Maternal hCG concentrations in early IVF pregnancies: associations with number of cells in the Day 2 embryo and oocytes retrieved.

STUDY QUESTION: Do number of cells in the transferred cleavage stage embryo and number of oocytes retrieved for IVF influence maternal hCG concentrations in early pregnancies? SUMMARY ANSWER: Compared with transfer of a 2-cell embryo, transfer of a 4-cell embryo results in higher hCG concentrations on Day 12 after transfer, and more than 20 oocytes retrieved were associated with low hCG concentrations. WHAT IS KNOWN ALREADY: Maternal hCG concentration in very early pregnancy varies considerably among women, but is likely to be an indicator of time since implantation of the embryo into the endometrium, in addition to number and function of trophoblast cells. STUDY DESIGN, SIZE, DURATION: We followed 1047 pregnancies after IVF/ICSI from oocyte retrieval until Day 12 after embryo transfer. Women were recruited in Norway during the years 2005-2013. PARTICIPANTS/MATERIALS, SETTING, METHODS: Successful pregnancies after transfer of one single embryo that had been cultured for 2 days were included. Maternal hCG was quantified on Day 12 after embryo transfer by chemiluminescence immunoassay, which measures intact hCG and the free ß-hCG chain. Information on a successful pregnancy, defined as birth after >16 weeks, was obtained by linkage to the Medical Birth Registry of Norway. MAIN RESULTS AND THE ROLE OF CHANCE: Transfer of a 4-cell embryo resulted in higher maternal hCG concentrations compared with transfer of a 2-cell embryo (134.8 versus 87.8 IU/l, P < 0.05). A high number of oocytes retrieved (>20) was associated with low hCG concentrations (P < 0.05). LIMITATIONS, REASONS FOR CAUTION: The factors studied explain a limited part of the total variation of hCG concentrations in early pregnancy. Although embryo transfer was performed at the same time after fertilization, we do not know the exact time of implantation. A further limitation to our study is that the number of pregnancies after transfer of a 2-cell embryo was small (27 cases). WIDER IMPLICATIONS OF THE FINDINGS: Number of cells in the transferred embryo and number of oocytes retrieved may influence the conditions and timing for embryo implantation in different ways and thereby influence maternal hCG concentrations. Such knowledge may be important for interpretation of hCG concentrations in early pregnancy.

Vulvovaginal photodynamic therapy vs. topical corticosteroids in genital erosive lichen planus: a randomized controlled trial.

BACKGROUND: Genital erosive lichen planus (GELP) in women is a chronic inflammatory disease characterized by painful vulval and vaginal erosions. Topical photodynamic therapy (PDT) is increasingly used in premalignant and malignant diseases and may have an effect in inflammatory diseases. OBJECTIVES: To assess the feasibility, efficacy and safety of hexyl 5-aminolevulinate-hydrocloride (HAL)-PDT in GELP. METHODS: Forty women, diagnosed with GELP at a specialized vulva clinic, were randomized to one session HAL-PDT in vulva and/or vagina (n = 20) or daily applications of clobetasol propionate 0·05% ointment in vulva and optional hydrocortisone acetate 1·0% foam in vagina for 6 weeks (n = 20). After 6 weeks, all patients were allowed to use topical corticosteroids as needed. Clinical examinations were performed at weeks 0, 6 and 24, using a clinical score developed for the study. All patients wrote a weekly log on pain, topical corticosteroid use and adverse events. RESULTS: Three patients, all in the corticosteroid group, withdrew from the study after 1-3 weeks. The mean reduction in clinical scores was similar in the PDT group and the corticosteroid group; 25% vs. 22% after 6 weeks (P = 0·787) and 35% vs. 38% after 24 weeks (P = 0·801). The mean reduction in pain visual analogue scale scores was 38% vs. 55% after 6 weeks (P = 0·286) and 39% vs. 12% after 24 weeks (P = 0·452). Patients in the PDT group reported significantly less topical corticosteroid use during weeks 7-24 than those in the corticosteroid group. No major adverse events were reported. CONCLUSIONS: Vulvovaginal HAL-PDT seems to be an effective and safe treatment for GELP.

Maternal age and emergency operative deliveries at term: a population-based registry study among low-risk primiparous women.

