiphene citrate or the gonadotrophin hormone-releasing hormone(GnRH) agonist buserelin, the latter either as a short ‘flare’regimen or as a ‘long’ regimen to induce pituitarydesensitization. There were 282 spontaneous abortions (26.6%)and 54 ectopic pregnancies (5.1%). The mean age of women withongoing pregnancies was 32.2 (SD 3.9) years compared with 33.2(SD 4.1) years in those who miscarried, which were significantlydifferent (P = 0.008). There was no relation between the miscarriagerate and the indication for IVF. The miscarriage rate was 23.6%in women with normal ovaries compared with 35.8% in those withpolycystic ovaries [P = 0.0038, 95% confidence interval (CI)4.68–23.10%]. There was no difference in the miscarriagerate between treatment with HMG or FSH. Women whose ovarieswere normal on ultrasound were just as likely to miscarry ifthey were treated with clomiphene or with the long buserelinprotocol. Those with polycystic ovaries, however, had a significantreduction in the rate of miscarriage when treated with the longbuserelin protocol, 20.3% (15/74), compared with clomiphenecitrate, 47.2% (51/108) (P = 0.0003, 95% CI 13.82–40.09%).     

Comparison of concurrent pregnancy rates for in-vitro fertilization-embryo transfer, pronuclear stage embryo transfer and gamete intra-Fallopian transfer

Concurrent pregnancy and implantation (sacs/embryos transferred)rates were compared for 84, 77 and 49 cases of in-vitro fertilization–embryotransfer (TVF–ET), pronuclear stage embryo transfer (PROST)and gamete intra-Fallopian transfer (GIFT), respectively. Allcases reported occurred during an 18-month interval since theinitiation of PROST by our programme. Leuprolide acetate wasused with follicle stimulating hormone and human menopausalgonadotrophin for follicular stimulation of all but donor oocytecases (n = 9). Clinical pregnancy (per transfer) and implantationrates were significantly higher (P < 0.03) for PROST (52.4%,20.2%) in comparison with IVF–ET (26.9%, 11.4%). Ratesfor GIFT (48.9%, 18.4%) were not significantly higher (P = 0.10,0.14) than for IVF—ET. This was probably due to the lowernumber of GIFT than PROST procedures performed. The total pregnancyrate for GIFT (biochemical, ectopk and clinical combined) wassignificantly greater (P < 0.05) than for IVF—ET. Pregnancyand implantation rates for PROST and GIFT were similar. Theseresults support the use of PROST rather than IVF—ET forall cases in which the woman has one functional Fallopian tube.Furthermore, to maintain equivalent rates of pregnancy withPROST and GIFT, it is suggested that GIFT should not be usedfor cases of male-factor infertility without first documentingnormal rates of in-vitro fertilization with PROST.     

Endocrinology: Prediction of ovarian hyperstimulation syndrome of baseline ovarian volume prior to stimulation

The aim of the study was to find out whether the estimationof the baseline ovarian volume prior to stimulation would bea suitable predictor for the risk of ovarian hyperstimulationsyndrome (OHSS). A total of 101 patients underwent in-vitrofertilization (IVF) and embryo transfer. They had a 3-D volumetricassessment of the ovaries and body weight estimations on thefirst day of hormonal stimulation. A second measurement wasperformed on the day of ovulation induction with human chorionicgonadotrophin (HCG) together with an oestradlol 17 estimationin serum. During the IVF programme 15 women developed OHSS and86 did not. There was a significant correlation between thebaseline ovarian volume and subsequent occurrence of OHSS (P=0.03).Other significant relationships were foimd between the occurrenceof OHSS and the number of follicles (P=0.002), the number ofoocytes retrieved (P=0.0001) and the length of the cycle (P=0.0001).The body weight before and after the stimulation was significantlylower in the group of women who did develop the syndrome (P=0.011resp.0.03). The oestradiol 17 concentration on the day of HCGadministration in the serum of the patients who had OHSS wassignificantly higher (P=0.0001). In conclusion, voluinetry ofthe ovaries could help to detect patients at risk and preventthe occurrence of OHSS by early adjustment of the hormonal dosage.Recent advances in ultrasound technology (3-D ultrasound) enablequick and highly accurate volumetric assessments. Furthermore,our study confirms previous observations that low body weightand long cycles seem to be additional risk factors for the developmentof OHSS.     

