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.     

Endocrinology: Prospective randomized study of clomiphene citrate and gonadotrophins versus goserelin and gonadotrophins for follicular stimulation in assisted reproduction

We performed a prospective randomized study of goserelin, along-acting gonadotrophin-releasing hormone agonist (GnRHa)and human menopausal gonadotrophin (HMG) versus clomiphene citrateand HMG for follicular stimulation in assisted reproductionto investigate whether the use of this GnRHa provides a clearadvantage in terms of pregnancy per treatment cycle in unselectedpatients, who entered a first trial of assisted reproduction.From a retrospective analysis comparing the two stimulationprotocols, a relative increase of the pregnancy rate per cycleof 50% was anticipated. To detect this difference with a powerof 90%, 300 patients had to be included. The main prognosticfactors affecting the outcome of assisted reproduction wereequally divided among the two groups by a minimization procedure.The pregnancy rates per cycle were significantly better in thegoserelin/HMG group than in the clomiphene citrate/HMG group,both for all procedures of assisted reproduction combined (36.8versus 24.5%; P < 0.02) and for the main procedure of in-vitrofertilization (IVF) (37.0 versus 23.5%; P < 0.02). Differencesin pregnancy rates per oocyte retrieval and per embryo transferwere less pronounced (37.8 versus 30.8%; P = 0.40 and 44.4 versus36.8%; not significant). On the other hand, stimulation withgoserelin/HMG was associated with a higher number of ampoulesof HMG (44.9 versus 9.9; P < 0.0001), a longer duration ofstimulation (11.2 versus 8.7 days; P < 0.0001) and an incidenceof ovarian stimulation of 4.5% (7/154) versus 0% in the clomiphenecitrate/HMG group. Goserelin was well tolerated and proved tobe very reliable as an adjunct of follicular stimulation inassisted reproduction. The main determinants of the higher efficacyof goserelin/HMG in assisted reproduction were the virtual absenceof cancellation of the cycle and the increased number of oocytes.     

Ovarian stimulation with buserelin/HMG/HCG: prospective randomized study of short versus long protocol

The combined administration of the gonadotrophin-releasing hormone(GnRH) agonist buserelin and human menopausal gonadotrophin(HMG) was evaluated in 527 cycles (428 patients) of an assistedreproduction programme. All women were randomly allocated accordingto the ovulation induction protocol into two groups: group I(short protocol; 318 cycles) was given buserelin (1 mg/day)intranasally from cycle day 1 and HMG (2 ampoules/day) fromday 3 until human chorionic gonadotrophin (HCG) administration:group H (long protocol; 209 cycles) was given buserelin (1 mg/day)intranasally from cycle day 1 for at least 14 days and then2 ampoules HMG/day were added, increasing progressively accordingto the ovarian response. The number (mean ± SEM) of folliclesdeveloped was higher in group II than in group I (9.1 ±0.4 versus 7.7 ± 0.3, respectively; P < 0.05). Moreoocytes were retrieved in group II (8.4 ± 0.5) than ingroup I (6.5 ± 0.3) (P < 0.001), as well as more embryos(6.3 ± 0.5 and 4.0 ± 0.3, respectively; P <0.001). Moreover, in group II there was a better correlationbetween oestradiol and the total follicular volume (r = 0.5391)on cycle day 0 compared with group I (r = 0.458), while oestradiolvalues were similar between the two groups. No differences wereobserved in the cancellation rate, fertilization rate and maturityof the oocytes between the two groups. The pregnancy rate pertransfer was slightly better in group II (25.8%) than in groupI (19.4%), but this difference was not significant. More stimulationdays were needed in group II than in group I (11.8 ±0.2 and 10 ± 0.2, respectively) (P < 0.001) and moreHMG ampoules (37.7 ± 1.4 and 27.9 ± 0.1, respectively)(P < 0.001). In conclusion, the administration of the longprotocol is associated with a higher number of follicles developed,oocytes retrieved and embryos obtained, while it seems morepromising concerning the pregnancy rates. Nevertheless, treatmentwith this protocol increases the stimulation days and the numberof HMG ampoules administered and hence the cost.     

