Thyroid hormone regulates oligodendrocyte accumulation in developing rat brain white matter tracts

Thyroid hormone (TH) is necessary for normal axonal myelination. Myelin basic protein (MBP) is a structural protein essential for myelin function. In this study, we demonstrate that perinatal hypothyroidism regulates MBP mRNA levels via indirect mechanisms. We observed decreased MBP mRNA accumulation in the hypothyroid rat brain at postnatal (PN) d 10 and 50. Acute TH replacement did not rescue hypothyroid MBP mRNA levels at PN5, 10, or 50. TH is necessary for normal intrahemispheric commissure development including the anterior commissure (AC) and the corpus callosum (CC). We determined that perinatal hypothyroidism decreases AC area and cellularity in the developing rat brain by PN10 and 50. In the developing CC, hypothyroidism initially increases area and cellularity by PN5, but then ultimately decreases area and cellularity by PN50. MBP-expressing oligodendrocytes are a recognized target of TH and are responsible for myelination within intrahemispheric commissures. We found that hypothyroidism reduces the number of mature oligodendrocytes within both the AC and CC. This reduction is noted at PN5, 10, and 50 in the AC and by PN10 and 50 in the CC. Together, these data suggest that TH regulates MBP mRNA levels through indirect mechanisms. These data demonstrate the complex mechanisms whereby TH regulates myelination in the developing brain.

Differential expression and regulation of inducible nitric oxide synthase (iNOS) mRNA in human trophoblasts in vitro

OBJECTIVES

To determine the expression of inducible nitric oxide synthase (iNOS) in human trophoblast and to examine the possible regulation of iNOS gene by cytokines.

MATERIALS AND METHODS

Total RNA was isolated from: 1) homogenized placental tissue; from 2) isolated and purified cytotrophoblast cells; and 3) cytotrophoblast and syncytiotrophoblast cells treated with cytokines in vitro. RNA was reverse transcribed and amplified by polymerase chain reaction, using specific primers for iNOS. Trophoblast cells were treated in vitro by interferon-gamma (IFN-gamma) in a dose of 10 ng/mL, Interleukin 1beta (IL-1beta) (4 ng/mL) and leukemia inhibitory factor (LIF) (1 ng/mL). Trophoblasts were also subjected to immunocytochemistry using iNOS-specific antibody to detect iNOS protein expression in these cells.

RESULTS

The expression of iNOS mRNA was found both in placental tissue and isolated cytotrophoblast cells. In culture, the highly differentiated syncytiotrophoblast expressed more mRNA than cytotrophoblast cells. IFN-gamma and LIF, but not IL-1beta, induced iNOS mRNA expression in trophoblast cells in vitro. The effects of these cytokines on iNOS mRNA were only observed in syncytiotrophoblast cells, but not in cytotrophoblast cells. Immunocytochemical staining confirmed the trophoblast cells as a major source of the iNOS synthase production.

CONCLUSIONS

1) Human trophoblast cells are able to express the iNOS mRNA, hence suggesting a role for NO in placental growth and function. 2) LIF and IFN-gamma, but not IL-1beta, induce the iNOS mRNA expression in syncytiotrophoblast cells in vitro, suggesting possible similar regulatory mechanisms in vivo. 3) This study, for the first time, demonstrates the stimulating effect of LIF on iNOS gene expression in human tissue.

The role of nutrition and nutritional supplements in women's health

OBJECTIVE

To review the current literature on nutrition to provide a basis for counseling patients.

DESIGN

Literature review.

RESULT(S)

Studies on nutrition and nutritional supplements in women's health are found primarily in literature not typically read by reproductive endocrinologists and gynecologist/obstetricians. A surprising number of people do not receive the vitamins and minerals that they need. Soy and soy isoflavones should be considered an important part of the diet.

CONCLUSION(S)

A better understanding of nutrition and nutritional supplements may reduce or prevent illness, saving the health care system millions of dollars each year.

Human sperm cryobanking. Use of modified liquid nitrogen vapor

OBJECTIVE

To study a modified liquid nitrogen vapor cryopreservation technique for human spermatozoa.

STUDY DESIGN

The freezing rate of the modified liquid nitrogen vapor method was controlled using thermocouple probes to simultaneously measure the temperature of both the liquid nitrogen vapor and semen specimen. Sperm cryosurvival and postthaw velocity were compared using a programmable biologic freezer and our modified vapor freezing procedure.

