Elevated follicular fluid angiotensin II and pregnancy outcome

OBJECTIVE

To assess whether a relationship exists between follicular fluid (FF) angiotensin II (AII) concentration and pregnancy outcome or earlier fecundity parameters and whether correlations exist among FF AII concentrations and P, E2, T, androstenedione (A), or various ratios of these.

DESIGN

Retrospective study in which hormone concentrations in FF samples were measured.

SETTING

In vitro fertilization clinic-Assisted Reproductive Technology Program, Rush Medical Center.

PATIENTS

Twenty-six female patients underwent ovarian stimulation for IVF.

INTERVENTION

Leuprolide acetate was combined with hMG and FSH for ovarian stimulation.

MAIN OUTCOME MEASURE

Follicular fluid aspirates were collected and oocytes were recovered 34 to 36 hours after hCG injection. The patients proceeded to undergo IVF and ET. Follicular fluid hormones were measured using standard RIA. Angiotensin II and steroid hormone concentrations in FF were compared for pregnant versus nonpregnant women using the Student's t-test and rank-sum test. Pearson multiple-correlation analysis was performed to calculate correlation coefficients among AII concentrations and steroid concentrations in FF aspirates.

RESULTS

Mean FF concentration of AII was significantly lower in samples from women showing clinical pregnancies (112.2 +/- 13.9 pg/mL [107.3 +/- 13.3 pmol/L]) compared with samples from women who did not achieve pregnancy (217.1 +/- 23.8 pg/mL [207.5 +/- 22.7 pmol/L]) (mean +/- SE). A negative correlation was observed between FF concentrations of AII and P. Correlations of AII with E2, T, A, or with ratios of these did not show significance.

CONCLUSION

These data suggest that high AII concentration at time of oocyte recovery may indicate poor pregnancy outcome in women undergoing ovarian stimulation for IVF. These data corroborate previous results in animal models showing that AII predisposes follicles to undergo atresia-like conditions.

Pituitary sarcoidosis causing secondary amenorrhea. A case report

A 32-year-old woman with hypogonadotropic amenorrhea and sarcoidosis had an enlarged pituitary stalk and gland on computed tomography. Concentrations of luteinizing and growth hormone did not increase after the administration of gonadotropin releasing hormone and insulin-induced hypoglycemia, respectively. The absence of response possibly was the consequence of the patient's estrogen deficiency. The response of thyroid stimulating hormone, prolactin and cortisol was normal after provocative pituitary stimulation. Central nervous system sarcoidosis occurs in 3.5-5.0% of patients with systemic sarcoidosis. Hypothalamic or pituitary sarcoidosis occurs in approximately 0.5% of patients. Diabetes insipidus and hyperprolactinemia are the most frequent manifestations of hypothalamic-pituitary sarcoidosis, occurring in one-half and one-third, respectively, of such patients. Menstrual disturbances, including amenorrhea, are reported infrequently. Computed tomography and provocative pituitary-hypothalamic testing are useful in detecting central nervous system sarcoidosis and in delineating the site of involvement.

Level of reading difficulty in the American College of Obstetricians and Gynecologists patient education pamphlets

Written educational and informational materials are an important and potentially useful means to complement verbal instructions, assure that consent for tests and procedures is informed, and enhance compliance with treatment. In specialties other than obstetrics and gynecology, many of these materials have been found to be written at a level of difficulty above the reading ability of the intended audience. The SMOG formula was used to assess the level of reading difficulty of all 74 English-language patient education pamphlets developed by The American College of Obstetricians and Gynecologists (ACOG) Committee on Patient Education. Sixty-one of these pamphlets are written at a reading difficulty level of 11th grade or higher. Although the mean reading education level in the United States is at grade 12.6, the mean literacy level is at or below eighth grade. With the exception of one ACOG pamphlet written specifically for low-readability audiences (p-063, Birth Control Pills), all the pamphlets are written at a level higher than the literacy level of many women. The information is unlikely to be understood if it is written above the reading ability of the intended audience. This disparity is accentuated for health-education materials because scientific and technical terms further reduce the level of comprehension. The SMOG formula is a simple means to ensure that educational materials are written at a level appropriate for the intended audience.

