Menotropins as a possible risk factor for premature deliveries in triplet pregnancies

This study was undertaken in order to evaluate pregnancy outcome in three groups of triplet conceptions. Of 36 delivered triplet gestations, seven were spontaneous, 12 achieved using clomiphene citrate and 17 induced by menotropins. The mean gestational age (weeks) at delivery was 36.5 +/- 1.0 SD, for spontaneous and clomiphene citrate pregnancies it was 35.9 +/- 1.9 SD which differed significantly from that in pregnancies induced by menotropins which was 32.9 +/- 3.7 SD. Similarly, triplets born following menotropin treatment had a significantly lower gestational weight (g) of 1656 +/- 516 SD vs. 2015 +/- 198 SD and 2176 +/- 315 SD for spontaneous and clomiphene citrate gestations, respectively. It is concluded that triplets following menotropins are at an increased risk for premature delivery and low birth weight.

The correlation between sperm cell morphology and fertilization after zona pellucida slitting in subfertile males

OBJECTIVE

This work was undertaken to evaluate the correlation between sperm cell morphology and fertilization after zona pellucida slitting in subfertile males.

DESIGN

Twenty-two couples who failed at least one in vitro fertilization attempt because of lack of oocytes fertilization underwent a zona-slitting micromanipulative procedure. A total of 245 oocytes were retrieved and inseminated by three different modes: 151 oocytes underwent micromanipulation, 2 were damaged, and the remaining 149 inseminated by the husband's sperm (group A). Fifty-five oocytes were not manipulated and inseminated by the husband's sperm (group B), and 39 oocytes were not manipulated and inseminated by a donor sperm (group C).

RESULTS

Fertilization rates were 26.8%, 5.5%, and 53.8% in groups A, B, and C, respectively, and differed significantly between group A and group B. The cleavage rates were lower for oocytes fertilized by the husband's sperm (48.6%) than that obtained by donor (90%), suggesting a sperm factor contributing to this phenomenon. The procedure was most efficient in patients with a total motile sperm count after preparation of greater than or equal to 5 million and with either normal sperm morphology or defects localized to the acrosome or tail region only. Sperm with nuclear morphological abnormalities demonstrated a marked reduction in fertilization potential.

CONCLUSION

It is concluded that the zona-slitting technique enhances fertilization of severely subfertile sperm, and its efficacy is affected by sperm morphology and a threshold concentration of motile cells.

Production of 6-keto-PG F1 alpha in hyperstimulated cycles: in vivo and in vitro studies

Prostacyclin (PG12), a potent vasodilator, is believed to be involved in increasing permeability within the wall of the preovulatory follicle. In ovarian hyperstimulation syndrome (OHSS), increased vascular permeability has been shown to lead to massive fluid accumulation in ovarian cysts and the peritoneal cavity. The objective of the in vitro and in vivo studies reported herein was to examine the production of 6-keto PGF1 alpha (a breakdown metabolite of PG12) during the luteal phase of women who develop OHSS, as well as the capacity of human granulosa luteal cells (GLC) obtained from stimulated in vitro fertilization (IVF) cycles to synthesize PGF1 alpha in vitro in long-term cultures. The in vivo results showed that during the luteal phase of women with OHSS, there is no increase in 6-keto PGF1 alpha production compared with the levels obtained from the luteal phase of normal ovulatory women. The GLC (representing early corpus luteum function) secreted significant amounts of 6-keto PGF1 alpha, but only in the first 48 hours of culture. Human chorionic gonadotropin (hCG) had no additional augmentative effect upon the production of 6-keto PGF1 alpha throughout the culture period. It is concluded that 6-keto PGF1 alpha is not produced in significant amounts during the luteal phase, and therefore PG12 probably does not play a major role in the etiology of OHSS.

