Treatment with pulsatile luteinizing hormone-releasing hormone modulates folliculogenesis in response to ovarian stimulation with exogenous gonadotropins in patients with polycystic ovaries

Combined treatment with pulsatile LH-RH and hMG, given to eight patients who had anovulation associated with PCO and resistant to CC, significantly reduced the number of large follicles induced by hMG alone. A direct effect of pulsatile LH-RH on the ovary is postulated. This combined treatment eased the problems of multifollicular development, thereby increasing efficiency and reducing complications in patients with PCO stimulated by gonadotropins.

Induction of ovulation with pulsatile GnRH

The use of pulsatile GnRH to treat infertile women who do not ovulate has been shown to be safe, simple, and effective and the preferred method of inducing ovulation in appropriately selected patients who are resistant to treatment with clomiphene citrate. Treatment with GnRH is particularly effective for restoring ovulation in patients with idiopathic hypogonadotrophic hypogonadism and partially recovered weight-related amenorrhoea, but less successful in patients with polycystic ovary syndrome and organic hypothalamic pituitary disease. Based on personal experience, we advocate routine use of the subcutaneous route, using 15 micrograms per pulse every 90 min, and we monitor the patient's progress by serial ultrasound scanning and measurement of serum gonadotrophin and oestradiol concentrations. If the patient does not respond we recommend adding treatment with clomiphene citrate (Homburg et al, 1988b). Treatment with intravenous GnRH is reserved for women who do not respond to the above combination of drugs. We do not treat patients with GnRH until their body mass index is in the normal range (between 20-25) and we avoid GnRH treatment in patients with hypersecretion of LH during the follicular phase. If LH concentrations are raised, an alternative method of treatment is recommended, such as ovarian diathermy (Armar et al, 1990). Finally, the question of whether GnRH deficiency in patients with hypogonadotrophic hypogonadism is caused by a specific genetic lesion is not yet fully resolved. Yang-Feng et al (1986) used a cDNA clone encoding the human GnRH precursor molecule in order to assign the GnRH gene to a particular human chromosome. They found a single site for GnRH sequences in the human genome and that the gene coding for GnRH is located on the short arm of chromosome 8. Experiments in the congenitally hypogonadal mouse have shown that it is possible to restore gonadal development and gametogenesis by gene transfer (Mason et al, 1987). Clearly an abnormality at the level of the genome may be responsible for the secretory defect in patients with hypogonadotrophic hypogonadism, but it has yet to be defined (Weiss et al, 1989). Presumably elucidation awaits the development of more refined methods because both the genetics and the clinical associations of GnRH deficiency are most persuasive. Meanwhile replacement treatment with GnRH provides a simple and safe form of treatment for managing the clinical syndromes of GnRH deficiency.

A comparative study of single-dose growth hormone therapy as an adjuvant to gonadotrophin treatment for ovulation induction

One intramuscular injection of biosynthetic human growth hormone (24 IU), administered on the first day of gonadotrophin treatment for ovulation induction, significantly augmented the ovarian response to gonadotrophic stimulation in seven patients. Compared with a protocol involving six injections of 24 IU of GH given on alternate days to the same patients, the smaller dose had an intermediate but highly significant effect in reducing the amount, duration of treatment and daily effective dose of hMG needed to induce ovulation. The difference between the effect of the one-dose and six-dose protocols was small. The action of growth hormone on the human ovary, probably mediated by insulin-like growth factor-1 (IGF-1), appears effective in enhancing the response to gonadotrophin therapy even when given in a single dose.