OBJECTIVE: To study the association between maternal age and emergency operative delivery. The roles of in-labour indications, and birthweight ≥ 4000 g, gestational age ≥ 42 weeks, induction of labour, and epidural use, according to maternal age were explored. DESIGN: Population-based study. SETTING: Medical Birth Registry of Norway and Statistics Norway. POPULATION: We studied 169 583 low-risk primiparous mothers with singleton, cephalic labours, at ≥37 weeks of gestation, from 1999 to 2009. METHODS: The associations between maternal age and mode of delivery were analysed using multinomial regression analyses, adjusting for sociodemographic factors. MAIN OUTCOME MEASURES: Emergency caesarean section and operative vaginal delivery. RESULTS: Of women aged ≥40 years, 22% had emergency caesarean sections and 24% had operative vaginal deliveries, giving adjusted relative risk ratios (RRRs) of 6.60 (95% confidence interval, 95% CI 5.53-7.87) and 3.30 (95% CI 2.79-3.90), respectively, when compared with women aged 20-24 years. Adjustments for sociodemographic factors only slightly changed the estimates. Dystocia was the main indication, followed by fetal distress. All of the listed factors increased the level of emergency operative deliveries, mainly because of an increase in dystocia. The increase in risk for emergency caesarean section by all factors, and for operative vaginal deliveries by epidural, were greater in older than in younger women, but were significant for epidural only. CONCLUSIONS: We found a close association between maternal age and emergency operative delivery in low-risk primiparas. Contributory factors increased the risk for both emergency operative delivery and epidural more in older than in younger women.

Concentrations of human chorionic gonadotrophin in very early pregnancy and subsequent pre-eclampsia: a cohort study.

STUDY QUESTION: Are low serum concentrations of human chorionic gonadotrophin (hCG) in very early pregnancy associated with pre-eclampsia risk? SUMMARY ANSWER: Low hCG concentrations in very early pregnancy are associated with increased risk of severe pre-eclampsia. WHAT IS KNOWN ALREADY: Low maternal serum concentrations of hCG early in pregnancy may indicate impaired proliferation or invasion of trophoblast cells, and thus low hCG concentrations may serve as a marker for impaired placental development. Impaired placental development is assumed to be a cause of pre-eclampsia, but there is little prospective evidence to support this hypothesis. STUDY DESIGN, SIZE, DURATION: We performed a prospective cohort study of pregnancies after IVF at Oslo University Hospital 1996-2010 with linkage to the Medical Birth Registry of Norway to obtain information on pre-eclampsia development. PARTICIPANTS/MATERIALS, SETTING, METHODS: We included 2405 consecutive singleton pregnancies and examined the association of maternal serum hCG concentrations (measured using Elecsys, Roche) on Day 12 after embryo transfer with the risk of any pre-eclampsia and of mild and severe pre-eclampsia. MAIN RESULTS AND THE ROLE OF CHANCE: HCG concentrations were inversely associated with pre-eclampsia risk in a dose-dependent manner (Ptrend 0.02). Compared with women with hCG ≥150 IU/l, women with hCG <50 IU/l were at 2-fold higher overall risk of pre-eclampsia [absolute risk 6.4 versus 2.8%; odds ratio (OR) 2.3, 95% confidence interval (CI) 1.2-4.7]. The inverse association was restricted to severe pre-eclampsia (Ptrend 0.01), thus, women with hCG <50 IU/l were at 4-fold higher risk of severe pre-eclampsia than women with hCG ≥150 IU/l (absolute risk 3.6 versus 0.9%; OR 4.2, 95% CI 1.4-12.2). For mild pre-eclampsia, there was no corresponding association (Ptrend 0.36). LIMITATIONS, REASONS FOR CAUTION: Results for IVF pregnancies may not be generalizable to spontaneously conceived pregnancies. WIDER IMPLICATIONS OF THE FINDINGS: Plausible causes of low maternal hCG concentrations very early in pregnancy include impaired placental development and delayed implantation. Thus, these results provide prospective evidence to support the hypothesis that impaired placental development may be associated with subsequent development of severe pre-eclampsia. STUDY FUNDING/COMPETING INTEREST: The study was financially supported by the Research Council of Norway. None of the authors has any conflict of interest to declare.