Inability of sonography to detect imminent ovulation

Sonographic visualization of the cumulus oophorus or of morphologic alterations in the wall of the dominant follicle have been reported to be reliable signs of imminent ovulation when conventional transabdominal sonography is used. To determine if transvaginal sonography could allow a more frequent and confident prediction of imminent ovulation, we prospectively monitored 22 ovulatory menstrual cycles in four women undergoing artificial insemination and in 13 normally menstruating volunteers. Scanning was done on alternate days in the periovulatory period; a 7.5-MHz transvaginal transducer was used. Despite the improved resolution obtained with transvaginal sonography, confident identification of the cumulus oophorus or of mural changes in the follicle was not possible in any of the cycles followed. No other consistent follicular characteristic predicted imminent ovulation. We conclude that confident prediction of imminent ovulation is not possible with sonographic analysis.

A semiquantitative human chorionic gonadotropin assay for the detection of ectopic pregnancy

Human chorionic gonadotropin (hCG) was measured in 117 serum samples with known quantities of hCG after a dilutional modification of a reliable, simple, and inexpensive qualitative assay for hCG. The modification yielded a semiquantitative assay for hCG with a sensitivity of 5000 mIU/mL. At hCG concentrations below 4000 mIU/mL, the assay had no false-negative or false-positive results; above 6500 mIU/mL, there were also no false-negative or false-positive results. In the range of 4000-6500 mIU/mL, the clinical false-positive rate was 28%. Using the described dilutional modification of this qualitative hCG assay, the test is semiquantitative, and is useful in selecting the appropriate time to perform ultrasound and laparoscopy in women suspected of having an ectopic pregnancy.

Serum and seminal plasma prolactin concentrations in men with normospermia, oligospermia, or azoospermia

Semen analyses were performed and serum and seminal plasma prolactin (PRL) concentrations were determined in 165 samples from 120 men seen with their wives because of infertility. The mean (+/- standard deviation) serum and seminal plasma PRL concentrations were 6.5 +/- 3.3 and 7.5 +/- 3.1 ng/ml, respectively. The mean concentrations of PRL in serum and seminal plasma were similar in groups of men divided by sperm concentration. Seven men had an increased serum PRL concentration. Three of these 7 men had sperm concentrations less than 20 million/ml and none of these 7 men had an increased seminal plasma PRL concentration. Four men had an increased seminal plasma PRL concentration; the serum PRL concentration, sperm concentrations, and motilities were normal in all 4. No man had a decreased serum or seminal plasma PRL concentration. Increased serum PRL concentrations were found infrequently and the increase was slight (23.2 ng/ml or less). Seminal plasma PRL concentrations were related directly to sperm concentrations and motilities, relationships that were statistically significant.

The effect of epidural analgesia on the frequency of instrumental obstetric delivery

In a retrospective study, 155 women who had epidural analgesia only for pain relief during labor and delivery were matched by age, parity, and race with 155 women who had either pudendal or local analgesia for delivery. Infant birth weights were similar in the two groups. The frequency of low forceps, vacuum extraction, and midforceps delivery in the epidural group was significantly higher than in the control group (P less than .05). Women having epidural analgesia who delivered their infants in an occiput anterior position also had a significantly higher frequency of instrumental delivery. Thus, epidural analgesia increased the frequency of instrumental delivery, an increase that was not a consequence of larger infants or fetal malposition.

