The effect of gonadotropin-releasing hormone agonist on embryo quality and pregnancy rate following cryopreservation

OBJECTIVE

To examine the effect of GnRH analogue (GnRH-a) on the quality of frozen-thawed embryos and the pregnancy rate (PR) resulting from transfer.

DESIGN

A retrospective study of two groups of women undergoing transfers of frozen-thawed embryos. In group 1 ovulation induction with hMG was begun after hypophyseal desensitization with GnRH-a for 2 weeks. In group 2 ovulation was induced with hMG only. The freezing and thawing techniques were identical for both groups.

SETTING

In vitro fertilization unit at a university hospital.

PATIENTS

The study group (group 1) included 108 women who underwent 137 transfer cycles of frozen-thawed embryos, and the control group (group 2) included 44 women in 51 cycles of thawed ETs.

INTERVENTIONS

Ovum pick-up and ET techniques were the same for both groups. Methods of embryo freezing and thawing were identical, as were the morphological criteria for grading the embryos.

RESULTS

The morphology of embryos was similar in both groups, as was the number of embryos that had at least 50% intact blastomeres (83% +/- 23% and 78% +/- 30% for group 1 and group 2, respectively). The PR (16 of 137 [11.7%] and 6 of 51 [11.8%], respectively) as well as the abortion rate (30%) were similar for both groups.

CONCLUSIONS

The use of GnRH-a does not affect the quality of embryos nor the pregnancy outcome. Because the yield of frozen embryos per ovum pick-up is higher in cycles stimulated by GnRH-a/hMG, the PR per pick-up cycle is thus anticipated to be higher.

Discordancy in triplets

Discordancy in twins is generally described as a weight difference between the fetuses of 15 to 25% and its prevalence in normal twin gestations is estimated at 15 to 29%. The present study was performed in order to determine the frequency of discordant newborns in uncomplicated triplet gestations. One hundred and fourteen normal triplet newborns were delivered during a period of 11 years. Their birthweight ranged from 493 to 2533 gm, with a mean of 1894.2 +/- 468.5 gm (+/- sd). In 58% of these 38 sets of triplets the difference in weight between the largest and smallest newborn was more than 15%. About a quarter of the newborns had a greater than 25% dissimilarity in their birthweights. There was no substantial fetal-fetal transfusion or difference in the Apgar scores between the discordant fetuses. It may be concluded that triplet newborns have a rate of discordancy double that of twins. Discordance per se does not necessarily mark an underlying complication of pregnancy or a bad perinatal outcome.

Sonographic growth curves of triplet conceptions

The diagnosis of inappropriate intrauterine fetal growth in triplet pregnancies requires normal standard sonographically determined growth curves. The aim of the present study was to establish such nomograms. The biparietal diameter (BPD), femur length, head and abdominal circumferences (HC, AC) were once in 3 weeks sonographically evaluated in 108 normal triplet fetuses. The resulting growth curves were compared with those of normal singleton fetuses. The data showed that, compared with singletons, the mean triplet fetal BPD progressively lags to a maximum of 2 1/2 weeks as pregnancy continuous from the 25th to the 36th gestational week. Similarly, mean femur length of triplet fetuses gradually shortfalls to the greatest of 2 weeks as gestation advances from the 25th to the 36th week. HC to AC ratio of the triplet fetuses does not differ from the singletons curve. It may be concluded that a normal fetal growth curve in triplet pregnancies demonstrates a 1- to 3-week delay compared with singleton gestations.

The efficacy and safety of zona pellucida drilling by a 193-nm excimer laser

OBJECTIVE

To examine the efficiency of argon fluoride excimer laser drilling of the zona pellucida of mouse oocytes in improving in vitro fertilization (IVF) at low sperm concentrations and to assess its safety.

DESIGN

Oocytes obtained from (Balb/c x C57BL6)CB6F1 female mice were drilled by laser and divided into two groups: group I (89 oocytes) were inseminated with 10(5) sperm cells/mL, and group II (94 oocytes) were inseminated with 10(6) sperm cells/mL. Both groups' fertilization rate and development in vitro was compared with control oocytes that underwent the same preparation steps but no drilling (94 and 88 oocytes for group I and group II, respectively).

