The predictive value of the sperm-cervical mucus interaction test on the outcome of in vitro fertilization and ovulation induction combined with intrauterine insemination.

We investigated the effect of the sperm-cervical mucus penetration tests (SPT) on the fertilization rate (FR) and pregnancy rate (PR) in patients treated with either in vitro fertilization (IVF) or ovulation induction combined with intrauterine insemination (OI + IUI). Infertile couples where the women had normal ovarian function and a normal pelvis at laparoscopy and her partner had normal seminology who had failed at least 2 SPTs were treated with either IVF or OI + IUI. These patients were compared with similar couples in whom SPTs were satisfactory (SPT/ve). Group A (SPT+ve) consisted of 46 patients who underwent 78 treatment cycles of IVF and Group B (SPT-ve) comprised 31 patients who underwent 35 IVF cycles. Group C (SPT/ve) consisted of 39 patients who underwent 84 treatment cycles with OI + IUI, and Group D (SPT-ve) consisted of 15 patients who underwent 37 cycles with the same treatment. In patients treated with IVF, the FR and PR per embryo transfer were 77.0% and 20.0% respectively in Group A, and 64.0% and 22.6% respectively in Group B. The difference in FRs was statistically significant (p > 0.001) but there was no difference in the PRs. In patients treated with OI + IUI, the PR per cycle were 22.0% in Group C and 16.2% in Group D. These results indicate that SPT failure was associated with a lower FR in IVF but this did not affect the PRs. Similarly there was no difference in PRs following OI + IUI.

Purified urinary follicle stimulating hormone induces different hormone profiles compared with menotrophins, dependent upon the route of administration and endogenous luteinizing hormone activity.

The effects of treatment of patients with gonadotrophin-releasing hormone analogue (GnRHa) combined with purified follicle stimulating hormone (FSH) for in-vitro fertilization (IVF) were investigated in detail to determine the influences of different administration routes and the degree of suppression of luteinizing hormone (LH). Responses to exogenous gonadotrophins were studied in infertile women (n = 60) with normal menstrual rhythm whose endogenous gonadotrophin activity was suppressed using a GnRHa in a long protocol. They were randomized to receive i.m. administration of human menopausal gonadotrophins (HMGim, Pergonal) or purified follicle stimulating hormone (FSH, Metrodin High Purity) administered either i.m. (MHPim) or s.c. (MHPsc). Responses were assessed by measuring plasma FSH, LH, oestradiol, testosterone and progesterone. After stimulation day 4, the MHPsc group showed significantly higher circulating concentrations of FSH than either the MHPim or HMGim group. However, the HMG group showed significantly higher oestradiol concentrations after stimulation day 5 than either MHP group. The differences in circulating oestradiol concentrations in the MHP-treated patients appeared to be strongly influenced by the mean circulating concentrations of LH in the follicular phase. The patients who showed mean follicular phase LH concentrations of < 1 IU/l showed longer follicular phases, lower circulating oestradiol and testosterone concentrations and also lower follicular fluid concentrations of oestradiol and testosterone, indicating a reduction in the normal follicular metabolism of progesterone to androgens and oestrogens under these conditions. This group of patients also showed longer follicular phases, which may have consequences for future clinical management.

The effect of sperm-mucus interaction test on the outcome of in vitro fertilization and ovulation induction combined with intrauterin insemination.

OBJECTIVE: To investigate the effect of sperm mucus penetration tests (SPT) on the fertilization rate (FR) and pregnancy rate (PR) in patients treated with either in vitro fertilization (IVF) or ovulation induction combined with intrauterine insemination (OI + IUI). METHODS: Retrospective analysis of a regional Infertility Unit database. Infertile couples where the women had normal ovarian function and a normal pelvis at laparoscopy and her partner had normal seminology who had failed at least two SPTs who were treated with either IVF or OI + IUI. These patients were compared with similar couples in whom SPTs were satisfactory (SPT + ve). Group A (SPT + ve) consisted of 46 patients who underwent 78 treatment cycles of IVF and Group B (SPT - ve) comprised 31 patients who underwent 35 IVF cycles. Group C (SPT + ve) consisted of 39 patients who underwent 84 treatment cycles with OI + IUI, and Group D (SPT - ve) consisted of 15 patients who underwent 37 cycles with the same treatment. RESULTS: In patients treated with IVF, the FR and PR per embryo transfer were 77.0% and 20.0%, respectively in Group A, and 64.0% and 22.6%, respectively in Group B. The differences in FRs were statistically significant (p < 0.001) but there was no difference in the PRs. In patients treated with OI + IUI, the PR per cycle were 22.0% in Group C and 16.2% in Group D. CONCLUSION: The results indicate that SPT failure was associated with a lower FR in IVF but this did not affect the PRs. Similarly there was no difference in PRs following OI + IUI.

