Role of vascular endothelial cell growth factor in Ovarian Hyperstimulation Syndrome.

Controlled ovarian hyperstimulation with gonadotropins is followed by Ovarian Hyperstimulation Syndrome (OHSS) in some women. An unidentified capillary permeability factor from the ovary has been implicated, and vascular endothelial cell growth/permeability factor (VEGF) is a candidate protein. Follicular fluids (FF) from 80 women who received hormonal induction for infertility were studied. FFs were grouped according to oocyte production, from group I (0-7 oocytes) through group IV (23-31 oocytes). Group IV was comprised of four women with the most severe symptoms of OHSS. Endothelial cell (EC) permeability induced by the individual FF was highly correlated to oocytes produced (r2 = 0.73, P < 0.001). Group IV FF stimulated a 63+/-4% greater permeability than FF from group I patients (P < 0. 01), reversed 98% by anti-VEGF antibody. Group IV fluids contained the VEGF165 isoform and significantly greater concentrations of VEGF as compared with group I (1,105+/-87 pg/ml vs. 353+/-28 pg/ml, P < 0. 05). Significant cytoskeletal rearrangement of F-actin into stress fibers and a destruction of ZO-1 tight junction protein alignment was caused by group IV FF, mediated in part by nitric oxide. These mechanisms, which lead to increased EC permeability, were reversed by the VEGF antibody. Our results indicate that VEGF is the FF factor responsible for increased vascular permeability, thereby contributing to the pathogenesis of OHSS.

A simplified method of timing frozen embryo transfers.

OBJECTIVE: Our purpose was to compare a simple artificial hormone replacement regimen with two other protocols incorporating pituitary down-regulation with gonadotropin-releasing hormone agonist for frozen embryo transfers. STUDY DESIGN: We performed a retrospective analysis of pregnancy outcomes after 366 frozen embryo transfers timed by one of three hormone replacement regimens. The three regimens used were regimen A, leuprolide acetate and transdermal estradiol patches; regimen B, leuprolide acetate and oral micronized estradiol; regimen C, only oral micronized estradiol. RESULTS: The outcomes of 366 consecutive frozen embryo transfers according to one of the three regimens were compared and analyzed. The clinical pregnancy rates were 13.7%, 11.4% and 13.5% in regimens A, B and C, respectively. No statistical differences were found among the three regimens. The mean age of the patients in the three groups was comparable. The mean number of frozen embryos transferred with regimen B was slightly higher, but it did not have a positive impact on the pregnancy rate in this group. CONCLUSION: Controlled sequential hormone replacement results in an endometrium suitable for frozen embryo transfers. Pituitary down-regulation is not necessary. Therefore this regimen is not only more simple to use but also more economical.

Successful implantation of frozen sibling embryos is influenced by the outcome of the cycle from which they were derived.

OBJECTIVES: To determine if the success of frozen embryos obtained from assisted reproductive technology (ART) cycles is dependent upon the outcome of the ART cycle from which they were derived and to determine if the length of time in cryostorage affects pregnancy rates (PRs). DESIGN: Retrospective analysis of pregnancy outcome of consecutive frozen ETs compared with their corresponding "'fresh" cycles. SETTING: University-affiliated private ART program. PATIENTS: Between July 1986 and December 1992, 375 oocyte retrieval cycles had at least one subsequent frozen ET for comparison. Of the 375 patients, 94 achieved a clinical pregnancy during their fresh cycle (group A) and 281 patients did not (group B). INTERVENTIONS: Frozen ETs were performed using either natural (unstimulated) cycles (n = 79) or artificial cycles (n = 296). Transfers during natural cycles were timed with a combination of serum LH levels and ultrasound (US). These transfers were performed 2 days after ovulation. Ovarian suppression with leuprolide acetate followed by sequential estrogen and P replacement were used in the artificial cycles. These transfers were performed on the 3rd day of P administration. Clinical pregnancies were defined as the presence of a gestational sac on transvaginal US. MAIN OUTCOME MEASURES: Patients were compared based on the pregnancy outcome of their frozen ET cycle and fresh ART cycle. chi 2 analysis and Student's-tests were used to test for statistical significance. RESULTS: Twenty-three patients (24.1%) from group A achieved a pregnancy from their frozen transfers compared with only 24 patients (8.5%) in group B who achieved a pregnancy from their frozen cycle. PRs did not differ based on the method of follicle aspiration, laparoscopy versus transvaginal US retrieval. Significantly lower PRs were noted in frozen ETs done within the first 10 months after cryopreservation compared with fresh cycle PRs. CONCLUSIONS: Sibling embryos from a prior successful ART cycle are more likely to initiate a frozen pregnancy and prolonged cryostorage did not affect PRs. This higher PR probably reflects better quality in both fresh and frozen embryos. Therefore, the outcome of the initial cycle can be used to predict the success or failure of subsequent frozen transfers and oocyte-embryo quality appears to be key.