MAIN OUTCOME MEASURES

The fertilization rate and the development in vitro of the laser-drilled groups is compared with that of the control. In addition, in vivo development of embryos generated from laser-drilled oocytes after transfer to pseudopregnant recipients is assessed.

RESULTS

For both sperm concentrations, laser drilling significantly enhanced fertilization over control (67% versus 31% at 10(5) sperm cells/mL and 90% versus 54% at 10(6) sperm cells/mL). The development into the blastocyst stage after 96 hours of incubation was similar for both the laser-drilled and control groups at any sperm cell concentration. However, complete hatching at this point was significantly enhanced by the drilling procedure. Normal litters were obtained from the transfer of embryos developed from zona-drilled oocytes into pseudopregnant recipients.

CONCLUSIONS

Excimer laser drilling enhanced IVF at low sperm cell concentration. The procedure is safe and did not interfere with embryo development in vitro or in vivo.

Diagnosing sphingolipidoses in murine and human embryos

The aim of this study was to diagnose lipid storage diseases in embryos at the preimplantation stage. Two parallel approaches were employed. Firstly, activities of several sphingolipid hydrolases were determined in extracts of murine embryos and also human oocytes and polyspermic embryos. Sensitive fluorescent or fluorogenic procedures provided indications that Tay-Sachs, Gaucher and Krabbe diseases might be diagnosed in one human blastomere, while for Niemann-Pick disease two might be required. Secondly, pyrene lipids were administered into murine embryos and their fluorescence was quantified by computerized imaging microscopy. As a model of Gaucher disease, the fluorescent substrate pyrene glucosylceramide was administered into murine embryos in the presence or absence of an inhibitor of the enzyme beta-glucosidase. Because of decreased degradation of the substrate in enzyme-inhibited cells, the fluorescence per blastomere was considerably greater relative to those which received no inhibitor. The results indicated that lipid storage diseases might be diagnosed in single human blastomeres at the preimplantation stage, obviating the need for pre-natal diagnosis and abortion of affected foetuses.

Conception rate after in vitro fertilization in patients who conceived in a previous cycle

OBJECTIVE

To evaluate whether a previously successful in vitro fertilization and embryo transfer (IVF-ET) cycle is a favorable prognostic factor for a subsequent cycle.

DESIGN

A retrospective comparison between current IVF patients who have previously conceived in an IVF versus natural cycle.

SETTING

The IVF unit of a university hospital.

PATIENTS

Group A consisted of 51 patients (70 cycles of IVF-ET) who previously conceived in an IVF-ET cycle, and group B included 141 patients (201 cycles of IVF-ET) who previously conceived in a natural cycle. All couples with male factor infertility were excluded. Ovulation induction protocol was identical for both groups and consisted of gonadotropin-releasing hormone agonist pretreatment followed by gonadotropin stimulation.

MAIN OUTCOME MEASURES

Pregnancy rate per ET, cumulative pregnancy rate, and livebirth rate in both groups.

RESULTS

The following parameters were comparable for both groups: age, menotropin dosage required for an adequate stimulation, ovarian response, mean number of oocytes retrieved per cycle, fertilization and cleavage rates, and the mean number of embryo transferred. Group A attained a significantly higher pregnancy rate (PR) than group B (31.4% versus 19.4%). Group A also achieved a significantly higher livebirth rate (22.9% versus 11.4%) than group B. Similarly, the cumulative PR curves and the cumulative livebirth rate curves for three consecutive IVF-ET cycles differed significantly between the two groups.

CONCLUSION

A previous successful IVF cycle is a positive prognostic factor for a repeated IVF attempt. This effect could be because of either an improved endometrial response or a better embryo quality. It may be that this patient population is relatively immune to the known untoward effects of ovulation induction on endometrial development and, therefore, may represent a potential clinical model that can be used to further identify the factors influencing uterine receptivity after ovulation induction.

