Seminal vesicles ultrasound features in a cohort of infertility patients.

OBJECTIVES: Previous studies concerning ultrasound evaluation of the seminal vesicles (SV) were performed on a limited series of subjects, and considered few parameters, often only before ejaculation and without assessing the patients' sexual abstinence. The aim of this study was to evaluate the volume and the emptying characteristics of the SV and their possible correlations with scrotal and transrectal ultrasound features. METHODS: The SV of 368 men seeking medical care for couple infertility were evaluated by ultrasound. All patients underwent, during the same ultrasound session, scrotal and transrectal evaluation, before and after ejaculation, and the ejaculate was subjected to semen analysis. A new parameter, SV ejection fraction, calculated as: [(SV volume before ejaculation - SV volume after ejaculation)/SV volume before ejaculation] × 100, was evaluated. RESULTS: After adjusting for sexual abstinence and age, both pre-ejaculatory SV volume and SV ejection fraction were positively associated with ejaculate volume. As assessed by receiver operating characteristic curve, a cut-off for SV ejection fraction of 21.6% discriminates subjects with normal ejaculate volume (≥1.5 ml) and pH (≥7.2 ml) with both sensitivity and specificity equal to 75%. Subjects with SV ejection fraction of <21.6% more often had a higher post-ejaculatory SV volume and ejaculatory duct abnormalities. Furthermore, a higher post-ejaculatory SV volume was associated with a higher prostate volume and SV abnormalities. Higher epididymal and deferential diameters were also detected in subjects with a higher post-ejaculatory SV volume or reduced SV ejection fraction. No association between SV and testis ultrasound features or sperm parameters was observed. Associations with SV ejection fraction were confirmed in nested 1:1 case-control analysis. CONCLUSIONS: The SV contribute significantly to the ejaculate volume. A new parameter, SV ejection fraction, could be useful in assessing SV emptying. A SV ejection fraction of <21.6% was associated with prostate-vesicular and epididymal ultrasound abnormalities.

Ultrasonographic and clinical correlates of seminal plasma interleukin-8 levels in patients attending an andrology clinic for infertility.

This study was aimed at evaluating the association between seminal plasma interleukin-8 (sIL-8) and colour-Doppler ultrasound (CDU) characteristics of the male genital tract in a series of patients fulfilling the criteria of male accessory gland infections (MAGI). Of 250 subjects seeking medical care for couple infertility, 79 (mean age: 36.4 ± 7.5 years) met the criteria of MAGI and scored higher than the rest of the sample on the National Institutes of Health-Chronic Prostatitis Symptom Index score. All patients underwent simultaneous hormone evaluation and seminal analysis (including sIL-8), along with scrotal and transrectal CDU before and after ejaculation. After adjusting for age, sIL-8 in patients with MAGI was significantly related to several abnormal semen and CDU parameters. In particular, leucocytospermia was closely associated with sIL-8. Ejaculate volume, unlike other semen or hormonal parameters, was negatively associated with sIL-8. When scrotal CDU was performed, sIL-8 was positively related to CDU inhomogeneous, hypo-echoic, hyper-echoic epididymis and to epididymal calcifications. In addition, a positive correlation among sIL-8, hyperaemic epididymis and an increased size of epididymal tail was found. When transrectal CDU was performed, an association among sIL-8 and hyper-echoic seminal vesicles, dilated ejaculatory ducts and duct calcifications was also observed. Finally, sIL-8 was positively related to prostate CDU abnormalities such as calcifications, inhomogeneous/hypo-echoic texture, hyperaemia and high arterial blood flow. No association was found with testis parameters. In conclusion, sIL-8 levels in patients with MAGI are associated with several parameters and CDU abnormalities of epididymis, seminal vesicles, ejaculatory ducts and prostate, but not of the testis. Furthermore, sIL-8 positively correlates with CDU signs of ejaculatory duct inflammatory subobstruction.

Elevated body mass index correlates with higher seminal plasma interleukin 8 levels and ultrasonographic abnormalities of the prostate in men attending an andrology clinic for infertility.