A detailed study of the effect of videoframe rates of 25, 30 and 60 Hertz on human sperm movement characteristics.

A comparison was made of the movement characteristics of human spermatozoa analysed at three videoframe rates (25, 30 and 60 Hz) using two computerized motility analysers from Hamilton-Thorn Research (the HTM-2030 and the IVOS) operating at 25 and 30 Hz respectively. Analysis at 30 and 60 Hz was performed on the IVOS. The use of uncapacitated, capacitated and pentoxifylline-stimulated spermatozoa ensured a full range of movement characteristics was analysed. The velocity parameters curvilinear velocity and average path velocity were highly frame-rate dependent, and mean values increased with videoframe rate. An interaction of framing rate and time of data collection resulted in an increase in straight-line velocity with framing rate. Mean lateral head displacement and linearity were similar at 25 or 30 Hz but significantly depressed at 60 Hz. Beat-cross frequency increased by 74% when analysed at 60 rather than 30 Hz. The following criteria: curvilinear velocity > 100 microns/s, linearity < 65% and lateral head displacement > 7.5 microns, were used to define hyperactivated spermatozoa. Significantly more hyperactivated cells were identified at 30 Hz than 25 Hz (1-10%) but not at 60 Hz. A different population of cells is likely to have been identified as hyperactivated at 60 Hz due to alterations in component movement parameters from which the definition of hyperactivation was derived. In conclusion, direct comparisons should not be drawn between data analysed at 25 and 30 Hz. Analysis at 60 Hz introduced complex alterations which made simple comparisons with 30 Hz data invalid.

Randomized comparison of ovulation induction with and without intrauterine insemination in the treatment of unexplained infertility.

The aim of this prospective randomized controlled study was to determine the possible role of ovulation induction with intrauterine insemination (IUI) in the treatment of unexplained infertility. A total of 100 patients were randomized to receive ovulation induction with or without IUI. All patients were treated with long-course gonadotrophin-releasing hormone analogue (GnRHa), starting in the luteal phase, and exogenous follicle stimulating hormone (FSH) to induce follicular growth. Ovulation was induced using human chorionic gonadotrophin and timed intercourse (TI) was advised 24-48 h later or IUI was effected 36-48 h later. Both the cycle fecundities (21.8 and 8.5%) and the cumulative ongoing pregnancy rates after three cycles (42 and 20%) were significantly higher (P < 0.03) in the IUI group than in the TI group respectively. This is a clear indication that ovulation induction with IUI is an effective treatment method for unexplained infertility, but ovulation induction with TI has a negligible impact in this large group of patients.

Pregnancy outcome following exposure to gonadotrophin-releasing hormone analogue during early pregnancy: comparisons in patients with normal or elevated luteinizing hormone.

The outcomes of established pregnancies following the treatment of infertile women with pituitary down-regulation before and during treatment with ovulation induction and either intrauterine insemination or timed intercourse were reviewed. Once started on gonadotrophin-releasing hormone analogue (GnRHa) treatment, the patients were maintained on GnRHa therapy throughout the following luteal phase to facilitate the start of the next treatment cycle if no pregnancy was established. This resulted in patients taking GnRHa until a positive pregnancy test indicated cessation of the treatment. The aim of our study was to determine whether exposure to GnRHa during early pregnancy constituted a risk. Patients who were diagnosed as having elevated follicular phase luteinizing hormone (LH) concentrations during their investigations were analysed as a separate cohort to assess whether this diagnosis had implications with respect to pregnancy outcome. Out of 226 recorded clinical pregnancies, 173 were traced and the data collated: 16 cases resulted in clinical abortions, two were ectopic pregnancies and 155 women had live births at various ages of gestation. There were three pregnancies which were complicated by congenital abnormalities. Patients with elevated LH concentrations on examination showed a higher rate of total pregnancy loss than those with normal LH concentrations, despite the fact that the LH was suppressed during the cycle in which they conceived. The results suggest that pregnancy outcome is not adversely affected by GnRHa administration during the luteal phase of the conception cycle, and that the group diagnosed as having elevated LH concentrations may retain their propensity to higher rates of pregnancy loss even when their LH concentrations are suppressed during treatment.