The effect of a prolonged artificial follicular phase on endometrial development in an oocyte donation program

Stretching the duration of an artificial follicular phase in an oocyte donation program facilitates greatly the synchronization between the donor and the recipient. In order to investigate the limits of such a prolonged endometrial preparation, 18 patients with ovarian failure were studied during 20 treatment cycles. These patients were prospectively and randomly divided into three groups (A, B, and C in eight, six, and six cycles respectively). All groups were treated with oral estradiol and estriol (at a 2:1 ratio), 4 mg/day for 21, 28, and 35 days, respectively. At this stage 50 mg/day of intramuscular progesterone was added for additional 7 days. Endometrial adequacy was evaluated by late follicular and midluteal endometrial biopsies. During treatment no patient suffered from breakthrough bleeding. The mean estradiol and progesterone levels during the follicular and luteal phases did not differ significantly between groups. All late follicular biopsies showed a normal proliferative endometrium with no signs of glandular cystic hyperplasia. The midluteal biopsy showed a secretory endometrium adequate for 18.6 +/- 1.8, 21.8 +/- 1.8, and 18.6 +/- 1.5 days in groups A, B, and C, respectively, with no significant glandular-stromal disparity. We conclude that an artificial prolonged follicular phase does not seem to affect adversely the endometrial preparation in an oocyte donation program.

Multicenter registry of angioplasty therapy of cardiogenic shock: initial and long-term survival

This retrospective multicenter study reviews the role of acute percutaneous transluminal coronary angioplasty in the treatment of cardiogenic shock complicating acute myocardial infarction to determine whether early reperfusion affects in-hospital and long-term survival. From 1982 to 1985, 69 patients were treated with emergency angioplasty to attempt reperfusion of the infarct-related artery. Balloon angioplasty was unsuccessful in 20 patients (group 1) and successful in 49 patients (group 2). Initial clinical and angiographic findings in the groups with unsuccessful and successful angioplasty were similar with respect to age (60.5 +/- 2.3 versus 57 +/- 1.8 years), infarct location (65% versus 65% anterior) and gender (65% versus 67% male). Hemodynamic variables in the two groups, including systolic blood pressure (68 +/- 4.3 versus 73 +/- 1.6 mm Hg), left ventricular end-diastolic pressure (24.4 +/- 2.4 versus 27 +/- 1.0 mm Hg) and initial ejection fraction (28.5 +/- 4% versus 32 +/- 2%), were also similar. Twenty-nine patients received thrombolytic therapy with streptokinase; the overall rate of reperfusion was 34%. Group 1 patients had a short-term survival rate of 20%, compared with 69% in group 2 patients (p less than 0.0005). Thirty-eight patients survived the hospital period and were followed up for 24 to 54 months (mean 32.5 +/- 2.4). Five patients (all in group 2) died during follow-up. The long-term incidence rate of congestive heart failure was 19%, arrhythmia 21%, need for repeat angioplasty 17% and coronary artery bypass grafting 26%. Twenty-four month survival was significantly better in group 2 patients (54%) versus group 1 patients (11%, p = 0.003).(ABSTRACT TRUNCATED AT 250 WORDS)

The value of menotrophin treatment for unexplained infertility prior to an in-vitro fertilization attempt

This work was undertaken in order to evaluate retrospectively the relative efficacy of ovulation induction by menotrophins and that of in-vitro fertilization and embryo transfer (IVF-ET) in the treatment of unexplained infertility. These two treatments were compared between two groups of patients: 87 couples undergoing 446 cycles of ovulation induction by menotrophins (group A) and 72 couples undergoing 108 cycles of IVF-ET (group B). A total of 30 and 20 pregnancies were achieved in groups A and B for a rate of 34 and 28% per patient, respectively. A similar cumulative pregnancy rate (CPR) was achieved for three cycles of ovulation induction (23%) and one cycle of IVF-ET (22%). The cumulative live birth rate (CLBR) in group A was 22% after three cycles and exceeded that of one IVF-ET cycle (17%). It is concluded that menotrophin treatment in unexplained infertility is highly beneficial and should precede an IVF attempt.

Technique for cellular microsurgery using the 193-nm excimer laser

A new cell surgery technique has been developed to produce well-defined alterations in cells and tissue without detectable heating and/or other structural damage in the surroundings. The technique involves the use of an argon fluoride excimer laser, in the deep ultraviolet (UV) region of the spectrum at 193 nm, which is guided through a glass pipette filled with a positive air pressure. To demonstrate the method, holes were drilled in the zona pellucida of mouse oocytes. The diameter of the drilled hole was determined by the pipette tip size, and its depth by an energy emitted per pulse and number of pulses. Scanning electron microscopy of the drilled mouse oocytes showed uniform, round, well-circumscribed holes with sharp edges. Oocytes that had their zona pellucida drilled with this new method fertilized in vitro and developed to the blastocyst stage in a rate similar to that of control group. These results demonstrate the nonperturbing nature of this cold laser microsurgical procedure. In addition to the extension of our results for clinical in vitro fertilization purposes, such as enhancement of fertilization and embryo biopsy, there are wide-ranging possible uses of our method in fundamental and applied investigations that require submicron accuracy in cellular alteration.

