Human in vitro fertilization employing individualized ovulation induction by human menopausal gonadotropins

Freeze-all embryos during treatment with assisted reproduction: Health economic aspects

Assisted reproductive technologies are evolving, with the most recent example being the introduction of the freeze-all policy during which a fresh embryo transfer does not take place and all embryos of good quality are cryopreserved to be used in future frozen embryo transfers. As the freeze-all policy is becoming more prevalent, it is important to review the economic aspects of this approach, along with considerations of efficacy and safety, and the role of emerging freeze-all-specific ovarian stimulation strategies. Based on the available evidence, the freeze-all policy presents distinct clinical advantages, particularly for high responders. Available health economic evaluations are limited. Two good-quality cost-effectiveness analyses based on randomized controlled trials suggest that the freeze-all strategy is unlikely to be cost-effective in non-polycystic ovarian syndrome (non-PCOS), normally responding patients. However, the cost-effectiveness of the freeze-all strategy in different populations of patients and in different settings has not been evaluated, nor has the clinical and economic efficacy of modern freeze-all-specific ovarian stimulation protocols that are likely to simplify treatment and make it more affordable for patients. Economic evaluations that incorporate good practice health technology assessment (HTA) methods are needed to compare freeze-all with conventional embryo transfer strategies. Furthermore, future research should address the unique limitation of traditional HTA methods in valuing a life conceived through fertility treatment.

Stimulation of folliculogenesis in domestic cats with human FSH and LH

Folliculogenesis in response to exogenous stimulation by human urinary follicle stimulating hormone (huFSH) and human menopausal gonadotropin (hMG) was evaluated in the domestic queen (Felis catus). The role of LH and/or FSH in folliculogenesis was examined by measuring concentrations of estradiol 17beta (E(2)) and progesterone (P) in the serum. Additionally, changes in the number and size of follicles from before the administration of exogenous hormones to surgical oocyte collection were monitored. Findings indicated that in queens receiving huFSH or hMG followed by human chorionic gonadotropin (hCG) to induce ovulation, the numbers of follicles from 1 to 3 mm increase with statistical significance (P<0.005) from before the initiation of treatment to surgical collection of oocytes. Although E(2) concentrations in cats receiving hMG increased above baseline by the third exogenous hormone injection, mean E(2) concentrations did not increase in the groups that received both huFSH and hCG, or hCG only, until after the administration of hCG. This suggests that the exogenous administration of LH contained in both hMG and hCG was necessary for E(2) to rise to levels associated with estrus.

GnRH agonist increases pregnancy potential of retrieved oocytes given adequate preincubation before insemination: a comparative study

Preincubation of oocytes aspirated from follicles in IVF-ET programs is a controversial approach. While some investigators recommend this technique others doubt its necessity. We have studied the embryo quality in 100 women, undergoing IVF-ET, in whom ovulation was induced by the combination of GnRH agonists (GnRHa) and menotropins and compared to a control group in whom ovulation was induced with menotropins alone. No statistically significant difference was noted with regard to the fertilization and cleavage rates as well as to the preincubation period. Significantly higher pregnancy rates (P less than 0.001) were encountered in the first group in comparison with the control group.

The impact of embryo quality on pregnancy outcome in elderly women undergoing in vitro fertilization-embryo transfer (IVF-ET)

Most IVF-ET units limit the procedure to women below age 38. Nevertheless, demands for infertility treatment, including IVF therapy, are more frequent nowadays. We compared 46 cycles for ovulation induction for IVF in 46 women aged 40 or more (Group I) to 51 induced cycles for this procedure in younger women of mean age 30.2 years (Group II). Cancellation rates due to early luteinization or ovulation were significantly higher in group I than in group II (28.2 and 17.6%, respectively) (P less than 0.001). Also, significantly higher abortion rates were observed in older women (62.5%), in comparison to the younger control group, (25%), (P less than 0.001). It is suggested that the high abortion rate considered to be due to genetic factors in older women, may possibly also be due to the aging uterine environment. Furthermore, while embryos with fragmentations may often produce clinical pregnancies in the young, the aging uterus in the elderly woman does not encourage the development of clinical pregnancies in such embryos. Consequently the higher abortion rate in the elderly woman.