Spontaneous follicular and luteal function in infertile women with oligomenorrhoea: role of luteinizing hormone.

OBJECTIVE: There is a paucity of longitudinal endocrine studies of infertile patients with oligomenorrhoea. We have assessed the frequency and quality of spontaneous follicular development and luteal function in patients with oligomenorrhoea and infertility (PCOS), and have related the observed criteria to circulating LH activity. DESIGN: Prospective detailed investigations in a cohort of unselected patients. PATIENTS: Infertile women with oligomenorrhoea (PCOS, n = 131) presenting to the infertility clinic at the Royal Infirmary, Glasgow. MEASUREMENTS: Patients were monitored with frequent plasma oestradiol (E2) concentration assessments over a minimum period of 3 weeks, starting more than 2 weeks after a menstrual bleed. When follicular maturation was identified the patient provided daily blood samples through to her ensuing menstrual bleed, and E2, progesterone, total testosterone, FSH and LH were assessed in these samples. Luteal phase progesterone profiles were assessed between the days LH surge +2 and LH surge +6 by means of a progesterone index. RESULTS: Forty-eight per cent of the patients showed evidence of follicular development. The oestradiol profiles in the patients showing follicular growth were normal, but the progesterone curve was sub-normal in the early luteal phase, due to a high proportion of deficient luteal phases. The mean LH concentrations were elevated in the whole group, but no difference was observed between the mean LH values for those patients showing spontaneous follicular development and those who did not, and the incidence of ovulation was similar in the normal LH and elevated LH groups. Similarly, no relation was established between LH and the quantitative assessment of luteal phase progesterone profiles (progesterone index), and the distribution of progesterone indices was similar in the normal LH and elevated LH groups. Testosterone concentrations were positively correlated with LH (p = 0.008) but not with the incidence of spontaneous follicular growth. There was no significant difference in the incidence of spontaneous ovulation between the patients with elevated or normal mean follicular phase testosterone concentrations. CONCLUSION: The data indicate that both LH and testosterone secretion in PCOS were closely linked, but that neither was directly linked to the incidence or inhibition of spontaneous follicular development in PCOS, or to the disturbance in luteal phase progesterone profiles.

Growth factors in human ovarian follicle fluid and growth factor receptors in granulosa-luteal cells.

The levels of oestradiol (E2), progesterone (P4), transforming growth factor alpha (TGF alpha), transforming growth factor beta 2 (TGF beta 2), insulin-like growth factor I (IGF-I), platelet-derived growth factor AB (PDGF-AB) and epidermal growth factor (EGF) were measured in follicular fluids obtained from patients undergoing ovarian stimulation as part of an in vitro fertilisation program. Each of the substances was detected in all of the fluid samples tested, except TGF alpha (which was detected in 90% of samples tested), PDGF-AB (70%) and EGF (2%). Comparisons were made between each of these factors, follicular maturity, successful oocyte recovery and the outcome of fertilisation and embryo transfer. No statistically significant correlations were found. The presence of receptors for EGF, IGF-I and PDGF in extracts from granulosa-luteal cells isolated from follicular fluids was detected by means of Western blotting. The co-localisation of these growth factors and their receptors within the ovarian follicle suggests a likely role in control of follicular development.

A comparison of two starting doses of human menopausal gonadotrophin for follicle stimulation in unselected patients for in-vitro fertilization.

