The dual trigger study: Rationale and study design of a prospective double-blind randomized clinical trial comparing pregnancy rates after co-administration of low dose hCG at the time of GnRH agonist trigger or 35 h later for the prevention of OHSS

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication of controlled ovarian stimulation. The use of gonadotropin releasing hormone (GnRH) agonist for the trigger of oocyte maturation is effective in the prevention of OHSS although it may result in a lower pregnancy rate. The use of adjuvant low dose human chorionic gonadotropin (hCG) at the time of trigger or at the time of oocyte retrieval may improve pregnancy rates. The goal of this dual trigger study is to evaluate the safety and efficacy of the use of low dose hCG administered at the time of GnRH agonist trigger or 35 h later as well as the potential impact on pregnancy rates. The population will consist of 82 women undergoing IVF treatment who are at risk of developing OHSS. This study will be a single center prospective randomized double-blind placebo controlled trial. The randomization schedule will be administered by the Investigational Drug Services of the University. After controlled ovarian stimulation, induction of oocyte maturation will be achieved using a GnRH agonist and patients will be randomized to receive either low dose hCG 1000 IU at the time of trigger and placebo at oocyte retrieval (Study group) or placebo at the time of trigger and hCG 1500 IU at the time of oocyte retrieval (Control group). The main outcomes will be live birth rates and incidence of OHSS. Two ancillary studies will include a quality of life survey and serum assessment of independent corpus luteum function.

Survey assessing obesity policies for assisted reproductive technology in the United States

OBJECTIVE

To determine what assisted reproductive technologies (ART) policies, if any, have been instituted in response to an increasingly overweight and obese patient population.

DESIGN

Cross-sectional survey.

SETTING

University-affiliated IVF clinic.

PATIENT(S)

Women in the overweight and obese body mass index (BMI) categories seeking ART treatments.

INTERVENTION(S)

Anonymous survey sent to medical directors at 395 IVF centers listed in Society for Assisted Reproductive Technology database.

MAIN OUTCOME MEASURE(S)

Assessment of recommendations, policies, and restrictions for patients who are overweight/obese and who desire treatment for infertility, including in IVF, IUI, and donor egg cycles.

RESULT(S)

Seventy-seven anonymous responses were received (19.5% response rate): 64.9% of centers have a formal policy for obesity, and 84% of those have a maximum BMI at which they will perform IVF, while 38% of those have a maximum BMI for performing IUI; 64.6% of respondents reported anesthesia requirements/concerns as the primary criteria for patient exclusion. Other primary considerations included safety during ongoing pregnancy and ART outcomes.

CONCLUSION(S)

Centers that have policies regarding obesity and access to ART consider efficacy, procedural safety, safety in pregnancy, and overall health status. Policies vary widely. The patient's autonomy must be balanced with nonmaleficence and the avoidance of interventions that may be unsafe both immediately and long term.

Progestin and AdipoQ Receptor 7, Progesterone Membrane Receptor Component 1 (PGRMC1), and PGRMC2 and Their Role in Regulating Progesterone's Ability to Suppress Human Granulosa/Luteal Cells from Entering into the Cell Cycle

The present studies were designed to determine the role of progesterone receptor membrane component 1 (PGRMC1), PGRMC2, progestin and adipoQ receptor 7 (PAQR7), and progesterone receptor (PGR) in mediating the antimitotic action of progesterone (P4) in human granulosa/luteal cells. For these studies granulosa/luteal cells of 10 women undergoing controlled ovarian hyperstimulation were isolated, maintained in culture, and depleted of PGRMC1, PGRMC2, PAQR7, or PGR by siRNA treatment. The rate of entry into the cell cycle was assessed using the FUCCI cell cycle sensor to determine the percentage of cells in the G1/S stage of the cell cycle. PGRMC1, PGRMC2, PAQR7, and PGR mRNA levels were assessed by real-time PCR and their interactions monitored by in situ proximity ligation assays (PLAs). These studies revealed that PGRMC1, PGRMC2, PAQR7, and PGR were expressed by granulosa/luteal cells from all patients, with PGRMC1 mRNA being most abundant, followed by PAQR7, PGRMC2, and PGR. However, their mRNA levels showed considerable patient variation. P4's ability to suppress entry into the cell cycle was dependent on PGRMC1, PGRMC2, and PAQR7 but not PGR. Moreover, PLAs indicated that PGRMC1, PGRMC2, and PAQR7 formed a complex within the cytoplasm. Based on these studies, it is proposed that these three P4 mediators form a complex within the cytoplasm that is required for P4's action. Moreover, P4's ability to regulate human follicle development may be dependent in part on the expression levels of each of these P4 mediators.

Effect of GnRH analogues on apoptosis and expression of Bcl-2, Bax, Fas and FasL proteins in endometrial epithelial cell cultures from patients with endometriosis and controls

BACKGROUND

Our purpose was to evaluate the effect of the GnRH agonist (GnRHa), leuprolide acetate (LA), and the GnRH antagonist (GnRHant), Antide, on apoptosis and expression of apoptosis-related proteins in endometrial epithelial cell (EEC) cultures from patients with endometriosis and controls (infertile women without endometriosis).

