The role of pituitary gonadotropins in follicular stimulation and oocyte maturation in the human

The serum estradiol (E2) values in normally ovulating infertile women stimulated first by a combination of follicle stimulating hormone (FSH) and luteinizing hormone (LH) [human menopausal gonadotropin (HMG)] and second by FSH only were similar in both stimulation cycles. The serum FSH and LH values measured in one patient were also similar. Basal LH declined by 16 hours after HMG or FSH administration. These data suggest that exogenous LH is not required for follicular maturation as measured by E2 synthesis during ovulation induction in normal women. Maturation of the oocyte, at least in some patients, also progressed normally after the administration of FSH alone, followed by human chorionic gonadotropin (HCG), as indicated by the retrieval of viable oocytes which fertilized and cleaved in all patients and the initiation of a pregnancy which progressed normally.

Luteal phase serum estradiol and progesterone in in vitro fertilization

One hundred seventy-five cycles in patients with irreparable tubal disease were stimulated by human menopausal gonadotropin/human chorionic gonadotropin for the purpose of in vitro fertilization. The pregnancy rate was found to be related to the height and pattern of serum estradiol (E2) response in the follicular phase. The mean serum E2 and progesterone (P) during the luteal phase showed no statistically significant difference between the pregnant and nonpregnant patients in the series except after luteal day 11. The mean serum E2 in most of the luteal phase days was highest in the high responders followed by the normal and the low responders. However, the mean P values were similar for the high and normal responders but higher than the low responders on cycle days 18, 20, and 22. The mean serum E2 and P in the luteal phase showed no statistically significant difference among the three most common patterns. This was also true for the pregnant and nonpregnant values in each category of height and pattern of response. We concluded that the success and failure of in vitro fertilization was probably less related to the peripheral E2 and P in the luteal phase than to the number and quality of eggs.

In vitro fertilization in Norfolk, Virginia, 1980-1983

Three years of progress of the Vital Initiation of Pregnancy (VIP) Program in Norfolk is reported. No conception resulted from 41 oocyte aspirations during spontaneous menstrual cycles in 1980. An average of 3.7 oocytes per cycle, or a 73.5% recovery rate, resulted in 362 human menopausal gonadotropin/human chorionic gonadotropin-induced cycles from January 1981 to March 1983. Forty percent of the oocytes recovered from these cycles were preovulatory, 35% atretic, and 25% immature. Immature oocytes were often matured in vitro, fertilized, and found to produce pregnancies. A total of 62 pregnancies occurred, which represents a 17 or 23% pregnancy rate, based on laparoscopies or embryo transfers, respectively. There were 11 preclinical and 7 clinical miscarriages. Twenty-nine normal babies have been delivered, including a set of twins. The remainder appears to be normally progressing pregnancies. Polyspermia was observed in 8.8% of the fertilizable oocytes.

Correlation of human menopausal gonadotropin/human chorionic gonadotropin stimulation and oocyte quality in an in vitro fertilization program

One hundred forty-seven cycles in normal ovulatory patients are reported. All were stimulated with human menopausal/human chorionic gonadotropin. Three estrogen responses were identified: normal, high, and low. Patients who achieved pregnancy formed a fourth category, the pregnancy group. The number of preovulatory and immature oocytes, the preovulatory and immature oocytes that fertilized normally or abnormally, the ones that cleaved in culture, and the ones that were transferred were used as parameters to compare quality of the oocytes in each of the estrogen responders. No significant differences were found in any of them. Abnormal zonae pellucidae are described as possibly due to overmaturation of the follicle. No significant difference in the proportion of abnormal zonae in the different categories was found.

What is a pregnancy? A question for programs of in vitro fertilization

Pregnancy outcome in studies of normal reproduction and in programs of in vitro fertilization (IVF) is usually classified as "chemical beta-human chorionic gonadotropin (beta-hCG) abortion," "trimester abortion," and "term delivery." The distinction between a chemical beta-hCG abortion and a first-trimester abortion is not clearly stated in the literature, although such terms are commonly used. It is proposed that in programs of IVF pregnancy outcome be classified as "menstrual abortion," "preclinical abortion," "clinical abortion," or "viable pregnancy." Pregnancy outcome of 190 consecutive cycles induced by human menopausal gonadotropin/human chorionic gonadotropin in the program of IVF at Norfolk is compared with contemporary studies of pregnancy outcome in normal reproduction. The in vitro data indicate that the Norfolk program has recorded no menstrual abortions, a 33% preclinical and clinical abortion rate, and a viable pregnancy rate that approaches but does not equal the term delivery rate of normal reproduction. However, these results have been achieved by the transfer of multiple concepti, whereas normal reproduction depends on the fertilization of a single oocyte.