BACKGROUND: Obesity is associated with a systemic, low-grade inflammatory state. Although the relationship between obesity and semen parameters or prostate diseases has been previously investigated, the association between body mass index (BMI), prostate inflammatory diseases and color- Doppler ultrasound (CDU) of the male genital tract (MGT) has been poorly studied. AIM: To evaluate the association between BMI and CDU features of the MGT, signs and symptoms of prostate inflammation, semen parameters. MATERIALS/SUBJECTS AND METHODS: We studied 222 men seeking medical care for couple infertility. According to the World Health Organization classification, subjects were divided into 3 groups: normal weight (no.=131, BMI=18.5-24.9 kg/m2), overweight (no.=71, BMI=25.0-29.9 kg/m2), obese (no.=20, BMI≥30.0 kg/m2). All patients underwent simultaneous testosterone evaluation and seminal analysis, including interleukin 8 (sIL-8), along with scrotal and transrectal CDU, before and after ejaculation. Prostatitis symptoms were evaluated by National Institutes of Health- Chronic Prostatitis Symptom Index questionnaire. RESULTS: After adjusting for age and testosterone levels, higher BMI was significantly related to higher prostate volume and several CDU features of the prostate, including macro-calcifications, inhomogeneity, higher arterial peak systolic velocity (the latter adjusted also for blood pressure), but not with abnormalities of testis, epididymis, seminal vesicles. Furthermore, higher BMI and BMI class were significantly related to higher sIL-8, a reliable surrogate marker of prostate inflammatory diseases, even after adjustment for age. Conversely, no associations among BMI, clinical symptoms of prostatitis or semen parameters were observed. CONCLUSIONS: Subjects with higher BMI might develop CDU and biochemical signs suggestive of prostate inflammation, although not clinically overt.

Local anesthesia versus intravenous infusion of remifentanil for assisted reproductive technologies. A retrospective study.

AIM: The aim of the work was to compare two different techniques, local anaesthesia versus continuous intravenous administration of remifentanil for oocyte retrieval. The impact on the medical assisted procreation (PMA) procedures in terms of number and quality of oocytes collected was evaluated. METHODS: The experimental design was a retrospective study which compared two different techniques, local anaesthesia versus continuous intravenous administration of remifentanil. 548 women with the same infertility duration and ovarian reserve were classified in two groups of 274 women each, that underwent to oocytes retrieval with intravenous infusion of remifentanil (first group) or with local anesthesia (second group). RESULTS: The analysis showed that the intravenous infusion of remifentanil doesn't interfere in the quality of oocytes retrieved and embryo score. CONCLUSION: The administration of intravenous remifentanil makes easier the pick-up of oocytes because women had no pain during the procedure. In this way, it was possible to recover more oocytes and to verify that the drug doesn't interfere with the exitus of the techniques. For these reasons we decided to continue in using intravenous infusion of remifentanil for the retrieval of oocytes.

Soluble HLA-G molecules in follicular fluid: a tool for oocyte selection in IVF?

Currently, different approaches are used to select oocytes for in vitro fertilization (IVF) procedures, but they do not assure a significant association with the pregnancy outcome. Since several studies have proposed the expression of HLA-G antigens in early embryos to be a possible marker of elevated implantation rate, we have investigated the presence of soluble HLA-G molecules in 50 follicular fluids (FFs). The results have shown soluble HLA-G antigens (sHLA-G) in 19/50 (38%) FFs. Furthermore, we have related the presence of sHLA-G molecules in FFs to detection of the soluble antigens in culture supernatants of the corresponding fertilized oocyte, evidencing a significant relationship (p=1.3 x 10(-6); Fisher exact p-test). Specific ELISA and Western blot approaches identified both HLA-G5 and soluble HLA-G1 molecules in FFs while immunocytochemical analysis indicated polymorphonuclear-like and granulosa cells as responsible for production of sHLA-G1 and HLA-G5 molecules. In contrast, only sHLA-G1 antigens were detected in culture supernatants of fertilized oocytes. Overall, these results suggest a role for sHLA-G molecules in the ovulatory process and propose the FFs analysis for sHLA-G molecule presence as a useful tool for oocyte selection in IVF.

Evaluation of clinical efficacy of three different insemination techniques in couple infertility. A randomized study.

