Ovarian autoimmunity: greater frequency of autoantibodies in premature menopause and unexplained infertility than in the general population

The objective of this study was to: (1) assess the relative prevalence of ovarian, thyroid, nuclear, and cardiolipin antibodies associated with premature menopause and unexplained infertility and (2) compare ovarian and thyroid antibodies in premature menopause, unexplained infertility, and the general population. Autoantibodies were evaluated in women with premature menopause (n = 30), unexplained infertility with (n = 38) or without (n = 15) prior gonadotropin-induced ovulation, and normal cycling controls (n = 12) and in a population of women obtained from a blood bank (n = 53). Antibodies to ovary (OVAB), thyroid (THYAB; thyroid peroxidase and thyroglobulin), cardiolipin, and eight nuclear antigens were assessed by enzyme immunoassay. Organ-specific antibodies (ovary and thyroid) were present with significantly greater frequency than non-organ-specific antibodies (nuclear and cardiolipin) in premature menopause and unexplained infertility (60% (50/83) vs 16% (13/83) respectively; P < 0.0001). OVAB (53%, 44/83) were significantly more frequent than THYAB (30%, 25/83) in premature menopause and unexplained infertility (P = 0.0030). THYAB did not differ among all groups (P = 0.78). In premature menopause and treated or untreated unexplained infertility OVAB frequencies were 53, 61, and 33%, respectively, and were significantly more frequent than in the population (17%) (P = 0.0001). In unexplained infertility, individuals with no prior gonadotropin-induced ovulation had a lower frequency of OVAB than treated individuals (P = 0.07). The frequency distribution of optical density values for OVAB was significantly higher for premature menopause and unexplained infertility than for population or normal cycling women (P < 0.0001). Thus, only ovarian antibodies were significantly more frequent than other antibody markers of autoimmunity in premature menopause and unexplained infertility.

The effect of the oviduct, uterine, and in vitro environments on zona thinning in the mouse embryo

OBJECTIVE

To evaluate the impact of the oviduct, uterine, and in vitro environments on zona pellucida thinning in the mouse embryo.

DESIGN

Female mice were stimulated with pregnant mare serum gonadotropin and mated and hCG injection. Unilateral oviduct ligation was performed on day 2 of gestation using the dorsal approach. The mice were divided into equal groups and killed on days 2, 3, 4, 5, and 10 of gestation. In vitro incubated embryos served as controls. Average daily zona thickness measurements were subjected to analysis of variance and paired Student's t-test.

SETTING

The laboratory of the assisted reproductive program of Rush University Medical Center.

MAIN OUTCOME MEASURE(S)

Progressive daily decrease in average zona thickness.

RESULT(S)

Zona measurements of embryos flushed out of uterine horns, ligated oviducts, and in vitro incubation demonstrated statistically significant decreases in zona thickness, from 9.6 +/- 1.6 microns (day 3) to 6.0 +/- 0.8 microns (day 5), from 11.6 +/- 2.2 microns (day 2) to 6.0 +/- 1.6 microns (day 5), and from 11.1 +/- 2.0 microns (day 2) to 6.0 +/- 1.6 microns (day 5), respectively. There were no differences in average zona thickness for embryos in the same cell stage and same protocol day in all three locations.

CONCLUSION(S)

Zona thinning seems to be induced primarily by the dividing embryo before implantation. A substantial tubal and uterine contribution to zona thinning was not detected in this mouse embryo model.

Comparison of mouse embryo development in open and microdrop co-culture systems

Co-culture with numerous cell lines has been shown to improve in-vitro embryo development. It is usually performed in open culture without an oil overlay, or in relatively large volumes of medium (e.g. 0.5 ml) under oil. We compared the efficacy of open and microdrop co-culture systems using human endometrial and tubal cell lines and mouse zygotes. Although the mean pH values of the media from the tubal cell cultures (both open and oil-covered) decreased significantly over 5 days of culture, this did not appear to impair embryo development. Both co-culture and microdrop culture significantly improved blastocyst and hatching blastocyst formation rates. The combination of the two techniques (microdrop and co-culture) demonstrated the highest blastocyst formation and hatching blastocyst formation rates, as well as the highest mean cell numbers in hatching blastocysts. Co-culture in a microdrop is a superior system for mouse embryo culture.

Optimizing tubal epithelial cell growth promotes mouse embryo hatching in coculture

PURPOSE

This study investigates the relationship between human tubal epithelial cell growth characteristics and mouse embryonic development to determine which cellular requirements should be preferentially provided in a coculture system.

METHODS

Cell growth and viability were assessed for 5 days in alpha-minimal essential medium or human tubal fluid supplemented with 10% human serum or 10% synthetic serum. Two-cell mouse embryo development to blastocyst and hatching blastocyst stages was also assessed with or without coculture.

RESULTS

Both epithelial cell growth and embryo development were dependent on serum supplementation with better cell viability and growth rates in human serum and better blastocyst development in synthetic serum. The highest proportion of hatching blastocysts was found in alpha-minimal essential medium and human serum with coculture.

CONCLUSIONS

Culture conditions which improve tubal epithelial cell growth also improve the hatching rate of mouse embryos in coculture. This indicates that by meeting the metabolic and nutritional demands for epithelial cell growth, the beneficial effects of coculture on embryo development may be optimized.

