Follicular development: lessons learned from human in vitro fertilization

Antral follicle responsiveness to follicle-stimulating hormone administration assessed by the Follicular Output RaTe (FORT) may predict in vitro fertilization-embryo transfer outcome

BACKGROUND

Looking for a qualitative marker of ovarian function, we aimed to verify whether responsiveness of antral follicles to FSH administration, as reflected by the Follicular Output RaTe (FORT), is related to their reproductive competence.

METHODS

We studied 322 IVF-ET candidates aged 25-43 years who underwent controlled ovarian hyperstimulation with similar initial FSH doses. Antral follicle (3-8 mm) count (AFC) and pre-ovulatory follicle (16-22 mm) count (PFC) were performed, respectively, at the achievement of pituitary suppression (before FSH treatment) and on the day of hCG administration. The FORT was calculated by PFC × 100/AFC. FORT groups were set according to tercile values: low (<42%; n= 102), average (42-58%; n= 123) and high (>58%; n= 97).

RESULTS

The average FORT was 50.6% (range, 16.7-100.0%). Clinical pregnancy rates per oocyte retrieval increased progressively from the low to the high FORT groups (33.3, 51.2 and 55.7%, respectively, P< 0.003) and such a relationship assessed by logistic regression was independent of the confounding covariates, women's ages, AFC and PFC.

CONCLUSIONS

The observed relationship between IVF-ET outcome and the percentage of antral follicles that effectively respond to FSH administration reaching pre-ovulatory maturation suggests that FORT may be a qualitative reflector of ovarian follicular competence. Further studies with broader inclusion criteria and more personalized protocols are needed to validate these results.

Androgens and poor responders: are we ready to take the plunge into clinical therapy?

OBJECTIVE

To review and summarize data from the scientific literature on the use of androgens to improve ovarian function.

DESIGN

Review of pertinent literature.

SETTING

University hospital.

PATIENT(S)

Women exposed to androgens.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Critical review of the literature.

RESULT(S)

The artificial increase of intra-ovarian androgen concentrations constitutes an attractive concept for improving the deficient ovarian function of poor responders. Data from studies conducted in animals treated with high-dose androgens, together with observations made in hyperandrogenic women or female-to-male transsexuals receiving virilizing androgen doses, indicate that androgens may increase follicle responsiveness to FSH and/or the number of growing follicles in the ovary. Yet, definite clinical demonstration of such a concept still is not available.

CONCLUSION(S)

Current clinical approaches aiming at increasing androgen availability in the ovary showed conflicting results. Therefore, additional studies using proper strategies to achieving higher intra-ovarian androgen concentrations for longer intervals are required to define the clinical efficiency of androgens in poor responders.

Serum steroids concentration might be used for monitoring the growth of follicles in friendly in vitro fertilization

Background:  Steroid levels have been used as the predictive parameters for oocyte maturation and embryo development. In the present study, estradiol and progesterone concentrations in the follicular fluid and serum were evaluated in conventional in vitro fertilization (IVF; follicle stimulating hormone [FSH] and/or human menopausal gonadotropin [hMG] after pituitary desensitization) and friendly IVF (no stimulation, clomiphene citrate, small dose of FSH or hMG without pituitary desensitization). The purpose of the present study was to evaluate the differences in steroid distribution between conventional and friendly IVF. Methods:  Concentrations of estradiol, progesterone, FSH, and luteinizing hormone (LH) in serum and follicular fluid were determined in conventional and friendly IVF protocols by an enzyme-linked immunosorbent assay kit. Correlations between follicular fluid and serum steroid concentrations in these different protocols, and between pregnant cycles and steroid concentrations were evaluated. Results:  Two hundred and thirty-four samples of follicular fluid from 74 IVF patients were analyzed. In conventional IVF, there was no relationship in steroid levels in between follicular fluid and serum steroids, whereas serum steroid concentrations correlated with the number of developing follicles. There was a relationship between the serum and follicular fluid estradiol levels (r = 0.467, P < 0.0001) as well as progesterone levels (r = 0.227, P = 0.0488) from friendly IVF patients. Conclusions:  Serum steroid concentrations were mainly associated with the number of developing follicles. In the cases of friendly IVF, which had a small number of developing follicles, serum steroids might be used to monitor follicular fluid steroid concentrations. (Reprod Med Biol 2006; 5: 277-282).