Ovarian responses and embryology data were compared in patients undergoing in-vitro fertilization following follicular stimulation using long course gonadotrophin-releasing hormone (GnRH) analogue/human menopausal gonadotrophin (HMG) in which the initial daily dose was two (150 IU) or three ampoules (225 IU) maintained for a minimum of 7 days. Group 1 (n = 31; centre A) patients were treated with a starting dose of two ampoules, while group 2 (n = 46; centre A) patients were treated chronologically immediately before group 1 with a starting dose of three ampoules per day. Group 3 (n = 74; centre B) patients were treated with three ampoules per day simultaneously with group 1. There was no difference in the distributions of patient ages or reasons for treatment between the three groups. Group 1 required longer treatment before the plasma oestradiol attained 250 pg/ml than did both the other groups (group 1, 9.0; group 2, 6.9; group 3, 6.7 days; P < 0.01), and this resulted in a longer follicular phase for group 1 (mean: 14.5 days compared with 12.7 and 12.8 for groups 2 and 3 respectively; P < 0.05). The numbers of follicles > 16 mm in diameter at human chorionic gonadotrophin (HCG) administration and the numbers of eggs and embryos were all significantly lower (P < 0.04) in group 1, and cycle cancellations due to insufficient ovarian responses were higher (P < 0.02) in group 1. There was no difference in the numbers of ampoules used, the oestradiol concentration at HCG, the fertilization and pregnancy rates or the incidence of hyperstimulation syndrome in the three groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of pentoxifylline and progesterone on human sperm capacitation and acrosome reaction.

This study was designed to test the effects of pentoxifylline and progesterone upon capacitation of fresh human spermatozoa. Capacitation and acrosomal integrity were assessed using the fluorescent probe chlortetracycline on spermatozoa co-stained with a supravital fluorescent dye, Hoechst 33258. Hyperactivated motility was measured using computer-assisted movement analysis. After exposure to pentoxifylline (1 mg/ml; 30 min), the fluorescent 'B' pattern, characteristic of capacitated, acrosome-intact cells, increased significantly (P < 0.01), though no increase in 'AR' pattern, characteristic of acrosome-reacted cells, was detected. There was a significant increase in hyperactive motility (P < 0.001). Exposure to progesterone (1 microgram/ml; 60 min) resulted in a significant increase in 'B' pattern (P < 0.05) and 'AR' pattern (P < 0.005), though no effect on the expression of hyperactivation was detected. No effect upon hyperactivation was detected on exposure of fresh or cryopreserved spermatozoa to a physiological range of progesterone concentrations (0.1-1000 ng/ml). Sequential exposure to pentoxifylline then progesterone resulted in a significant increase in 'B' pattern, acrosome loss and hyperactivation. Sperm viability was not affected in any treatment group. These observations suggest that pentoxifylline and progesterone affect capacitation through independent mechanisms. Stimulation of both capacitation and acrosome reaction resulted from sequential exposure to pentoxifylline and progesterone. This may have implications for sperm handling for assisted reproductive techniques.

Ovarian stimulation in an infertile patient with growth hormone-deficient Oliver-Mcfarlane syndrome.

Several authors have suggested that growth hormone may augment ovarian responses to follicle stimulating hormone in women (Homburg et al., Clin. Endocrinol., 29, 1988; Ibrahim et al., Fertil. Steril., 55, 1991), and that this effect may be mediated by insulin-like growth factor I (IGF-I) (Davoren and Hsueh, Endocrinology, 118, 1986). Menashe et al. (Hum. Reprod., 6, 1991) reported spontaneous pregnancies in women with a deficiency in growth hormone receptors and, consequently, low serum concentrations of IGF-I. In this report, we present the case of a patient with a rare syndrome first described by Oliver and Mcfarlane (Arch. Ophthalmol., 74, 1965). The patient was shown to be growth hormone deficient, with hypopituitarism as part of the syndrome. Adjuvant growth hormone did not influence her ovarian responses to exogenous gonadotrophins during assisted conception treatment, as reflected by the required total number of ampoules of human menopausal gonadotrophin, the number of developing follicles, the rate of follicular growth and the serum oestradiol concentrations.

The chromosome constitution of human preimplantation embryos fertilized in vitro.

