Delaying human chorionic gonadotropin administration in human menopausal gonadotropin-induced cycles decreases successful in vitro fertilization of human oocytes

Relationship between follicular volume and oocyte competence, blastocyst development and live-birth rate: optimal follicle size for oocyte retrieval

OBJECTIVE

To analyze oocyte competence in gonadotropin-releasing hormone agonist (GnRHa) stimulation cycles with regard to maturity, fertilization and blastocyst rate, as well as clinical outcome (pregnancy and live-birth rate), in relation to follicular volume, measured by three-dimensional transvaginal sonography (3D-TVS), and follicular fluid composition.

METHODS

This was a prospective single-center study conducted between June 2012 and June 2014, including 118 ovum pick-ups with subsequent embryo transfer. Ovarian stimulation was performed using the GnRHa long protocol. Of 1493 follicles aspirated individually, follicular volume was evaluated successfully in 1236 using automated 3D-TVS during oocyte retrieval. Oocyte maturity and blastocyst development were tracked according to follicular volume. Intrafollicular concentrations of estradiol, testosterone, progesterone, luteinizing hormone, follicle-stimulating hormone and granulocyte-colony stimulating factor were quantified by immunoassay. Clinical outcome, in terms of implantation rate, (clinical) pregnancy rate, miscarriage and live-birth rate (LBR), was evaluated.

RESULTS

Follicles were categorized, according to their volume, into three arbitrary groups, which included 196 small (8-12 mm/0.3-0.9 mL), 772 medium (13-23 mm/1-6 mL) and 268 large (≥ 24 mm/> 6 mL) follicles. Although oocyte recovery rate was significantly lower in small follicles compared with medium and large ones (63.8% vs 76.6% and 81.3%, respectively; P < 0.001), similar fertilization rates (85.1% vs 75.3% and 81.4%, respectively) and blastocyst rates (40.5% vs 40.6% and 37.2%, respectively) per mature metaphase II oocyte were observed. A trend towards higher LBR after transfer of blastocysts derived from small (< 1 mL) follicles compared with medium (1-6 mL) or large (> 6 mL) follicles (54.5% vs 42.0%, and 41.7%, respectively) was observed. No predictive value of follicular fluid biomarkers was identified.

CONCLUSIONS

Our data indicate that the optimal follicular volume for a high yield of good quality blastocysts with good potential to lead to a live birth is 13-23 mm/1-6 mL. However, oocytes derived from small follicles (8-12 mm/0.3-0.9 mL) still have the capacity for normal development and subsequent delivery of healthy children, suggesting that aspiration of these follicles should be encouraged as this would increase the total number of blastocysts retrieved per stimulation. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

[Ovarian hyperstimulation syndrome: pathophysiology, risk factors, prevention, diagnosis and treatment]

The ovarian hyperstimulation syndrome is a major complication of ovulation induction for in vitro fertilization, with severe morbidity and possible mortality. Whereas its pathophysiology remains ill-established, the VEGF may play a key role as well as coagulation disturbances. Risk factors for severe OHSS may be related to patients characteristics or to the management of the ovarian stimulation. Two types of OHSS are usually distinguished: the early OHSS, immediately following the ovulation triggering and a later and more severe one, occurring in case of pregnancy. As no etiologic treatment is available, the therapeutic management of OHSS should focus on its related-complications. Thrombotic complications that can occur in venous or arterial vessels represent the major risk of OHSS, possibly conducting to myocardial infarction and cerebrovascular accidents. Once the OHSS is diagnosed, prevention of thrombotic accidents remains the major issue.

The time interval between hCG priming and oocyte retrieval in ART program: a meta-analysis

OBJECTIVE

To evaluate the relationship between different hCG priming-to-oocyte retrieval intervals and assisted reproductive technology (ART) outcome.

METHODS

We systematically searched PubMed, EMBASE, the Cochrane Library, Science Citation Index, Chinese biomedicine (CBM) literature database, and Chinese Journal Full-text Database for randomized controlled trials (RCTs) published up to November 2010. Data was extracted from the studies by two independent reviewers. Statistical analysis was performed with Cochrane Collaboration's Review Manager (RevMan) 5.0.2. From extracted data, Risk Ratio (RR) with 95% confidence interval (CI) was calculated.