RESULTS

There were no significant differences in postthaw sperm viability between the two methods.

CONCLUSION

This modified vapor freezing technique permits controlled cooling that is efficient, rapid and inexpensive.

Expression of Wilms' tumor suppressor gene (WT1) in term human trophoblast: regulation by cyclic adenosine 3',5'-monophosphate

The Wilms' tumor suppressor gene (WT1), which is deleted in some Wilms' tumors, encodes a zinc finger transcription factor. We studied WT1 messenger ribonucleic acid (mRNA) in human term placenta and cytotrophoblasts differentiating into syncytiotrophoblasts in vitro by RT-PCR. The results suggest that WT1 mRNA is expressed in the trophoblasts in a cell-specific fashion. WT1 mRNA expression has been observed to decline remarkably in trophoblast cells after 72 h, when these cells are morphologically differentiated into multinucleated syncytiotrophoblasts. As it is well known that cAMP as a second messenger plays a significant role in cellular proliferation and differentiation of placental cells, we examined the effect of 8-bromo-cAMP on WT1 mRNA expression in undifferentiated cytotrophoblasts and differentiated syncytiotrophoblasts. We observed that cAMP enhanced WT1 mRNA expression in cytotrophoblasts, but remained ineffective in altering WT1 mRNA in syncytiotrophoblasts. In summary, the results of this investigation demonstrate that the WT1 gene is developmentally regulated during trophoblast differentiation. An involvement of the cAMP-mediated system in regulating the WT1 gene in the trophoblast is suggested.

Preimplantation genetic diagnosis of chromosome balance in embryos from a patient with a balanced reciprocal translocation

Duplications or deletions are present in a high percentage of the gametes produced by individuals carrying balanced translocations. Preimplantation genetic diagnosis was used to examine chromosome balance in embryos from a patient having a reciprocal translocation within the short arms of chromosomes 5 and 8 (46,XX,t(5;8)(p13;p23)). This woman has two sisters with the translocation unbalanced, resulting in a partial trisomy for chromosome 5 and partial monosomy for chromosome 8 (46,XX,-8, +der(8)t(5;8)(p13;p23)) with associated mental retardation and physical abnormalities. The patient and her husband desired to have children without the abnormal chromosome balance and wished to reduce the likelihood of spontaneous abortion or need for therapeutic abortion. Fluorescence in-situ hybridization (FISH) probes for the alpha-satellite region of chromosome 8 and for a region on the short arm of chromosome 5 (5p15.2) were tested initially on lymphocytes from the patient and her sisters. The hybridization signal for chromosome 5 was detected in the expected two copies for the patient and three copies for the sisters in 87% of the cells. Two hybridization signals for chromosome 8 were detected in 96% of the cells from all individuals. Additional probe testing was done using blastomeres from polyspermic embryos. The couple then proceeded with a stimulated in-vitro fertilization (IVF) cycle and biopsies were done on 13 embryos at the 7-10-cell stage using a method of zona drilling and fluid displacement. Diagnosis was possible on at least one blastomere for nine embryos. Three embryos had nuclei with three hybridization signals for chromosome 5, three had fewer than two signals for one or both chromosomes, one was mosaic, and two had two signals for each chromosome. The latter were transferred to the patient, but pregnancy was not achieved. The results demonstrate that preimplantation genetic diagnosis for patients with reciprocal translocations can be used to identify embryos having normal chromosome balance. The potential advantages and limitations of this approach are discussed.

Transvaginal amniotic puncture for cytogenetic evaluation of missed abortions

Transvaginal amniotic puncture (TAP) was performed on 20 consecutive missed abortions immediately prior to dilatation and evacuation and the cytogenetic results compared. The information received from products of conception (POC) and TAP was in concordance in only 5 of 20 (25%) cases. Tissue obtained from POC yielded cells in all instances. However, only 3 of 20 POC samples yielded findings other than normal female. In contrast, 92.8% of the conclusive diagnoses would have been achieved by TAP alone. These data strongly suggest that TAP is superior to POC for accurate cytogenetic assessment of missed abortion and should lead to a reevaluation of our current understanding and management of pregnancy loss.