The interplay of human chorionic gonadotropin (hCG) with basic fibroblast growth factor and adipokines on angiogenesis in vitro.

INTRODUCTION: Human chorionic gonadotropin (hCG) is suggested to regulate placental angiogenesis, however, its role is incompletely understood. hCG may directly stimulate angiogenesis or influence the effect of other angiogenic factors. We examined the effect of hCG and the interplay of hCG with basic fibroblast growth factor (bFGF) and with various adipokines on proliferation of vascular endothelial cells in vitro. METHODS: Human umbilical vein endothelial cells (HUVEC) were incubated for 2 days with combinations of hCG, bFGF, leptin, resistin, adiponectin, IL6 and TNFα. Incorporation of radiolabelled thymidine was used to assess cell proliferation. Immunofluorescence and flow cytometry were used to examine activation of p44/42 mitogen-activated kinase (MAPK). RESULTS: hCG induced proliferation of HUVEC alone and in combination with bFGF. Cells exposed to both hCG and bFGF displayed increased activation of p44/42 MAPK as compared to hCG or bFGF alone. Increased HUVEC proliferation was observed in the presence of increasing concentrations of leptin, resistin, adiponectin, and IL6, whereas HUVEC proliferation decreased in the presence of TNFα. hCG in combination with leptin, resistin, adiponectin or IL6 stimulated HUVEC proliferation beyond the effect of hCG alone. DISCUSSION: An interplay of hCG with adipose tissue-derived factors with angiogenic properties is plausible. Thus, maternal obesity may affect placental angiogenesis in pregnancy. CONCLUSIONS: hCG may directly stimulate angiogenesis. Also, hCG may indirectly stimulate angiogenesis through interplay with bFGF and adipokines.

Is unilateral oophorectomy associated with age at menopause? A population study (the HUNT2 Survey).

STUDY QUESTION: Is unilateral oophorectomy associated with age at menopause? SUMMARY ANSWER: Women who had undergone unilateral oophorectomy entered menopause 1 year earlier than women with two ovaries intact. WHAT IS ALREADY KNOWN: There is substantial variation in age at natural menopause. Unilateral oophorectomy implies a significant reduction of the ovarian follicular reserve. Thus, one might expect that the time to menopause is shortened by several years in women who have undergone unilateral oophorectomy. STUDY DESIGN, SIZE AND DURATION: A retrospective cohort study of 23 580 Norwegian women who were included in the population-based HUNT2 Survey during the years 1995-1997. PARTICIPANTS/MATERIALS, SETTING, METHODS: Data were obtained by two self-administered questionnaires at study inclusion. Cox proportional hazard models were used to estimate relative risks of menopause according to unilateral oophorectomy status with and without adjustment for birth cohort, parity, smoking, body mass index (BMI) and age at menarche. MAIN RESULTS AND THE ROLE OF CHANCE: Women who had undergone unilateral oophorectomy were younger at menopause [mean 49.6 years; 95% confidence interval (CI): 49.2-50.0] than women without unilateral oophorectomy (mean 50.7 years; 95% CI: 50.6-50.8) (P < 0.001). The crude relative risk of menopause was 1.28 (95% CI: 1.15-1.42) and remained similar after adjustment for the study factors above (adjusted relative risk 1.27; 95% CI: 1.14-1.41). In addition, recent birth cohort and high BMI were associated with higher age at menopause. LIMITATIONS, REASONS FOR CAUTION: Information on unilateral oophorectomy was based on self-reports. Some women may therefore have been misclassified. WIDER IMPLICATIONS OF THE FINDINGS: Although the effect of unilateral oophorectomy on the age at menopause is similar to that of smoking, it is weaker than anticipated from the loss of ovarian follicular reserve. Thus, compensatory mechanisms may occur in the remaining ovary.

Paternal age, placental weight and placental to birthweight ratio: a population-based study of 590,835 pregnancies.