RESULTS

5 RCTs totaling 895 participants were included. Oocyte maturation rate was higher in the long interval group compared with short interval group (RR, 0.67; 95% CI, 0.62-0.73). There were no significant difference between the two groups with regard to fertilization rate (RR, 0.99; 95% CI, 0.94-1.04), implantation rate (RR, 0.91; 95% CI, 0.40-2.04), and pregnancy rate (RR, 0.79; 95% CI, 0.58-1.08).

CONCLUSION

The percentage of mature (MII) oocytes can be increased by prolonging the interval between hCG priming and oocyte retrieval. The prolonged interval could not increase the fertilization rate, implantation rate, and pregnancy rate. Although there was evidence to confirm the results, they still need to be confirmed by large-sample, multicenter, randomized controlled trials. The time interval dependent mechanisms responsible for ART performance need to be elucidated.

Unstimulated in vitro fertilization revisited

The first attempts at in vitro fertilization (IVF) of human oocytes were performed during cycles utilizing human menopausal gonadotropin (hMG) and human chorionic gonadotropin (hCG). These early cycles resulted in a successful conception, which unfortunately ended as a tubal gestation. The birth of Louise Brown in 1978, the first successful IVF birth, was actually achieved following fertilization during a spontaneous cycle in which ovulation was triggered with endogenous luteinizing hormone (LH).However, due to the greater margin for error afforded by larger numbers of follicles, the practice of IVF rapidly evolved towards the use of controlled ovarian hyperstimulation (COH) to achieve higher pregnancy rates. It is easy to understand why this approach evolved. Oocyte harvesting was accomplished primarily by laparoscopy. Since oocyte yield per follicle was less than 100% and fertilization rates were limited, the relatively traumatic follicle aspiration process was more likely to result in embryo transfer if a greater number of follicles was present.

Prospective cohort study of three- versus two-dimensional ultrasound for prediction of oocyte maturity

OBJECTIVE

To determine whether three-dimensional follicular ultrasound (3-D) measurements are better predictors of optimal timing of hCG administration than two-dimensional (2-D) images, the current standard.

DESIGN

Prospective, cohort study.

SETTING

Tertiary referral center.

PATIENT(S)

Seventy-six patients undergoing IVF.

INTERVENTION(S)

Seventy-six consecutive patients undergoing serial follicular monitoring during IVF had an additional daily 3-D volume scan of their ovaries once lead follicles had reached 16 mm diameter.

MAIN OUTCOME MEASURE(S)

Number of mature oocytes retrieved.

RESULT(S)

The 2-D follicular diameter measurements predicted 25.4% of the observed variance in the number of mature oocytes retrieved. The 3-D follicular volume measurements were more predictive of outcome, accounting for 29.2% of the observed variance in number of mature oocytes retrieved. Follicles >22 mm diameter and 5 mL volume were associated with fewer mature oocytes reflecting an undesired postmature state. Follicles measuring 11 to 15 mm had a 50% chance of yielding a mature oocyte.

CONCLUSION(S)

Three-dimensional follicular volume measurements have a stronger correlation with the number of mature oocytes retrieved than 2-D measurements. As 3-D technology improves, this parameter may replace 2-D measurements in the optimal timing of hCG before oocyte retrieval.

Optimized hormonal stimulation is critical for production of viable embryos and establishment of subsequent implantation

PURPOSE

To investigate the effects of follicle number and size at the time of hCG administration, and ovarian stimulation length on the outcome of in vitro fertilization and pregnancy rate.

METHODS

During the ovarian stimulation regimen, the follicular number and size were determined by transvaginal ultrasonographic examination. Ovulation was induced as early as three or more follicles were at least 16 mm in their greatest diameter.