Elective suture of uterine cervix in triplets

The incidence of triplet pregnancies has increased several times due to the widespread use of ovulation induction agents. Premature delivery is the main complication of triplet gestations. In twin conceptions it was shown definitely that elective cervical suture does not prolong these pregnancies. However, in higher order multifetal gestations the uterus is extremely overdistended and the application of cerclage is equivocal. This work intended to assess the value of elective cervical sutures in prolonging triplet pregnancies. Twelve of 35 women with triplet conceptions hospitalized at our high-risk pregnancy unit underwent an elective cerclage at 12 to 14 weeks and 23 women served as control subjects. None of them had any history or physical findings of cervical incompetence prior to the procedure. The gestational age (weeks) at delivery was 33.0 +/- 5.1 and 34.7 +/- 2.8 (mean +/- SD) for the sutured and noncerclage groups, respectively. The birthweight (grams) of the neonates was 1833.0 +/- 524.5 and 1884 +/- 455.5 (mean +/- SD) for the cerclage and nonsutured women, respectively. It seems that triplet gestations as such do not benefit from an elective cervical suture.

The value of an electronic microcomputerized basal body temperature measurement device (Bioself) in in vitro fertilization cycles

The Bioself 110 electronic basal body temperature (BBT) measurement device was employed in 18 women undergoing in vitro fertilization (IVF). This microcomputer-operated device records, charts and accurately analyzes the mean temperature measurements. These temperature recordings were used in addition to transvaginal ovarian sonography and serum estradiol and progesterone levels. The BBT rise correlated significantly (p < 0.0002) with progesterone elevation following human chorionic gonadotropin (hCG) administration. It is suggested that this electronic device may be used as an additional tool in the detection of premature progesterone secretion in IVF cycles.

Interleukin-1: local production and modulation of human granulosa luteal cells steroidogenesis

OBJECTIVES

To investigate the possibility of local interleukin-1 (IL-1) and IL-1 inhibitor production by human granulosa and cumulus cells and to assess their direct effects on the steroidogenesis of these cells in vitro.

DESIGN

Prospective study.

PARTICIPANTS

Normal ovulatory women undergoing ovulation induction for in vitro fertilization.

INTERVENTION

Pretreatment of patients with gonadotropin-releasing hormone analogue, human menopausal gonadotropin, and human chorionic gonadotropin (hCG).

MAIN OUTCOME MEASURES

Retrieval and isolation of granulosa luteal cells and follicular fluid (FF). Granulosa luteal cells and cumulus cells cultured and analyzed by fluorescent activated cell sorter. Follicular fluid separated and bioassayed for IL-1 and IL-1 inhibitory activity. Steroid measurement performed. Interleukin-1 inhibitor purified. Interleukin-1 and IL-1 inhibitor bioassay performed. Statistical analysis made and interpreted.

RESULTS

Interleukin-1, but not IL-1 specific inhibitory activity, was found in granulosa and cumulus cell cultures and also in FF, only after its purification on a high-pressure liquid chromatography column. Under nonstimulated conditions, neither IL-1 nor IL-1 inhibitor had any effect on basal progesterone (P) or estradiol (E2) secretion. However, IL-1 inhibitor demonstrated significant (P < 0.01) inhibition of hCG-stimulated P secretion (from 200 to 110 ng/10,000 cells per 24 hours). In addition, IL-1 demonstrated a significant (P < 0.05) and dose-dependent inhibition of hCG-stimulated E2 production (from 6,832 +/- 460 to 4,237 +/- 141 pg/10,000 cells per 24 hours).

CONCLUSIONS

Interleukin-1 may exert a significant local autocrine regulatory role in the human ovary.

The effect of growth hormone supplementation on in vitro fertilization outcome: a prospective randomized placebo-controlled double-blind study

OBJECTIVE

To determine the effect of growth hormone (GH) supplementation to a long gonadotropin-releasing hormone agonist (GnRH-a)/human menopausal gonadotropin (hMG) treatment protocol, on ovarian response, embryo quality, and clinical outcome in in vitro fertilization (IVF).

