Biopsy-induced inflammatory conditions improve endometrial receptivity: the mechanism of action

A decade ago, we first reported that endometrial biopsy significantly improves the success of pregnancy in IVF patients with recurrent implantation failure, an observation that was later confirmed by others. Recently, we have demonstrated that this treatment elevated the levels of endometrial pro-inflammatory cytokines and increased the abundance of macrophages (Mac) and dendritic cells (DCs). We therefore hypothesised that the biopsy-related successful pregnancy is secondary to an inflammatory response, and aimed at deciphering its mechanism of action. Supporting our hypothesis, we found that the pro-inflammatory TNFα stimulated primary endometrial stromal cells to express cytokines that attracted monocytes and induced their differentiation into DCs. These monocyte-derived DCs stimulated endometrial epithelial cells to express the adhesive molecule SPP1 (osteopontin (OPN)) and its receptors ITGB3 and CD44, whereas MUC16, which interferes with adhesion, was downregulated. Other implantation-associated genes, such as CHST2, CCL4 (MIP1B) and GROA, were upregulated by monocyte-derived Mac. These findings suggest that uterine receptivity is mediated by the expression of molecules associated with inflammation. Such an inflammatory milieu is not generated in some IVF patients with recurrent implantation failure in the absence of local injury provoked by the biopsy treatment.

Mitochondrial DNA STR analysis as a tool for studying the green sea turtle (Chelonia mydas) populations: the Mediterranean Sea case study

The Mediterranean population of the green sea turtle Chelonia mydas is critically endangered. Genetic analysis of this population using the ordinary haplotyping system, based on sequence analysis of a segment of the mitochondrial DNA (mtDNA) D-loop (control region), revealed very little variation. The most common haplotype, CM-A13, was observed in all but three individuals in hundreds of samples in previous studies. In search for a more informative marker we sequenced the 3' of the mitochondrial control region which contains an AT-rich microsatellite. We found a unique pattern that consists of four AT short tandem repeats (STRs) with varying copy numbers. This allowed us to construct a new haplotyping system composed of four different STR sizes for each mtDNA sequence. Our new mitochondrial STR (mtSTR) haplotyping approach revealed 33 different haplotypes within the nesting and stranded sea turtles along the Mediterranean Israeli seashore. The Israeli coast nesting females had 10 different haplotypes that can be used for monitoring and conservation purposes. The mtSTR haplotyping system can clearly assist in fingerprinting of individual turtles. Moreover, it can be used for estimating phylogenetic distances within populations. This case study shows that the mtSTR haplotyping is applicable for the study of global green sea turtle populations and could also be considered as markers of genetic variability in other species.

The use of recombinant human LH (lutropin alfa) in the late stimulation phase of assisted reproduction cycles: a double-blind, randomized, prospective study

BACKGROUND

The effect of recombinant human LH (r-hLH; lutropin alfa) in women undergoing controlled ovarian stimulation with recombinant human FSH (r-hFSH) prior to IVF was investigated.

METHODS

After down-regulation with the GnRH agonist, buserelin, 114 normo-ovulatory women (aged 18-37 years) received r-hFSH alone until the lead follicle reached a diameter of 14 mm. Patients were then randomized in a double-blind fashion to receive r-hFSH in addition to r-hLH, 75 IU s.c., or placebo daily for a maximum of 10 days prior to oocyte retrieval and IVF. The primary end-point was the number of metaphase II oocytes.

RESULTS

There were no significant differences between treatment groups for the primary end-point. Serum estradiol concentrations on the day of HCG administration were significantly higher in the group receiving r-hLH plus r-hFSH than in the group receiving r-hFSH alone (P = 0.0001), but there were no significant differences between the groups in dose and duration of r-hFSH treatment required, oocyte maturation, fertilization rate, pregnancy rate and live birth rate.

CONCLUSION

In this patient population, the addition of r-hLH during the late follicular phase of a long GnRH agonist and r-hFSH stimulation cycle provides no further benefit in terms of oocyte maturation or other end-points.

Temporal analysis of connexin43 protein and gene expression throughout the menstrual cycle in human endometrium

OBJECTIVE

To analyze the pattern of connexin43 gene and protein expression in human endometrium throughout the menstrual cycle.

DESIGN

Controlled clinical study.

SETTING

An academic research center.

PATIENT(S)

Women with 28-day menstrual cycles who had mechanical infertility and failed to conceive after IVF treatment.

INTERVENTION(S)

Endometrial and blood samples were collected on days 8, 12, 14, 21, and 25 of spontaneous menstrual cycles.

MAIN OUTCOME MEASURE(S)

Endometrial expression of connexin43 protein and messenger RNA, endometrial thickness, and serum concentrations of gonadotropins and steroids.