RESULTS

The fertilization rates were significantly increased with the longer length of stimulation (10-12 days: 75.4% and 13-16 days: 83.2%). However, no significant differences in the chemical pregnancy, clinical pregnancy, and implantation rates were found between 10-12 days (53.7%, 43.9%, and 21.8%) and 13-16 days (50.0%, 43.8%, and 23.4%) of stimulation. There were no significant differences in fertilization and chemical pregnancy rates between two groups with > or = and <18 follicles in the ovaries on the day of hCG (human chorionic gonadotrophin) administration. However, the clinical pregnancy and implantation rates (47.2% and 26.0%) in the group with <18 follicles were significantly higher than those (33.3% and 15.5%) in the group with > or =18 follicles, respectively.

CONCLUSIONS

Excessive and rapid ovarian stimulation appears to decrease the survival of embryos at later stages after transfer. The advantage of prolonged stimulation may outweigh the potential adverse effects in some patients.

Early unilateral follicular aspiration compared with coasting for the prevention of severe ovarian hyperstimulation syndrome: a prospective randomized study

Thirty women undergoing in-vitro fertilization or intracytoplasmic sperm injection considered to be at high risk of ovarian hyperstimulation syndrome (OHSS) were randomly allocated to have early unilateral follicular aspiration (EUFA) (group 1) or coasting (group 2) when the serum oestradiol concentration was >6000 pg/ml and there were more than 15 follicles each of >/=18 mm diameter in each ovary. EUFA was performed in group 1 at 10-12 h after the human chorionic gonadotrophin (HCG) trigger injection and human menopausal gonadotrophin (HMG) were withheld for 4.9 +/- 1.6 days until serum oestradiol concentrations fell below 3000 pg/ml when HCG was administered. The mean total dose and duration of administration of HMG were similar in groups 1 and 2 (48.3 +/- 17.4 and 50.2 +/- 16.5 ampoules; 13.7 +/- 2.2 and 14.1 +/- 3.2 days respectively). The mean serum oestradiol concentrations (9911 pg/ml versus 10 055 pg/ml) and number of follicles (43.3 versus 41.4) seen in both ovaries on the day of HCG administration in group 1 and on the day coasting was commenced in group 2 were also similar. After coasting, the mean serum oestradiol concentration on the day of HCG administration in group 2 was lower than in group 1 (1410 pg/ml versus 9911 pg/ml; P < 0.001). The mean serum progesterone concentrations on the day of HCG administration in both groups were similar, and fell in all women in group 2. The mean number of oocytes retrieved and percentage of oocytes retrieved per follicle punctured was significantly higher in group 1 (15.4 +/- 2.1 versus 9.6 +/- 3.2, P < 0.001; 91.4 +/- 4.4% versus 28.3 +/- 3.7%, P < 0.001 respectively). The fertilization and embryo cleavage rates were similar in both groups. Clinical pregnancy was diagnosed in 6/15 (40%) patients in group 1 and in 5/15 (33%) patients in group 2, while four women in group 1 and three in group 2 developed severe OHSS.

Effect of follicular size on oocyte retrieval, fertilization, cleavage, and embryo quality in in vitro fertilization cycles: a 6-year data collection

OBJECTIVE

To determine the effect of follicular size, including the size of the leading follicle, on oocyte retrieval, fertilization, cleavage, and embryo quality in IVF cycles based on a large data collection.

DESIGN

Retrospective analysis of 1,109 IVF cycles between 1987 and 1993 at the Hospital of the University of Pennsylvania including 606 patients ranging in age from 23 to 49 years.

RESULTS

Follicles with a volume < or = 1 mL show a significantly lower oocyte recovery rate than follicles with a volume of > 1 mL. The highest recovery rate (83.5%) was found in follicles with a volume of 3 to 4 mL. Above a follicular volume of 7 mL, the oocyte recovery drops below that observed for follicles between 1 and 7 mL. Fertilization and cleavage rates were also higher in oocytes obtained from follicles > 1 mL compared with follicles < or = 1 mL. Although fertilization rates were fairly stable above volumes of 1 mL, cleavage rates continued to rise to a peak percentage of 92% with volumes between 6 and 7 mL. Leading follicle size did not have an effect on fertilization and cleavage rates of cohort oocytes. Embryo quality was not influenced significantly by follicular volume.