DESIGN

Growth hormone or placebo were administered in a prospective randomized double-blind manner.

PATIENTS

Forty-two normal ovulatory, women who were 38 years of age or less with mechanical factor infertility and a normal male factor were selected for this study.

INTERVENTIONS

Gonadotropin-releasing hormone agonist, 0.5 mg/d, was initiated in the midluteal phase of the preceding cycle and continued until the day of human chorionic gonadotropin (hCG) administration. Ovulation induction with hMG was started 14 days after pituitary down regulation (17 beta-estradiol [E2] serum level less than 30 pg/mL). Growth hormone (12 IU/d) or placebo were administered on days 1, 3, 5, and 7 of hMG treatment.

RESULTS

Breaking the code at the completion of the study revealed that 20 women received GH and 22 placebo. The age and duration of infertility did not differ between the two groups. Follicular phase duration, hMG ampules used, serum E2, and number of follicles (greater than or equal to 14 mm) on day of hCG as well as number of oocytes and embryos achieved were similar in both groups. Embryo morphology and rate of cleavage were also similar. Insulin-like growth factor-I (IGF-I) serum levels did not change after pituitary down regulation and increased significantly both after GH/hMG and placebo/hMG ovulation induction treatment. Clinical pregnancy rate (PR) per embryo transfer and implantation rate were 40% versus 32% and 17.9% versus 11.3% in the GH and placebo groups, respectively, and were not statistically different.

CONCLUSIONS

In normo-ovulatory women undergoing ovulation induction for IVF, GH supplementation to hMG after GnRH-a pituitary down regulation does not seem to augment ovarian response or improve embryo quality. The effect of this regimen on actual PRs and implantation rates needs further clarification.

Births in Israel resulting from in-vitro fertilization/embryo transfer, 1982-1989: National Registry of the Israeli Association for Fertility Research

Our objective was to describe the characteristics of pregnancies, deliveries and children at birth following in-vitro fertilization (IVF) and related technologies in Israel, from 1982 to 1989. A national survey with collaboration from all IVF units in the public hospitals was designed and data were collected on individual patients. Comparison of results was made with data from a national delivery census and from other national IVF registries. During the period covering this survey, 1149 deliveries resulted in 1475 newborns; 98% of deliveries occurred following conventional IVF and embryo transfer (IVF-ET), 2% after in-vivo fertilization and gamete intra-Fallopian transfer. Following IVF-ET, 23% of the pregnant women were hospitalized due to a complication of pregnancy and 47.3% of the deliveries were by Caesarean section (41% if multiple births are omitted). The male to female birth ratio was 1.07:1.0; 23.6% of the deliveries were multiple births, 28.6% of deliveries were pre-term and the median length of gestation decreased with multiple births. At delivery, 23.8% of newborns weighed less than 2500 g. The incidence of low birthweight newborns was significantly higher in multiple births. The ratio of perinatal mortality (22.8/1000), double the incidence found in a national census (13/1000), increased dramatically with multiple births (12.7, 24.5 and 75.8/1000 for singleton, twins and triplets respectively). The incidence of a major congenital malformation was 2.2%, no higher than in the general population. A survey of published national IVF registries from Australia and New Zealand, Great Britain, USA and France showed much similarity in all aspects of pregnancy outcome following IVF and related technologies.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of melatonin on progesterone production by human granulosa lutein cells in culture

OBJECTIVE

To test the hypothesis that melatonin modulates steroid synthesis in the human ovary.

DESIGN

Granulosa lutein cells obtained from in vitro fertilization cycles were cultured in medium containing melatonin and human chorionic gonadotropin (hCG).

RESULTS

Progesterone (P) secretion by granulosa lutein cells increased progressively in both basal and hCG-stimulated conditions, up to 96 hours in culture, plateaued at 144 and decreased thereafter. Melatonin (10(-7), 10(-9), 10(-11) M) had no effect on basal P or 17 beta-estradiol production. The addition of melatonin to the hCG-treated granulosa lutein cells significantly (P less than 0.05) potentiated the stimulatory effect of hCG on P production. The effect was most prominent after 144 and 196 hours of incubation.