Mononuclear cell subpopulations in human follicular fluid from stimulated cycles

The study of lymphocyte subsets from human follicular fluid (FF) provides an opportunity to evaluate immunological features of the ovary. We investigated the mononuclear cell subsets in FF and peripheral blood obtained at the time of laparoscopy from ten in vitro fertilization (IVF) patients. Midcycle nonpregnant peripheral blood was used as the control. A marked increase in the proportion of monocytes (CD14+) was observed in FF. Although FF was enriched with CD8+ lymphocytes, a decrease in the proportion of CD4+ lymphocytes was observed. "Memory" T cells in FF, identified by the CD4+ CD45R- phenotype, predominated over "naive" T cells (CD4+ CD45R+) at a ratio of 2:1, which differs from the ratio yielded by control blood samples (1:1). The percentage of activated T cells (CD3+ HLA-DR+ cell) increased significantly in FF. When lymphocyte subsets were studied in the peripheral blood of IVF patients, changes similar to but less significant than those in FF were found. These data support the concept that lymphocytes play an important role in ovarian physiology.

Immunosuppressive properties of human follicular fluid

Human preovulatory follicular fluids (FF) obtained in the course of stimulated cycles were analyzed for their possible immunologic functions. Different concentrations of FF (20%, 2%, 1%) inhibited the mitogenic response of normal human lymphocytes to concanavalin A (Con A). Lymphocytes were assessed for immunosuppressor activity after preincubation with FF. Lymphocyte mitogenic response to Con A was only suppressed by cells preincubated with FF at concentrations of 2% and 1% for at least 48 hours. No evidence of suppressor cell induction was seen following incubation of lymphocytes with 20% FF, nor was any significant relationship between FF immunosuppressor activity and the outcome of in vitro fertilization observed. We conclude that some factor(s) in FF may be capable of directly inhibiting lymphocyte response and inducing immunosuppressor cell activity in vitro.

The association between chlamydial-specific IgG and IgA antibodies and pregnancy outcome in an in vitro fertilization program

Chlamydial-specific IgG and IgA antibodies were determined by a single serovar (L2) immunoperoxidase assay (IPA) in the serum of all patients that have conceived in an in vitro fertilization and embryo transfer (IVF & ET) program (n = 106) and in a group of patients that went through the program at the same period of time and did not conceive (n = 94). The prevalence rate of elevated IPA IgG (titers greater than or equal to 1:128) and IPA IgA (titers greater than or equal to 1:16) specific to chlamydiae was significantly higher (P less than 0.001) in the IVF & ET pregnancy loss and nonconception groups ("failures") versus the IVF & ET term pregnancy group ("successes") (74 vs 47%, odds ratio = 4.1, and 34 vs 14%, odds ratio = 4.3, respectively). Stepwise discriminant analysis revealed that elevated specific chlamydial IgG had the greatest effect on the variance between successes and failures in this study group. Our study indicates the possible role of past or chronic active chlamydiae infection on the "take-home baby rate" in an IVF & ET program.

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.