A double-blind study comparing a new non-ergot, long-acting dopamine agonist, CV 205-502, with bromocriptine in women with hyperprolactinaemia

Twenty-two hyperprolactinaemic women were randomly allocated to two groups and treated with bromocriptine or the new, non-ergot, long-acting dopamine agonist, CV 205-502. The study was double-blind for 6 months. Four patients in the bromocriptine group, but none in the CV 205-502 group, discontinued the study because of adverse reactions. Adverse reactions in those receiving the new drug were milder and more transient than with bromocriptine. With once-daily doses of 0.075 mg CV 205-502, eight of 11 women achieved normal PRL concentrations after 8 weeks treatment (median (95% confidence limits), 352 (70-987) mU/l) compared with two of nine receiving a divided daily dose of 5 mg bromocriptine (1802 (1205-4438) mU/l) (P less than 0.002). With doses of 0.075-0.15 mg of CV 205-502, 10 of 11 women achieved normal PRL concentrations at 24 weeks compared with three of the remaining seven women on doses of 5-10 mg of bromocriptine. Regular menstrual bleeding was restored and galactorrhoea relieved in the majority of patients, with marginally greater efficacy with CV 205-502. CV 205-502 is highly effective for the long-term treatment of hyperprolactinaemia. It is better tolerated than bromocriptine, is effective in a once-daily dose, appears to be safe, and provides a valuable alternative to the dopamine agonist drugs in use today.

Cotreatment with human growth hormone and gonadotropins for induction of ovulation: a controlled clinical trial

A randomized, double-blind, placebo-controlled trial of cotreatment with biosynthetic, human sequence, growth hormone (GH), and human menopausal gonadotropins (hMG) for induction of ovulation was performed in 16 women with amenorrhea and anovulatory infertility. Patients were randomly allocated to treatment with hMG + GH (24 IU on alternate days, total dose 144 IU) or hMG + placebo. Those who received placebo were given GH in a subsequent course of treatment. On cotreatment with GH compared with placebo, there was a significant reduction in the required dose of hMG, duration of treatment, and the daily effective dose of gonadotropins. Serum insulin-like growth factor-I (IGF-I) rose during treatment with GH but not with placebo. We conclude that growth hormone augments the response of the human ovary to stimulation by gonadotropins. These results suggest a role for the use of GH in induction of ovulation.

Combined luteinizing hormone releasing hormone analogue and exogenous gonadotrophins for the treatment of infertility associated with polycystic ovaries

This study was designed to compare the results of treatment with, firstly, exogenous gonadotrophins, with (57 cycles) and without (65 cycles) pretreatment with a superactive analogue of luteinizing hormone releasing hormone (LHRH) and, secondly, pure follicle stimulating hormone (FSH) (50 cycles) with those of human menopausal gonadotrophin (HMG) (72 cycles) in 46 women with clomiphene-citrate-resistant anovulation associated with polycystic ovaries. Patients randomly allocated to the analogue group received buserelin (Suprefact, Hoechst, UK, Ltd, Hounslow, Middlesex), 800 micrograms/day by nasal insufflation and when hypogonadism was achieved, patients were again randomly allocated for ovarian stimulation with either FSH or HMG. Controls received FSH or HMG alone. Patients pretreated with the analogue had similar pregnancy and ovulation rates, needed larger doses and more days of gonadotrophin therapy and had more ovarian overstimulation than those receiving no pretreatment. The role of superactive LHRH analogues for induction of a single ovulation for in-vivo fertilization is thus uncertain. Pure FSH had no advantages over HMG, the LH content of HMG having no deleterious effect on the ovary.

One hundred pregnancies after treatment with pulsatile luteinising hormone releasing hormone to induce ovulation

OBJECTIVE

To review treatment with pulsatile luteinising hormone releasing hormone in infertile women who do not ovulate and are resistant to clomiphene after 100 pregnancies achieved with this treatment.

DESIGN

Retrospective analysis of 146 courses of treatment over 434 cycles.

SETTING

Infertility clinic.

PATIENTS

118 Women whose failure to ovulate was due to idiopathic hypogonadotrophic hypogonadism (n = 39), amenorrhoea related to low weight (n = 17), organic pituitary disease (n = 15), or polycystic ovaries (n = 47).