Ovulation induction in women with premature ovarian failure: a prospective, crossover study.

A prospective crossover study comparing ovulation induction techniques in eight women with premature ovarian failure is presented. These patients were treated with FSH rebound techniques using the GnRH-a, LA, alone in one treatment cycle and the same plus menopausal gonadotropins in the other treatment cycle. Two women ovulated in each group. We conclude that ovulation does occur in women with premature ovarian failure, but that luteal P may be inadequately secreted.

Severe ovarian hyperstimulation in a spontaneous singleton pregnancy.

Ovarian hyperstimulation syndrome in a spontaneous ovulatory cycle is exceedingly rare. We report a case of severe ovarian hyperstimulation associated with a spontaneous, otherwise normal singleton pregnancy.

Predicting pregnancy outcome by the observation of a gestational sac or of early fetal cardiac motion with transvaginal ultrasonography.

Transvaginal ultrasound (US) allows for observation of the gestational sac and cardiac motion as early as 3 and 4 weeks after ovulation, respectively. The purpose of this study was to determine how well the first observation of cardiac motion, using weekly transvaginal US examinations, predicted pregnancy outcome. Three hundred sixteen pregnancies wherein the date of ovulation was known and a single gestational sac was visualized at 3 weeks after ovulation were studied. Cardiac motion was first detected at 4 weeks after ovulation in 226 (71.5%), and at 5 weeks in 67 (21.2%). In 23 patients, cardiac motion was never observed. In those patients with cardiac motion visible at 4 weeks after ovulation, 94.2% have subsequently delivered viable infants. This contrasts with only 70.1% for those patients who first had observable cardiac motion 1 week later (P = 6.7 X 10(-6]. This study demonstrates that the solo finding of a gestational sac is a poor predictor of pregnancy outcome (82.3% accurate) and that the earlier that cardiac motion is initially observed, the better the pregnancy prognosis.

Gamete intrafallopian transfer: the effect of the number of eggs used and the depth of gamete placement on pregnancy initiation.

The role of the fallopian tube in initiating pregnancy was examined in 246 consecutive gamete intrafallopian transfer (GIFT) cycles. Before actual transfer, the ampulla of each tube was measured to determine the depth at which gametes could be placed. Fifty-seven transfers were made with four oocytes into a single tube; of these, when gametes were deposited deeper than 4 cm, the pregnancy rate was higher than when they were placed at between 3 to 4 cm (69.6% compared with 41.2%). Presumably, a deeper placement is more secure and decreases the likelihood of gamete displacement. The pregnancy rate also rose with the number of oocytes used: from 0% with a single oocyte to 42.9% with four oocytes.

Twenty-four-hour progesterone and luteinizing hormone profiles in the midluteal phase of the infertile patient: correlation with other indicators of luteal phase insufficiency.