Preimplantation development of mouse and human embryos biopsied at cleavage stages using a modified displacement technique

A modified embryo biopsy method was tested on four- and eight-cell stage mouse embryos and used on human embryos to obtain blastomeres for preimplantation genetic diagnosis. The biopsy method tested combines zona drilling and fluid displacement to force one or two cells through an opening in the zona pellucida of the cleavage-stage embryo. Rates of cell division and the percentage of mouse embryos forming blastocysts following biopsy at the eight-cell stage were not significantly different from those observed in unoperated control embryos. The percentage blastocyst formation was not significantly different in embryos biopsied at the four-cell stage and in control embryos, although cell division was significantly retarded following biopsy. 96% of the mouse blastomeres isolated at the eight-cell stage were recovered intact and 96% of those placed in culture underwent cell division. Survival and division of cells isolated at the four-cell stage were 92 and 84% respectively. Most of the cultured blastomeres cleaved several times and formed small trophoblast vesicles. Chromosomes were observed in 59% of blastomeres incubated in the presence of colcemid. In the initial use of this biopsy technique for human preimplantation genetic diagnosis, blastocyst formation was observed in 9 of 13 human embryos biopsied at the 7- to 10-cell stage. These findings support the use of this biopsy method as an alternative to aspiration techniques.

The developmental potential of mouse oocytes matured in serum-free culture conditions

Studies were undertaken to identify serum-free conditions for the maturation of mouse oocytes in vitro. Oocytes were recovered from the antral follicles of juvenile mice 48 h after injection with gonadotrophin and allowed to resume meiosis in modified Ham's F-10 (mHF-10) medium unsupplemented or supplemented with bovine serum albumin (BSA), fetal calf serum, human pre-ovulatory serum, human follicular fluid or EDTA. They were inseminated 14-16 h later, scored for polar body extrusion after 4-6 h with spermatozoa, and transferred to protein-free mHF-10 for further development. In-vivo matured ova were inseminated and cultured in parallel as controls. Fertilization and development were scored as two cells 24 h after insemination and blastocysts 4 days following insemination respectively. Surprisingly, 41% of oocytes cultured in unsupplemented mHF-10 completed meiosis I, and of those, 50% fertilized; serum supplementation did not improve maturation or fertilization rates. Although the addition of human follicular fluid to the mHF-10 improved meiosis (69%) and fertilization (68% of eggs with polar bodies) to levels comparable with the in-vivo control eggs (79 and 66% respectively), BSA supplementation was equally beneficial. Blastocyst development varied, but within each maturation/fertilization group, the development from in-vitro matured eggs was comparable with embryos from in-vivo matured eggs. In addition, two out of eight 4-cell embryos from oocytes cultured in mHF-10 with BSA and EDTA gave rise to apparently normal pups following transfer to pseudopregnant recipients.(ABSTRACT TRUNCATED AT 250 WORDS)

Semen leukocytes: friends or foes?

OBJECTIVE

To test the hypothesis that male reproductive tract leukocytes function in the elimination of abnormal spermatozoa from ejaculated semen.

DESIGN

Semen specimens with > or = 2 x 10(6) nonspermatozoal cells/mL were examined for leukocytes and for mature sperm with ideal morphology.

SETTING

Andrology laboratory of a Center of Assisted Reproductive Technology.

RESULTS

Semen specimens with elevated concentrations of leukocytes contained a significantly higher frequency of sperm with ideal morphology than semen specimens with elevated numbers of immature germ cells and low numbers of leukocytes.

CONCLUSIONS

The direct correlation between leukocyte density and sperm with ideal morphology supports the concept that sperm surveillance is a normal function of male reproductive tract leukocytes. Understanding such germ cell-leukocyte interactions may provide valuable new insights into immunologic control mechanisms in male reproductive tract tissues.

Toward reducing risks and costs of egg donation: a preliminary report

OBJECTIVE

To use clomiphene citrate for ovarian stimulation of egg donors as a means of reducing the risk, discomfort, and inconvenience for egg donors and reducing costs for recipients.

DESIGN

Prospective nonrandomized clinical study.

SETTING

Private reproductive center.

PATIENTS

Egg donation recipients and their anonymous donors.

INTERVENTION

Clomiphene citrate was administered to egg donors rather than a GnRH agonist and gonadotropins before oocyte retrieval.

MAIN OUTCOME MEASURE

Pregnancy.

RESULTS

Eleven oocyte retrievals were performed and conception occurred in four cycles, three of which delivered.