INTERVENTIONS

Dose of 15 micrograms luteinising hormone releasing hormone/pulse subcutaneously every 90 minutes given with a miniaturised pump throughout cycle monitored by ultrasound. Women with hypogonadotrophic hypogonadism had 48 courses, women with amenorrhoea related to low weight 23, women with organic pituitary disease 18, and women with polycystic ovaries 57.

END POINT

Follow up of 100 pregnancies achieved in 77 women during six years after introducing treatment. MEASUREMENTS and main results--One hundred pregnancies (seven multiple, 28 miscarriages). Cumulative rates of pregnancy were 93-100% at six months in women with idiopathic hypogonadotrophic hypogonadism, amenorrhoea related to low weight, and organic pituitary disease. In women with polycystic ovaries (cumulative rate of pregnancy 74%) adverse prognostic factors were obesity, hyperandrogenism, and high luteinising hormone concentrations, which were also associated with a high rate of early pregnancy loss.

CONCLUSIONS

Treatment with pulsatile luteinising hormone releasing hormone is safe, simple, and effective, and the preferred method of inducing ovulation in appropriately selected patients. Compared with exogenous gonadotrophin treatment there is little need for monitoring, no danger of hyperstimulation, and a low rate of multiple pregnancies.

Resistant cases of polycystic ovarian disease successfully treated with a combination of corticosteroids, clomiphene, and bromocriptine

Eight successively examined anovulatory women with polycystic ovarian disease (PCOD) who had remained resistant to treatment with clomiphene and dexamethasone (DEX) (and some to hMG/hCG) and had mildly elevated prolactin levels were treated with a combination of clomiphene, DEX, and bromocriptine. There was a decrease in the LH:FSH ratio and androgen and prolactin levels to normal values; within five to eleven treatment cycles, all were pregnant. These results were probably achieved because of the inhibition of prolactin secretion by the dopamine agonist, but may also be due to repletion of a suggested possible functional depletion of dopamine within hypothalamic nuclei in PCOD. This combination treatment is therefore highly recommended before resorting to hMG/hCG therapy or surgery, both of which have intrinsic disadvantages.

Influence of serum luteinising hormone concentrations on ovulation, conception, and early pregnancy loss in polycystic ovary syndrome

Women with the polycystic ovary syndrome do not respond well to treatment with luteinising hormone releasing hormone. To determine whether this might be due to an underlying endocrine disturbance basal concentrations of luteinising hormone were measured in 54 infertile women treated with pulsatile luteinising hormone releasing hormone and concentrations at the time of maximum follicular growth were measured in 23 of the patients. Forty one patients ovulated. Forty one patients ovulated and 27 conceived, but nine pregnancies terminated within four weeks after ovulation. Basal luteinising hormone concentrations were significantly lower in those who conceived (12.4 (range 1.3-29.0) IU/l) than in those who did not (19.0 (3.5-50.0) IU/l) and in those whose pregnancy progressed (9.6 (1.3-29.0) IU/l) than in those with early loss of pregnancy (17.9 (7.0-29.0) IU/l). Concentrations at the time of maximum follicular growth were significantly lower in women who ovulated (9.4 (2.9-35.4) IU/l) than in those who did not (29.0 (7.0-50.0) IU/l) and in those who conceived (6.2 (2.9-8.5) IU/l) than in those who did not (17.9 (4.0-50.0) IU/l). These results indicate that high concentrations of luteinising hormone during the follicular phase in women with polycystic ovaries have a deleterious effect on rates of conception and may be a causal factor in early pregnancy loss.

Bleeding esophageal varices in pregnancy. A report of two cases

Hemorrhage from esophageal varices during pregnancy in women with cirrhosis is a rare occurrence with a high mortality rate. Two such women, previously treated surgically for bleeding varices, one with additional sclerotherapy, had massive hemorrhages at 35 weeks necessitating cesarean section for fetal distress. Both neonates were healthy. One woman died one week postpartum. Pregnancy does not appear detrimental to the maternal prognosis despite the theoretical probability of raised portal pressure. About 70% of those with demonstrable varices will bleed during pregnancy; the overall mortality rate is 20%. Endoscopy and sclerotherapy before and in early pregnancy may help reduce the mortality rate. An awareness of the possibility of unpredictable bleeding and of the available treatments in a pregnant woman with esophageal varices is essential.

