The 2019 PGDIS position statement on transfer of mosaic embryos within a context of new information on PGT-A.

BACKGROUND: A recently published Position Statement (PS) by the Preimplantation Genetics Diagnosis International Society (PGDIS) regarding utilization of preimplantation genetic testing for aneuploidy (PGT-A) in association with in vitro fertilization (IVF) contained inaccuracies and misrepresentations. Because opinions issued by the PGDIS have since 2016 determined worldwide IVF practice, corrections appear of importance. METHODS: The International Do No Harm Group in IVF (IDNHG-IVF) is a spontaneously coalesced body of international investigators, concerned with increasing utilization of add-ons to IVF. It is responsible for the presented consensus statement, which as a final document was reached after review of the pertinent literature and again revised after the recent publication of the STAR trial and related commentaries. RESULTS: In contrast to the PGDIA-PS, we recommend restrictions to the increasing, and by IVF centers now often even mandated, utilization of PGT-A in IVF cycles. While PGT-A has been proposed as a tool for achieving enhanced singleton livebirth outcomes through embryo selection, continued false-positive rates and increasing evidence for embryonic self-correction downstream from the testing stage, has led IDNHG-IVF to conclude that currently available data are insufficient to impose overreaching recommendations for PGT-A utilization. DISCUSSION: Here presented consensus offers an alternative to the 2019 PGDIS position statement regarding utilization of preimplantation genetic testing for aneuploidy (PGT-A) in association with in vitro fertilization (IVF). Mindful of what appears to offer best outcomes for patients, and in full consideration of patient autonomy, here presented opinion is based on best available evidence, with the goal of improving safety and efficacy of IVF and minimizing wastage of embryos with potential for healthy births. CONCLUSIONS: As the PGDIS never suggested restrictions on clinical utilization of PGT-A in IVF, here presented rebuttal represents an act of self-regulation by parts of the IVF community in attempts to control increasing utilization of different unproven recent add-ons to IVF.

The total pregnancy potential per oocyte aspiration after assisted reproduction-in how many cycles are biologically competent oocytes available?

PURPOSE: While stimulation of women prior to assisted reproduction is associated with increased success rates, the total biological pregnancy potential per stimulation cycle is rarely assessed. METHODS: Retrospective sequential cohort study of the cumulative live birth rate in 1148 first IVF/ICSI-cycles and 5-year follow up of frozen embryo replacement (FER) cycles were used. Oocyte number, number of embryos transferred, and cryopreserved/thawed and transferred embryos in a FER cycle were registered for all patients. Children per oocyte and per transferred embryo and percentage of cycles with births were calculated. RESULTS: We obtained 9529 oocytes. Embryos (2507) were transferred in either fresh or FER cycles, resulting in 422 births and 474 live born children. Median age of the women was 32.5 years (range 20-41.5 years). In total, 34.3 % of all cycles ended with a live birth while in 65.7 % of the cycles, no oocytes were capable of developing into a child. The average number of oocytes needed per live born child after transfer of fresh and thawed embryos was 20 as only 5.0 % of oocytes aspirated in the first IVF/ICSI cycle had the competence to develop into a child. CONCLUSIONS: In our setting, overall 5.0 % of the oocytes in a first cycle were biologically competent and in around 2/3 of all cycles, none of the oocytes had the potential to result in the birth of a child.

Birthweight distribution in ART singletons resulting from embryo culture in two different culture media compared with the national population.