Sonographic determination of a possible adverse effect of clomiphene citrate on endometrial growth

We recently demonstrated, using transvaginal sonography, thatconception cycles in in-vitro fertilization (IVF) are associatedwith a significantly thicker endometrium at mid-cycle than non-conceptioncycles, suggesting that endometrial growth may influence implantation.In the present study, to examine whether the type of stimulationprotocol affects endometrial development, we compared the sonographicappearance of the endometrium in 22 patients randomized to receiveclomiphene citrate and human menopausal gonadotrophin (CC/HMG)and in 19 who received HMG alone. A significantly thicker endometriumwas observed in the HMG patients compared to the CC/HMG group(P < 0.005) throughout the follicular phase of the cycle,although serum concentrations of oestradiol (E₂) did not differin the two groups. Twenty-three patients (13 in the HMG groupand 10 in the CC/HMG group) had previous IVF cycles with CC/HMGstimulation in which endometrial thickness was measured. A thinendometrium recurred with subsequent CC/HMG cycles while increasedgrowth occurred with HMG only compared to previous CC/HMG cycles.Therefore, ultrasound examination of the endometrium in thisstudy demonstrated that CC results in a thinner endometriumthan HMG alone. We believe these findings may be of importancein improving pregnancy rates in IVF and possibly in other infertilitytherapy which involves the use of clomiphene citrate.     

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.     

The effect of progesterone supplementation prior to the induction of ovulation in women treated for in-vitro fertilization

Thirty-one patients superovulated with clomiphene citrate (CC)and human menopausal gonadotrophin (HMG) were given a singleinjection of 25 mg progesterone (P group) 6 h prior to injectionof human chorionic gonadotrophin (HCG). Levels of urinary andplasma luteinizing hormone (LH) were significantly higher (P<0.001)immediately prior to HCG in the P group compared with thirty-onecontrol patients who had HCG on the same night. Plasma levelsof progesterone remained significantly elevated (P<0.02)for 80 h after injection in the P group, thereafter the levelwas similar to controls. The number of oocytes recovered, fertilizedand replaced per patient was identical in both groups. However,four control patients had no embryos replaced due to failedfertilization. It is concluded that (i) in the majority of Ppatients the timing of ovulation induction by HCG injectionwas appropriate as an LH surge was elicited thus reflectinga physiological stage of readiness, and (ii) elevated plasmaprogesterone levels around the time of oocyte recovery and inthe early luteal phase do not increase the likelihood of theestablishment of pregnancy in patients stimulated for in-vitrofertilization and embryo replacement (TVF/ER) with CC and HMG.     

Regulation of corpus luteum function

The effects have been studied of different ovulation inductionregimens [either domiphene citrate or buserelin in combinationwith human menopausal gonadotrophin (HMG)] on the circulatingconcentrations of progesterone, oestradiol, relaxin and humanchorionic gonadotrophin (HCG) during the first trimester ofpregnancy. Ovulation induction with clomiphene resulted in elevatedconcentrations of gonadotrophins in both phases of the cycle,while during ovulation induction with buserelin, gonadotrophinconcentrations were elevated in the follicular phase only. Theconcentrations of all corpus luteum products were greater inclomiphene pregnancies compared with spontaneous pregnancies,but only oestradiol and relaxin concentrations were greaterin clomiphene pregnancies compared with buserelin pregnancies.The concentrations of HCG were significantly reduced in clomiphenepregnancies compared to natural pregnancies. Relaxin concentrationswere significantly higher from 7 weeks gestation in buserelincompared with spontaneous pregnancies, while progesterone, oestradioland HCG concentrations were not consistently different. Consistentassociations were found between relaxin and HCG concentrationsin spontaneous pregnancies and between the concentrations ofrelaxin and both progesterone and oestradiol in pregnanciesachieved after ovulation induction. These data suggest that(i) given the similarity in the circulating concentrations ofHCG, the relatively lower circulating gonadotrophin concentrationsduring the luteal phase of the cycle of conception result inreduced circulating concentrations of oestradiol and relaxin;while in the case of relaxin this effect is partially reversible,there is no evidence that this is so for oestradiol; (ii) synthesisof progesterone in the corpus luteum is less affected by lowerconcentrations of gonadotrophins during the luteal phase; (iii)ovulation induction with clomiphene results in pregnancies withlower concentrations of HCG, suggesting that trophoblast functionmay be impaired; and (iv) corpus luteum function is linked withplacental steroidogenesis.     

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.     

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

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

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

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

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.     