Growth hormone facilitates ovulation induction by gonadotrophins

The addition of biosynthetic human growth hormone (GH) to treatment with human menopausal gonadotrophin (hMG) significantly augmented the ovarian response in four patients treated for in-vivo and three patients treated for in-vitro fertilization who had previously been resistant to hMG. The amount, duration of treatment and daily effective dose of hMG were all reduced by growth hormone. This action of growth hormone offers a new approach to ovulation induction.

Improved treatment for anovulation in polycystic ovarian disease utilizing the effect of progesterone on the inappropriate gonadotrophin release and clomiphene response

The treatment of anovulatory, clomiphene-resistant patients with polycystic ovarian disease (PCOD) is difficult. Ten such women were given progesterone, 50 mg/day i.m. for 5 days to achieve luteal phase concentrations. Immediately following progesterone treatment, plasma concentrations of FSH were reduced in all patients (P = 0.001) and seven of the 10 had reduced plasma LH concentrations. Following the withdrawal bleeding these seven all became responsive to clomiphene as shown by ovulation, and three conceived after a single progesterone/clomiphene cycle. LH pulsatility, studied in five women over 4 h, before and immediately following progesterone treatment, showed a slowing of the pulse frequency (62 +/- 26 min to 105 +/- 51 min, P less than 0.05) and an increase in pulse amplitude (6 +/- 1.9 IU/l to 16.7 +/- 20 IU/l). The LH and FSH response to GnRH was blunted by progesterone. It would thus appear that progesterone modulates LH pulsatility and reduces pituitary sensitivity to GnRH, reducing LH levels and possibly inducing more FSH synthesis and storage, similar to its action in the normal ovulatory cycle. These changes provide a more favourable environment for ovulation induction by clomiphene and we suggest that short-term progesterone treatment may be utilized to improve the efficiency and results of clomiphene treatment in PCOD.

Synergism of pulsatile LHRH therapy with oral clomiphene treatment

Eighteen anovulatory patients who were resistant to induction of ovulation with clomiphene and with subcutaneous pulsatile LHRH were treated with these two agents given simultaneously. Twelve of the 14 patients with polycystic ovary syndrome, 1 patient with weight-related amenorrhea and 1 of 3 patients with intrinsic pituitary disease responded to the combined treatment. Serial determinations of serum gonadotropin concentrations showed that these remained unchanged by clomiphene treatment, suggesting a direct action on the ovary. For induction of ovulation for in vivo fertilization, the combination of oral clomiphene with subcutaneous pulsatile LHRH is worth trying before proceeding to intravenous LHRH or hMG therapy.

An infant with multiple deformations born to a myasthenic mother

An infant with multiple deformations born to a mother with untreated myasthenia gravis presented with arthrogryposis multiplex, craniofacial dysmorphism, kyphoscoliosis of the thoraco-lumbar spine, severe hypotonia, absence of the sucking reflex, and other neurological deficits. The neurological state of the infant supported the diagnosis of congenital myasthenia gravis, but the negative Tensilon test and the lack of clinical improvement after prolonged Mestinon treatment ruled out this diagnosis. We believe that the multiple deformations and reduced fetal movements are related to the maternal myasthenic environment associated with mild polyhydramnion.

Endocrine studies of the ovulatory disturbances in Wilson's disease (hepatolenticular degeneration)

Women with Wilson's disease may have severe oligomenorrhea or amenorrhea whose cause is unknown. The endocrine profile of four such cases was investigated by measuring basal values and the response to dynamic tests of hypothalamic, pituitary, thyroid, and adrenal function, which all proved normal. Ovarian function was disturbed, as witnessed by low estradiol, high total testosterone (T) levels with normal free T, and mildly elevated androstenedione. An interference of ovarian follicular aromatase activity possibly due to copper intoxication could explain these findings as the cause of the ovulatory disturbances of Wilson's disease.