Sonographically monitored ovarian stimulation for assisted reproduction: a prospective, blind study

OBJECTIVE

To assess prospectively the appropriateness of follicular sonography alone for monitoring ovarian stimulation and to compare it to ovarian monitoring with both follicular sonography and hormone level determinations.

STUDY DESIGN

Prospective, blind, clinical study in which the investigator made cycle management decisions based on follicular sonography only.

RESULTS

Follicular sonography alone predicted 88% of the decisions made by the combination of follicular sonography, luteinizing hormone (LH), estradiol (E2) and progesterone measurements. Follicular sonography was unable to predict abnormal E2 patterns in eight (8%) of the patients' scans. Follicular sonography did not detect three (3%) patients with a premature LH surge.

CONCLUSION

Follicular sonograms alone performed during ovarian stimulation predicted 88% of cycle decisions. One could argue that hormone measurements could be either reduced or eliminated during ovarian stimulation for assisted reproductive technology and that follicular sonography only would be a cost-effective compromise. The effect of such simplified monitoring on pregnancy rates would require further prospective evaluation.

Luteal phase estradiol and pregnancy outcome in gonadotropin releasing hormone agonist/human menopausal gonadotropin-treated gamete intrafallopian transfer cycles

To correlate luteal estradiol (E2) levels with pregnancy outcome, 36 consecutive conceptions resulting from gamete intrafallopian transfer in gonadotropin releasing hormone agonist/human menopausal gonadotropin (GnRH-a/hMG) cycles were analyzed. GnRH-a was initiated during the preceding luteal phase. HMG was adjusted individually. Human chorionic gonadotropin (hCG), 5,000 IU, was administered when E2 was > 500 pg/mL and the leading follicle > 17 mm (day 0). The luteal phase was supported by (1) hCG, 1,500 IU in three doses from day 5 and (2) progesterone (P) from day 7. E2 and P levels were analyzed in three groups of patients: normally progressing pregnancy (NPP), abortion (AB) and preclinical abortion (PAB). No significant differences in mean E2 levels were seen between the groups from day 0 through day 5 after hCG. Midluteal E2 levels were significantly different between the groups (P < .05). Late luteal E2 values were significantly higher for NPP than for either AB or PAB (P < .05). There were no significant differences in luteal P values between the NPP, AB and PAB groups. Decreased luteal E2 appears to be associated with early pregnancy wastage; this may be due to inadequate endometrial support.

Evaluation of co-culture and alternative culture systems for promoting in-vitro development of mouse embryos

The goal of this study was to compare mouse embryo development in a defined synthetic medium (human tubal fluid) against the same medium supplemented with a defined synthetic serum (SS), co-culture on human tubal epithelium (TECC), and culture on human fibronectin (FN) with and without SS. After 48 h, TECC, SS and FN + SS cultures demonstrated accelerated development with > 70% achieving > or = 8-cell stage. After 72 h, these culture conditions also significantly increased the proportion of embryos reaching the blastocyst stage but only TECC significantly increased the number of hatching blastocysts. Nuclei of the trophectoderm of unhatched and hatched blastocysts were stained with propidium iodide before fixing and labelling both the trophectoderm and inner cell mass with bisbenzimide. Blastocysts from the TECC contained a significantly higher total cell number (TCN) and trophectoderm and inner cell mass cell numbers than all other groups. These findings indicate equivalent improvements in mouse embryo development to the blastocyst stage in response to TECC, SS and FN and an enhanced number of cells and rate of hatching found only with TECC.

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.

Effects of induced hyperprolactinemia on in vitro fertilization cycles

OBJECTIVE

To investigate the effect of induced endogenous hyperprolactinemia on the luteinization process, as expressed by the shift in the P:E2 ratio after hCG injection in IVF cycles.

PATIENTS AND INTERVENTIONS

Serum PRL, E2, and P levels were measured in 49 IVF patients (leuprolide acetate and hMG protocol) on the day of hCG injection. Estradiol and P also were measured on the day after hCG. Serum P:E2 ratios were calculated for two groups of patients; group I (control): PRL < or = 20 ng/mL (conversion factor to SI unit, 1.00); group II (hyperprolactinemia): PRL > 20 ng/mL. Estradiol and P also were measured in follicular fluid (FF) and the gamete performance was compared between groups.

RESULTS

Data analysis showed no significant differences in the mean +/- SD serum peak E2 (pg/mL; conversion factor to SI unit, 3.671) between groups: group I, 1,769 +/- 843; group II, 2,333 +/- 1,194; the mean FF E2 (pg/mL) group I, 351 +/- 221; group II, 370 +/- 186; or the mean FF P (ng/mL; conversion factor to SI unit, 3.180) group I, 8,357 +/- 3,127; group II, 11,354 +/- 12,888. No significant differences were found between groups in the P:E2 ratios on days 1 or 2: group I, 78 +/- 48 and 209 +/- 137; group II, 70 +/- 47 and 224 +/- 197, respectively. The magnitude of the P shift also showed no significant difference between the two groups; the mean +/- SD shift in the P level was 2.9 +/- 2.2 for group I, and 4.3 +/- 5.1 for group II. The serum PRL level had no effect on the fertilization rate (60% for group I and 70% for group II) or on the pregnancy rate (17% for group I and 23% for group II).

