Mullerian inhibiting substance levels at the time of HCG administration in IVF cycles predict both ovarian reserve and embryo morphology

BACKGROUND

Pre-antral and early antral follicles secrete Müllerian inhibiting substance (MIS), suggesting that MIS may directly reflect ovarian reserve. Since little is known about how ovarian reserve affects oocyte quality, we attempt here to assess the predictive value of MIS on embryo morphology and IVF outcome. To do so, we measured MIS at the time of HCG administration 36 h prior to oocyte retrieval.

METHODS

A total of 257 patients undergoing IVF were prospectively recruited. We measured MIS levels by enzyme-linked immunosorbent assay at the time of HCG, and compared the MIS values to day 3 FSH levels in the prediction of embryo morphology and IVF outcome.

RESULTS

The distribution of MIS levels was skewed, with a median of 2.7 ng/ml (range 0 to 28.5 ng/ml). MIS values at the time of HCG administration inversely correlated with basal FSH levels (P = 0.002), and both correlated significantly with patient age, number of mature follicles, number of oocytes retrieved and serum estradiol levels. MIS levels correlated significantly with a greater number of 6-cell embryos and better embryo morphology score, while basal FSH levels did not correlate with these outcome variables. MIS levels > or =2.7 ng/ml portended improved oocyte quality as reflected in a higher implantation rate (P = 0.001) and a trend toward a better clinical pregnancy rate (P = 0.084).

CONCLUSIONS

MIS levels seem to predict not only ovarian reserve, but also embryo morphology. Measurement of MIS at the time of HCG administration may, therefore, in the future improve management of patients undergoing treatments with assisted reproductive technology.

Contribution of diminished ovarian reserve to hypofertility associated with endometriosis

OBJECTIVE

To determine if ovarian reserve, as measured by day 3 levels of E2 and FSH, was different in patients with endometriosis as compared to controls.

STUDY DESIGN

Case-control study of 75 women with laparoscopically staged endometriosis and 75 age-matched controls undergoing in vitro fertilization/embryo transfer for male factor infertility.

RESULTS

In women with stage III/IV endometriosis (revised American Fertility Society staging), day 3 E2 and FSH levels were significantly higher than control levels (51.9 pg/mL and 12.6 mIU/mL versus 34.7 pg/mL and 9.7 mIU/mL, P < .03). In contrast, women with stage I/II endometriosis did not differ significantly when compared to controls (36.8 pg/mL and 10.4 mIU/mL versus 34.0 pg/mL and 10.2 mIU/mL). The total group showed significantly higher E2 levels (41.8 pg/mL versus 34.1 pg/mL, P < .03), but no significant differences in FSH levels were observed.

CONCLUSION

These data show that women with stage III/IV endometriosis have relatively diminished ovarian reserve, while this situation is not noted in women with stage I/II endometriosis. This observation is consistent with progressive loss of ovarian reserve in women with increasing stages of endometriosis independent of age.

Inhibin B response to EFORT is associated with the outcome of oocyte retrieval in the subsequent in vitro fertilization cycle

OBJECTIVE

To examine whether the magnitude of the rise in inhibin B levels after gonadotropin challenge is associated with subsequent response to ovarian stimulation during IVF.

DESIGN

Inhibin B serum levels after EFORT (exogenous follicle-stimulating hormone ovarian reserve test).

SETTING

Academic clinical practice.

PATIENT(S)

Serum samples from women who had undergone ovarian reserve screening with FSH in preparation for IVF. Thirteen of these women had a poor response in IVF (canceled cycle for low estradiol and/or no oocytes retrieved), and 19 had a good response (> or =10 oocytes retrieved).

INTERVENTION(S)

EFORT test.

MAIN OUTCOME MEASURE(S)

Baseline (day 3) serum E(2) (bE(2)), FSH (bFSH), and inhibin B (bInhB) levels and inhibin B and E(2) levels 24 hours after EFORT (DeltaInhB and DeltaE(2)).

RESULT(S)

The mean bInhB and DeltaInhB levels were significantly higher in good vs. poor responders. The odds ratio of having a good response for women with a DeltaInhB of 202 pg/mL was 51.8 times (95% CI = 6.1-1,244) the corresponding odds for women with a DeltaInhB of 49 pg/mL. As expected, DeltaE(2) was also significantly higher in good vs. poor responders; however, combination of DeltaE(2) plus DeltaInhB did not improve the odds for predicting IVF response.

CONCLUSION(S)

Our data suggest that DeltaInhB after EFORT may provide a method for predicting ovarian response to hyperstimulation in a subsequent IVF cycle.

Environmental factors in infertility

In conclusion, several studies indicate that there is an association between cigarette smoking and adverse reproductive outcomes in women as well as men. Some studies indicate that alcohol consumption impairs the reproductive capacity of women. Exposures to PCE in the dry cleaning industry, toluene in the printing business, ethylene oxide and mixed solvents have been associated with decreased fecundity. Abnormalities in sperm production have been found in men exposed to radiant heat or heavy metals. Environmental exposure to chlorinated hydrocarbons (e.g., DDT, PCB, pentachlorophenol, hexachlorocyclohexane) has been associated with an increase in rates of miscarriage and endometriosis. Clinicians should counsel patients who are trying to achieve a successful pregnancy to stop smoking and limit alcohol intake. Clinicians can additionally counsel patients who are in contact with potentially harmful occupational and environmental toxicants to limit their exposure. It is important to recognize, however, that many of the studies to date are limited by small sample size, poor exposure assessment, poor outcome measurements, recruitment bias, or recall bias. Additional studies will be necessary to clarify the magnitude of risk associated with these factors.

New treatments of hyperandrogenism and hirsutism

Approximately 5% to 8% of the female population demonstrates some form of hirsutism, the presence of prominent facial and body hair caused by excessive androgen effect. Treatment methods are classified into three categories: (1) hormonal suppression consisting of medical therapy to decrease androgen production, (2) the administration of antiandrogens to block the androgen effect at the hair follicle, and (3) physical methods of hair removal. Most patients require a combination of medical and physical therapy.

Do women with unexplained recurrent pregnancy loss have higher day 3 serum FSH and estradiol values?

OBJECTIVE

To determine the potential role of diminished ovarian reserve in unexplained habitual abortion.

DESIGN

Retrospective comparative analysis.

SETTING

University-based practice.

PATIENT(S)

Fifty-seven women who presented for evaluation of recurrent pregnancy loss (RPL).

INTERVENTION(S)

The test group (n = 36) comprised women with unexplained RPL. The control group (n = 21) comprised women with a known cause of RPL. Mean age, parity, day 3 serum FSH and E(2) levels, and presence or absence of a history of infertility were compared between groups.

MAIN OUTCOME MEASURE(S)

Day 3 serum FSH and E(2) levels.

RESULT(S)

Both day 3 FSH and E(2) levels were elevated in the unexplained group compared with the control group. When combined, FSH or E(2) levels, or both, were elevated in 58% of the unexplained RPL group and 19% of the control group (odds ratio, 5.95 [95% CI, 1.7-21.3]; P<.004). Age, parity, and presence of infertility did not differ between groups.

CONCLUSION(S)

Women with unexplained RPL have a greater incidence of elevated day 3 serum FSH and E(2) levels than do women with a known cause of RPL. Therefore, diminished ovarian reserve may contribute to recurrent pregnancy loss and should be considered part of the work-up for RPL.

