Timed unilateral ovarian follicular aspiration prior to administration of human chorionic gonadotrophin for the prevention of severe ovarian hyperstimulation syndrome in in-vitro fertilization: a prospective randomized study

Unilateral ovarian follicular aspiration 6-8 h prior to trigger administration of human chorionic gonadotrophin (HCG) was performed or not in 31 women at serious risk of ovarian hyperstimulation syndrome (OHSS) after ovarian stimulation for in-vitro fertilization (IVF)-embryo transfer or intracytoplasmic sperm injection (ICSI) in this prospective randomized study. Unilateral follicular aspiration was performed in 16 women (group 1) matched for age, indication for fertility treatment, and the amount and duration of gonadotrophin exposure with 15 women not receiving aspiration treatment (group 2). There was a statistically significantly (P < 0.001) lower mean number of oocytes obtained from group 1 women (14.9 +/- 1.8 vs 22.6 +/- 2.4). The fertilization (53.2 +/- 2.6 vs 65.5 +/- 1.35%) and embryonic cleavage (91.3 +/- 2.1 vs 90.2 +/- 1.75%) rates were similar in both groups. OHSS occurred in women from both groups (group 1: 25% vs group 2: 33.3%) being severe OHSS in two women from group 1 and one from group 2. We conclude that unilateral ovarian early follicular aspiration prior to HCG trigger administration does not reduce the occurrence of severe OHSS in women at risk.

Placental protein 14 production by human Fallopian tube epithelial cells in vitro

We studied the in-vitro secretory function of non-polarized and polarized cultured Fallopian tube epithelial cells by measurement of the placental protein 14 (PP14) secretion in primary cultures and subcultures from Fallopian tubes obtained from eight premenopausal women in different phases of the ovarian cycle. Primary cultures were established in minimal essential medium in Earle's salts supplemented with fetal bovine serum and the cells were subcultured for six passages, in the polarized cell cultures, the cells being seeded on an extracellular matrix system. Cell freezing was carried out using 10% dimethyl sulphoxide. PP14 secretion into the culture media was measured by a radioimmunoassay using 125I-PP14 as label and rabbit anti-human PP14 serum. There was a large amount of PP14 secretion into the culture media in primary cultures, the secretion decreasing considerably after subculture 1. PP14 secretion after subculture 2 was not different from the control values. Polarized and non-polarized cells secreted similar amounts of PP14 and frozen-thawed cells did not appear to secrete PP14. Epithelial cells from Fallopian tubes obtained at different phases of the ovarian cycle did not appear to show any difference in PP14 secretion rates. Our data suggest that the in-vitro secretion of PP14 by human Fallopian tube epithelial cells is adversely affected by cell ageing and freezing.

Pregnancy rates after intracytoplasmic sperm injection in relation to sperm recovery techniques

PURPOSE/METHODS

Clinical outcome after intracytoplasmic sperm injection (ICSI) was evaluated in relation to three techniques of sperm recovery, mini-Percoll, simple concentration, and centrifugation and washing.

RESULTS

Whereas fertilization and embryonic cleavage rates were similar in the three groups, the rates of implantation and clinical pregnancy were statistically significantly higher following sperm recovery by the techniques of mini-Percoll and centrifugation and washing.

Serum parameters and nuchal translucency in first trimester screening for fetal chromosomal abnormalities

OBJECTIVE

To assess the relation between serum parameters and nuchal translucency in pregnancies affected by fetal aneuploidy in the first trimester.

DESIGN

Retrospective study of different serum parameters collected prior to chorionic villus sampling and measurement of nuchal translucency in relation to fetal aneuploidy.

SETTING

Switzerland (German and Italian sector) and Bregenz, Austria.

POPULATION

One thousand one hundred and fifty-one women aged 25 to 44 years at 10 to 13 weeks of gestation undergoing chorionic villus sampling, mostly for advanced maternal age. Fetal aneuploidy was found in 23 pregnancies including four cases of trisomy 21, five of trisomy 18 and one case of trisomy 13.