Diminished intrafollicular estradiol levels in in vitro fertilization cycles from women with reduced ovarian response to recombinant human follicle-stimulating hormone

OBJECTIVE

To correlate serum and intrafollicular E(2) levels in women receiving GnRH agonist and recombinant human (h)FSH for IVF.

DESIGN

Prospective study.

SETTING

Academic IVF center.

PATIENT(S)

Twenty-three nonhirsute ovulatory women.

INTERVENTION(S)

In vitro fertilization cycles were classified as high- or low-normal response, according to whether the amount of recombinant hFSH administered was below or above, respectively, the mean recombinant hFSH given to all women combined. Serum bioactive LH and immunoreactive FSH were measured during pituitary desensitization preceding recombinant hFSH and repeated at oocyte retrieval. The first mature follicle aspirated from either ovary had a mean diameter >15 mm.

MAIN OUTCOME MEASURE(S)

Serum and follicular fluid (FF) insulin, bioactive LH, immunoreactive FSH, and steroid levels.

RESULT(S)

Basal serum gonadotropin levels were comparable between female groups. Serum immunoreactive FSH levels, but not bioactive LH levels, at oocyte retrieval were greater in cycles of low-normal vs. high-normal response, whereas maximum serum E2 levels and total oocyte counts were similar between both groups. Despite elevated FF immunoreactive FSH levels, FF E2 was decreased in low-normal response cycles. Intrafollicular T and P also were decreased and increased, respectively, in cycles of low-normal response, although FF bioactive LH levels were comparable in both groups.

CONCLUSION(S)

Intrafollicular E2 is decreased in cycles of reduced ovarian responsiveness to GnRH agonist and recombinant hFSH and is not predicted by maximal serum E2 or number of oocytes retrieved.

In vitro fertilization and embryo transfer in seminatural cycles for patients with ovarian aging

OBJECTIVE

To investigate whether seminatural cycle is a reasonable management for ovarian aging patients.

DESIGN

Prospective study.

SETTING

ART Unit, Clamart, France.

PATIENT(S)

Seventy-five women, 158 cycles.

INTERVENTION(S)

Infertile women who presented with ovarian aging (defined as low ovarian reserve and characterized by cycle day 3 high FSH, high E2, and/or low inhibin B and/or previous cycle cancellations due to poor ovarian response to COH) were studied. Patients were offered up to three cycles. Treatment was scheduled as follows. From cycle day 8 onward the selection of the dominant follicle was monitored by ultrasound and hormonal measurements. When the dominant follicle appeared, patients received GnRH antagonist and, thereafter, hMG to support further follicular development.

MAIN OUTCOME MEASURE(S)

Implantation rate and clinical pregnancy.

RESULT(S)

Twenty-eight of 158 cycles were cancelled (17.7%). Oocyte pickups were performed in 119 (75.3%) cycles, 91 (57.6%) mature oocytes were retrieved, and 67 (42.4%) embryos transferred. Nineteen clinical pregnancies were obtained; the cumulative pregnancy rate per patient, after 3 cycles, was 35.2%.

CONCLUSION(S)

Use of a seminatural cycle is a reasonable management for patients with ovarian aging who have ovulatory menstrual cycles. It achieves a high implantation rate (28.3%).

Effects of controlled ovarian hyperstimulation on oocyte quality in terms of the incidence of apoptotic granulosa cells

PURPOSE

The aim was to investigate which ovarian hyperstimulation protocol performed in the same patients causes development of oocytes of good quality.

METHODS

Twenty normo-ovulatory women underwent three different controlled ovarian hyperstimulation protocols for in vitro fertilization-embryo transfer. Patients underwent follicle aspiration after administration of human chorionic gonadotropin (hCG). The total number of retrieved oocytes, the number of mature oocytes, and the rate of mature oocytes were examined. Recovered granulosa cells were stained with Hoechst 33258 and examined by fluorescence microscopy to estimate the incidence of apoptotic cells.