AIM: The aim of the study was to compare the clinical results and efficiency of three insemination technique: intraperitoneal insemination (IPI), fallopian sperm perfusion (FSP) and intrauterine insemination (IUI). METHODS: The experimental design was a prospective, randomized trial. A total of 101 homologous insemination cycles were performed in 71 consecutive couples with unexplained or male subfertility. Couples were randomized to receive IPI or FSP or IUI by predefined tables of randomization and each couple was submitted to the same insemination technique. The primary outcome of the study was the achievement of clinical pregnancy. RESULTS: The results of the study underlined firstly that basal couple composition was not statistically different between the three groups. Moreover, no significant difference in clinical pregnancy rate was observed, despite a clearly positive trend for FSP, especially for unexplained infertility. CONCLUSIONS: Our results showed that the three techniques of insemination IUI, FSP and IPI have similar efficacy on the achievement of clinical pregnancy in couples affected by longstanding infertility.

Comprehensive investigation in patients affected by sperm macrocephaly and globozoospermia.

The aim of this study was to provide a comprehensive genetic/phenotypic characterization of subjects suffering infertility owing to sperm macrocephaly (n = 3) or globozoospermia (n = 9) and to investigate whether the patients' genetic status was correlated with the alteration of various sperm parameters. AURKC was sequenced in case of sperm macrocephaly while the DPY19L2 status has been analyzed by multiple approaches including a novel qPCR-based copy number assay in case of globozoospermia. Globozoospermic patients were also analyzed for SPACA1, a novel candidate gene herein tested for the first time in humans. The effect of the patients' genetic status was interrogated by implementing the molecular screening with the characterization of several sperm parameters: (i) routine sperm analysis, integrated with transmission electron microscopy; (ii) sperm fluorescent in situ hybridization (FISH) analysis; (iii) sperm DNA fragmentation (DF) analysis. Moreover, for the first time, we performed microsatellite instability analysis as a marker of genome instability in men with sperm macrocephaly and globozoospermia. Finally, artificial reproductive technology (ART) history has been reported for those patients who underwent the treatment. Macrocephalic patients had an AURKC mutation and >89% tetraploid, highly fragmented spermatozoa. DPY19L2 was mutated in all patients with >80% globozoospermia: the two homozygous deleted men and the compound heterozygous showed the severest phenotype (90-100%). The newly developed qPCR method was fully validated and has the potential of detecting also yet undiscovered deletions. DPY19L2 status is unlikely related to FISH anomalies and DF, although globozoospermic men showed a higher disomy rate and DF compared with internal reference values. No patient was mutated for SPACA1. Our data support the general agreement on the negative correlation between macro/globozoospermia and conventional intracytoplasmic sperm injection outcomes. Microsatellites were stable in all patients analyzed. The comprehensive picture provided on these severe phenotypes causing infertility is of relevance in the management of patients undergoing ART.

Non-classic sHLA class I in human oocyte culture medium.

Soluble human leukocyte antigen (sHLA) class I molecules have been described in all human fluids. These molecules play a significant role in immune function. sHLA has been shown to produce tolerance and to induce apoptosis in cytotoxic alloreactive T cells. They are also present in the supernatant of many cultured cells. Similarly, non-classic HLA class I antigens in soluble form are present in human fluids. Among these, HLA-G is the most important because of its location in fetal tissue that suggests maternal immunological tolerance of the fetal semiallograft. In our present study we show that using two monoclonal antibodies, w6/32 and TP25.99, in the enzyme-linked immunosorbent assay allows the detection of non-classic sHLA class I molecules in the medium from human embryo cultures. The sample were collected from oocytes cultures. Oocyte donors were 11 women attending the in vitro fertilization program. The results showed a significant association (chi2 = 9.66, p = 0.002) between sHLA antigens and the oocyte cleavage rate measured 48 h after fertilization.

Inhibitory effect of luteinising hormone-releasing hormone analogues on human endometrial cancer in vitro.

We studied the effects of luteinising hormone-releasing hormone (LHRH) agonist leuproreline (1 microM for 96 h) and LHRH antagonist cetrorelix on the cell growth of primary cultures from nine human endometrial cancers using the sulphorhodamine colorimetric test. Histological examinations and reverse transcription and polymerase chain reaction amplification (RT-PCR) for LHRH receptors were also performed. The endometrial cancers examined had a medium to high degree of proliferative activity and a low degree of apoptotic power; furthermore, they expressed the LHRH receptor RNA variably, detectable in 71% of cases. The addition of leuproreline or cetrorelix to cell cultures inhibited growth in a statistically significant way compared to untreated control cells; nevertheless, the percentage of cell growth inhibition obtained was very variable. These data suggest that LHRH analogues can exert differential inhibitory effects on the growth of endometrial cancer, which seems to be independent of the expression of specific LHRH receptors.