STUDY QUESTION: Is there a difference in birthweight distribution in ART singletons born after IVF culture in two different culture media? SUMMARY ANSWER: There is no effect of culture media on both crude and adjusted birthweight distributions in ART singletons from nulliparous mothers. WHAT IS KNOWN ALREADY: Studies on human ART singletons have reported a difference in birthweight in singletons following IVF culture in different culture media. However, other studies comparing different culture media have not shown any significant differences in birthweight. STUDY DESIGN, SIZE, DURATION: This study was a retrospective comparison of birthweights in IVF/ICSI singletons conceived after fresh embryo transfer following embryo culture in Cook or Medicult medium and in a national cohort of naturally conceived singletons in nulliparous women. The study compares four independent groups consisting of singletons in nulliparous women from Cook-d2: 2-day culture in Cook medium at Rigshospitalet (n = 974), Medicult-d2: 2-day culture in Medicult EmbryoAssist medium at Rigshospitalet (n = 147), Medicult-d3: 3-day culture in Medicult EmbryoAssist medium with and without added GM-CSF (n = 204), and DK: pregnancies from the Danish birth registry (n = 106842). PARTICIPANTS/MATERIALS, SETTING, METHODS: The study compares the birthweights of singletons from nulliparous women in the four independent groups mentioned above; Cook-d2: Medicult-d2: Medicult-d3: and DK. In addition, distributions of large and small for gestational age infants were compared between the groups and a multiple linear regression analysis was used to determine which factors determined birthweight. MAIN RESULTS AND THE ROLE OF CHANCE: We found no significant difference in the crude birthweight distributions between singletons born after culture in Cook-d2 or Medicult-groups. Singleton girls from the Cook-d2 group weighed 3302 ± 28 g, versus 3252 ± 76 in the Medicult-d2 group (difference 50 g; P = 0.547). Singleton boys from the Cook-d2 group weighed 3430 ± 27 g, versus 3354 ± 56 in the Medicult-d2 group (difference 76 g; P = 0.279). In the background population, mean birthweights for singleton girls and boys were 3383 ± 2.4 g and 3494 ± 2.5 g, respectively. The mean birthweights of girls, 3315 ± 61 g, and boys, 3383 ± 64 g, in the Medicult-d3 group were not significantly different from that in the Medicult-d2 group. When pooling data from all culture media groups, we found the same slightly lower mean birthweight in IVF/ICSI singletons when compared with the national birth cohort as has been previously reported (Cook-d2 + Medicult-d2 + d3 versus birth cohort; girls: P < 0.001, boys: P < 0.001). We also pooled data on boys and girls and calculated the mean birthweight for the Cook-d2, Medicult-d2 and Medicult-d3 groups and found no significant differences. LIMITATIONS, REASONS FOR CAUTION: The retrospective design and the inherent risk of confounding factors is a limitation. Selection bias cannot be excluded as the embryos cultured in Cook-d2 and Medicult-d2 were from single centre studies while data in Medicult-D3 group were derived from a multicentre study. WIDER IMPLICATIONS OF THE FINDINGS: This large cohort of singletons born after IVF/ICSI shows no difference in crude mean birthweight after culture in two different culture media, indicating that if such a difference exists, this must be specific for certain culture media. As expected we found a slightly lower mean birthweight in ART compared with naturally conceived singletons. This suggests that parental characteristics or IVF technique related factors other than type of culture medium may influence the birthweight in ART singletons. STUDY FUNDING/COMPETING INTERESTS: No external funding was used for this study. No conflicts of interest are declared.

Syncytin-1 and its receptor is present in human gametes.

MAIN PURPOSE AND RESEARCH QUESTION: To determine whether the true fusogen Syncytin-1 and its receptor (ASCT-2) is present in human gametes using qRT-PCR, immunoblotting and immunofluorescence. METHODS: Donated oocytes and spermatozoa, originating from a fertility center in tertiary referral university hospital, underwent qRT-PCR, immunoblotting and immunofluorescence analyzes. RESULTS: Quantitative RT-PCR of sperm samples from sperm donors showed that syncytin-1 is present in all samples, however, protein levels varied between donors. Syncytin-1 immunoreactivity predominates in the sperm head and around the equatorial segment. The receptor ASCT-2 is expressed in the acrosomal region and in the sperm tail. Moreover, ASCT-2, but not syncytin-1, is expressed in oocytes and the mRNA level increases with increasing maturity of the oocytes. CONCLUSIONS: Syncytin and its receptor are present in human gametes and localization and temporal appearance is consistent with a possible role in fusion between oocyte and sperm.

Kinetic markers of human embryo quality using time-lapse recordings of IVF/ICSI-fertilized oocytes.