The authors have further analyzed women diagnosed as having luteal phase insufficiency in hope of determining the value of specific screening tests as well as determining the degree of heterogeneity of pathophysiologic mechanisms involved in the disorder. Twelve women with the disorder were identified, 6 with two consecutive midluteal serum progesterone (P) levels less than 10 ng/ml (group 1) and 6 with two consecutive late luteal phase endometrial biopsies out of phase (group 2); 4 infertile women with normal serum P and late luteal biopsies also were studied (group 3). All underwent serum sampling for P and luteinizing hormone (LH) at 20-minute intervals for 24 hours, beginning at 9:00 A.M. of day 7 post-LH surge. No significant differences were noted among the three groups for LH area under the curve, pulse frequency, or pulse amplitude. Furthermore, no differences were ascertained for P area under the curve. However, individuals were identified who had one or more hormonal abnormalities but no abnormal biopsy, as well as patients with normal hormonal profiles but having abnormal endometrial development. Receiver Operating Characteristic curves demonstrated that pooled morning serum P levels provided optimal predictive ability of biopsy results. The authors conclude that luteal phase insufficiency is a heterogeneous disorder, and that neither endometrial biopsy nor serum hormonal analysis obviates the need for the other.

Management of unruptured ectopic gestation by linear salpingostomy: a prospective, randomized clinical trial of laparoscopy versus laparotomy.

This study was designed to compare prospectively the parameters of morbidity, cost, length of hospital stay, and fertility outcome after linear salpingostomy by laparoscopy versus laparotomy. Entry criteria included stable vital signs, hematocrit greater than 30%, age over 18 years, and desire for future fertility. All patients underwent diagnostic laparoscopy. Sixty patients with unruptured ectopic gestations of 5 cm or smaller were randomized to either laparoscopy (N = 30) or laparotomy (N = 30). Postoperative follow-up included serial measurements of serum beta-hCG titers at 3-day intervals and hysterosalpingography at 12 weeks. The laparoscopy and laparotomy groups were similar in age, height, weight, gravidity, gestational age, hematocrit, ectopic pregnancy size, and preoperative beta-hCG levels. The estimated blood loss was significantly (P less than .001) lower in patients undergoing laparoscopy, and was not affected by vasopressin injection. Two patients in the laparoscopy group required laparotomy for hemostasis, and two patients undergoing laparotomy had wound infection. One patient in each group had persistent trophoblastic activity. Baseline serum beta-hCG levels and the rate and magnitude of postoperative beta-hCG decline were similar in both groups. The length of hospital stay was significantly (P less than .001) shorter after laparoscopic salpingostomy (1.4 +/- 0.1 days) than after laparotomy (3.3 +/- 0.2 days). Postoperative hysterosalpingography showed patency of the involved tube in 16 of 20 (80%) and 17 of 19 (89%) of patients in the laparoscopy and laparotomy groups, respectively. Pregnancy rates were ten of 18 (56%) and 11 of 19 (58%) in these groups, respectively, and all pregnancies were conceived within 6 months of surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Menstrual function and hirsutism in patients with gonadal dysgenesis.

Thirty adult patients with gonadal dysgenesis were identified over the five-year period between January 1981 and December 1985 in the Reproductive Endocrinology and Infertility Clinic at the University of Southern California/Los Angeles County Medical Center. Six patients had previous menstrual function and presented with secondary amenorrhea. Chromosome analysis revealed three patients with 45,X karyotypes and three patients with 45,X mosaics. One of these patients (45,X/47,XXX) presented with secondary amenorrhea and elevated follicle-stimulating hormone, and conceived twice after being placed on estrogen replacement therapy. Three additional patients presented with hirsutism as their primary complaint, and had karyotypes of 45,X/46,XY, 45X/46X,i(Yq), and 45,X. The latter patient, who had her karyotype confirmed by analysis of four tissue sources, had a streak gonad and a dysgenetic gonad, with both follicles and seminiferous tubules.

Secretory dynamics of bioactive and immunoreactive prolactin in polycystic ovary syndrome.