STUDY QUESTION: Is the age of the father associated with placental weight or the ratio of placental weight to birthweight? SUMMARY ANSWER: Placental weight and placental to birthweight ratio increased according to increasing paternal age, also after adjustment for maternal age. WHAT IS KNOWN ALREADY: High paternal age and also high placental to birthweight ratio have been associated with adverse pregnancy outcome. STUDY DESIGN, SIZE AND DURATION: We performed a population-based study and included all singleton births after 22 weeks of gestation in the Medical Birth Registry of Norway (n = 590,835) during the years 1999-2009. PARTICIPANTS/MATERIALS, SETTING, METHODS: We compared mean placental weight and placental to birthweight ratio between paternal age groups. The association of paternal age with placental weight was estimated by linear regression analyses, and adjustments were made for maternal age, birthweight, parity, offspring sex, gestational age at birth, maternal smoking, pre-eclampsia, maternal diabetes mellitus and pregnancy after assisted reproductive technology (ART). MAIN RESULTS AND THE ROLE OF CHANCE: In pregnancies with fathers aged 20-24 years old, the mean placental weight was 656.2 g [standard deviation (SD) 142.8], whereas it was 677.8 g (SD 160.0) in pregnancies with fathers aged 50 years or older (P < 0.001). The mean offspring birthweight in pregnancies with fathers aged 20-24 year old was 3465.0 g (SD 583.8), and it was 3498.9 g (SD 621.8) when the father was 50 years or older (P < 0.001). The placental to birthweight ratio in the corresponding paternal age groups were 0.191 (SD 0.039) and 0.196 (SD 0.044) (P < 0.001). In multivariable linear regression analysis the placentas in pregnancies fathered by a man of 50 years or older were estimated to weigh 13.99 g [95% confidence interval (CI) 10.88-17.10] more than in pregnancies with a 20-24-year-old father (P < 0.001) after adjustment for maternal age, birthweight, parity, offspring sex, gestational age at birth, maternal smoking, pre-eclampsia, maternal diabetes mellitus and pregnancy after ART. LIMITATIONS, REASONS FOR CAUTION: Paternal age explains only a small proportion of the total variation in placental weight. WIDER IMPLICATIONS OF THE FINDINGS: Our findings may increase the understanding of the father's role in human pregnancy. STUDY FUNDING/ COMPETING INTEREST(S): Norwegian Resource Centre for Women's Health, Norway. No conflict of interest. TRIAL REGISTRATION NUMBER: N/A.

Impact of gender on vitamin D deficiency in morbidly obese patients: a cross-sectional study.

BACKGROUND/OBJECTIVE: Obesity is associated with vitamin D deficiency (25-hydroxyvitamin D (25(OH)D) <50 nmol/l). We aimed to examine the effect of gender on vitamin D status in severe obesity. SUBJECTS/METHODS: Cross-sectional study of 2026 morbidly obese patients examined consecutively at a tertiary care centre between November 2005 and June 2010. Serum 25(OH)D concentration and use of vitamin D supplements were registered in all patients. Total vitamin D intake (µg/day) was assessed in a subgroup of 154 patients using a validated food frequency questionnaire. RESULTS: The male (n=690) and female (n=1336) patients had a mean (s.d.) age of 45.0 (12.1) years and 42.2 (12.2) years (P<0.001), body mass index (BMI) of 44.6 (6.0) kg/m(2) and 44.3 (5.9) kg/m(2) (P=0.30) and waist circumference (WC) of 140 (13) cm and 127 (13) cm (P<0.001), respectively. Male patients had significantly lower mean 25(OH)D concentrations than female patients 50.0 (22.0) nmol/l versus 53.6 (22.4) nmol/l (P=0.001) and a higher rate of vitamin D deficiency (56% versus 47%; P<0.001). Obese men had significantly higher odds of vitamin D deficiency than women (odds ratio=1.41; 95% confidence interval: 1.17-1.70, P<0.001), also after adjustment for season, age, current smoking, intake of vitamin D supplements, BMI and WC (odds ratio=1.39; 95% confidence interval: 1.10-1.76). CONCLUSIONS: Morbidly obese Norwegian men seeking weight loss treatment have significantly higher odds of vitamin D deficiency than women. Monitoring of 25(OH)D concentrations in obese patients should therefore take gender into account.

Placental weight in singleton pregnancies with and without assisted reproductive technology: a population study of 536,567 pregnancies.