MAIN OUTCOME MEASURE

Fetal karyotype, serum levels of free beta-hCG, pregnancy-associated plasma protein A (PAPP-A) and alpha-fetoprotein and the measurement of nuchal translucency.

RESULTS

Serum PAPP-A was decreased in all common chromosomal abnormalities. Free beta-hCG levels were increased in trisomy 21 but decreased in trisomy 18, whereas alpha-fetoprotein was low in trisomy 21, 18 and other chromosomal abnormalities. Nine of twenty-three abnormal embryos had evidence of an increased nuchal translucency. Nuchal translucency, however, did not seem to be associated with any alteration in the levels of the biochemical parameters in either chromosomally normal or abnormal embryos. A low serum PAPP-A or an increased nuchal translucency was seen in two-thirds of all pregnancies with chromosomal abnormalities.

CONCLUSION

A nuchal translucency > or = 3 mm and depressed serum PAPP-A levels have a good predictive value in the detection of fetal aneuploidy at 10 to 13 weeks of pregnancy. Serum free beta-hCG and alpha-fetoprotein levels may give additional information. An increased nuchal translucency was not associated with altered serum parameters. This would allow these different markers to be used in combination.

Mimicking the high levels of activity of a large in-vitro fertilization unit leads to early success at the commencement of an in-vitro fertilization and embryo transfer programme

Infertile couples seeking treatment will endeavour to obtain the highest standards of care at a conveniently located centre. The success rated of a centre would also be an important concern. The busier in-vitro fertilization (IVF) units (> 400 cycles per year) have substantially higher pregnancy rates than those carrying out < 300 cycles per year. We report our experiences at the IVF centre, Maternity Hospital, Kuwait of mimicking the high level of activity of a large IVF unit. Infertile couples were treated in groups of 30-35 every 4-6 weeks. Patients in each group had menstrual cycles synchronized to their luteal phase using progestogens. Thereafter they were down-regulated with gonadotrophin-releasing hormone agonist (long protocol). Oocyte retrieval and embryology activities were concentrated and completed in 7-10 days in each group. This episodic high level of activity was aimed at mimicking that of a busy large IVF centre, although continuous in the latter. The overall results in terms of fertilization cleavage, implantation and clinical pregnancy rates were similar to those obtained in large IVF units. The clinical pregnancy rate per cycle was 25.8-39.1% in IVF and 46.1% in intracytoplasmic sperm injection.

Incidence of microbial growth from the tip of the embryo transfer catheter after embryo transfer in relation to clinical pregnancy rate following in-vitro fertilization and embryo transfer

A total of 110 consecutive women was studied prospectively at the time of transcervical embryo transfer following conventional in-vitro fertilization and intracytoplasmic sperm injection procedures. Microbiological cultures were performed on endocervical swabs and embryo transfer catheter tips. Positive microbial growths were observed from endocervical swabs in 78 (70.9%) women and from catheter tips in 54 (49.1%) women. The clinical pregnancy rates were 57.1% in the group of patients without growth and 29.6% in the group with positive microbial growth from catheter tips. As microbial contamination at embryo transfer may influence implantation rates, prospective studies are justified to determine whether eradication of endocervical micro-organisms is possible and whether their eradication will improve implantation rates.

First-trimester biochemical screening for Down syndrome with the use of PAPP-A, AFP, and beta-hCG

Biochemical screening for Down syndrome (DS) is well established in the second trimester of pregnancy, but there is little information available on its value in the first trimester. This study describes our preliminary results with biochemical screening for DS in the first trimester of pregnancy in order to evaluate its efficacy at this time. Our study population, including 19 DS pregnancies, was evaluated using maternal serum levels of alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (beta-hCG), and pregnancy-associated plasma protein A (PAPP-A). At a false positive rate (FPR) of 5 per cent, the detection rate (DR) for DS is 9 per cent for beta-hCG, 18 per cent for AFP, and 66 per cent for PAPP-A when considering these parameters individually. With different combinations of the analytes, the best detection rates are obtained with the association of PAPP-A and AFP (85 and 82 per cent DR for a 10 and 5 per cent FPR, respectively). Our data support the value of first-trimester biochemical screening for DS and that of PAPP-A as a single marker.

