Determinants of the outcome of intrauterine insemination: analysis of outcomes of 9963 consecutive cycles.

OBJECTIVE: Our aim was to determine which factors influence the effectiveness of intrauterine insemination. STUDY DESIGN: This article is a retrospective statistical analysis of outcomes of 9963 consecutive intrauterine insemination cycles. RESULTS: Patient age was the main determinant of pregnancy outcome (analysis of variance F ratio = 29, P <.0001), followed by the number of follicles at the time of intrauterine insemination (analysis of variance F ratio = 9, P <.0001) and sperm motility in the inseminate (analysis of variance F ratio = 4, P =.002). A total of 18.9% of all patients <26 years old conceived, compared with 13.9% of those 26-30 years old, 12.4% of those 31-35 years old, 11.1% of those 36-40 years old, 4.7% of those 41-45 years old, and 0.5% of patients >45 years old (P <.001). When analyzed by single years, ongoing pregnancy rates after intrauterine insemination remained high through age 32 years. Across all ages and causes of infertility, 7.6% of patients with 1 follicle at the time of intrauterine insemination conceived, compared with 10. 1% with 2, 14.0% with 4, and 16.9% with 6 follicles (P <.01). When ovulation occurred before intrauterine insemination (ie, no visible follicular structures), 4.6% of patients conceived. The likelihood of pregnancy was maximized when motile sperm numbers were >/=4 million and sperm motility was >/=60%. Differences in pregnancy outcomes between sperm processing options were related to differences in sperm motility after processing; use of methods incorporating motility enhancement with pentoxifylline and motile sperm concentration through silica gradients yielded the highest overall pregnancy rates. CONCLUSION: When the results of ongoing retrospective analysis of intrauterine insemination outcomes are applied, overall intrauterine insemination pregnancy rates have increased from 5.8% per cycle in 1991 to 13.4% per cycle in 1996, during which time the average age of patients undergoing intrauterine insemination has increased from 36.1 (+/-0.2) to 39.2 (+/-0.1) years.

Assessment of sister chromatid exchange in mouse embryos produced by microsurgical fertilization.

The treatment of male factor-related infertility has been approached with the advent of several methods for microsurgical fertilization, such as the partial dissection of the zona pellucida (PZD) and the injection of sperm into the perivitelline space (PVSI) of oocytes. These techniques are designed to increase sperm-oolemma interaction by circumventing passage of the sperm through the zona pellucida. The present study was performed to evaluate the influence of PZD and PVSI on the in vitro development of mouse embryos by assessing the rate of sister chromatid exchange (SCE). SCE is considered to be a sensitive indirect indicator of DNA lesions due to various conditions. Oocytes were cultured in vitro after PZD or PVSI and then examined for SCE. There was no significant difference in SCE between control and treatment groups of embryos and the values were similar to those reported by Saito et al. (Fertil Steril 41:460-464, 1984). The rate of SCE was low during the first two mitotic cycles, then increased from cycle two to three before declining slightly between the 3rd and 4th cycles of cell division. These data demonstrate that the direct interaction of sperm and oocyte by PZD or PVSI did not have an adverse effect on the development of mouse embryos as assessed by the rate of SCE.

Numbers and quality of oocytes after induction of multiple folliculogenesis in women and in mice with different lots of human menopausal gonadotropins.

OBJECTIVE: To develop a murine in vivo bioassay that is sensitive to inherent variability of hMG. DESIGN: Female F1 hybrid mice were mated after injection with fixed dosages of each of four lots of hMG. Oocytes/embryos were collected and monitored during 5 days of culture. Outcome measures were compared with retrospective outcomes of ovarian stimulation of women with the same hMG lots. The bioassay was then used to compare biopotencies of six different lots of hMG. SETTING: Center for assisted reproductive technology. INTERVENTIONS: None. PATIENTS: Outcomes of controlled ovarian stimulation and IVF were retrospectively analyzed from 43 patients. MAIN OUTCOME MEASURES: Numbers of oocytes/embryos recovered, numbers fertilized, and numbers progressing beyond fertilization. RESULTS: Differences in biopotencies of hMG lots in the murine in vivo bioassay were consistent with differences in outcomes of patients treated with the same hMG lots during controlled ovarian stimulation. Bioassay outcomes also differed between different lots of hMG. CONCLUSION: The bioassay described in this study is sensitive to between-lot differences in hMG that affect follicle recruitment and oocyte quality in women (and in mice). In this respect, the bioassay could be of value in screening hMG lots, before its exploitation in a patient population. One such application is explored.