The chromosome constitution of five haploid, 178 diploid and 11 triploid embryos fertilized in vitro was determined after fixation on day 2 or day 3 of development. Karyotype analysis of 178 diploid embryos revealed abnormalities in 40 (22.5%) cases: 34 (19.1%) aneuploids, four (2.2%) mosaic embryos and two (1.1%) structural anomalies were identified. The majority of aneuploid karyotypes (28/34) involved a single chromosome but six embryos had aneuploidy of two or three chromosomes. The E group was most frequently involved in aneuploid karyotypes (10/23 hyperdiploid embryos) and trisomy 16, the most common single anomaly in diploid embryos, was detected in 2.2% (4/178) of cases. Only one case of sex chromosome monosomy was identified. An excess of female karyotypes was detected in abnormal cases (sex ratio 0.48); this ratio was significantly (P < 0.05) different from that observed in normal cases (74:64, XY:XX). The incidence of aneuploidy increased with maternal age but this did not reach statistical significance. Embryo morphology and growth rate, assessed by embryo development rating (EDR), did not distinguish between normal (mean score 7.9; mean EDR 96.1) and aneuploid (mean score 8.1; mean EDR, 92.1) embryos. Numbers of hyperploid (n = 17) and hypoploid (n = 11) embryos (non-mosaic cases involving single chromosomes) were not statistically different. The relative proportions of chromosomes involved in trisomic karyotypes showed a remarkable similarity to the pattern in spontaneous abortions. Pronuclear status was an unreliable predictor of ploidy. Small numbers of karyotyped triploid embryos revealed equal proportions of XXX, XXY and XYY embryos.

Assessments of embryo transfer after in-vitro fertilization: effects of glyceryl trinitrate.

The role of embryo transfer and its associated difficulties on the outcome of human in-vitro fertilization (IVF) were examined using a standardized procedure and a scoring system (embryo transfer scores 1-5). This system was used to assess any effects of the smooth muscle relaxant glyceryl trinitrate (GTN) on embryo transfer. Patients (n = 120) were randomized in a double-blind manner at their first embryo transfer to receive sublingual GTN or placebo before the transfer. Retrospective analysis showed that higher pregnancy rates were associated with uncomplicated transfers (score 1; P < 0.01). The outcome measures included pregnancy rate, total time of cervical manipulation (embryo transfer time) and embryo transfer score. All pregnancies had a transfer score of 1 or 2, but no recorded parameter differentiated between pregnant or non-pregnant cycles, and GTN had no significant effect on any parameter.

Pentoxifylline stimulates hyperactivation in human spermatozoa.

The effects of pentoxifylline on the movement characteristics of human spermatozoa incubated under capacitating conditions were examined using automated digital image analysis. Washed spermatozoa from cryopreserved and fresh normozoospermic, and fresh oligozoospermic semen were incubated in the presence of pentoxifylline (3.6 mM) for 30 min. In each group, pentoxifylline caused an increase in the average lateral head displacement and curvilinear velocity and a decrease in the linearity of progression. This related to a significant increase in the population of spermatozoa developing hyperactivation. The effect was maximal at between 15 and 75 min incubation. No detrimental effect on sperm vitality was demonstrated. It was shown that hyperactivation remained elevated compared with the control after washing pentoxifylline from the suspension. This effect was maintained for 1 h, but became insignificant after 3 h. These data demonstrate that pentoxifylline stimulates the development of hyperactivation in washed human spermatozoa, a phenomenon which may be of value in the treatment of some forms of male factor infertility.

Absence of effect of adjuvant growth hormone therapy on follicular responses to exogenous gonadotropins in women: normal and poor responders.

OBJECTIVE: To examine the effects of growth hormone (GH) on ovarian responses to exogenous gonadotropins after pituitary desensitization in normal and poor responder patients undergoing in vitro fertilization. DESIGN: A prospective study with comparison of control and GH-treated cycles. PATIENTS: Poor responder patients (n = 10) required > 44 ampules of human menopausal gonadotropin (hMG) to achieve criteria for administration of human chorionic gonadotropin (hCG) on day 0 or cancellation in control cycles, and normal responder patients (n = 10) required < 45 ampules. MAIN OUTCOME MEASURES: Ovarian responses to hMG assessed by duration of stimulation required to achieve first significant estradiol (E2) response and hCG criteria. Total doses and duration of hMG, follicular development and E2 concentrations on day 0, and embryology were also assessed. RESULTS: Growth hormone showed no effect on any of the parameters studied in either patient group. CONCLUSION: Follicular recruitment, E2 secretion by mature follicles, and oocyte yield and quality were uninfluenced by GH treatment.