CONCLUSION

These findings suggest that mild endogenous hyperprolactinemia induced by ovarian stimulation does not affect granulosa cell luteinization and gamete performance in humans.

The paternal inheritance of the centrosome, the cell's microtubule-organizing center, in humans, and the implications for infertility

Successful fertilization in humans, achieved when parental chromosomes intermix at first mitosis, requires centrosome restoration and microtubule-mediated motility. Imaging of inseminated human oocytes reveals that the sperm introduces the centrosome. The centrosome then nucleates the new microtubule assembly to form the sperm aster--a step essential for successful fertilization. Oocytes from some infertile patients failed to complete fertilization because of defects in uniting the sperm and egg nuclei, indicating that failure to properly effect the cytoplasmic motions uniting the nuclei results in human infertility. These discoveries have important implications for infertility diagnosis and managing reproduction.

Preoperative serum CA-125 and CA-72 in predicting endometriosis in infertility patients

CA-125, a high-molecular-weight glycoprotein antigen, has been identified as a possible marker for endometriosis, with discrepant results. CA-72, another glycoprotein antigen, is expressed by a variety of adenocarcinomas, including endometrial carcinoma. This controlled, prospective study evaluated serum CA-125 and CA-72 levels in 35 consecutive patients with endometriosis of varying stages and in patients without endometriosis. Serum CA-125 and CA-72 were measured with immunoradiologic methods prior to diagnostic laparoscopy for infertility evaluation. Endometriosis, scored by American Fertility Society guidelines, was identified in 19 patients, and 16 patients had normal pelvic findings. CA-125 and CA-72 levels were not different between patients with no pelvic disease (controls) and women with stage I-IV endometriosis. The positive predictive value of CA-125 was 0%; the negative predictive value was 47%. The positive predictive value of CA-72 was 5%; the negative predictive value was 53%. CA-72 and CA-125 are not helpful in the routine workup of the infertile woman to determine the likelihood that she has pelvic endometriosis.

Human chorionic gonadotropin levels in conception cycles after uterine and tubal embryo transfer

OBJECTIVE

To describe the rate of rise of beta-hCG levels in normal single gestations after uterine and tubal embryo transfer.

DESIGN

A prospective study from 1991 through 1992 in which infertility patients who conceived after ovulation induction and ET were monitored with serum beta-hCG levels.

SETTING

Infertility unit at Rush-Presbyterian-St. Luke's Medical Center in Chicago, Illinois.

PATIENTS

Ninety-eight women conceived after ovarian stimulation and ET. This study included only patients who conceived after uterine ET (n = 12) and tubal ET (n = 25) and had an exponential rise of beta-hCG levels and sonographic evidence of an intrauterine gestation.

RESULTS

The rate of rise of mean beta-hCG levels after ET preceded that of tubal ET by 24 hours until day 14 when the two approximate each other.

CONCLUSION

There appears to be a unique interaction between the trophoblast and endometrial surface that may account for the early detection of beta-hCG after uterine versus tubal ET.

Selective salpingography for the diagnosis and treatment of early tubal pregnancy

OBJECTIVE

To determine whether selective salpingography can accurately diagnose and treat patients with early ectopic pregnancies (EPs).

DESIGN

Prospective clinical case study.

SETTING

Selective salpingography was performed in an outpatient setting under i.v. sedation.

PATIENTS

Selective salpingography was performed in 10 women who had clinical presentation suggestive of EP, two consecutive abnormal hCG measurements < 2,000 mIU/mL, and inconclusive vaginal probe sonogram.

INTERVENTION

Selective salpingography was performed under fluoroscopy. A cervical cannula was placed, and the tubal ostium was cannulated with a curved selective salpingography catheter (Bard Gynecology and Radiology, Covington, GA). Methotrexate (MTX) (25 or 50 mg) was injected into the affected tube through the selective salpingography catheter.

MAIN OUTCOME MEASURE

The accuracy of selective salpingography in the diagnosis of early EP was determined by the rate of fluoroscopic imaging of an ampullary radiolucency upon injection of contrast material through the selective salpingography catheter. Resolution of the EP after injection of MTX into the tube was detected by serial declining hCG measurements.

RESULTS

Selective injection of contrast material into the fallopian tubes detected seven ampullary pregnancies in 10 patients. Two patients demonstrated neither tubal pregnancy nor intrauterine pregnancy. One patient with apparent bilateral proximal cornual occlusions on selective salpingography underwent laparoscopy, followed by salpingostomy of an ampullary pregnancy. All 7 patients who received MTX through the selective salpingography catheter completely resolved the EP. Four patients demonstrated patent fallopian tubes on hysterosalpingograms performed 3 to 6 months later.

CONCLUSION

Selective salpingography may diagnose early tubal pregnancies of some patients with equivocal clinical, laboratory, and sonographic findings. These patients can be successfully treated at the same time with a single dose of MTX delivered into the affected tube. Selective salpingography reduced the need for laparoscopy and operative intervention. Selective salpingography is a simple and relatively inexpensive diagnostic and therapeutic alternative in patients with suspected early tubal pregnancy.