Rib fractures as a cause of immediate neonatal tachypnoea

Two macroscopic term neonates are described who presented with uncomplicated tachypnoea immediately following vaginal delivery. The tachypnoea was not associated with lung injury, metabolic, endocrine or cardio-respiratory disease but with multiple unilateral posterior rib fractures. The neonatologist should be aware that neonatal tachypnoea immediately after vaginal term delivery, especially in macrosomic infants, may be caused by the pain of fractured ribs. The diagnosis can be made only by careful inspection of the ribs on chest X-ray.

An examination of the relationship between fetal movements and infant motor activity

Fifty-one patients recorded fetal movement counts for several weeks, 29 while hospitalized for complications of pregnancy (group 1) and 22 with normal pregnancies and ambulant (group 2). The motor activity of group 1 neonates was examined 24-72 hours following delivery, using a partial Brazelton neonatal assessment scale. Group 2 infants were examined at age 10-12 months, using a method specially designed for this study to assess motor activity. No significant correlation was found between the mean number of fetal movements and the motor activity of neonates, versus those of one-year-old infants. These findings suggest that fetal movements are most probably influenced by numerous factors differing from those influencing the motor activity of the neonate and infant.

Neonatal factor XIII deficiency

We describe a patient diagnosed in the neonatal period as having factor XIII deficiency who presented with persistent umbilical bleeding. Factor XIII deficiency is the only coagulation factor deficiency that cannot be detected by classical hemostatic tests, and a rapid diagnosis is vital during the first decade of life. A newborn presenting with persistent umbilical stump bleeding should be screened for factor XIII deficiency when routine coagulation tests prove normal.

Oxytocin-stressed and unstressed cardiotocograms for the prediction of fetal compromise

The results of unstressed and oxytocin-stressed cardiotocograms recorded in 222 high-risk pregnancies within 48 h of delivery were compared with signs of fetal distress in labour and Apgar scores. Thirty-nine (18%) developed a late deceleration pattern in labour and 18 newborn (8%) had Apgar scores of less than 7 at 1 min. A direct comparison of the predictive value of unstressed and stressed cardiotocograms, using Fisher's exact test, showed a very significant difference in favour of the stressed cardiotocogram for the prediction of both fetal compromise and fetal well-being. The exclusion, or very selective use, of the oxytocin-stressed cardiotocogram and reliance on the unstressed cardiotocogram for the antepartum investigation of high-risk pregnancies sacrifices accuracy for convenience.

Clinical evaluation of fetal movements

Fetal movement was examined in 200 pregnancies to establish normal patterns, influencing factors, possible clinical value and practical application. The mean number of movements per hour was 26 in hospitalized and 40 in ambulatory patients. These values remained fairly steady throughout pregnancy except for a significant decrease in the week preceding labor. Individual variations were large. The number of movements was uninfluenced by parity and fetal sex but was lower for small-for-gestational-age babies, in mothers suffering from both hypertension and diabetes and in mothers treated with diazepam. Fetal movement count may be used as a parameter of fetal well-being.

Management of patients with a live fetus and cessation of fetal movements

Sixty-seven patients with a history of no fetal movements for at least 12 hours and a live fetus were managed according to a fixed protocol. Twelve of these patients were found to have meconium-stained amniotic fluid and/or abnormal unstressed or oxytocin-stressed cardiotocograms; all of them were delivered within 24 hours of a live infant. The remaining 55 patients had no meconium and normal unstressed and stressed cardiotocograms, and their pregnancy, was allowed to continue. All felt fetal movements again and were delivered of live babies one to ten weeks later.