Serum luteinizing hormone during ovulation induction with human menopausal gonadotropin for in vitro fertilization in normally menstruating women

Sixteen cycles in 14 normally menstruating women, stimulated with human menopausal gonadotropin in order to recruit more than one follicle for a successful in vitro fertilization process, were adequately monitored to identify the appearance of the spontaneous luteinizing hormone (LH) surge. Daily serum LH determinations, increased to every 4 hours in the presumptive preovulatory period, showed that in these women the endogenous estrogen-triggered LH midcycle peak did not occur at the expected time. It is hypothesized that the mechanism responsible for this suppression is a negative feedback mediated by an increased circulating protein with an inhibin-like action.

The importance of the follicular phase to success and failure in in vitro fertilization

One hundred seventy-five cycles in patients with irreparable tubal disease were stimulated by human menopausal gonadotropin/human chorionic gonadotropin for the purpose of in vitro fertilization. As judged by the height of the peripheral estradiol response, the patients were classified as high, intermediate, or low responders. In addition, the estradiol pattern of the response was found to be separable into six categories. The pregnancy rate was found to be related to the height and to the pattern of peripheral response. The overall pregnancy rate in this consecutive series was 19% but varied according to the height and pattern of response from 40% to 0%.

Decline of follicular oocyte maturation inhibitor coincident with maturation and achievement of fertilizability of oocytes recovered at midcycle of gonadotropin-treated women

To examine whether a decline in follicular oocyte maturation inhibitor (OMI) is associated with attainment of oocyte maturation and fertilizability, OMI was measured in follicular fluid (FF) of 39 follicles of 20 normal women given human menopausal gonadotrophin and human chorionic gonadotrophin to induce follicular growth and maturation. Oocytes were aspirated per laparoscope, the fluid was saved, and the egg was observed, incubated, and inseminated with the husband's sperm. Concepti that developed to the 4- to 8-cell stage were transferred to the uterus and the women were followed for pregnancy. OMI activity in each FF was measured by using cultured cumulus-enclosed porcine oocytes (30-40 oocytes per FF sample). Estrogen, progesterone, oocytes (30-40 oocytes per FF sample). Estrogen, progesterone, and delta 4-androstenedione were measured in FF by radioimmunoassay. The FF of 13 preovulatory follicles yielding oocytes that were mature and fertilizable had significantly less OMI activity (mean +/- SEM) (0.58 +/- 0.10 unit/ml) compared to follicles yielding immature oocytes (2.8 +/- 0.56 units/ml; n = 9), atretic oocytes (5.5 +/- 2.5 units/ml; n = 7), or preovulatory oocytes with fractured zonae (1.9 +/- 0.63 units/ml; n = 7). The estrogen concentration (mean +/- SEM) of preovulatory follicles yielding mature fertilizable eggs or mature eggs with fractured zonae was greater (396 +/- 34 ng/ml; n = 20) compared to follicles yielding immature or atretic eggs (203 +/- 59 ng/ml; n = 9 and 97 +/- 47 ng/ml; n = 7, respectively; P less than 0.05). Progesterone concentration (mean +/- SEM; ng/ml) of FF was generally elevated in all preovulatory follicles (635 +/- 53) compared to immature or atretic follicles (230 +/- 64 and 76 +/- 17, respectively; P less than 0.05). It may be concluded that in normal follicle maturation there is a decline in OMI in the follicle containing an oocyte that becomes mature and fertilizable. There is also an increase in estrogen, progesterone, and follicle size. It is also possible to have an abnormal follicle maturation when there is an increase in size as well as FF, estrogen, and progesterone, but withut a decline in OMI--a situation which can lead to production of a nonfertilizable oocyte.