BACKGROUND: Pregnancies conceived by assisted reproductive technology (ART) are at increased risk of adverse outcomes. Previous studies have suggested increased placental weight and increased placental weight/birthweight ratio in pregnancies associated with adverse outcomes. We therefore studied the association of ART with placental weight and placental weight/birthweight ratio. METHODS: We included all singleton births in the Medical Birth Registry of Norway during the period 1999-2008 (n = 536 567, including 8259 after ART). We divided placental weight and placental weight/birthweight ratio into quartiles, and calculated the proportions of ART and spontaneous pregnancies in the lowest and the highest quartile by length of gestation. Thereafter, we estimated crude and adjusted odds ratios (ORs) for being in each quartile of placental weight for ART pregnancies with spontaneous pregnancies as the reference. The analyses were repeated with ART pregnancies subgrouped into IVF or ICSI. RESULTS: Mean placental weight was 678.9 g in pregnancies conceived by ART, and 673.0 g in pregnancies after spontaneous conception. ART pregnancies were overrepresented in the highest quartile of placental weight and underrepresented in the highest quartile of birthweight, independent of length of gestation at delivery. Thus, placental weight/birthweight ratio was higher in ART pregnancies. For ART pregnancies, the OR for being in the highest quartile of placental weight was 1.37 (95% confidence interval 1.30-1.45) after adjustment for length of gestation, offspring birthweight, parity, fetal sex, maternal age, pre-eclampsia and diabetes. There was no difference in placental weight/birthweight ratio between IVF and ICSI pregnancies. CONCLUSIONS: We found larger placentas and a higher placental weight/birthweight ratio among pregnancies conceived by ART compared with spontaneous pregnancies, and the difference was independent of length of gestation at delivery and ART method.

Complete surgical removal of minimal and mild endometriosis improves outcome of subsequent IVF/ICSI treatment.

Surgical eradication of minimal and mild endometriosis has been shown to increase the birth rate both spontaneously and after intrauterine insemination. This study from a reproductive medicine unit at a referral university hospital examined whether surgical eradication of minimal and mild endometriosis prior to IVF improved the treatment outcome. Records of infertile patients with minimal and mild endometriosis (American Society for Reproductive Medicine stages I and II) with no prior IVF/intracytoplasmic sperm injection (ICSI) treatments were analysed. During the first treatment cycle, women who had undergone complete removal (n=399) of endometriotic lesions experienced, compared with women with diagnostic laparoscopy only (n=262), a significantly improved implantation rate (30.9% versus 23.9%, P=0.02), pregnancy rate (40.1% versus 29.4%, P=0.004) and live-birth rate per ovum retrieval (27.7% versus 20.6%, P=0.04). Surgical removal of minimal and mild endometriotic lesions also gave shorter time to first pregnancy and a higher cumulative pregnancy rate. The study shows that women with stages I and II endometriosis undergoing IVF/ICSI have significantly shorter time to pregnancy and higher live-birth rate if all visible endometriosis is completely eliminated at the time of diagnostic surgery. Surgical elimination of minimal and mild endometriosis has been shown to increase the birth rate both spontaneously and after intrauterine insemination. In this study from a reproductive medicine unit at a referral university hospital, we examined whether surgical elimination of minimal and mild endometriosis prior to IVF improved the outcome of this treatment as well. During the first IVF treatment cycle, women who had undergone complete surgical removal of endometriosis experienced, compared with women who still had their endometriosis, an improved rate of embryo implantation, pregnancy rate and live birth rate per ovum retrieval. Surgical removal of minimal and mild endometriotic lesions also gave shorter time to first pregnancy and a higher cumulative pregnancy rate. In summary, our study shows that women with minimal and mild endometriosis undergoing IVF have shorter time to pregnancy and higher live-birth rate if all visible endometriosis is completely eliminated before the start of treatment.

IVF/ICSI outcome and serum LH concentration on day 1 of ovarian stimulation with recombinant FSH under pituitary suppression.