RESULTS

The total number of oocytes and the number of mature oocytes in gonadotropin-releasing hormone agonist (GnRHa) + human menopausal gonadotropin (hMG) + hCG and hMG + hCG cycles were higher than those in the natural cycle (P < 0.0001). The rate of mature oocytes in hMG + hCG cycle was the highest among the three protocols (P < 0.04). In the mural granulosa cells, the incidence of apoptotic cells in the GnRHa + hMG + hCG cycle was significantly higher than those of the natural (P < 0.002) and hMG + hCG cycles (P = 0.0002). The incidence of apoptotic cumulus granulosa cells in the GnRHa + hMG + hCG cycle was significantly higher than those of natural and hMG + hCG cycles (P < 0.002). Moreover, the incidence of apoptotic cumulus granulosa cells in the hMG + hCG cycle was significantly lower than that in the natural cycle (P < 0.01).

CONCLUSIONS

These results indicated that hMG + hCG is the most appropriate controlled ovarian hyperstimulation protocol among the three examined with regard to oocyte quality.

Female poor responders

Female poor responders are represented by normovulatory women showing a 'gonadal failure' in term of inadequate number of recruited follicles under conventional controlled ovarian hyperstimulation (COH) for assisted reproductive technologies (ART). ARTs offers today a high chance of pregnancy to infertile couples when a normal ovarian response provides a large choice of embryos for transfer. On the contrary, failure of the ovary to produce enough oocyte for treatment, reduces significantly the likelihood of conceiving in ART, not only in the treatment cycle, but also predicting a poor prognosis in subsequent cycles. Up to date, poor response remains one of the most frequent problems in the field of assisted reproduction. First described in 1981, poor response has been investigated by several authors, but many aspects are still controversial. In this paper definition, pathophysiology and management of poor response are revised and discussed.

Young low responders protected from untoward effects of reduced ovarian response

OBJECTIVE(S)

To correlate fertilization and clinical pregnancy rates (PRs) in low responders with their E2 levels (<500, 500-800, >800-1,000 pg/mL), age (20-30, 31-40, >40 years), number of follicles, and number of oocytes retrieved.

DESIGN

A retrospective study.

SETTING

The IVF unit of an academic hospital.

PATIENT(S)

One hundred forty-three women who failed to attain E2 levels of 1,000 pg/mL on the day of hCG administration.

INTERVENTION(S)

Controlled ovarian hyperstimulation, blood E2 and progesterone measurements, ultrasonographic scanning of ovarian follicles, oocyte retrieval after hCG administration, and ET.

MAIN OUTCOME MEASURE

Clinical PR.

RESULT(S)

Although E2 levels, fertilization rates, age, and number of oocytes did not differ significantly between the three age groups, the PR achieved in the youngest group was approximately three times as high (19.3%) as that achieved in the two older groups.

CONCLUSION

Young low responders represent a unique subset in that their age protects them from the deleterious effects of poor ovarian response.

Cytokines in the human ovary: presence in follicular fluid and correlation with leukotriene B4

PURPOSE

This study was undertaken to correlate the follicular levels of interleukin (IL)-1 alpha, IL-2, tumor necrosis factor-alpha (TNF-alpha), and leukotriene (LT) B4 with oocyte maturity, fertilization, and achievement of pregnancy.

METHODS

The material was obtained from 22 women undergoing IVF, 8 of whom became pregnant and 14 of whom did not.

RESULTS

All of the studied cytokines and LT B4 were found in follicular fluids, but there were no significant differences according to oocyte maturity, fertilization, embryo quality, and achievement of pregnancy. On the other hand, a significant positive correlation was found between IL-1 alpha and TNF-alpha, IL-1 alpha, and LT B4 as well as between TNF-alpha and LT B4 in follicular fluids with subsequently fertilized oocytes.

CONCLUSIONS

It seems that IL-1 alpha, TNF-alpha and LT B4 may take part in the process of follicle wall degradation, and their follicular correlations may suggest more optimal follicular and oocyte development and maturation.