RESULT(S)

The expression of connexin43 gene and protein decreased on day 12 and day 14 of the menstrual cycle and then increased on day 21 and day 25, respectively. A serum LH surge accompanied by a peak in the FSH concentration was observed on days 12-14. The progesterone concentration increased on days 21-25, but there was no significant change in the E2 concentration. The thickness of the endometrium increased between days 8 and 12 and did not change further between days 21 and 25.

CONCLUSION(S)

The expression of connexin43 gene and protein in human endometrium changes during the menstrual cycle in a pattern that is associated with the secretion of LH, FSH, and progesterone. This pattern may serve as a marker for implantation competence.

Ovarian hyperstimulation following the sole administration of agonistic analogues of gonadotrophin releasing hormone

Ovarian hyperstimulation following the sole administration of gonadotrophin-releasing hormone agonists (GnRHa) is exceedingly rare. We hereby report on two infertile patients undergoing in-vitro fertilization-embryo transfer who developed ovarian hyperstimulation under such circumstances. In both patients, GnRHa were administered using the 'long protocol' regimen. The first patient developed ovarian hyperstimulation on two occasions, with mid-luteal depot administration of triptorelin and with early follicular triptorelin, administered as daily subcutaneous injections. In both cycles, within 2 weeks of triptorelin therapy, massive ovarian multifollicular enlargement occurred, concomitant with high serum oestradiol concentrations, which resolved spontaneously following expectant management. The second patient developed ovarian hyperstimulation following daily injections of leuprolide acetate starting at the mid-luteal phase. The final stage of ovulation was triggered by human chorionic gonadotrophin (HCG) and 11 oocytes were retrieved. In-vitro fertilization resulted in embryo formation, but failed to result in pregnancy. The same phenomenon recurred in a subsequent cycle despite preventive pretreatment with an oral contraceptive. A negative GnRH test, performed just before HCG administration, suggested than an ongoing 'flare-up effect' was unlikely to cause ovarian stimulation. Ovarian hyperstimulation can occur following the sole administration of GnRHa irrespective of the preparation used and the administration protocol. Although spontaneous resolution is the rule, once this condition has developed, HCG administration and oocyte retrieval are feasible. This rare entity probably represents an exaggerated form of ovarian cyst formation following GnRHa administration, the underlying pathophysiology of which remains unresolved.

Ovarian stimulation and in vitro fertilization in women with mature cystic teratomas

OBJECTIVE

To report the results of ovulation induction and in vitro fertilization-embryo transfer (IVF-ET) in patients with ovarian cystic teratomas.

METHODS

Six women with ultrasonographically diagnosed ovarian cystic teratomas (mean diameter 2.4 cm) who presented with infertility underwent IVF-ET (n = 4) or ovulation induction (n = 2). Serial ultrasound examinations were used to determine the size of the cystic teratomas during therapy and throughout pregnancy.

RESULTS

Ovarian stimulation was successful, as evidenced by the serum estradiol concentration on the day of hCG administration (mean in IVF-ET patients, 3558+/-1319 pg/mL) and the number of oocytes retrieved (10+/-4.24). Three patients having IVF-ET and both patients having ovulation induction conceived, and six healthy infants were born. Cyst sizes remained unchanged throughout treatment and pregnancy. There were no cyst-related complications during ovulation induction or IVF-ET, or during the entire course of pregnancy, labor, and delivery.

CONCLUSION

The presence of ovarian cystic teratoma should not be considered a contraindication for therapy in women undergoing ovulation induction and IVF-ET.

Induction of Ad4BP/SF-1, steroidogenic acute regulatory protein, and cytochrome P450scc enzyme system expression in newly established human granulosa cell lines