BACKGROUND: Down-regulation with GnRH agonist has been suggested to result in a profound suppression of LH bioactivity, reduced estradiol synthesis, and thus impaired IVF and pregnancy outcome. The aims of this study were: (i) to assess the usefulness of serum LH measurement on stimulation day 1 as a predictor of ovarian response, conception and pregnancy outcome in patients treated with long-term down-regulation with GnRH agonist and recombinant FSH, and (ii) to define the best threshold LH value, if any, to discriminate between women with different outcomes of IVF. METHODS: Records of 2625 cycles in 1652 infertile women undergoing IVF (n = 1856) and/or ICSI (n = 769) treatment were reviewed. RESULTS: The range of LH concentrations on stimulation day 1 overlapped among non-conception cycles, conception cycles, ongoing pregnancies and early pregnancy losses. Receiver operating characteristic (ROC) analysis showed that serum LH concentrations on stimulation day 1 were unable to discriminate between conception and non-conception cycles (AUC(ROC) = 0.51; 95% CI: 0.49-0.54) or ongoing pregnancies versus early pregnancy loss groups (AUC(ROC) = 0.52; 95% CI: 0.47-0.57). Stratification for various low serum levels of LH did not reveal significant differences with respect to conception or pregnancy outcome among different LH levels on stimulation day 1. CONCLUSIONS: Serum LH concentration on stimulation day 1 cannot predict ovarian response, conception and pregnancy outcome in women receiving long-term down-regulation during assisted reproduction treatment.

The impact of insulin resistance on the outcome of laparoscopic ovarian electrocautery in infertile women with the polycystic ovary syndrome.

In this study we assessed how insulin resistance affects pregnancy rates in infertile women with the polycystic ovary syndrome (PCOS) treated with laparoscopic ovarian electrocautery. Sixty-four PCOS women were included in the study in a consecutive fashion. Following the CIGMA (continuous infusion of glucose with model assessment) test, 28 women were classified as insulin resistant and 36 women as non-insulin resistant. After the ovarian electrocautery patients were observed for 12-18 months. If pregnancy did not ensue, they were referred for one or more cycles of in vitro fertilization (IVF). Following ovarian electrocautery the non-insulin-resistant women more frequently achieved a regular menstrual cycle and ovulation than the insulin-resistant PCOS women. Consequently 18 (50%) of the non-insulin-resistant PCOS women achieved a pregnancy versus only five (18%) of women in the insulin-resistant PCOS group. Following treatment with both ovarian electrocautery and IVF, 27 (75%) of the non-insulin resistant PCOS women achieved a successful pregnancy, while 13 (46%) of the insulin-resistant PCOS group achieved this. In conclusion, insulin resistance may be an important marker of a poor outcome of treatment in PCOS infertility. Further studies are needed to evaluate the possible effect of treatment alternatives to alleviate the unfavorable influences of insulin resistance and hyperinsulinemia on ovulation induction in PCOS women.

Cycle characteristics of day 3 embryo transfers with 4-cell embryos only.

PURPOSE: Patient and cycle characteristics of day 3 transfers with developmentally lagging 4-cell embryos only were analyzed and related to the outcome of a live birth. METHODS: Day 3 transfers with either 4-cell embryos only (study group; n = 138) or 8-cell embryos only (control group; n = 282) were compared retrospectively. RESULTS: The total dose of FSH per treatment was higher, while the number of oocytes, zygotes, and transferred embryos was lower in the study group cycles compared to controls. The implantation, pregnancy, and live birth rates were dramatically lower in the study group compared to the control group. In the study group, the few cycles resulting in a live birth were characterized by a normal ovarian response to stimulation, similar to that of control group cycles with- or without a live birth. CONCLUSIONS: In cycles characterized by intensive ovarian stimulation, but poor response, the chance for a live birth is extremely low after day 3 transfer of 4-cell embryos.

The effect of metformin on ovarian stimulation and in vitro fertilization in insulin-resistant women with polycystic ovary syndrome: an open-label randomized cross-over trial.

Metformin effectively restores insulin sensitivity in insulin-resistant women with polycystic ovary syndrome (PCOS). We examined whether metformin, given prior to and during ovarian stimulation for in vitro fertilization (IVF), altered follicle stimulating hormone (FSH) requirement and increased the number of collected oocytes in these women. Seventeen insulin-resistant women with PCOS were recruited to our IVF unit to receive two consecutive cycles of ovarian stimulation with or without metformin co-treatment, the order of treatments being randomized using a table of random numbers. Metformin treatment (1500 mg/day) started 3 weeks before downregulation with buserelin acetate and was continued throughout ovarian stimulation with human recombinant FSH. Nine women completed both cycles, the results of eight women being excluded because of pregnancy after the first cycle (n = 4) or because the protocol of the study was not followed (n = 4). Mean total FSH dose was 2301 IU (range 1500-6563 IU) in metformin cycles and 2174 IU (range 1200-3900 IU) in parallel control cycles, while the mean number of collected oocytes was 8.6 (range 2-28) and 4.6 (range 1-16), respectively. Bayesian analysis showed probabilities of 0.05 that metformin reduces FSH requirement by at least 10%, and of 0.61 that at least 10% more oocytes are collected after metformin co-treatment. Co-administration of metformin is therefore likely to increase the number of oocytes collected after ovarian stimulation in insulin-resistant women with PCOS but is unlikely to reduce the requirement for FSH.