CONCLUSION

Clomiphene citrate appears to be a reasonable less expensive method of ovarian stimulation for egg donation in normospermic males and appears more acceptable to potential donors.

Parameters that predict success for natural cycle in vitro fertilization-embryo transfer

OBJECTIVES

To analyze our natural cycle IVF-ET experience in order to identify parameters predictive for success.

DESIGN

Retrospective study.

SETTING

Private-based reproductive center.

PATIENTS

All patients who presented for IVF-ET interested in unmedicated cycles.

MAIN OUTCOME MEASURES

Routine monitoring for IVF-ET was performed. In addition, serum values for FSH, PRL, E2, and P were analyzed.

RESULTS

Day 3 FSH values were not useful, whereas elevated day 3 LH values adversely correlated with outcome. Age was the single most important predictor of success. With two cycles, 87.5% of pregnancies occurred.

CONCLUSION

With proper patient selection, natural cycle IVF-ET results can be substantially improved.

Fertilization and implantation

Recent advances in seemingly remote areas of investigation, i.e. yeast cell cycle research and DNA amplifications, have opened spectacular avenues for understanding reproduction. The new insights on the single cell and subcellular level of processes, such as egg maturation, sperm-egg interaction and implantation enhance, immensely, the power of assisted fertilization. These techniques, have become the mainstay of infertility therapy. This review focuses on the recent developments in these areas.

Expression and potential function of the c-mos proto-oncogene in human eggs

OBJECTIVE

To investigate the expression and possible function of the c-mos proto-oncogene in human eggs.

DESIGN

Eggs obtained as discarded material from assisted reproductive technology procedures were analyzed for c-mos messenger RNA by reverse transcriptase-polymerase chain reaction. As an approach to investigating c-mos function, we measured maturation-promoting factor (MPF) activity (histone H1 kinase) in eggs without and with inhibition of protein synthesis. Detection of RNA transcripts of c-raf was included as control.

RESULTS

Transcripts of c-mos were detected in small fractions of individual eggs, indicating that c-mos is abundantly transcribed. Inhibition of protein synthesis resulted in loss of MPF, leading to chromatin decondensation and reformation of a nucleus. C-raf maternal messages were also detectable in individual human eggs.

CONCLUSION

The c-mos proto-oncogene is an abundant maternal message in human eggs as in other species. The effects of inhibiting protein synthesis in human eggs are similar to those obtained in mouse and Xenopus eggs, either as a consequence of protein synthesis inhibition or specific ablation of c-mos RNA by injection of anti-sense oligonucleotides. The c-mos gene product is thus likely to play a critical role in human oocyte meiosis by regulating the activity of MPF.

Altered pulsatile secretion of luteinizing hormone in women with epilepsy

Menstrual disorders and infertility are common among women with epilepsy of temporal lobe origin (TLE). Reproductive endocrine disorders may be the cause. Polycystic ovarian syndrome (PCO) and hypothalamic amenorrhea (hypogonadotropic hypogonadism, HH), in particular, are significantly overrepresented and attributable to hypothalamic dysfunction. We therefore compared the hypothalamic function of 14 women with clinically and electrographically documented TLE with that of eight age-matched normal controls by determining the interictal pulse frequency and amplitude of luteinizing hormone (LH) secretion. Serum for LH measurement was drawn every 15 minutes from 8 AM to 4 PM in both groups. LH pulse frequency values were significantly more variable (p < 0.05) and lower (p < 0.05) among women with TLE than among controls. Women with left temporal EEG foci showed a trend toward higher pulse frequencies compared to women with right foci (p = 0.05 to 0.10). Among five women with reproductive endocrine disorders, the three with PCO had left-sided foci and average LH pulse frequency two times higher than that of the two women with HH, who had right-sided foci. Eight reproductively normal, medically treated women with TLE had significantly lower LH pulse frequencies than did the one reproductively normal, untreated woman with TLE (p < 0.05) and the eight normal controls (p < 0.001). These findings suggest that LH pulse frequencies in women with TLE may be influenced by the laterality of the epileptic focus, the reproductive endocrine status, and the use of antiseizure medications.