Super high estradiol response to gonadotropin stimulation in patients undergoing in vitro fertilization

The likelihood of establishment of a term pregnancy from in vitro fertilization (IVF) is related to the estradiol (E2) pattern and peak level. To examine the influence of super high E2 peak levels (greater than or equal to 2000 pg/ml), we reviewed the clinical outcomes of all IVF cycles with follicular phase E2 levels greater than 2000 pg/ml from May 1982 through June 1987. Among 1651 IVF cycles initiated during this time, 102 cycles (6.2%) had super high E2 levels. Twenty-seven of these cycles occurred in 34 IVF attempts in 12 women. Stimulation was performed with human menopausal gonadotropin (hMG) in 96 cycles and follicle-stimulating hormone (FSH) in 6 cycles. A mean of 9.3 +/- 0.7 oocytes per cycle was recovered, of which 5.5 +/- 0.5 fertilized and underwent cleavage. In 11 cycles, with a mean of 6.8 oocytes recovered, none fertilized. Polyploid fertilization occurred in 23 of 90 cycles (25.6%), and 40 of 558 fertilized oocytes (7.2%). From these cycles, 10 clinical pregnancies (9.8%) have resulted: 6 pregnancies in 59 cycles with luteal-phase progesterone support (10.2%) and 4 pregnancies in 31 cycles without luteal-phase progesterone support (12.9%). Among the 1549 cycles with peak E2 levels less than or equal to 2000 pg/ml, 143 (9.2%) resulted in clinical pregnancies. We conclude that there is a small subset of patients who will have super high E2 responses to gonadotropin stimulation and that there is a tendency to stimulate repetitively in this fashion.(ABSTRACT TRUNCATED AT 250 WORDS)

Ovarian stimulation for in vitro fertilization and embryo transfer, human menopausal gonadotropin versus pure human follicle stimulating hormone: a randomized prospective study

A randomized, prospective study was conducted to compare ovarian stimulation with human menopausal gonadotropin (hMG) and human follicle-stimulating hormone (hFSH) in an in vitro fertilization and embryo transfer (IVF-ET) program. Minimal inclusion criteria included age less than or equal to 37, tubal infertility, regular menstrual cycles before IVF, and a normal semen analysis. Equivalent doses (225 IU/day) of either hMG (N = 20) or hFSH (N = 20) were administered, and the patients followed by serum estradiol (E2) levels and pelvic ultrasound. Parameters related to the ovarian response to therapy, the number and quality of ova recovered, and the cycle outcome were compared in the two groups using the Student's t-test and chi-square analysis. No difference was detected between the groups in peak E2 levels (828 +/- 78 versus 819 +/- 79 in the hMG and hFSH groups, respectively), day of human chorionic gonadotropin (hCG) administration (9.3 +/- 0.3 versus 9.7 +/- 1.01), occurrence of spontaneous luteinizing hormone (LH) surge (44% versus 27%, P greater than 0.05, chi square analysis), average number of ova recovered (5.0 +/- 0.7 versus 5.6 +/- 1), ova maturation (7.5% versus 12.7% rate of immature ova), rate of normal and abnormal fertilization (9.2% versus 8.1% polyspermic fertilization), cleavage stage at transfer (3.6 +/- 0.4 versus 3.4 +/- 0.7 cells per embryos), the number of embryos transferred (2.5 +/- 0.3 versus 2.6 +/- 0.3), or the occurrence of pregnancy (1 in the hMG group and 2 in the hFSH group).(ABSTRACT TRUNCATED AT 250 WORDS)

Laparoscopic and transvaginal ova recovery: the effect on ova quality

Transvaginal follicle aspiration guided by transvaginal ultrasound for ova recovery is rapidly gaining popularity in many centers practicing in vitro fertilization and embryo transfer (IVF-ET). Cycle outcome following this new method has not been directly compared to the traditional, laparoscopic recovery technique. To this end, the authors evaluated multiple parameters in 66 laparoscopic (group A), and 44 transvaginal ova recovery procedures (group B) in patients undergoing IVF-ET. No statistically significant differences could be demonstrated between the groups in all but the rate of ova fertilization. The rate of fertilization was higher in the ova recovered by transvaginal follicle aspiration (59.6 versus 69.2%; P less than 0.01). No difference could be demonstrated between the groups in the other parameters examined, which included the number of ova recovered (5.7 +/- 0.4 versus 6.0 +/- 0.7), ova maturity (87 versus 84% intermediate ova), rate of polyspermic fertilization (3.9 versus 5%), rate of cleavage (88 versus 91%), cleavage stage at transfer (3.7 +/- 0.8 versus 3.5 +/- 0.4 cells per embryo), number of embryos transferred per patient (2.7 +/- 0.1 versus 3.3 +/- 0.2), and pregnancy rates. The potential detrimental effects of general anesthesia and CO2 pneumoperitoneum present during laparoscopy but not ultrasound guided recovery on ova quality may underlie the observed difference in fertilization between the groups.