Identification, localization and functional activity of oxytocin receptors in epididymis.

Oxytocin (OT) is a neurohypophysial hormone with unclear physiological functions in the male. Several previous studies indicated that OT might have a role in the ejaculatory process, stimulating sperm release from the epididymal storage. In this study we investigated on the presence and function of OT receptor (OTR) in rabbit and human epididymis. By using RT-PCR, Western and binding studies, we found that OTR gene and protein is expressed in the human epididymis and stimulates in vitro contractility. The immunolocalization of OTR suggests that the receptor is not only present in the smooth muscle cells of the human epididymis but also in the epithelial compartment. Experiments performed in rabbit epididymal epithelial (rEE) cells in culture indicate that OT induces the release of an other potent stimulator of epididymal contractility, endothelin-1 (ET-1), Blocking the ET(A) subtype of the ET-1 receptors, by using a specific antagonist (BQ-123), partially counteracts the contractile effect of OT, suggesting positive interactions between the two peptides in regulating epididymal contractility. Finally, to investigate whether an acute OT administration increases sperm release also in humans, we treated oligozoospermic patients with an intravenous bolus of OT (2.5 IU), just before sperm collection. In a small, single blind study, we found that OT almost doubled sperm retrieval when compared with vehicle administration. Our results indicate that OT might have physiological functions also in the male, controlling epididymal motility and sperm progression through the male genital tract.

Sugar residues content and distribution in atrophic and hyperplastic postmenopausal human endometrium: lectin histochemistry.

A lectin histochemical study was performed to investigate the glycoconjugate saccharidic moieties of the human postmenopausal endometrium (14 atrophic and 15 hyperplastic). For this purpose a battery of seven horseradish peroxidase-conjugated lectins (PNA, SBA, DBA, WGA, ConA, LTA and UEA I) was used. No differences in lectin binding between atrophic and hyperplastic endometria were observed. This investigation allowed us to provide a basic picture of the oligosaccharidic distribution in postmenopausal endometria. The data on the saccharidic distribution at the postmenopausal endometria showed a large amount of sugar residues at all the investigated sites, i.e. the lining and glandular epithelium, the stroma and the vessels (capillary and large vessels). Furthermore, at the endometrial lining epithelium, at the glands and at the wall of the blood vessels of some postmenopausal women the presence of alpha-L-fucosyl residues which bind via alpha (1-6) linkage to penultimate glucosaminyl residues and/or difucosylated oligosaccharides was demonstrated for the first time.

Lectin binding in the human endometrium in early luteal phase following controlled ovarian hyperstimulation.

A lectin histochemical study was performed to investigate the glycoconjugate saccharidic moieties on the endometrial epithelium and stroma in 12 women undergoing controlled ovarian hyperstimulation (COH) for in-vitro fertilisation for embryo transfer (IVF-ET) in early luteal phase. 7 control subjects were also evaluated. For this purpose a battery of seven horseradish peroxidase-conjugated lectins (PNA, SBA, DBA, WGA, ConA, LTA and UEA I) was used. Cytochemical controls were performed for specificity of lectin-sugar reaction. As far as the endometrial glands and stroma are concerned, the obtained data showed no differences in the endometrial lectin binding between the subjects of the control group and the ones undergoing COH, with the exception of PNA reactivity at the level of the apical portion of the glandular cells, which was detected only in COH women. It is noteworthy that, although the endometrial dating using the Noyes's criteria showed marked dissynchronies between the stroma and the glands in COH subjects, a uniformity of lectin binding, revealing the same type and localization of terminal oligosaccharides, was observed in all the examined subjects. The uniformity in distribution of the sugar residues detected in the endometrial specimens following COH might be due to the massive FSH and/or hCG treatment which probably determines an endometrial environment almost equal in all the examined subjects. In all the treated subjects reactivity with sialidase-WGA and ConA, revealing the presence of N-acetyl-D-glucosamine and D-mannose respectively, was detected at the level of the lining epithelium.

Ageing of the human oviduct: lectin histochemistry.