Ovarian follicular wave synchronization and superstimulation in prepubertal calves

Two experiments were designed to artificially alter the follicular wave pattern in calves to determine if the mechanisms controlling the well-ordered pattern of follicular growth in adults are extant in prepubertal animals as well. Experiment 1 was designed to test the hypothesis that follicle ablation in a random group of calves will induce synchronous emergence of a new follicular wave which is not different from a spontaneous wave. Experiment 2 was designed to test the hypothesis that ovarian superstimulatory response in calves is enhanced when treatment is initiated before rather than after the time of selection of the dominant follicle. In Experiment 1, 6-month-old calves were assigned randomly to an ablation group (n = 10) and a control group (no ablation, n = 10). Follicle ablation was accomplished by transvaginal ultrasound-guided needle aspiration of all follicles > or = 4 mm in diameter. Blood samples were taken and ovarian changes were monitored daily. A rise (P < 0.01) in mean plasma FSH concentration was detected 24 h after follicle ablation (1.51 ng/ml in the ablation group and 0.93 ng/ml in the control group). Wave emergence was detected earlier (P < 0.01) and with less variation (P < 0.0001) in the ablation group than the control group (1.2 +/- 0.1 vs 4.0 +/- 0.7 d). Characteristics of the induced wave were not different from those of the spontaneous wave. In Experiment 2, 7-month-old calves were assigned randomly to a pre-selection group in which superstimulation treatment was initiated at the time of wave emergence (1 d after follicle ablation, n = 11), or to a post-selection group in which superstimulation treatment was initiated after selection of a dominant follicle (4 d after follicle ablation, n = 11). Superstimulation treatment consisted of 30 mg of FSH im twice daily for 3 d. Ultrasound-guided transvaginal follicle ablation was used to synchronize follicle wave emergence at the outset of the experiment. The mean diameter of the largest follicle at the start of superstimulation treatment was 3.2 versus 8.5 mm in the pre- and post-selection groups, respectively (P < 0.001). The day after the last treatment, the number of follicles > or = 3 mm in diameter was greater (P < 0.002) in the pre-selection group than in the post-selection group (19.3 +/- 1.7 versus 11.3 +/- 1.3). In summary, ultrasound-guided follicle ablation resulted in synchronous wave emergence in a random group of calves, and superstimulation treatment initiated at the time of wave emergence (pre-selection group) resulted in the growth of more follicles than treatment initiated later (post-selection group). Mechanisms involved in the control of follicle recruitment, selection, and suppression are extant in calves, similar to those found in adults.

Estrogen biosynthesis--regulation, action, remote effects, and value of monitoring in ovarian stimulation cycles

OBJECTIVE

To review current knowledge regarding estrogen biosynthesis, its regulation and action, specifically concerning local as opposed to remote effects of this hormone, and to examine the effectiveness and prognostic value of monitoring hormone concentrations and endometrial response in cycles of controlled ovarian hyperstimulation.

DATA IDENTIFICATION AND SELECTION

Studied that relate specifically to estrogen biosynthesis, enzymatic pathways, estrogen receptor physiology, and the clinical aspects of estrogen monitoring were identified through literature and Medline searches.

RESULTS

Folliculogenesis is the basic unit of ovarian activity, which has a dual purpose: oocyte maturation and steroid production. Steroidogenic granulosa and theca cells cooperate under gonadotropin control to produced estrogens by stimulating synthesis of steroidogenic enzyme messenger RNAs. Steroid synthesis is amplified further by local growth factors and follicular cell multiplication. Estrogen synthesis is directed by FSH, and only small amounts of LH are needed to amplify the follicular estrogenic potential. However, the growth of preovulatory follicles can proceed without LH, under FSH regulation only, even in the presence of low peripheral estrogen levels. Oocyte maturation and fertilization may proceed independently of ambient estrogen levels, leading to the assumption that estrogen exerts a minimal autocrine-paracrine function. The notable effect of follicular estrogen production is to promote adequate receptive endometrium for embryo implantation. Clinical treatment cycles may be monitored more effectively by evaluating end-organ response to estrogen rather than by evaluating absolute serum E2 concentrations or sonographic follicular measurements.

CONCLUSION

Follicular estrogen production is regulated by a complex set of signals that synergize to produce optimal steroidogenesis. Most importantly, the effect of estrogen is truly an endocrine effect, as it prepares the endometrium for implantation. Therefore, the goal of effective treatment and monitoring strategies should focus on direct assessment of the biologic activity of estrogen as it optimizes endometrial receptivity in anticipation of subsequent implantation.