We have established immortalized human granulosa cells by triple transfection of primary cells obtained from in vitro fertilization patients with SV40 DNA, Ha-ras oncogene, and a temperature sensitive (ts) mutant of the tumor suppressor gene p53 (p53val135). Forty-one clones were isolated, and their steroidogenic responses were analyzed. While all the cell lines proliferate rapidly and show only traces of progesterone production, upon stimulation with 50 microM of forskolin (FK), which elevates intracellular cAMP, they become steroidogenic as evidenced by progesterone production. The steroidogenic response of the cell lines was stable even after 20 generations and several cycles of freezing and thawing. A highly responsive cell line (HO-23) was further examined for characteristics of the steroidogenic response. Cells stimulated with FK and 8-Br-cAMP produced high levels of pregnenolone, progesterone, and 20alpha-hydroxy-4-pregnen-3-one (20alpha-OH-progesterone) comparable with amounts produced by highly differentiated primary human granulosa-luteal cells. Hydrocortisone and dexamethasone highly augment the cAMP-stimulated progesterone production, whereas testosterone and PRL enhanced cAMP-induced progesterone synthesis only moderately. Estradiol, insulin-like growth factor I, and insulin showed no significant effect on cAMP-induced steroidogenesis. The phorbol ester TPA, and basic fibroblast growth factor, dramatically suppress cAMP-induced production of progesterone, whereas bovine corneal endothelial cell ECM (BCE/ECM) enhanced cAMP-induced progesterone and antagonized basic fibroblast growth factor suppression of cAMP-induced steroidogenesis. Steroidogenic factor 1 (Ad4BP/SF-1) was expressed in control cells, and its expression was augmented by FK, whereas the steroidogenic acute regulatory protein showed low expression in the nonstimulated cells but was clearly elevated upon cAMP stimulation and was slightly decreased by TPA in cAMP-stimulated cells. Expression of the electron carrier adrenodoxin (ADX), which is a part of the cytochrome P450scc enzyme system, was very low in nonstimulated cells but was dramatically elevated in FK- and 8-Br-cAMP-stimulated cells, whereas no reduction of ADX was evident in cells costimulated with FK and TPA. Immunocytochemical studies revealed a weak staining of ADX in mitochondria of nonstimulated cells and intensive staining in highly clustered mitochondria of FK- or 8-Br-cAMP-stimulated cells. Only moderate reduction in ADX staining was evident in cells costimulated with FK and TPA. These unique cell lines can provide a useful model for the investigation of induced steroidogenesis in human granulosa cells.

Is hydrosalpinx fluid cytotoxic?

Accumulation of oviductal fluid in the ampullar lumen as a result of occlusion of the infundibulum is referred to as hydrosalpinx. A low pregnancy rate (10%) after in-vitro fertilization (IVF) in hydrosalpinx patients and a relatively high incidence (50%) of abortions during the first trimester suggested that leakage of this fluid into the uterine cavity may exert a cytotoxic effect on the developing embryo. To examine this possibility, we analysed the composition of the hydrosalpinx fluid and tested its effect on human granulosa cells and embryos. Hydrosalpinx fluids and granulosa cells were collected from IVF patients at ovum pick-up. IVF eggs containing three pronuclei (3PN) were employed for this study. Analysis of hydrosalpinx fluids revealed electrolyte concentrations similar to those in serum with lower amounts of total protein and albumin. No blood cells were detected and bacterial cultures were negative. Granulosa cells incubated in hydrosalpinx fluid-containing medium (diluted 1:1) were not morphologically different and showed a steroidogenic capacity that was higher than that of cells incubated in its absence. Fertilized 3PN eggs incubated in IVF culture medium successfully developed into 6- to 8- and 8- to 16-cell embryos within 48 and 72 h, respectively. This rate of embryonal development was not impaired by hydrosalpinx fluid (at either 50 or 100% concentration). In the absence of a demonstrable detrimental effect we suggest that the low implantation rate in hydrosalpinx IVF patients may not be due to an embryotoxic effect. We further suggest that constant passage of fluid into the uterine cavity in these patients could possibly introduce some mechanical interference that may result in implantation failure.

Acute changes in endometrial thickness after aspiration of functional ovarian cysts

OBJECTIVE

To evaluate the influence of aspiration of functional ovarian cysts on endometrial thickness.

DESIGN

Prospective study.

SETTING

An IVF Unit of an academic medical center.

PATIENT(S)

Twenty-two patients from our IVF program, in whom administration of a gonadotropin-releasing hormone agonist preparation in the "long protocol" failed to induce pituitary desensitization, as evidenced by a serum E2 concentration of >55 pg/mL and the presence of an ovarian cyst of >20 mm in diameter.

INTERVENTION(S)

Transvaginal ultrasonographic-guided cyst aspiration was performed, and 2 days later, serum E2 concentration and endometrial thickness were reassessed.

MAIN OUTCOME MEASURE(S)

The values of serum E2 concentration and endometrial thickness before and after cyst aspiration were compared.

RESULT(S)

Two days after ovarian cyst aspiration, the serum E2 concentration dropped from a mean (+/-SD) of 203 +/- 93 to 37 +/- 34 pg/mL. The mean (+/-SD) endometrial thickness was 9.6 +/- 2.0 mm before cyst aspiration and decreased to 5.9 +/- 2.4 mm after the procedure.

CONCLUSION(S)

Within 48 hours after ovarian cyst aspiration, a significant reduction in endometrial thickness occurs concomitant with a sharp decline in serum E2 levels. The phenomenon of acute reduction in endometrial thickness in response to acute estrogen withdrawal has not been described previously. The exact mechanism and endometrial component involved in the "shrinking" process should be further investigated.

Association of the Lewis blood-group phenotype with infertility in women

OBJECTIVE

To evaluate the distribution of Lewis blood group phenotype and secretor status among women treated for infertility.

SETTING

In vitro fertilization unit of a university hospital.

