Aromatization mediates testosterone's short-term feedback restraint of 24-hour endogenously driven and acute exogenous gonadotropin-releasing hormone-stimulated luteinizing hormone and follicle-stimulating hormone secretion in young men.

The present clinical study examines the neuroregulatory hypothesis that feedback restraint of LH and FSH secretion by testosterone requires in vivo aromatization. To test this postulate, we prospectively and randomly assigned 47 healthy young men to 1 of 5 parallel short-term (5-day) double-blind interventions with: 1) placebo; 2) high-dose ketoconazole (KTCZ, 400 mg orally 4 times daily) to block both Leydig-cell and adrenal steroidogenesis; 3) KTCZ and transdermal testosterone delivery (7.5 mg daily); 4) KTCZ and transdermal estradiol (0.05 mg daily); or 5) KTCZ, testosterone, and the selective and potent aromatase inhibitor, anastrazole (5 mg orally twice daily). Blood was sampled every 10 min for 27 h on the last day of intervention to quantitate 24-h mean spontaneous and 3-h post-GnRH-stimulated (100 ng/kg iv bolus) LH and FSH release. KTCZ administration lowered the serum total testosterone concentration markedly from (mean +/- SEM) 423 +/- 57 ng/dL (15 +/- 2.0 nmo/L) during placebo ingestion to 58 +/- 8.6 ng/dL (2.0 +/- 0.3 nmol/L) (P < 10(-3)). Transdermal androgen addback along with KTCZ blockade increased testosterone levels to 607 +/- 57 ng/dL (21 +/- 2.0 nmol/L). KTCZ exposure alone drove a 3-fold increase in serum LH concentrations (P < 10(-3)) and a 2.5-fold rise in FSH secretion (P = 0.015), as assessed by high-specificity immunoradiometric assays. Concomitant transdermal testosterone (or estradiol) delivery repressed the elevated secretion of both LH and FSH to mid-normal baseline values. A 3-fold administration of anastrazole, KTCZ, and testosterone completely opposed exogenous testosterone's suppression of 24-h LH and FSH secretion. Anastrazole coadministration likewise abolished testosterone-dependent inhibition of 3-h GnRH-stimulated LH and FSH release. In summary, assuming the specificity of anastrazole's inhibition of aromatase activity, we conclude that circulating testosterone in healthy men curtails endogenously driven as well as exogenous GnRH-stimulated LH and FSH secretion conditional on its in vivo aromatization.

Impact of a cryopreservation program on the multiple pregnancy rate associated with assisted reproductive technologies.

OBJECTIVE: To determine the impact of a cryopreservation program on pregnancy rates and multiple-pregnancy rates in ART cycles. DESIGN: Retrospective study. SETTING: University teaching hospital. PATIENT(S): Women who underwent stimulation for in vitro fertilization at the Jones Institute for Reproductive Medicine between October 1987 and June 1999. INTERVENTION(S): Analysis of pregnancy and multiple-pregnancy rates based on the number of embryos transferred. MAIN OUTCOME MEASURE(S): Implantation; pregnancy and multiple-pregnancy rates. RESULT(S): Pregnancy rates per transfer increased from 9% when one embryo was transferred to 20% with two embryos, 35% with three embryos, 40% with four embryos, and 41% with five embryos. The rate of twin pregnancies increased to 21% with two embryos, 23% with three embryos, 21% with four embryos, and 22% with five embryos. The triplet pregnancy rates were 8% with three embryos, 9% with four embryos, and 2% with five embryos. A theoretical model limiting the number of embryos transferred to two with cryopreservation and subsequent transfer yields a cumulative pregnancy rate of 77%, a twin rate of less than 20%, and no triplet or higher-order pregnancies. CONCLUSION(S): The use of a cryopreservation program can help maximize pregnancy rates while minimizing multiple-pregnancy rates. Cryopreservation should be considered in all assisted reproductive technology cycles.

Vaginal misoprostol enhances intrauterine insemination.