A time-lapse system was used to study the timing and coordination of events during early development from zygote to cleavage stage embryo. The aim was to identify markers linked to good-quality embryos and implantation. A total of 102 fertilized oocytes were followed for 20-24 h. Events such as appearance and disappearance of (pro)nuclei and timing and synchronization of cell cleavage were logged as time points after fertilization. Averages for these events and their synchrony were calculated and linked with fertilization method, embryo quality and implantation success. Fertilized oocytes that developed into > or =4-cell embryos had an earlier pronuclei disappearance and first cleavage than those that developed to 3- or 2-cell embryos. Intracytoplasmic sperm injection-fertilized 4-cell embryos spent a significantly shorter period as 2-cell compared with IVF-fertilized embryos (P = 0.0090). Development in the time-lapse system was similar to their siblings cultured in normal incubators, suggesting that the data from the time-lapse system can be extrapolated to the clinic's laboratory setting. Early disappearance of pronuclei and onset of first cleavage after fertilization was correlated with a higher number of blastomeres on day 2 after oocyte retrieval. In addition, synchrony in appearance of nuclei after the first cleavage was significantly associated with pregnancy success (P < 0.05).

Progesterone supplementation during early gestation after in vitro fertilization has no effect on the delivery rate.

OBJECTIVE: To compare the delivery rate with IVF or ICSI in women who did and did not receive progesterone supplementation in the first 3 weeks after a positive hCG test result. DESIGN: Retrospective study. SETTING: Fertility Clinic, Rigshospitalet University Hospital, Copenhagen, Denmark. PATIENT(S): 200 pregnant women who did not receive progesterone (intervention group) and 200 pregnant women who received progesterone for 3 weeks after a positive hCG result. INTERVENTION(S): In the study group, vaginal progesterone therapy was withdrawn on the day of positive hCG result. In the control group, treatment with progesterone, 600 mg/d, was continued for 3 weeks after a positive hCG result. Both groups received 600 mg of progesterone starting on the day of embryo replacement until testing positive for pregnancy 14 days after embryo transfer. MAIN OUTCOME MEASURES: Delivery rate. RESULT(S): The number of deliveries was 126 in the study group and 128 in the control group. CONCLUSION(S): The delivery rate was the same in pregnant women who received and those who did not receive progesterone for 3 weeks after a positive hCG result. Progesterone supplementation for more than 2 weeks after embryo transfer may therefore yield no benefit in terms of pregnancy.

[Micro-insemination with intracytoplasmic sperm injection]. / Mikroinsemination med intracytoplasmatisk saedcelleinjektion.

Intracytoplasmic sperm injection (ICSI) is now established in the treatment of infertility. Fertilization is achieved by microinjection of a single spermatozoon into the ooplasma. Oligoasthenoteratozoospermia is the main indication, but ICSI is also used in cases of failed fertilization after standard IVF, retrograde ejaculation and male immunological infertility. In obstructive azoospermia ICSI is performed after aspiration of epididymal or testicular spermatozoa. In some anejaculatoric men spermatozon can be obtained following penile vibration or electro-stimulation, but they often have poor motility and ICSI may be used for fertilization. ICSI may also be used after thawing of semen cryopreserved prior to treatment of a malignant disease. Since 1991 the ICSI technique has been improved, and today the pregnancy rates are at least as good as after standard IVF. So far, studies of the foetuses and children born after ICSI show that the number of malformations and abnormal karyotypes is within the range of the normal population.

[Infertility in ethnic groups. Etiology and treatment]. / Infertilitet hos etniske par. Arsager og behandling.

In this retrospective case control study we analysed the causes and treatments of infertility in 100 ethnic couples consecutively discharged from the Fertility Clinic in the period October 1995 to March 1999. The mean age at referral was 28 years (19-37) for ethnic women and 31 years (24-39) for Danish women. Male infertility was the most frequent cause in ethnic couples compared to Danish couples (24% vs. 16%; NS). Tubal infertility was less frequent in ethnic than in Danish couples (19% vs. 45%; p < 0.01), ovulatory defects were more frequent in ethnic couples than in Danish (13% vs. 4%; p < 0.04). Among ethnic couples 57 (118 cycles) underwent IVF and ICSI treatment vs. 85 (198 cycles) Danish couples (p < 0.01). The ongoing pregnancy rate per initiated cycle was 29.6% in ethnic couples vs. 24.2% in Danish couples (NS). Forty four percent of the ethnic couples did not complete the whole treatment program vs. 29% of Danish couples (p < 0.04). This may be due to cultural differences and difficult communication.

Nuclei size in relation to nuclear status and aneuploidy rate for 13 chromosomes in donated four cells embryos.