To further investigate prolactin (PRL) secretion in polycystic ovary syndrome (PCO), the authors evaluated immunoreactive (immuno) and bioactive (bio) PRL levels in the basal state and in response to provocative testing with intravenous dopamine (DA), metoclopramide (MCP), and gonadotropin-releasing hormone (GnRH), before and after disulfiram. Basal measurements of immuno-PRL, bio-PRL, and the ratio of bio/immuno-PRL were similar in PCO and controls. The immuno-PRL decrement after DA was greater than that of bio-PRL in both groups (P less than 0.05). After MCP, immuno-PRL increased more than bio-PRL in PCO (P less than 0.01), and this immuno-PRL increment was greater than that of controls (P less than 0.05). Bio-PRL and immuno-PRL increased after GnRH in PCO, but not controls, and these responses were inhibited by disulfiram. These data confirm PRL hypersecretion in some women with PCO, which is better expressed by immunoreactivity than bioactivity. Given the assay systems and patients studied, bioactivity

Effect of androgen on adrenal steroidogenesis in normal women.

Ovarian hyperandrogenism may induce adrenal enzymatic defects that mimic true inherited disorders of adrenal hormone biosynthesis. To assess the effect of hyperandrogenism on adrenal steroidogenesis, seven normal ovulatory women were studied on 2 days during the early follicular phase of their cycles. Plasma 17-hydroxyprogesterone (17-Prog), 17-hydroxypregnenolone, dehydroepiandrosterone (DHEA), DHEA sulfate, androstenedione (Adione), testosterone (T), 11-deoxycortisol, and cortisol concentrations were measured every 15 min for 3 h after iv injection of 0.25 mg ACTH (day 1) and pretreatment with dexamethasone on each day. On the second study day, T (80 micrograms/h) was infused iv for 5 h, and ACTH was given after 2 h of T infusion. The T infusion raised mean serum T levels from 1.2 +/- 0.3 (+/- SE) to 8.6 +/- 0.6 nmol/L. The maximum incremental (delta max) plasma Adione response to ACTH was significantly higher (2.6 +/- 0.3 to 3.2 +/- 0.4 nmol/L; P less than 0.009) during the T infusion, while the delta max responses of the other steroids did not change. There was an increase in the delta max 17-Prog to cortisol ratio (4.9 +/- 0.7 to 7.0 +/- 1.0; P less than 0.05), but no change in the delta max 17-Prog to Adione or 17-hydroxypregnenolone to DHEA ratios and no changes in the delta max delta 5- to delta 4-steroid ratios. These data suggest that acute T elevations result in subtle inhibition of 21-and/or 11 beta-hydroxylase activities, but not in 17-20-desmolase or 3 beta-ol activities.

Further evidence against dopamine deficiency as the cause of inappropriate gonadotropin secretion in patients with polycystic ovary syndrome.

Previous studies suggested that a relative dopamine (DA) deficiency may explain the altered LH secretory dynamics that occur in patients with polycystic ovary syndrome (PCO). These studies included findings of decreased urinary excretion of homovanillic acid (HVA), a metabolite of DA, and increased urinary excretion of 3-methoxy-4-hydroxyphenylglycol (MHPG), the major brain metabolite of norepinephrine. To further explore the role of DA in these patients, disulfiram (250 mg) was administered daily for 2 weeks to alter the conversion of DA to norepinephrine and to increase both peripheral and central DA in patients with PCO and in normal women. LH pulse frequency and amplitude and the serum LH response to GnRH were assessed before and during disulfiram administration. A dopaminergic effect during disulfiram administration was evidenced by a decrease in serum PRL in the PCO patients and an increase in urinary HVA excretion and a decrease in the ratio of 3-methoxy-4-hydroxyphenylglycol to HVA in urine in both groups (all P less than 0.05). This increase in DA did not significantly alter the serum estrogen level, the mean serum LH level, LH pulse amplitude, or serum LH responses to GnRH in either the PCO patients or the normal women. These data suggest that increasing endogenous DA does not correct the inappropriate gonadotropin secretion characteristic of PCO and places further doubt on the importance of DA in explaining the altered LH secretory dynamics in these patients.