PATIENTS

Forty-seven consecutive infertile women with mechanical (n = 31) or unexplained (n = 16) infertility scheduled for IVF-ET. The control group was formed of 47 fertile women from our database and additional new women matched for age.

MAIN OUTCOME MEASURES

Determination of ABO and Lewis blood group phenotypes.

RESULTS

Of the 47 subfertile women, 12 had blood type A (25.5%), 10 type B (21.3%), 4 type AB (8.5%), and 21 type O (44.7%); 38 had Le (a-b+) (80.9%), 4 had Le (a+b-) (8.5%), and 5 had Le (a-b-) (10.6%). Of the 47 controls, 17 had type A (36.2%), 12 type B (25.5%), 4 type AB (8.5%), 14 type O (29.8%); 26 had Le (a-b+) (55.3%), 11 had Le (a+b-) (23.4%), and 10 had Le (a-b-) (21.3%). The difference in the proportions of the A, B, AB, and O phenotypes was not statistically significant. The proportion of combined recessive and nonsecretor phenotypes Le (a+/-b-) was significantly lower in subfertile women (9/47) as compared with fertile controls (21/47) (P = 0.014). The difference in the proportions of the Lewis blood group phenotypes between the unexplained and the mechanical infertility groups was not statistically significant.

CONCLUSIONS

Subfertile women have an increased frequency of the Le (a-b+) blood group phenotype. Our hypothesis is that the presence of exposed fucosylated determinants such as Le(b) on the surface of endometrial cells may interfere with implantation.

Prospective evaluation of endometrial thickness as a predictor of pituitary down-regulation after gonadotropin-releasing hormone analogue administration in an in vitro fertilization program

OBJECTIVE

To determine whether pituitary down-regulation after gonadotropin-releasing hormone analogue (GnRH-a) administration can be accurately predicted by transvaginal ultrasonographic measurement of endometrial thickness.

DESIGN

Prospective study.

SETTING

An IVF unit of an academic medical center.

PATIENT(S)

One hundred eighty-one patients undergoing 265 IVF-ET treatment cycles using GnRH-a in the long protocol.

MAIN OUTCOME MEASURE(S)

Serum concentrations of E2 were determined, and endometrial thickness was measured by transvaginal sonography. The accuracy of endometrial thickness for predicting pituitary down-regulation was calculated.

RESULT(S)

Pituitary down-regulation, defined as a serum E2 concentration of < or = 55 pg/mL, was achieved in 77% (204 of 265) of the cycles. An endometrial thickness of < or = 6 mm was found in 92.2% (188 of 204) of cycles in which down-regulation was achieved. An estradiol level of < or = 55 pg/mL was present in 95.9% (188 of 196) of cycles with endometrial thickness of < or = 6 mm.

CONCLUSION(S)

A state of relative hypoestrogenism after GnRH-a administration, indicative of pituitary down-regulation, can be predicted with a high degree of accuracy by ultrasonographic measurement of endometrial thickness. Thus, routine testing for serum E2 concentration may be safely omitted. This may allow further simplification of IVF protocols and increase both cost-effectiveness and patients' convenience.

Expression of Ad4-BP/cytochrome P450 side chain cleavage enzyme and induction of cell death in long-term cultures of human granulosa cells

Freshly isolated granulosa cells obtained from women undergoing in-vitro fertilization (IVF) become refractory to further gonadotrophin stimulation in culture due to their previous hormonal treatment. However, when precultured for 7 days in gonadotrophin-free medium they regain their response to both human chorionic gonadotrophin (HCG) and follicle stimulating hormone (FSH) with a 10-fold and 5-fold increase in progesterone production respectively, within an additional 7 days of culture. Forskolin, a direct activator of adenylate cyclase, increased progesterone levels 12-fold compared with non-stimulated cultures. Oestradiol formation was also significantly elevated (P < 0.005) following 48 h stimulation with luteinizing hormone (LH), FSH or forskolin. Intracellular cAMP levels rose 1.5-fold, 10-fold and 15-fold after 1 h of FSH, HCG or forskolin treatment. Expression of both cytochrome P450 side chain cleavage enzyme (SCC) and the steroidogenic transcription factor SF1/Ad4BP could be demonstrated by Western blotting. However, elevation of P450 SCC alone was evident following FSH and HCG stimulation. In the presence of serum, the ultrastructure of these cultured cells displayed numerous lipid droplets and well-developed mitochondria, characteristic of highly steroidogenic cells. The proportion of apoptotic nuclei in these cultures was < 30%. Removal of the serum increased apoptotic incidence to 40%, whereas addition of FSH prevented cell death significantly (P < 0.01). HCG and forskolin increased apoptosis to approximately 50%, while treatment with 8Br-cAMP led to 80% cell death. Our data suggest that, after prolonged culture, human granulosa cells can regain cAMP and steroidogenic response to gonadotrophin stimulation. Moreover, our experiments indicate that apoptosis and steroidogenesis can coexist in the same cell population while the interrelationship between these processes can be determined by the intracellular levels of cAMP.