PURPOSE: The aim was to elucidate if the nuclear size and number are indicative of aberrant chromosome content in human blastomeres and embryos. METHODS: The number of nuclei and the nucleus and blastomere size were measured by a computer controlled system for multilevel analysis. Then the nuclei were enumerated for 13 chromosomes by a combination of PNA and DNA probes. RESULTS: In the mononucleated embryos there was no difference in the mean size of chromosomally normal and abnormal nuclei but a significant difference in the mean nuclei size of nuclei that had gained chromosomes compared to nuclei that had lost chromosomes. The nuclei from multinucleated blastomeres had a significant smaller mean size and the frequency of chromosomally aberrant blastomeres was significantly higher. CONCLUSION: The mean nuclear size is not a marker for the chromosome content in mononucleated embryos. However, it seems that the nuclei size can be related to multinucleation and maybe to the chromosome content.

Biochemical pregnancy after fertilization of an oocyte aspirated from a heterotopic autotransplant of cryopreserved ovarian tissue: case report.

Autotransplantation of frozen/thawed ovarian tissue in women undergoing cancer therapy has so far led to the birth of two healthy babies. In both cases, it can be discussed whether the fertilized oocyte originated from the transplant or from the native ovary. We now present a biochemical pregnancy achieved after heterotopical autotransplantation of cryopreserved ovarian cortical tissue and hence the unquestionable proof that pregnancy can occur after transplantation of cryopreserved ovarian tissue. A woman diagnosed with Hodgkin's lymphoma had ovarian tissue cryopreserved at the age of 28, before receiving chemotherapy and radiation therapy that rendered her amenorrhoeic. After complete remission, she had autotransplantation of ovarian tissue to the remaining ovary, to the right pelvic wall and to a midline subperitoneal pocket on the lower abdominal wall. The transplanted tissue resumed hormone secretion and follicles developed in all three locations. Three times during 8 months, when follicles could not be visualized in other locations, oocytes were aspirated from the subperitoneal autotransplanted tissue on the lower abdominal wall. Twice, an oocyte was retrieved, fertilized by intracytoplasmatic sperm injection (ICSI) and transferred to the woman's uterus. One of the treatments resulted in a positive pregnancy test 14 days after transfer. Clinical pregnancy, however, was not achieved. In conclusion, heterotopic autotransplantation of cryopreserved ovarian tissue can sustain follicle development. The oocytes of aspirated mature follicles are capable of fertilization after ICSI, and the resulting embryo is competent of producing hCG at detectable levels.

Sequential FISH analysis using competitive displacement of labelled peptide nucleic acid probes for eight chromosomes in human blastomeres.

BACKGROUND: The aim was to introduce a new strategy based on peptide nucleic acid (PNA) probes and competitive displacement for using fluorescence in-situ hybridization (FISH) analysis on human blastomeres. METHODS: Sequential FISH analysis with PNA probes and competitive displacement was performed using three different probe sets. The first set consisted of labelled probe only. The second and third sets included labelled as well as unlabelled probe, corresponding to the labelled probes in the previous cycles. The probes for enumeration were for chromosome 1, 13, 16, 17, 18, 21, X and Y. RESULTS: The performance of PNA probes was similar to the established DNA probes. The strategy of competitive displacement resulted in a destabilization of already bound probe before the next FISH cycle at only 50 degrees C, which allowed for up to five sequential FISH cycles without loss of signal. CONCLUSIONS: PNA probes are a good alternative to DNA probes in the present set-up, since the low temperature required both for binding and destabilization of PNA probes minimizes the loss of signal, and several FISH cycles can therefore be carried out before FISH errors occur.

Serum levels of free androstenedione, testosterone and oestradiol are lower in the follicular phase of conceptional than of non-conceptional cycles after ovarian stimulation with a gonadotrophin-releasing hormone agonist protocol.

Serum concentrations of total and free androstenedione, testosterone and oestradiol were followed during the follicular phase in women undergoing ovarian stimulation for treatment by in-vitro fertilization and embryo transfer (IVF-ET) and compared to those in natural unstimulated cycles. In addition, 10 conceptional and 18 non-conceptional cycles were compared in an attempt to understand the background for successful IVF cycles. The ultra-short gonadotrophin-releasing hormone agonist protocol was used for ovarian stimulation. Throughout the follicular phase, levels of total and free androstenedione and oestradiol were significantly lower in conceptional than in non-conceptional IVF cycles. In addition, levels of free testosterone during the follicular phase were significantly lower in women who conceived compared to non-conceptional IVF cycles, whereas levels of total testosterone were similar. Levels of both free and total androstenedione increased significantly from the second day of the menstrual cycle until oocyte retrieval in non-conceptional IVF cycles, whereas levels in conceptional IVF cycles and unstimulated cycles showed no increase. On the day of oocyte retrieval levels of free and total androstenedione were significantly higher in non-conceptional IVF cycles than in conceptional IVF cycles and unstimulated cycles, which were similar. This study suggests that appropriate levels of free biologically active androgens and oestradiol are important parameters for successful conception.(ABSTRACT TRUNCATED AT 250 WORDS)