Progesterone, inhibin, and hCG multiple marker strategy to differentiate viable from nonviable pregnancies

OBJECTIVE

To determine whether a combination of serum and urine biomarkers drawn from symptomatic pregnant women will help early differentiation of viable from nonviable pregnancies.

METHODS

We conducted a prospective cohort study of 220 women who presented in the first trimester of pregnancy with complaints of pain, cramping, bleeding, or spotting. Serum samples for progesterone, inhibin A, and hCG, and urine beta-core hCG, were collected at presentation. To evaluate whether those biomarkers could predict viable and nonviable outcomes in pregnancy, we used likelihood ratios to compare operating characteristics of single and multiple biomarker strategies.

RESULTS

Of 220 pregnancies studied, 98 were viable and 122 nonviable. Among single biomarkers, progesterone alone appears to have the greatest utility (area under the receiver operator characteristic curve = 0.923). Among dual-biomarker strategies, progesterone plus hCG and progesterone plus inhibin A improved specificity but not sensitivity. At 95% sensitivity, the combination of progesterone and hCG improved specificity from 0.29 to 0.66 (improvement = 0.37 [95% confidence interval 0.23, 0.52]). A triple-biomarker combination did not show substantial improvement over the dual-biomarker strategy. Also, combinations that used urine beta-core hCG did not improve diagnostic accuracy.

CONCLUSION

Serum progesterone appeared to be the single most specific biomarker for distinguishing viable from nonviable pregnancies. When a dual-biomarker strategy was applied, combining serum progesterone with hCG, specificity improved significantly, which suggests that a multiple biomarker strategy might help distinguish viable from nonviable pregnancies in early gestation.

Women with declining ovarian reserve may demonstrate a decrease in day 3 serum inhibin B before a rise in day 3 follicle-stimulating hormone

OBJECTIVE

To test the hypothesis that women with declining ovarian reserve may demonstrate a decrease in day 3 serum inhibin B levels before a rise in day 3 serum FSH levels.

DESIGN

Case-control study.

SETTING

Tertiary care fertility center.

PATIENT(S)

One hundred nine women with nonovarian infertility (tubal factor or male factor) and 47 women with declining ovarian reserve who underwent assisted reproductive techniques.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Serum inhibin B and FSH levels, number of ampules of gonadotropins administered, E2 levels on the day of hCG administration, number of oocytes retrieved, clinical pregnancy rate, and cycle cancellation rate.

RESULT(S)

Women who had declining ovarian reserve as demonstrated by an increased gonadotropin requirement, a decreased E2 response, fewer retrieved oocytes, a lower clinical pregnancy rate, and a higher cycle cancellation rate had lower day 3 serum inhibin B levels despite having nonelevated day 3 FSH levels similar to those of women with nonovarian infertility.

CONCLUSION(S)

Women with declining ovarian responsiveness and clinical outcomes consistent with declining ovarian reserve had decreased day 3 serum inhibin B levels despite having nonelevated day 3 serum FSH concentrations. Declining ovarian reserve may be demonstrated by a decrease in day 3 inhibin B levels before a rise in day 3 FSH levels.

Infertility treatment and informed consent: current practices of reproductive endocrinologists

OBJECTIVE

To determine current practice patterns of obtaining informed consent for infertility treatment by reproductive endocrinologists and to assess changes in response to reports of an association between ovulation induction and ovarian cancer.

METHODS

Board-certified reproductive endocrinologists (n = 575) were surveyed by mail regarding how they informed patients and obtained consent for infertility treatments and how their practices had been influenced by studies suggesting a link between ovulation induction and ovarian cancer. Data were analyzed using chi2 and logistic regression analyses.

RESULTS

The return rate was 62.1% (357 of 575 surveys). Most respondents (92%) used discussions with physicians to inform their patients of risks and benefits of all infertility treatments. Additional means, such as audiovisual aids, were used significantly more often for assisted reproductive technologies (including intracytoplasmic sperm injection and use of donated eggs) than for less invasive therapies (31-43% versus 4-11%, P < .001). Most physicians (46-66%) used verbal consent alone for hysterosalpingogram, intrauterine insemination, and ovulation induction. Formal written consent was used significantly more often for the various assisted reproductive technologies than for hysterosalpingogram, intrauterine insemination, or ovulation induction (94-95% versus 26-44%). Although most physicians (70%) did not believe that ovulation induction increases the risk of ovarian cancer, 83% addressed this risk when obtaining consent and 47% reported changing their practices since an association was reported. Common changes included limiting length of treatment and addressing ovarian cancer risk.

CONCLUSION

Current practice patterns of obtaining informed consent for various infertility treatments by board-certified reproductive endocrinologists show, as expected, that informed consent is more rigorous for assisted reproductive technologies. Although most surveyed did not believe that ovulation induction increases risk of ovarian cancer, the majority of physicians addressed that risk when obtaining consent and nearly half changed their practices on the basis of a possible association.

Effects of ovarian source, patient age, and menstrual cycle phase on in vitro maturation of immature human oocytes

OBJECTIVE

To determine the efficiency of in vitro maturation, expressed by nuclear maturation, of oocytes aspirated during gynecologic surgeries or collected from excised ovaries. To assess the effect of patient age and cycle phase at collection on the oocyte's ability to mature in vitro. To examine the time course of oocyte maturation in vitro.

DESIGN

Nuclear maturation based on patient criteria compared.

SETTING

University-based IVF program and research center.

PATIENT(S)

Consented patients undergoing gynecologic surgeries or patients undergoing oophorectomy.

INTERVENTION(S)

Oocytes were maintained in culture for 48 hours and evaluated for maturation.

MAIN OUTCOME MEASURE(S)

Nuclear maturation evaluated as germinal vesicle breakdown (GVBD) or progression to the metaphase II (MII) stage.

RESULT(S)

A significantly higher percentage of oocytes collected during the follicular phase of the menstrual cycle underwent GVBD than did oocytes collected during the luteal phase (60% versus 48%, respectively). The percentage of oocytes reaching the MII stage, from these two groups, was not different. No statistically significant differences in maturation were observed in oocytes from different ovarian sources or from patients >40 or <40 years of age.

CONCLUSION(S)

These data suggest that oocytes collected during the follicular phase are more likely to undergo GVBD than oocytes collected during the luteal phase. In this study, ovarian source, age, or cycle phase did not influence the final meiotic maturation of oocytes to metaphase II.

Activin A stimulates meiotic maturation of human oocytes and modulates granulosa cell steroidogenesis in vitro

OBJECTIVE

To test the hypothesis that activin A promotes in vitro human oocyte meiotic maturation while inhibiting steroid secretion by nonluteinized antral granulosa cells.

DESIGN

Prospective randomized controlled study.

SETTING

A university medical center.

PATIENT(S)

Nine women ranging in age from 31-44 years who were undergoing oophorectomy for nonovarian pathology.

INTERVENTION(S)

Analysis of meiotic maturation of oocytes and steroid secretion by granulosa cells cultured in the presence or absence of activin A.

MAIN OUTCOME MEASURE(S)

Germinal vesicle breakdown (GVBD) and attainment of metaphase II (MII) in oocytes, and progesterone and E2 secretion by granulosa cells.

