Efficacy of AT in pre-eclampsia: a case-control prospective trial

Pre-eclampsia is an extremely severe condition. It is associated with vasospasm, activation of the coagulation system and abnormal haemostasis. In pre-eclamptic patients increased plasmatic concentrations of fibronectin, laminin, von Willebrand factor (VWF) and endothelin are observed. Experimental studies on rats have also shown that the doses of antithrombin III (AT) needed to mediate anti-inflammatory processes are much higher than those required to obtain the anti-coagulant effect. The study aimed to evaluate the clinical efficacy of treatment with high AT doses (HD) in comparison with standard doses (SD). The primary endpoint was the prolongation of pregnancy defined as time (in days) from enrollment to delivery and to assess the maternal bleeding at and after delivery. The secondary endpoint was to demonstrate a role for AT in controlling haemostasis at conventional doses, and the inflammatory state at higher doses. The biochemical parameters assessed were: AT activity (%), Fibronectin (Fn), Fibrinogen, D-dimer, Uricemia, Proteinuria 24h, Protein C Reactive (PCR), Granulocyte Elastase and Endothelin. This study included 23 pre-eclamptic women. Patients were randomly subdivided into two groups: 10 patients (“cases”) were treated with high doses of AT (6 vials: 3000 units) once daily for 5 days, or until delivery, while 13 women (“controls”) were treated with doses of AT sufficient to maintain at least 80% of the activity. High-dose therapy was associated with prolongation of pregnancy by 2.5 days more when compared with controls (p = 0.03; Mann-Whitney test). The incidence of clinical significant bleeding was lower in cases than in controls (mean 550 mL vs. 650 mL, respectively). Preventiveand conservative-type treatment of moderatesevere pre-eclampsia, based on the administration high doses of AT, allows a significant prolongation of pregnancy, and thus a better neonatal outcome, as well as less maternal intra-and post-operative bleeding. Fn, PCR and elastase levels (markers of inflammation) decrease in the HD group in comparison with SD group. In the HD group, the AT plasma levels were obviously higher both at the end of the treatment (p < 0.0001) and after delivery (p = 0.03), in comparison with SD group. The fibrinogen and D-dimer levels were above the reference interval in both groups. TPA and PAI 1 were found to be significantly raised in the course of pre-eclampsia. In conclusion, the biochemical findings support a role for AT in controlling the haemostasis at conventional doses, and the inflammatory state at higher doses.

Luteal phase support for assisted reproduction cycles

BACKGROUND

Progesterone prepares the endometrium for pregnancy by stimulating proliferation in response to human chorionic gonadotropin(hCG) produced by the corpus luteum. This occurs in the luteal phase of the menstrual cycle. In assisted reproduction techniques(ART), progesterone and/or hCG levels are low, so the luteal phase is supported with progesterone, hCG or gonadotropin-releasing hormone (GnRH) agonists to improve implantation and pregnancy rates.

OBJECTIVES

To determine the relative effectiveness and safety of methods of luteal phase support provided to subfertile women undergoing assisted reproduction.

SEARCH METHODS

We searched databases including the Cochrane Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO and trial registers. We conducted searches in November 2014, and further searches on 4 August 2015.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of luteal phase support using progesterone, hCG or GnRH agonist supplementation in ART cycles.

DATA COLLECTION AND ANALYSIS

Three review authors independently selected trials, extracted data and assessed risk of bias. We calculated odds ratios (ORs) and 95%confidence intervals (CIs) for each comparison and combined data when appropriate using a fixed-effect model. Our primary out come was live birth or ongoing pregnancy. The overall quality of the evidence was assessed using GRADE methods.

MAIN RESULTS

Ninety-four women RCTs (26,198 women) were included. Most studies had unclear or high risk of bias in most domains. The main limitations in the evidence were poor reporting of study methods and imprecision due to small sample sizes.1. hCG vs placebo/no treatment (five RCTs, 746 women)There was no evidence of differences between groups in live birth or ongoing pregnancy (OR 1.67, 95% CI 0.90 to 3.12, three RCTs,527 women, I2 = 24%, very low-quality evidence, but I2 of 61% was found for the subgroup of ongoing pregnancy) with a random effects model. hCG increased the risk of ovarian hyperstimulation syndrome (OHSS) (1 RCT, OR 4.28, 95% CI 1.91 to 9.6, low quality evidence).2. Progesterone vs placebo/no treatment (eight RCTs, 875 women)Evidence suggests a higher rate of live birth or ongoing pregnancy in the progesterone group (OR 1.77, 95% CI 1.09 to 2.86, five RCTs, 642 women, I2 = 35%, very low-quality evidence). OHSS was not reported.3. Progesterone vs hCG regimens (16 RCTs, 2162 women)hCG regimens included comparisons of progesterone versus hCG and progesterone versus progesterone + hCG. No evidence showed differences between groups in live birth or ongoing pregnancy (OR 0.95, 95% CI 0.65 to 1.38, five RCTs, 833 women, I2 = 0%, low quality evidence) or in the risk of OHSS (four RCTs, 615 women, progesterone vs hCG OR 0.54, 95% CI 0.22 to 1.34; four RCTs,678 women; progesterone vs progesterone plus hCG, OR 0.34, 95% CI 0.09 to 1.26, low-quality evidence).4. Progesterone vs progesterone with oestrogen (16 RCTs, 2577 women)No evidence was found of differences between groups in live birth or ongoing pregnancy (OR 1.12, 95% CI 0.91 to 1.38, nine RCTs,1651 women, I2 = 0%, low-quality evidence) or OHSS (OR 0.56, 95% CI 0.2 to 1.63, two RCTs, 461 women, I2 = 0%, low-quality evidence).5. Progesterone vs progesterone + GnRH agonist (seven RCTs, 1708 women)Live birth or ongoing pregnancy rates were lower in the progesterone-only group and increased in women who received progester one and one or more GnRH agonist doses (OR 0.62, 95% CI 0.48 to 0.81, nine RCTs, 2861 women, I2 = 55%, random effects, low quality evidence). Statistical heterogeneity for this comparison was high because of unexplained variation in the effect size, but the direction of effect was consistent across studies. OHSS was reported in one study only (OR 1.00, 95% CI 0.33 to 3.01, 1 RCT, 300 women, very low quality evidence).6. Progesterone regimens (45 RCTs, 13,814 women)The included studies reported nine different comparisons between progesterone regimens. Findings for live birth or ongoing pregnancy were as follows: intramuscular (IM) versus oral: OR 0.71, 95% CI 0.14 to 3.66 (one RCT, 40 women, very low-quality evidence);IM versus vaginal/rectal: OR 1.24, 95% CI 1.03 to 1.5 (seven RCTs, 2309 women, I2 = 71%, very low-quality evidence); vaginal/rectal versus oral: OR 1.19, 95% CI 0.83 to 1.69 (four RCTs, 857 women, I2 = 32%, low-quality evidence); low-dose versus high-dose vaginal: OR 0.97, 95% CI 0.84 to 1.11 (five RCTs, 3720 women, I2 = 0%, moderate-quality evidence); short versus long protocol:OR 1.04, 95% CI 0.79 to 1.36 (five RCTs, 1205 women, I2 = 0%, low-quality evidence); micronised versus synthetic: OR 0.9, 95%CI 0.53 to 1.55 (two RCTs, 470 women, I2 = 0%, low-quality evidence); vaginal ring versus gel: OR 1.09, 95% CI 0.88 to 1.36 (oneRCT, 1271 women, low-quality evidence); subcutaneous versus vaginal gel: OR 0.92, 95% CI 0.74 to 1.14 (two RCTs, 1465 women,I2 = 0%, low-quality evidence); and vaginal versus rectal: OR 1.28, 95% CI 0.64 to 2.54 (one RCT, 147 women, very low-quality evidence). OHSS rates were reported for only two of these comparisons: IM versus oral, and low versus high-dose vaginal. No evidence showed a difference between groups.7. Progesterone and oestrogen regimens (two RCTs, 1195 women)The included studies compared two different oestrogen protocols. No evidence was found to suggest differences in live birth or ongoing pregnancy rates between a short and a long protocol (OR 1.08, 95% CI 0.81 to 1.43, one RCT, 910 women, low-quality evidence) or between a low dose and a high dose of oestrogen (OR 0.65, 95% CI 0.37 to 1.13, one RCT, 285 women, very low-quality evidence).Neither study reported OHSS.

AUTHORS' CONCLUSIONS

Both progesterone and hCG during the luteal phase are associated with higher rates of live birth or ongoing pregnancy than placebo.The addition of GnRHa to progesterone is associated with an improvement in pregnancy outcomes. OHSS rates are increased with hCG compared to placebo (only study only). The addition of oestrogen does not seem to improve outcomes. The route of progester one administration is not associated with an improvement in outcomes.

Endometrial thickness affects the outcome of in vitro fertilization and embryo transfer in normal responders after GnRH antagonist administration

BACKGROUND

The goal of this study was to assess the association between endometrial thickness on the chorionic gonadotropin (hCG) day and in vitro fertilization and embryo transfer (IVF-ET) outcome in normal responders after GnRH antagonist administration.