The expression of gonadotropin-releasing hormone and its receptor in endometrial cancer, and its relevance as an autocrine growth factor

The presence of a direct extra-pituitary action of gonadotropin-releasing hormone (GnRH) via specific receptors in endometrial cancer (EC) has been suggested as an explanation for the therapeutic effect of GnRH analogue (GnRHa) in recurrent disease. We have sought the expression of the GnRH peptide and functional GnRH receptor (GnRH-R) in human tissues and cell lines to investigate the possibility of an autocrine growth regulation mechanism. Using reverse transcription-PCR, differing GnRH mRNA transcripts were detected in two EC cell lines (Ishikawa and HEC-1A), a choriocarcinoma (JEG3) cell line, and tissues from endometrium and placenta. However, secretion of immunoreactive GnRH could be detected by RIA in only 1 of 10 EC tissues in primary culture, and in none of the cell lines. Low levels of GnRH-R mRNA expression were found in the same cells, which were only detectable by reverse transcription-PCR and Southern blotting of the PCR product. In radioligand binding assays using GnRHa goserelin, no pituitary-like, high-affinity GnRH binding sites could be found in either EC cell lines or tissues. Low affinity binding (Kd = 1.0 - 3.1 x 10(-7)M) was detected in three of eight (37%) EC tissues. Furthermore, receptor signal transduction measurements carried out in these cells showed no increases in either total inositol phosphate, cyclic AMP production, or cytosolic Ca2+ in response to either GnRH or GnRHa. Finally, no effect of either GnRH or GnRHa on the growth of EC cell lines was detected in vitro, under estrogen-free conditions, assessed by DNA content. Our data suggest that although there is a potential for autocrine activity for GnRH in EC as judged by the presence of mRNA for peptide and receptor, no functional receptor activity could be detected in vitro. Alternative mechanisms should be studied to explain the in vitro action of GnRHa.

Outcome of assisted reproduction technology in infertile couples of consanguineous marriage

PURPOSE

The outcome of pregnancies resulting from assisted reproduction technology does not seem to differ from the outcome of those arising from spontaneous natural conception.

METHODS

There is increased risk of chromosomal abnormality in spontaneous natural pregnancies resulting from consanguineous marriage, with consequent higher rates of miscarriage, stillbirth, and congenital abnormalities.

RESULTS

This study has shown a trend of an increased miscarriage rate (but not statistically significant) in pregnancies achieved in infertile couples of consanguineous marriages by assisted reproductive technology.

CONCLUSIONS

Selecting embryos for transfer on the basis of their morphology does not appear to reduce the risk of chromosomal abnormality in these couples.

[Isolation and purification of pregnancy-associated plasma protein A]

We tried to purify pregnancy-associated plasma protein A (PAPP-A) from normal term maternal serum in this study by means of a three step chromatographic procedure. At first 30 ml of maternal serum samples were applied to a column for sieve chromatography and eluted according to molecular weight. PAPP-A was detected in the high molecular weight fraction area by radioimmunoassay for PAPP-A, and 91% of the total amount of PAPP-A in the maternal samples was recovered. Secondary PAPP-A containing fractions were applied to a Heparin-Sepharose column and eluted by a stepwise increase in NaCl 0.15, 0.30 and 0.60 M in 0.05 M Tris-HCl buffer, pH 7.8. Ninety-three percent of PAPP-A in applied samples was recovered under the 0.6 M NaCl condition. Thirdly the pooled fractions which contained PAPP-A after Heparin-Sepharose affinity chromatography were applied to DEAE-Sephacel Chromatography and eluted by a stepwise increase in NaCl 0.15, 0.30 and 0.45 M in 0.01 M acetate buffer, pH 5.5. Ninety-one percent of PAPP-A in applied samples was recovered under the 0.3 M NaCl condition. Finally PAPP-A containing fractions were concentrated 10 times and 3.8 IU (1.7 mg) of PAPP-A was isolated. The purification schedule removed approximately 99% of total protein in the maternal serum while 74% of PAPP-A was recovered. The purification factor (fold), which was calculated as the increase in specific activity (mIU:PAPP-A/mg:protein) in comparison with the starting value in the maternal serum, was 526. And the purity (mg:PAPP-A/mg:protein) of the final product was 68.4%. Analysis of the final purified material by SDS-PAGE showed a single band of 200kDa, and western blot analysis showed that the main purified protein was PAPP-A. The immunological identity of the PAPP-A purified in this study to the PAPP-A donated by Teisner et al., was recognized by crossed immunoelectrophoresis and tandem crossed immunoelectrophoresis. We hope that the new PAPP-A purified in this study can be utilized for the development of a sensitive and convenient assay for PAPP-A and its standard material, and also for basic study to clarify the biological function of PAPP-A in the human body.