The use of surrogate gestational carriers for assisted reproductive technologies.

OBJECTIVES: We determined the effect of embryo transfer, zygote intrafallopian transfer, and frozen embryo transfer on clinical outcomes after surrogate gestational transfers. STUDY DESIGN: Prospective randomization was carried out. RESULTS: Forty-five infertile couples were matched with a gestational surrogate carrier and underwent 81 cycles of embryo transfer with various assisted reproductive technologic procedures. Nineteen cycles produced a clinical pregnancy, with delivery in 15 of 81 cycles (18.5% live-birth rate). Fifteen of the 45 couples (33%) had a child from the surrogate gestational carrier program. CONCLUSION: No significant differences in clinical outcome were observed on the basis of the type of procedure performed or the age of the patient.

Ovarian responses to menopausal gonadotropins in groups of patients with differing basal growth hormone levels.

OBJECTIVE: To investigate the relationship between endogenous serum levels of human growth hormone (hGH) and ovarian response to human menopausal gonadotropins (hMG). DESIGN: Retrospective analysis of patient response to hMG. SETTING: Center for assisted reproductive technology. PATIENTS: Eighty women who had undergone controlled ovarian hyperstimulation with hMG. Basal levels of hGH in sera from 40 of these patients were less than 5.0 microIU/mL (low hGH), values for the remaining 40 were greater than 5.0 microIU/mL (high hGH). Levels of hGH in day 2 sera were analyzed against numbers of oocytes recovered in an additional 182 patients. MAIN OUTCOME MEASURES: Serum estradiol (E2) levels and numbers of oocytes recovered at oocyte pick-up. RESULTS: Average (+/- SE) levels of hGH in sera of high-hGH and low-hGH patients were 10.2 +/- 0.6 and 2.47 +/- 0.3 microIU/mL, respectively (P less than 0.05). Respective peripheral levels of insulin-like growth factor-I were 105.3 +/- 2.9 and 97.2 +/- 2.8 ng/mL. Levels of E2 in serum of high-hGH patients exceeded respective (P less than 0.05) low-hGH values throughout folliculogenesis, and more oocytes were recovered from high-hGH patients (8.1 +/- 0.9 versus 4.7 +/- 0.5 for low-hGH patients; P less than 0.05). Serum progesterone values did not differ. Higher day 2 hGH levels were associated with higher numbers of oocytes recovered after controlled ovarian hyperstimulation. CONCLUSIONS: The present findings indicate that endogenous hGH may augment gonadotropins during follicle recruitment and during multiple folliculogenesis in women. The phase of maximum ovarian sensitivity to hGH/gonadotropin synergism and the nature of synergism remain unclear.

Growth hormone in serum of women during the menstrual cycle and during controlled ovarian hyperstimulation.

STUDY OBJECTIVE: To investigate the interrelationships between circulating levels of endogenous human growth hormone (hGH), gonadotropins, estradiol (E2), and progesterone (P). DESIGN: Retrospective. SETTING: Assisted reproductive technology center. PATIENTS: Nine normally cycling women from whom blood samples were drawn daily; 18 patients undergoing controlled ovarian hyperstimulation. RESULTS: During the menstrual cycle, average (+/-SE) hGH levels in serum ranged between 7.97 +/- 2.71 microIU/mL on day 11 and 2.11 +/- 0.38 microIU/mL on day 22. Serum hGH levels did not correlate with peripheral levels of follicle-stimulating hormone (FSH), luteinizing hormone, P, or E2 and were related to the serum E2:FSH ratio (adhibited as an index of ovarian response to FSH) on cycle day 10 only. Levels of hGH in sera of patients undergoing controlled ovarian hyperstimulation were near 4 microIU/mL and were directly related to peripheral E2 levels at the time of induction of oocyte maturity. When corrected for differences in follicle number between stimulated patients, changes in serum E2 content were independent of respective hGH levels. CONCLUSION: The findings challenge speculation that endogenous peripheral hGH content might relate to ovarian responsiveness to FSH.