METHODS

A retrospective cohort study was performed in normal responders with GnRH antagonist administration from January 2011-December 2013. Patients were divided into four groups according to endometrial thickness, as follows: <7 mm (group 1), > = 7- < 8 mm (group 2), > = 8- < 14 mm (group 3), and > =14 mm (group 4).

RESULTS

A total of 2106 embryo transfer cycles were analyzed. The pregnancy rate (PR) was 44.87%.The clinical pregnancy rate, ongoing pregnancy rate and the implantation rate (17.28%, 13.79%, 10.17%, respectively) were significantly lower in group 1 compared to the other three groups (p < 0.05). The miscarriage rate was higher in patients with endometrial thickness less than 7 mm. The clinical pregnancy rate, ongoing pregnancy rate and implantation rate were highest in patients with endometrial thickness higher than 14 mm, but showed no difference in patients with those of endometrial thickness between 8-14 mm.

CONCLUSIONS

There is a correlation between endometrial thickness measured on hCG day and clinical outcome in normal responders with GnRH antagonist administration. The pregnancy rate was lower in patients with endometrial thickness less than 7 mm compared with patients with endometrial thickness more than 7 mm.

Administration of angiotensin II and a bradykinin B2 receptor blocker in midpregnancy impairs gestational outcome in guinea pigs

BACKGROUND

The opposing renin-angiotensin system (RAS) and kallikrein-kinin system (KKS) are upregulated in pregnancy and localize in the utero-placental unit. To test their participation as counter-regulators, circulating angiotensin II (AII) was exogenously elevated and the bradykinin B2 receptor (B2R) was antagonized in pregnant guinea-pigs. We hypothesized that disrupting the RAS/KKS balance during the period of maximal trophoblast invasion and placental development would provoke increased blood pressure, defective trophoblast invasion and a preeclampsia-like syndrome.

METHODS

Pregnant guinea-pigs received subcutaneous infusions of AII (200 μg/kg/day), the B2R antagonist Bradyzide (BDZ; 62.5 microg/kg/day), or both (AII + BDZ) from gestational day 20 to 34. Non-pregnant cycling animals were included in a control group (C NP) or received AII + BDZ (AII + BDZ NP) during 14 days. Systolic blood pressure was determined during cycle in C NP, and on the last day of infusion, and 6 and 26 days thereafter in the remaining groups. Twenty six days after the infusions blood and urine were extracted, fetuses, placentas and kidneys were weighed, and trophoblast invasion of spiral arteries was defined in the utero-placental units by immunocytochemistry.

RESULTS

Systolic blood pressure transiently rose in a subgroup of the pregnant females while receiving AII + BDZ infusion, but not in AII + BDZ NP. Plasma creatinine was higher in AII- and BDZ-treated dams, but no proteinuria or hyperuricemia were observed. Kidney weight increased in AII + BDZ-treated pregnant and non-pregnant females. Aborted and dead fetuses were increased in dams that received AII and AII + BDZ. The fetal/placental weight ratio was reduced in litters of AII + BDZ-treated mothers. All groups that received interventions during pregnancy showed reduced replacement of endothelial cells by extravillous trophoblasts in lateral and myometrial spiral arteries.

CONCLUSIONS

The acute effects on fetal viability, and the persistently impaired renal/placental sufficiency and incomplete arterial remodeling implicate the RAS and KKS in the adaptations in pregnancy. The results partially confirm our hypothesis, as a preeclampsia-like syndrome was not induced. We demonstrate the feasibility of characterizing systemic and local modifications in pregnant guinea-pig, supporting its use to study normal placentation and related disorders.

Pharmacological use of progesterone and 17-alpha-hydroxyprogesterone caproate in the prevention of preterm delivery

Preterm delivery (PTD) is defined by the World Health Organization as birth before 37 completed weeks of gestation. In Western countries, PTD accounts for over 75% of all perinatal morbidity and mortality. The social importance of PTD derives from the consideration that it causes near three quarter of neonatal deaths not caused by malformations. Progesterone is a steroid hormone which plays a crucial role in each step of human pregnancy. Early in pregnancy progesterone is produced by the corpus luteum and it is fundamental for pregnancy maintenance until placenta takes over this function at 7-9 weeks of gestation. Late in pregnancy, the role of progesterone is less clear: certainly, it may be importance in maintaining uterine quiescence in the latter half of pregnancy by limiting the production of stimulatory prostaglandins and inhibiting the expression of contraction-associated protein genes (ion channels, oxytocin and prostaglandin receptors, and gap junctions) within the myometrium. In this review, the authors included those controlled clinical studies that have used either 17 hydroxy progesterone caproate (17P), or progesterone (P) or its synthetic derivatives (progestins) in order to avoid or reduce the incidence of preterm delivery, in populations of women at increased risk of preterm birth. The authors conclude that: 1) the treatment with 17P reduces the incidence of PTD in pluriparous women with a previous history of PTD or with recurrent abortion, as well as in nulliparous women with an actual risk; 2) the treatment with P reduces PTD in nulliparous women, namely in the presence of a silent cervical shortening; 3) 17P has no efficacy in multiple pregnancy and it is proven not to have adverse effects on the infants.

Comparative analysis of the uterine and mammary gland effects of drospirenone and medroxyprogesterone acetate

The role of progestins in combined hormone therapy is the inhibition of uterine epithelial cell proliferation. The Women's Health Initiative study provided evidence for an increased risk of breast cancer in women treated with conjugated equine estrogens plus the synthetic progestin medroxyprogesterone acetate (MPA), compared with conjugated equine estrogens-only treatment. These findings continue to be discussed, and it remains to be clarified whether the results obtained for MPA in the Women's Health Initiative study are directly applicable to other progestins used in hormone therapy. In this study we compared in a mouse model the effects of the synthetic progestins, MPA, and drospirenone in two major target organs: the uterus and mammary gland. As quantitative measures of progestin activity, we analyzed maintenance of pregnancy, ductal side branching in the mammary gland, and proliferation of mammary and uterine epithelial cells as well as target gene induction in both organs. The outcome of this study is that not all synthetic progestins exhibit the same effects. MPA demonstrated uterine activity and mitogenic activity in the mammary gland at the same doses. In contrast, drospirenone behaved similarly to the natural hormone, progesterone, and exhibited uterine activity at doses lower than those leading to considerable proliferative effects in the mammary gland. We hypothesize that the safety of combined hormone therapy in postmenopausal women may be associated with a dissociation between the uterine and mammary gland activities of the progestin component.

Atrazine and reproductive function: mode and mechanism of action studies

Atrazine, a chlorotriazine herbicide, is used to control annual grasses and broadleaf weeds. In this review, we summarize our laboratory's work evaluating the neuroendocrine toxicity of atrazine (and related chlorotriazines) from an historic perspective. We provide the rationale for our work as we have endeavored to determine: 1) the underlying reproductive changes leading to the development of mammary gland tumors in the atrazine-exposed female rat; 2) the cascade of physiological events that are responsible for these changes (i.e., the mode of action for mammary tumors); 3) the potential cellular mechanisms involving adverse effects of atrazine; and 4) the range of reproductive alterations associated with this pesticide.

Early pregnancy failure induced by dibutyltin dichloride in mice

In this study, we examined the adverse effects of dibutyltin on initiation and maintenance of pregnancy after maternal administration during early pregnancy in mice. Following successful mating, female ICR mice were given dibutyltin dichloride (DBTCl) at 0, 7.6, 15.2, or 30.4 mg/kg bw/day by gastric intubation on days 0-3 or days 4-7 of pregnancy. Female mice were sacrificed on day 18 of pregnancy, and the pregnancy outcome was determined. After administration of DBTCl on days 0-3, the rate of nonpregnant females and the incidence of preimplantation embryonic loss were significantly increased at 30.4 mg/kg bw/day. The incidences of postimplantation embryonic loss in females given DBTCl on days 0-3 at 15.2 mg/kg and higher and on days 4-7 at 7.6 mg/kg bw/day and higher were increased. No increase in the incidence of fetuses with external malformations was observed after the administration of DBTCl on days 0-3 or days 4-7. A decline in the serum progesterone levels was detected in mice given DBTCl at 30.4 mg/kg bw/day on days 0-3 or days 4-7 of pregnancy. The data show that DBTCl adversely affects the initiation and maintenance of pregnancy when administered during early pregnancy in mice and suggest that the decline in serum progesterone levels is responsible for pregnancy failure.

Comparisons of maternal and perinatal outcomes in Taiwanese women with complete and partial HELLP syndrome and women with severe pre-eclampsia without HELLP

AIM

To analyze the variations between maternal complications and perinatal outcome among women with complete hemolysis, elevated liver enzyme levels, and low platelet count (HELLP) syndrome, partial HELLP syndrome, and women with severe pre-eclampsia and normal laboratory tests. We also examine the effect of corticosteroid therapy for treatment of HELLP.