Ovarian response to exogenous gonadotropins during pregnancy

Multiple ovarian follicles were successfully induced in a patient undergoing superovulation for a gamete intrafallopian transfer (GIFT) procedure despite the presence of an undiagnosed ectopic pregnancy. Midluteal gonadotropin releasing hormone agonist (GnRH-a) treatment should be coupled with mechanical contraception in the previous cycle in patients with patent tubes.

Culture of human endometrial cells under polarizing conditions

Glandular epithelial and stromal cells were isolated from human endometrial biopsies and cultured in a dual-chambered system (Millicell; Millipore, Bedford, Ma., USA) that provides access of the medium to both sides of a membrane coated with reconstituted basement membrane material (Matrigel; Collaborative Research Inc., Bedford, Ma., USA). Examination by electron microscopy revealed that the epithelial cells formed a polarized cuboidal-columnar monolayer on the Matrigel surface. The cells exhibited apical microvilli, basal nuclei, and numerous cytoplasmic structures consistent with a well-differentiated cytoplasm; they were joined basally by interdigitating processes and apically by tight junctions and desmosomes. In contrast, epithelial cells cultured in parallel on plastic dishes were flattened, had fewer microvilli and cytoplasmic structures, and no junctional complexes.

In vitro fertilization. Correlation of vaginal cytology and hormonal profile with success rates

Cytologic parameters of the vaginal epithelium in 59 women undergoing in vitro fertilization-embryo transfer (ET) were correlated with plasma levels of 17-beta estradiol and progesterone on the oocyte pickup (OPU) and ET days. On the OPU day a late proliferative/late proliferative-early secretory pattern was observed in 84.6% of the 13 women who conceived (group 1) but in only 52% of the 46 who failed to conceive (group 2) (P less than .04). On the ET day a secretory phase appeared in 100% and 61% of group 1 and 2 patients, respectively (P less than .01). Between the OPU and ET days the mean karyopyknotic index dropped by 60% and 13% in group 1 and 2 patients, respectively (P less than .001). It seems that a high estrogenic effect followed by an advanced progestational environment, on the OPU and ET days, respectively, can provide a favorable milieu for implantation.

In-vitro steroid production by human granulosa lutein cells in long-term cultures

delta 4 and delta 5 pathway steroidogenesis by human granulosa lutein cells (GLC) in long-term cultures (6-8 days) was investigated under basal (10% serum + medium + GLC) and stimulated (human chorionic gonadotropins (hCG), 100 mIU/ml) conditions. In the delta 4 pathway, 17-hydroxyprogesterone (17-OHP) secretion increased from 160-fold at 48 hours of culture to 360-fold at 144 hours under basal conditions, when compared with the respective controls (concentrations in the 10% serum added to the medium) (p less than 0.005). HCG further augmented 17-OHP production significantly at 96, 144 and 192 hours of culture. Progesterone (P) secretion behaved similarly, and increased from 150-fold at 48 hours to 560-fold at 96 hours when compared with controls, being further stimulated by hCG. In contrast, androstenedione (A) secretion throughout the entire culture period increased only slightly (3-5-fold) under both basal and stimulated conditions, when compared with the respective controls. In the delta 5 pathway, the secretory pattern of 17-hydroxypregnenolone (17-OHPregn) and dehydroepiandrosterone (DHEA) was similar to that observed with A, and both steroids increased only slightly under basal and stimulated conditions, when compared with their respective controls. In conclusion, 17-OHP and P are secreted in very significant amounts during the entire culture period while 17-OHPregn, DHEA and A are secreted in extremely small amounts. These results demonstrate that the delta 5 pathway is inactive in long-term human GLC cultures while the delta 4 pathway is active in certain portions only.(ABSTRACT TRUNCATED AT 250 WORDS)

Successful microsurgical removal of a pronucleus from tripronuclear human zygotes