Impact of gonadotrophin dose on pre-embryo recovery and development in superovulated mice.

A dose-response analysis was performed by stimulating mice with Humegon, which contains approximately equal amounts of follicle stimulating hormone (FSH) and luteinizing hormone (LH). The effect of increasing stimulation was assessed by monitoring the number and developmental stages of pre-embryos flushed from the tubes, and the developmental potency of these pre-embryos after culturing for 72 h. Increasing the stimulation doses resulted in an increased recovery of 2-cell pre-embryos. A maximal plateau of 40-50 2-cell pre-embryos was reached after stimulation with 15-30 IU FSH/LH. Higher stimulation doses up to 50 IU FSH/LH showed no further increase in pre-embryo recovery. Increased stimulation doses did not affect the number of 1-cell pre-embryos or the number of pre-embryos which developed further than the 2-cell stage. An average of 88 +/- 1.7% of the flushed pre-embryos were 2-cell pre-embryos. The fraction of flushed pre-embryos which developed into blastocysts after 72 h of culturing was constant at all stimulation doses, with an average of 81 +/- 1.9%. A maximal plateau of 35-40 blastocysts was reached after stimulating with 15-30 IU FSH/LH. The group of pre-embryos at less advanced developmental stages and the group of degenerated pre-embryos showed a small but dose dependent increase in number. In conclusion, we found that increasing doses of Humegon resulted in an increased recovery of pre-embryos capable of preimplantation development. This increased recovery occurred despite the high level of LH contained in this FSH/LH stimulation.

Single intragenic microsatellite preimplantation genetic diagnosis for cystic fibrosis provides positive allele identification of all CFTR genotypes for informative couples.

This study is part of a strategy aimed at using fluorescent polymerase chain reaction (PCR) on informative genetic microsatellite markers as a diagnostic tool in preimplantation genetic diagnosis (PGD) of severe monogenic disease. Two couples, both of whom had previously had children who were compound heterozygote for severe cystic fibrosis mutations, were offered PGD using fluorescent PCR of the highly polymorphic cystic fibrosis transmembrane conductance regulator (CFTR) intragenic microsatellite marker IVS17bTA. Cleavage-stage embryo biopsy followed by PCR resulted in transfer of one unaffected carrier embryo for each couple. This approach eliminates the need for single cell multiplex PCR strategies to detect CF compound heterozygotes. It also provides a control of chromosome 7 ploidy in the blastomeres and a selection against allele dropout by positive detection of each CFTR copy of all genotypes in preimplantation embryos from genetically informative families.

Results of intracytoplasmic sperm injection in relation to indication.

BACKGROUND: Intracytoplasmic sperm injection (ICSI) was first introduced as a treatment to couples that were infertile due to severe male factors. Later, the ICSI technic has also been used on other indications like low or no fertilization in previous IVF cycles. METHODS: A total of 262 ICSI cycles performed in 180 patients were reviewed and the results related to the indications. The indications were severely impaired semen quality (182 cycles) or absent or low fertilization in previous IVF attempts (80 cycles). RESULTS: A total of 2298 oocytes were aspirated and 1939 oocytes were injected resulting in 1172 fertilized (60%) and 995 cleaved oocytes (51%). Of these, 547 preembryos were transferred in 240 cycles and 287 preembryos were cryopreserved. We obtained 99 pregnancies (41%/transfer) of which 63 were ongoing pregnancies (26%/transfer). The pregnancy rate was significantly lower (p = 0.025) in couples referred for ICSI due to previously failed IVF (29%/ transfer) compared to couples with impaired semen quality (46%/transfer). Seventy-seven children have been born. Forty-eight healthy children were born from singleton pregnancies with a mean gestational age of 39.8 weeks and an average birthweight of 3561 g. Thirteen sets of healthy twins and one set of healthy triplets were born. In 29 of the 63 ongoing pregnancies amniocenteses were performed and all karyotypes were normal. CONCLUSION: IVF with ICSI gave good clinical results in couples with severe male factor infertility. The technic can also be used in couples with unexplained fertilization failure, but the pregnancy rate may be lower.