Evaluation of different ovarian stimulation protocols for in vitro fertilization

In this study we evaluated retrospectively the efficacy of five different ovarian stimulation protocols in an in vitro fertilization program, in which 512 women were involved. Ovulation was induced by the following protocols: group I (271 cycles): buserelin short protocol (1 mg/day, intranasally) with human menopausal gonadotropin/human chorionic gonadotropin (hMG/hCG); group II (45 cycles): buserelin (short protocol) with pure follicle stimulating hormone (p-FSH)/hMG/hCG; group III (24 cycles): clomiphene citrate (100 mg/day) with hMG/hCG; group IV (122 cycles): hMG (3 ampules/day) and hCG; group V (113 cycles): hMG/hCG and prednisolone (7.5 mg/day) after cycle programming with oral contraceptives. The lowest cancellation rate (3.3%) was noted in group I, followed by group V (9.7%). The highest number of follicles was observed in groups I (8.3 +/- 0.3; mean +/- SEM) and V (7.8 +/- 0.5). Also, more oocytes were retrieved in group I (7.2 +/- 0.3, p < 0.001), which were of good quality based on oocyte maturity as well as on the fertilization rate, and more embryos (4.5 +/- 0.3, p < 0.05) were developed. The correlation between estradiol and the total follicular volume on the day of hCG administration was also examined in the five groups. The best correlation (r = 0.6502) was found in group I, followed by group V (r = 0.5810). Significant differences were observed in the five groups with regard to the number of hMG ampules administered (p < 0.0001, F = 15.393) and the stimulation days (p < 0.0001, F = 35.32). Sixty-six clinical pregnancies were achieved: 37 (17.5%) in group I, seven (25.9%) in group II, one (10%) in group III, ten (15.6%) in group IV and 11 (15.5%) in group V (differences were not statistically significant). In conclusion, all five protocols were satisfactory in ovarian stimulation for in vitro fertilization, and gonadotropin releasing hormone (GnRH) analogs seemed to be more advantageous by reducing the cancellation rate, enhancing the number of oocytes retrieved and embryos developed and by improving the pregnancy rates.

Hormonal profiles in successful and unsuccessful implantation in IVF-ET after combined GnRH agonist/gonadotropin treatment for superovulation and hCG luteal support

The luteal phase of in vitro fertilization-embryo transfer (IVF-ET) cycles has come under great scrutiny as the cause for the discrepancy between fertilization rates (> 70%) and pregnancy rates (around 20%) in most IVF programs is sought. The effects of the various stimulation protocols on the subsequent hormonal events of the luteal phase are both important and controversial but information regarding cycles where ovarian stimulation has been carried out with gonadotropins under pituitary suppression is scanty. The effect of high levels of estrogen in the late follicular phase and around the time of implantation is a matter of concern. As combined gonadotropin-releasing hormone analog (GnRH-a) gonadotropin treatment for superovulation is associated with supraphysiological ovarian steroid levels, both in the follicular and luteal phase of IVF cycles, we compared preovulatory (estradiol), midluteal (estradiol, progesterone and prolactin) and late luteal (estradiol and progesterone) hormone levels in on-going pregnancies, abortions and non-conception cycles in 222 patients accomplishing their first IVF-ET attempt who received such ovarian stimulation therapy. For both successful and unsuccessful implantation cycles, estradiol on the day of human chorionic gonadotropin (hCG) administration correlated positively with progesterone and estradiol levels and negatively with the progesterone/estradiol ratio in the midluteal phase. Mean peak follicular estradiol, midluteal estradiol and progesterone levels, mean mid- and late luteal progesterone/estradiol ratio, and mean midluteal prolactin concentration, were similar in the three groups studied. The mean late luteal estradiol and progesterone in the on-going pregnancy group were significantly higher than in non-conception cycles (p < 0.005 and p < 0.001, respectively) as a reflection of trophoblastic hCG production. Forty-eight patients (21.6%) had hyperprolactinemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Ovarian synchronization following ultrasound-guided transvaginal follicle ablation in heifers