Spectrophotometric absorbance of follicular fluid: a predictor of oocyte fertilizing capability

Follicular fluid volume, scoring of the oocyte-cumulus-corona-complex (OCCC), and spectrophotometric absorbance of the follicular fluid were separately compared between a group of fertilized (n = 53) and unfertilized oocytes (n = 35). Scoring of the OCCC and follicular fluid volumes was not found to be statistically different between the two groups. Spectrophotometric analysis of the follicular fluid in the visible spectrum demonstrated two peaks of maximum absorbance at 415 nm and 455 nm. The group of oocytes that fertilized was associated with follicular fluids that had significantly higher absorbances at 415 nm and 455 nm. In conclusion, follicular fluid volume and scoring of the OCCC were poor predictors of fertilizing capability; however, spectrophotometric absorbance, particularly at 455 nm, was positively correlated with oocyte fertilization.

The effect of periovarian adhesions on follicular development in patients undergoing ovarian stimulation for in vitro fertilization-embryo transfer

It has been suggested that the presence of periovarian adhesions might impair the ovarian response to gonadotropins. Periovarian adhesions were recorded in 49 women, and the total percentage of accessible ovarian cortex was described at the initiation of the operative procedure. Adhesiolysis was performed as needed for oocyte recovery. Ovarian access did not correlate with serum estradiol level on either the day of human chorionic gonadotropin (hCG) administration or the day after hCG administration. Similarly, neither the total number of follicles on the day of hCG or on the day after hCG, nor the number of follicles 1.0 to 1.4 cm or greater than or equal to 1.5 cm correlated with ovarian access. We conclude that periovarian adhesions are not a major determinant of the ovarian response to gonadotropin stimulation.

Weight of babies conceived in vitro

Recent studies suggested that infants delivered after in vitro fertilization and embryo transfer IVF-ET had low birth weights. To assess further the relationship between birth weight and EGA in these offspring, a review was made of all infants delivered at our institution from May 1, 1983 to July 15, 1986. Forty-five infants in 39 deliveries were identified. Seventeen of 37 (46%) were delivered vaginally, 20 by cesarean section. Forty-two infants were delivered at term (after 36 weeks). The six sets of twins delivered at 254 +/- 7 days (mean, 36 weeks). Eighteen of 39 deliveries (46%) delivered at or beyond 40 weeks EGA. The mean weight at delivery for the term infants was 3225 +/- 90 g. Thirty-eight infants were size appropriate for dates as assessed by the Lubchenco scale, while the weight in the remaining seven infants exceeded the 90th percentile for their gestational age. We conclude that infants conceived through IVF-ET are not predisposed per se to a low birth weight or delivery at an early gestational age. However, prior studies suggesting lower birth weights for IVF infants may have resulted in part from early delivery due to patient pressure and anxiety.

Comparison of follicular fluid hormones in patients with one or two ovaries participating in a program of in vitro fertilization