Androgen and estrogen secretion by normal and neoplastic ovaries in premenopausal women

Peripheral and ovarian venous concentrations of estradiol-17 beta, estrone, testosterone, and androstenedione were measured in 47 premenopausal women at the time of laparotomy. Ovarian histology was normal in 32 women, and 15 women had a unilateral (N = 13) or bilateral (N = 2) ovarian neoplasm. That the concentrations of these steroids in women with normal ovaries were comparable to values reported by others suggests that surgical stress did not affect the results. The concentration of both estrogens in the vein draining a nonfunctional neoplasm were significantly less than estrogen concentrations in the vein draining the ovary with the dominant follicle or corpus luteum. Peripheral venous estrogen, as well as androgen concentrations were normal in women with a nonfunctional neoplasm. Peripheral concentrations and concentrations of both androgens in the vein draining the ovary with a functional neoplasm were increased significantly. In 21 to 33% of all women with a neoplasm, the ovarian venous concentration of one or both androgens was increased significantly. No woman with an ovarian neoplasm had a significant increase in ovarian venous estrogen concentration. Although we did not define the mechanism for a selective increase in ovarian androgen secretion in a fraction of women, we conclude that any ovarian neoplasm may be associated with abnormal ovarian secretion of sex steroids.

Secretion of androgens and estrogens by normal and neoplastic ovaries in postmenopausal women

Peripheral and ovarian venous concentrations of testosterone, androstenedione, estradiol-17 beta, and estrone were measured in 30 postmenopausal women. Ovarian venous concentrations of testosterone and estradiol-17 beta were 5.6 and 4.3 times the peripheral concentrations of women with normal ovaries. This suggests that the ovaries of postmenopausal women continue to secrete these two steroids. Mean peripheral testosterone concentrations in 14 postmenopausal women with a nonfunctional or functional ovarian tumor were increased significantly. Ovarian venous concentrations of these four steroids from the side draining the tumor-bearing ovary were increased in 40 to 80% of the women. The venous concentrations from the normal ovary were also increased in 22% or more of the women with an ovarian tumor. Any ovarian neoplasm in postmenopausal women may be associated with increased ovarian sex-steroid secretion.

Premature ovarian failure

The diagnosis of premature ovarian failure was made in 35 women (ages 17 to 40) with increased concentrations of follicle-stimulating hormone and luteinizing hormone. Three had primary amenorrhea, 29 had secondary amenorrhea (less than one to 15 years), and three had irregular menstrual intervals of less than six months. Symptoms and signs of estrogen deficiency were present in fewer than 50% of these women and were not helpful in distinguishing the different causes of ovarian failure. Six of these women had an autoimmune disorder associated with ovarian failure. Thirteen of 16 women had a normal 46,XX karyotype, and five of 14 women who had an ovarian biopsy had a specimen that contained follicles with oocytes. Two women conceived after they developed ovarian failure and while taking cyclic estrogen and progestin.

Atypical ovarian hyperthecosis in a virilized postmenopausal woman

Ovarian venous concentrations of testosterone (18.7 ng/mL and 8.2 ng/mL) were three to six times higher than the peripheral concentrations (2.8 ng/mL) in a hirsute postmenopausal woman. She had cystic hyperplasia of the endometrium and atypical hyperthecosis of the ovary. Postoperatively, the testosterone levels returned to normal. From the results of the immunoperoxidase reaction, the luteinized stromal cells of the ovaries were the site of increased production of the testosterone and estradiol. By the same technic, these cells were negative for LH but strongly positive for FSH. From these data, the authors conclude that the luteinized cells were the primary source of the excessive testosterone, that the same cells were the direct and indirect (by peripheral testosterone conversion) source of estradiol, that LH was very likely not involved in the process of steroid hormone production, and that FSH may be the trophic stimulus responsible for the functional activity of the luteinized stromal cells in this virilized postmenopausal woman.

The 24-hour secretory pattern of LH and the response to LHRH in transsexual men

Ten separate aspects of hypothalamic and pituitary function were studied in 13 male-to-female transsexuals and compared to the results of 7 heterosexual adult men. In 4 of 5 transsexuals, the 24-hour mean serum concentration of LH, the LH pulse frequency or amplitude, or the apparent half-life of disappearance of serum LH were greater than the 95% confidence limit of normal men. The maximum concentration of LH or FSH following the administration of 100 micrograms LHRH, the area under the response curve of LH or FSH following LHRH, or both were significantly greater than normal in 5 of 13 male-to-female transsexuals. The response of LH following the administration of LHRH was repeated in 3 subjects during estrogen therapy, and in one there was a paradoxical increase in the response of LH. Transsexualism may be associated with a neuroendocrine defect in the hypothalamus or pituitary that is characterized by high-frequency, high-amplitude pulsatile secretion of pituitary LH.