Sequential clomiphene citrate and human menopausal gonadotrophin for ovulation induction: comparison to clomiphene citrate alone and human menopausal gonadotrophin alone

The need for frequent injections and monitoring, the possibilityof multiple gestations, and the higher cost compared to clomiphenecitrate, prevents many clinicians from using human menopausalgonadotrophin (HMG) for ovulation induction. A sequential medicationregimen, in which HMG is taken after clomiphene, overcomes theseproblems. We retrospectively compared per cycle fecundity andbirth rates in 119 cycles of clomiphene—HMG, 524 cyclesof clomiphene alone, 57 cycles of HMG alone, and 79 cycles ofconcurrent HMG and clomiphene in patients receiving intra-uterineinsemination (IUI), who were free of endometriosis or tubaldisease. Per cycle fecundity for clomiphene—HMG was 22%[95% confidence interval (CI) 12–34%], double that ofclomiphene alone (11%) (95% CI 8–14%) (P < 0.01), andequal to HMG alone (18%) (95% CI 7–29%) or HMG and clomiphenetogether (19%) (95% CI 10–28%). The multiple birth ratefor clomiphene—HMG (7/21) equalled that for HMG alone(3/12) and HMG and clomiphene together (3/8). The average numberof ampoules of HMG required [follicle stimulating hormone (FSH)75 mIU, luteinizing hormone (LH) 75 mIU] was decreased by 65%from 24.5 ± 1.0 for HMG or HMG and clomiphene togetherto 8.6 ± 0.3 for clomiphene—HMG (P < 0.001).Per cycle fecundity was identical when one, two or three ampoulesof HMG per day were administered after clomiphene. We concludethat ovulation induction with sequential clomiphene—HMGresults in fecundity double that of clomiphene alone and equalto HMG alone or concurrent with clomiphene, thereby reducingthe requirement for HMG.     

Endocrinology: Luteal phase oestradiol and progesterone levels are stronger predictors than follicular phase follicle stimulating hormone for the outcome of in-vitro fertilization treatment in women with tubal infertility

Basal follicle stimulating hormone (FSH) in a natural cycle,FSH on cycle days 3 and 10 in a domiphene citrate-stimulatedcycle and oestradiol and progesterone area under the curve (AUC)in the luteal phase of the ciomiphene citrate-stimulated cyclewere evaluated as hormonal predictors for the outcome of FVFtreatment in 53 normally cycling women with tubal infertility.The pregnant women had significantly fewer treatment cycles(P < 0.001) and needed fewer ampoules of gonadotrophins (P< 0.001). They also had more oocyte retrievals (P < 0.001),more oocytes per retrieval (P < 0.01), higher fertilizationrate (P < 0.001) and more replaced pre-embryos per replacement(P < 0.01) as compared with non-pregnant women. Significantdifferences were found in FSH concentrations on cycle days 3(P < 0.05) and 10 (P < 0.001) after domiphene citratestimulation and for oestradiol and progesterone AUC in the lutealphase (P < 0.001) between those women who became pregnantand those who did not become pregnant after IVF treatment Lutealoestradiol and progesterone had considerably stronger predictivevalue for the outcome of IVF treatment as compared to basalFSH and domiphene citrate challenge test.     

The origin of serum progesterone during the follicular phase of menotropin-stimulated cycles

The study was designed to investigate the source of progesterone secretion during pituitary suppression and ovarian stimulation. It involved 416 women undergoing in-vitro fertilization (IVF) who were treated with gonadotrophin-releasing hormone agonist (GnRHa) and human menopausal gonadotrophin (HMG) (group I), 139 women undergoing ovulation induction with HMG only (group II) and nine women who were diagnosed previously as late-onset adrenal hyperplasia and treated continuously with dexamethasone, in addition to ovulation induction (group III). During HMG treatment, serum oestradiol and progesterone were measured every 1-2 days. If progesterone concentration exceeded 3.0 nmol/l, at least 36 h before human chorionic gonadotrophin (HCG) administration, the patients were prospectively randomized to treatment with dexamethasone or not and the hormones concentrations were measured again 12 h later. Mean age and pretreatment serum concentrations of dehydroepiandrosterone sulphate, androstenedione, testosterone and luteinizing hormone/follicle stimulating hormone (LH/FSH) ratio, were not significantly different in the patients with and without progesterone elevation. Pituitary down-regulation did not reduce the incidence of progesterone elevation (13.9 and 12.2% in groups I and II respectively), while in group III, progesterone concentrations did not increase. After dexamethasone administration a significant decrease in serum progesterone concentration was demonstrated (mean +/- SD, -2.1 +/- 1.4 and -1.6 +/- 1.2 in groups I and II respectively, while in the untreated patients it increased (+1.9 +/- 1.9 and +4.2 +/- 4.8). The increase in serum progesterone concentrations was not accompanied by an increase in cortisol and 11-deoxycortisol but by an increase in LH. After dexamethasone administration the concentrations of cortisol, 11- deoxycortisol and LH significantly decreased. Progesterone concentration was positively correlated with both oestradiol concentration (r = 0.290; P < 0.05) and the number of oocytes retrieved (r = 0.207; P < 0.05). We conclude that at least a part of serum follicular-phase progesterone appears to be of adrenal origin. High oestrogen concentrations (or other ovarian factors) may cause changes in the hypothalamic-pituitary-adrenal axis and in adrenal enzyme activity as a part of the complex 'cross-talk' between the hypothalamic- pituitary-ovarian and the hypothalamic-pituitary-adrenal axes.      