RESULT(S)

Activin A significantly enhanced GVBD (91% vs. 65%) for control and maturation to MII (56% vs. 35% for control) of immature oocytes. Activin A significantly suppressed basal, and inhibin A-and FSH-stimulated progesterone and E2 secretion by nonluteinized granulosa cells.

CONCLUSION(S)

Activin A is a promoter of oocyte maturation in vitro and a modulator of granulosa cell steroidogenesis in culture.

Elevated level of follicular fluid vascular endothelial growth factor is a marker of diminished pregnancy potential

OBJECTIVE

To evaluate whether differences in follicular fluid vascular endothelial growth factor (FF VEGF) concentrations are observed between women achieving a clinical pregnancy and those failing to conceive.

DESIGN

Retrospective chart review and analysis of FF VEGF concentrations.

SETTING

University teaching center.

PATIENT(S)

Fifty-seven women < or =42 years of age undergoing follicular aspiration in preparation for IVF or GIFT.

INTERVENTION(S)

Analysis of FF VEGF concentrations and chart review of a single IVF or GIFT cycle.

MAIN OUTCOME MEASURE(S)

Follicular fluid VEGF concentrations, clinical pregnancy rate, age, ampules of gonadotropins used, oocytes retrieved, peak estradiol serum concentrations, day 3 FSH levels, and fertilization rate.

RESULT(S)

Women who did not conceive had higher FF VEGF concentrations than women achieving a clinical pregnancy (4.409 + 2,387 versus 2.793 +/- 1,180 pg/mL: P < .001). A negative correlation was observed between FF VEGF concentrations and peak estradiol levels and number of oocytes retrieved. A positive correlation was found for FF VEGF and patient's age and ampules of gonadotropins used.

CONCLUSION(S)

Elevated FF VEGF concentrations are associated with poor conception rates after IVF or GIFT.

Environmental toxicants and female reproduction

OBJECTIVE

To review current knowledge on the potential effects of environmental toxicants on female reproduction in laboratory animals, wildlife, and humans.

DESIGN

Published literature about the effects of endocrine disruptors, heavy metals, solvents, pesticides, plastics, industrial chemicals, and cigarette smoke on female reproduction.

RESULT(S)

Published data indicate that chemical exposures may cause alterations in reproductive behavior and contribute to subfecundity, infertility, pregnancy loss, growth retardation, intrauterine fetal demise, birth defect, and ovarian failure in laboratory animals and wildlife. Data on the association of chemical exposures and adverse reproductive outcomes in humans are equivocal and often controversial. Some studies indicate that chemical exposures are associated with infertility, spontaneous abortion, or reproductive cancer in women. In contrast, other studies indicate that there is no association between chemical exposures and adverse reproductive outcomes. The reasons for ambiguous findings in human studies are unknown but likely include the fact that many studies are limited by multiple confounders, inadequate methodology, inappropriate endpoints, and small sample size. The mechanism by which chemicals alter reproductive function in all species is complex and may involve hormonal and/or immune disruption, DNA adduct formation, altered cellular proliferation, or inappropriate cellular death.

CONCLUSION(S)

Studies are needed to clarify which toxicants affect human reproduction and by which mechanisms of action. Furthermore, methods should be developed to minimize exposure to known reproductive toxicants such as dioxins and cigarette smoke.

The detection of diminished ovarian reserve in infertile women

Women in their mid to late 30s and early 40s with infertility constitute the largest portion of the total infertility population. These women frequently undergo multiple testing, and most will require expensive and invasive therapies, including assisted reproductive technologies, with markedly reduced pregnancy rates in those older than 40. These women also have a higher incidence of pregnancy loss even after documentation of fetal cardiac activity by ultrasonography. Identifying those women who have a very low chance of pregnancy (and a high chance of pregnancy loss) with their own gametes presents a daily challenge to the practicing clinician, especially before embarking on expensive treatments. This article reviews the contemporary investigation of reproductive aging with basal and provocative tests. Women with markedly diminished ovarian reserve should be counseled on their low chances of conception with their own gametes, even with assisted reproductive technologies.

Dimeric inhibin: a direct marker of ovarian aging

OBJECTIVE

To investigate whether luteal secretion of inhibin-a is altered in the perimenopausal transition and to evaluate whether luteal inhibin secretion is correlated with other markers of ovarian reserve such as FSH and inhibin-b.

DESIGN

Prospective study.

SETTING

Reproductive Endocrinology Laboratories at The Ohio State University.

PATIENT(S)

Twenty-five women 39-52 years of age with regular menstrual cycles.

INTERVENTION(S)

Daily urine samples were monitored (LH predictor kit) to identify the day of ovulation. Blood samples obtained on days 6 and 8 after the LH surge and on day 3 of the subsequent follicular phase were assayed for FSH, E2, progesterone. inhibin-a, and inhibin-b.

MAIN OUTCOME MEASURE(S)

Serum levels of inhibin-a, inhibin-b, FSH, E2, and progesterone.

RESULT(S)

Luteal phase inhibin-a and follicular phase inhibin-b were correlated inversely with age in perimenopausal women. In addition, luteal phase inhibin-a and follicular phase inhibin-b levels were correlated inversely with follicular phase FSH levels.

CONCLUSION(S)

Both luteal phase inhibin-a and follicular phase inhibin-b levels are correlated inversely with age during the fifth decade of life. These findings suggest that corpus luteum function is altered during the perimenopausal transition. Moreover, these direct measures of ovarian function may be more sensitive indicators of "ovarian reserve" than indirect indicators such as pituitary FSH secretion.

Predicting probabilities of pregnancy and multiple gestation from in vitro fertilization--a new model

OBJECTIVE

To develop a statistical model that adjusts for variation between patients and adequately predicts the observed distribution of pregnancies among singletons and multiple gestations of various orders.

METHODS

All in vitro fertilization (IVF) cycles from the inception of the IVF program at Women and Infants' Hospital on May 26, 1988, until December 31, 1993, were evaluated using logistic regression in selected subsets.

RESULTS

A new cycle-one specific model uses three different probabilities: P1, the probability of pregnancy (predicted by age and total embryo score); P2/P1, the conditional probability of finding a second implantation in those who had become pregnant with at least one (predicted by total embryo score); and P3/P2, the conditional probability of finding a third implantation in those who had become pregnant with at least two (with no significant predictors). This is the first model to use these three adjusted probabilities.

CONCLUSION

P1 increases with increasing total embryo score but decreases with increasing age. P2/P1 increases with increasing total embryo score but does not depend on age. Embryo scoring is useful because the total embryo score is a better predictor of P1 and P2/P1 than the number of embryos alone. By using patient-specific information (age and total embryo score) and cycle-specific tables, an estimate of the probability of pregnancy and multiple gestation can be provided before embryo transfer.

Inhibin-B: the physiologic basis of the clomiphene citrate challenge test for ovarian reserve screening

OBJECTIVE

To determine inhibin-B concentrations during ovarian reserve screening in women with normal and diminished ovarian reserve as determined by the clomiphene citrate challenge test.

DESIGN

Retrospective.

SETTING

Tertiary fertility center.

PATIENT(S)

Women undergoing ovarian reserve screening for a routine fertility evaluation.

INTERVENTION(S)

Clomiphene citrate challenge test.

MAIN OUTCOME MEASURE(S)

Inhibin-B concentrations on menstrual days 3 and 10.