The aim of the present research was to investigate the changes of the sugar residues in the oviduct in the course of ageing in postmenopausal women vs normally menstruating women, by means of lectin histochemistry. Twenty asymptomatic postmenopausal women (48-83 years old) were recruited among patients who underwent a vaginal hysterectomy. Eight normally menstruating women were recruited as controls. Fragments of Fallopian tubes (pars ampullaris) were fixed in 10% formalin and routinely processed. The sections were labelled with HRP-lectins (PNA, SBA, DBA, WGA, Con A, LTA, UEAI). Some sections were pre-treated with neuraminidase prior to staining with HRP-lectins. Among the postmenopausal patients, our histochemical data showed that there was no difference in the localization and distribution of sugar residues of glycoconjugates as detected by various HRP-lectins. Moreover, our results demonstrated that the oviductal epithelium is characterized by apical reactivity in both ciliated and non-ciliated cells. In the course of ageing, the ciliated cells changed their morphology from bathyprismatic to large and rounded shape. ConA lectin reacted intensely with such highly degenerating ciliated cells and could be considered a marker of these cells. The degenerating ciliated cells are also characterized by the absence of sialic acid. In comparison with the sugar residues present in the control group, the oviductal epithelium of postmenopausal women is characterized by the loss of reactivity with DBA, WGA and ConA. Moreover, PNA reactive material was present at the free border of the ciliated and non-ciliated cells. The latter findings were statistically confirmed and could be considered strictly related to the ageing process.

Decidual progesterone and estrogen receptors in the first trimester of pregnancy.

Receptor content of human decidua in early pregnancy (weeks 6-12) was investigated. Fifty-three tissue samples were obtained from voluntary patients undergoing abortion and whose gestational age range from 6 to 12 weeks. Blood samples were drawn at the time of operation in order to measure circulating estradiol (E) and progesterone (P) concentrations. Tissue samples underwent first histological confirmation and then were analyzed for receptor content by immunohistochemistry (IH) and by the conventional ligand binding technique (LBA). Estrogen receptors (ER) appeared to be always undetectable by IH (53 samples). LBA measured a significant amount of ER (> 10 fmol/mg) in two samples, borderline values (3-10 fmol/mg) in 6 and no binding in the other three. No relation was apparent between PR levels and either gestational age or blood P concentration. ER were possibly downregulated by the high E levels, and their synthesis inhibited by the high P levels.

Analysis of the action of corticosteroid treatment in immunologic infertility: a preliminary report and an alternative hypothesis.

The presence of sperm antibodies can be demonstrated in 8-10% of the male partners of infertile couples. The therapeutic schedule with which the highest pregnancy rate has been obtained in these cases is that proposed by Shulman, which uses methylprednisolone (MP). If treatment with corticosteroids (CS) is effective, the way in which it acts is not entirely clear. In this study we report the results of 16 treatment cycles with CS administered to eight male patients having sperm antibodies in their serum, in which several parameters of humoral immunity were evaluated. The results are conflicting: several parameters (such as IgG concentration) underwent only slight variations after 7 days of therapy, whereas in 12 cycles out of 16, the Tray agglutination test (TAT) indicated that a reduction or disappearance of the antibodies had been obtained. This confirms the usefulness of CS in immunological infertility, and allows us to hypothesize that the beneficial effect may be found in a reduction of inflammation rather than in a suppression of the immunological response, since CS are well known to have these two kinds of effect.

Fertilisation and implantation failure in an oral contraceptive user.

We report the case of a young woman taking a low-dose oral contraceptive (gestodene 0.075mg and ethinylestradiol 0.02mg) in whom we documented by both hormonal assays and sonographic evaluations the occurrence of ovulation, oocyte fertilization and embryo implantation. However, the implantation process did not complete and only a biochemical pregnancy was registered. On the basis of known actions of estroprogestin on endometrium that are not conducive to implantation, it is possible that the pregnancy loss was originated by oral contraceptive's hormonal influence at endometrial level.

Maternal serum CA 125 levels in first trimester abortion.

OBJECTIVE: To assess the source of maternal serum CA 125 during the first trimester of pregnancy. STUDY DESIGN: CA 125 was measured in stored samples from nonviable pregnancies of 8-13 weeks gestation. The study group comprised 19 women with vaginal bleeding and 13 non-bleeders. Only patients in whom chromosome analysis of the products of conception demonstrated a normal caryotype were included. CA 125 levels were expressed in multiples of the median (MoM) for normal pregnancies of the same gestational age. RESULTS: Median MoM values of CA 125 were significantly higher in women with vaginal bleeding (1.81 MoM) as compared both to non-bleeders (0.82 MoM; p < 0.01-Mann-Whitney U-test) and to the normal pregnancies (1.01 MoM; p < 0.05). No significant difference was found between non-bleeding women and controls. CONCLUSIONS: The present study indicates that in non-viable pregnancies with euploid fetuses an increase in maternal serum CA 125 levels was found only in presence of decidual disruption associated to vaginal bleeding. These findings are compatible with a prevalent decidual source of this antigen.