METHODS

In this retrospective study, six patients with complete HELLP syndrome and 46 with partial HELLP syndrome, were compared and contrasted with 212 patients with severe pre-eclampsia but without HELLP syndrome.

RESULTS

In Protocol 1, multiple organ dysfunction syndrome (MODS) was the strongest morbidity factor associated with patients among complete HELLP, partial HELLP, and severe pre-eclampsia. After post-hoc analysis, disseminated intravascular coagulation (DIC) was the significant outcome variable between complete and partial HELLP. In Protocol 2, after adjustment, we found that MODS (adjusted OR, 15.2, 95% CI, 6.18-35.53; P < 0.001); Apgar score less than 5 at 1 minute (adjusted OR, 2.17, 95% CI, 0.94-5.01; P = 0.069) and DIC (adjusted OR, 9.51, 95% CI, 1.68-53.7, P = 0.011) remained significantly associated with HELLP syndrome. There was a favorable outcome found in the complete HELLP group. Neither the dexamethasone group nor the aggressive therapy group could benefit from the treatment protocol.

CONCLUSION

The different categories of HELLP syndrome, the protocol 1 and protocol 2 have been noted as differential effects on pregnancy outcome. MODS and DIC would be two significant outcome variables and corticosteroid therapy may not benefit HELLP patients.

Pregnancy, Bovine Somatotropin, and Dietary n-3 Fatty Acids in Lactating Dairy Cows: II. Endometrial Gene Expression Related to Maintenance of Pregnancy

The objectives were to examine the effects of bovine somatotropin (bST), pregnancy, and dietary fatty acids on expression of key endometrial genes and proteins regulating prostaglandin synthesis in lactating dairy cows. Two diets were fed, at about 17 d in milk (DIM), in which oil of whole cottonseed (control diet) was compared with calcium salts of fish oil-enriched lipid (FO). Ovulation was synchronized in cows with a presynchronization plus Ovsynch protocol and cows were inseminated artificially or not inseminated on d 0 (d 0 = time of synchronized ovulation; 77 +/- 12 DIM). On d 0 and 11, cows received bST (500 mg) or no bST, and were slaughtered on d 17 to recover uterine secretions and endometrial tissue. Number of cows in the control diet: 5 bST-treated cyclic (bST-C), 5 non-bST-treated cyclic (no bST-C), 4 bST-treated pregnant (bST-P), and 5 non-bST-treated pregnant (no bST-P) cows and in the FO diet: 4 bST-treated FO-cyclic (bST-FO-C) and 5 non-bST-treated cyclic (no bST-FO-C) cows. The FO diet increased progesterone receptor (PR) mRNA, and treatment with bST increased PR mRNA concentration in endometrium of no bST-C, but not in no bST-FO-C or no bST-P cows. Concentrations of estrogen receptor-alpha (ERalpha) mRNA and protein, and oxytocin receptor (OTR) mRNA were decreased in no bST-P cows compared with no bST-C cows. Treatment with bST tended to increase OTR and ERalpha mRNA concentrations in cyclic cows fed control or FO diets. Immunohistochemistry demonstrated effects of bST, FO, and pregnancy on distributions of ERalpha and PR proteins in endometrium. Pregnancy and FO feeding decreased ERalpha abundance in luminal epithelium. Prostaglandin H synthase-2 (PGHS-2) protein was elevated in pregnant cows and localized to the luminal epithelium. Both FO and bST treatments reduced staining intensity of PGHS-2 protein. Concentrations of prostaglandin E synthase mRNA were elevated in either cyclic or pregnant cows in response to bST, whereas bST decreased prostaglandin F synthase mRNA in pregnant cows. Uterine lumen fluids had more PGF2alpha and prostaglandin E2 in pregnant than cyclic cows. Uterine lumen fluids of bST-P cows contained more prostaglandin E2 than those from no bST-P cows. In summary, both pregnancy and bST altered endometrial gene expression, and cyclic cows responded differently to bST than pregnant cows. Feeding FO modulated PR, ERalpha, and PGHS-2 expression and distribution among endometrial cell types in a manner that may favor establishment and maintenance of pregnancy.

A randomised placebo-controlled trial of prolonged prednisolone administration to patients with HELLP syndrome remote from term

OBJECTIVES

To evaluate the effect of prolonged administration of high-dose prednisolone on early onset HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome during expectant management.

STUDY DESIGN

A randomized, double-blind trial was performed in 31 pregnant women with HELLP syndrome with an onset before 30 weeks gestation. Patients received either 50mg prednisolone or placebo intravenously twice a day. Primary outcome measures were the entry-to-delivery interval and the number of recurrent HELLP exacerbations in the antepartum period.

RESULTS

Serious maternal morbidity was considerable, in particular in the placebo group where even on maternal occurred as a consequence of liver rupture. The mean entry-delivery interval did not differ between the prednisolone group (6.9 days) and the placebo group (8.0 days). However, patients in the prednisolone group had a significant lower risk of a recurrent HELLP exacerbation after the initial crisis had subsided, as compared to patients in the placebo group (HR 0.3, with 95% CI 0.3-0.9). Platelet count recovered faster in the prednisolone group as compared to the placebo group (mean 1.7 days versus 6.2 days, P<0.01).

CONCLUSIONS

HELLP syndrome remote from term causes high risk for serious maternal morbidity and mortality. When expectant management is pursued in selected patients with a HELLP syndrome remote from term, prolonged administration of prednisolone reduces the risk of recurrent HELLP syndrome exacerbations.

Urinary oestradiol and testosterone levels from novel male mice approach values sufficient to disrupt early pregnancy in nearby inseminated females

Previous research has established that exposure to novel male mice can disrupt intrauterine implantation of fertilised ova in inseminated females and that much of this effect is mediated by factors in the male urine. The present studies were designed to examine whether the steroid content of male urine is sufficient to account for this effect. Pregnancy was terminated by exogenous 17β-oestradiol administered intranasally on days 2–4 after insemination in doses as low as 0.14 μg/day. Enzyme immunoassay indicated that male mouse urine reliably contains unconjugated 17β-oestradiol and testosterone. A small but significant increase in the amount of urinary oestradiol was observed in males housed nearby previously inseminated females as opposed to those housed in isolation. This influence was absent in the sire and absent in novel males when the sire was also present. The quantity of active steroids in novel male urine approaches the level sufficient to account for the disruption of implantation in nearby inseminated females.

Addition of platelet transfusions to corticosteroids does not increase the recovery of severe HELLP syndrome

OBJECTIVE

The objective was to evaluate the effect of dexamethasone and platelet transfusion treatment on recovery in patients with class 1 hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome.

MATERIAL AND METHODS

All women with class 1 HELLP syndrome (true HELLP syndrome) who were seen at the hospital Complejo Hospitalario de la Caja de Seguro Social de Panama, Panama between July 1996 and June 2004 took part in a retrospective, comparative study. They were divided into two groups. One group received dexamethasone and the other group received dexamethasone plus platelet transfusion. True HELLP syndrome was defined as hemolysis, elevated liver enzymes, and maternal platelet nadir < or =50,000 platelets/microl.

MAIN OUTCOME MEASURE

The primary endpoint was resolution of the HELLP syndrome as recognized by normalization of the platelet count (> or =150,000/microl) and the mean length (measured in days) of the postpartum stay in hospital.

RESULTS

Forty-six women with true HELLP syndrome were studied. Twenty-six patients received dexamethasone and 20 received dexamethasone plus platelet transfusion. The normalization of the platelet count was significantly more rapid in the dexamethasone group (p<0.004) and the postpartum hospital stay was significantly more prolonged in the dexamethasone plus platelet transfusion group (p<0.02). There was no maternal death.

CONCLUSIONS

The findings suggest the initiation of high-dose dexamethasone therapy in women with true HELLP syndrome, with the next step being delivery, and probably platelet count < or =50,000/microl alone is not always an indication for platelet transfusion.

Maintenance or interruption of pregnancy by human chorionic gonadotrophin in adrenalectomized albino rats

In the present study, we investigated the efficacy of human chorionic gonadotrophin (HCG) in the maintenance of pregnancy in adrenalectomized rats. Holtzman's strain albino rats were adrenalectomized on day 8 of pregnancy and at the same time were laparotomized to observe the number of implantations. Adrenalectomy on day 8 caused abortions or fetal resorption in almost all rats. Administration of 5 or 50 IU HCG in adrenalectomized rats, from day 8 through 14 or 19, was not able to maintain gestation, resulting in fetal resorption with many placentomas and placental scars. However, a single injection of 5 IU or 1 IU HCG administered on day 8 only maintained the pregnancy to full term in adrenalectomized rats. Hence, the present experiment indicates that replacement therapy of a single dose of 5 IU or 1 IU HCG might be sufficient for maintaining pregnancy in adrenalectomized rats.