Transvaginal ultrasonography and the assessment of luteal phase endometrium

OBJECTIVE

The goal of this study was to determine if ultrasonography of the endometrium could be used to identify in a noninvasive manner patients with luteal phase defects.

STUDY DESIGN

Patients underwent midluteal transvaginal ultrasonography with photographing of the endometrial image, an endometrial biopsy, and two serum hormonal profiles. The ultrasonographic images were graded and compared with the histologic results and the serum hormonal profiles.

RESULTS

There was a trend toward a higher grade image being associated with normal histologic studies. There was no significant difference between the mean hormonal profiles in patients with normal and those with abnormal biopsy specimens. There was no significant difference between the hormonal values drawn before and those drawn after the biopsies.

CONCLUSIONS

Although the endometrial appearance on ultrasonography appears to reflect secretory transformation, it cannot replace endometrial biopsy for full evaluation of luteal endometrial development. Short-term variability in serum concentrations of midluteal hormones was not demonstrated.

Hormonal profiles of early gestations with abnormal karyotype

OBJECTIVE

To describe the hormonal profiles of chromosomally abnormal pregnancies during the first trimester.

DESIGN

A prospective study from 1984 through 1990 in which infertility patients who conceived were monitored weekly with serum E2, P, and beta-hCG levels.

SETTING

The infertility practice at Rush-Presbyterian-St. Luke's Medical Center in Chicago, Illinois.

PATIENTS

Study included 15 women who had dilatation and curettage for first trimester fetal losses with confirmed abnormal karyotype, 6 women with chromosomally normal male abortuses, and 60 consecutive women whose pregnancies yielded normal term infants.

RESULTS

After natural conception, E2 demonstrated a moderate rise in both normal and chromosomally abnormal pregnancies to approximately 300 pg/mL by day 29 (6 weeks of gestation). In normal gestations, E2 continued a steady increase to exceed the level of 1,000 pg/mL by day 64 (11 weeks of gestation). In chromosomally abnormal pregnancies, the mean E2 plateaued and remained at approximately 200 pg/mL until fetal demise was noted. In stimulated conceptions, the rise of E2 was sharp and early (1,200 pg/mL by day 29); in normal pregnancies, E2 steadily increased to an average of 1,400 pg/mL by the end of the first trimester, whereas in karyotypically abnormal gestations, E2 declined to approximately 200 pg/mL by day 64. In pregnancies yielding a male abortus, a sharp decline and plateau at 800 pg/mL by day 56 (10 weeks of gestation) was observed. In both natural and stimulated normal pregnancies, hCG levels first demonstrated a linear rise, followed by a curvilinear increase from day 29 until day 56, with a peak of approximately 110,000 mIU/mL. The beta-hCG in chromosomally abnormal pregnancies, as well as in pregnancies yielding a male abortus, was characterized by a slow and gradual rise to a maximum of 40,000 mIU/mL, which remained relatively linear until day 64 when fetal demise was detected in all cases. Progesterone level data were excluded from analysis because of frequent P supplementation.

CONCLUSIONS

There were significant differences in the hormonal profiles of chromosomally normal and abnormal pregnancies. Serial measurements of serum E2 and beta-hCG from the 6th week of gestation may be useful in predicting an abnormal karyotype sooner than other current diagnostic tests.

Acrosin activity in human spermatozoa in relation to semen quality and in-vitro fertilization

Acrosin, a sperm proteinase released during acrosomal exocytosis, facilitates penetration through the oocyte vestments. The purpose of this investigation was to determine if a correlation exists between the acrosin activity of ejaculated human spermatozoa, before motility enrichment techniques, and in-vitro fertilization (IVF) success using selected (glass wool or swim-up) spermatozoa. Since all the oocytes were retrieved from women receiving exogenous hormonal stimulation and a mixed population of mature and immature oocytes were encountered, only cases with > or = 50% mature oocytes were analysed. Under these conditions, the acrosin activity was significantly greater (P < 0.01) in the ejaculates in which spermatozoa ultimately fertilized > or = 70% of the mature oocytes, than in the ejaculates in which spermatozoa ultimately fertilized < 70% of the mature oocytes. Furthermore, a strong correlation (r = 0.962, P = 0.0001) was detected between pre-IVF acrosin activity and subsequent high (> or = 70%) IVF success. Acrosin activity from normozoospermic and oligo-asthenozoospermic men was also compared and was significantly (P < 0.01) higher for the normozoospermic group. These data suggest that measurement of acrosin activity may be a valuable clinical laboratory assay for assessing the sperm fertilizing potential and that low acrosin activity is associated with abnormal semen characteristics.

Human chorionic gonadotropin rise in normal and vanishing twin pregnancies

OBJECTIVE

The purpose of the study was to describe and to compare the rate of rise of human chorionic gonadotropin (hCG) in vanishing twin and normally progressing twin pregnancies during the first trimester.

DESIGN

All patients with twin pregnancies between 1985 and 1989 were prospectively studied. Human chorionic gonadotropin was measured one to three times per week between days 12 and 52 after luteinizing hormone (LH) surge or day of hCG administration (day 0). Pelvic ultrasound (US) was performed weekly beginning on day 24.

SETTING

The study was performed at Rush-Presbyterian-St. Luke's Medical Center in an academic private practice setting of the Section of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology.