I. Aging of the human endometrium: a basic morphological and immunohistochemical study.

OBJECTIVE: To evaluate if human endometrium presents morphological variations suggestive of an age-related decline in endometrial receptivity. STUDY DESIGN: Peri-implantation endometrium of younger (<30 years of age: n = 13) and older (>40 years of age: n = 17) normally menstruating women was studied. Endometrial specimens were routinely fixed in buffered formalin and embedded in paraffin. Sections (5 mu m) were stained with hematoxylin-eosin, periodic acid-Schiff (PAS) and Trichrome conforming to Masson according to conventional histologic examination. Several consecutive sections were used for the following immunohistochemical study: vascular localization (CD34), cellular proliferation index (PCNA), progesterone and estrogen receptors. RESULTS: Using both the traditional morphological evaluation and monoclonal antibodies, no significant differences were found between the endometria of women <30 years of age and those of women >40. CONCLUSIONS: Our results suggest that human endometrium does not age, at least while cyclic hormonal stimulation and menstruation are present.

Aging of the human endometrium: peri-implantation phase endometrium does not show any age-dependent variation in lectin binding.

OBJECTIVE: To evaluate if the peri-implantation endometrium shows age variations in lectin patterns, which suggest possible age variations in embryo-maternal recognition. STUDY DESIGN: Peri-implantation endometria of younger ( < 30 years of age: n = 13) and older ( > 40 years of age: n = 17) normally menstruating women was studied. Endometrial specimens were routinely fixed in buffered formaline and embedded in paraffin. Sections (5 microns) were studied using seven lectins: DBA (Dolicus biflorus, binding specificity alpha-D-GalNAc), PNA (Arachis hypogea, binding specificity D-Gal (beta 1 --> 3)-D-GalNAc), SBA (Glycine max binding specificity alpha/beta-D-GalNAc > D-Gal), WGA (Triticum vulgare binding specificity (alpha-D-GlcNAc)n and sialic acid), ConA (Canavalia ensiformis binding specificity alpha-D-Man > alpha-D-Glc), LTA (Lotus tetragonolobus binding specificity alpha-L-fucose) and UEA 1 (Ulex europaeus binding specificity alpha-L-fucose). RESULTS: No significant differences were found in the glycoconjugates sugar residue content and distribution between the endometria of women < 30 years of age and those of women > 40. CONCLUSIONS: Our results suggest that human endometrium does not age, at least while cyclic hormonal stimulation and menstruation are present.

Hormonal patterns, steroid receptors and morphological pictures of endometrium in hyperstimulated IVF cycles.

OBJECTIVE: The purpose of this contribution is to investigate the pathophysiology of the abnormal endometrial development in hyperstimulated IVF cycles. STUDY DESIGN: In 12 IVF-patients who did not have embryo transfer because of failure of oocyte fertilization, serum values of 17 beta-estradiol, progesterone, FSH, LH, total and free testosterone, and androstenedione were measured on the pick-up day and were evaluated with respect to the values normally expressed in the day of ovulation; in the endometrial specimens collected 2 days later, at the time of embryo replacement, estrogen and progesterone receptors were immunohistochemically determined and dating by the Noyes method was performed. RESULTS: 17 beta-Estradiol values are constantly higher, and progesterone levels are, only in four cases, higher than expected for the day of ovulation in a natural cycle. These hormonal patterns can only partially explain the pattern of steroid receptors: progesterone receptors are expressed sparsely both in glands and stroma, while estrogen receptors are abundant in the glands and absent in the stroma. In 11 of 12 patients an abnormal endometrial development with stromal advancement was observed: this morphological picture of the endometrium could partially be explained only in the four cases presenting high progesterone levels by serum values and endometrial receptor content of estrogen and progesterone. CONCLUSIONS: The abnormal endometrial development in hyperstimulated IVF cycles could only in part be explained by estrogen and progesterone, and other factors have to be considered.