Transmembrane potential of isolated rat alveolar type II cells

Type II cells were isolated from rat lungs by elastase digestion and purified by centrifugal elutriation. The fluorescent dye, Di-S-C3(5), was used as a probe to monitor transmembrane potential (Em) of cells suspended in N-2-hydroxyethylpiperazine-N'-2-ethanesulfonic acid (HEPES)-buffered medium. With this technique, the Em of type II cells was estimated to be -27 +/- 2 mV. This resting Em is very close to the equilibrium potential for chloride (-21 mV), which suggests that chloride is passively distributed in type II cells. The resting Em of type II cells is more dependent on the extracellular concentration of potassium (K+) than on external sodium (Na+); i.e., the membrane depolarizes as external sodium is replaced by potassium, suggesting that in unstimulated type II cells the membrane is more permeable to potassium than to sodium. In addition, the resting potential appears to be due, in part, to the activity of a ouabain-sensitive, Na-K pump, which acts to hyperpolarize type II cells. Addition of a membrane perturbant, phorbol myristate acetate (PMA, 10 micrograms/ml), to a type II cell suspension results in an increase in oxygen consumption and membrane depolarization. Both of these responses are sodium dependent and thus appear to be linked to a PMA-induced increase in sodium permeability.

Fractures of the femoral shaft in a regional hospital setting

We reviewed the efficacy of treatment techniques for femoral shaft fractures in our regional rural hospital setting. One hundred fifty consecutive primary femoral shaft fractures were managed at the Medical Center Hospital of Vermont during the period 1974 through 1979. The method of treatment was determined by the attending orthopedic faculty. Each case was evaluated at the time of initial hospital treatment, at 30 days postinjury, and at 1 year postinjury. Patient profiles, methods of injury, types of fracture, and associated injuries were reviewed. The choice of operative or nonoperative treatment in the first 30 days was the most important factor in the result at 1 year. Results were graded as "good' if angulation was 0-5 degrees in the A-P and/or lateral views; "fair', 6-10 degrees; and "poor', greater than 10 degrees or any need for supplemental surgery to achieve union. Shortening, infection, and thrombophlebitis were infrequent in this series. (formula: see text) Overall rate of supplemental surgery was 37% for the initially nonoperative treated femoral shaft fractures. In this series operative intervention gave surer results with an earlier return to full ambulation and more anatomic repair than nonoperative methods.

Maturation and fertilization of morphologically immature human oocytes in a program of in vitro fertilization

Oocytes of varying stages of maturity were aspirated from follicles primed with either human menopausal gonadotropin (hMG) and human chorionic gonadotropin (hCG) or a combination of follicle-stimulating hormone (FSH), hMG and hCG. Of the aspirated oocytes from 44 cycles, 74 were considered to be immature by virtue of morphologic characteristics of the oocytes and the degree of intercellular expansion of the associated cumular and membrana granulosa cells. After incubation periods of 22 to 35 hours in a Ham's F-10-based culture medium, these immature oocytes were inseminated with sperm donated by the patient's husband. Ultimately, 44 conceptuses were transferred to the respective uteri of 30 patients. Eight pregnancies were established as a result of these 30 transfers, two of which resulted from the transfer of only developed immature oocytes.

Transport properties of isolated type II alveolar epithelial cells

Type II cells are granular cells located in the alveolar epithelium. In addition to the synthesis and secretion of surfactant, these pneumocytes exhibit several other interesting properties. Although type II cells possess a high permeability to sodium, they maintain a low free intracellular sodium concentration by the presence of a Na-K pump. The activity of the Na-K pump is high and can result in substantial net movement of solute and water. Therefore, type II cells may employ this pumping capacity to play a significant role in the transepithelial transport of water. Type II cells are also relatively resistant to oxidant damage and play a role in the regeneration of the alveolar epithelium after oxidant injury. Ascorbate is a known antioxidant that is accumulated by type II cells via a specialized transport system for the uptake of ascorbate and sodium. The presence of this specialized transport system in type II cells and alveolar macrophages may explain in part why these cells are more resistant to oxidant injury than other pneumocytes.

Human menopausal gonadotropin/human chorionic gonadotropin follicular maturation for oocyte aspiration: phase II, 1981

Ovulation was induced in 24 cycles of normal ovulatory patients for in vitro fertilization using a modified human menopausal gonadotropin and human chorionic gonadotropin (hMG/hCG) protocol. This modification was based on experience in 31 cycles previously studied. The individual ovarian threshold response to hMG seen previously was again confirmed, and successful stimulation and oocyte retrieval depended upon the recognition of this patient's "sensitivity." A rapid serum estradiol (E2) assay, in conjunction with estimation of the patient's biologic response to the E2 levels, as measured by changes in vaginal smears and cervical mucus (biologic estrogen shift), was the key to determining the amount of hMG necessary. The biologic shift was the best indicator for discontinuation of gonadotropins in the low E2 responder group. The serum E2 levels were the best indicators for the normal and high E2 responder groups. Ultrasound was used as confirmatory evidence for satisfactory follicular development. Postmaturity of the oocyte did not occur in this series, due to compensation of excessive hMG stimulation in rapid responders by a shortening of the interval between hMG discontinuation and hCG administration, thus initiating the oocyte meiotic process earlier. Maturation of immature oocytes was accomplished in this series by an increase in the time in culture prior to insemination. Due to the improved protocol of drug administration and the ability to mature immature oocytes in vitro, five pregnancies resulted from the stimulation of these 24 cycles.