Regulation of myometrial smooth muscle functions

Regulation of myometrial functions during gestation, labor and birth are in the forefront of research in reproductive sciences. The complexity of the problem is reflected by our scant understanding of the intimate cellular and molecular events underlying these phenomena, despite extensive efforts spanning several decades. Unlike other smooth muscles, the myometrium is, to a large extent, under hormonal control. Of these, the steroid hormones, progesterone and estrogen, play dominant roles in terms of uterine growth, the maintenance of quiescence during gestation and the preparation of the uterus for labor and delivery. In addition to steroid hormones, there are a number of factors that modulate myometrial contractility (oxytocin, prostaglandins, endothelin, platelet activating factor) and relaxation (corticotropin releasing hormone, prostacyclin, nitric oxide). Although notable advances have been made towards understanding some of the key steps in receptor signaling that define the actions of these factors, a good deal of new information is needed to fully understand this fundamental life process. Pharmaceutical agents have been used extensively to induce labor or to prolong pregnancy in the case of preterm labor that represents the major cause of perinatal morbidity and mortality. Because preterm labor is a syndrome of multiple etiologies, pharmacologic agents will have to be targeted accordingly. This review attempts to present a critical overview of these topics.

Drug intervention in early pregnancy after assisted reproductive technology

Implantation in humans is a complex, closely regulated, highly selective and relatively poorly understood process. Humans have the highest rate of miscarriage in mammals and various pharmacological manipulations have been used to minimize pregnancy losses in both spontaneous pregnancies and pregnancies resulting from assisted reproduction technology. The widespread application of protocols using numerous drugs in assisted reproduction treatment has led to an increasing number of pregnancies exposed to these drugs. The vast majority of these protocols have been based on data from a few observational and often retrospective clinical studies. This paper reviews the recent literature on drug interventions in early pregnancy after assisted reproduction treatment. It is concluded that there are still numerous issues about the safety of most drugs for both the women and their fetus. In many cases, the benefits are theoretical and the possible long-term side-effects are untested. There is an urgent need for more epidemiological studies and randomized controlled trials to explore the use, efficacy and side-effects of both old and new drugs in early pregnancy after assisted reproduction treatment.

Depletion of CD8+ cells abolishes the pregnancy protective effect of progesterone substitution with dydrogesterone in mice by altering the Th1/Th2 cytokine profile

One of the most remarkable immunological regulations is the maternal immune tolerance toward the fetal semiallograft during pregnancy, which has been referred to as immunity's pregnant pause. Rejection of the semiallogeneic trophoblast cells must be selectively inhibited and pathways presumably include Th2 cytokines unopposed by Th1 cytokines. Steroid hormones, including progesterone, have similar effects. Low levels of progesterone and Th2 cytokines and high levels of Th1 cytokines are attributable for increased abortions in mammalians, which may be triggered by psychoemotional stress. Thus, the aim of the present study was to provide experimental evidence for the mechanism involved in the mediation of immune responses by endocrine signals during pregnancy and stress-triggered pregnancy failure. DBA/2J-mated CBA/J female mice were randomized in three groups: 1) control females, 2) mice exposed to stress on gestation day 5.5, and 3) mice exposed to stress and substituted with dydrogesterone, a progestogen with a binding profile highly selective for the progesterone receptor on gestation day 5.5. On gestation days 7.5, 9.5, and 10.5, mice of each group were sacrificed, and the frequency of CD8(+) cells and cytokine expression (IL-4, IL-12, TNF-alpha, IFN-gamma) in blood and uterus cells was evaluated by flow cytometry. Additionally, some mice were depleted of CD8 cells by injection of mAb. We observed that progesterone substitution abrogated the abortogenic effects of stress exposure by decreasing the frequency of abortogenic cytokines. This pathway was exceedingly CD8-dependent, because depletion of CD8 led to a termination of the pregnancy protective effect of progesterone substitution.

Effect of post-insemination supplementation with PRID on pregnancy in repeat-breeder Holstein cows

Embryonic mortality contributes to repeat-breeding in dairy cows; luteal insufficiency is a known cause of embryonic mortality. The objective of this study was to assess the efficacy of supplementation with exogenous progesterone for 14 days on pregnancy maintenance in inseminated repeat-breeder dairy cows. On Day 5 after insemination, treated cows ( n=143 ) received a modified PRID (i.e. without estradiol capsule), which was removed on Day 19. Control cows ( n=148 ) did not receive any treatment. Overall there was no effect of PRID supplementation on pregnancy rates. However, when the study population was stratified by parity and stage of lactation, PRID supplementation significantly improved pregnancy rate in first and second parity late lactation cows (risk ratio = 3.26; 95% CI 1.22, 8.69). Pregnancy rates did not differ between PRID-treated cows with ( n=81 ) and without vaginitis. Control cows tended ( P=0.077 ) to have a higher proportion of abortions than PRID-treated cows (7/50 versus 2/51, respectively). In conclusion, young late lactation repeat-breeder cows benefited from progesterone supplementation, in terms of maintaining pregnancy until traditional time of pregnancy diagnosis.

[Immunotherapy for prevention of abortion and for improving implantation in extracorporeal fertilization]

In women with a history of recurrent in-vitro fertilization failure (at least three transfers of good quality embryos), there is an increased prevalence of organo-specific and not organo-specific autoantibodies, similar to women with a history of recurrent miscarriage. It is still unknown whether these autoantibodies are causally related to the failure of implantation or merely reflect an underlying systemic disorder. Several therapeutic intervention for the improvement of implantation after in-vitro fertilization and embryo transfer have been tried, including prednisolone (10 mg/d), heparin and aspirin (80-100 mg/d) alone or in combination with immunoglobulins and active immunotherapy using partner's leukocytes. At present, these interventions in combination with IVF should be regarded as experimental, as controlled, randomized and prospective trials in a large number of couples are still lacking.

[Endocrinologic aspects of habitual abortion]

Disorders of the luteoplacental progesterone shift in the first and second trimester lead to a insufficient progesterone secretion, thus constituting an important cause of early and late abortions. The endocrinological disorders caused by ovarian malfunction normally occur between the 5th and 10th weeks of pregnancy. We can distinguish early and late disorders of the corpus luteum graviditatis from a relative luteal deficiency owing to ovarian hyperstimulation. The delayed shift, however, is caused by trophoblast disorders and disturbances of placentation, thus leading to low blood levels of progesterone. Progesterone replacement therapy for the duration of insufficiency leads to significantly reduced rates of abortion. An increase in the rate of malformations is not to be expected.

Antiprogestagen activity of 5H-progesterone metabolites and their analogues, 16alpha,17alpha-cyclohexane-5H-pregnan-3,20-diones

Antiprogestin activity of 5H-progesterone metabolites and their analogues 16alpha,17alpha-cyclohexan-5H-pregnan-3,20-diones was tested on rats. Modified pregnancy interruption test showed that 5alpha (H)-isomers of natural and synthetic hormones exhibit maximum activity.

Nestorone: a progestin with a unique pharmacological profile

Nestorone(R) (Nestorone 16-methylene-17alpha-acetoxy-19-norpregn-4-ene-3,20-dione), formerly referred to as ST 1435, is a potent progestin when given parenterally via sustained release formulations. The pharmacological profile of Nestorone was compared with that of levonorgestrel and 3-keto-desogestrel by steroid receptor binding studies and by in vivo bioassays in rats and rabbits. 3-Keto-desogestrel showed the highest binding affinity to progesterone receptors (PR) followed by Nestorone, levonorgestrel, and progesterone. The binding affinity of Nestorone to androgen receptors (AR) was 500- to 600-fold less than that of testosterone. However, both levonorgestrel and 3-keto-desogestrel showed significant binding (40 to 70% of testosterone) to AR. None of the progestins bound to estrogen receptors (ER). The progestational activity of Nestorone, levonorgestrel, and progesterone was compared using McPhail index in immature rabbits and pregnancy maintenance and ovulation inhibition tests in rats after subcutaneous (s.c.) administration. In all three tests, Nestorone was the most potent progestin. The progestational activity of Nestorone was also compared after oral and s.c. administration in rabbits. The potency of Nestorone was over 100-fold higher upon s.c. administration than via the oral route. The androgenic activity of progestins, based on the stimulation of ventral prostate (androgenic target) and levator ani (anabolic target) growth in castrated immature rats, showed good correlation with their binding affinity to AR. Nestorone showed no androgenic or anabolic activity. Nestorone did not bind to sex hormone binding globulin (SHBG), whereas both levonorgestrel and 3-keto-desogestrel showed significant binding to SHBG. The estrogenic/antiestrogenic activity of Nestorone was investigated in immature ovariectomized rats. In contrast to estradiol and levonorgestrel, Nestorone showed no uterotropic activity in ovariectomized rats. Despite significant binding to glucocorticoid receptors (GR), Nestorone showed no glucocorticoid activity in vivo. It is concluded that a strong progestational activity, combined with lack of androgenic, estrogenic, and glucocorticoid-like activities, confer special advantages to Nestorone for use in contraception and hormone replacement therapy.