The authors recently reported on the follicular response to clomiphene citrate (CC) and human menopausal gonadotropins (hMG) in patients with one or two ovaries participating in a program of in vitro fertilization. This study was designed to analyze the follicular fluid hormones in patients with one or two ovaries in order to elucidate the compensatory mechanisms by which a single ovary achieves folliculogenesis equal to that of two ovaries. Twenty-one follicles from ten patients with one ovary were compared to 30 follicles from eight patients with two ovaries present. Ovulation induction was achieved using a standard protocol with sequential CC and hMG. Human chorionic gonadotropin (hCG) was administered after appropriate estradiol (E2) values and ultrasonic findings, and oocyte aspiration by laparoscopy was performed 33 hours later. Follicular fluid (FF) hormones were assayed by standard radioimmunoassay techniques and no differences were found in the levels of progesterone (P), testosterone, estradiol/testosterone ratio, prolactin, follicle-stimulating hormone, and luteinizing hormone. However, follicles from patients with one ovary had a lower mean concentration of E2 (286 versus 542 ng/ml, P = 0.001) and a lower mean E2/P ratio (0.055 versus 0.107, P = 0.016). Also, the mean follicular diameters and volumes were similar in both groups. In view of the authors' previous finding of a comparable number of mature oocytes from patients with either one or two ovaries, these data suggest that follicles from patients with a single ovary may achieve comparable oocyte maturity despite less efficient production of E2. Although FF E2 levels were lower in patients with one ovary, this dysynchrony between oocyte maturity and FF E2 values does not appear to affect outcome adversely.

Results of in vitro fertilization attempts in women 40 years of age and older: the Norfolk experience

Twenty-nine patients 40 years of age or older were stimulated with gonadotropins, starting on day 3 of the cycle, in a total of 64 cycles (January 1983 to June 1985) for multiple follicular development for in vitro fertilization. Most patients' infertility was due to tubal disease (n = 8) or pelvic endometriosis (n = 14). The mean number of preovulatory and immature oocytes recovered per laparoscopy was 2.53 +/- 1.73 and 1.57 +/- 1.58, respectively. There were no statistically significant differences between the number of preovulatory and immature oocytes harvested, fertilized, or transferred in this group and the number in patients younger than 40 years of age. No statistically significant differences were observed between peripheral estradiol and progesterone levels in patients 40 years of age or older and levels in patients 39 years of age or younger. There were 15 pregnancies in this group of patients, for a pregnancy rate of 23.4% per stimulated cycle, 27.7% per laparoscopy, and 29.4% per transfer. The ongoing pregnancy rate (12%) was lower, and the total abortion rate (60%) was higher, in patients 40 years of age or older in comparison with patients 39 years of age or younger. Patients 40 years of age or older should be counseled regarding the high abortion rate in this group.

Primate in vitro fertilization research: preliminary results on the folliculogenic effects of three different ovulatory induction agents on the chacma baboon, Papio ursinus

1. A study was conducted on the chacma baboon, Papio ursinus with three ovulation induction agents in an effort to define a preferential stimulatory protocol with regards to the number and quality of oocytes obtained. 2. Three folliculogenic agents applied in four stimulatory protocol regimens comprised clomiphene citrate in a high (100 mg/day) and low (50 mg/day) dosage, a combination of clomiphene citrate and pregnant mare serum, and human menopausal gonadotropin. 3. A total of 159 oocytes were aspirated by laparotomy from 10 baboon females in 20 induced cycles with an average of 8.0 +/- 5.4 oocytes per aspiration. 4. The highest mean number of oocytes (11.3 +/- 6.7) were obtained with the clomiphene/pregnant mare serum gonadotropin combination. 5. The best fertilization rate was obtained with clomiphene 50 mg. 6. The highest incidence of oocytic cleavage and embryo transfer were achieved with human menopausal gonadotropin (14.8%).

Quadruplet pregnancy in IVF

The frequency of multiple pregnancy following IVF with the presently accepted methods is ten times higher than in natural cycles, and is identical to that following induction of ovulation with HMG. In spite of the fact that multifetal pregnancy exposes both fetus and mother to certain dangers, most couples joining IVF programs expose themselves to, and generally accept the risk of, multiple pregnancy, since this is their last resort for having a baby of their own. We report such a case of quadruplet pregnancy after the IVF procedure and review the literature.