The frequency of androgen receptor deficiency in infertile men

To ascertain the frequency of androgen resistance as the cause of male infertility and to determine whether endocrine abnormalities are a universal feature of the disorder, we measured the androgen receptor in fibroblasts cultured from the genital skin of 28 unrelated phenotypically normal men with idiopathic azoospermia or oligospermia. The amounts of androgen receptor were compared with those in genital skin fibroblasts from a variety of other subjects, including 10 men with azoospermia of known cause, 5 normal men, 28 subjects with disorders of androgen formation of metabolism of known cause, and 28 persons with documented disorders of the androgen receptor (testicular feminization and Reifenstein syndrome). The mean androgen receptor Bmax (amount of high affinity binding) was 12 fmol/mg protein or greater in 10 infertile men with azoospermia of known cause and in 6 infertile men with mild oligospermia. In fibroblasts from 1 to 4 individuals with severe oligospermia of unknown cause (less than 1 million/ml) and 8 of 18 subjects with idiopathic azoospermia, the androgen receptor Bmax was less than 12 fmol/mg protein. The mean value in these 9 men was not significantly different from that in subjects with testicular feminization or Reifenstein syndrome. Serum concentrations of testosterone and LH were normal in 6 of these 9 infertile men, and plasma production rates of testosterone were elevated in only 2 of the 6 men studied in whom the Bmax values in genital skin fibroblasts were less than 12 fmol/mg protein. We conclude that androgen resistance may be the cause of a significant fraction (40% or more) or idiopathic male infertility due to azoospermia or severe oligospermia, and that this disorder may not be manifested by a functional defect in the pituitary-testicular axis.

Factors affecting the success of donor insemination

Of 81 women who completed six ovulatory cycles of properly timed donor insemination using freshly ejaculated semen, 65 (80%) conceived. The mean sperm concentration and motility in cycles of conception were 79.5 million/ml and 69%. In cycles where conception did not occur, the mean sperm concentration and motility were 78.4 million/ml and 67%, values similar to those in cycles of conception. There was also no significant difference between conception and nonconception cycles in the following: number of inseminations per cycle (2.43 versus 2.34), percentage of cycles with a preovulatory fall in basal temperature (35.1% versus 45.4%), maximum spinnbarkeit (5.6 versus 5.2 cm), and the interval between basal temperature nadir and maximum spinnbarkeit (0 versus 0.1 days). The distribution of inseminations in relation to the basal temperature nadir was similar in conception to that of nonconception cycles. Sixteen women (20%) did not conceive, and there was an apparent explanation in 3 of these: 1 was occasionally anovulatory during several cycles; 1 had no intraperitoneal passage of CO2; and 1 of 3 women who underwent laparoscopy had peritubal adhesions.

Age, estrogen, and the endometrium

Three facts are strongly supported by clinical and experimental evidence. First, postmenopausal women produce estrogen, occasionally in sufficient quantities to be associated with uterine bleeding and adenocarcinoma. The estrogen is produced in extraglandular sites and is not secreted by the ovaries. Second, the estrogen produced by these women is biologically active. Third, many of the biologic effects of estrogen are antagonized by progesterone. None of these observations proves that estrogen causes endometrial cancer but each can be added to the growing body of evidence that suggests a casual role for estrogen.