Embryo morphology or cleavage stage: how to select the best embryos for transfer after in-vitro fertilization.

This retrospective study of 1001 in-vitro fertilization (IVF) cycles included a consecutive series of single transfers (n = 341), dual transfers (n = 410) and triple transfers (n = 250) where all the transferred embryos in each cycle were of identical quality score and identical cleavage stage. In our 2 day culture system, transfer of 4-cell embryos resulted in a significantly higher implantation rate and pregnancy rate (23 and 49%) compared with 2-cell embryos (12 and 22%) and 3-cell embryos (7 and 15%). Furthermore, the transfer of 4-cell embryos resulted in a significantly higher pregnancy rate compared with embryos that had cleaved beyond the 4-cell stage (28%). The implantation rate (21%) and pregnancy rate (43%) after transfer of embryos of score 1.0 were significantly higher than after transfer of embryos of score 2.0 (14 and 32% respectively). Transferring embryos of score 2.1 resulted in significantly higher implantation rates (26%) and similar pregnancy rates compared with score 1.0. Transferring embryos of score 2.2-3.0 resulted in a significantly lower implantation rate (5%) and pregnancy rate (15%). A striking finding was that embryos of quality score 2.0 had a significantly lower implantation rate compared with embryos of quality score 1.0 and 2.1 and a significantly lower pregnancy rate compared to embryos of quality score 1.0. We also found a lower implantation rate and pregnancy rate when transferring 3-cell embryos. These findings may indicate periods of increased sensitivity to damage during the cell cycle. In conclusion, these results substantiate the idea of the superiority of 4-cell embryos and demonstrate that minor amounts of fragments in the embryo may not be of any importance. These findings may call for a shift when weighing the two main morphological components (quality score and cleavage stage) in the sense that reaching a 4-cell cleavage stage even with the presence of a minor amount of fragments should be preferred to a 2-cell embryo with no fragments.

Sperm morphology using strict criteria after Percoll density separation: influence on cleavage and pregnancy rates after in-vitro fertilization.

The main purpose of the study was to evaluate the use of sperm morphology assessment by strict criteria on the post-Percoll separated spermatozoa used for oocyte insemination in an in-vitro fertilization programme. This study included a consecutive unselected series of 213 oocyte aspirations in 159 women. In 177 aspirations the patient had tubal infertility and in 36 unexplained infertility. Data have been analysed from 197 aspirations where the semen sample used for insemination had a normal sperm concentration (> or = 20 x 10(6)/ml). A total of 1413 oocytes were aspirated, resulting in 863 oocytes which were fertilized and cleaved (cleavage rate 61%). In all, 492 pre-embryos were transferred in 193 cycles, resulting in a pregnancy rate of 42% per transfer. Sperm morphology evaluation using strict criteria showed that Percoll separation significantly increased the percentage of sperm cells with normal morphology from 7.7 to 11.3%. Sperm morphology analysis showed that Percoll separation decreased the number of sperm samples in the 'poor prognosis pattern' group from 31 to 13% and increased the number of sperm samples classified as 'normal' from 16 to 33%. After Percoll separation the poor prognosis pattern group had a cleavage rate of 46%, which was significantly lower than in the good prognosis pattern and the normal groups. However, the poor prognosis pattern group had a significantly higher pregnancy rate than the normal group (P < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Impact of recombinant FSH dose adjustments on ovarian response in the second treatment cycle with IVF or ICSI in "standard" patients treated with 150 IU/day during the first cycle.