PATIENTS

Forty patients who conceived after treatment of infertility and who had two gestational sacs on US examination were included in the study after the following criteria were met: (1) both sacs progressed to exhibit a fetal pole and (2) day of LH surge and/or day of hCG administration was known.

MAIN OUTCOME MEASURE

The rate of rise of hCG was slower in vanishing twin pregnancies than in normally progressing twin gestations for the entire time period studied (P less than 0.05).

RESULTS

A vanishing twin occurred in one third of the twin pregnancies. Forty-six percent of these losses occurred after fetal heart activity had been established.

CONCLUSIONS

Vanishing twin phenomenon occurred in a large proportion of twin pregnancies in this infertility population. Fetal heart activity was not a reliable predictor of continuing fetal viability in early twin gestations. Vanishing twin conceptions were characterized by a slower rate of rise of hCG than normally progressing twin pregnancies.

Progesterone:estradiol ratios at implantation in ongoing pregnancies, abortions, and nonconception cycles resulting from ovulation induction

The purpose of this study was to compare progesterone (P):estradiol (E2) ratios after ovulation induction at the time of implantation in cycles resulting in ongoing pregnancies or abortions and in nonconception cycles. Material included 43 stimulated conception cycles, 29 with human menopausal gonadotropins (hMG) and human chorionic gonadotropins (hCG), 14 with clomiphene citrate (CC) with or without hCG, and 28 nonconception cycles (13 hMG and hCG, 15 CC with or without hCG). Midluteal P and E2 were measured and expressed in ng/mL. There were no differences in P:E2 ratios (mean +/- SE) for ongoing pregnancies after hMG and hCG (n = 20, 112.6 +/- 14.9), CC and hCG (n = 6, 97.0 +/- 15.9), or CC alone (n = 5, 96.2 +/- 25.5), and the data were pooled. Progesterone:estradiol ratios in 31 ongoing pregnancies and 28 nonconception cycles were 107.0 +/- 10.7 and 115.2 +/- 12.5, respectively, both significantly higher than in 12 abortions (64.5 +/- 13.2).

IN CONCLUSION

(1) P:E2 ratios at the time of implantation were similar after CC with or without hCG and hMG and hCG treatment; (2) high luteal P:E2 ratio was associated with ongoing pregnancies; and (3) lower P:E2 ratio was seen in cycles leading to spontaneous abortion.

Ovarian suppression induced with Buserelin or danazol in the management of endometriosis: a randomized, comparative study

The effectiveness of Buserelin (Hoechst-Roussel Pharmaceuticals, Inc., Somerville, NJ) (0.2 mg subcutaneously [SC] or 1.2 mg intranasally [IN] per day) and danazol (800 mg per day) in inducing ovarian suppression for the management of endometriosis was compared in a prospective randomized study. During 6 months of treatment, peripheral follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol concentrations were suppressed to a similar degree in both groups. Symptomatic improvement and laparoscopically assessed regression of endometriotic lesions also were comparable. After treatment, 8 of 18 infertile women treated with Buserelin and 5 of 8 treated with danazol conceived. General and hypoestrogenic side effects were similar in both groups, while androgenic and anabolic were more frequent with danazol. High density lipoprotein (HDL)-cholesterol increased in the Buserelin and decreased in the danazol group. The study indicates that at the dose tested, buserelin and danazol induce a similar degree of ovarian suppression resulting in a comparable clinical improvement and regression of endometriotic lesions.

A randomized, prospective comparison of endocrine changes induced with intranasal leuprolide or danazol for treatment of endometriosis

A prospective, randomized trial compared hormonal changes induced with intranasal leuprolide 1.6 mg/day to danazol 800 mg/day for treatment of endometriosis. Both regimens induced anovulation and ovarian suppression in all subjects. Mean estradiol (E2) and progesterone (P) levels were suppressed with both regimens, but were lower with leuprolide. There was no difference in cumulative follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels, although at times during treatment mean levels of these hormones were lower with leuprolide. Higher P levels in the danazol group, most likely of adrenal origin, indicated a suppressive effect on adrenal steroidogenesis. Symptomatic improvement was significant in both groups. Laparoscopy after treatment also demonstrated a decrease in endometriosis scores in both groups. At 12 months after treatment, cumulative pregnancy and live birth rates were similar in both groups. Leuprolide offers an attractive alternative to danazol for the medical treatment of endometriosis.

Danazol but not gonadotropin-releasing hormone agonists suppresses autoantibodies in endometriosis

The effect of treatment with danazol (n = 10) or gonadotropin-releasing hormone agonists (GnRH-a) (n = 10) on autoantibody (AA) production (IgG, IgM and, IgA to 6 phospholipids, 5 histones, and 4 polynucleotides) in endometriosis was evaluated blindly in a longitudinal, prospective, randomized study. Clinical improvement, ovarian suppression, and resolution of endometriosis were comparable in both groups. Approximately 50% of patients had significant AA abnormalities initially. During treatment with danazol but not GnRH-a, AA gradually decreased in concentration and in number/patient. Total immunoglobulin levels (IgG, IgM, and IgA) also decreased only in the danazol group. This study indicates that danazol, but not GnRH-a, lowers abnormal AA associated with endometriosis.