Synthesis and biological activity of a new progestogen, 16-methylene-17alpha-hydroxy-18-methyl-19-norpregn-4-ene-3, 20-dione acetate

The progestational activity of second- and third-generation progestins in oral contraceptives were markedly increased by addition of an 18-methyl group. A new progestin, the 18-methyl analog of Nestorone, 16-methylene-17alpha-hydroxy-18-methyl-19-norpregn-4-ene-3,2 0-dione acetate (10), was synthesized. The relative binding affinity and biologic activity of 10 was compared with Nestorone, levonorgestrel, and progesterone using a binding assay for rat progesterone receptors, the Clauberg assay in the rabbit, and by assessing pregnancy maintenance in the rat. These studies, as summarized in Table 4, show that 10 is three to ten times more potent than Nestorone. The addition of the 18-methyl group to Nestorone markedly increased its potency as noted above, but is unlikely to change its rate of delivery from sustained release systems. 10 should be ideally suited for administration by implants or small skin patches.

Adverse effects of diphenyltin dichloride on initiation and maintenance of pregnancy in rats

The objective of this study was to characterize the adverse effects of diphenyltin dichloride (DPTCl) during early pregnancy. Following successful mating, female rats were given DPTCl by gastric intubation at 0, 4.1, 8.3, 16.5, 24.8 or 33.0 mg/kg on days 0-3 or days 4-7 of pregnancy. Female rats were sacrificed on day 20 of pregnancy and pregnancy outcome was determined. The pregnancy rate was significantly decreased after administration of DPTCl on days 0-3 at 24.8 mg/kg and on days 4-7 at 33.0 mg/kg. The incidence of preimplantation loss was significantly increased after administration on days 0-3 at 16.5 mg/kg and above and on days 4-7 at 33.0 mg/kg. In females having implantations, the numbers of implantations and live fetuses and the incidences of pre- and postimplantation loss in the groups given DPTCl on days 0-3 were comparable to the controls. The incidence of postimplantation loss was significantly increased after administration of DPTCl on days 4-7 at 33.0 mg/kg. A pair-feeding study revealed no evidence of pre- and postimplantation embryolethality induced by food restriction. It could be concluded that DPTCl during early pregnancy causes early embryonic loss and DPTCl has greater effects on reproduction when administered during earlier than later stages of blastogenesis.

Minimal progesterone support required for the maintenance of pregnancy in mice

A study of the degree of progesterone support required for the maintenance of various stages of pregnancy was undertaken in mice. Mated females were ovariectomized at various stages of pregnancy and progesterone and oestradiol support provided by s.c. Silastic implants with known release characteristics. In the earliest stages of pregnancy (days 1-5), very low concentrations of progesterone (<25% of normal physiological values) were sufficient to maintain pre-implantation stages and allow implantation. In the immediate post-implantation period (days 5-9), the development of implantation sites and decidualization required considerably higher progesterone support. In mid-pregnancy (days 11-14), progesterone alone could not maintain pregnancy unless present in very high amounts; however, the presence of oestradiol during this period lowered the progesterone requirements to well within the physiological range. This effect of oestradiol started on day 11 but required the level of oestradiol support to be kept within strictly defined limits, with high concentrations inducing abortion. Progesterone alone was able to maintain pregnancy from day 15. These results indicate that the minimal progesterone support required for pregnancy in mice varies considerably at different stages of pregnancy and is at least partly modulated by oestradiol.

Role of urinary trypsin inhibitor in the maintenance of pregnancy in mice

OBJECTIVE

To investigate the mechanisms whereby urinary trypsin inhibitor prevents lipopolysaccharide-induced preterm delivery in mice.

METHODS

On day 15 of pregnancy, C3H/HeNCrg female mice impregnated by Crg:B6D2F1 male mice were treated intraperitoneally with lipopolysaccharide (50 micrograms/kg, twice at a 3-hour interval) to induce preterm delivery. Urinary trypsin inhibitor (2.5 x 10(4), 7.5 x 10(4), or 25 x 10(4) units/kg, ten times at 1-hour intervals) or saline solution was administered intraperitoneally to the animals.

RESULTS

The incidence of preterm delivery was significantly decreased on a dose-related basis by urinary trypsin inhibitor treatment. Urinary trypsin inhibitor prevented the morphologic and functional changes in fetal membranes and cervical ripening preceding the onset of preterm delivery. Urinary trypsin inhibitor also suppressed the increase in plasma and amniotic fluid concentrations of interleukin-1 alpha, interleukin-6, and tumor necrosis factor-alpha after the lipopolysaccharide dosing in this animal model for preterm delivery.

CONCLUSION

Urinary trypsin inhibitor prevents the pathogenicity of preterm delivery through the suppression of cytokine production.

Embryotoxicity of a regressing corpus luteum in beef cows supplemented with progestogen

Postpartum cows with short-lived corpora lutea produce embryos that arrive at the uterus, but pregnancy rates are low even with exogenous progestogen. Four experiments were conducted to determine whether prostaglandin (PG) F2 alpha, known to cause early luteolysis, could have a direct effect on embryonic loss. Exogenous progestogen was injected s.c. twice daily in each experiment, starting 3 or 4 days after estrus (day of estrus = Day 0). Nonlactating, cycling beef cows were mated and injected i.m. every 8 h on Days 4 through 7 (experiment 1) or 5 through 8 (experiment 3) with either 15 mg PGF2 alpha or 3 ml saline. In experiment 1, cows in a third group received 1 g flunixin meglumine i.m. every 8 h. Ten of 18 PGF2 alpha-treated cows in experiment 3 were luteectomized on Day 5. Pregnancy rates were higher (p < 0.05) in cows given saline or flunixin meglumine (5 of 7) than in cows given PGF2 alpha (1 of 5) in experiment 1, and in cows given saline (6 of 9) or given PGF2 alpha, and luteectomized (8 of 10) than in cows given PGF2 alpha (2 of 8) in experiment 3. Postpartum beef cows, mated at weaning-induced first estrus, received i.m. injections every 8 h on Days 4 through 9 of 3 ml saline or 1 g flunixin meglumine (experiment 2); 14 flunixin meglumine-treated cows were luteectomized on Day 7. Pregnancy rates were higher in cows given flunixin meglumine and luteectomized (7 of 14) than in cows given saline (4 of 15) or flunixin meglumine alone (3 of 15; p < 0.05). In experiment 4, postpartum cows were luteectomized or sham-operated on Day 5. Pregnancy rates (2 of 13 and 2 of 14, respectively) did not differ. Thus, both reduction of endogenous PGF2 alpha and luteectomy were required for embryo survival in postpartum cows with short-lived corpora lutea, whereas luteectomy alone prevented effects of exogenous PGF2 alpha in cycling cows.

Continuation of a donor oocyte pregnancy in a functionally agonadal patient without early oestrogen support

A 40 year old functionally agonadal patient was the recipient of fertilized donated oocytes. She accidentally discontinued all oestrogen support on the day preceding embryo transfer until it was reinstated 12 days later. However, a pregnancy was established and resulted in the birth of healthy normal twin infants. This case report suggests that minimal amounts, if any, of oestradiol are sufficient to maintain an early pregnancy, provided adequate amounts of progesterone are given. This is consistent with a recent study conducted in subhuman primates.

Drospirenone: a novel progestogen with antimineralocorticoid and antiandrogenic activity

Drospirenone (ZK 30595; 6 beta, 7 beta, 15 beta, 16 beta-dimethylen-3-oxo-17 alpha-pregn-4-ene-21, 17-carbolactone) is a novel progestogen under clinical development. Drospirenone is characterized by an innovative pharmacodynamic profile which is very closely related to that of progesterone. Potential applications include oral contraception, hormone replacement therapy and treatment of hormonal disorders. The pharmacological properties of drospirenone were investigated in vitro by receptor binding and transactivation experiments and in vivo in appropriate animal models. In qualitative agreement with progesterone, the compound binds strongly to the progesterone and the mineralocorticoid receptor and with lower affinity to androgen and glucocorticoid receptors. There is no detectable binding to the estrogen receptor. Steroid hormone agonistic and antagonistic activities of progesterone and drospirenone were compared in transactivation experiments. Individual steroid hormone receptors were artificially expressed together with a reporter gene in appropriate cell lines. Both hormones were unable to induce any androgen receptor-mediated agonistic activity. Rather, both progesterone and drospirenone distinctly antagonized androgen-stimulated transcriptional activation. Likewise, both compounds only very weakly activated the mineralocorticoid receptor but showed potent aldosterone antagonistic activity. Drospirenone did not induce glucocorticoid receptor-driven transactivation. Progesterone was a weak agonist in this respect. Drospirenone exerts potent progestogenic and antigonadotropic activity which was studied in various animal species. It efficiently promotes the maintenance of pregnancy in ovariectomized rats, inhibits ovulation in rats and mice and stimulates endometrial transformation in the rabbit. Furthermore, drospirenone shows potent antigonadotropic, i.e., testosterone-lowering activity in male cynomolgus monkeys. The progestogenic potency of drospirenone was found to be in the range of that of norethisterone acetate. The majority of clinically used progestogens are androgenic. Drospirenone, like progesterone, has no androgenic but rather an antiandrogenic effect. This property was demonstrated in castrated, testosterone propionate substituted male rats by a dose-dependent inhibition of accessory sex organ growth (seminal vesicles, prostate). In this model, the potency of drospirenone was about a third that of cyproterone acetate. Drospirenone, like progesterone, shows antimineralocorticoid activity, which causes moderately increased sodium and water excretion. This is an outstanding characteristic which has not been described for any other synthetic progestogen before. Drospirenone is eight to ten times more effective in this respect than spironolactone. The natriuretic effect was demonstrable for at least three weeks upon daily treatment of rats with a dose of 10 mg/animal. Drospirenone is devoid of any estrogenic, glucocorticoid or antiglucocorticoid activity. In summary, drospirenone, like progesterone, combines potent progestogenic with antimineralocorticoid and antiandrogenic activity in a similar dose range.(ABSTRACT TRUNCATED AT 400 WORDS)