BACKGROUND: A dose of 150 IU/day of recombinant follicle stimulating hormone (rFSH) is commonly used as a "standard" dose for "standard" patients in the first in vitro fertilization (IVF) treatment cycle. In the second cycle, the starting dose is adjusted in those patients who had an inappropriate response during the first cycle. The purpose of the study was to assess the impact of dose adjustments on ovarian response. MATERIALS AND METHODS: Retrospective study including 567 first IVF/intracytoplasmic sperm injection (ICSI) cycles using the long agonist protocol in "standard" patients. In the second cycle 385 patients who had failed to achieve an ongoing pregnancy were included. The starting dose in the second cycle was adjusted according to the response in the first cycle. RESULTS: A total of 215 patients (55.8%) had altered starting dose in the second cycle: 193 (50.1%) received >150 IU/day, whereas 22 (5.7%) had <150 IU/day. In the group given >150 IU/day, significantly more follicles (9.8 vs. 8.3, p = 0.002) and oocytes (8.4 vs. 6.7, p <0.0001) were obtained in the second cycle. In the group given <150 IU/day, there were significantly fewer follicles (20.4 vs. 13.5, p <0.0001) and oocytes (16.4 vs. 11.4, p = 0.005) in the second cycle. In the group given <150 IU/day in the second cycle, six (27.3%) had an appropriate ovarian response (5-14 oocytes) in the first cycle compared to 14 (63.6%) women in the second cycle (p = 0.01). The ongoing pregnancy rates in all of the first (32.1%) and second cycles (27%) were similar (p = NS). CONCLUSION: In a "standard" patient population, 55.8% needed an altered starting dose in the second cycle and rFSH dose adjustments had a significant impact on the ovarian response.

Requirements for human chorionic gonadotropin and recombinant human luteinizing hormone for follicular development and maturation.

PURPOSE: Our purpose was to evaluate the requirements for human chorionic gonadotropin (hCG) and recombinant luteinizing hormone (rec-LH) for follicular development and maturation in mice. METHODS: We carried out ovarian stimulation of immature mice. Output parameters were the preembryos created in vivo and frequency of blastocyst formation in vitro. RESULTS: hCG at 0 to 1 IU resulted in a dose-dependent recovery of preembryos (0 to 39.7 +/- 4.3; mean +/- SE) per mouse. hCG at 1 and 10 hCG gave similar results, whereas higher doses significantly reduced the number of preembryos. Potential for blastocyst formation was independent of hCG dose. hCG and rec-LH together exerted a synergistic effect on the recovery of preembryos. CONCLUSIONS: Optimal follicular development required a combination of 20 IU follicle stimulating hormone and 1-10 IU hCG. The potency of hCG was higher than that of rec-LH, but a synergistic effect of rec-LH and hCG was observed. The results may be pertinent for the development of strategies for ovarian stimulation of women with low levels of endogenous LH.

Insulinomimetic effect on glucose transport by epidermal growth factor when combined with a major histocompatibility complex class I-derived peptide.

Peptides derived from the alpha 1-region of the murine H-2Dk molecule enhance glucose uptake in rat adipose cells above the maximum obtained with insulin stimulation alone (Stagsted, J., Reaven, G. M., Hansen, T., Goldstein, A., and Olsson, L. (1990) Cell 62, 297-307). We now describe that epidermal growth factor (EGF) in combination with the same peptides, Dk-(61-85) and Dk-(62-85), stimulates cellular glucose uptake 5-7 times over the basal level, i.e. to 30-50% of the maximal insulin effect. EGF alone increased glucose uptake by only approximately 50% above basal and the peptide alone by 100% above basal. Maximal effect of EGF and peptide was reached in 10-20 min with 30 microM peptide (EC50 10-15 microM) and 50 nM EGF (EC50 1-2 nM). The effect of EGF and peptide on glucose uptake was additive to that of insulin and peptide until the maximal level attained with insulin and peptide was reached. The combined effect of EGF plus peptide on glucose transport was associated with a recruitment of GLUT4 molecules to the plasma membrane. However, the phosphatidylinositol (PI) kinase which is activated by insulin was not activated by EGF plus peptide. Thus, the effect of EGF plus peptide on glucose uptake seems independent of the activity status of the insulin receptor. 125I-Labeled EGF bound specifically to rat adipose cells with an apparent affinity of approximately 2 nM and Bmax approximately 5 x 10(3). However, the major histocompatibility complex (MHC) peptides did not affect EGF-stimulated internalization of EGF receptor, in contrast to their effect on the insulin receptors. Transforming growth factor alpha had an effect similar to EGF on glucose uptake. Three other peptides derived from other parts of murine MHC class I had no effect on glucose uptake in combination with EGF. Thus, EGF in combination with certain MHC class I-derived peptides is insulinomimetic concerning glucose transport and this effect is independent of the insulin receptor activity.