The use of potassium-titanyl-phosphate laser for laparoscopic removal of ovarian endometrioma.

From January 1989 through January 1990, 31 patients thought to have ovarian endometrioma at ultrasonography were treated by operative laparoscopy and potassium-titanyl-phosphate laser. The endometriomas ranged from 2 to 9.2 cm in diameter by preoperative transvaginal ultrasonography. The operative procedure used was a three-puncture technique with a 600 micron fiber attached to a potassium-titanyl-phosphate laser. The power setting was 10 W with a continuous pulse. In all cases endometriomas were opened, drained, and irrigated, and the potassium-titanyl-phosphate laser was used to vaporize or remove the entire cyst lining. The ovarian edges were inverted with the laser at the end of the procedure. With one exception, there was no recurrence of endometrioma at 1, 3, and 6 months after the procedure, on the basis of transvaginal ultrasonography or laparoscopy. In one case, 4 months after the initial laparoscopic procedure, exploratory laparotomy was performed for resection of a large, recurrent endometrioma. The use of the potassium-titanyl-phosphate laser allows the laparoscopic surgeon an aggressive approach to ovarian endometriomas that in the past necessitated exploratory laparotomy.

Between-lot variability in chromatographic and biochemical properties of hMG.

Ten lots of dissociated hMG were characterized by reverse-phase gradient high-performance liquid chromatography. Areas of 12 discrete peaks were directly related to dosages of hMG injected. The lots were further analysed for immunoactive-FSH (41.6-106.2 IU/ampule), immunoactive-LH (11.0-20.4 IU/ampule), bioactive-LH (2.7-17.1 IU/ampule) and bioactive-hMG (149-298 pg E2/mIU immunoactive-FSH/ml). Relationships between integrated areas of the HPLC peaks and biochemical properties of the hMG lots were analysed by stepwise multiple linear regression. Between-lot differences in immunoactive-LH and immunoactive-FSH were related to HPLC peak areas (p less than 0.05); differences in bioactive-LH were not. Areas of 8 peaks were related to differences in bioactive-hMG activity, facilitating close approximation of bioactive-hMG from the derived multi-linear model (p less than 0.001). Rapid characterization of hMG by HPLC is of relevance as recent reports have shown that ovarian responses and pregnancy outcomes of patients are related to the immunoactive and bioactive gonadotropin content of hMG preparations used to induce multiple folliculogenesis before oocyte aspiration, in vitro fertilization, and embryo replacement.

Detection and management of pathological, non-palpable, cystic adnexal masses.

Ten patients with normal bimanual pelvic examinations were found to have small, non-palpable adnexal cysts by transvaginal ultrasound examination. After failing to respond to a course of observation and suppressive therapy with combination oral contraceptives, surgical evaluation was performed. In each case, histological examination returned a pathological diagnosis (endometrioma, serous cystadenoma, mature cystic teratoma, inflammatory cyst). This series suggests that transvaginal ultrasonography may be used to detect adnexal pathology before it is clinically apparent. A scheme for management of this clinical entity is proposed.

PIP: 10 women being evaluated for infertility by intravaginal ultrasonography had small, non-palpable cystic adnexal masses, which after conservative management proved pathological. The women ranged from 22-35 years old, with infertility of 1-4 years' duration. The ultrasound exams were performed with the ADR 4000 or Ultramark IV with 3.5 mHz vaginal probe. Women were re-examined with ultrasound after 1 month's observation, then after each of 3 cycles of treatment with either Ortho-Novum 1/35 (norethindrone 1 mg, ethinyl estradiol 35 mcg) or Ovral (norgestrel 0.5 mg, ethinyl estradiol 50 mcg) combined oral contraceptives. After this period of suppression, 6 of the masses had grown, 3 were unchanged, and 1 was slightly smaller. After diagnostic laparoscopy and laparotomy, there were no functional cysts, but 6 endometriomas, 2 serous cystadenomas, 1 inflammatory cyst, and 1 mature cystic teratoma. This preliminary series suggests that small cysts seen on vaginal ultrasound be followed with observation, then with suppression for at least 2 cycles of combines, not triphasic, oral contraceptives. The prevalence of non-palpable pathologic cysts needs to be determined.