We have microsurgically extracted a pronucleus from 11 tripronuclear human zygotes under two different experimental conditions. One group of six zygotes was incubated in cytochalasin D for 30 minutes before manipulation. The remaining five zygotes were manipulated without preincubation in cytoskeletal relaxing agents. When cytoskeletal relaxants were used, all six embryos survived manipulation and cleaved. One embryo arrested spontaneously at the two-cell stage; all others cleaved to at least four cells, and one embryo reached the advanced morula stage. Of the five eggs manipulated without prior cytochalasin D and colcemid treatment, none survived for more than 30 minutes after manipulation. In none of the tripronuclear eggs was it possible to definitely identify the male pronuclei. Because development was interrupted for karyotyping, it is likely that these embryos would have otherwise continued to develop to more advanced stages. These results indicate that it is possible to microsurgically "epronucleate" tripronuclear human zygotes and obtain further development and that use of cytoskeletal relaxants facilities this manipulative procedure. However, because epronucleated embryos have significant developmental potential, chromosome studies are needed to confirm complete removal of a male pronucleus before such techniques can be applied clinically.

Human follicular fluid protease and antiprotease activities: a suggested correlation with ability of oocytes to undergo in vitro fertilization

Plasminogen activator activity was determined in human follicular fluids (FFs) obtained during in vitro fertilization procedures. The fibrinolytic activity of plasminogen activator was significantly higher in fluids from follicles that contained oocytes that were later found to fertilize in vitro (group F) as compared with fluids from follicles that contained oocytes that failed to fertilize (NF). To assess whether this difference in overt plasminogen activator activity reflects differences in conversion of an inactive, latent plasminogen activator to the active enzyme, the ability of exogenous trypsin to enhance plasminogen activation was measured. The plasminogen-dependent hydrolysis of the chromogenic substrate S-2444 in presence of trasylol (Bayer, Leverkusen, Germany) was taken as a measure of plasminogen activator activity in these experiments. No activity was found in untreated FFs, while exposure to trypsin resulted in emergence of marked plasminogen activator activity. In addition, FFs exhibited trasylol-sensitive chromogenic activity indicative of serine-protease activity. Both the plasminogen activator and serine-protease levels after tryptic activation were significantly higher in NF than in F samples. Thus, while F samples have most of their plasminogen activator in an active form, NF samples have most of their plasminogen activator in a latent, trypsin-activatable form. Follicular fluids also contain inhibitory activities toward plasmin and trypsin. The inhibition of these enzymes correlates positively with the latency of plasminogen activator. These results suggest a direct relationship between the ability of oocytes to fertilize and the overt to latent plasminogen activator activity ratios in the FFs.

Double transfer of embryos in in vitro fertilization, or is there a delayed receptivity of the endometrium?

Sixty-seven in vitro fertilization (IVF) patients who underwent ultrasonically guided oocyte pickup (OPU) after induction of superovulation with human menopausal gonadotropins were submitted to two different protocols of embryo transfer. In the first group of 33 patients, four to five embryos were transferred to the uterus 48 hr after OPU. In the second group of 34 patients two to three embryos were transferred at 48 hr after OPU and two other embryos were transferred after freezing and thawing 48 hr later (96 hr after OPU). The pregnancy rate achieved in the double embryo transfer (ET) protocol was significantly higher than in the single-ET protocol (32.4 vs. 18.2%, respectively; P less than 0.05).

Manipulating the follicular phase in IVF cycles: a comparison of two hMG stimulation protocols

The results of two human menopausal gonadotropin (hMG) protocols of ovulation induction for in vitro fertilization (IVF) were compared. With the first protocol, 28 women (group 1) were treated with an hMG dosage which was increased stepwise. With the second, 30 women (group 2) were treated with a high dose of hMG for 2 days, then given a constant daily dose. The two groups were compared with regard to ovarian response, luteal phase and laboratory and clinical outcomes of IVF. They were comparable as regards the total number of hMG doses required, the number of large follicles (mean diameter greater than 15 mm) on day 0 (day of human chorionic gonadotropin (hCG) administration), serum estrogen (E2) and progesterone (P) levels throughout the cycle and IVF laboratory and clinical outcomes. They differed significantly (p less than 0.01) only in the number of secondary smaller follicles (mean diameter less than 15 mm) observed on day 0 (3.7 +/- 0.4 for group 1 and 5.3 +/- 0.4 for group 2). Manipulating the hMG dosage during the early-mid follicular phase does not affect follicular synchrony, the number of oocytes harvested and the number of embryos achieved.

Assisted reproductive technology. A clinical appraisal

With the various types of reproductive technology now available, the overall pregnancy rates still are less than 25%. An increase in those rates would permit physicians to provide relief from infertility to a much larger population.

