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.     

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

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

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

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

Endocrinology: The effects of ICI 182, 780, a pure anti-oestrogen, on the hypothalamic-pituitary--gonadal axis and on endometrial proliferation in pre-menopausal women

ICI 182, 780 has shown pure oestrogen antagonism in vitro andin vivo in animals. A total of 17 women with normal menstrualc2Medical Research Department, Zeneca Pharmaceuticals, Mereside,Alderley Park, Macclesfield, Cheshire SK10 ycles were administeredICI 182, 780, 12mg daily for 7 days in the follicular phaseprior to hysterectomy; 11 normal women were used as controls.Of the 17 patients, three (18%) experienced a luteinizing hormone(LH) surge in the treatment group compared with five (45%) inthe controls (P = 0.24), and these patients were only includedup to the surge. There were no differences in the daily meanplasma LH and follicle stimulating hormone concentrations betweenthe treatment (n = 17) and control (n = 10) groups. The meanplasma oestradiol was higher in the treatment group than controls(P < 0.05) on days 5, 6 and 7. However, there was no increasein endometrial thickness in the treatment group throughout thestudy. In the control group, endometrial thickness increasedduring the study and was significantly higher (P < 0.05)on day 7. There was no ultrasonic evidence of ovarian hyperstimulationand no serious adverse events reported. This study shows thattreatment for 7 days with ICI 182, 780 does not cause ovarianhyperstimulation and has a potent anti-oestrogenic action onthe endometrium. We conclude that ICI 182, 780 may be a usefulcompound in the treatment of oestrogen-dependent gynaecologicaldisease.     

Endometrial thickness: a predictor of implantation in ovum recipients?

In a retrospective study, the relationship between endometrialthickness and pregnancy rate has been studied in 59 ovum recipientwomen. Transvaginal ultrasound assessment of endometrial thicknesswas performed immediately prior to ovum transfer: 19 pregnantrecipients had a mean endometrial thickness of 10.24 mm ±2.63 SD, 40 nonpregnant recipients had an endometrial thicknessof 8.62 mm ± 3.49 SD (t = 1.805, P = 0.0382). Only twopregnancies occurred in 15 recipients with an endometrial thickness<7.5 mm, and none when the endometrial thickness was <7.5mm,and none when the endometrial thickness was <5mm. Our resultsindicate that endometrial thickness is related to the functionalreceptivity of the endometrium.     

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

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

Endometrial thickness as a predictor of pregnancy after in-vitro fertilization but not after intracytoplasmic sperm injection

An ultrasonographic evaluation of the endometrium was performedin 158 patients undergoing ovarian stimulation for an in-vitroassisted reproduction programme. Endometrial thickness was evaluatedin 109 patients undergoing in-vitro fertilization (IVF) forfemale indications and in 49 patients undergoing intracytoplasmicsperm injection (ICSI) for male indications. The maximal endometrialthickness was measured on the day of human chorionic gonadotrophin(HCG) administration by longitudinal scanning of the uteruson the frozen image using electronic callipers placed at thejunction of the endometrium-myometrium interface at the levelof the fundus. Cases in which the endometrial thickness was10 mm were included in group A; cases in which the endometrialthickness was <10 mm were assigned to group B. The age ofthe patients, serum 17- oestradiol concentrations on the dayof HCG administration, the length of follicular stimulation,the number of follicles, 17- oestradiol concentrations per follicleon the day of HCG and the number of embryos transferred wereanalysed in each case. When comparing endometrial thicknessand results in IVF and ICSI patients, an endometrium <10mm predominated in IVF patients (27.5%) compared with thoseundergoing ICSI (16.7%) (P=0.05); conversely an endometrium10 mm was more frequent in ICSI than in IVF patients. The incidenceof pregnancy was higher in IVF group A patients (32/79; 41%)than in IVF group B patients (5/30; 17%) (P=0.03), whereas nosignificant difference was found between ICSI group A (13/42;31%) and ICSI group B (3/7; 43%) patients. Thus, a higher percentageof IVF patients had thin endometrium when compared with ICSIpatients; thin endometrium was a prognostic indicator of pregnancyonly in the case of a female indication for infertility (IVF).A thin endometrium in cases of female infertility may reflecta previous or present uterine pathology, whereas in indicationsof male infertility (i.e. cases using ICSI), in the absenceof any associated uterine pathology, the presence of a thinendometrium is not predictive.     