In Experiments 1 and 2, ultrasound-guided transvaginal follicle aspiration was used as a method of follicle ablation to induce and synchronize subsequent follicular wave emergence and enhance ovulation synchrony following PGF2alpha administration. Heifers were at unknown stages of the estrous cycle at the start of both experiments in which all follicles>or=5 mm in diameter were ablated; luteolysis was induced 4 d later with cloprostenol (500 ug/dose, im). In Experiment 1, heifers were randomly assigned to either an ablation (n=17) or a procedural control (no follicle ablation, n=17) group. Ablation-induced wave emergence was indicated by a significant increase in the total number of follicles>or=5 mm within 2 d of ablation (mean, 1.5 d), which was preceded by a significant surge in circulating FSH. Although the mean (+/-SEM) interval from PGF2alpha administration to ovulation did not differ between follicle-ablated heifers (5.1+/-0.5 d range, 3 to 9 d) and control heifers (5.1+/-1.0 d; range, 1 to 5 d), the variability of the interval was different (P<0.05). Inequality of variance between the 2 groups was attributed to a greater (P<0.08) degree of ovulation synchrony in the ablation group than in the control group; 13/16 (81%) versus 9/17 (53%), respectively, ovulated within 5 d of cloprostenol administration. Relative asynchrony of ovulations in control heifers was associated with the status of the follicular wave at the time of PGF2alpha administration and, in part, to incomplete luteolysis following a single dose of PGF2alpha. Experiment 2 was designed to examine the efficacy of 2 doses of cloprostenol 12 h apart (n=7) versus a single dose (n=8) to induce complete luteolysis subsequent to follicle ablation-induced wave emergence. Two doses of cloprostenol potentiated ovulation synchrony; more (P<0.05) 2-dose heifers (7/7, 100%) than single-dose heifers (4/8, 50%) ovulated within 5 d after PGF2alpha administration. In summary, ultrasound-guided transvaginal follicle ablation, done at random during the estrous cycle, induced and synchronized subsequent follicular wave emergence, and resulted in a high degree of ovulation synchrony among heifers after PGF2alpha induced luteolysis, especially when 2 doses of PGF2alpha were administered 12 h apart.

Number of follicles, oocytes and embryos in human in vitro fertilization is relative to serum estradiol and progesterone patterns during different types of ovarian hyperstimulation

Preovulatory serum estradiol and progesterone levels as well as their ratio were compared in different types of ovulation induction in order to determine whether these findings could be used to predict the number of preovulatory follicles, number of oocytes aspirated and embryos obtained. Significantly more oocytes were retrieved by follicular aspiration and significantly more embryos developed in patients receiving gonadotropin-releasing hormone agonist and human menopausal gonadotropins than in those given other ovulation inductors. On days -2 and -1 of the cycle, serum estradiol levels were significantly lower in pure follicle-stimulating hormone induction. Serum progesterone was significantly higher in pure follicle-stimulating hormone cycles on days -4 and -3. In clomiphene citrate and human menopausal gonadotropin induction, progesterone levels were significantly lower on days -2 and -1, and on the day of follicular aspiration. Ratios of estradiol/progesterone were lower in pure follicle-stimulating hormone group from day -3 to day -1 of the cycle. A significant correlation was found between estradiol and progesterone serum levels and the numbers of preovulatory follicles, oocytes and embryos. The study revealed the usefulness of serum estradiol and progesterone determinations in assisted reproduction.

The role of estrogen support during the luteal phase of in vitro fertilization-embryo transplant cycles: a comparative study between progesterone alone and estrogen and progesterone support

OBJECTIVE

To evaluate the possible role for estrogen supplementation to the P luteal phase support of GnRH agonists (GnRH-a)- and hMG-induced IVF-ET cycles.

SETTING

In vitro fertilization unit in a tertiary care university hospital.

DESIGN

A prospectively randomized study.

PATIENTS

One hundred consecutive patients undergoing ET after IVF were assigned into one of two luteal supplementation regimens.

INTERVENTIONS

In all patients enrolled in the study, ovulation was induced using the midluteal regimen for pituitary down regulation with GnRH-a followed by follicular stimulation with hMG. The first group received IM P 50 mg/d, as luteal phase support, starting the day of ET. The second group received the same dosage of P, combined with oral E2 valerate, 2 mg/d. Serum levels of P and E2 were monitored every 4 days for 16 days after ET.