Natural cycle IVF in unexplained, endometriosis-associated and tubal factor infertility.

BACKGROUND: To elucidate possible differences between unexplained and minimal peritoneal endometriosis-associated infertility, we studied their outcome in natural cycle IVF (NIVF). METHODS: A prospective cohort study was carried out on unexplained (33 couples), minimal peritoneal endometriosis-associated (30 couples) and tubal factor (24 couples) infertility in 223 NIVF cycles, using human chorionic gonadotrophin (HCG) for ovulation induction. RESULTS: During the first NIVF attempt, follicular and luteal phase oestradiol, FSH, LH and progesterone concentrations, as well as endometrial thickness and follicular diameter were similar among the three groups. Periovulatory follicular growth monitored from day of HCG administration to oocyte aspiration was significantly lowered in unexplained infertility compared with minimal endometriosis-associated and tubal factor infertility. The fertilization rate, clinical pregnancy rate per initiated cycle, per successful oocyte retrieval and per embryo transfer, in minimal endometriosis (80.0, 10.4, 16.0 and 23.5% respectively) were similar to that in tubal factor infertility patients (68.6, 5.8, 11.4 and 16.0%) but significantly higher (P < 0.05) than that of the unexplained infertility group (62.2, 2.6, 5.4 and 8.7%). CONCLUSIONS: The significant reduction in follicular periovulatory growth, fertilization and pregnancy rates in unexplained infertility compared with minimal peritoneal endometriosis patients may be explained by sub-optimal follicular development with possibly reduced oocyte quality, intrinsic embryo quality factors or by impaired implantation. From a clinical point of view, NIVF is less suited to unexplained infertility treatment, but might represent an interesting treatment option for minimal peritoneal endometriosis-associated infertility.

Effects of follicular fluid and steroid hormones on chemotaxis and motility of human spermatozoa in vitro.

The 'Transwell system' was used to test the response of human spermatozoa to human follicular fluid, progesterone, estradiol and mifepristone. Motility parameters were assessed with computer-assisted sperm analysis. Follicular fluid and progesterone induced significant accumulation of spermatozoa. Changes compatible with an increased progressive and hyperactivation-like motility were obtained with follicular fluid but not with progesterone. Mifepristone eliminated the progesterone-induced accumulation of spermatozoa but had no significant effect on the accumulation of spermatozoa in wells containing human follicular fluid. Furthermore, mifepristone abolished the motility changes effected by follicular fluid. Estradiol had no effect on accumulation or motility of spermatozoa. Human follicular fluid exerted a strong effect on sperm chemoattraction and motility in vitro, while progesterone influenced sperm chemoattraction only.

Simplification of continuous infusion of glucose with model assessment in the evaluation of insulin resistance in women with PCOS.

Ninety-seven women with polycystic ovary syndrome (PCOS) were tested for insulin resistance and glucose tolerance by means of the continuous infusion of glucose with model assessment (CIGMA) test. The mean concentrations of glucose and insulin at 50, 55 and 60 min of glucose infusion were interpreted using a mathematical model of glucose and insulin homeostasis, and an insulin resistance index (IR1) was obtained. Using insulin and glucose values at 60 min only, a new insulin resistance index (IR2) was obtained using the same mathematical method. In addition, fasting insulin, fasting C-peptide, fasting glucose, fasting insulin:glucose ratio and fasting C-peptide:glucose ratio were also used to assess insulin resistance. There were significant correlations between IR1 and IR2, fasting glucose, fasting insulin, fasting insulin:glucose ratio, fasting C-peptide:glucose ratio. IR2 had the highest correlation with IR1 (r = 0.97, p < 0.001) and provided the best combination of sensitivity (82.9%), specificity (93.9%), positive predictive value (91.9%) and negative predictive value (86.8%). In conclusion, the simplified CIGMA test, using insulin and glucose concentration at 60 min of glucose infusion only, is a highly sensitive and specific measure of insulin sensitivity in women with PCOS.