RESULT(S)

Nineteen patients with normal ovarian reserve and 15 with diminished ovarian reserve had serum inhibin-B concentrations determined during ovarian reserve screening. For all patients, day 10 inhibin-B concentrations were higher than day 3. Women with normal ovarian reserve had higher inhibin-B concentrations on both days 3 and 10 than women with diminished ovarian reserve. Inhibin-B concentrations demonstrated a negative correlation with FSH levels on both cycle days 3 and 10 and a positive correlation with E2 on cycle day 10.

CONCLUSION(S)

Women with diminished ovarian reserve during ovarian reserve screening had reduced granulosa cell inhibin-B production compared with women with normal ovarian reserve. The lower inhibin-B concentrations may be responsible for the elevated FSH concentrations and may be indicative of the aging follicular apparatus.

Follicular fluid vascular endothelial growth factor concentrations are elevated in women of advanced reproductive age undergoing ovulation induction

OBJECTIVE(S)

To determine whether follicular fluid (FF) from women of advanced reproductive age had a relative deficiency of the angiogenic cytokine vascular endothelial growth factor/vascular permeability factor. Furthermore, we sought to determine whether luteinized granulosa cells secrete vascular endothelial growth factor/vascular permeability factor in response to hypoxia.

DESIGN

Retrospective cohort study.

SETTING

University teaching hospital.

PATIENTS

Women undergoing follicular aspiration after superovulation in preparation for IVF-ET. Women of advanced reproductive age consisted of 21 women > or = 38 years old (range, 38 to 46 years); 15 subjects < or = 30 years served as the control population.

INTERVENTION(S)

Granulosa cells and FF were collected by transvaginal aspiration 35 hours after hCG. Granulosa cells from two women were cultured for 24 and 48 hours in M199 + 10% fetal bovine serum in 1% O2-5% CO2-94% N2 (hypoxic) or 95% air-5% CO2 (normoxic) without or with 0.1 mol/L cobalt chloride.

MAIN OUTCOME MEASURE(S)

Pooled FF vascular endothelial growth factor/vascular permeability factor concentrations and media vascular endothelial growth factor/vascular permeability factor accumulation at 24 and 48 hours were determined.

RESULT(S)

Follicular fluid vascular endothelial growth factor/vascular permeability factor concentrations were higher in advanced reproductive age women compared with younger women (3,735 +/- 2,155 versus 2,205 +/- 952 pg/mL, mean +/- SD). Accumulation of vascular endothelial growth factor/vascular permeability factor at 24 and 48 hours was 391 +/- 54 and 744 +/- 2 pg/mL in media maintained in 5% CO2 and air. Cobalt chloride induced a marked increase in vascular endothelial growth factor/vascular permeability factor (2,008 +/- 52 pg/mL at 24 hours and 3,630 +/- 519 pg/mL at 48 hours). An intermediate but significant increase in vascular endothelial growth factor/vascular permeability factor (733 +/- 35 pg/mL at 24 hours and 2,675 +/- 864 pg/mL at 48 hours) was observed with 1% O2 compared with normoxic controls.

CONCLUSION(S)

After hMG and hCG administration the FF from women of advanced reproductive age showed increased vascular endothelial growth factor/vascular permeability factor concentrations compared with younger women. Increased vascular endothelial growth factor/vascular permeability factor concentrations could be consistent with a hypoxic environment within follicles of older women.

Multiple immunoreactive inhibin proteins in serum from postmenopausal women with epithelial ovarian cancer

Inhibin is an ovarian protein previously shown, using a nonspecific assay, to be elevated in serum of women with ovarian cancer. However, inhibin is secreted in multiple biochemical forms, including dimeric inhibin A and B and alpha inhibin precursors (pro-alphaC), each of which can now be specifically measured. We have examined the secretion of inhibin B and pro-alphaC inhibin in serum from women with epithelial ovarian cancer (EOC) for the first time, and have compared these analytes to inhibin A and total inhibin (inhibin A + B + pro-alphaC) as potential serum markers for EOC in postmenopausal women. Of all the immunoreactive inhibin proteins studied, the best serum marker was pro-alphaC, with 22% of women with EOC having levels that exceeded the range of values in women without EOC. Since CA 125 and pro-alphaC levels were not significantly correlated, combination of these markers resulted in 87% of EOC cases having elevated preoperative serum levels, a 9% increase over CA 125 alone. These data suggest that alpha inhibin secretion, especially pro-alphaC, may be useful in addition to CA 125 as a serum marker for EOC in postmenopausal women.

The impact of hydrosalpinx on successful pregnancy in tubal factor infertility treated by in vitro fertilization

OBJECTIVE

To determine the impact of hydrosalpinx on pregnancy rates in patients undergoing IVF for infertility caused by tubal disease.

DESIGN

Review of the records of all patients who had undergone IVF for tubal factor infertility at our institution between May 1988 and October 1994.

SETTING

A university-sponsored, hospital-based IVF facility.

PATIENT(S)

Two hundred fifty patients were identified with infertility due to tubal disease; 67 of these had at least one documented hydrosalpinx whereas the remaining 183 did not.

MAIN OUTCOME MEASURE(S)

Numbers of oocytes retrieved and fertilized, the number of embryos transferred and implanting, and resulting pregnancy rates.

RESULT(S)

The groups were similar in age and cycle cancellation rates. The patients with hydrosalpinx had greater numbers of oocytes retrieved per cycle (15.0 versus 11.6) and embryos transferred per cycle then those without hydrosalpinges (4.21 versus 3.98). The hydrosalpinx group also undertook more cycles per patient (2.31 versus 1.96). Fertilization rates between the two groups were similar, but implantation rates were decreased in those with hydrosalpinx (8.5% versus 11.2%).

CONCLUSION(S)

Hydrosalpinx did not result in impaired ovarian stimulation or decreased oocyte fertilization. It did, however, interfere with implantation and reduce to some degree the success of IVF in achieving an ongoing pregnancy. The validity of routine salpingectomy for hydrosalpinx is debatable, but its use in selected individuals may well be appropriate.

Day 3 serum inhibin-B is predictive of assisted reproductive technologies outcome

OBJECTIVE

To determine if women with day 3 serum inhibin-B concentrations < 45 pg/mL (conversion factor to SI unit, 1.00) demonstrate a poorer response to ovulation induction and assisted reproductive technologies outcome relative to women with inhibin-B values > or = 45 pg/mL.

DESIGN

Analysis of inhibin-B, FSH, and E2 concentrations in day 3 serum samples.

SETTING

Academic clinical practice.

PATIENT(S)

One hundred fifty-six women who underwent 178 assisted reproductive technology (ART) cycles with luteal phase GnRH agonist suppression plus hMG and urofollitropin stimulation.

MAIN OUTCOME MEASURE(S)

Serum E2 on day of hCG, number of oocytes retrieved per patient, fertilization rate, cleavage rate, clinical pregnancy rate (PR) per initiated cycle, cancellation rate per initiated cycle, and spontaneous abortion rate.

RESULT(S)

Women with day 3 serum inhibin-B < 45 pg/mL demonstrated 70% of the E2 response, had 66.6% of the number of oocytes retrieved per patient, with 28% of the clinical PR per initiated cycle, and three times the cancellation rate per initiated cycle than women with day 3 inhibin-B > or = 45 pg/mL. After controlling for age, day 3 serum FSH, day 3 serum E2, patient cycle number, and method of ART, day 3 serum inhibin-B > or = 45 pg/mL was noted to be prognostic of the number of oocytes retrieved and clinical PR. The adjusted odds ratio of clinical pregnancy for those with day 3 serum inhibin-B > or = 45 pg/mL versus those with inhibin-B < 45 pg/mL was 6.8 (95% confidence interval 1.8 to 25.6).