Effect of human follicular fluids from pregnant and nonpregnant patients on the development of mouse zygotes in vitro.

Mouse zygotes were cultured in medium containing follicular fluid from patients who had follicles containing oocytes which fertilized, did not fertilize, or were atretic and who did or did not become pregnant after in vitro fertilization and embryo replacement. The inhibitory effect was least with the follicular fluid from follicles in which the oocytes subsequently fertilized, greater when the oocytes did not fertilize, and most inhibitory when the follicle contained an atretic oocyte. More mouse zygotes developed to blastocysts when culture medium was supplemented with follicular fluid from patients who became pregnant compared to those who did not become pregnant. There was no difference in pregnancy outcome when an oocyte which subsequently fertilized was obtained from the follicle. These results indicate that follicles contain a substance(s) which inhibits mouse zygote development in vitro and that the inhibitory activity is related to the developmental potential of the oocyte in the follicle.

Suboptimal laboratory conditions can affect pregnancy outcome after embryo transfer on day 1 or 2 after insemination in vitro.

We have demonstrated that the replacement of pronuclear stage human embryos on the day after insemination in IVF-ET results in a pregnancy rate as good as, if not better than, the rate after ET on day 2. The pregnancy rate appears to be influenced by the culture environment used for the gametes. We would recommend that ET be undertaken as soon as possible after insemination on day 1 so that if suboptimal culture conditions are present, they do not have sufficient time to affect the viability of the embryos and reduce the subsequent chance of pregnancy after replacement. If culture conditions have been optimized there is no difference in pregnancy rate after embryo transfer on day 1 or day 2 and one can then replace embryos on either day and expect the pregnancy rate obtained in either case to be similar.

Concentrations of follicle regulatory protein, steroids and gonadotrophins in antral fluids from women stimulated with metrodin and hCG.

Concentrations of immunoreactive follicle regulatory protein (FRP) were determined in 184 follicular fluid samples recovered from 30 patients in whom ovarian stimulation before oocyte recovery and in-vitro fertilization was induced with FSH (150 i.u./day). Ovum recovery was scheduled when the diameters of greater than or equal to 2 follicles reached 15-17 mm and serum oestradiol values were 740 pM/follicle. The mean level of FRP in fluid from follicles yielding oocytes which fertilized and cleaved within 48 h of recovery (24.4 +/- 3.08 immunoreactive units [IRU]/ml; 1 IRU = approximately 1 ng pig FRP) was higher than that in fluid from follicles yielding oocytes which did not fertilize (10.5 +/- 1.67 IRU/ml, P less than 0.05). FRP in fluid from follicles yielding oocytes which fertilized but did not cleave within 48 h of recovery was 17.2 +/- 2.89 IRU/ml. Overall, concentrations of FRP did not correlate with follicular fluid volume or with FSH or LH concentrations, but were positively related to prolactin, oestradiol and total protein levels (P less than 0.04). The results indicate that the FRP content of follicular fluid may be predictive of follicle/oocyte maturity. A dose-dependent increase in release of FRP by pig granulosa cells cultured in medium supplemented with 10-100 ng prolactin/ml was demonstrated. Prolactin may, therefore, be an important determinant of FRP production by granulosa cells.

Responses of patients to different lots of human menopausal gonadotropins during controlled ovarian hyperstimulation.

Responses of patients treated with different lots of human menopausal gonadotropin (hMG) during controlled ovarian hyperstimulation were analyzed. Levels of luteinizing hormone (LH) in serum varied between groups of patients treated with different hMG lots, serum follicle-stimulating hormone (FSH) levels did not differ. In the analysis of levels of estradiol (E2) in serum of patients pretreated with leuprolide acetate (gonadotropin-releasing hormone analog; GnRH-a), there was an interaction between hMG lot and day of stimulation. E2 levels/follicle also diverged between hMG batches as ovum pick-up approached. Within the groups of patients pretreated with GnRH-a, serum FSH/LH ratios varied between 5 and 20, with a batch x day interaction. Ongoing pregnancy rates in the hMG-treatment groups ranged between 0/24 and 7/33 (21%).