CONCLUSION

Based on this evaluation of a large number of follicles, follicular size is a useful indicator of oocyte recovery, fertilization, and cleavage in IVF cycles. For optimal results, the follicular fluid volume in gonadotropin- and hCG-stimulated cycles should be > 1 mL, which corresponds to a follicle diameter of > 12 mm, and not larger than 7 mL (24 mm). For timing of hCG administration, the number of adequate size follicles appears to be more important than the size of the leading follicle(s).

Infertility treatment: from cookery to science. The epidemiology of randomised controlled trials

OBJECTIVES

To review the epidemiology of published randomised controlled trials in infertility treatment over the last 25 years, with special emphasis on the number and quality of trials.

DESIGN

Computer literature review by MEDLINE backed up by a manual search of 41 journals. Each trial was classified according to the methodology described and quality criteria. The results were recorded in a computer database. Odds ratios (OR) and confidence intervals (CI) were calculated where the data were sufficient.

SUBJECTS

Couples suffering from primary or secondary infertility. The trials studied 33,761 patients overall.

SETTING

Institute of Epidemiology and Health Services Research, Leeds.

RESULTS

Five hundred and one randomised trials in male and female infertility treatment were identified between 1966 and 1990. Pregnancy was an outcome in 291 (58%) and these were the subject of detailed analysis. Two hundred and twenty-four (77%) and 67 (23%) 'pregnancy trials' were concerned, respectively, with female and male infertility. Four per cent of the trials were preceded by a sample size calculation, and the average sample size was 96 patients (range 5-933); 700 patients per group would be required to demonstrate plausible success rates for most treatments. The method of randomisation was unstated or pseudo-randomised in 206 (71%) of trials where pregnancy was an outcome. Only 29 (5.8%) of studies were multicentre. The method of confirmation of pregnancy was omitted for 70% of papers. Cross-over design was used in 103 (21%) of cases. Meta-analysis is possible for selected topics such as the use of anti-oestrogens in idiopathic oligospermia and unexplained female infertility. Eight cases of double reporting were identified.

CONCLUSIONS

Trials using randomised methodology were relatively few in comparison with other branches of medicine, although their use is important in the evaluation of treatment for infertility as treatment-independent pregnancy is common. It was encouraging to note that an exponential increase in the use of this methodology occurred during the last three years, especially in association with assisted conception techniques, and meta-analysis has become possible for selected topics. However, many trials suffer from an unrealistically small sample size, inappropriate use of cross-over design or pseudo-randomisation. The trend towards properly controlled studies should be encouraged but these studies should be of improved quality and organised on a multicentre or even international basis.

The routine use of gonadotropin-releasing hormone agonists prior to in vitro fertilization and gamete intrafallopian transfer: a meta-analysis of randomized controlled trials

OBJECTIVE

To assess the efficacy of gonadotropin-releasing hormone agonists (GnRH-a) used in ovulation induction for in vitro fertilization and embryo transfer (IVF-ET) and gamete intrafallopian transfer (GIFT).

DESIGN

Meta-analysis of 10 trials comparing treatment cycle outcomes after GnRH-a (n = 914) with other ovulation induction protocols (n = 722) and 7 trials comparing outcomes after short flare-up (n = 368) with longer suppression (n = 476) GnRH-a protocols.

MAIN OUTCOME MEASURES

The outcome of primary interest was clinical pregnancy rate (PR) per treatment cycle commenced. Data describing the amount of gonadotropin used, cycle cancellation rate, clinical pregnancy per ET, and multiple pregnancy and abortion rates were also analyzed.

RESULTS

Clinical PR per cycle commenced was significantly improved after GnRH-a use for IVF (common odds ratio [OR] 1.80, 95% confidence interval [CI] 1.33 to 2.44) and GIFT (common OR 2.37, 95% CI 1.24 to 4.51). Clinical PR per embryo transfer was also significantly improved with GnRH-a use (common OR 1.40, 95% CI 1.01 to 1.95). Cycle cancellation was decreased (common OR 0.33, 95% CI 0.25 to 0.44), whereas spontaneous abortion rate was similar with and without GnRH-a use. Cycle cancellation and PRs after short flare-up and longer suppression protocols were similar between groups.