Proper selection of patients for intermediate-dose pure follicle stimulating hormone

Forty-four polycystic ovary syndrome (PCO) patients were treated for a total of 61 cycles with intermediate-dose pure follicle stimulating hormone (FSH). Patient selection was based on hyperandrogenism, oligoovulation and physical signs. Patients with multiple-factor infertility were excluded from the study. Seventeen conception cycles occurred in 17 patients (pregnancy cycles). The spontaneous abortion rate was 29.4%. Forty cycles did not result in conception (Nonpregnancy cycles, 23 patients). Treatment was discontinued in four patients who had suboptimal response. Sixteen pregnancies (94%) occurred within the first two treatment cycles. Pregnancy and nonpregnancy cycles were compared for characteristics associated with a successful outcome. The data suggest that (1) an intermediate-dose pure FSH protocol is most likely to be successful among more "classic" PCO patients, those with obesity, high body surface area, elevated luteinizing hormone/FSH ratio and higher testosterone; (2) if pregnancy is to occur, it is most likely to within two treatment cycles; and (3) ovarian hyperstimulation is more likely to occur in nonconception cycles.

The influence of epidermal growth factor on progesterone production by human granulosa--luteal cells in culture

Epidermal growth factor (EGF) stimulates progesterone production by human granulosa--luteal cells in culture. The present study investigated some of the parameters that affect the magnitude of human granulosa--luteal cells' response to EGF. Cells from pre-ovulatory follicles obtained 36 h post-human chorionic gonadotrophin (HCG) were cultured for 12 days with or without EGF (20 ng/ml). Medium was changed every 48 h and assayed for progesterone by radioimmunoassay. DNA content of the cultured cells was determined fluorometrically. EGF was added every other day to the culture medium, starting on either day 4, 6 or 8 of culture, up to day 10, and compared with controls. When EGF was initiated on day 4, the medium had significantly higher progesterone concentration than control samples on days 6, 8, 10 and 12 of culture (P < 0.01). When EGF was withheld until day 6 or 8, progesterone concentrations were not significantly higher than control values. When EGF was added on day 4 and discontinued on day 8 or 10, progesterone concentrations were reduced significantly (P < 0.001) compared with the group where EGF was added continuously from day 4 to 10. These data suggest that: (i) human granulosa--luteal cells require the early exposure and continuous presence of EGF for the stimulatory effect on progesterone secretion, (ii) cells not exposed initially to EGF do not respond in a similar way, (iii) EGF is capable of maintaining progesterone production for a period > 12 days. Therefore, normal luteal function may require the early and continuous presence of EGF.

The inhibitory effects of müllerian-inhibiting substance on epidermal growth factor induced proliferation and progesterone production of human granulosa-luteal cells

This study was undertaken to determine if Müllerian-inhibiting substance (MIS) could block basal and/or epidermal growth factor (EGF)-induced proliferation and progesterone production by cultured human granulosa-luteal cells. Cells from follicles of individual patients were pooled, counted, and aliquoted into Ham's F-10 medium containing 10% MIS-free female fetal calf serum at 37 C in 95% air and 5% CO2. After assessing viability, cells were counted on days 4, 8, 12, and 16 of culture. EGF was added every other day at 0.2, 2, and 20 ng/mL beginning on culture day 4. The greatest stimulatory effect of EGF on cell proliferation was observed at 20 ng/mL on days 12 and 16. EGF increased progesterone production per cell after 4 days exposure, but this effect was lost after 8 days. Granulosa-luteal cells were cultured with 0.2, 2, and 20 ng/mL immunoaffinity purified recombinant human MIS (rhMIS) or conditioned medium from Chinese hamster ovary cells transfected with the human MIS gene, beginning on culture day 4. rhMIS demonstrated its greatest inhibitory effect on cell proliferation at 20 ng/mL on day 16. The rhMIS decreased progesterone production per cell after 4 days exposure, but only in the higher doses. Maintaining EGF at 20 ng/mL and varying rhMIS yielded significant reduction in EGF-mediated proliferation and progesterone production per cell at 2 and 20 ng/mL rhMIS. These experiments demonstrate rhMIS inhibits basal and EGF-stimulated human granulosa-luteal cell proliferation and progesterone production.

Minimal endometriosis and intrauterine insemination: does controlled ovarian hyperstimulation improve pregnancy rates?