Abnormal amniotic fetal antigen 2 concentrations in trisomy 18 and trisomy 21

Fetal antigen 2 (FA-2) is a human protein, first identified in amniotic fluid, and shown to be identical to the aminopropeptide of the alpha 1 chain of collagen type I. It exists in several different size and charge forms. In the present study, FA-2 was measured in amniotic fluid using two different assays: a rocket line immunoelectrophoretic assay which measured total FA-2, and a radioimmunoassay which was specific for the high molecular mass forms of FA-2. Both assays gave similar results. FA-2 concentrations were measured in amniotic fluid samples collected from normal pregnancies at 10-23 weeks gestation; they were shown to rise steeply from 10-14 weeks, peak at 17 weeks and then fall slightly by 23 weeks. Comparison between amniotic fluid from normal pregnancies and pregnancies affected by trisomy, showed significantly higher FA-2 concentrations in trisomy 21 and significantly lower concentrations in trisomy 18.

Crown-rump length in aneuploid fetuses: implications for first-trimester biochemical screening for aneuploidies

This study examined the effect of estimation of gestational age from the menstrual history compared with that from crown-rump length (CRL) measurement on the detection rate of screening for aneuploidies in the first trimester. Pregnancy-associated plasma protein A (PAPP-A) was assayed in blood collected prior to chorionic villus sampling in 356 women with unaffected pregnancies and 28 women with an aneuploid pregnancy. There were 14 Down's syndrome (DS) pregnancies. All pregnancies were dated from menstrual history and CRL measurement. The average CRL gestation in the aneuploid population was 2.5 days less than that derived from the LMP (95 per cent confidence interval (CI) for LMP-CRL gestation: using the algorithm based on unaffected pregnancies 0-3.5 days; using the matched case-control approach 1-4.5 days). The average CRL gestation in the DS population was 2 days less but this did not reach statistical significance (95 per cent CI for LMP-CRL gestation: using the algorithm -1 to 4.5 days; using the matched case-control approach 0 to 5.5 days). The detection rate of aneuploidies in the first trimester using maternal serum PAPP-A was reduced by 7 per cent (and by 3 per cent for DS) for a 5 per cent false-positive rate when using CRL rather than LMP to date the pregnancy. This phenomenon is a consequence of an apparent reduction of gestational age when estimated by CRL in the aneuploid population. Further studies are required to evaluate whether CRL is an unbiased estimate of gestation for Down's syndrome pregnancies.

The Euro-Team Early Pregnancy (ETEP) protocol for recurrent miscarriage

The underlying causes and rationale for treatment of recurrent abortion are not entirely clear. The Euro-Team early pregnancy protocol was developed as a diagnostic work-up based on the evaluation of risk factors. Possibilities for therapy can be based only on the expectancy that elimination of some risk factors may improve the prognosis.