The impact of obesity and insulin resistance on the outcome of IVF or ICSI in women with polycystic ovarian syndrome.

The impact of insulin resistance on the outcome of IVF or intracytoplasmic sperm injection (ICSI) in women with polycystic ovarian syndrome (PCOS) was examined. Insulin sensitivity was measured by the continuous infusion of glucose with model assessment (CIGMA) test. Insulin-resistant (n = 26) and non-insulin-resistant women (n = 30) with PCOS underwent a total of 100 cycles of long-term down-regulation with buserelin acetate, stimulation with human recombinant FSH, and IVF or ICSI. Blood samples were taken throughout ovarian stimulation for hormone assays. Insulin-resistant and non-insulin-resistant women had similar concentrations of FSH, LH, testosterone and androstenedione throughout stimulation, but insulin-resistant women had hyperinsulinaemia and lower sex hormone binding globulin concentrations. Insulin-resistant women also had lower oestradiol concentrations during stimulation and required higher FSH doses, but these differences disappeared after controlling for the higher body weight in the group of insulin-resistant women. Groups had similar number of oocytes collected, similar implantation and pregnancy rates, and the incidence of ovarian hyperstimulation syndrome was also similar. Obesity, independent of hyperinsulinaemia, was related to a lower oocyte count and increased FSH requirement. It is concluded that in PCOS women receiving long-term down-regulation and stimulation with recombinant FSH, insulin resistance is neither related to hormone levels nor to IVF outcome. Obesity, independent of insulin resistance, is associated with relative gonadotrophin resistance.

Recombinant follicle-stimulating hormone stimulates ovarian androgen synthesis in down-regulated ovulatory women.

In order to study androgen secretion during controlled ovarian hyperstimulation for in-vitro fertilization-embryo transfer, an open randomized study comparing the response to recombinant or urinary follicle-stimulating hormone (FSH) in down-regulated cycles was performed. During FSH administration significant increases in testosterone, androstenedione and dehydroepiandrosterone sulfate (DHEAS) levels were observed. During the same period a slight decrease in luteinizing hormone (LH) levels was seen. At all times during the stimulation period a significant correlation between estradiol and testosterone or androstenedione levels was observed. We conclude that FSH, through granulosa derived paracrine factors, initiates thecal androgen synthesis and secretion.

Impaired insulin action on granulosa-lutein cells in women with polycystic ovary syndrome and insulin resistance.

We studied the in vitro response to insulin of granulosa-lutein cells derived from patients with polycystic ovary syndrome (PCOS) and clinically defined insulin resistance. Insulin sensitivity was assessed by continuous infusion of glucose with model assessment test (CIGMA). Insulin resistant (PCOS-IR; n = 8), noninsulin resistant (PCOS-NIR; n = 9) patients with PCOS, and women with tubal factor infertility (TF; n = 8) underwent controlled ovarian stimulation with long-term gonadotropin-releasing hormone (GnRH) agonist, recombinant follicle stimulating hormone (FSH), and in vitro fertilization. Primary cultures of granulosa-lutein cells were incubated with insulin (10, 100, 500 ng/ml) and/or luteinizing hormone (LH) (10, 100 ng/ml) in the presence of low density lipoprotein (100 micrograms/ml). The progesterone and lactate accumulation were measured in the culture medium. LH potently stimulated the progesterone secretion in all groups. Insulin alone had no effect on progesterone release in any of the groups, but stimulated lactate formation in the PCOS-NIR and TF groups. Insulin augmented the effect of LH on progesterone secretion selectively in the PCOS-NIR group. The expression of the insulin receptor was determined by Western blotting in separate cultures of granulosa-lutein cells, and showed receptor down-regulation in the PCOS-IR patients. We infer that the in vitro effect of insulin on progesterone and lactate release by granulosa-lutein cells is impaired in insulin resistant PCOS patients.