CONCLUSION(S)

Women with low day 3 serum inhibin-B concentrations demonstrate a poorer response to ovulation induction and are less likely to conceive a clinical pregnancy through ART relative to women with high day 3 inhibin-B.

Apoptosis as a function of ovarian reserve in women undergoing in vitro fertilization

OBJECTIVE

To test the hypothesis that preovulatory follicles from women with diminished ovarian reserve contain fewer numbers of luteinized granulosa cells and have a greater percentage of cells undergoing apoptosis as compared with women with uncompromised ovarian reserve undergoing superovulation for IVF-ET.

DESIGN

Comparative study.

SETTING

Academic clinical practice.

PATIENTS

Luteinized granulosa cell counts were determined from follicular aspirates harvested from 19 women with day 3 serum FSH < or = 6 mIU/mL (conversion factor to SI unit, 1.00) and from 15 women with FSH levels > or = 10 mIU/mL. The second part examined the percent of proliferating and apoptotic cells harvested from nine women with day 3 serum FSH < or = 6 mIU/ mL and from eight women with FSH levels > or = 10 mIU/mL.

MAIN OUTCOME MEASURES

Cell counts by hemacytometer and percent of proliferating and of apoptotic granulosa cells by flow cytometry.

RESULTS

The mean number of viable cells isolated per follicle were 2.7 x 10(5) (95% confidence interval [CI] 2.3 to 3.1 x 10(5) from the low FSH group and 1.8 x 10(5) (95% CI 1.4 to 2.3 x 10(5) from the high FSH group. Although the percentage of proliferating cells was the same, the mean percentage of apoptotic cells was 0.5% (95% CI 0.2% to 1.4%) from the low group and 2.0% (95% CI 1.1% to 3.7%) from the high group.

CONCLUSIONS

Women undergoing IVF with day 3 serum FSH > or = 10 mIU/mL have preovulatory follicles with fewer luteinized granulosa cells and an increase in the percentage of cells undergoing apoptosis as compared with women with day 3 serum FSH < or = 6 mIU/mL.

Autologous granulosa cell coculture demonstrates zygote suppression of granulosa cell steroidogenesis

OBJECTIVE

To determine if embryos can modulate steroid hormone production by luteinized granulosa cells.

DESIGN

Granulosa cells obtained from follicular aspirates were cultured alone or in the presence of a two-pronuclear zygote. The production of E2 and P by these cultures was evaluated by RIA.

SETTING

In Vitro Fertilization Unit in an academic research environment.

PATIENTS

Sixteen women undergoing IVF.

INTERVENTIONS

Standard IVF-ET treatment cycle using leuprolide acetate for pituitary desensitization before hMG or urofollitropin for ovarian stimulation.

MAIN OUTCOME MEASURES

Estradiol and P concentration in culture media of luteinized granulosa cells alone or granulosa cells cocultured with a two-pronuclear embryo.

RESULTS

Both E2 and P production by luteinized granulosa cells was reduced when cultured in the presence of an embryo.

CONCLUSIONS

Human embryos secrete a factor that regulates granulosa cell steroidogenesis.

Effects of fetal number and multifetal reduction on length of in vitro fertilization pregnancies

OBJECTIVE

To determine the effects of multifetal reduction and other variables on the duration of gestation of in vitro fertilization (IVF) pregnancies.

METHODS

All 274 IVF pregnancies from the inception of the Women and Infants' Hospital IVF Program on May 26, 1988, until December 31, 1993, were evaluated.

RESULTS

Spontaneous reduction occurred in ten pregnancies, and multifetal reduction was elected in 28 multiple gestations. Among 260 pregnancies that remained viable beyond 20 weeks, 162 singletons (37.9 +/- 0.29 weeks; mean +/- standard error) had a longer mean gestation than did 64 twins (34.6 +/- 0.61 weeks), 25 pregnancies reduced to twins (33.4 +/- 1.0 weeks), or nine triplets (29.7 +/- 1.9 weeks). Triplets delivered 4.9 weeks earlier than nonreduced twins (P < .05) and 3.7 weeks before twins resulting from multifetal pregnancy reduction (P < .05). Regression analysis showed that at the 8-week ultrasound, each viable fetus could be expected to reduce the duration of the gestation by about 3.6 weeks, and each fetus reduced medically or as a result of natural causes could be expected to prolong the gestation by approximately 3.0 weeks. Only 14% of triplet pregnancies underwent spontaneous multifetal reduction.

CONCLUSION

Multifetal reduction of pregnancies with three or more fetuses was beneficial and increased the duration of gestation.

Serum inhibin levels are lower in ectopic than intrauterine spontaneously conceived pregnancies

OBJECTIVE

To determine if serum inhibin concentrations are lower in ectopic (EP) versus intrauterine pregnancies (IUPs) that are conceived spontaneously.

DESIGN

Case-control study.

SETTING

Academic clinical practice.

PATIENTS

Serum samples were obtained from 19 women who had EP confirmed at surgery and by pathology. For comparison, serum samples were collected from 24 women of similar chronological and gestational age with sonographic evidence of an IUP.

MAIN OUTCOME MEASURE

Serum dimeric inhibin-A, total inhibin, P, and hCG.

RESULTS

Serum total and dimeric inhibin concentrations in women with EP were < 60% of the concentrations for women with single IUPs. Total inhibin, but not dimeric inhibin-A, was elevated in maternal serum before week 8 of gestation relative to normal menstrual cycle levels.

CONCLUSIONS

Serum inhibin concentrations are lower in EP as compared with IUPs that are spontaneously conceived and the relative amounts of dimeric inhibin-A, B, and alpha inhibin subunit in maternal serum may change throughout gestation.

A combined cytogenetic and molecular approach for diagnosing delayed puberty

A phenotypic female aged 15 4/12 years was referred because of delayed puberty and short stature. Chromosomal analysis of peripheral blood leukocytes revealed two subpopulations of cells. The modal cell line was hypodiploid with a missing X chromosome while the other cell line was diploid with one X chromosome and a G-sized chromosome that resembled a Y chromosome in morphology. Subsequent fluorescent in situ hybridization yielded results consistent with the above conventional cytogenetic studies. To provide unequivocal evidence of the Y-chromosome material, molecular analyses using the polymerase chain reaction and various primers were carried out which identified an intact short arm and centromere of the Y chromosome and structurally altered long arms. A laparoscopic bilateral gonadectomy, performed because of the risk of neoplasia, also yielded cells with both 45,X and 46,XY karyotypes. The present report thus illustrates the usefulness of a combined approach for diagnosing delayed puberty.