CONCLUSIONS

This meta-analysis supports the routine use of GnRH-a for IVF and GIFT. Further research is needed, however, to assess the potential for increased rates of multiple pregnancy and ovarian hyperstimulation syndrome, which may be associated with this treatment.

Outpatient gamete intrafallopian transfer: a clinical analysis of 710 cases

From February 1986 to June 1989 445 infertile couples were treated with a total of 710 treatment cycles involving laparoscopic gamete intrafallopian transfer (GIFT). The median age of the female partner was 33.5 years (range, 24 to 49 years) and the median duration of infertility was 4 years (range, 2 to 20 years). The final outcome of all 217 clinical pregnancies is known. There were 150 live births among which all but one baby survived, comprising 112 singleton births, 28 twin births, nine triplet births and one quadruplet birth. There were no still births, but there were two premature, multiple live births (one triplet, one quadruplet) among which no babies survived the neonatal period. Overall, 40 of the 152 potentially viable pregnancies were multiple (26.3%). Three of 206 potentially viable babies were born with congenital anomalies (1.5%). There were 50 clinical spontaneous abortions (24.8% of uterine pregnancies), one termination of pregnancy for Down's syndrome, and 14 ectopic pregnancies rate was 30.6% per laparoscopy and, among 740 initiated cycles, a live and surviving birth-per-initiated-cycle rate of 20.2%, or 33.7% to date per couple entering the programme. The 710 laparscopies resulted in two serious complications (0.3%), one of which required laparotomy. Eight other patients were admitted to hospital for rest and observation because of painful ovarian enlargement in the luteal phase. The total inpatient admission rate was 1.4%. Outpatient laparoscopic GIFT under general anaesthesia is a safe and effective procedure when conventional treatment for infertility has been unsuccessful.

Dose of human menopausal gonadotropin influences the outcome of an in vitro fertilization program

This study compares outcomes of in vitro fertilization (IVF) in two groups of 57 patients when either 2 (group 1) or 3 (group 2) ampules of human menopausal gonadotropin (hMG) were administered daily. Treatment began on day 3 of the cycle and was discontinued when at least 2 follicles attained diameters greater than or equal to 1.5 cm. Human chorionic gonadotropin (hCG) was given either 24 or 48 hours after the last dose of hMG. Although serum estradiol levels were lower in group 1, the average number of oocytes retrieved (3.2 versus 2.9), fertilized (1.9 versus 2.0), and cleaved (1.7 versus 1.8) per completed cycle did not differ between groups 1 and 2. Likewise, the number of oocytes that fertilized abnormally was similar in both groups (0.5 versus 0.3/cycle). However, the number of atretic oocytes (0.03 versus 0.5/cycle) and the percent of oocytes recovered from the cul-de-sac (0 versus 7.2%) were significantly (P less than 0.05) lower in group 1. In group 1, administration of hCG 48 hours after the last dose of hMG was associated with a higher number of cleaving embryos (2.1 versus 1.5/cycle) and a higher pregnancy rate (34.8 versus 14.7%; P less than 0.05) when compared with injection at 24 hours. In group 2, the interval between hMG and hCG did not influence these results. Together, the associations between fewer oocytes that were atretic or recovered from the cul-de-sac, and a trend toward a higher pregnancy rate, suggest that follicular recruitment with 2 ampules of hMG is more appropriate than 3 ampules in an IVF program.

Rescue of menotrophin cycles prone to develop ovarian hyperstimulation

In an attempt to prevent the loss of 'overstimulated cycles' associated with human menopausal gonadotrophin (hMG)-induced ovulation, oestradiol levels and ovarian follicular state were monitored in 12 women with 'overstimulated cycles' after withholding hMG for several days. Human chorionic gonadotrophin (hCG) was administered when oestradiol levels were less than or equal to 1700 pg/ml and the leading follicles between 17 and 22 mm in diameter. During the withholding period follicular growth continued in all patients, while oestradiol levels declined in all but three. These three patients conceived. Ovulation was observed in six additional women. Ovarian hyperstimulation did not occur in any of the 12 patients. We conclude that a rescue of 'overstimulated cycles' is sometimes possible. Conception seems to depend on a continuing rise of E2 levels and early detection of 'overstimulation'.