The typing of fetal antigen 2 in human amniotic fluid

Fetal antigen 2 (FA-2) has been identified in amniotic fluid and shown to be of fetal origin. In this study we have extended previous observations on FA-2 heterogeneity with respect to both size and charge using gel filtration, ion-exchange chromatography, non-dissociating polyacrylamide gel electrophoresis and sodium dodecyl sulphate polyacrylamide gel electrophoresis. From the diversity of forms we have been able to define two principal FA-2 types, type A and type B. Type A has a high molecular mass (140 kDa), has subunits of 33 kDa and 29 kDa, and elutes at approximately 0.27 mol/l sodium chloride from diethylaminoethyl (DEAE)-Sephacel. Type B has the same mass and subunits as type A, but elutes at approximately 0.24 mol/l sodium chloride from DEAE-Sephacel. Other low molecular mass forms of FA-2 have also been identified. All FA-2 forms described were shown to be common to all amniotic fluid samples studied and were not attributable to artefacts of collection or storage. It was also demonstrated that the recently described FA-2 RIA is specific for FA-2 types A and B and the conversion of arbitrary units FA-2 into micrograms applies to type A. The typing is discussed with respect to (i) the aminopropeptide of the alpha 1 chain of human procollagen type I, (ii) the 24 kDa phosphoprotein in developing bone and (iii) fetal calf ligament protein 1 (FCL-1), suggesting that they are the same protein.

Screening for Down syndrome in the first trimester

Second-trimester maternal serum screening for Down syndrome is now well established, and permits detection of up to 70% of cases. The disadvantage of this sort of screening is that the timing of maternal blood sampling is relatively late (after 15 weeks). There is an accumulating body of evidence to suggest that in the first trimester concentrations of a number of pregnancy-associated proteins and hormones differ in chromosomally normal and abnormal pregnancies. A first-trimester maternal serum screening test for Down syndrome may therefore be possible. In addition, new methods of screening have recently been described based on ultrasound findings at 11 to 13 weeks of gestation. This review article presents a discussion of published data on the feasibility of first-trimester screening for Down syndrome.

The value of single versus repeated insemination in intra-uterine donor insemination cycles

Pregnancy rates per cycle of intra-uterine donor insemination following ovulation induction were compared retrospectively for those patients having a single, and those having repeated insemination using frozen donor semen. Single insemination was performed in 69 cycles in which 15 women became pregnant (pregnancy rate = 22%). Of 65 cycles in which repeated insemination was performed, 16 women became pregnant (pregnancy rate = 25%). This difference in pregnancy rates was not statistically significant (chi 2 = 3.6, P = 0.84). We conclude that cycle fecundity may not be increased by repeating insemination.

Serum PAPP-A and free beta-hCG are first-trimester screening markers for Down syndrome

Serum measurements of pregnancy-associated plasma protein A (PAPP-A) and the free beta-human chorionic gonadotrophin (hCG) subunit were made in 13 women with Down syndrome (DS) pregnancies and six other women with fetal aneuploidy ascertained at chorionic villus sampling (CVS), as well as 89 women with contemporaneous normal control pregnancies. Median serum PAPP-A measurements (0.31 MOM, 95 per cent confidence interval (CI) 0.22-0.65 vs. normal 1.06, 95 per cent CI 0.89-1.20) were lower and free beta-hCG subunit measurements (1.13 MOM, 95 per cent CI 0.93-2.63 vs. normal 0.91, 95 per cent CI 0.79-1.03) were higher at statistically significant levels. Receiver operator characteristics (ROC) curves showed that the highest sensitivity for detection, 71.2 per cent (95 per cent CI 54.7-87.6 per cent), was for depressed PAPP-A levels; the combination of low serum PAPP-A levels, maternal age, and elevated free beta-hCG levels yielded a detection rate of 78.9 per cent (95 per cent CI 64.9-92.8 per cent) of the affected pregnancies at 8-12 weeks' gestation.

Pregnancy-associated plasma protein A levels in maternal serum, extraembryonic coelomic and amniotic fluids in the first trimester

First trimester maternal serum levels of pregnancy-associated plasma protein A(PAPP-P) are reduced in women with a Down's syndrome pregnancy. We have examined the concentration of this molecule in the amniotic (AF) and extra-embryonic coelomic (EECF) fluids surrounding the developing fetus. Maternal serum levels of PAPP-A were elevated in all samples and steadily rose from a median of 480 mIU/1 at 8 weeks to a median of 6375 mIU/1 at 14 weeks gestation. Levels of PAPP-A were low in EECF and undetectable in the AF until 14 weeks gestation. This pattern of distribution is in contrast to that of most other trophoblast-associated antigens. This may reflect PAPP-A physiology and its specific production by the syncytiotrophoblast.