Genetics: Association of dopamine D2 receptor gene haplotypes with anovulation and fecundity in female Hispanics

Dopamine is an important neurotransmitter in the hypo-thalamiccontrol of gonadotrophin secretion. Neuron response is mediatedthrough one of five different dopamine receptors. We exploredthe association of D₂ receptor gene polymorphisms with disordersof ovulation. We utilized a multiplex allele specific polymerasechain reaction (PCR) to detect two bi-allelic polymorphisms(four potential haplotypes) in intron 5 and exon 6 of the D₂receptor gene. A second PCR/restriction endonuclease digestwas utilized to verify this. Using these assays, 185 femaleHispanics (51% with known ovulatory dysfunction and 49% withnormal function) were haplotyped. One allele (3) was not presentin the population and there were no significant differencesin remaining allele distribution between ovulatory and anovulatorypatients. However, significant associations were noted betweenalleles and gonadotrophins and fecundity. The 4 allele had adifferent reproductive profile compared to the 2 allele. The4 allele was associated with significantly higher concentrationsof lutein-izing hormone (LH) (means ± SE) (19.2 ±2.2 versus 12.3 ± 1.3 mIU/ml, P < 0.02) and folliclestimulating hormone (FSH) (13.2 ± 2.0 versus 10.0 ±0.6 mIU/ml, P < 0.05), significantly lower concentrationsof prolactin (7.9 ± 0.8 versus 14.9 ± 3.5 ng/ml,P < 0.02) and higher parity (1.4 ± 0.12 versus 0.92± 0.13) and lower miscarriage rates (0.89 ± 0.1versus 1.33 ± 0.24, P < 0.04). We conclude that D₂receptor alleles may be associated with reproductive successthrough altered gonadotrophin secretion and that this effectmay be independent of ovulatory function.     

Does controlled ovarian stimulation prior to chemotherapy increase primordial follicle loss and diminish ovarian reserve? An animal study

BACKGROUND: Storage of embryos for fertility preservation before chemotherapyis widely practiced. For multiple oocyte collection, the ovariesare hyperstimulated with gonadotrophins that significantly alterovarian physiology. The effects of ovarian stimulation priorto chemotherapy on future ovarian reserve were investigatedin an animal model. METHODS: Cyclophosphamide (Cy) in doses of 0, 50 or 100 mg/kg was administeredto 38 adult mice (control, unstimulated). A second group of12 mice were superovulated with equine chorionic gonadotrophin(eCG, 10 IU on Day 0) before Cy administration; hCG (10 IU)was administered (Day 2) followed by 0, 50 or 100 mg/kg Cy (Day4). In both groups ovaries were removed, serially sectioned(7-day post-Cy), primordial follicles were counted and differencesbetween groups evaluated. RESULTS: Follicle number dropped from 469 ± 24 (mean ±SE) to 307 ± 27 and 234 ± 19 with 50 or 100 mg/kgCy, respectively (P < 0.0001). In the eCG pretreated group,follicle count dropped from 480 ± 31 to 345 ±16 and 211 ± 26 when 50 or 100 mg/kg Cy were administered(P < 0.0001). There were no significant differences in folliclecount between the pretreated eCG group and controls for eachchemotherapy dose. CONCLUSIONS: This animal study indicates that ovarian stimulation beforeadministration of Cy does not adversely affect ovarian reservepost-treatment. These results provide support for the safetyof fertility preservation using ovarian stimulation and IVF–embryocryopreservation procedures prior to chemotherapy.     

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.     

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.