CONCLUSION

This observation suggests a role for melatonin in the intraovarian control of P production in the human ovary.

Ovarian hyperstimulation syndrome in novel reproductive technologies: prevention and treatment

OBJECTIVE

To overview the world literature on ovarian hyperstimulation syndrome (OHSS) and modes of prevention and treatment of OHSS.

STUDY SELECTION

All the pertinent literature on OHSS, its prevention, and strategies for treatment were reviewed.

PREVENTION

Key to prevention is proper identification of the population at risk, which includes women with either the hormonal or the morphological signs of polycystic ovarian disease, high serum estradiol (E2) before human chorionic gonadotropin (hCG) administration (E2 greater than 4,000 pg/mL), multiple follicular response (greater than 35), younger age, and lean habitus. When a high risk situation is recognized, ovulatory dose of hCG may be reduced, avoided (with cycle cancellation), or substituted by gonadotropin-releasing hormone or its agonist. Luteal support with hCG is to be bypassed. To minimize risk of OHSS, endogenous pregnancy-drived hCG may be eluded by judicious cryopreservation of all embryos. Last, follicular aspiration will allow higher levels of E2 and larger number of follicles to be matured with lesser risk of OHSS than conventional ovulation induction without follicular aspiration.

TREATMENT

In-house for the severe and intensive care for the critical form. Meticulous fluid and electrolyte balance using both crystalloids and colloids (albumin) until hemoconcentration abates. Paracentesis is indicated for tight ascites, deteriorating kidney functions, and symptomatic relief. Diuretics may be prudently used once hemodilution is achieved. Dopamine drip may be used as a renal rescue, whereas heparin is indicated for thromboembolic phenomena and surgery reserved for abdominal catastrophies. Therapeutic interruption of an early gestation may be lifesaving when all other measures have failed.

CONCLUSIONS

Although severe and critical OHSS may not be completely avoided, early recognition of high-risk factors, judicious prevention schemes, and treatment strategies should reduce the complication and long-term sequelae of this iatrogenic syndrome.

The correlation between interleukin 2 and soluble interleukin 2 receptors to oestradiol, progesterone and testosterone levels in periovulatory follicles of in-vitro fertilization patients

The present study was performed to evaluate the correlation between follicular fluid levels of interleukin 2 (IL-2) and IL-2 soluble receptor (sIL-2R), oestradiol, progesterone and testosterone levels, oocyte fertilization, embryo quality and pregnancy rates. Twenty-eight patients with a pure tubal factor and undergoing in-vitro fertilization and embryo transfer were randomly chosen and treated with gonadotrophin releasing hormone agonist (GnRHa) in the midluteal phase (long protocol) coupled with follicular phase administration of human menopausal gonadotrophin. Transvaginal follicular aspiration was performed 36 h after human chorionic gonadotrophin administration, followed 48 h later by embryo transfer. One hundred and twenty-three follicular fluids were sampled. The mean follicular fluid levels (+/- SD) were 2.30 +/- 0.80 fmol for IL-2, 458.2 +/- 236.0 units/ml for sIL-2R, 28.5 +/- 58.1 ng/ml for oestradiol, 2360.5 +/- 2846 ng/ml for progesterone and 7.22 +/- 7.08 ng/ml for testosterone. There was a significant (P less than 0.01) correlation between IL-2 and testosterone levels. No correlation was found between the lymphokines and serum oestradiol, follicular fluid progesterone, oocyte fertilization, embryo quality and pregnancy. It may be concluded that significant concentrations of IL-2 and sIL-2R exist in follicular fluid. Wide variations in follicular IL-2 and sIL-2R concentrations of different follicles were found in the same patients.

Defective oocytes: a new subgroup of unexplained infertility

OBJECTIVE

To define a new category of unexplained infertility and its potential treatment.

DESIGN

Normal infertile couples underwent prospectively, cross-fertilization attempts in which the wife's oocytes were inseminated by the husband and donor semen. After recurrent failure of fertilization, cross insemination of donor oocytes was attempted with the husband sperm.