Detection of fetal risk in postmaturity

Ninety-seven postmature pregnancies were monitored by amnioscopy or amniocentesis (to determine presence or absence of meconium), oxytocin challenge tests (OCT), 24-hour urinary oestriol estimations and fetal movement counts. The colour of the amniotic fluid and the result of the OCT predicted almost all cases of fetal distress in labour and infants with low Apgar scores. Oestriol estimations and fetal movement counts predicted fetal distress only when combined with other positive tests. Of 50 patients with no abnormal test results, 49 had uneventful labours. The Caesarean section rate was not above average and all babies were liveborn.

Loss of beat-to-beat variability and a negative oxytocin challenge test: an ominous prognostic sign

The reputation of the predictive accuracy of a negative oxytocin challenge test (OCT) has been somewhat tarnished by recent sporadic reports of intrauterine fetal death relatively soon after a negative OCT. We have analyzed probable causes and the possibilities of reducing to a minimum "false-negative" results of the OCT. In particular, several of these reports did not take into account the loss of baseline fetal heart rate (FHR) variability recorded during the OCT and, in the absence of late decelerations, the OCT was interpreted as negative. We suggest that recordings showing a loss of baseline beat-to-beat FHR variability and a negative OCT illustrate a complete inability of the fetus to react to any stimulus and that, in these cases, a negative OCT should in no way be reassuring, but rather a warning sign of severe fetal compromise. Two cases are presented to illustrate this phenomenon.

Hormonal and clinical responses in amenorrhetic patients treated with gonadotropins and a nasal form of synthetic gonadotropin-releasing hormone

Synthetic gonadotropin-releasing hormone (GnRH) in the form of nasal drops was self-administered by five amenorrheic patients in an attempt to assess its therapeutic value in anovulatory infertility. After follicular maturation had been induced with human menopausal gonadotropins (HMG), a total daily dose of 7.5 mg of GnRH in the form of nasal drops was self-administered at 2-hour intervals for 6 hours on 3 consecutive days. In four patients, plasma luteinizing hormone (LH) levels were significantly elevated over a period of at least 8 hours. In three of these patients, in addition, there was a definite upward shift in the basal body temperature (BBT) curve, and uterine bleeding occurred 6 to 9 days after the first dose of GnRH. In the fourth patient, ovulation was induced as indicated by a biphasic BBT curve, a plasma progesterone level of 13 ng/ml, and a luteal phase of 15 days. In the remaining patient, there was a borderline LH response and no clinical response. It is concluded that GnRH, in the form of nasal drops, is effective in eliciting and maintaining elevated plasma LH levels in patients in whom follicular maturation has been induced with HMG. By obtaining ovulatory LH levels, such a regimen can lead to ovulation. In addition, intranasal self-administration of GnRH is convenient and may provide an alternative route of administration for long-term therapy with this hormone.

An evaluation of etiologic factors and therapy in 665 infertile couples

Six hundred and sixty-five unselected infertile couples were investigated and treated in a private clinic during a 15-year span. Male infertility factors were involved in 28%, ovulatory disturbances in 31.5%, tubal factors in 16.3%, and undiscovered factors in 17.6% (117 couples). In 50 couples (7.5%) fertility-reducing factors were found in both partners, with a 14% pregnancy rate, compared with a 54.3% pregnancy rate when only a female factor was involved. The chances of successful treatment of females decline steadily with age, correlating with the fact that the longer the exposure time before the start of treatment, the less the chance of pregnancy. Investigation following 1 year of exposure should be advised. Pregnancy rates were 50% in ovulatory disturbances and 30% with tubal factors. Predictably, a progressive increase in the pregnancy rate was noted during the span of this study.

The hypothalamus as a regulator of reproductive function

In this review of the role of the hypothalamus as a regulator of reproductive function we have presented a short history of the important anatomical and physiological findings, the structure and properties of gonadotrophin releasing hormone and its function and mode of action in the reproductive process. The latest clinical studies have been presented and we have discussed the therapeutic and diagnostic applications of GnRH. Although the progress in the last few years has been relatively enormous, research on the physiological and clinical implications of these discoveries has probably only now reached its peak and it was thus felt that the time was ripe to write this summary.