Comparison of sperm parameters, in vitro fertilization results, and subsequent pregnancy rates using sequential ejaculates, collected two hours apart, from oligoasthenozoospermic men

OBJECTIVE

To evaluate the effect of second consecutive ejaculate collected 2 hours after the first one from infertile men on sperm quality and fertilization and pregnancy rates (PRs) in IVF.

DESIGN

A prospective case-control study.

SETTING

In vitro fertilization unit of a university hospital.

PATIENTS

Thirty-nine consecutive infertile patients with oligoasthenozoospermia scheduled for IVF-ET.

MAIN OUTCOME MEASURES

Two consecutive ejaculates were obtained 2 hours apart and were assessed for volume, sperm count, motility, morphology, and quality of swim-up fraction. The subsequent fertilization, cleavage, and PRs (as defined by the appearance of intrauterine gestational sac) were compared between the two ejaculates.

RESULTS

In 28.2% of the individuals the semen analysis of the first ejaculate precluded proceeding with IVF. A statistically significant improvement was shown in sperm cell motility (31.9% +/- 20.7% versus 15.6% +/- 15.3%) and in motile count after swim-up (4.9 +/- 4.5 versus 2.6 +/- 3.1 x 10(6) sperm). No improvement could be demonstrated in sperm density or morphology. The volume of the second ejaculate was decreased significantly as compared with the first one. The fertilization rate, the cleavage rate, and PR were all increased when oocytes were exposed to sperm from the second ejaculate compared with oocytes exposed to sperm from the first ejaculate. The overall PR in our series was 25.6%.

CONCLUSIONS

We suggest that in the group of infertile men with oligoasthenozoospermia, whose partners are scheduled for IVF-ET, if on the day of retrieved oocytes insemination, the ejaculate is of unacceptable quality, a second ejaculate collected 2 hours after collection of the initial ejaculate may produce a sample that exhibits improvements in both semen parameters and reproductive potential.

Intravenous albumin for the prevention of severe ovarian hyperstimulation syndrome in an in vitro fertilization program: a prospective, randomized, placebo-controlled study

OBJECTIVE

To evaluate the efficacy of i.v. administration of human albumin solution for the prevention of severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

A prospective, randomized, placebo-controlled study comparing the effects of i.v. administration of human albumin solution versus sodium chloride 0.9% solution at the time of oocyte retrieval with patients undergoing IVF-ET who are at high risk for the development of severe OHSS.

SETTING

Specialized assisted reproduction unit.

PATIENTS

Thirty-one patients undergoing IVF-ET who had serum E2 levels of 1,906 pg/mL (> 7,000 pmol/L) and multiple follicular development on the day of hCG administration.

INTERVENTIONS

After hCG administration, patients were randomized to receive i.v., either 50 g of human albumin diluted in 500 mL of sodium chloride 0.9% or 500 mL of sodium chloride 0.9% at the time of oocyte retrieval.

MAIN OUTCOME MEASURES

Ovarian size as measured by pelvic ultrasonography, development of ascites, serum E2 concentrations during the luteal phase, and results of the IVF-ET cycles.

RESULTS

Although no patient who had received human albumin solution developed severe OHSS, there were four such cases in the control group. All four were hospitalized with marked ascites and ovarian enlargement. There were no significant differences between the two groups comparing serum E2 levels on the day of hCG administration and during the luteal phase, the number of oocytes retrieved, fertilization, and pregnancy rates.

CONCLUSIONS

Our preliminary results suggest that the administration of human albumin solution may help to prevent the development of severe OHSS in high-risk patients. Further research is needed to assess the potential of this novel approach.

Overnight secretion pattern of growth hormone, sex hormone binding globulin, insulin-like growth factor-1 and its binding protein in obese and non-obese women with polycystic ovarian disease

The pathophysiological mechanism underlying polycystic ovarian disease (PCOD) is different in obese and lean women. In obese patients the basic disorder is insulin resistance and hyperinsulinemia. In non-obese women the dominant derangement is a relative excess of luteinizing hormone (LH) and growth hormone (GH) production. The levels of GH, LH, sex hormone binding globulin (SHBG) and insulin-like growth factor binding protein-1 (IGFBP-1) were significantly lower and insulin levels considerably higher in obese PCOD women as compared to their non-obese counterparts. There was, however, no difference in the mean IGF-1 levels found in these two groups. The present study was designed to investigate whether, in addition to the mean levels, the overnight pattern of GH, IGF-1, IGFBP-1 and SHBG differed in obese women with polycystic ovaries as compared to that observed in the non-obese PCOD patients. Eight women with PCOD diagnosed by clinical, sonographic and hormonal means were studied. Four had basal body mass index exceeding 27. Blood samples were collected every 20 min over a period of 8 h, starting at 23:00 h. Twenty-four samples were collected from each patient and examined in one batch for GH, IGF-1, IGFBP-1, SHBG and insulin. The secretion patterns of the above substances during the late night (23:00-03:00 h) and early morning (03:00-07:00 h) hours were examined and compared in obese and non-obese PCOD women. Neither GH nor IGF-1 showed a distinct overnight secretion pattern. The overnight secretion patterns of IGFBP-1 and SHBG were similar in obese and non-obese women--the former showing a constant rising during the night and the latter exhibiting a converse trend. The integrated insulin levels were much higher during the late night as compared to early morning hours in all patients. It is proposed that the specific secretion pattern of IGFBP-1 is not directly dependent on body fat mass but is regulated by insulin in both obese and non-obese patients.