Occult ovulatory dysfunction in women with minimal endometriosis or unexplained infertility

Characteristics of follicular development and hormonal patterns were evaluated in 17 women with minimal endometriosis and 11 with unexplained infertility. The controls were 7 women with male factor infertility and 8 who conceived during an investigational cycle. Women with minimal endometriosis had more and smaller follicles at luteinizing hormone (LH) surge, lower preovulatory estradiol (E2), and lower E2 at LH surge. Women with unexplained infertility had lower LH surges and a trend to a shorter follicular phase. Occult ovulatory dysfunction and may contribute to infertility in women with minimal endometriosis or unexplained infertility.

Microsurgical enucleation of tripronuclear human zygotes

Polyspermic fertilization of human oocytes in vitro produces genetically abnormal embryos whose replacement in utero represents a potential obstetrical risk. Microsurgical removal of extra male pronuclei offers the possibility that normal ploidy can be restored in these zygotes. Pronuclear removal was attempted in three tripronuclear human oocytes fertilized in vitro. Male pronuclei were distinguished by their larger size and an associated sperm tail piece. Zygotes were pretreated with cytochalasin B and colcemid in phosphate-buffered saline before microsurgery. Enucleation was completed in all embryos; syngamy occurred in one embryo, but cleavage was not observed.

High progesterone/estradiol ratio in follicular fluid at oocyte aspiration for in vitro fertilization as a predictor of possible pregnancy

Eighteen women undergoing in vitro fertilization (IVF) procedures were studied. All had optimal (900 to 1600 pg/ml) peak serum estradiol (E2) response to the same stimulation regimen with clomiphene citrate and menotropins; fertilization rate was above 64%; and two to four embryos in two to eight cell stages were replaced in each patient. All were considered to have optimal chances for conception. The authors compared progesterone (P), E2, and P/E2 ratio in serum and follicular fluid (FF) at the time of oocyte aspiration in eight patients who conceived (group I) and ten who did not (group II). Mean serum P and E2 levels and serum P/E2 ratio were not significantly different between the groups. In contrast, mean FF P concentrations (ng/ml) were significantly (P less than 0.05) higher in group I (9721 versus 5385), as was FF P/E2 ratio (19.0 versus 11.8; P less than 0.02). There was no significant difference in mean FF E2 concentrations between the groups. These data indicate that in IVF cycles with optimal serum E2 response to the stimulation protocol, FF P and P/E2 ratio at the time of oocyte aspiration may be predictive of subsequent implantation and pregnancy.

Bone mineral density in women with endometriosis before and during ovarian suppression with gonadotropin-releasing hormone agonists or danazol

Lumbar bone mineral density (BMD) was evaluated by dual photon absorptiometry (DPA) in 38 women with laparoscopically diagnosed and staged endometriosis. DPA was performed before and at the completion of 26 weeks of treatment with either gonadotropin releasing hormone agonist (GnRHa) or danazol. Twenty-five women received GnRHa either nasally or subcutaneously and 13 women received danazol 200 mg four times daily by mouth. During treatment amenorrhea and suppressed estradiol levels were observed in all patients. Each patient took a supplement of oral calcium 1 gm daily. DPA (reproducibility +/- 1.5%) was read by a single observer unaware of the treatment assignment of the patient. The mean (+/- standard error) of the entire group prior to treatment was 98.8% +/- 0.03% of a control population of women from the same geographic area matched for race, age, and weight. At the completion of treatment, BMD was slightly decreased in the GnRHa group and marginally increased in the danazol group but neither change was significant. Women with endometriosis have lumbar BMD in the normal range and ovarian suppression with either GnRHa or danazol produces no significant change in BMD.

Cryopreservation of in vitro-fertilized human embryos: histologic and cytogenetic analysis of an ectopic conceptus

In this study, 39 embryos from 17 patients were cryopreserved in a Planer R204 cell freezer using the protocol of Mohr et al. (J Vitro Fert Embryo Transfer 2:1-10, 1985). The procedure was modified by supplementing the cryoprotectant with 10% heat-inactivated and filtered (0.22 micron) maternal serum instead of fetal calf serum, and embryos were frozen in 500-microliter plastic straws instead of glass ampoules. After 12-25 weeks of storage in liquid nitrogen, 12 embryos from six patients were thawed at 8.0 degrees C min to room temperature, incubated in 75% maternal serum with Ham's F-10, and replaced in utero. One pregnancy occurred. The patient was a 34-year-old nulligravida with occluded fallopian tubes. A year prior, she conceived triplets from three embryos during an in vitro fertilization (IVF) cycle, but she delivered at 21 weeks and the infants did not survive. The second IVF attempt produced four embryos. Two were replaced during the IVF cycle, but they did not implant. Two were cryopreserved and replaced 25 weeks later. On day 28 after replacement, beta human chorionic gonadotropin (beta-hCG) was 4126 IU, but there was no gestational sac in utero on ultrasonographic examination. Laparoscopy disclosed a right tubal pregnancy which was removed with the fallopian tube. Histological examination demonstrated normal chorionic villi. The chromosomal pattern was 46 XX by direct analysis and cell culture.