Steroid production in a woman with gonadal dysgenesis, breast development, and clitoral hypertrophy

Androgen and estrogen production was measured in a 46,XX woman with gonadal dysgenesis, breast development, and clitoral hypertrophy. The production rates of androstenedione (438 micrograms/24 hr), estrone (26 micrograms/24 hr), and estradiol-17 beta (13 micrograms/24 hr) were low compared to values obtained in normal young women. The production rate of testosterone (239 micrograms/24 hr) was similar to that of normal women. Bilateral nodular streaks were found in the usual anatomic site occupied by ovaries. By microscopic examination of the streaks, fibrous tissue containing nests of hilar cells was found. The karyotype of skin, peripheral leukocytes, and gonadal streak fibroblasts in culture was 46,XX. The possible causes and implications of breast development and clitoral enlargement in subjects with gonadal dysgenesis are discussed.

Androgen and estrogen production in elderly men with gynecomastia and testicular atrophy after mumps orchitis

Gynecomastia developed in three men 1-30 yr after the occurrence of testicular atrophy due to mumps orchitis. At the time of study, these men were 63-68 yr of age. In these men the mean plasma production rate of testosterone was 816 microgram/24 h, a value 20% of that found in normal elderly men without gynecomastia. The plasma production rate of androstenedione averaged 1317 microgram/24 h. The mean production rates of 17 beta-estradiol and estrone in these subjects were 33 and 48 microgram/24 h, values comparable to those of normal young men. Extraglandular formation of estrogen from plasma prehormones accounted for all of the 17 beta-estridiol and most of the estrone produced by these elderly men with gynecomastia. Serum gonadotropin concentrations were elevated in these men, probably because plasma testosterone production rates were decreased. These findings are consistent with the view that the capacity of Leydig cells to secrete testosterone was impaired after mumps orchitis in these subjects, but the capacity to form estrogen was not similarly impaired, since most estrogen is formed in extraglandular sites. Thus, the impairment in Leydig cell testosterone secretion after mumps orchitis together with the normal increase in extraglandular aromatization that accompanies aging bring about a striking reduction in the ratio of testosterone to estrogen production rates, and gynecomastia may result.

Androgen insensitivity as a cause of infertility in otherwise normal men

To ascertain if androgen insensitivity causes severe oligospermia or azoospermia we studied three unrelated, phenotypically normal men with long histories of infertility. The mean plasma concentrations and production rates of testosterone were 14.3 ng per milliliter and 10.1 mg per day, respectively, values approximately twice the average found in normal men. Serum luteinizing hormone concentrations were elevated in two of the three subjects. The specific high-affinity dihydrotestosterone binding capacity of cultured genital-skin fibroblasts was 8, 0 and 10 fmol per milligram of cellular protein, values half (or less) of those from normal men and women but similar to values in subjects with partial androgen insensitivity manifested by incomplete testicular feminization or Reifenstein syndrome. The low amount of androgen receptor and the combination of high serum gonadotropins and plasma testosterone production rates suggest that the defective spermatogenesis in these infertile men was the consequence of androgen insensitivity.

Studies of gonadotropin-gonadal dynamics in patients with androgen insensitivity

Four patients with androgen insensitivity had plasma LH and FSH measured at 20-min intervals for 24 h and at 15- to 30-min intervals for 3 h after the injection of LRH. Twenty-four-hour mean testosterone (T), estradiol, and androstenedione (delta 4) levels were also measured. Patients with androgen insensitivity had significantly elevated LH levels (P less than 0.05) and an increase in the number of LH secretory episodes (P less than 0.001) compared to normal subjects. The amplitude of the LH secretory episodes, expressed as the absolute increment, was significantly higher than normal controls (P less than 0.005). The LH response to LRH (absolute increment) was twice that of normal, but was not significantly different from normal subjects. The 24-h mean FSH levels were normal in three of the patients and elevated in one. This patient had the mildest degree of androgen insensitivity on clinical exam and the greatest degree of testicular atrophy. The 24-h mean T, estradiol, and delta 4 levels were higher than normal, but only the delta 4 was significantly increased (P less than 0.05). To determine if the elevated LH levels were in response to a decrease in the free T level, we measured T-binding capacity (TBG), TBG was higher than normal controls but was not significantly different, suggesting that elevated LH levels were probably in response to a decrease in T action at the hypothalamic-pituitary level. This was further supported by the inability of prolonged dihydrotestosterone administration to affect LH secretion in one of the patients with the Reifenstein syndrome.