Evolution of a highly successful in vitro fertilization-embryo transfer program

During the first 2 1/2 years of operation of the University of California at Los Angeles in vitro fertilization-embryo transfer program, 47 clinical pregnancies were achieved in 154 laparoscopies for oocyte aspiration (31%). Two of these pregnancies were achieved through transfer of cryopreserved embryos when ongoing pregnancy did not result from embryo transfer in the stimulated cycle. An increase in clinical implantation was noted with a reduction of transfer volume and proportion of air, with 34% of laparoscopies being followed by clinical pregnancy over the last 18 months. No difference in the rate of clinical pregnancy was noted relative to uterine depth or position. The high rate of multiple implantation (47%) suggested a high level of embryo quality. The success rate was attributed to a strong ovarian, human menopausal gonadotropin stimulation, accurate timing of human chorionic gonadotropin, a high oocyte retrieval rate, meticulous laboratory technique, atraumatic, high-fundal transfer of embryos, and initiation of embryo cryopreservation.

Choice of an ovarian stimulation protocol according to the follicular puncture method in an in vitro fertilization programme

In order to ascertain the adequacy of ovarian stimulation protocols with a type of follicular puncture, 126 women undergoing in vitro fertilization received either combination clomiphene/hMG or hMG alone according to a randomized test protocol. Within both groups patients for whom a pelvic examination was required had laparoscopies, while others had transvaginal ultrasonically guided punctures as far as possible. Clomiphene/hMG was more efficient than hMG alone as assessed from the cleavage rate (68% vs. 54%; p less than 0.01) and the pregnancy per attempt rate (16% vs. 5%; p less than 0.05). Laparoscopic punctures were more efficient than ultrasonically guided punctures (mean number of recovered oocytes: 4.8 +/- 2.6 vs. 3 +/- 2.5; p less than 0.001), but slightly better results were achieved by this latter method in ongoing pregnancy per puncture rate (18% vs. 8%; NS). With ultrasonically guided punctures, stimulation by clomiphene/hMG allowed better oocyte recoveries (3.8 +/- 2.5 vs. 2.3 +/- 1.9, p less than 0.05). Such results constitute an argument for preferential use of the clomiphene/hMG stimulation protocol with ultrasonically guided punctures.

Preimplantation development following in vitro fertilization of mouse oocytes: effects of timing of superovulation and preincubation in vitro

The early embryonic development of in vitro fertilized oocytes was assessed following superovulation in F1 hybrid (C57BL/6 X CBA/Ca) mice. Decreasing the time interval between the administration of constant doses of pregnant mare's serum gonadotropin (PMSG) and human chorionic gonadotropin (hCG) resulted in decreases in the frequency of development to the blastocyst stage but had no significant effect on development to the two-cell stage. Preincubation of postovulatory oocytes in vitro prior to insemination did not compensate for the reduced preovulatory development in vivo but resulted in decreases in the frequency of development to the blastocyst stage. The results indicate that inadequate preovulatory development of superovulated mouse oocytes can adversely affect the preimplantation development of in vitro fertilized embryos in the absence of a visible inhibitory effect on development to the two-cell stage and also that preincubation of postovulatory oocytes in vitro prior to fertilization reduces subsequent developmental capacity.

In vitro fertilization and embryo transfer as related to endogenous luteinizing hormone rise or human chorionic gonadotropin administration

After ovarian stimulation with clomiphene citrate combined with human menopausal gonadotropin for in vitro fertilization, the appearance of a spontaneous luteinizing hormone (LH) surge before fulfillment of the minimal criteria of follicular maturity (at least one follicle greater than 19 mm and serum estradiol [E2] greater than 400 pg/ml/follicle greater than 17 mm) is associated with reduced pregnancy rates. In these cases, follicles are smaller and serum E2 values are lower at the time of the LH surge. Oocyte recovery rate is reduced, embryonic anucleate fragments are more frequently observed, and the level of luteal progesterone on day 4 after oocyte retrieval is lower. Hyperandrogenic patients are more prone to display such premature spontaneous LH surge. We concluded that in case of an untimely LH rise, laparoscopy for oocyte retrieval should be cancelled.