This study examined whether the prostaglandin E(1) analogue misoprostol (400 microgram), when placed vaginally at the time of intrauterine insemination (IUI) improves pregnancy rates. A prospective, placebo-controlled, randomized and double-blind study involving 274 women in 494 IUI cycles resulted in a total of 64 pregnancies (13% per cycle). Misoprostol cycles totalled 253, with 43 pregnancies (17% per cycle), whereas placebo cycles totalled 241, with 21 pregnancies (9% per cycle). The cumulative pregnancy rate with misoprostol treatment was significantly greater than with placebo (P = 0.004, Cox proportional hazards regression). The benefit of misoprostol was seen in clomiphene cycles (14 versus 4%, P = 0.006), and was indicated in FSH cycles (33 versus 15%, borderline significance) and natural cycles (15.6 versus 7.7%, not significant), but was not seen in clomiphene/FSH cycles (18.2 versus 23.5%, not significant). Misoprostol treatment did not increase pain score on the day of IUI (1.1 versus 1.4) and at 1 day post IUI (0.6 versus 0.8). Complications were rare in both groups [six (2%) subject cycles in the misoprostol cycles compared with two (1%) in the placebo group]. It is concluded that the use of vaginal misoprostol may improve the chance for pregnancy in women having IUI in a wide variety of cycle types.

Expression of parathyroid hormone-related peptide (PTH-rp) and its receptorin the porcine ovary: regulation by transforming growth factor-beta and possible paracrine effects of granulosa cell PTH-rp secretion on theca cells.

Parathyroid hormone-related peptide (PTH-rp) and the PTH-rp receptor are expressed in certain cancers as well as in many normal tissues. To evaluate the expression of this Ca(2+)-regulating hormone and its receptor in porcine ovary, we isolated partial cDNAs encoding homologous PTH-rp and PTH-rp receptor using reverse transcription-polymerase chain reaction (RT-PCR). The cDNA encoding PTH-rp (419 base pairs [bp]) was 92% and 87% homologous to human and rat sequences, respectively, while the PTH-rp receptor clone (167 bp) was 94% and 91% identical to the human and rat genes. Qualitative estimates of PTH-rp mRNA by RT-PCR indicated that the PTH-rp gene is expressed at high levels in the corpus luteum but is undetectable in granulosa and theca cells isolated from small (1-5 mm) and medium-sized (5-8 mm) antral follicles. In contrast, PTH-rp receptor transcripts were most abundant in corpora lutea and theca cells, and least abundant (albeit detectable) in granulosa cells. Regulation of PTH-rp protein production was assessed in serum-free monolayer cultures of porcine granulosa cells. Transforming growth factor (TGF)-beta1 (100 ng/ml) increased PTH-rp concentrations (assayed by two-site immunoradiometric assay of culture media) as well as corresponding PTH-rp mRNA accumulation (assessed by RT-PCR) in a time-dependent manner, with maximal responses of 3- to 5-fold at 96 h. TGF-beta1 dose-response studies revealed an ED(50) of 0. 24-0.38 ng/ml with a maximal effect at 30 ng/ml. Other growth factors and hormones, including insulin, insulin-like growth factor (type I), epidermal growth factor, FSH, estradiol, and interleukin-1, failed to alter PTH-rp secretion. Biological effects of PTH-rp were evident in purified porcine theca cells. Using the Ca(2+)-sensitive fluorescent indicator dye, fura-2, and digital imaging videomicroscopy, we found that PTH-rp (1 microM) stimulated intracellular free calcium ion concentrations ([Ca(2+)](i)) in single porcine theca cells. The [Ca(2+)](i) elevation was characterized by a slow and prolonged rise. After PTH-rp stimulation, theca cells maintained responsiveness to hormone stimulation by LH, which elicited a typical theca cell [Ca(2+)](i) response. Our results allow a hypothesis of a paracrine intrafollicular signaling system involving interaction between theca cell-derived TGF-beta and granulosa cell-derived PTH-rp, with feedback by PTH-rp on theca cells. Alternatively, expression of mRNAs encoding PTH-rp and its receptor in corpora lutea suggests that this peptide may play a role in luteal cell function. The precise role of this intraovarian PTH-rp system will require further study.

Evaluation of the clinical efficacy of embryo cryopreservation.