Percutaneous transluminal coronary angioplasty improves survival in acute myocardial infarction complicated by cardiogenic shock

Modest survival benefits have been reported in patients with acute myocardial infarction complicated by cardiogenic shock who were treated with early surgical revascularization or thrombolytic therapy. To determine whether coronary angioplasty improves survival, 87 patients with cardiogenic shock complicating acute myocardial infarction at the University of Michigan, Ann Arbor, Michigan, from 1975 to 1985 were retrospectively analyzed. Patients in group 1 (n = 59) were treated with conventional therapy; patients in group 2 (n = 24) were treated with conventional therapy and angioplasty. Extent of coronary artery disease, infarct location, and incidence of multivessel disease were similar between groups. Hemodynamic variables including cardiac index, mean arterial pressure, and pulmonary capillary wedge pressure were also similar. The 30-day survival was significantly improved for group 2 patients (50% vs. 17%, p = 0.006). Survival in group 2 patients with successful angioplasty was 77% (10 of 13 patients) versus 18% (two of 11 patients) in patients with unsuccessful angioplasty, (p = 0.006). The findings suggest that angioplasty improves survival in cardiogenic shock compared with conventional therapy with survival contingent upon successful reperfusion of the infarct-related artery.

The cytology of vaginal, cervical and endometrial smears obtained at the time of embryo transfer during in vitro fertilization

Seventy-four women enrolled in an in vitro fertilization (IVF) program had cytologic smears of the vagina, cervix and endometrium obtained at the time of embryo transfer (ET). Of these, 68 vaginal, 46 cervical and 25 endometrial smears were available for cytologic examination. Of the 68 vaginal smears, 4% showed a proliferative pattern, 40% were early secretory and 56% were advanced secretory. The 46 cervical smears demonstrated a delayed hormonal effect, with 70% showing a proliferative pattern, 23% early secretory and 7% advanced secretory cytology. Endometrial cells were obtained only when the Jones catheter, which has a side opening, was used. Twenty-two patients had both vaginal smears and suitable endometrial smears. Of these, 8 of the 9 patients with early secretory vaginal cytology had secretory endometrium while 10 of the 12 patients with mid-secretory vaginal cytology had secretory endometrium. The value of endometrial cytology in predicting conception following IVF-ET is unknown. It seems, however, that a good correlation exists between endometrial and vaginal cytology and that the latter may be of value as an additional, noninvasive tool for the evaluation of endometrial development.

Magnetic resonance imaging of the menstrual cycle

This study examines the ability of magnetic resonance imaging (MRI) to monitor follicular and endometrial development during the menstrual cycle. MR scans, sonograms and hormonal levels of estradiol (E2) and progesterone (P) obtained from five ovulatory volunteers were evaluated on approximately days 4, 8, 12, 16, 20 and 24 of the cycle. MRI reliably demonstrated folliculogenesis in all of the volunteers. Changes depicted in the endometrial and junctional zones of the uterus reflected physiologic events occurring during the normal cycle. Important implications exist for infertile women undergoing stimulated cycles and/or in-vitro fertilization.

In vitro effects of clomiphene citrate on human endometrium

Since cis-clomiphene citrate (CC) used for ovulation induction may affect embryo implantation during in vitro fertilization, direct effects of the drug on human endometrium were tested. Estrogenic and antiestrogenic effects were evaluated in vitro by measuring changes in prostaglandin (PG) output provoked by estradiol (E2), CC, and mixtures of E2 and CC; progestagenic effects were tested with E2 17 beta-dehydrogenase activity and glycogen accumulation as end points. In secretary endometrium, 10(-6)M CC about doubled the basal output of PGF2 alpha and PGE2; 10(-8)M E2 increased the production of these PGs 3-fold and 1.8-fold, respectively. The effects of E2 at this concentration were not diminished by the addition of CC, even at 100-fold molar excess, under conditions in which 10(-7)M progesterone or 10(-6)M 4-hydroxytamoxifen suppressed completely the action of the natural estrogen. In proliferative endometrium, 10(-8)M and 10(-6)M CC had no consistent effect on E2 17 beta-dehydrogenase activity or glycogen accumulation. These results demonstrate that, under in vitro conditions, CC can exert direct estrogenic effects on the endometrium but does not act as an antiestrogen or a progestagen.