Polycystic ovaries in non-obese and obese patients: possible pathophysiological mechanism based on new interpretation of facts and findings

This study was designed to investigate the basic concentrations of different hormones in obese and non-obese patients with polycystic ovarian disease (PCOD). Eight women with PCOD, of whom four were obese with body mass index (BMI, kg/m2) of > 25 and four were non-obese with BMI < 25, volunteered to participate in this study. Serum samples were taken every 20 min over an 8 h period, starting at 2300 h, on day 5 of a spontaneous or gestagen-induced cycle. Basic insulin concentration was found to be significantly higher in the obese women compared with their non-obese counterparts (P < 0.0001). Serum concentrations of insulin-like growth factor binding protein (IGFBP-I) and sex hormone binding globulin (SHBG) were found to be significantly lower (P < 0.001 for both hormones) in the obese compared with the non-obese women. Serum concentrations of insulin-like growth factor I (IGF-I) did not differ between the two groups. The non-obese women had significantly higher serum concentrations of luteinizing hormone (LH) (P < 0.001) and of growth hormone (GH) (P < 0.002) than their obese counterparts. Based on these results, two models of the development of PCOD were suggested. In obese women, hyperinsulinaemia causes an excessive production of androgens through the enhancement of IGF-I receptors which, in synergism with LH, causes increased activity of cytochrome P-450c 17a. In non-obese patients, relative increase of GH concentration stimulates excessive ovarian IGF-I production. At this point synergism with LH results in excessive production of androgens by the same mechanism as in obese patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Early pregnancy termination: an improved technique for 'menstrual regulation' with ultrasound assistance

We performed aspiration of early pregnancy on 100 women requesting termination, using a low caliber angled catheter under sonographic guidance, without analgesia or anesthesia. The sonographic inclusion criteria for the study were: (1) mean gestational sac diameter less than 30 mm, or (2) crown rump length less than 10 mm when an embryo was visualized. The uterine content was successfully evacuated in all cases and none needed an additional curettage. Two women developed mild endometritis which responded to antibiotic therapy. This refinement of this 'menstrual regulation' technique seems to be safer when compared with the reported results of the original technique.

Aspiration of ectopic pregnancy under guidance of vaginal ultrasonography

This case report describes the treatment of tubal pregnancy by aspiration of the gestational sac content and injection of methotrexate by transvaginal sonographic guidance. The confirmation of the embryo aspiration as indicated by disappearance of the embryo with its heart beat and the resulting 46,XY karyotype, raises the question whether methotrexate injection is necessary.

Endometrial morphology and hormonal profiles in in vitro fertilization patients

Endometrial biopsy was performed in 27 infertile women participating in the IVF program. Their mean age was 31.8 years, 33% of the women being over 35 years old. The average duration of infertility was 6.9 years. The superovulation protocol consisted of hMG/hCG in 5 cases, of combined GnRH analog/gonadotropin therapy in 20 women, and 2 patients received combined contraceptive pill/gonadotropin treatment. Judging by hormonal profiles, follicular growth rate and number of oocytes retrieved, the response to stimulation was normal. The mean estradiol (E2) levels increased from 132.7 pg/ml on day -5 (SEM = 9.67) to 1272 pg/ml (SEM = 103.7) on the day of hCG administration and to 1813 pg/ml (SEM = 209.6) 1 day later. One day before the hCG application, the mean progesterone and LH levels were 1.34 ng/ml and 8.38 IU/ml, respectively. Only one patient had clinical hyperstimulation syndrome. Ova were harvested in all women, the mean number of oocytes being 7.7 (SEM = 0.83) per patient. In all 27 cases lack of fertilization or faulty ovum cleavage were observed. Thus, an endometrial biopsy (EB) was performed 72 h after oocytes retrieval. The mean estrogen and progesterone levels on the EB day were 610.9 pg/ml (SEM = 78.44) and 45.4 ng/ml (SEM = 7.53), respectively. Histologic examination of the endometrium showed normal secretory endometrium consistent with day 16-17 of spontaneous ovulatory cycle. Two women who received combined contraceptive pills/gonadotropin therapy showed inactive endometrium with subnuclear vacuoles and decidual reaction in the stroma similar to that observed in women on estrogen-progestin birth control medication.(ABSTRACT TRUNCATED AT 250 WORDS)

Can premature luteinization in superovulation protocols be prevented by aspiration of an ill-timed leading follicle?