Human menopausal gonadotropin/human chorionic gonadotropin follicular maturation for oocyte aspiration: phase I, 1981

Thirty-one human menopausal gonadotropin and human chorionic gonadotropin (hMG/hCG) ovulation induction cycles from 25 normally ovulating patients who applied to a program for the Vital Initiation of Pregnancy (VIP) are discussed. Three different categories of serum estradiol (E2) response were found. Serum E2 and progesterone responses were inversely related to the amount of hMG, indicating a patient sensitivity rather than a dosage relationship. Luteinizing hormone levels were suppressed by gonadotropins. Daily evaluation of vaginal smear, cervical mucus, serum E2 determinations, and pelvic ultrasound are necessary for an optimum ovulation induction with gonadotropins. Two successful pregnancies are reported.

Artificial insemination with fresh donor semen using the cervical cap technique: a review of 278 cases

Two hundred twenty-six patients received artificial insemination with fresh donor semen (AID) using the cervical cap technique; 52 patients underwent the procedure for 2 conceptions. Using life-table analysis to adjust for uneven patient follow-up, the cumulative pregnancy rate was 62.5% after 6 months of AID, and 82.4% after 10 months. Moreover, using a mathematical model of cumulative pregnancy following AID, the estimated cure rate was not significantly different from 100%, and the estimated monthly probability of pregnancy among those cured was 15.5%. Age was found to be inversely related to pregnancy success, while parity had no effect. For those who continued to undergo AID beyond 6 months, the monthly probability of pregnancy did not decline. Patients can be advised that their chance of conception with AID should approach that of normal fertile couples.

The program for in vitro fertilization at Norfolk

Several aspects of the program of in vitro fertilization (IVF), or, as it is called in Norfolk, the program for the Vital Initiation of Pregnancy (VIP), have been or are in the process of publication. However, because there has been no overall account, it seems appropriate to give a brief report of a general nature covering the period from the beginning of the effort in late February 1980 through December 31, 1981. Although minor changes were constantly made in the protocol, there were two major revisions. Therefore, a discussion of the program during three distinct periods, i.e., 1980, 1981-Phase I, and 1981-Phase II, is necessary. During 1980 and 1981 all patients had either no fallopian tubes or irreparable tubes.

Ionic content and regulation of cellular volume in rat alveolar type II cells

Alveolar type II epithelial cells were isolated by elastase digestion of rat lungs and purified by centrifugal elutriation. This method yields an enriched fraction of 1 x 10(7) cells/rat containing 85% pure type II pneumocytes. Purified type II cells exhibit a high rate of oxygen consumption, 215 nmol O2 . 10(6) cells-1 . h-1, which is unaffected by the addition of succinate. Type II cells contain 2 microliters H2O/10(7) cells and are approximately 325-330 micrometers 3 in volume. These pneumocytes contain 107 nmol K/l cell H2O and 70 mmol Cl/l cell H2O. In addition, type II cells have a high Na content, i.e., 156 mmol/l cell H2O. However, most of this Na is bound with only 33% being exchangeable. Therefore, the cytoplasmic concentration of free Na is 51 mmol/l cell H2O. Na uptake is very rapid and type II cells i.e., specific activity equilibrium is reached in 15 min with a half time of 5 min. In addition to this large passive transport of Na, type II cells exhibit a highly active Na-K pump involved in the regulation of cellular volume. Volume regulation is inhibited by a decrease in temperature (2 degrees C) and by the addition of ouabain (10(-4) M), Hg (10(-5) M), or Cu (10(-3) M).