METHODS

Biopsy specimens of eutopic endometrium were obtained from 22 patients with endometriosis and from 14 women that served as controls. Apoptosis was examined in EEC after incubation with LA and Antide. Bax, Bcl-2, Fas and FasL expression was evaluated after exposure to LA, Antide or a combination of both. The percentage of apoptotic cells (%ApC) was assessed by the acridine orange-ethidium bromide technique, and protein expression was evaluated by western blot and immunocytochemistry.

RESULTS

LA 100 and 1000 ng/ml increased the %ApC in EEC from patients with endometriosis (both P < 0.05) and controls (p < 0.05 and P < 0.01, respectively). Antide 10(-5) M increased the %ApC in EEC from patients with endometriosis and controls (P < 0.01). In EEC from women with endometriosis, Bax expression increased after treatment with LA, Antide and LA + Antide (P < 0.05, P < 0.001 and P < 0.001), whereas Bcl-2 expression decreased after exposure to LA and Antide (P < 0.001 and P < 0.01). FasL expression increased after LA, Antide and LA + Antide treatments (P < 0.01, P < 0.001 and P < 0.01). No significant changes were observed on Fas expression.

CONCLUSIONS

GnRH analogues enhanced apoptosis in EEC, and this was accompanied by an increase in expression of the pro-apoptotic proteins Bax and FasL and a decrease in expression of the anti-apoptotic protein Bcl-2.

Relationship of ovarian stimulation response with vascular endothelial growth factor and degree of granulosa cell apoptosis

BACKGROUND

The aim of this study was to evaluate the concentration of vascular endothelial growth factor (VEGF) in follicular fluid and in granulosa cell cultures in relation to the degree of apoptosis in granulosa cells from patients with different types of ovarian response to controlled ovarian hyperstimulation.

METHODS

We studied 30 women who underwent controlled ovarian hyperstimulation and oocyte retrieval. Group A comprised patients with 1-4 follicles (n = 10), group B patients with 5-14 follicles (n = 10) and group C patients with >15 follicles (n = 10).

RESULTS

Mean (+/-SD) VEGF concentrations in follicular fluid were 1232 +/- 209, 813 +/- 198 and 396 +/- 103 pg/ml for groups A, B and C respectively (P > 0.01). Concentrations of VEGF in granulosa cell supernatant were 684 +/- 316, 1101 +/- 295 and 1596 +/- 227 pg/ml respectively (P < 0.05). Percentages of apoptotic cells in granulosa cells culture was 55.02 +/- 7.5, 23.98 +/- 4.4 and 14.2 +/- 2.3% respectively (A versus B, P < 0.01, A versus C, P < 0.006, B versus C, NS).

CONCLUSIONS

Our findings showed that in patients with decreased ovarian response to controlled ovarian hyperstimulation, follicular fluid VEGF concentration is elevated, the concentration from granulosa cells culture supernatant is decreased and the percentage of apoptotic granulosa cells is increased, while opposite findings occurred in patients with normal or hyper-responses.

A sequential analysis of the effect of progesterone on specific sperm functions crucial to fertilization in vitro in infertile patients

The objective of these studies was to evaluate the modulatory effect(s) of progesterone on sperm functions crucial to fertilization in infertile men with abnormal sperm parameters. A prospective, controlled study applying a sequential diagnostic analysis capable of identifying specific dysfunctions of the male gamete was performed. Patients (n = 14) were allocated to the study group if they had a history of infertility of > 1 year duration and after semen evaluation showed teratozoospermia (< 14% normal sperm forms as diagnosed by strict criteria) or terato-asthenozoospermia (< 50% progressive motility). After swim-up separation of the motile sperm fraction, the following functions were assessed with and without previous exposure to progesterone (1.0 micrograms/ml): acrosome reaction (using Pisum sativum agglutinin), hyperactivated motility (using a computerized semen analyser), sperm-zona pellucida binding (in the hemizona assay), sperm-zona pellucida penetration (in a sperm-zona penetration assay), and sperm-oocyte penetration (using the hamster zona-free oocyte/sperm penetration assay). Progesterone did not affect the percentage of acrosome-reacted spermatozoa after 1 or 3 h of incubation. Hyperactivated motility was significantly enhanced by progesterone after 1 h (12 +/- 4 versus 6 +/- 2% in controls; P < 0.02). Although progesterone did not affect sperm-zona binding, it significantly enhanced both sperm-zona pellucida penetration (27 versus 12% in controls; P = 0.03) and sperm-oocyte penetration (15 versus 8% in controls; P < 0.05). Because those sperm functions enhanced by progesterone are crucial to fertilization, the steroid may have value in the treatment of some male-factor patients undergoing assisted reproductive therapy.

Defective calcium influx and acrosome reaction (spontaneous and progesterone-induced) in spermatozoa of infertile men with severe teratozoospermia

OBJECTIVE

To evaluate the acrosome reaction and its prerequisite, a calcium influx, in spermatozoa of infertile men with a high incidence of abnormal sperm forms.