In 12 patients stimulated for in vitro fertilization and embryo transfer (IVF-ET), a single leading follicle developed, whereas the other follicles were 6 mm smaller. In 7 patients chosen at random (group A), the leading follicle was aspirated, whereas in the other 5 the leading follicle was allowed to continue growing (group B). Comparison of the hormonal pattern of both groups showed that a premature luteinizing hormone (LH) surge was avoided only in group A, and only in this group a second follicle aspiration for IVF-ET was done, and two pregnancies were achieved. In group B, aspiration for IVF-ET was canceled because of premature LH surge. It is suggested that aspiration of a single leading follicle during ovulation induction may be an efficient method to avoid premature LH surge enabling other follicles to develop up to the preovulatory stage.

[Ultrasonically-guided aspiration of clear pelvic cysts]

In 33 women aged 13-80, clear pelvic cysts were aspirated. The diameter of the cysts was between 4-11 cm and the aspiration, by either the vaginal or abdominal routes, was ultrasonically guided. In 25 cases (76%) there was no recurrence of a cyst during continuing follow-up. In 8 cases in which a cyst recurred, 4 were operated on and benign tumors were found. Ultrasonically guided aspiration is appropriate treatment for clear pelvic cysts.

Combined diagnostic laparoscopy and follicular aspiration for human in vitro fertilization

Laparoscopic retrieval of oocytes from stimulated follicles for in vitro fertilization and embryo transfer (IVF-ET) was performed at the time of diagnostic laparoscopy in 36 infertile women. Their mean rates of cleavage, embryo transfer and pregnancy did not differ from those obtained in 86 patients (101 cycles) who underwent ultrasonically guided transvaginal oocyte retrieval following diagnostic laparoscopy performed earlier as a separate procedure. In view of the advantages in terms of reduced patient morbidity, time and cost benefits, and the opportunity for oocyte-sperm compatibility testing in vitro, the combined procedure appears to be the best method in patients scheduled to undergo diagnostic laparoscopy.

Development of human embryos in the presence of a copper intrauterine device

This study was designed to examine the teratogenic potential of copper releasing intrauterine contraceptive devices on the developing embryo. The tissues and organs of 11 whole embryos between 7 and 12 weeks of gestation were histologically examined for copper absorption after exposure to a copper intrauterine device in utero. The findings were not significantly different when compared with a control group of 7 embryos. No malformation or copper aggregates were observed in the various organs and placentas. The observations in this small sample would suggest that the copper-releasing intrauterine device has no deleterious effects on fetal development. The question remains whether malformations reported in some cases are associated with copper deposits in the tissues or with free copper ions in the fetal circulation. The implications are discussed.

Tamoxifen treatment in women with failure of clomiphene citrate therapy

Fourteen pregnancies were achieved with tamoxifen therapy in 12 women who failed to conceive with clomiphene citrate. There were no side-effects and fewer treatment cycles were required than with clomiphene citrate treatment. Ovulation and cervical score with tamoxifen therapy were significantly higher (p less than 0.005).

Simultaneous tubal and intra-uterine pregnancy following in vitro fertilization and embryo transfer

A case of simultaneous ectopic and intra-uterine pregnancy following in vitro fertilization and embryo transfer (IVF-ET) is described. On day 56 after ET the tubal pregnancy ruptured, with massive hemoperitoneum. Following salpingectomy, the intra-uterine pregnancy continued to term when delivery was carried out by cesarean section owing to non-progress of labor and suspected fetal distress. The pitfalls in diagnosing a simultaneous pregnancy of this kind following IVF-ET are discussed.

Modulation of intermediate-filament expression in developing cochlear epithelium

The present study was designed to characterize the expression and distribution of intermediate filaments (IFs) in the diverse cellular elements of inner-ear epithelium in guinea pig and man. Using immunofluorescence microscopy with a battery of IF-specific monoclonal antibodies, we show that the epithelium of the otocyst expresses cytokeratin (CK) polypeptides typical of simple epithelia. Cells in the early otic ganglion were also positively labelled for cytokeratins, suggesting that they are of otocystic epithelial origin. Cytokeratin distribution was largely homogeneous in the early cochlear duct as the epithelium differentiated, differences in the distribution of cytokeratin between the various cell types became detectable. Characteristically, cochlear hair cells became devoid of cytokeratin labelling, and remained unlabelled with antibodies specific for all other IF classes. The neural tissue of the inner ear was also devoid of cytokeratins and was typically positive for neurofilaments. Vimentin IFs were abundant in the mesenchymal tissues around the membranous labyrinth. Desmin and glial fibrillary acidic protein were not detectable in the cochlea. The apparent absence of all IFs from the cochlear hair cells in both guinea pig and man, as revealed by immunofluorescence and electron microscopy, and the possible significance of their absence for cochlear physiology, are discussed.