Drospirenone: a novel progestogen with antimineralocorticoid and antiandrogenic activity. Pharmacological characterization in animal models

Drospirenone (ZK 30595; 6 beta, 7 beta, 15 beta, 16 beta-dimethylen-3- oxo-17 alpha-pregn-4-ene-21, 17-carbo-lactone) is a novel progestogen under clinical development. Potential applications include oral contraception, hormone replacement therapy and treatment of hormonal disorders. Drospirenone is characterized by a pharmacodynamic profile very closely related to that of progesterone. The progestogenic activity of drospirenone has been analysed in a variety of animal models. The compound efficiently promotes the maintenance of pregnancy in rats, inhibits ovulation in rats and stimulates endometrial transformation in the rabbit. Furthermore, drospirenone shows potent antigonadotropic, i.e. testosterone-lowering, activity in male cynomolgus monkeys. The progestogenic potency of drospirenone was found to be in the range of that of norethisterone acetate or cyproterone acetate. Like progesterone, drospirenone has been shown to have an antimineralocorticoid effect in rats and humans. It has now been demonstrated that the compound has a long-lasting natriuretic activity in rats on administration of a daily dose of 10 mg s.c. for three weeks. Under identical conditions, spironolactone, a widely-used antimineralocorticoid, becomes ineffective after the initial treatment phase. Drospirenone exhibits antiandrogenic activity in castrated, testosterone-substituted male rats as shown by dose-dependent inhibition of accessory sex organ growth (prostate, seminal vesicles). In this model, the potency of drospirenone was found to be about one-third that of cyproterone acetate. The compound is devoid of androgenic, estrogenic, glucocorticoid and antiglucocorticoid activity. Possible drug interaction between drospirenone and ethinylestradiol (EE) was also investigated. EE did not interfere with either the progestogenic or the antimineralocorticoid activity of drospirenone. In conclusion, drospirenone represents a novel type of synthetic progestogen since it combines potent progestogenic characteristics with antimineralocorticoid and antiandrogenic activity. Thus, the pharmacological profile of drospirenone is more closely related to that of the natural hormone progesterone than is that of any other synthetic progestogen in use today. Therefore, drospirenone is anticipated to give rise to a number of additional health benefits both for users of oral contraceptives and hormone replacement therapy recipients.

Comparative progestational activity of norgestimate, levonorgestrel-oxime and levonorgestrel in the rat and binding of these compounds to the progesterone receptor

The progestational activity of norgestimate (NORG), levonorgestrel-oxime (LNG-oxime) and levonorgestrel (LNG) were compared in a pregnancy maintenance study in rats. The compounds were administered subcutaneously to pregnant rats at several doses, blood samples were collected repeatedly, and the concentration of LNG was measured in these samples. It could be demonstrated that following the administration of NORG and LNG-oxime, LNG was a major metabolite present in the serum. The pharmacological response in rats treated with NORG and LNG-oxime could be related to the systemic exposure of these animals to metabolically derived LNG. Thus, both NORG and LNG-oxime can be regarded as pro-drugs of LNG, the latter being almost exclusively responsible for the pharmacological activity of both pro-drugs. This notion was further supported by studies on the comparative binding affinity of these compounds to rabbit and human progesterone receptor (PR). LNG exhibited the highest binding affinity of the compounds studied. Relative binding affinity (RBA) values of LNG using progesterone as reference (100%) were found to be 125% for rabbit PR (rPR), 143% for human uterine PR (hPR) and 125% for recombinant hPR, respectively. In contrast to LNG, NORG exhibited only a low affinity to the PR, which is documented by RBA values of 1.2% for rPR, 3.2% for uterine hPR and 9% for recombinant hPR. The corresponding values of LNG-oxime were 30% (rPR), 20% (uterine hPR) and 18% (recombinant hPR), respectively. Thus, the combined experimental evidence of the present study does not support the view of NORG being a progestogen on its own as has been suggested by others.

Rescue of pregnancy and maintenance of corpora lutea in infertile transgenic mice expressing an ovine metallothionein 1a-ovine growth hormone fusion gene

Transgenic female mice expressing a temporally regulatable ovine metallothionein 1a-ovine growth hormone (oMT1a-oGH) fusion gene can cycle, mate, and support early embryonic development; but they fail to maintain pregnancy or, in most cases, to exhibit signs of pseudopregnancy. The present study was designed to determine whether or not the infertility of oMT1a-oGH transgenic female mice is due to luteal insufficiency. A series of five experiments was conducted in which various hormonal therapies were utilized in an attempt to overcome this infertility. Provision of 1 mg progesterone to oMT1a-oGH females from Days 1 to 17 of gestation rescued pregnancy in 19 of 20 females with an increased mean litter size (p < 0.01) compared to that of wild-type control females. Supplementation with progesterone also appeared on the basis of gross anatomical appearance to maintain CI. Provision of 2 mg progesterone in combination with 25 ng estradiol-17 beta from Days 4 to 17 rescued pregnancy in 14 of 24 oMT1a-oGH females, while provision of 100 or 25 micrograms ovine prolactin from Days 3 to 17 failed to overcome oMT1a-oGH infertility. Transgenic females with rescued pregnancies lactated and raised heavier pups than wild-type females by Day 15 postnatal (p < 0.05). Results indicate that infertility of oMT1a-oGH transgenic mice is caused by luteal insufficiency. Supplementation of transgenic females with progesterone appeared to maintain morphologically normal CL and pregnancy with subsequently increased litter size and normal lactation.

Comparative progestational and androgenic activity of norgestimate and levonorgestrel in the rat

The androgenic and the progestational activity of norgestimate (NORG) and levonorgestrel (LNG) were compared in two animal studies. During a Hershberger test in immature castrated male rats and a pregnancy maintenance test in pregnant rats, NORG and LNG were administered subcutaneously at several doses, serum samples were collected from each animal during the treatment period and the concentration of LNG was measured in these samples. It could be shown in both studies that in those animals which were treated with NORG, LNG was a major metabolite present in the serum. The difference in the pharmacological response in LNG- and NORG-treated rats was equivalent to the difference in the exposure of the animals to either directly administered or metabolically derived LNG. This was true for the androgenic and the progestational activity of NORG. It is concluded that according to the present results, NORG can be described as a pro-drug of LNG and that the latter is probably mainly responsible for the pharmacological effects observed during treatment with NORG. It cannot be excluded, however, that NORG itself or other metabolites of this drug may also contribute to the pharmacodynamic response.

[Action of synthetic progestin]

Chemical compound that can bind the progesterone receptor in the nucleus and cause proliferative change of the endometrium is designated as progestin (gestagen, progestogen). Progesterone (natural progestin) is secreted from corpus luteum of the ovary. Synthetic progestin can be divided into two groups: (1) progesterone derivatives, such as medroxyprogesterone acetate and (2) testosterone derivatives, such as norethisterone. The former has progestane structure and a marked progestational activities but little estrogenic and androgenic activities. While, most of the testosterone derivatives keep androgenic activities and show even estrogenic activities due to its estrane structure or production of estrogen as the metabolite. Thus, understanding the characteristics of mode of action in each synthetic progestin, we should select the appropriate one for clinical treatment.