Persistent ovarian cysts following administration of human menopausal and chorionic gonadotropins: an attenuated form of ovarian hyperstimulation syndrome

Ovarian cysts persisting after the onset of menses were demonstrated by ultrasound (US) in 40 of 71 (56%) nonconception cycles following ovulation induction with human menopausal gonadotropins (hMG) and human chorionic gonadotropin (hCG). Persistent cysts were self-limited and all resolved spontaneously within two cycles. They developed more frequently during stimulation cycles with (1) higher mean pre-hCG serum estradiol (E2), (2) a greater number of medium and large follicles at peak pre-hCG E2, and (3) a larger leading follicle diameter at peak pre-hCG E2. Persistent ovarian cysts frequently occurred despite a peak pre-hCG E2 lower than 1000 pg/ml. Although ovarian enlargement in the presence of cysts exceeded 5 X 5 cm in 25% of cases, no patient developed clinical symptoms of ovarian hyperstimulation syndrome (OHSS). Repeated induction of ovulation with hMG/hCG in the presence of nonfunctional, persistent cysts resulted in pregnancies in 6 of 15 cases (40%). Asymptomatic persistent ovarian cysts frequently follow an hMG/hCG regimen and, when nonfunctional, are not a contraindication to repeated ovarian stimulation. Persistent ovarian cysts appear to be an attenuated form of OHSS.

Successful use of gonadotropin-releasing hormone agonist leuprolide for in vitro fertilization in a patient with polycystic ovarian disease and infertility unresponsive to standard treatment

A patient with PCO and primary infertility had undergone numerous failed attempts of ovulation induction. She then was treated with GnRHa leuprolide 500 micrograms subcutaneously daily for 4 weeks, later combined with hMG 225 IU IM daily for 8 days and hCG 5000 IU IM. Six oocytes were retrieved for IVF, four fertilized and two were replaced. Twin pregnancy was established and delivered at term. Hyperstimulation syndrome was managed conservatively.

Rhesus monkey sperm penetration into zona-free hamster ova: comparison of preparation and culture conditions

A major problem in development of nonhuman primate in vitro fertilization is the selection of donor males and repeated collection of consistent sperm samples. In practice, collection of a viable semen sample is highly dependent on operator technique and the type of animal restraint. We report an updated method for semen collection from the rhesus monkey (Macaca mulatta), use of TES-Tris (TEST) Yolk Buffer (TYB) for prolonged sperm storage and improved results of hamster ovum penetration assay. Semen was obtained from adult males restrained with 2.0 mg/kg IM ketamine hydrochloride prior to direct penile stimulation (Grass SD-9, frequency 150, delay 9, duration 7, volts 12-18, repeat mode, twin pulse). Liquified semen was washed and centrifuged twice at 100 X g for 5 min in BWW, Ham's F-10 and TALP and allowed to swim-up 60 min at 37 degrees in 5% CO2 and air. Alternatively, semen was mixed 1:1 with TYB, refrigerated 20 h at 4 degrees C, centrifuged at 100 X g for 5 min, and the pellet resuspended in 1.0 ml of TALP or BWW prior to use. Hamster ova penetration was achieved with capacitated macaque sperm. Penetration was significantly improved (P less than .001) with preincubation in TYB followed by resuspension in TALP (79%).

Mild endometriosis and ovulatory dysfunction: effect of danazol treatment on success of ovulation induction

The effectiveness of ovulation induction with clomiphene citrate or human menopausal gonadotropins was evaluated in 52 infertile women with stage I or stage II endometriosis and ovulatory dysfunction: anovulation or luteinized unruptured follicle (LUF) syndrome before (group I) and after (group II) danazol treatment. The incidence of anovulation and LUF in the endometriosis population was 9% and 34%, respectively. In group I, 10 of 36 patients (27.8%) conceived, with an average of 17.6 induction cycles per pregnancy. In group II, 21 of 30 patients (70%) conceived, with an average of 4.5 cycles per pregnancy (difference significant at P less than 0.001). There was no difference in the average number of ovulation induction cycles per patient between groups I and II (4.9 and 3.1, respectively). Of 14 patients who did not conceive in group I and crossed over to group II, 9 (64.3%) conceived (not different from group II). Spontaneous abortion rates were 20% in group I and 14% in group II. These results indicate that mild endometriosis may interfere with conception through mechanisms other than ovulatory dysfunction and that treatment with danazol appears to more than double the fertility rate.

Effect of heterologous seminal plasma on the fertilizing capacity of human spermatozoa as assessed by the zona-free hamster egg test

The spermatozoa from 8 of 27 men showed a major increase (greater than 15%) in the oocyte penetration rate, the spermatozoa from 7 men showed a major decrease (less than 15%), and no major changes were noted in the other men when the spermatozoa were washed and preincubated with heterologous seminal plasma for 20 minutes before assessing their activity in the zona-free hamster egg assay. No difference was noted in motility or forward progression between the test and control spermatozoa. The increase or decrease in the oocyte penetration rate was consistent for all the ejaculates of a donor; i.e., a donor whose sperm showed an increase in the rate never showed a decrease, and vice versa. Additionally, the oocyte penetration rate of "epididymal-like" spermatozoa, obtained by ejaculation of the first fraction of a semen sample into a large volume of buffer, was enhanced when the spermatozoa were preincubated in their own seminal plasma, obtained from the other fraction of the ejaculate. It is concluded that seminal plasma can have a beneficial influence on the oocyte-penetrating capacity of spermatozoa that is independent of an effect on motility. However, the influence is probably often masked by the presence of antifertility factors in seminal plasma. The penetration-enhancing factor of seminal plasma has a molecular weight of less than 10,000, is quite heat-labile, but is stable at 4 degrees C. The penetration-enhancing factor is somewhat less stable at -20 degrees C and is unstable to lyophilization and reconstitution in H2O. Fertil Steril 40:512, 1983.