DESIGN

Prospective, controlled study.

SETTING

Academic tertiary assisted reproduction center.

PATIENTS

Patients (n = 14) were allocated in the study after semen evaluation showed teratozoospermia (< 14% normal sperm forms) as diagnosed by strict criteria.

INTERVENTIONS

After swim-up separation of the motile fraction, acrosome reactions were evaluated using Pisum sativum agglutinin (both spontaneously and exogenously induced with P and the calcium ionophore A23187, both at 10 microM); the intracellular-free [Ca2+]i was assessed by the fluorescent fura-2 indicator (basal and after P).

RESULTS

Patients did not show the typical P-induced wave of [Ca2+]i that was observed in controls but rather a blunted response, no response at all, or abnormal basal [Ca2+]i levels. The percent of basal acrosome reaction was significantly lower for patients versus controls postswim-up, and at 1 hour and 3 hours. Furthermore, there was a significant difference in the response of acrosome reaction to P both at 1 hour and 3 hours, with patients showing almost no response at all. However, patients' acrosome reaction response to the calcium ionophore was similar to those of fertile men.

CONCLUSION

Infertile patients with a high incidence of abnormal sperm forms as diagnosed by strict criteria have a low incidence of spontaneous acrosome reaction and a diminished P-stimulated acrosome reaction, whereas the nonspecific response to a calcium ionophore is conserved. Parallel abnormalities of [Ca2+]i were observed in patients, suggesting that these sperm populations may have a defective nongenomic P sperm receptor and/or abnormalities of other membrane transduction systems.

Detection of endotoxin in human in vitro fertilization by the zona-free mouse embryo assay

Endotoxin has been found to be a contaminant in human in vitro fertilization (IVF), leading to low pregnancy rates, mostly through embryo fragmentation. We wished to determine if standard quality control assays (one-cell and two-cell mouse embryo culture) were able to detect the presence of endotoxin and how they compared with the zona-free mouse embryo assays. Endotoxin was detected by the zona-free mouse embryo assays but not by the one- or two-cell mouse embryo assays. When excessive embryo fragmentation is noticed in the human IVF system, the use of zona-free mouse embryo assays is recommended.

Reduction of primary postoperative adhesion formation under calcium channel blockade in the rabbit

Preliminary studies in a hamster model have demonstrated calcium channel blocking agents to be potent inhibitors of primary post-traumatic peritoneal adhesion formation. The present investigation was designed to extend these observations to an extensively studied model, the rabbit, and to evaluate the optimal route of administration of these drugs for intraabdominal surgery. Rabbits were subjected to a standardized traumatic lesion of the left uterine horn. Subsequently, animals were divided into the following treatment groups: subcutaneous vehicle control (n = 7), intraperitoneal (ip) vehicle control (n = 8), subcutaneous verapamil treatment (n = 6), low-dose (2.5 micrograms/kg/hr) ip verapamil treatment (n = 10), and high-dose ip (25 micrograms/kg/hr) verapamil treatment (n = 6). All animals were reexplored at 1 week postop for evaluation of adhesion formation (scale: 0 to 4+). Calcium channel blockade-treated animals formed significantly fewer adhesions (0.45) than controls (3.93) (P less than 0.01). There was no significant difference between animals treated with sc with verapamil sc and those treated with low- or high-dose verapamil ip (0.33 vs 0.20 vs 1.0). These data confirm our preliminary results, suggesting that calcium channel blockade potently modulates peritoneal healing and regeneration. Furthermore, intraperitoneal delivery and systemic administration appear equipotent in this model. Further study of these agents as potential adjuvants for intraperitoneal surgery is indicated.

The use of calcium channel blockade for the prevention of postoperative adhesion formation

Prevention of postoperative adhesion formation is an issue of fundamental concern to the reproductive surgeon. The disappointing results of current adjunctive regimens have prompted a search for more potent antiadhesion therapies. Administration of nifedipine hydrochloride, a prototypical calcium channel blocking agent, to hamsters receiving a standardized traumatic lesion of the left uterine horn significantly inhibited primary adhesion formation as compared to control animals. These preliminary results suggest that calcium channel blockade may have the potential to favorably influence events related to peritoneal repair; further study of these agents as surgical adjuvants in the treatment of chronic pelvic adhesive disease is indicated.

Correlation of semen transferrin concentration and sperm fertilizing capacity

To determine whether a correlation exists between semen transferrin and sperm fertilizing capacity, transferrin concentration was determined in the semen of 52 male patients referred for the hamster ova penetration test (group 1) and in 17 men participating in the human in vitro fertilization program (group 2). In both groups 1 and 2 seminal transferrin levels were also compared to semen volume, sperm density, and motility. Serum follicle-stimulating hormone and luteinizing hormone concentrations that were determined in 34 individuals (24 in group 1, 10 in group 2) showed no correlation with seminal transferrin levels. In conclusion, low seminal transferrin levels correlated with low sperm density and with poor fertilizing ability of human oocytes in vitro.