Factors affecting fertility in the postpartum cow: role of the oocyte and follicle in conception rate

Four experiments were designed to examine the contribution of the oocyte or the follicular, oviductal, or early uterine environments to low fertility associated with the first ovulation postpartum. At 17-25 days postpartum in experiments 1, 2, and 3, suckled beef cows were assigned at random to receive 6 mg norgestomet, via ear-implant, for 9 days (NOR) or to serve as controls (CON). Calves were weaned from all cows 7 days after assignment to treatment in order to induce estrus, an LH surge, ovulation, and subsequent formation of CL. As cows were detected to be in estrus, they were bred first by natural service and 12 h later by artificial insemination. In experiment 1, on Day 3 after estrus, the oviduct ipsilateral to the side of ovulation was removed and flushed for recovery of an embryo or oocyte. Rates of recovery (86%), fertilization (68%), and development of fertilized oocytes to the 4- to 8-cell stage (100%) did not differ between CON and NOR cows. In experiment 2, uteri were flushed nonsurgically on Day 6 after estrus. Rates of recovery of embryos from the uterus were similar between CON (86%) and NOR (71%) cows. In experiment 3, one half of the cows in each group (CON and NOR) were fed melengestrol acetate (MGA) beginning on Day 4 after estrus and continuing until Day 35. The remaining cows in each group served as controls. Treatment with NOR increased (p < 0.05) the proportion of cows that maintained pregnancy until Day 35 (9/22) as compared to controls (0/18).(ABSTRACT TRUNCATED AT 250 WORDS)

Pregnancy can be established in superovulated adult rats treated with progesterone and an aromatase inhibitor

An adult superovulated rat model has been developed and is characterized by high ovulation rates, early morphological degeneration of embryos, complete embryo loss within 48 hours of conception and elevated peripheral estradiol(E2)/progesterone(P4) ratios. In this study, three trials were conducted using the superovulated adult rat model. First, control naturally cycling rats were compared with superovulated rats supplemented with 1 mg P4 on days 0-3 of pregnancy. A sperm positive vaginal smear is designated as day 0 of pregnancy. The P4 treated rats demonstrated improved embryo retrieval on day 1 of pregnancy, continued embryo recovery with a decrease in normal morphologic characteristics of integrity on day 2, with nearly total embryo loss by day 3. On each day, P4 levels were elevated 2-3 times over control. The second trial compared 3 groups of rats, 1) naturally cycling, 2) superovulated unsupplemented and 3) superovulated rats supplemented with 1 mg P4/rat/day and the aromatase inhibitor, 4-hydroxyandrostenedione (4-OHA), 12.5 mg/rat/day. The superovulated unsupplemented rats had no embryo recovery after day 2 of pregnancy, while the P4 and 4-OHA treated rats showed a variable ability to maintain normally developing embryos through day 4 of pregnancy. E2 levels were elevated in both superovulated groups on days 1-4 of pregnancy as were P4 levels on days 2-4. The E2/P4 ratio was significantly lowered only on day 1 of pregnancy in the P4 and 4-OHA treated group. The third trial demonstrated implantation in 50% of the superovulated rats supplemented with P4 and 4-OHA. In conclusion, implantation in the superovulated adult rats can occur with P4 and 4-OHA supplementation, however, this biologic phenomenon could not be explained by obvious changes in peripheral E2 and P4 levels.

Effect of 1,25-dihydroxyvitamin D3 on the female reproductive system in rats

Parenteral application of the active metabolite of vitamin D3, 1,25-dihydroxyvitamin D3, has been anticipated to have remarkable efficacy in secondary hyperparathyroidism. However, in a reproduction seg. I study in rats, poor reproductive performance was reflected in a decrease in the number of matings, implantations and live births. These changes were though reversible after treatment with the compound was discontinued. In order to clarify the mechanism of these reversible toxicities, the following were examined in female rats treated with the D3 metabolite: 1. effect on the estrous cycle (no treatment for 2 weeks, treatment for 3 weeks and recovery for 2 weeks), and 2. effect on the maintenance of pregnancy (treatment for 2 weeks before mating and during the gestation period). In both groups, the levels of calcium, calcitonin, PTH and progesterone in serum were measured, and histopathological examination of the thyroid, parathyroid, ovary and uterus was carried out. The following results were observed: 1) disturbance of the estrous cycle, 2) hypofunctional changes in the corpus luteum in the ovary, and the epithelium, endometrium and uterine gland in the uterus with a decrease in the serum progesterone level and 3) hypercalcemia with a decrease in calcitonin or PTH levels in serum with morphological changes including atrophy and cyst-formation in the parathyroid. However, the above changes were reversible, and recovery was observed after administration of the compound was discontinued. These results indicate that the hypercalcemia caused by 1,25-dihydroxyvitamin D3 disrupts endocrinological homeostasis which in turn temporarily disrupts the female reproductive system. Furthermore, it was suggested that 1,25-dihydroxyvitamin D3 itself directly influences on endocrinological organs (hypothalamus, pituitary, parathyroid and thyroid) and reproductive organs (ovary and uterus).

Evidence against a role for blastocyst-secreted oxytocin in early pregnancy maintenance in sheep

Analysis of ovine conceptus RNA by slot blotting, Northern analysis and nested polymerase chain reaction failed to detect oxytocin-neurophysin prohormone mRNA. Probes used hybridized with both the 3' end of the prohormone mRNA and the oxytocin-coding sequence. Northern analysis of bovine and porcine conceptus RNA was also negative, and polymerase chain reaction demonstrated oxytocin-neurophysin mRNA in ovine corpus luteum, but not in human corpus luteum or decidua, or in ovine endometrium. Infusion of oxytocin into the uterine lumen in cyclic ewes between days 9 and 19 or 20 after oestrus failed to prolong the luteal phase of the cycle and had no effect on endometrial oxytocin receptor concentrations or uterine prostaglandin F secretion. Oxytocin administered systematically prevented luteolysis and reduced uterine prostaglandin F secretion. Taken together, these data suggest that blastocyst-derived oxytocin is unlikely to contribute to corpus luteum maintenance in early pregnancy. They are inconsistent with a previous report that the ovine blastocyst synthesizes and secretes oxytocin.

Aldosterone antagonists. 4. Synthesis and activities of steroidal 6,6-ethylene-15,16-methylene 17-spirolactones

Several steroidal 6,6-ethylene-15,16-methylene 17-spirolactones were synthesized to find new progestogens that exhibit both progestational and antimineralocorticoidal activities. The influence of substituents in the 10- and 13-position of the steroidal framework on both properties was investigated. It was found that only compound 12, carrying methyl groups at the 10- and 13-positions, possesses high progestational and antimineralocorticoidal activity.

Survival of bovine embryos transferred to progesterone-treated asynchronous recipients

Treatment of recipient cows with 100 mg of progesterone daily from Days 1 to 5 of the oestrous cycle increased plasma progesterone compared with vehicle-treated recipients. Embryo transfer to progesterone-treated recipients which showed oestrus 72 h after the donor cows resulted in pregnancy rates at Day 35 similar to those of synchronous (+/- 12 h) recipients (42 vs. 50%). Only 1 of 22 (4.8%) asynchronous (-72 h) vehicle-treated recipients established pregnancy. Similar treatments of cyclic cows with progesterone shortened (P less than 0.01) the interoestrous interval by 3.2 days. When assessed on Day 7 of pregnancy, administration of progesterone to superovulated donor cows on Days 1-4 of pregnancy did not affect early embryo development compared with superovulated cows treated with vehicle alone. Plasma progesterone increased rapidly in superovulated cows compared with cows during the oestrous cycle. The results indicate that administration of progesterone early in the oestrous cycle of the recipient can effectively advance uterine receptivity for the transfer of older asynchronous embryos.

Evaluation of progesterone deficiency as a cause of fetal death in mares with experimentally induced endotoxemia

The role of decreased luteal activity in embryonic loss after induced endotoxemia was studied in mares 21 to 35 days pregnant. Fourteen pregnant mares were treated daily with 44 mg of altrenogest to compensate for the loss of endogenous progesterone secretion caused by prostaglandin F2 alpha (PGF2 alpha) synthesis and release following intravenous administration of Salmonella typhimurium endotoxin. Altrenogest was administered daily from the day of endotoxin injection until day 40 of gestation (group 1; n = 7), until day 70 (group 2; n = 5), or until day 50 (group 3; n = 2). In all mares, secretion of PGF2 alpha, as determined by the plasma 15-keto-13,14-dihydro-PGF2 alpha concentrations, followed a biphasic pattern, with an initial peak at 30 minutes followed by a second, larger peak at 105 minutes after endotoxin injection. Plasma progesterone concentrations decreased in all mares to values less than 1 ng/ml within 24 hours after endotoxin injection. In group 1, progesterone concentrations for all mares were less than 1 ng/ml until the final day of altrenogest treatment. In 6 of 7 mares in group 1, the fetuses died within 4 days after the end of treatment, with progesterone concentrations less than 1 ng/ml at that time. In the mare that remained pregnant after the end of treatment, plasma progesterone concentration was 1.6 ng/ml on day 41 and increased to 4.4 ng/ml on day 44. In group 2, all mares remained pregnant, even though plasma progesterone concentrations were less than 1 ng/ml in 4 of 5 mares from the day after endotoxin injection until after the end of altrenogest treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of bromocriptine administration on maintenance of late pregnancy in the pig

Plasma concentrations of prolactin, luteinizing hormone (LH) and progesterone were determined in pregnant gilts (n = 6) administered bromocriptine from 67-72 days of pregnancy. Blood samples were taken daily at 2 h intervals from 60 to 80 days of pregnancy. Bromocriptine treatment reduced prolactin from 9.7 +/- 1.4 before to 1.9 +/- 0.6 ng/ml during the treatment (p less than or equal to 0.05) and then returned to the pre-treatment concentrations (10.5 +/- 2.0) following cessation of bromocriptine. Bromocriptine increased LH from 1.4 +/- 0.2 before treatment to 2.9 +/- 0.5 ng/ml (p less than or equal to 0.01) during administration and maintained elevated (3.0 +/- 0.7) in the post-treatment period (p less than or equal to 0.05). Administration of bromocriptine did not alter progesterone concentration in plasma (7.5 +/- 1.2; 7.2 +/- 1.6 and 6.6 +/- 1.6 ng/ml in pretreatment, treatment and post-treatment periods, respectively). This study shows that decrease of prolactin level by bromocriptine treatment does not cause depletion of progesterone secretion in late pregnant pigs.