Sperm interaction with the zona-free hamster egg

The interaction of sperm with the zona-free hamster egg was studied. Hamster sperm were capacitated in Tyrodes media, containing 50% heat-inactivated serum and used to inseminate zona-free eggs in BWW containing 10% serum. Capacitated sperm began fusing with eggs within the first hour of insemination and by 3 h penetration had ceased as indicated by the absence of further changes in the mean number of sperm incorporated per egg. Penetration by capacitated hamster sperm was linearly related to the log of the motile sperm concentration at concentrations above 10(4) cells/ml. The viability of sperm and eggs in culture was limited in these studies to approximately 3-5 h. The existence of a block to unlimited sperm penetration of the zona-free egg was sought in reinsemination experiments. A relatively low sperm concentration was used to initiate egg responses, followed, at timed intervals, by reinsemination with a high challenge concentration of sperm. Subsequent polyspermy levels reflected the presence or absence of the egg's block to polyspermy response. In order to circumvent the problems arising from the rapid aging of hamster sperm in culture, mouse sperm were employed, a convenience afforded by the lack of species specificity in this egg. Reinseminated eggs incorporated additional sperm during the challenge; therefore, the hamster egg is not capable of preventing unlimited sperm penetration. The implications of these findings to the use of the zona-free hamster egg test in fertility evaluation is discussed.

The effect of albumin gradients and human serum on the longevity and fertilizing capacity of human spermatozoa in the hamster ova penetration assay

The motility and the capability to penetrate zona-free hamster eggs of Y-enriched or washed sperm were evaluated after protracted in vitro incubation with and without the addition of preheated human serum. The addition of 50% preheated serum decreased the motility loss over time for both the washed and Y-enriched sperm. Such motility loss was decreased by 25% and 27% at 20 hours, by 31% and 39% at 30 hours, and by 30% and 40% at 40 hours of incubation for the washed and Y-enriched sperm, respectively. The washed and Y-enriched sperm suspensions with and without addition of preheated human serum achieved 100% penetration rate after 2 hours of preincubation. However, when scored by the sperm per egg ratio, washed sperm achieved 1.2 +/- 0.2 (mean +/- standard error [SE]) sperm per egg, while the Y-enriched sperm achieved 3.0 +/- 0.4 sperm per egg. After 24 hours of incubation, penetration by washed sperm decreased to a mean of 62.8%. The Y-enriched sperm penetrated a mean of 18% of the ova. Addition of preheated serum increased the egg penetrating capacity of washed sperm at 24 hours but failed to improve the Y-enriched spermatozoa. This study suggests that for optimum conception rates, precise ovulation timing is crucial when Y-enriched fractions are used for insemination.

Penetration of the zona-free hamster egg by human sperm

Human sperm become capable of penetrating zona-free hamster eggs after preincubation in an appropriate culture medium. This observation has led to the development of an assay for characterizing the fertilizing capacity of human spermatozoa. In the present study, the incorporation of sperm by zona-free hamster eggs was quantitated, and several parmeters that contribute to penetration were evaluated. The importance of the motile sperm concentration was established; no penetration was seen at concentrations lower than 6 x 10(5) motile cells/ml, whereas above this level the mean number of incorporated sperm per egg was linearly related to concentration. Freeze-thawed sperm, although capable of penetrating zona-free hamster eggs, did so with lesser frequency than did fresh sperm at equal concentrations of motile sperm. Kinetic experiments indicated that eggs were maximally penetrated after 5 hours of exposure to capacitated sperm and that the cessation in sperm incorporation seen at this time resulted from egg-related changes that occurred during aging in vitro. A protocol for evaluating "fertilizing capacity" of human sperm samples was outlined incorporating the findings from the present study. Using these conditions, reproducible penetration levels were obtained when several ejaculates obtained from the same donor over a 3-month interval were tested at similar motile sperm concentrations.

In-vitro maturation and penetration of mouse primary oocytes after removal of the zona pellucida

The spontaneous maturation of intact, cumulus-free and zona-free oocytes of the mouse was studied in complex and in simple media. The rates and frequencies of maturation from the germinal vesicle to the metaphase II stage were similar for all oocytes, indicating that these investments are not critical to maturation. The penetration characteristics of zona-free oocytes were examined; before germinal vesicle breakdown (GVB), evidence for penetration was obtained only when the ionophor, A23187, was included in the medium. After GVB, oocytes readily incorporated spermatozoa and were usually polyspermic when inseminated with 10(5) capacitated epididymal spermatozoa/ml. The kinetics of sperm incorporation indicated that primary oocytes were capable of a plasmalemma block to penetration similar to that seen with tubal eggs.