SETTING

In vitro fertilization unit at a teaching hospital.

PATIENTS

Three couples who were diagnosed as suffering of unexplained infertility and treated by in vitro fertilization (IVF).

RESULTS

The female partner of these couples produced morphologically normal oocytes that were demonstrated to be functionally defective and failed to fertilize in vitro with both husband and donor sperm. Donated oocytes inseminated by the husband's sperm were fertilized in all patients, demonstrating the normal fertilizing ability of the husbands' semen. One patient conceived and delivered after an oocyte donation.

CONCLUSIONS

Conclusive diagnosis of defective oocytes as a cause of infertility may be made only after IVF and oocyte donation.

Artificial endometrial preparation for oocyte donation: the effect of estrogen stimulation on clinical outcome

Morphologic studies of the endometrium have demonstrated that varying the duration of an artificial follicular phase (AFP) in women with ovarian failure did not adversely affect its developmental capacity. The aim of this study was to evaluate whether such manipulations of endometrial stimulation could influence the pregnancy rate in women undergoing oocyte donation (OD). Twenty-nine women were investigated in 51 cycles of OD. Endometrial preparation was performed with a fixed dose of micronized estradiol, 4 mg/day, administered for 5-35 days in accordance with oocyte availability. On the day of donation progesterone in oil, 50 mg/day, was added to the regimen. Oocytes were donated anonymously by patients undergoing routine in vitro fertilization. Fifteen clinical pregnancies were achieved, for a success rate of 29.4%. Using logistic regression analysis the success rate was found to be closely associated with the duration of estrogen stimulation. The pregnancy rate was 7.7, 52, and 7.7% after an AFP of 4-11, 12-19, and 20-29 days, respectively. It seems that for optimal results in an OD program, estrogen stimulation should be kept at between 12 and 19 days. These results also imply that, contrary to endometrial morphology, which seems to be tolerant to extreme AFP durations, functional receptivity is less permissive and is adversely affected by such manipulations.

Treatment of male infertility by gamete micromanipulation

Over the past decade, in vitro fertilization (IVF) has become a routine and acceptable tool in the treatment of infertility. However, major limitations in solving certain infertility problems still remain. Male infertility is one area in which only a small fraction of patients have benefited from IVF. Union of male and female gametes, either in vivo or in vitro, requires sperm penetration through the cumulus oophorus and the zona pellucida. Failure of fertilization despite the increased number of spermatozoa introduced into the oocyte's vicinity by IVF, has been shown to be directly related to abnormalities in sperm cell morphology and motility. The improved technology for micromanipulation of gametes has made it possible to circumvent the oocyte barriers to sperm penetration, thereby greatly reducing the number of normal sperm cells needed to achieve fertilization. This paper reviews the three major micromanipulative strategies which have been developed over the past five years, patient selection for the different procedures and the methods of sperm preparation to improve the yield of the applied technique.

Enhancing in vitro fertilization of mouse oocytes by partial zona pellucida digestion

This work was undertaken in order to evaluate the effect of partial zona digestion on fertilization in vitro of mouse oocytes and assess zona surface changes induced by the procedure. Three hundred forty-six oocytes allocated for treatment were exposed to Ham's F-10 medium supplemented with 0.5% Pronase for either 3 min (188 oocytes) or 5 min (158 oocytes); 324 oocytes served as controls. Oocyte losses incurred as a result of the procedure were small (15 oocytes; 4.3%). Control and Pronase-treated oocytes were each divided into four subgroups and inseminated with 5 x 10(5), 5 x 10(4), 5 x 10(3), or 5 x 10(2) sperm cells/ml. Fertilization was assessed 8 hr following insemination by the appearance of two pronuclei and development to the two- to four-cell stage the following day. The morphology of the zona pellucida following Pronase treatment was assessed by phase-contrast and scanning electron (SEM) microscopies performed immediately after treatment. Fertilization rate of control oocytes was 80% at a sperm concentration of 500,000/ml and gradually declined to approximately 30% at 500 cells/ml. In contrast, treated oocytes inseminated with 500 sperm cells/ml demonstrated a normal rate of fertilization. At this low sperm concentration the longer Pronase treatment was significantly (P less than 0.05) more efficient in enhancing fertilization (69 and 88% for 3 and 5 min of Pronase treatment, respectively). Polyspermic fertilization was not observed in any of the subgroups. Phase-contrast microscopic examination of oocytes at the time of Pronase treatment showed an initial swelling of the zona pellucida for 30-60 sec with a time-dependent increase in its transparency.