To fully evaluate the advantages of a cryopreservation program a method needs to be established to express the additional patients pregnant from cryopreservation. The patient specific method considers cryopreservation as augmentation only among patients without a pregnancy from the fresh transfer, or from previously transferred frozen material from the same harvest. In an analysis of the pregnancy rate at the Jones Institute between January 1996 and December 1998 we found a fresh pregnancy rate of 40.8% in the good responders and 28.8% in poor responders. The patient specific pregnancy rate in the same cycles was 53.4% in good responders and 32.3% in poor responders. Good responders less than 35 years of age with ten or more mature eggs at retrieval had a fresh pregnancy rate of 40.2% and a patient specific pregnancy rate of 57.9%. It is exceedingly important for the physician and patient to understand and comprehend the potential in cryopreserved material.

Late uterine wedge resection of placenta increta.

BACKGROUND: Recently, preferences for preserving reproductive potential has sparked increasing interest in the conservative management of placenta accreta, increta, and percreta. CASE: A 23-year-old gravida 3 para 2 had a vaginal delivery complicated by retained placenta. The placenta was delivered in multiple fragments followed by sharp curettage. Her postpartum course was complicated by pelvic pain and menorrhagia, unrelieved by sharp curettage. Four months postpartum, transvaginal ultrasonography and magnetic resonance imaging demonstrated an intramyometrial mass. Exploratory laparotomy was done with wedge resection of the anterior wall of the uterus under real-time ultrasonographic guidance. Pathologic examination found placenta increta. CONCLUSION: Conservative management of placenta increta can be used selectively to preserve reproductive potential.

Hyperreactio luteinalis associated with pregnancy: a case report and review of the literature.

Hyperreactio luteinalis is a condition associated with bilateral and, in rare cases, unilateral ovarian enlargement due to theca lutein cysts. Hyperreactio luteinalis is a benign condition, usually found incidentally at cesarean section, which can appear anaplastic and lead to unnecessary ovarian resection. A 21-year-old Hispanic woman, G2P1, presented at 19 weeks with a singleton pregnancy, bilaterally enlarged ovaries, and a normal beta hCG. Over the next four months, her ovaries increased 75% in size with the right ovary becoming entrapped in the pelvis. The patient underwent a primary low transverse cesarean section. The ovaries had an anaplastic appearance and on frozen section revealed multiple benign theca lutein cysts. There are 51 reported cases of hyperreactio luteinalis associated with a normal pregnancy in the literature. It is estimated that approximately 60% of the cases of hyperreactio luteinalis unassociated with trophoblastic disease occur with normal singleton pregnancy. There are multiple benign ovarian lesions including hyperreactio luteinalis that can mimic ovarian neoplasms. Accordingly, it is important to exclude these from the differential diagnosis via a wedge biopsy and frozen section to avoid unnecessary surgical excision.

Elevated maternal serum alpha-fetoprotein levels: what is the risk of fetal aneuploidy?

OBJECTIVE: Our purpose was to present the findings of a project to determine the efficacy of including routine fetal karyotyping in the investigation of an elevated maternal serum alpha-fetoprotein concentration. STUDY DESIGN: Targeted ultrasonographic examinations were performed in 658 patients with elevated maternal serum alpha-fetoprotein levels. The scans were normal in 557 women, of whom 427 consented to amniocentesis; 435 fetuses were karyotyped. In the 101 patients with abnormal ultrasonographic examinations 75 had fetal karyotyping. RESULTS: In the 435 fetuses with normal scans, two had karyotypic anomalies, a 47,XYY and an inherited balanced translocation. Three fetuses with normal karyotypes and high amniotic fluid alpha-fetoprotein levels had congenital nephrosis. In the 101 patients with abnormal scans, 75 fetuses were karyotyped. There were four aneuploidies. Among the 26 patients with abnormal scans who declined amniocentesis one fetus with multiple anomalies was karyotyped after delivery and triploidy was discovered. CONCLUSIONS: These results provide little justification for including fetal karyotyping in the investigation of elevated maternal serum alpha-fetoprotein when the targeted ultrasonographic examination is normal. When it is abnormal, selective rather than routine karyotyping is more appropriate.