Ultrasonically guided oocyte collection under local anesthesia: the first choice method for in vitro fertilization--a comparative study with laparoscopy

Ultrasonically guided oocyte collection gradually replaces laparoscopy in many in vitro fertilization (IVF) centers. In the present study we compare the efficacy of both methods in our IVF program. One hundred twenty patients were prospectively randomized into two groups. Sixty women underwent oocyte collection during laparoscopy under general anesthesia, and 60 women under ultrasound guidance with local anesthesia. Superovulation was induced with human menopausal gonadotropin/human chorionic gonadotropin. For the oocyte collection a cannula with a trocar was used for single percutaneous puncture, through which both ovaries could be reached by the aspiration needle. The number of aspirated oocytes and transferred embryos was higher in the laparoscopy group as compared with the ultrasound group (5.3 versus 4.0 per woman and 3.0 versus 2.3 per woman, respectively); but the clinical pregnancy rate per cycle was similar in both groups (12.5% versus 14.5%). Ultrasound aspiration seems to be as effective as laparoscopy in terms of oocyte retrieval and conception rates. Because the procedure is simple and inexpensive, we believe that it may replace laparoscopy as a method for oocyte collection in most patients who undergo IVF.

The association between preovulatory serum 17 beta-estradiol pattern and conception in human menopausal gonadotropin-human chorionic gonadotropin stimulation

One hundred forty-four women suffering from obstructive tubal disease underwent laparoscopy for in vitro fertilization and embryo transfer (IVF-ET). Ovulation was induced by a human menopausal gonadotropin/human chorionic gonadotropin (hMG/hCG) protocol. The patients were divided according to their estradiol (E2) response to hMG/hCG administration: group A, an increase of E2 levels on the day after hCG administration (day +1); group B, a decrease of E2 levels on the day after hCG administration. Each of these groups was further subdivided into high responders (E2 greater than 500 pg/ml on day 0), designated A-1 and B-1, respectively, and low responders (E2 less than 500 pg/ml on day 0), designated A-2 and B-2, respectively. Patients responding in an A-1 pattern had significantly higher E2 levels from day 0 to day +8. Fertilization and cleavage rates did not differ among the groups, nor did luteal-phase progesterone. Twenty-one pregnancies were achieved from 126 transfers (17%), of which 16 (75%) occurred in women responding in an A pattern. We recommend that laparoscopy be deferred in women responding with a B pattern, because this preselection may increase pregnancy rates per IVF-ET cycle.

The value of ultrasonographic endometrial measurement in the prediction of pregnancy following in vitro fertilization

This work was undertaken for evaluation of the value of endometrial thickness as an early predictor for the success of in vitro fertilization (IVF). Endometrial changes were evaluated ultrasonographically in 47 women undergoing IVF. A high-dose gonadotropin protocol was used for induction of multiple follicular development. Thirty-seven women did not conceive following the procedure (group I), and 10 conceived (group II). Ultrasonographic endometrial measurements were performed repeatedly throughout the cycle. Serum 17 beta-estradiol and progesterone levels were evaluated concomitantly. Three consecutive growth patterns of the endometrium were observed. The first was a rapid one with a daily growth rate of about 0.5 mm from approximately 9 mm on day -3 to 12 mm on day +2 (day 0 being the day of human chorionic gonadotropin administration). The second phase, following follicular aspiration, showed a decrease in growth rate to about 0.1 mm per day until day +11, when a thickness of about 13 mm was measured. In group I growth was arrested from day +11 until menstruation, whereas in group II an accelerated growth rate of about 0.4 mm per day could be demonstrated from day +14 onward. Endometrial growth did not correlate with serum estradiol or progesterone levels. No conception occurred with an endometrial thickness below 13 mm on day +11. It is concluded that endometrial thickness follows a distinct pattern of growth in human menopausal gonadotropin-induced cycles and does not correlate with serum sex hormones.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of synthetic culture medium and patient serum for human in vitro fertilization and embryo replacement