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.     

Comparison of a fixed and dynamic protocol for embryo replacement in an IVF/ET programme

Implantation after embryo transfer is considered a major obstadein terms of pregnancy rates after in-vitro fertilization. Aflexible approach to the date of replacement, based on the factthat the most suitable embryonic structure for proper implantationis the four- to eight-cell embryo, has been studied. One-hundred-and-twentypatients with various aetiologies of infertility were stimulatedwith HMG or combined HMG and FSH, then treated by three differentmethods of embryo replacement. In group I embryos were replacedin mothers 48 h after ovum retrieval; in group II replacementswere carried out 72 h after retrieval; and in group III replacementswere related to embryonic cleavage development. Mean levelsof oestradiol when HCG was given averaged 1301 ± 121pg/ml, 1016 ± 96 pg/ml and 1182 ± 101 pg/ml inthe three groups, respectively. There was no significant differencein the average number of embryos transferred among the variousgroups. The pregnancy rates per transfer were 21.8, 24.2 and38.7%, respectively (P < 0.001). Although more investigationis required, a dynamic approach to embryo replacement mightsignificantly improve pregnancy rates, because of improved interactionsbetween the embryos and the uterus.     

Questioning the efficacy of Fallopian tube sperm perfusion

The aim of this work was to compare the efficiency of standard intrauterine insemination (IUI) and Fallopian tube sperm perfusion (FSP) in the treatment of infertility. Ninety-six consecutive patients with infertility in 100 cycles were included in the study. Those randomized to standard IUI included 48 patients in 50 cycles [25 clomiphene citrate only and 25 clomiphene citrate/human menopausal gonadotrophin (HMG) cycles] (group I). Patients subjected to FSP included 48 patients in 50 cycles (18 clomiphene citrate only and 32 clomiphene citrate/HMG cycles) (group II). The overall pregnancy rate per cycle (16% versus 18%) was not significantly different in the two groups. The pregnancy rates were also similar in the two groups when compared for the cause of infertility: ovulatory disorder 16.7% versus 16%, tubal impairment 10% versus 9.1%, cervical hostility (no pregnancy occurred in this group) and unexplained infertility 21.4 % versus 25 %. The overall pregnancy rate (for the two groups) appeared higher when clomiphene citrate/HMG was used for ovulation induction (21.1%) than when clomiphene citrate only was used (11.6%).      

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.     

Circulating placental protein 14: in the first trimester of spontaneous and IVF pregnancies

Circulating placental protein 14 (PP14) levels were measuredduring the first trimester in three groups of pregnant women:(i) natural conception (n = 15); (ii) pituitary desensitizationwith buserelin and ovarian stimulation with human menopausalgonadotrophin (HMG) followed by in-vitro fertilization and embryotransfer (IVF—ET) (n = 15); and (iii) ovarian stimulationwith clomiphene citrate and HMG, followed by IVF—ET (n= 16). A 7- to 8-fold increase in serum PP14 levels was observedin normal pregnancies between weeks 4 and 10. This increasewas earlier and less marked in group (ii) and absent in group(iii). These findings support the concept that endometrial functionis altered in pregnancies achieved following ovarian stimulation.Alternatively, if the ovary is an important source of PP14,then these data suggest that in contrast to ovarian synthesisof steroids and the peptide relaxin, ovarian stimulation resultsin an impairment of PP14 synthesis, and that this is most markedwhen clomiphene citrate has been used.     

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

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