Volcanic ash: toxicity to isolated lung cells

Samples of volcanic ash from Mount St. Helens were collected from Spokane, Washington, after the major eruption of May 18, 1980. The toxicity of ash to the lung was estimated by monitoring the effects of in vitro and in vivo exposure on various physiological parameters of isolated lung cells. Volcanic ash had little effect on O2 consumption of rabbit type II pneumocytes, O2 consumption or superoxide release of resting rat alveolar macrophages, or membrane integrity of rat alveolar macrophages. Ash also caused no significant lipid peroxidation in rat lung microsomes. However, volcanic ash did inhibit superoxide anion release from zymosan-stimulated rat alveolar macrophages. Since superoxide is an antibacterial substance, this result suggests that exposure to volcanic ash may adversely affect the ability of alveolar macrophages to protect the lung from infection.

Corpus luteum function after follicle aspiration for oocyte retrieval

Follicle aspiration for in vitro fertilization is associated with a statistical disruption of the luteal phase. The severity of the disruption seems to be in relation to the vigorousness and the number of aspirations and therefore the number of granulosa cells that are dislodged from the membrana granulosa layer. Although the statistical importance of this disruption from a biologic point of view does not seem to be significant, as measured by the length of the luteal phase, an analysis of individual cases must be made in order to determine the frequency with which a biologically significant luteal defect may be produced. At the present time, it seems that the fewer the granulosa cells removed at aspiration, the less the luteal disruption will be. The series is discounted as an important factor in inducing luteal dysfunction.

Fertility following bilateral ovarian wedge resection: a critical analysis of 90 consecutive cases of the polycystic ovary syndrome

Fertility following bilateral ovarian wedge resection (BOWR) was evaluated in a retrospective cohort study of 90 consecutive cases of the polycystic ovary syndrome. Post-BOWR follow-up was available for varying time spans of up to 10 years. BOWR resulted in the resumption of menstrual cyclicity in 91.1% (82/90) of the cases. However, within this ovulatory group, 26 patients were characterized by oligo-ovulation and a significantly reduced conception rate (29.2%), as compared with that of 56 normo-ovulatory counterparts (60.3%). Although the crude overall conception rate for this series was 47.8%, the overall cumulative probability of conception at the end of follow-up as determined by life table analysis was 73%. The likelihood of conception at any given point in time was estimated by a monthly fecundability rate of 1.34%. Our findings also indicate that the probability of post-BOWR conception was unaffected by age, race, ward status, or duration of infertility. In contrast, persistent post-BOWR oligo- or anovulation and the presence of concurrent tuboperitoneal disease were reaffirmed as the most important determinants of the likelihood of post-BOWR conception. A minimum incidence of 7.8% was documented for acquired post-BOWR pelvic disease.

Prediction of the time of ovulation

Prediction of ovulation was established by correlation of clinical parameters, follicular development by ultrasound, and estradiol, progesterone, and luteinizing hormone (LH) determination in 71 menstrual cycles. Laparoscopic follicular aspiration was accomplished in 41 of those cycles. A 28-hour interval from the ascending limb of the LH seems to be the "ideal time" for retrieval of a preovulatory oocyte. The variability in the amount of LH to which the follicle is exposed during the LH surge seems to indicate that there is a relatively low specific value necessary for ovulation. Ovulation occurs approximately 10 +/- 5 hours from the LH peak. Progesterone occurs in relation to the LH surge and is helpful for the retrospective analysis of the menstrual cycle.

Breast cancer incidence in women with a history of progesterone deficiency

In order to investigate the nature of the association of involuntarily delayed first birth and risk of breast cancer, 1083 white women who had been evaluated and treated for infertility from 1945-1965 were followed prospectively through April 1978 to ascertain their breast cancer incidence. These women were categorized as to the cause of infertility into two groups, those with endogenous progesterone deficiency (PD) and those with nonhormonal causes (NH). Women in the PD group had 5.4 times the risk of premenopausal breast cancer compared to women in the NH group. This excess risk could not be explained by differences between the two groups in ages at menarche or menopause, history of oral contraceptive use, history of benign breast disease or age at first birth. Women in the PD group also experienced a 10-fold increase in deaths from all malignant neoplasms compared to the NH group. The incidence of postmenopausal breast cancer did not differ significantly between the two groups.

Abnormal responses of granulocytes in chronic granulomatous disease

Stimulation of normal granulocytes with chemotactic factor, phorbol myristate acetate, concanavalin A, and calcium ionophore results in rapid depolarization which precedes the 'respiratory burst'. Treatment of granulocytes in chronic granulomatous disease with these stimulants fails to generate chemiluminescence. This defect is associated with an absence of transmembrane potential shifts in response to treatment with chemotactic factor, phorbol myristate acetate, and concanavalin A while depolarization in response to A23187 is unaffected by this disease state.