The use of heat-inactivated patient serum as both fertilization and embryo replacement medium was compared in a prospective randomized study with a fully synthetic culture medium containing human serum albumin without serum addition (B3 INRA Menezo). Another series of the author's IVF program was analyzed retrospectively when a commercially available synthetic medium with bovine serum albumin (B2 INRA Menezo) or B3, as mentioned above, was used without serum addition for fertilization but with 50-100% patient serum as embryo replacement medium. Fertilization rates were significantly higher in the synthetic culture media (70%) than in serum (57%). The rate of polyploid fertilization was significantly lowest in B3 medium. There was a clear trend toward better pregnancy rates when high-percentage or 100% patient serum was used for embryo replacement, no matter if one, two, three, four or more embryos were replaced. We conclude that there should be no need for any kind of serum addition to fertilization media. The present study proves our previous observation that the use of serum seems to be beneficial as embryo replacement medium. This might well be explained by a "protein stick effect" due to the high macromolecular contents of serum rather than by viscosity measurements, since no significant increase in viscosity was observed when a high percentage of serum was added to culture media.

Urinary oestrogen levels and follicle ultrasound measurements in clomiphene induced cycles with an endogenous luteinizing hormone surge

Total oestrogen in urine and the ultrasonic size of the follicles were measured in relation to the onset of the endogenous luteinizing hormone (LH) surge (day 0) in 18 cycles induced with clomiphene citrate in an in-vitro fertilization programme. Oestrogen values in urine (microgram/24 h) increased progressively during the late follicular phase up to the day of the onset of the surge. The mean maximum follicle diameter (22.3, SD 4.7 mm) estimated by ultrasound was measured on day 0. At the onset of the LH surge, the values of urinary total oestrogen showed a better relation with the total volume of the first three follicles in order estimated by ultrasound (r = 0.71) than with the mean ultrasonic diameter of the leading follicle (r = 0.56). A wide range of individual values for both urinary oestrogen and follicle size was found. In another group of 32 women treated with clomiphene for recovery of oocytes used for research purposes, a good correlation was found between the mean ultrasonic follicle diameter 16 h before the laparoscopy and the follicle diameter calculated from the fluid volume at aspiration (r = 0.80). These results suggest that the decision when to give human chorionic gonadotrophin (hCG) in an in-vitro fertilization programme remains arbitrary in many individual cases. Apart from the oestrogen levels, the calculation of the size of all follicles, instead of only the leading one, may give further help in timing the hCG.

Semen evaluation following preparation for in vitro fertilization of human oocytes

Semen preparation is an important step of in vitro fertilization (IVF) and can affect the success of this procedure. Prior to oocyte insemination, spermatozoa are washed to remove seminal plasma which is believed to contain decapacitation factors. This study was undertaken to evaluate the effect of preparation on semen quality and subsequent successful IVF. Oocytes were recovered from 12 hMG/hCG-stimulated women by laparoscopy, and 6 h later semen specimens were obtained from the male partners. After liquefaction, 1 ml of semen was centrifuged twice in Ham's F10 medium supplemented with 10% of homologous serum, and the final suspension was used to inseminate the preovulatory eggs. In the initial and washed-sperm suspensions, motility was evaluated by the MEP method, and the occurrence of acrosome reaction and sperm viability were evaluated by the triple-stain technique. Fertilization was documented by the formation of two pronuclei. Washing caused a significant decrease in the percentage of motile sperm from 68% to 59% but significantly increased mean sperm velocity from 26 to 29 micron/sec (p less than 0.01). The mean fertilization rate was 65%, and no correlation was found with any of the parameters of semen quality before or after washing. Semen preparation for IVF is associated with a decrease in the percentage of motile sperm that does not seem to affect the fertilizing ability of normal spermatozoa but may be of importance in patients with abnormal semen.