Follicular maturation parameters associated with the failure of oocyte retrieval, fertilization, and cleavage in vitro

Follicular maturation parameters predictive of decreased success in human in vitro fertilization were evaluated in 104 gonadotropin-stimulated cycles. Falling estradiol (E2) levels correlated with decreased fertilization (1.9 oocyte/cycle) and cleavage (1.4 oocyte/cycle), when compared with cycles with increasing E2 (2.4 and 2.1 oocyte/cycle, respectively). Likewise, polyspermic fertilization was higher in the former group. Falling E2 levels after human chorionic gonadotropin (hCG) administration correlated with similar trends. Delaying hCG (24 to 96 hours) relative to the last dose of gonadotropin did not affect the total number of oocytes fertilized per cycle. However, polyspermic fertilization and cancellation rates were higher. Leading follicles growing beyond 2.3 cm (determined by ultrasound examination) were associated with decreased recovery, fertilization, and cleavage, and increased polyspermic fertilization. We conclude that ultrasonography and E2 monitoring can predict decreased fertilization and cleavage and should also be monitored after hCG administration.

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.

Endometriosis and ovulatory disorder: reduced fertilisation in vitro compared with tubal and unexplained infertility

In-vitro fertilisation (IVF) was carried out once for each of 104 couples who had a single cause of infertility. The group with tubal damage was used as the reference for normal fertilising capacity of both oocytes and sperms: the IVF rates were 68% (71/105) per mature oocyte and 88% (37/42) for couples from whom mature oocytes were recovered. Couples with poor sperm/mucus penetration had reduced IVF rates: 32% (12/38) per oocyte and 60% (9/15) per couple. Sperm function, which was judged normal by means of standard seminal analysis and mucus penetration, was confirmed by normal IVF in unexplained infertility: 63% (37/59) per oocyte and 90% (18/20) per couple. Despite favourable sperm function in their partners, women with endometriosis (without tubal damage) had reduced IVF rates: 33% (19/58) per oocyte and 60% (9/15) per couple. These findings indicate that ovulatory disorder is present in endometriosis and suggest that it causes the associated infertility.

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.

The day of initiation of human menopausal gonadotropin stimulation affects follicular growth in in vitro fertilization cycles

The attainment of synchronous follicular development in human menopausal gonadotropin/human chorionic gonadotropin-stimulated cycles for in vitro fertilization (IVF) continues to be a perplexing problem. Two regimens of follicle stimulation for IVF cycles were, therefore, compared. Twenty-nine patients commenced human menopausal gonadotropin (hMG) therapy on day 1 of the menstrual cycle (Group I), while 30 women received hMG from the third day of the cycle (Group II). The hMG therapy was tailored to the individual patients's response, based on ultrasonographic measurements of follicular size and serum estradiol (E2) levels. Both groups of patients received a mean of 19.6 +/- 1.4 ampules of hMG over a mean of 6.1 +/- 0.2 days. The pattern of serum E2 and progesterone levels in the periovulatory and luteal phase was not affected by the day of initiation of hMG therapy, although Group I patients demonstrated lower (P less than 0.05) E2 levels on the 2 days prior to human chorionic gonadotropin (hCG) administration. In terms of follicle growth, Group II follicles consistently demonstrated a significantly (P less than 0.01, chi 2 test) larger proportion of medium- and large-sized follicles compared to Group I follicles on almost all of the days when ultrasonographic measurements were taken. In addition, Group II follicles demonstrated an earlier shift (day-1) to the larger follicles than Group I follicles (day 0). Significantly (P less than 0.001) more oocytes were recovered per aspirated follicle in Group II patients, but the fertilization rate per oocyte was greater (P less than 0.003) for Group I oocytes. Nevertheless, pregnancy rates did not differ between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)