Production and origin of estrogen in two true hermaphrodites

Two 46,XX true hermaphrodites with genital ambiguity since birth and gynecomastia were studied. The production rates of estradiol in these subjects, 77 and 71 microgram per 24 hours, and of estrone, 82 and 136 microgram per 24 hours, were approximately twice those of normal adult men. In one of these subjects the plasma production rates of androstenedione and testosterone were measured and found to be 389 and 1,271 microgram per 24 hours, respectively. In this subject all estrone production, 82 microgram per 24 hours, could be accounted for by extraglandular formation from plasma prehormones, whereas 71 microgram of estradiol per 24 hours could not be accounted for by extraglandular formation and presumably arose from glandular secretion. The concentration of testosterone in the testicular portion of the ovotestis of this subject was 465 ng. per gram of tissue, a value comparable to that found in testicular tissue obtained from adult men. In the other subject of this study, who had a malignant gonadal tumor, the plasma concentration of human chorionic gonadotropin was 3,000 ml.U. per milliliter. From the results of this study we conclude that both ovarian and testicular components of the gonads of these two individuals were endocrinologically active, and that their gynecomastia likely developed as a consequence of gonadal estradiol secretion.

Androgen and estrogen formation in women with ovarian hyperthecosis

Women with ovarian hyperthecosis were studied and found to have a plasma testosterone production rate of 2.1 mg/day, a value eight times greater than that of nonhirsute, ovulatory women. The severity of hirsutism and virilization in these women was more closely correlated with the amount of testosterone produced than with plasma testosterone concentrations. The mean plasma production rates of androstenedione in these women, 8.6 mg/day, was more than three times that found in young women with no evidence of androgen excess. There was a marked gradient between ovarian and peripheral venous plasma concentrations for both C19 steroids. Following ovarian wedge resection or oophorectomy, there was a precipitous fall in the peripheral venous concentrations of these steroids. These observations support the view that the major source of excess androstenedione and testosterone secretion in these subjects was the ovaries. The rate of estrone formation in these women, 106-345 microgram/day, was the result of extraglandular aromatization of plasma androstenedione.

The origin of androgen and estrogen in a virilized postmenopausal woman with bilateral benign cystic teratomas

Clitoromegaly was observed in a 73-year-old woman who had bilateral ovarian benign cystic teratomas that contained only epithelial derivatives. Scattered in the stroma of these ovaries were clusters of hyperplastic cells. The plasma testosterone production rate was 2.4 mg/day, a value that is ten times greater than that of normal postmenopausal women. The elevated plasma concentrations of testosterone and androstenedione decreased to normal by the second day after bilateral oophorectomy. Ovarian venous concentrations of testosterone and androstenedione were also increased and were considerably greater than those in peripheral blood. Estrone production was 68 microng/day, most of which could be accounted fo by the extraglandular formation from androstenedione. Estradiol production was 71 microng/day, of which 75% was computed to arise from extraglandular formation and the remainder likely arose by ovarian secretion. The modest increase in estrogen production was associated with slight cystic hyperplasia of the endometrium. From this study we conclude that the hyperplastic ovarian stroma was the source of the excessive androgen production.

X-ray pelvimetry of the pregnant adolescent. Pelvic size and the frequency of contraction

Pelvic dimensions by x-ray of 282 pregnant adolescents and 181 adult women were compared to ascertain if the pelvis of the adolescent was smaller and contracted with greater frequency. The majority of 10 pelvic dimensions for black and white adolescents were significantly smaller or contracted with significantly greater frequency. The pattern of signifcant differences suggests that the adolescent pelvis has yet to mature fully by age 16. As a consequence of physiologic events during puberty, described by several authors, the adolescent pelvis grows at an accelerated rate and typically changes from an anthropoid to a gynecoid configuration. Caution must be taken in applying these results since pelvic size is not synonymous with obstetric outcome.