Follicular development: lessons learned from human in vitro fertilization

In vitro fertilization has offered new insights into our understanding of ovulation induction, folliculogenesis, and luteal phase events. This new information is provided by the ability to precisely study these cycles in a frequent and sequential fashion through the use of peripheral blood markers, ultrasound evaluation, and follicular fluid constituents and cell culture techniques, as well as direct observation of the oocyte, fertilization, and cleavage. In these stimulated cycles the follicular phase serum estradiol levels in conjunction with ultrasound were evaluated; a poor correlation was shown between follicle size and number and estrogen production. This distinct dyssynchrony suggests the recruitment of a number of cohorts of follicles in each stimulated cycle. From the biochemical markers in follicular fluid, cyclic adenosine monophosphate has a distinct predictive value in regard to pregnancy in in vitro fertilization-embryo transfer cycles. In the luteal phase, the mass effect of aspiration of great numbers of granulosa cells, the effect of supplemental progesterone, and the influence of high follicular phase estradiol levels remain controversial and, therefore, a less clear cut pattern emerges. Variations in the protocol have not greatly improved the major problems of folliculogenesis associated with ovulation induction and an in vitro fertilization-embryo transfer program, that is, follicular asynchrony and luteal phase deficiency.

The combination of follicle-stimulating hormone and human menopausal gonadotropin for the induction of multiple follicular maturation for in vitro fertilization

One hundred fifty-one cycles in 134 consecutive patients were stimulated with 150 IU of human urinary follicle-stimulating hormone (FSH) and 150 IU of human menopausal gonadotropin (hMG) on cycle days 3 and 4 and then with 150 IU of hMG daily for the purpose of multiple follicular development for in vitro fertilization (IVF). Seventy-three patients did not have a prior IVF attempt, and 61 patients in 78 cycles had prior IVF attempts at least once with their previous cycles stimulated with the same method and/or hMG and/or FSH. There was an average of three preovulatory oocytes retrieved per laparoscopy and a pregnancy rate of 27% per transfer cycle. The results were equally favorable in "new" and "old" patient cycles. The pregnancy rate increased with the transfer of two or more conceptuses of preovulatory origin. The multiple pregnancy rate, but not the abortion rate, increased with increased numbers of conceptuses transferred.

High-dose human menopausal gonadotropin therapy for successful ovulation induction for in vitro fertilization in perimenopausal women

Five women with elevated gonadotropin levels were treated with high doses of human menopausal gonadotropin (hMG) in order to induce an ovulatory response. Three of the five patients did not show any increase in circulating estradiol levels nor any change in the size of follicles (as observed by ultrasound), even after prolonged stimulation with up to 1200 IU of hMG. Two patients achieved an ovulatory response, however. They underwent laparoscopy with successful oocyte retrieval and fertilization. Both patients had evidence of pregnancy: one showed a transient hCG rise (chemical pregnancy), while the other continued to 12 weeks' gestational age when fetal demise was diagnosed.

A simple technique of ovarian suspension in preparation for in vitro fertilization

Because laparoscopic ovum harvest for IVF is becoming more common, efforts must be made at the time of prior infertility surgery to render the ovaries accessible for ovum recovery. In this report, a simple technique of ovarian suspension in preparation for eventual IVF is described. Seventeen infertile patients undergoing lysis of adhesions underwent ovarian suspension by plication of the suspensory ligament of the ovary with a running suture of 3-0 Prolene, thus apposing the proximal pole of the ovary to the anterior-lateral surface of the uterus. Because the fallopian tube is independent of the sutured structures, the tubal anatomy was undisturbed. Fourteen of these 17 patients have since undergone laparoscopy during IVF. In 12 cases, despite the recurrence of adhesions, the ovaries were accessible for ovum recovery from all aspects. Two patients conceived normally after the lysis of adhesions. This simplified ovarian suspension represents an effective technique for facilitating ovum recovery for IVF which may not disturb fallopian tube ovum pickup or transport mechanisms.