Female pseudohermaphroditism with adrenal cortical tumor in adulthood

Data are presented concerning a case of female pseudohermaphroditism of unknown etiology. The child was born with labioscrotal fusion and clitoromegaly. From the age of 5 to the age of 25 there was no clinical evidence of a hormonal abnormality. At the age of 25 the patient presented with masculinization and Cushing's syndrome, and a left adrenal tumor was removed. The patient was restudied at the age of 29, when 21-hydroxylase deficiency was excluded. Other types of congenital adrenal hyperplasia are considered unlikely. The possible relationship between the ambiguous genitalia present at birth and the virilizing tumor diagnosed at the age of 25 is analyzed.

Lymphoid cells and granulocyte progenitors in early human fetal livers: immunological parameters and in vitro cellular interactions

Human fetal liver (HFL) transplantations have been performed in infants with severe combined immunodeficiency and in patients with aplastic anemia, but the success rates have been extremely low, partly due to insufficient cell doses in grafts from a single donor. In order to explore the possible use of combining several HFL grafts from multiple donors, we studied immunological parameters as well as the in vitro responses of HFL cells from 20 fetuses, at 6 to 11 weeks of gestation, to allogeneic HFL cells and to adult lymphocytes in the mixed lymphocyte reaction (MLR), and the granulocyte-macrophage colony-forming cells (GM-CFC) assay. HFL cells of 6 to 11 weeks of gestation were found to lack populations of cells bearing surface markers of T- and B-lymphocytes and were capable of proliferating into lymphoid colonies. Virtually no MLR was found to allogeneic HFL cells or to adult lymphocytes [stimulation index (SI) 0.63 to 1.94], whereas adult lymphocytes responded normally to HFL cells (SI 3.9 to 62.0). Coculturing mixtures of allogeneic HFL cells in agar did not lead to suppression of the GM-CFC capacity of each liver. It appears that HFL at 6 to 11 weeks of gestation lack immunocompetent cells capable of provoking positive MLR in response to allogeneic HFL cells or to adult lymphocytes, and also capable of inactivating HFL-derived hematopoietic stem cells. This model may represent an in vitro counterpart for the in vivo pooling of HFL cells from multiple donors performed in order to increase graft cell dosage in man.

Partial moles: a clinicopathologic study of 25 cases

This study is based on a review of all moles diagnosed at the Kaplan Hospital in Israel from 1968 to 1977. Histologic reevaluation revealed that of a total of 72 moles, 47 (65%) were complete and 25 (35%) partial. In contrast to complete moles, about one third of the partial moles showed fetal parts. An analysis of the patient records showed smaller uteri, less vaginal bleeding, absence of severe vomiting, lower gonadotropin levels, and normal follow-up in patients with partial moles as compared with those who had complete moles. These results indicate that the partial mole is a distinct clinicopathologic entity that can be suspected by the clinician and confirmed by the pathologist on morphologic grounds, even in the absence of cytogenetic analysis.

Granulocyte-macrophage colonies in cultures of human fetal liver cells: morphologic and ultrastructural analysis of proliferation and differentiation

Fetal liver cells from 6-12-week-old human fetuses were cultured in soft agar to study growth patterns of the granulocyte-macrophage colony forming cells (CFU(c)) and to characterize the cellular components of these colonies by morphologic, cytochemical and ultrastructural methods. Liver cell suspensions prepared from 31 fetuses obtained by vaginal interruptions of pregnancies, were seeded in soft agar over feeder layers of normal human leukocytes. At all gestational ages examined, agar colony numbers ranged from 44 +/- 15 to 89 +/- 44/2 x 10(5) cells seeded. Colony frequencies, size and gross morphology closely resembled those derived from adult human marrow. Morphologic, cytochemical and ultrastructural examinations showed that 92% of the colonies were granulocytic with incomplete maturation, as found in adult human marrow colonies. Density fractionation of the cells produced a low density cellular fraction which gave a 3- to 5-fold improved cloning efficiency. This study shows that human fetal livers of 6-12 weeks gestational age contain CFU(c) comparable to that found in adult marrow in their frequency, size, density and dependence on colony stimulating factor, and which differentiate mainly into mature or immature granulocytes. It is suggested that the lack of granulopoiesis in vivo in the early human fetal liver is probably not related to CFU(c) deficiency or defective differentiation. An alternative explanation involving impaired regulatory mechanism(s) should be sought.