Fifty normally menstruating women staged laparoscopically as having minimal endometriosis were given an option to be treated with intrauterine insemination with or without ovarian stimulation. Twenty-five patients had unmedicated natural cycles (ie, no medication for follicular stimulation), and 25 underwent controlled ovarian hyperstimulation. All subjects received hCG to time ovulation, followed 36 hours later with intrauterine insemination. Sixteen pregnancies, eight in each group, resulted from a total of 132 cycles. The cumulative probabilities of conception for the first, second, and third cycles were 0.13, 0.26, and 0.38 in the natural-cycles group and 0.12, 0.25, and 0.34 in the medicated-cycles group, respectively (P greater than .05). Monthly fecundity was 0.14 for the natural-cycles group and 0.13 for the medicated-cycles group (P greater than .05). We conclude that there is no difference in pregnancy rates or monthly fecundity over a 3-month period with controlled ovarian hyperstimulation as opposed to natural cycles combined with intrauterine insemination.

Value of subcutaneous and intravenous pulsatile gonadotropin releasing hormone in polycystic ovary disease

Nine patients with clomiphene-resistant polycystic ovary disease (PCOD) were treated with pulsatile gonadotropin releasing hormone (GnRH). The patients were started on subcutaneous (SC) GnRH. If they failed to ovulate on SC therapy, intravenous (IV) therapy was administered. Nine patients were treated for a total of 22 cycles; 13 were SC and 9, IV. There were nine ovulatory cycles (41%); four were SC (31%) and five, IV (56%). Two conceptions occurred, both among the IV cycles. One conception was a singleton; the infant was delivered uneventfully at term. The second conception was quadruplets, with the delivery of four healthy infants at 36 weeks. These data suggest that ovulation and conception in clomiphene-resistant PCOD patients using pulsatile GnRH are more likely to occur after IV than SC administration. However, the overall pregnancy rate was not greater than with gonadotropin treatment, and the risk of multiple births after IV administration is potentially high.

Novel approaches to the management of hyperprolactinemia

With improved radiologic detection and monitoring of prolactinomas, the management has shifted away from surgery toward a more conservative approach and medical management. The natural course of a microadenoma appears to be that of a non-progression, and for asymptomatic patients serial radiologic monitoring for growth may be a safe form of management. For symptomatic women, medical management remains the primary mode of therapy. Although bromocriptine remains the most widely used dopamine agonist, its side effects and short half-life have led to the development of newer agonists with better tolerance and similar or superior efficacy. Patients who tolerate oral bromocriptine poorly may find the medication more acceptable when administered either parenterally as with Parlodel LA (Sandoz, Basel, Switzerland), or vaginally. Different medications that have similar efficacy and tolerance to bromocriptine such as pergolide or cabergoline [corrected] may also represent alternatives, as intolerance to one ergot agonist does not necessarily imply intolerance to another. CV-205-502 (Sandoz), a promising and new long-acting nonergot derivative, appears to be safe, effective, and very well tolerated.

Results of in vitro fertilization pregnancies: experience at Boston's Beth Israel Hospital

The outcomes of 65 consecutive pregnancies achieved by in vitro fertilization (IVF) at Boston's Beth Israel Hospital (BIH) were studied. A total of 38 infants were delivered from the 65 pregnancies. The rate of multiple gestation was 17%. Premature delivery occurred in 24% of the IVF patients, and the cesarean section rate was 45% (neither significant versus controls); there was one IVF maternal death. Tocolytic agents were used more often (P less than 0.25) in IVF pregnancies than in controls, but no other pregnancy complication was statistically more frequent. The IVF perinatal mortality rate was 26.3 per 1,000. Of the BIH IVF infants, 55% had problems in the immediate neonatal period (P less than .01 compared with controls), and 37% of the IVF neonates required transfer to the neonatal intensive care unit. Congenital defects, including minor ones, were present in 8.6% of the IVF newborns. We concluded that IVF pregnancies and deliveries require careful monitoring.

The mind/body program for infertility: a new behavioral treatment approach for women with infertility

There is increasing evidence that a behavioral treatment approach might be efficacious in the treatment of the emotional aspects of infertility and may lead to increased conception rates. The first 54 women to complete a behavioral treatment program based on the elicitation of the relaxation response showed statistically significant decreases in anxiety, depression, and fatigue as well as increases in vigor. In addition, 34% of these women became pregnant within 6 months of completing the program. These findings established a role for stress reduction in the long-term treatment of infertility. They further suggest that behavioral treatment should be considered for couples with infertility before or in conjunction with reproductive technologies such as intrauterine insemination and gamete intrafallopian transfer.