In vivo and in vitro maturation of human oocytes: effects on embryo development and polyspermic fertilization.

OBJECTIVE: To compare the effects of in vivo and in vitro maturation of human oocytes. DESIGN: Women (n = 60) undergoing follicular stimulation for in vitro fertilization, using long-course analog therapy to suppress endogenous luteinizing hormone (LH), were randomly allocated to a short (34 hour) or long (39 hour) delay between human chorionic gonadotropin (hCG) administration and oocyte retrieval. Each patient's oocytes were divided into two groups that were either inseminated immediately or after 5 hours. RESULTS: The incidence of polyspermic fertilization was highest in oocytes inseminated immediately after a short hCG/oocyte retrieval interval (17/100) and was significantly (P less than 0.05) reduced by preincubation and/or a long hGG/oocyte retrieval interval. Fertilization rates were higher with 39 hours than with 34 hours in vivo maturation (84.2% versus 76.8%; P less than 0.05). The incidence of delayed fertilization was reduced by extending the hCG/oocyte retrieval interval (short, 12.9%; long, 3.9%; P less than 0.001). CONCLUSIONS: Extension of the in vivo maturation time increased fertilization rates and eliminated the requirement for preinsemination incubation, allowing simplification of laboratory procedures.

Luteal phase deficiency: ultrasonic and biochemical insights into pathogenesis.

Serial ovarian ultrasound and daily assessments of plasma concentrations of pituitary and ovarian hormones were used to investigate ovarian function in 175 women with unexplained infertility. Their endocrine and ultrasound profiles were compared with similarly derived data from 43 normal volunteers. Fifty-one (29.1%) of the study group showed subnormal luteal phase rises in progesterone concentrations, described as poor progesterone surge (PPS) cycles. Within this group, 23 women (45.1%) demonstrated luteal cyst formation, a pattern not seen in any of the control cycles. High concentrations of follicle stimulating hormone (FSH) and reduced concentrations of oestradiol (E2) were observed in the follicular phases of the PPS cycles suggesting that the phenomenon is a product of abnormal follicular metabolism. An association of PPS with infertility exists, perhaps related to a combination of disturbances in the follicular micro-environment compromising oocyte quality, a failure of oocyte release, and impaired endometrial receptivity.

Luteal cysts and unexplained infertility: biochemical and ultrasonic evaluation.

A prospective, controlled study of ovarian function using ovarian ultrasound and daily plasma hormone estimations (estradiol, progesterone [P], follicle-stimulating hormone [FSH], luteinizing hormone [LH]) was carried out on 175 spontaneously cycling patients with unexplained infertility. Forty-one (23.4%) demonstrated luteal phase cyst formation. In 21 cycles the dominant follicle reduced in size after the LH peak (cystic corpus luteum cycles), and in 20 no shrinkage was seen (luteinized unruptured follicles). Progesterone concentrations in the early luteal phase were significantly reduced in the luteinized unruptured follicle cycles. Elevation in plasma FSH was seen in the early follicular and luteal phases of both cyst forming groups and may be due to disturbances in ovarian metabolism. Follicular rupture is important for efficient P release by the corpus luteum.

Induction of multiple follicular development for IVF.

It is now accepted, almost universally, that multiple follicular development is a pre-requisite for a successful assisted conception programme. The reasons for this are based on abundant clinical evidence from the major IVF and GIFT centres of the world indicating the benefits of having multiple gametes available for transfer. The more embryos transferred, the better the pregnancy rate; the more embryos available for cryopreservation the better the chances of subsequent survival and replacement. However, the vast majority of patients in IVF/GIFT programmes have normal ovarian and pituitary function designed to produce a single dominant follicle and oocyte each month. Obtaining multiple follicular growth requires pharmacological manipulation of ovarian function and complicating factors may arise from both ovarian and pituitary sources. Methods employed to achieve multiple follicular growth vary considerably in the different centres and experiments continue in attempts to find either the simplest or the perfect system, or both. This would provide abundant oocytes and the ideal hormone environment for implantation, with no interfering factors at either the ovarian or endometrial level, while avoiding the drawbacks commonly encountered such as pre-operative ovulation or hyperstimulation syndrome. It should also be inexpensive, although in reality cost-effectiveness is more important.