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.     

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.     

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

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

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

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

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.     

Implantation: Endometrial thickness appears to be a significant factor in embryo implantation in in-vitro fertilization

To evaluate the role of endometrial thickness and pattern inin-vitro fertilization (IVF), these parameters were prospectivelymeasured in 516 cycles of IVF with embryo transfer at our clinic.Pregnancy and embryo implantation rates were assessed for eachmm of endometrial thickness and for each of three endometrialpatterns. Embryo implantation, clinical and ongoing pregnancyrates were significantly higher in the patients with an endometrialthickness >9 mm (24.4, 48.6 and 42.2% respectively) comparedwith those of <9 mm (14.3, 16.0 and 11.7% respectively; P< 0.005). Endometrial thickness was negatively influencedby age and positively influenced by oestradiol concentration.The majority of patients (69.8%) exhibited a ‘ring’endometrial pattern. Embryo implantation and clinical pregnancy(statistically significant), as well as ongoing pregnancy rates(not statistically significant), were lower in patients exhibitingthe ‘solid’ pattern. Endometrial thickness is independentof pattern in its effect on pregnancy outcome. In conclusion,endometrial thickness >9 mm as well as ring and intermediateendometrial patterns denoted a more favourable prognosis forpregnancy in IVF but thinner endometrium and those exhibitinga solid configuration had an acceptable pregnancy outcome.     

Physiology: Human follicular fluid maturity and endothelial cell mitogenesis

Follicular fluid, of varying maturity, (day 5–16 of cycle)was collected from the largest Graafian follicle of each of22 ovulatory patients during laparoscopic procedures. Threesamples were blood-stained and discarded. The mitogenic potentialof each sample was determined using bovine aortic endothelialcells in the CellTiter 96^TM Non-Radioactive Cell Proliferation/CytotoxicityAssay system. Intra- and inter-plate coefficients of variationwere <9%. The follicular fluid samples induced cell doublingtimes which varied from 12–24 h and final cell numberswhich, in the individual wells, ranged from 782–30 900(starting number 2000/well). Follicular fluid total proteincontent was unrelated to the mitogenic potential, (R² = 0%).Serum oestradiol was negatively correlated with the mitogenicpotential (R² = 26%). No correlation was found with day of themenstrual cycle (R² = 4.3%), maximum follicular diameter (R²= 1.8%), or serum concentration of progesterone (R² = 0.7%),luteinizing hormone (LH) (R² = 1.5%) or follicle stimulatinghormone (R² = 0.1%). Five subjects were in ‘early’and six in ‘mid’-follicular phase, six were in ‘early’and two in ‘late’ LH surge. There was no differencein the mitogenic response between these four groups by one-wayanalysis of variance (F = 0.21; P = 0.89). It is concluded thatthe mitogenic potential of human follicular fluid is not relatedto Graafian follicle maturity or, more particularly, to theLH surge.     

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.     

Endocrinology: A comparison of two starting doses of human menopausal gonadotrophin for follicle stimulation in unselected patients for in-vitro fertilization