Differential secretion of dimeric inhibin in cultured luteinized granulosa cells as a function of ovarian reserve

Day 3 serum FSH is an indirect assessment of ovarian reserve and has been shown to be prognostic of outcome in ovulation induction and assisted reproductive technology programs. The precise physiologic basis for day 3 serum FSH screening is unknown. We tested the hypothesis that dimeric inhibin is differentially secreted from luteinized granulosa cells collected from women in preparation for in vitro fertilization with low vs. high day 3 serum FSH levels. This prospective study consisted of luteinized granulosa cells harvested from 7 women with low day 3 serum FSH levels (< or = 6 IU/L) and from 8 women with high FSH levels (> or = 10 IU/L) in preparation for in vitro fertilization-embryo transfer. Following retrieval, cells were isolated and then pooled within each individual patient and plated at 50,000 cells per well. Media was removed at 24 and 48 h and analyzed for dimeric and total inhibin concentrations by immunoassay as well as estradiol and progesterone concentrations by RIA. Dimeric inhibin was secreted at 2-fold higher concentrations in the low FSH group 43.2 pg/ml (30.8-60.6) (geometric mean and 95% confidence interval) compared with the high FSH group, 21.0 pg/ml (15.0-29.6), P < 0.004. Total inhibin was secreted at 1.8-fold higher concentrations in the low FSH group, 1148.2 pg/ml (931.1-1415.8) compared with the high FSH group, 639.7 pg/ml (428.5-955.0), P < 0.013. No significant differences in either estradiol or progesterone concentrations were noted. These data suggest that day 3 serum FSH is an indirect bioassay of dimeric inhibin production at the granulosa cell level. Thus, these data provide a potential physiological basis for day 3 serum FSH screening in ovulation induction and ART programs.

Relaxin secretion in in vitro fertilization pregnancies

OBJECTIVE

This study was designed to determine whether the late luteal functional status of the corpora lutea in in vitro fertilization cycles alters the secretion of relaxin during pregnancy.

STUDY DESIGN

Analysis of serum relaxin, human chorionic gonadotropin, and steroid concentrations in sera of women with pregnancies viable beyond the twelfth week as a result of in vitro fertilization treatment was performed.

RESULTS

The serum estradiol and progesterone concentrations decreased 5.5- and 4-fold from days 5 to 6 after human chorionic gonadotropin to days 11 to 13 after human chorionic gonadotropin, respectively. The serum relaxin concentration increased 8-fold between the 11- to 15-day interval and the 16- to 50-day interval after human chorionic gonadotropin and another 6-fold to the 51- to 90-day interval after human chorionic gonadotropin (all p < 0.01). Multiple linear regression analysis showed that the serum estradiol level 11 to 13 days after human chorionic gonadotropin and the serum human chorionic gonadotropin level 11 to 15 days after human chorionic gonadotropin were the most powerful paired predictors of the concentration of serum relaxin measured in the 11- to 15-day interval after human chorionic gonadotropin interval (R2 = 0.39, n = 50), the 16- to 50-day interval (R2 = 0.61, n = 51), and the 51- to 90-day interval (R2 = 0.55, n = 39).

CONCLUSION

Secretion of relaxin is determined by an interaction of the late luteal functional status of the corpora lutea and the human chorionic gonadotropin secreted by the implanting pregnancy. These data allow for the hypothesis that inducing functional luteolysis by substituting one or more injections of luteinizing hormone for the human chorionic gonadotropin injection may decrease secretion of steroids, relaxin, and other factors from the corpora lutea during pregnancy, decreasing the risk of premature delivery in multiple gestations and the ovarian hyperstimulation syndrome.

Maternal and neonatal morbidity associated with in vitro fertilization

OBJECTIVE

The purpose of this case-control study was to examine the maternal and neonatal morbidities associated with in vitro fertilization (IVF) in a single large teaching hospital. It was hypothesized that IVF mothers would have more perinatal complications and IVF infants would have higher mortality and morbidity rates than non-IVF control subjects.

METHODS

One hundred forty-three gestations resulting from 101 IVF pregnancies, which included singletons (n = 62), twins (n = 72), and triplets (n = 9), were compared with equal numbers of non-IVF control subjects. Each pregnancy was matched by maternal age, race, insurance type, neonatal gender, order of gestation, order in delivery, and date of delivery (+/- 6 months). Among the 143 matched gestations, six IVF and seven control infants died, leaving 137 IVF and 136 control neonates for comparison.

RESULTS

The IVF mothers had more pregnancy-induced hypertension (21% vs 4%), premature labor (44% vs 22%), labor induction (25% vs 1%), and preterm delivery (37% vs 21%). The IVF infant survivors had a lower mean (+/- SD) birth weight (2623 +/- 857 gm vs 3006 +/- 797 gm), more frequent occurrence of low birth weight (42% vs 27%), and shorter gestations (37 +/- 4 vs 38 +/- 3 weeks). The IVF infants had longer hospitalizations, more days of oxygen therapy, more days of continuous positive airway pressure, and increased prevalence of respiratory distress syndrome, patent ductus arteriosus, and sepsis.

CONCLUSIONS

Couples who undergo IVF appear to be at increased risk of having low birth weight and preterm infants, and multiple gestations account for most of the neonatal morbidities. Both the mothers who conceive multiple gestations by means of IVF and their neonates are at an increased risk of having multiple morbidities.

Assessment of sex chromosome composition using fluorescent in situ hybridization as an adjunct to GTG-banding

Fluorescent in situ hybridization (FISH) using dual color X chromosome- and Y chromosome-specific probes was employed to assess further the sex chromosome copy number in cells of a phenotypic female patient with hypergonadotropic hypogonadism, primary amenorrhea and growth retardation. The GTG-banding analysis of peripheral blood lymphocytes had revealed the presence of predominantly 46,XY cells. A FISH analysis, undertaken to assess further the contribution of a minor cell line, yielded frequencies of 87% cells with the 46,XY constitution and 9% with the 45,X constitution. To establish unequivocally the presence of mosaicism, a skin biopsy was obtained for fibroblast culture, which further corroborated the results of the peripheral blood study. Fluorescent in situ hybridization analysis revealed 74% of the cells to be 46,XY and 12% to be 45,X. The unequivocal presence of XY cells puts the patient at risk for neoplastic transformation of the gonads. Laparoscopy and surgical removal of the patient's presumptive streak gonads were therefore undertaken. Cytogenetic results derived from the gonadal tissues further strengthened findings of previous cytogenetic analyses. It is our experience that FISH is a useful adjunct to established cytogenetic techniques in the management and monitoring of patients similar to the proband described in this study.

Laparoscopic management of ectopic pregnancy

Management of ectopic pregnancy includes a high index of suspicion coupled with established algorithms of diagnosis using serum beta-human chorionic gonadotropin and transvaginal ultrasound. Early diagnosis and intervention usually leads to conservation of the involved tube. Careful follow up for persistent ectopic pregnancy leads to appropriate medical or surgical management. The use of methotrexate, either systemically or by local injection, may provide an alternative to surgery in selected patients with ectopic pregnancy.

Laparoscopic-assisted tubal anastomosis

STUDY OBJECTIVE

To determine the length of procedure, length of hospital stay, complications, and postoperative pregnancy rates of traditional tubal anastomosis (TA) and laparoscopic-assisted TA (LATA).

DESIGN

A comparison of 8 women undergoing LATA with 11 patients operated on by the same surgeon during a similar time period who were not candidates for, or did not desire, a laparoscopic approach.

SETTING

Academic practice tertiary care setting.

PATIENTS

Women requesting reversal of tubal ligation.

INTERVENTIONS

Tubal anastomosis by laparoscopy or laparotomy.