The correlation of interleukin 1 and tumour necrosis factor to oestradiol, progesterone and testosterone levels in periovulatory follicular fluid of in-vitro fertilization patients

Data has accumulated suggesting reciprocity between cytokines and the reproductive system. The present study was performed in order to evaluate the correlation between interleukin 1 (IL-1) and tumour necrosis factor (TNF) concentrations in follicular fluid and its oestradiol, progesterone and testosterone levels. A total of 39 follicular fluid samples, from eight patients undergoing in-vitro fertilization and embryo transfer were evaluated. All of the patients were treated by a midluteal (long) protocol involving a gonadotrophin releasing hormone agonist (GnRHa) coupled with follicular phase human menopausal gonadotrophin. Mean levels in follicular fluid of IL-1, TNF, oestradiol, progesterone and testosterone were 1.58 +/- 0.42 fmol/0.1 ml, 4.69 +/- 4.18 pg/ml, 28.5 +/- 58.1 ng/ml, 2360.5 +/- 2846.3 ng/ml and 7.22 +/- 7.08 ng/ml respectively. There was a significant (P less than 0.01) positive correlation between IL-1 and progesterone levels. There was no significant correlation between the different lymphokines and oestradiol secretion, oocyte fertilization, embryo quality and pregnancy rates. It is concluded that IL-1 and TNF exist in follicular fluid. It may be hypothesized that IL-1 has a local regulatory action, possibly promoting luteinization.

Angiotensin-I-converting enzyme and its correlation with human follicular fluid steroids

Angiotensin-I-converting enzyme (ACE) is a peptidyl-dipeptide hydrolase which splits off the dipeptide His-Leu from the decapeptide angiotensin I and thus converts it to angiotensin II. We determined ACE activity in human preovulatory follicular fluid to further establish the intraovarian activity of the renin angiotensin system. Follicular fluids (n = 18) were obtained from eight patients undergoing in vitro fertilization (IVF) and embryo transfer (ET). ACE activity in follicular fluid and serum was determined by fluorescent spectrophotometry. The median follicular fluid ACE activity was 1.12 (range: 0.19-1.56) nmol/min/ml. This value was significantly lower than ACE activity in serum, 1.50 (range: 1.22-1.57) nmol/min/ml (P less than 0.001). In contrast to this 3:4 ratio between follicular fluid and serum ACE when expressed per ml fluid, the values were very similar when expressed per mg of protein: 0.025 vs. 0.023 nmol/min/mg in follicular fluid and serum, respectively. Correlations were sought between follicular fluid ACE activity and both serum and follicular fluid E2 and P4. A highly significant correlation (P less than 0.0005, r = 0.73) was found between ACE activity in follicular fluid and follicular fluid P4. The presence of significant ACE activity in human follicular fluid further supports the local-ovarian activity of the renin angiotensin cascade.

Maternal hemorrhagic complications following prophylactic low-dose aspirin and dipyridamole therapy

A case is reported of a severe postpartum maternal hemorrhagic complication, which was related to prophylactic antithrombotic therapy with daily low-dose aspirin (75 mg) combined with dipyridamole (225 mg) for the prevention of preeclampsia. The postpartum course was complicated by recurrent episiotomy site hematomas of nonclotted blood and prolonged bleeding time. Transfusion of platelet concentrates was necessary to control the bleeding. This case report draws attention to maternal hemorrhagic complications which may be associated with prophylactic low-dose aspirin and dipyridamole in pregnancy.