Reversal of stress-induced pregnancy blocks in mice by progesterone and metyrapone

It is established that diverse psychological stressors administered in the first trimester of pregnancy can cause the pregnancy to fail. The physiological mediators of this phenomenon are unknown. In Experiment 1, two strains of female mice were inseminated and randomly assigned to either first trimester physical restraint, restraint plus progesterone, or control conditions. Restrained females produced fewer pregnancies than did controls, and a reversal of this block through the daily administration of 500 micrograms progesterone was seen in HS but not C57 mice. Experiment 2 demonstrated that exposure to a predator will also block pregnancy in the first trimester in C57 mice, and that this can also be counteracted with progesterone administration. Experiment 3 showed that metyrapone, a drug which blocks the conversion of progesterone to corticosterone, also partially reverses a restraint-induced pregnancy block. These results suggest that lowered progesterone levels may be involved in pregnancy blocks induced by psychological stress.

Alteration of lymphocyte reactivity in pregnant women treated with the progesterone receptor inhibitor ZK 98734

Thirteen women during the 5th and 6th weeks of gestation were treated with a progesterone receptor blocker (ZK 98734) for pregnancy termination. Five patients received 100 mg/day of the compound, and eight patients received 50 mg/day for 4 days. Daily blood samples were obtained during the treatment period as well as on days 8 and 15 after the beginning of drug administration, and cytotoxic activity, progesterone sensitivity, and progesterone binding capacity of the lymphocytes were determined. Determination of SP-1 concentrations monitored the saturation state of trophoblastic progesterone receptors. High and low responders to the progesterone antagonist were identified. Lymphocytes of high responders treated with the 100 mg/day dose demonstrated a rapid increase of cytotoxicity, with a concomitant fall in progesterone sensitivity and progesterone binding capacity. Vaginal bleeding began as early as the 2nd day of treatment, and pregnancy was terminated by the 8th day of the treatment. Low responders receiving 100 mg/day demonstrated similar but attenuated changes. Low responders did not bleed during the first 4 days of treatment, and termination of pregnancy occurred later compared to high responders. Lymphocytes of high responders treated with 50 mg/day behaved similarly to those obtained from the low responders treated with 100 mg/day, and abortion was not completed before the 25th day after the beginning of the treatment. Lymphocytes function of low responders treated with 50 mg/day did not change significantly, the SP-1 concentration did not decline, and pregnancies continued. We conclude that a difference in sensitivity to the progesterone receptor blocker explains the selective block at trophoblastic binding sites only and the inability to block those in the lymphocytes.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of prostaglandin F2 alpha-analogue administration on luteal function, implantation of embryos and maintenance of pregnancy in bitches

The present experiment was carried out to clarify the effect of administration of the prostaglandin F2 alpha (PGF2 alpha)-analogue on the luteal function and the maintenance of pregnancy in bitches. Fifty-one bitches received a single inoculation of PGF2 alpha-analogue by intramuscular injection. The effect of this agent was observed by monitoring progesterone (P) levels and the state of the uterus by laparotomy, the occurrence of abortion, and the state of parturition. As a result, when bitches were administered with 100-400 micrograms at the beginning of the luteal phase, the decrease in the P level was temporary. In bitches inoculated with 100-800 micrograms of PGF2 alpha-analogue at the functional luteal stage, the P level began to decrease as early as on the following day after injection. In those treated with 100-200 micrograms of PGF2 alpha-analogue at 10-15 days of pregnancy, pregnancy was maintained in 3 of 5 bitches that had received the treatment at day 10, while in the remaining two, all embryos died after implantation. In those that had received the same treatment at day 15, only 2 of 7 maintained pregnancy. Pregnancy was interrupted in eight bitches treated with doses of 100-200 micrograms at days 25-45. In four bitches treated with doses of 100-200 micrograms at day 55, premature birth was induced after 30-44 hr. In conclusion, regression of the corpus luteum, abortion, and premature birth were induced in bitches treated with 100-200 micrograms at each stage, except the beginning of the luteal phase and of the pregnancy.

[The effect of RU486 and progesterone on luteal function during pregnancy]

In order to investigate the role of progesterone in the maintenance of pregnancy, an anti-progesterone agent, RU486 (RU) was injected subcutaneously into pregnant rats on day 12 (D12), and morphological changes of the uterus as well as endocrinological changes were observed. In all rats injected with RU, abortion occurred with macroscopic and microscopic intrauterine hemorrhage and degeneration or delivery of conceptuses. Endocrinologically, the levels of progesterone decreased rapidly 48 hours after the injection, while the levels of estradiol showed a tendency to increase. As progesterone is mainly produced by the corpus luteum but not by the placenta in rats, the decrease in progesterone is suspected to be due to luteolysis. Then in order to clarify the mechanism of luteolysis induced by RU and the effects of progesterone on this phenomenon, the dynamics of the luteotrophic factors (estradiol, LH, PRL) and specific binding capacity of the ovaries to LH/hCG were investigated in D7 pregnant rats treated with RU 1 mg/kg alone (RU group) or with both RU 1 mg/kg and progesterone 50mg/kg (RU + P group). The serum levels of progesterone in the RU group decreased significantly after 72 hours of administration, while those in the RU + P group remained within the levels of the control group. However, serum levels of luteotrophic factors in the RU group did not decrease, and some of them were even higher than those in the control group. In the RU + P group, luteotrophic factors remained within control levels. On the other hand, the specific bindings of LH/hCG to ovarian homogenates decreased significantly after 72 hours in the RU group. But in the RU + P group, the specific bindings were kept at the same levels as the controls. Scatchard analysis of these results disclosed that in the RU group, both affinity and numbers of receptors decreased compared to the controls, and that in the RU + P group only affinity decreased transiently and afterwards recovered quickly. From these results, it is concluded that deterioration of affinity and numbers of ovarian LH/hCG receptors seems to be one of the factors which induce luteolysis in pregnant rats treated with RU, and that progesterone can spare the effect of RU on the corpus luteum during pregnancy.

Antifertility effect of methoxychlor in female rats: dose- and time-dependent blockade of pregnancy

Long-term exposure to methoxychlor (MXC), an estrogenic pesticide, produces infertility in rats, and short-term exposure blocks the decidual cell response (DCR). To address the short-term effects of MXC on fertility, the differential effects of MXC dosage and timing of administration (relative to implantation) on several gestational parameters were investigated. When MXC was administered during early pregnancy (Days 1-8), a dose-dependent decline in implantations and uterine weight was seen with no effect on ovarian weight or corpora lutea; MXC reduced serum progesterone at all doses. Preimplantation administration of MXC (Days 1-3 of pregnancy) produced a decline in implantations and uterine weight, while postimplantation dosing (Days 4-8 of pregnancy) increased resorptions to 100%, decreased uterine weight, and reduced serum progesterone without affecting the number of implantations, ovarian weight, or number of corpora lutea. The DCR of pseudopregnancy was inhibited by 500 mg/kg/day MXC when administered either pre- or postimplantation, but 200 mg/kg/day was without effect in either regimen. When hormonally primed, long-term ovariectomized rats were exposed to doses of 500 mg/kg/day, MXC blocked the induced DCR seen in controls. The data show that short-term MXC dosing during early pregnancy produces a dose-related infertility. The bloickade of pregnancy by the preimplantation administration of MXC may be mediated by a direct effect on preimplantation uterine development. The fetal resorption seen following postimplantation dosing is considered a manifestation of both reduced serum progesterone and the direct disruption of normal decidual development by MXC.

Medroxyprogesterone acetate therapy in early pregnancy has no apparent fetal effects

Medroxyprogesterone acetate (MPA; Provera) was given orally to 449 women from the 5th to 7th week of pregnancy until at least the 18th week. Data are recorded from two treatment groups (recurrent abortion and threatened abortion) and are compared to a matched series. A total of 1,016 pregnancies are included in the study, and all patients were recruited from a subfertile population conceiving from a range of infertility treatments. Early pregnancy wastage was high throughout the groups and was significantly elevated (43%; P less than .001) in those women who had vaginal bleeding in early pregnancy. The study focuses on the question of potential teratogenicity of progestagens administered in the first trimester. There were 15/366 (4.1%) infants with congenital abnormalities in the MPA-treated group and 15/428 in the untreated group (3.5%). The difference was not significant, and MPA is considered to have no embryopathic risk, nor is it likely to retain an abnormal fetus that might otherwise abort. It appears that MPA is a safe drug to use in pregnancy although the question of efficacy has not been addressed in this report. Considering other recent negative epidemiologic studies with regard to teratogenicity, we add to the conclusion that MPA cannot be demonstrated to have a measurable teratogenic risk and certainly does not present a risk for congenital heart disease and limb reduction defects.