MEASUREMENTS AND MAIN RESULTS

Patients undergoing the two procedures did not differ by age or parity, although those selected for LATA had a lower body mass index (23.2 +/- 1.4 vs 30.8 +/- 2.0 kg/m2, p = 0.01). Although the LATA took longer (251 +/- 14 vs 194 +/- 10 min, p = 0.004), hospital stay was significantly shorter than for traditional TA (1.8 +/- 0.3 vs 3.0 +/- 0.1 days, p = 0.004). Of the eight LATAs, six were completed and two were converted to laparotomy. For all patients with follow-up, clinical pregnancy rates were 43% and 29% (NS) for TA and LATA, respectively, with 100% of the former and 80% (NS) of the latter group who did not conceive having at least one patent tube on hysterosalpingogram.

CONCLUSIONS

Laparoscopic-assisted TA is a possible alternative to the traditional TA performed by laparotomy. Ideal candidates for LATA appear to be women without obesity and with proximal tubal segments of 3 cm or greater. Larger studies with longer follow-up will define appropriate candidates and identify long-term results.

Follicular fluid insulin-like growth factor-I and insulin-like growth factor-II concentrations vary as a function of day 3 serum follicle stimulating hormone

We determined follicular fluid concentrations of insulin-like growth factor (IGF)-I, IGF-II and inhibin as a function of day 3 serum follicle stimulating hormone (FSH) in 16 women undergoing follicular fluid aspiration in preparation for in-vitro fertilization and embryo transfer. Follicular fluid concentrations of IGF-I and IGF-II were significantly less in the 'low' FSH group as compared to the 'high' FSH group. The mean IGF-I concentration was 67.6 ng/ml [confidence intervals (CI) 51.6-92.5] in the 'low' FSH group compared to 87.1 ng/ml (CI 72.8-104.2; P < 0.025) in the 'high' FSH group. Mean IGF-II concentrations were 354.8 ng/ml (CI 297.8-422.9) in the 'low' FSH group compared to 489.8 ng/ml (CI 384.6-624.5; P < 0.05) in the 'high' FSH group. Follicular fluid inhibin concentrations did not differ between groups. These differences in follicular fluid IGF as a function of day 3 FSH may raise questions regarding the role growth factors play in the physiological processes of the ageing follicle.

Reproductive potential after treatment for persistent ectopic pregnancy

We examined the success rate and reproductive outcome of 50 patients who had been treated for persistent EP after initial unsuccessful salpingostomy. All who underwent salpingectomy had successful treatment of their persistent EP. One treatment failure occurred after MTX. Of 50 women, 32 (61.5%) attempted conception after treatment for persistent EP. The cumulative clinical pregnancy rate after treatment for persistent EP was 59% at 36 months. There was a significant association between clinical pregnancy rate after persistent EP and those with normal contralateral fallopian tubes (P < 0.005). The relative risk of having a clinical pregnancy among those who attempted conception was 2.3 for those having a normal contralateral fallopian tube compared with those with a contralateral fallopian tube with obvious pathology. Intrauterine pregnancy rates after treatment of persistent EP were similar to those reported for primary treatment of EP.

Early and late presentation of the ovarian hyperstimulation syndrome: two distinct entities with different risk factors

This study was designed to identify clinical predictors for early and late ovarian hyperstimulation syndrome (OHSS). A retrospective analysis of all 592 in-vitro fertilization (IVF) cycles from the programme's inception in 1988 up to March 1993 was performed. Six patients (1.0% of cycles) had moderate or severe OHSS presenting 3-7 days post-human chorionic gonadotrophin (HCG), and four patients (0.7% of cycles) had severe OHSS presenting 12-17 days post-HCG. No patient with early OHSS went on to develop late OHSS, and no patient with late OHSS had demonstrated early OHSS. Stepwise logistic regression showed that early OHSS was predicted by the number of oocytes retrieved (range 18-46) (P = 0.0001) and the oestradiol concentration on the day HCG was given (range 12,122-24,454 pmol/l) (P = 0.0003). Late OHSS was predicted by the number of gestational sacs (range 2-3) on ultrasound 4 weeks after embryo transfer (P = 0.0001) but not by the number of oocytes or oestradiol. Early OHSS was an acute effect of the HCG administered prior to egg retrieval in women with high oestradiol and larger numbers of follicles (range 22-51). Late OHSS was induced by the rising serum concentration of HCG produced by the early pregnancy, and in this series of cases it was associated only with multiple gestation.

Aberrant estradiol flare despite gonadotropin-releasing hormone-agonist-induced suppression is associated with impaired implantation

Our results confirm the previous report that rapid suppression by GnRH-a is favorable relative to delayed suppression (1). They further indicate that the pattern of E2 production during GnRH-a-induced ovarian suppression may be predictive of cycle outcome. We suggest that imperfect pituitary suppression of bioactive LH as indicated by an aberrant rise in E2 during GnRH-a down-regulation may compromise oocyte quality and ultimately impair implantation. Further study of follicular phase E2 response to GnRH-a suppression may provide a prognostic marker for implantation.

Urine hCG beta-subunit core fragment, a sensitive test for ectopic pregnancy

hCG is a glycoprotein hormone composed of 2 dissimilar subunits, alpha and beta, joined non-covalently. hCG and its free beta-subunit are the principal hCG beta immunoreactivities in pregnancy serum samples, and the same plus beta-core fragment (beta-subunit residues 6-40 disulfide-linked to residues 55-92) in urine samples. Ectopic or tubal pregnancy is difficult to diagnose in emergency rooms. With the objective of finding better hCG-related assays for differentiating tubal and normal pregnancies, we tested 2 hCG, 1 free beta-subunit and 2 beta-core fragment immunoassays. Twelve urine samples were collected in the emergency room from women later shown by surgery to have tubal pregnancy. All were 38 to 80 days since last period. A further 36 urine samples were collected from the same period from those with normal intrauterine pregnancies. Using the 2 hCG assays the median level in tubal pregnancy samples was 1/38th and 1/48th of normal pregnancy concentrations. With the free beta-subunit assay tubal pregnancy levels were 1/28th of normal levels. Using 2 beta-core fragment assays (Ciba-Triton UGP kit and B204-FBT11 scavenger test), however, tubal levels were most different from intrauterine pregnancy, 1/149th and 1/800th of normal levels. A cut-off level of 100 micrograms/L was considered for the B204-FBT11 beta-core fragment test, at which a predictive value of > 98% was suggested for ectopic pregnancy. In an additional patient, levels were measured 15 days prior to the diagnosis of tubal pregnancy. At this time, results from the 2 hCG tests were 1/97th and 1/126th, from the free beta-subunit test was 1/8th and the 2 beta-core assays were 1/413th and 1/240th of median normal intrauterine pregnancy levels. While hCG levels are reduced in tubal pregnancy, beta-core fragment are reduced much further. beta-core fragment measurements may offer a major improvement over hCG in diagnosing tubal pregnancy in the Emergency Room, and in screening for this life threatening disease.