MAIN OUTCOME MEASURES

Pregnancy rates (PRs) and live birth rates per ET.

RESULTS

No significant difference in E2 or P levels throughout the cycle was observed between groups. Similar PRs per ET and the live birth rates were also observed between group A and B (28% versus 26.5% and 78.6% versus 76.1%, respectively).

CONCLUSION

No advantage was found in the addition of E2 valerate to P luteal phase support of GnRH-a- and hMG-induced IVF-ET cycles.

Hormone levels of follicular fluids with and without oocytes in patients who received gonadotropin-releasing hormone analogues and gonadotropins in an in vitro fertilization program

BACKGROUND

Are follicles where no oocytes are retrieved "empty follicles"?

METHODS

The levels of estradiol (E2), progesterone (P), testosterone (T), cortisol (F), and prolactin (PRL) of follicular fluids (FF) aspirated individually from 34 randomly selected IVF patients in whom no oocytes were recovered were compared with the respective hormone levels of FF obtained from the same patients when oocytes were retrieved. Two FF without oocytes of a 35th patient in whom no oocytes were retrieved were analyzed.

RESULTS

Hormones did not differ significantly in the paired samples, while in the two FF of the 35th woman they were in agreement with cystic follicles.

CONCLUSIONS

It is necessary to differentiate aspirated follicles where no oocytes are retrieved from the "empty follicle syndrome," which was not observed in the IVF series studied and should be rare in IVF patients.

High preovulatory serum luteinizing hormone level is unfavorable to conception

Serum estradiol, progesterone and luteinizing hormone (LH) levels of 16 pregnant and 58 non-pregnant stimulated in vitro fertilization-embryo transfer (IVF-ET) or gamete intrafallopian transfer (GIFT) cycles have been compared with regard to their predictive value for achievement of pregnancy. Serum estradiol and progesterone pattern of the pregnant and non-pregnant group did not show any significant difference. Around the time of ovulation induction by human chorionic gonadotropin (hCG) the serum LH values proved to be higher in the non-pregnant group than in the pregnant one. In spite of having a permissive function, preovulatory serum estradiol and progesterone seem not to have a predictive value with regard to pregnancy. Elevated preovulatory serum LH is detrimental for pregnancy, therefore the measurement of serum LH beyond hCG administration also, and the cancellation of cycles with high serum LH levels shortly before oocyte retrieval is recommended.

The role of superovulation with menotropins in ovulatory infertility: a review

The risks of menotropin therapy (ovarian hyperstimulation syndrome, multiple gestation, adnexal torsion) are well known and have been previously described. Superovulation should not be considered for the indications described herein until more traditional therapies for infertility have been tried and found unsuccessful and sufficient time has elapsed for conception to occur. The cost of superovulation is high: the medications are expensive, frequent E2 monitoring and US studies are costly, and pregnancy complications relating to the higher rate of pregnancy loss and multiple gestation may add substantially to the overall cost. Yet, compared with IVF and GIFT, superovulation cycles combined with IUI cost between one third to one sixth that of an IVF cycle. Protocols involving combined CC/hMG/hCG, which reduce the total number of ampules of Pergonal needed per cycle and still provide multiple follicular development, may further reduce costs. There is a growing consensus that superovulation-IUI protocols should be attempted before GIFT and IVF in couples with normal pelvic viscera. There is little doubt that IVF and GIFT cycles are more costly, stressful, and complex. No comparative data have clearly shown IVF and GIFT to be superior to superovulation protocols in ovulatory women with normal pelvic anatomy. In the only study examining this issue published to date, Kaplan et al. retrospectively analyzed all GIFT and superovulation/IUI cycles at a single university center and found GIFT to be three times more efficient. However, the inherent limitations of a nonrandomized, nonprospective study of this kind are obvious as these authors have suggested. Therefore, it may be wise to consider the use of superovulation before assisted reproductive technologies until this issue is settled. It would be interesting to determine if the high PRs reported for couples with unexplained infertility or mild endometriosis in IVF and GIFT cycles in some centers not incorporating superovulation/IUI protocols would hold up if such an approach was routinely followed. Despite the increasing acceptance of superovulation protocols, we must be aware that many of the studies suggesting a role of hMG in treating ovulatory infertile women with normal pelvic anatomy suffer from deficiencies in experimental design. In a payor-driven system, such as in the United States, the difficulties in designing and carrying out scientifically sound clinical studies examining infertility therapies are obvious. The lack of federal or outside funding for the study of infertility issues contributes to the problem. It is our hope that better designed studies examining the role of superovulation in the treatment of ovulatory infertile women with normal pelvic anatomy will be forthcoming.