The effect of endometriomas on in vitro fertilization outcome

To determine the effect of ovarian endometriomas on in vitro fertilization (IVF) outcome, two groups of patients were studied. Group I consisted of seven patients with ovarian endometriomas and severe pelvic adhesions treated for a total of 12 cycles. Group II patients consisted of eight patients with hydrosalpinges and comparable pelvic adhesions treated for a total of 27 cycles. There were no differences in the number of days required for stimulation or in the serum estradiol levels attained between the two groups. Group I patients were noted to have significantly fewer preovulatory follicles (1.42 vs 3.33, P less than 0.005), cycles with fertilization (28 vs 84%, P less than 0.005), and embryos transferred (0.78 vs 2.56, P = 0.01) than Group II patients. Three pregnancies occurred in Group II, while there were no conceptions among Group I patients. This study suggests that the presence of an ovarian endometrioma(s) has an adverse effect on IVF outcome and suggests that patients with ovarian endometriomas should have them removed prior to undergoing IVF.

Periovulatory follicular fluid hormone levels in spontaneous human cycles

We measured follicular fluid hormone levels in 48 normally cycling infertile women who underwent follicle puncture and oocyte retrieval during diagnostic laparoscopy at time-bracketed intervals after an endogenous LH surge. Follicular fluid LH, FSH, PRL, estrone (E1), estradiol (E2), progesterone (P), androstenedione (A), and testosterone (T) concentrations and P/E2 and A/E2 ratios were determined. Oocytes were classified as germinal vesicle (gv), metaphase I (mI), metaphase II (mII), or degenerating (dg). Follicular fluid (ff) hormone levels then were correlated with the stage of oocyte maturation. There were no differences in ff E1 or E2 levels at any stage of oocyte maturation, except that the mean ff E2 concentration was significantly (P less than 0.05) lower in ff containing dg oocytes [2,474 +/- 1,435 (+/- SE) nmol/L] than in those containing the other oocyte stages. The mean P levels were significantly (P less than 0.0001) higher in ff containing mI (48,781 +/- 10,240 nmol/L) and mII (41,801 +/- 11,098 nmol/L) oocytes than in ff containing gv oocytes (1371 +/- 696 nmol/L). The mean A level was highest (P less than 0.01) in dg-associated ff. Similarly, T was highest (P less than 0.05) in ff containing dg (52 +/- 14 nmol/L) oocytes than in ff containing mI (10.7 +/- 10.1 nmol/L) or mII (10.1 +/- 4 nmol/L) oocytes, and it was also elevated (P less than 0.05) in gv ff (72 +/- 33 nmol/L) compared to mII ff. The above differences also were reflected in the P/E2 ratio, which was significantly higher (P less than 0.05) in mI and mII ff, as well as in the A/E2 ratio, which was higher (P less than 0.05) in ff containing mI and mII oocytes compared to ff containing gv or dg oocytes. These data define the evolving changes in the microenvironment of the follicular fluid of preovulatory follicles of normally cycling women. They also provide reference points for analysis of ff obtained from women during stimulated cycles intended for in vitro fertilization.

The effect of clomiphene citrate on human preovulatory oocyte maturation in vivo

Sixty-four infertile women underwent diagnostic laparoscopy in the periovulatory period at time-bracketed intervals following their endogenous luteinizing hormone (LH) surge. Forty-eight of these women were studied during natural cycles and 16 had mild oligoovulation and were administered clomiphene citrate (CC) to regulate their cycles. No patient received human chorionic gonadotropin. No patient was undergoing either in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT). Follicle puncture was performed and the oocytes were observed immediately for stage of maturation. Oocytes obtained from follicles exposed to CC were found to require an increased interval of time to reach metaphase I compared to oocytes obtained from natural cycles (27.75 +/- 2.2 vs 22.5 hr; mean +/- SE). Furthermore, the interval of time required for metaphase I oocytes to achieve metaphase II was statistically significantly shortened for CC cycles (2.4 hr for CC vs 10 hr for natural cycles. Nevertheless, there was no difference between natural and CC cycles in the time interval between LH surge onset and ovulation. These in vivo findings suggest a direct effect of CC on human oocyte maturation and may help explain the well-established discrepancy between the relatively high ovulation rate and the relatively low conception rate in clomiphene-induced cycles.