Dehydroepiandrosterone sulfate and anovulation increase serum inhibin and affect follicular function during administration of gonadotropins

To test the hypothesis that testosterone (T) derived from circulating dehydroepiandrosterone sulfate (DS) or produced in excess within the anovulatory ovary is a follicular regulator capable of stimulating inhibin secretion. DS and inhibin were determined by RIA in residual serum samples from in vitro fertilization cycles and analyzed along with other parameters using analysis of variance and stepwise multiple linear regression after log transformation of the RIA data. It was predicted that the serum concentration of inhibin would be higher in women with anovulation than in normal subjects and that the serum inhibin concentration would have a positive regression coefficient on the serum DS concentration. The serum concentrations of inhibin (P < 0.01) and estradiol (P < 0.001) on the day of hCG treatment were higher in women with anovulation than in normal subjects, as was the number of oocytes retrieved (P < 0.001). The FSH and LH doses (both P < 0.005) and age (P < 0.001) were significantly lower, and the average duration of gonadotropin therapy was 1 day shorter (P < 0.001) in anovulatory patients. There was no significant difference in serum DS (P > 0.2). Regression analysis showed that serum inhibin was positively related to the number of oocytes (P < 0.001) and serum DS (P = 0.05), with an increase in anovulatory subjects (P < 0.025). The duration of treatment with gonadotropins was related positively to the patient's age (P < 0.001) and negatively to serum DS (P < 0.025), with a decrease in anovulatory subjects (P < 0.025). The number of oocytes obtained was negatively related to age (P < 0.001) and positively to serum DS (P < 0.005). These data are consistent with a stimulatory effect of follicular T derived from either circulating DS or the anovulatory ovary, which affects the secretion of inhibin, the duration of gonadotropin treatment, and the number of oocytes retrieved.

Proliferative index of human luteinized granulosa cells varies as a function of ovarian reserve

OBJECTIVE

We examined whether the proliferative index of luteinized granulosa cells, as determined by flow cytometry, varied as a function of a woman's ovarian reserve, as reserve, as reflected by follicular-phase day 3 serum follicle-stimulating hormone.

STUDY DESIGN

This prospective cohort study consisted of 19 women of similar chronologic age preparing for in vitro fertilization-embryo who met specific day 3 serum follicle-stimulating hormone criteria. The "low follicle-stimulating hormone" group consisted of 11 women with day 3 serum follicle-stimulating hormone levels < or = 6 IU/L. The "high follicle-stimulating hormone" group consisted of eight women with day 3 serum follicle-stimulating hormone levels > or = 18 IU/L. A total of 56 preovulatory follicles containing > or = 10(4) luteinized granulosa cells were examined by flow cytometry. The low follicle-stimulating hormone group was compared with the high follicle-stimulating hormone group to examine proliferative index as a function of serum day 3 follicle-stimulating hormone levels.

RESULTS

The low follicle-stimulating hormone group had a greater proliferative index (11.1% +/- 0.4%) than did the high follicle-stimulating hormone group (8.3% +/- 0.6%), p < 0.001). This study demonstrates that in spite of the same chronologic age, luteinized granulosa cells from preovulatory follicles of women with day 3 serum follicle-stimulating hormone levels > or = 18 IU/L have a 25% decreased proliferative index compared with luteinized granulosa cells from women with day 3 serum follicle-stimulating hormone levels < or = 6.

CONCLUSIONS

This suggests that granulosa cell proliferation is influenced by ovarian reserve and may explain in part the more favorable response to ovulation induction protocols that younger women demonstrate compared with women of more advanced reproductive age.

Hematosalpinx after methotrexate treatment of unruptured ectopic pregnancy

A large asymptomatic hematosalpinx followed single low-dose MTX treatment of an unruptured EP, a previously unreported complication. Management and implications are discussed.

Absence of immunoreactive cytokines in supernatants of individual preimplantation human embryos

PROBLEM

The purpose of this study was to determine if it was possible to use commercially available enzyme-linked immunosorbent assay (ELISA) kits to quantitate specific cytokine production from individual embryos.

METHODS

We examined the supernatants of individual two to six cell preimplantation human embryos using commercially available kits for IL-1 alpha, IL-1 beta, IL-6, and LIF.

RESULTS

Cytokines were undetectable in all media samples analyzed.

CONCLUSION

While it is possible that individual preimplantation embryos may produce cytokines, we believe these concentrations are below the detectable limits of the commercial assays used in this study.

Selecting human chorionic gonadotropin immunoassays: consideration of cross-reacting molecules in first-trimester pregnancy serum and urine

OBJECTIVE

We investigated the variation in human chorionic gonadotropin results found with different commercial kits. Levels of human chorionic gonadotropin and related molecules were determined in pregnancy serum and urine and compared with the specificities of different laboratory, office, and home test kits.

STUDY DESIGN

Total human chorionic gonadotropin (nicked+nonnicked), nonnicked human chorionic gonadotropin, free beta subunit, and beta core fragment were measured in 242 serum samples and 125 urine samples from early pregnancies.

RESULTS

In serum, in the 2 weeks after the missed period when most pregnancy tests are performed, median levels of total, nonnicked, and beta human chorionic gonadotropin (total+free beta+beta core) were similar (< or = 12% difference). Individual values, however, varied significantly. For nonnicked human chorionic gonadotropin, values ranged from 41% to 145% and for beta from 101% to 145% of the total human chorionic gonadotropin level. In urine individual nonnicked values varied from < 1% to 148% and beta values from 102% to 547% of the total human chorionic gonadotropin level. A survey of 29 kits revealed that 10 were types detecting total human chorionic gonadotropin, five detecting nonnicked only, and 14 were beta assays.

CONCLUSIONS

Results from total, nonnicked, and beta human chorionic gonadotropin kits are not necessarily interconvertible. Individual variations in levels of nicked human chorionic gonadotropin, free beta and beta core, and differences in their recognition by immunoassays causes discordant results.

Gonadotropin-releasing hormone agonist-induced differences in granulosa cell cycle kinetics are associated with alterations in follicular fluid müllerian-inhibiting substance and androgen content

We have previously shown that the proliferative index (PI), as determined by flow cytometry of luteinized granulosa cells obtained at oocyte retrieval, is greater in ovulation induction regimens which include the GnRH analog (GnRH-a) leuprolide acetate than those using human menopausal gonadotropin (hMG) only. Specific growth factors or intrafollicular hormones may contribute to this leuprolide acetate-induced difference in cell cycle kinetics. We examined whether differences in the PI of these granulosa cells are associated with the alterations of follicular fluid content of Mullerian-inhibiting substance (MIS) and other intrafollicular hormones including FSH, estradiol, progesterone, androstenedione, and testosterone. The control group consisted of follicular fluid obtained from 18 follicles from 4 women receiving hMG alone. The GnRH-a treated group consisted of follicular fluids obtained from 55 follicles aspirated from 18 women receiving GnRH-a in addition to hMG. One-way analysis of variance using log-transformed data and expressed as geometric means with 95% confidence intervals, demonstrated that the follicles from the control group had a significant 14-fold higher concentration of 2.46 ng/mL MIS, 95% CI (1.8-4.8) vs. 0.18 ng/mL, 95% CI (0.13-0.24) P < 0.0005, a 3-fold higher concentration of 17.55 nmol/L androstenedione, 95% CI (14.6-20.9) vs. 5.76 nmol/L, 95% CI (3.1-10.5) P < 0.02, and a 1.5-fold higher concentration of 29.43 nmol/L testosterone 95% CI (22.5-38.14) vs. 19.3 nmol/L, 95% of CI (11.1-33.9) P < 0.01 than GnRH-a treated follicles, although the PI value in controls was half that of the GnRH-a group. These data demonstrate that GnRH-a induced differences in granulosa cell cycle kinetics are associated with alterations of MIS and androgen intrafollicular fluid content and suggest that MIS may be a mitotic inhibitor of human granulosa cells.