The endocrinologic evaluation of a 45,X true hermaphrodite.

A 13-year-old 45,X girl presented with spontaneous menses and the acute onset of progressive hirsutism. Complete endocrinologic evaluation of hirsutism was unremarkable. An exploratory laparotomy revealed a gonad containing ovarian and testicular tissue. Chromosome analysis from four different tissues confirmed the karyotype to be 45,X. She was H-Y antigen positive.

Hexamethylmelamine in ovarian cancer after failure of cisplatin-based multiple-agent chemotherapy.

A prospective study was initiated in 1979 to investigate the effect of hexamethylmelamine (HMM) as a second-line chemotherapeutic agent in the treatment of advanced adenocarcinoma of the ovary after failure of cisplatin-based multiple-agent chemotherapy. Of 20 evaluable patients, there were 5 patients (25%) who had objective responses (4 complete and 1 partial). Four additional patients have remained without evidence of disease. Six of these 9 patients are still alive, disease free. There were significant differences (P less than 0.001) in both the progression-free interval and survival time for these 9 patients, 13.3 and 15.1 months, respectively, as compared to the 15 nonresponders, 0.8 and 5.8 months, respectively. There was no significant difference in survival between the 4 patients with stable disease and the 11 patients with progressive disease. Performance status less than 2 (P less than 0.05) and absence of clinically measurable disease at the time of entry into the study (P less than 0.05) were found to be significant variables with regard to determining outcome. Only 2 of 24 patients suffered severe enough side effects from the HMM to warrant its discontinuation. This study demonstrates that HMM at doses of 6-8 mg/kg/day for 21 out of every 28 days can induce a complete response and provide an extended disease-free interval and prolonged survival with tolerable side effects in a significant number of patients with ovarian cancer who have previously failed cisplatin-based multiple-agent chemotherapy.

Problems in the cultivation of cervical bacteria.

Multiple variations in the types, species and prevalence of cervical bacteria are described in the literature. A review of the literature was undertaken to determine the effect of delay on the ability to identify bacteria. Experiments were initiated to elaborate on those observations. The rate of organism isolation was related to the delay in transport to the laboratory.

PIP: In clinical practice, the net result of delays between specimen isolation and plating may be inability to grow or identify the organisms present. 2 specimens each from 70 patients at a gynecologic office were prepared for either transport or mailing to a laboratory in order to test the effect of time and less-than-ideal conditions of transport on rates of microbial recovery. The 1st 39 patients were studied for presence of anaerobic bacteria and the remaining 31 for aerobic bacteria, yeast, and Trichomonas vaginalis. Specimens taken to the laboratory at the end of office hours had a maximum lag time from collection to plating of 9.0 hours, with a mean of 4.5 hours, while specimens mailed at the end of office hours were received by the laboratory 2-5 days later. Standard microbiologic techniques as described in the Centers for Disease Control Laboratory Manual were used throughout the study. Pretests of microbiologic materials for sterility showed that 10 of 30 control mailing envelopes cultured positive for a variety of organisms while 8 aerobic transport media showed no growth. Control culture plates opened at a variety of sites for no longer than 10 minutes showed growth of E. coli in 2 of 10 plates in a laminar flow hood, 5 of 10 in a laboratory, 3 of 10 in Cook County Hospital, and none of 10 in an obstetrics and gynecology clinic, indicating that airborne contamination is a real possibility in clinical settings. Cultures were positive for anaerobes in 14 of 39 transport samples (36%) versus 2 of the mailed samples (5%). All 31 cultures were positive for growth of aerobes after transport, whereas 22 of 31 (71%) were positive after mailing. After transport the number of species isolated per woman ranged from 1 to 5 with a mean of 31, but after mailing 18 samples were positive for 1 organism and only 4 for 2 organisms. Streptococcus organisms were isolated in 74% of transported but only 23% of mailed cultures, and gram-negative rods were found in 68% of transported and 25% of mailed cultures.