Ovarian responses and embryology data were compared in patientsundergoing in-vitro fertilization following follicular stimulationusing long course gonadotrophin-releasing hormone (GnRH) analogue/humanmenopausal gonadotrophin (HMG) in which the initial daily dosewas two (150 IU) or three ampoules (225 IU) maintained for aminimum of 7 days. Group 1 (n = 31; centre A) patients weretreated with a starting dose of two ampoules, while group 2(n = 46; centre A) patients were treated chronologically immediatelybefore group 1 with a starting dose of three ampoules per day.Group 3 (n = 74; centre B) patients were treated with threeampoules per day simultaneously with group 1. There was no differencein the distributions of patient ages or reasons for treatmentbetween the three groups. Group 1 required longer treatmentbefore the plasma oestradiol attained 250 pg/ml than did boththe other groups (group 1, 9.0; group 2, 6.9; group 3, 6.7 days;P < 0.01), and this resulted in a longer follicular phasefor group 1 (mean: 14.5 days compared with 12.7 and 12.8 forgroups 2 and 3 respectively; P < 0.05). The numbers of follicles>16 mm in diameter at human chorionic gonadotrophin (HCG)administration and the numbers of eggs and embryos were allsignificantly lower (P < 0.04) in group 1, and cycle cancellationsdue to insufficient ovarian responses were higher (P < 0.02)in group 1. There was no difference in the numbers of ampoulesused, the oestradiol concentration at HCG, the fertilizationand pregnancy rates or the incidence of hyperstimulation syndromein the three groups. The lower starting dose, therefore, yieldedinferior responses without significant reduction in the HMGrequirement.     

Uterus and endometrium: Endometrial thickness: individual and mean growth profiles for different hormone replacement regimens

Currently, there is a paucity of data describing endometrialgrowth, with most studies concentrating on endometrial thicknessimmediately prior to implantation or embryo transfer. This studylooked at the individual and combined growth profiles of 67volunteers receiving three different hormone replacement regimens.Each treatment regimen was in excess of that considered necessaryfor optimal growth, and all promoted an endometrial thicknessthat would be considered satisfactory for embryo transfer. Threepatterns of growth were identified, but overall there was adecrease in the rate of endometrial growth with duration oftreatment. As expected, analysis of variance did not show asignificant difference between the mean growth profiles forthe three hormone replacement regimens. The correlation (r =0.45, P 0.0001) between rank order on day 3 and day 10 of treatmentindicates that interim analysis during early treatment cannotaccurately predict later thickness, but a doubling of endometrialthickness can be expected in most cases. A relationship betweenendometrial thickness and either the treatment dose or serumconcentrations of oestradiol was not found. These findings suggestthat manipulation of endometrial growth is not possible by adjustmentof either the treatment dose or serum concentration. The findingsindicate that treatment beyond 12 days does not promote eithera clinically significant increase in endometrial thickness oran excessive thickness, suggesting that maintenance of an oocyterecipient in a pseudo-follicular phase is unlikely to be disadvantageousto implantation.     

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.     

Pregnancy: Reduced circulating placental protein concentrations during the first trimester are associated with preterm labour and low birth weight

Serum concentrations of human chorionic gonadotrophin (HCG),Schwangerschaftsprotein 1 (SP-1), pregnancy-associated plasmaprotein A (PAPP-A), progesterone and oestradiol were measuredat weekly intervals between the fifth (embryo transfer plus3 weeks) and 13th week of gestation during the first trimesterof pregnancies achieved following in-vitro fertilization (IVF)and embryo transfer in a group of women who delivered before(n = 8) or at term (n = 52). Those women who had a preterm deliveryhad significantly lower concentrations of PAPP-A (weeks 7–13;P = 0.0001–0.028) and SP-1 (weeks 6–8 and 10–12;P = 0.004–0.04). After correction of birth weight forsex and gestational age at delivery, preterm delivery was foundnot to be associated with growth retardation. However, comparisonof the circulating concentrations of the substances analysedin mothers who delivered babies of < 85% of the 50th centileof the normal range of birth weight for a given gestationalage and sex, with those who delivered babies of >85% revealedthat the concentrations of HCG (P = 0.012–0.04 on weeks6–9) and SP-1 (P = 0.003–0.03 on weeks 7, 9–13)were significantly lower in the former group. Weak, inconsistentassociations were found between the circulating concentrationsof HCG, SP-1 and PAPP-A and both corrected birth weight andgestational age at delivery. Thus, both the gestational ageat delivery and low birth weight may be related to impairedplacental development/function during the first trimester.     

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

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