Hysterosalpingography in perspective: the predictive value of oil-soluble versus water-soluble contrast media

This study of HSG in infertile patients compares the predictive values of OSCM with WSCM, relative to the laparoscopic diagnosis. The OSCM was found to have better sensitivity and higher predictive value for pelvic disease than the WSCM. HSG and laparoscopy are adjunctive procedures, which are not mutually exclusive.

Evaluation and therapy of polycystic ovarian syndrome

The amenorrhea associated with bilateral polycystic ovaries, described by Stein and Leventhal, actually represents a syndrome involving various organs and systems. Clinically, this symptom complex commonly presents as menstrual disturbances, infertility, excessive body weight, and hirsutism. An understanding of the pathophysiology that underlies these symptoms provides a logical basis for evaluation and treatment of the syndrome. The diagnostic approach may involve biochemical determinations (baseline, stimulated, and suppressed) and radiologic testing. Therapy is directed at chronic anovulation, the hyperandrogenism responsible for hirsutism and acne, and the prophylaxis against endometrial and breast carcinomas. Ovulation can be induced with various agents, many of which have a risk of ovarian hyperstimulation in the PCOD patient. The use of GnRH agonists with HMG or FSH for ovulation induction will probably increase in the future. Although classic wedge resection has little place in modern management of PCOD, the recent laparoscopic ovarian cautery remains largely unstudied with respect to long-term postoperative plasma androgen levels and pelvic adhesions. It is too premature to evaluate this new surgical therapy. Hirsutism is effectively treated with estrogen-progestin combinations, medroxyprogesterone acetate, androgen receptor blockers (spironolactone, cimetidine, cyproterone acetate, and cyproheptadine), and glucocorticoids. To date, the available GnRH agonists have not been found selective enough to be used in the treatment of hirsutism, owing to possible long-term complications. Most medical approaches should include electrolysis for permanent hair removal. At present, gynecologic surgery seems to have little place in the management of hirsutism.

The circadian rhythm of plasma melatonin during the normal menstrual cycle and in amenorrheic women

Plasma melatonin, PRL, and LH levels were measured in samples collected every 2 h for 24 h from 14 normally cycling women during the early follicular, periovulatory, and luteal phases of their menstrual cycles. Plasma melatonin levels also were measured in samples collected at the same interval from 7 patients with hypothalamic amenorrhea. A distinct daily rhythm in plasma melatonin was evident in all subjects, with peaks occurring around 0300 h. Each woman's rhythm was remarkably consistent throughout the menstrual cycle (in terms of the phase, amplitude, and total melatonin secreted). Plasma PRL levels also exhibited daily rhythms which did not change during the menstrual cycle; the nocturnal peak plasma PRL level tended to occur 1-2 h after that for melatonin. Among the amenorrheic women, both daytime and nighttime melatonin levels were significantly higher (P less than 0.005) than in the normal women. Their plasma PRL levels were similar to those in the normal women. We conclude that, as for PRL, the circadian rhythm of melatonin secretion does not change significantly during the normal menstrual cycle. The elevated plasma melatonin levels in women with hypothalamic amenorrhea suggest that the hormone may be involved in the neuroendocrine pathology underlying this disorder.

A comparison of the effects of Buserelin versus danazol on plasma lipoproteins during treatment of pelvic endometriosis

Twelve patients receiving Buserelin and seven patients receiving danazol for treatment of endometriosis were studied to assess the effect of medication on plasma lipoproteins. Danazol significantly lowered plasma HDL-C levels at 6 months of treatment. Total plasma cholesterol was elevated at 6 months of therapy in the Buserelin group. No effect by either drug on plasma triglycerides was seen.

Characteristics of in vitro steroidogenesis in a woman with hyperandrogenism, a granulosa cell tumor and polycystic ovary disease. A case report

A 20-year-old woman presented with hyperandrogenism presumed to be due to an androgen-secreting granulosa cell tumor. In order to confirm this unusual presentation, short-term tissue culture steroidogenesis of the granulosa cell tumor and contralateral polycystic ovary was performed. Testosterone and androstenedione were produced only by the polycystic ovary, whereas the tumor was producing estradiol and progesterone. The studies of in vitro steroidogenesis prevented an incorrect interpretation of the clinical presentation.