Steroid profiles of follicular fluids from a patient with the empty follicle syndrome

Steroid profiles of follicular fluid obtained from a patient during a cycle in which no oocytes were recovered in 12 follicular aspirates were compared with those of fluid obtained both from cycles of the same patient and from cycles of other patients when oocytes were recovered. Follicles aspirated in the cycle when no oocytes were recovered were shown to be neither atretic follicles, follicular cysts, nor prematurely luteinized follicles. The steroid profile of follicular fluid from the index cycle was characterized by a markedly increased estradiol-to-progesterone ratio and an increased androstenedione level. This, together with a comparison to the steroid profiles of fluid from follicles containing either fertilizable or nonfertilizable oocytes, suggests that the empty follicle syndrome may reflect a dysfunctional ovulation induction.

Relationship between the steroid and prolactin concentration in follicular fluid and the maturation and fertilization of human oocytes

Seventy-eight follicles and their follicular fluid were aspirated from 46 women undergoing in vitro fertilization (IVF) procedures after stimulation of the ovaries with a low-dose human menopausal gonadotropin/human chorionic gonadotropin stimulation regimen. The concentrations of estradiol (E2), progesterone (P), testosterone (T), and prolactin (PRL) were measured in follicular fluid and related to the maturation of the oocyte-corona-cumulus complex (OCCC) and the fertilization of oocytes. Follicles containing mature oocytes had significantly higher follicular fluid E2 and P levels than follicles with intermediate and immature oocytes. A constant decrease in PRL and T values with advancing follicular maturation was observed. Similar results were obtained when the fertilizing ability of the oocytes was examined. The gradual decline in follicular fluid PRL and T levels during follicular development was connected with increasing E2 and P biosynthesis and therefore seems to be an important precondition for normal follicular and oocyte maturation.

Intraovarian markers of follicular and oocyte maturation

The use of ovulation induction for multiple follicular growth in in vitro fertilization (IVF) has introduced the problem of follicular asynchrony. As a consequence of the asynchrony, the parameters most commonly used by IVF groups to assess follicular and oocyte quality within those follicles are not sufficiently sensitive or specific. Thus, each follicle must be considered separately, and specific markers of follicular and/or oocyte maturation must be sought from within the follicle. In this review we analyze previous reports of potential markers of follicular and oocyte maturation. In regards to the follicular fluid constituents, the level of estradiol in follicular fluid correlates with fertilization and pregnancy in stimulated cycles. Other steroids are only helpful when specific stimulation protocols are used. The level of some follicular proteins such as alpha-1-antitrypsin and fibrinogen also correlates with fertilization and pregnancy outcome. Cyclic AMP levels in follicular fluid are significantly reduced in follicles leading to conception. Regulators of oocyte maturation, such as the Oocyte Maturation Inhibitor (OMI) or the Meiosis Inducing Substance (MIS) have also been correlated with IVF outcome, but their exact structure remains still unknown. In addition, other sophisticated parameters, such as chemotactic activity of human leukocytes, or simple methods, such as the presence of intrafollicular echoes, have also been used as successful markers in predicting IVF outcome.

Comparison of the results of vaginal and abdominal follicle scans

The hormonal profile and sonographical assessing of the number and size of the follicles are important in hyperstimulated cycles. Follicular imaging obtained by abdominal scanning may be distorted by echoes from the intestine or by unfavourable location of the ovaries and patients must have a full bladder. We compared the number and size of the follicles at abdominal sonography with the results obtained by vaginal sonography in 37 patients. Vaginal sonography showed more follicles than abdominal sonography because of improved imaging of small follicles on early days of cycle. This might help one to tailor the hyperstimulation to an individual's endocrine response.