Tailoring a commercial radioimmunoassay to the range of levels of progesterone occurring in human serum during controlled ovarian hyperstimulation and following embryo/gamete transfer.

While the Pantex direct P radioimmunoassay is used widely in programs of assisted conception, its sensitivity and range do not encompass the wide range of levels of P in serum of many patients during COH and through the first trimester of pregnancy. The present communication details minor modifications to the proprietary Pantex assay which accommodate these requirements. The nature of the changes does not compromise the performance characteristics or simplicity of the original assay and facilitates precise, accurate, and rapid measurement of serum P between 0.05 and 1280 ng/ml.

Levels of interleukin-2 receptor in serum of patients during the menstrual cycle and following embryo/gamete transfer.

In an attempt to establish whether nidation elicits a measureable systemic immunologic response in vivo, levels of interleukin-2 receptor (IL-2R) have been determined in serum drawn from 34 pregnant patients (IUP) immediately before embryo/gamete transfer, and 7 and 14 days later. For comparison, these same values were determined for 41 subjects who did not conceive, and for 18 who spontaneously aborted (SAB) during the first trimester of gestation. Serum IL-2R values were near 320 U/ml and did not differ between days within outcomes, or within days between outcomes. Furthermore, levels of IL-2R and beta-hCG in serum were not interrelated on days 7 or 14 of pregnancy (SAB or IUP). Serum IL-2R levels did not change during the menstrual cycle. The present results appear to traverse presumptive elements of existing hypotheses of "placental immunotropism."

Heterotopic pregnancy associated with assisted reproductive technology.

The incidence of heterotopic pregnancy has been reported to be 1 per 30,000 pregnancies. This incidence may be much higher in pregnancies associated with assisted reproductive technology. Intravaginal ultrasonography and the use of quantitative beta-subunit assays of human chorionic gonadotropin should allow early diagnosis and treatment.

Gonadotropin and estradiol levels during ovarian stimulation in women treated with leuprolide acetate.

Levels of FSH, LH, and estradiol (E2) were measured in the serum of 209 gonadotropin-releasing hormone analogue-treated women and in 202 control subjects during the final 5 days of ovarian stimulation in our in vitro fertilization program. Levels of FSH and E2 in serum of gonadotropin-releasing hormone analogue-treated subjects significantly exceeded control values during the sampling period, whereas LH levels were significantly lower. Concentrations of E2 in serum of gonadotropin-releasing hormone analogue-treated and control subjects were similar when corrected for differences in numbers of follicles aspirated at oocyte retrieval (mean of 8.9 and 7.2 follicles per subject, respectively). Pregnancy rates by diagnostic ultrasound were 18 and 11%, respectively, a statistically significant difference.

Luteotropic activity in serum of women following embryo or gamete transfer in a program of assisted conception.

In an attempt to track the proliferation/demise of trophoblastic tissues in women following gamete transfer (GT) or in vitro fertilization/embryo transfer (IVF/ET), we have measured levels of human chorionic gonadotropin (hCG) in serum of 180 patients on days 7 and 14 following oocyte pickup (OPU). Serum hCG levels were measured by immunoassay and by a bioassay based on the capacity of the sample to stimulate testosterone secretion by cultured mouse Leydig cells. Based on determinations of bioactive and immunoactive hCG in serum from 18 of 180 patients who subsequently delivered (12 of 73 GT, 6 of 107 IVF/ET; P less than 0.05) and classification of patients in accord with their compliance or noncompliance with these ranges of values, about 70% of all patients in the present study were classified as "pregnant" 7 days following OPU. Based on these same criteria, about 23% were pregnant 7 days later. Biochemical pregnancy rates on days 7 and 14 following GT (near 73 and 27%, respectively) were not different from the respective values following IVF/ET (near 68 and 20%, respectively; P greater than 0.05). The luteotropin bioassay described is highly sensitive to hCG (to 0.02 mIU/ml serum) and appears appropriate to the characterization of proliferation/demise of embryonic tissues during the 14 days after gamete/embryo transfer. In addition, through its representation of the cumulative luteotropic properties of human serum and its insensitivity to biologically inactive hCG subunits, this bioassay appears more appropriate than hCG immunoassay in the monitoring of early embryonic signalling following assisted (or spontaneous) conception in the woman.