A new CentriSwim procedure to increase the recovery of motile spermatozoa.

A prospectively controlled in vitro study was performed to compare sperm concentration, sperm motility and progressive sperm motility recovered following the standard swim-up procedure and a new CentriSwim procedure. The CentriSwim procedure involves creating a centrifugal force to counteract the force of gravity during sperm swim-up procedure. Two aliquots of semen from 12 normozoospermic ejaculates and 12 laboratory-induced oligoasthenozoospermic specimens were diluted, centrifuged, and 1.0 ml of media layered over the sperm pellet. One aliquant was processed by standard swim-up technique. The other aliquant was processed by CentriSwim procedure involving centrifugation at 200 rpm on a 2-cm radius upward-directing arm, at an angle of 60 degrees for 10 min, creating roughly 0.8 g centrifugal force at room temperature (22-24 degrees C) to counteract the force of gravity. The numbers of spermatozoa recovered from the upper 0.5 ml of the medium following CentriSwim from the normozoospermic ejaculates and laboratory-induced oligoasthenozoospermic specimens were significantly higher than following standard swim-up procedure. No statistical differences in the recovery of percentage sperm motility and progressive sperm motility between the two techniques were observed. In conclusion, the CentriSwim procedure yields higher numbers of motile spermatozoa than the standard swim-up technique.

Vaginal leiomyoma co-existing with broad ligament and multiple uterine leiomyomas.

A 48 year old African American woman presented with bladder pressure leading to the diagnosis of broad ligament and multiple uterine leiomyomas. She was also found to have a lateral vaginal wall mass which was confirmed to be a leiomyoma. Unlike uterine leiomyomas, vaginal leiomyomas are uncommon and are most often found in Caucasian women. Cases of such coexisting tumors are rare and their etiologic relationship is uncertain.

Determination of laboratory specific percent normal sperm morphology value based on prevasectomy ("fertile") ejaculates.

Semen assessments were performed on ejaculates from 25 men with proven fertility requesting vasectomy. Multiple cytological slides were made simultaneously from each ejaculate and analyzed by a single technician. The morphology data obtained were analyzed for repeatability. The mean +/- SD for normal sperm morphology was 30.6+/-7.3, and the within-subject repeatability was < or =1 SD of the mean for 17 of 25 ejaculates. Technician and laboratory specific criteria for the percent normal sperm morphology component of a semen analysis report (that are clinically meaningful) can be developed using the approach described herein.

Increased recovery of swim-up spermatozoa by application of "antigravitational" centrifugation.

OBJECTIVE: To compare the quantity and quality of sperm recovered following the 10-minute application of an antigravitational force during the swim-up procedure with the standard 60-minute swim-up (SSU) procedure. DESIGN: Prospectively controlled in vitro study. SETTING: Private andrology laboratory and hospital-based infertility practice. INTERVENTION(S): Equal aliquots of semen were evaluated following various intervals of antigravitational centrifugation swim-up (ACSU). ACSU and SSU were then compared. PATIENT(S): Thirty-eight men undergoing therapeutic testing. MAIN OUTCOME MEASURES: Sperm concentration, sperm motility, and progressive sperm motility. RESULTS: The number of sperm recovered from the ACSU procedure was significantly higher than from the SSU procedure. No significant differences in percent motile sperm and progressive motile sperm recovery between the two procedures were observed. CONCLUSION: The ACSU procedure yields a higher number of motile spermatozoa in a much shorter time.

Gonadotropins induce higher active renin levels in the follicular fluid of normal and hyperstimulated cycles.

The objective of this study was to analyze follicular fluid active renin and its relationship to steroid hormones throughout the normal and gonadotropin-stimulated menstrual cycle. Active renin was measured in the follicular fluid of patients undergoing tubal sterilization (n = 16) and in vitro fertilization (IVF) (n = 25); IVF patients were either in a natural cycle (n = 7) or undergoing controlled ovarian hyperstimulation (n = 18). The largest visible follicle was aspirated at the time of laparoscopic tubal sterilization; ultrasound guided transvaginal follicular aspiration was used in the IVF group. Follicular fluid active renin, estradiol and progesterone levels were measured with immunoradiometric and fluoroimmunoassays. The cycle day was correlated with the spontaneous luteinizing hormone (LH) surge or human chorionic gonadotropin (hCG) administration, as well as active renin, estradiol, progesterone levels and the estradiol/progesterone ratio using simple and multiple regression and analysis of variance (ANOVA). Cycle day independently influenced active renin, progesterone and the estradiol/progesterone ratio in a statistically significant manner (p < 0.0001). The active renin and progesterone levels were highest during the periovulatory period (p < 0.0001 and p < 0.002, respectively) and the estradiol/progesterone ratio correlated inversely with cycle day (p < 0.003). Although the follicular fluid active renin, estradiol and progesterone levels were higher after controlled ovarian hyperstimulation when compared to natural cycles, this difference did not reach statistical significance. Our findings suggest that active renin levels in follicular fluid increase in the follicular phase of the menstrual cycle, reaching peak levels in the periovulatory period following the LH surge or hCG administration, providing indirect support for the hypothesis that the ovarian renin-angiotensin system (RAS) is under gonadotropin control.

Gonadotropins induce the release of interleukin-1 beta, interleukin-6 and tumor necrosis factor-alpha from the human preovulatory follicle.

PROBLEM: The effects of exogenous gonadotropin administration and steroid levels on the release of various cytokines into the human follicular fluid (FF) were studied. METHOD OF STUDY: Forty patients were included in two groups, those undergoing controlled ovarian hyperstimulation (COH) (n = 33) and natural cycles (n = 7). FF transvaginal aspirations were performed 36 hr after administration of human chorionic gonadotropin or a spontaneous surge of luteinizing hormone, respectively. FF cytokine measurements were performed with sensitive immunoassays. RESULTS: FF cytokine levels were higher after COH [interleukin (IL)-1 beta, 6.6 +/- 0.32 pg/ml; IL-6, 18.7 +/- 2.1 pg/ml; and tumor necrosis factor (TNF)-alpha, 32.5 +/- 4.9 pg/ml] than in natural unstimulated cycles (0.52 +/- 0.1 pg/ml, P < 0.001; 8.9 +/- 1.2 pg/ml, P < 0.01; and 13.2 +/- 2.6 pg/ml, P < 0.001, respectively). FF estradiol (E2) and progesterone levels were not statistically different between groups, despite the higher serum E2 levels observed in patients after COH. CONCLUSIONS: Gonadotropins might regulate ovarian secretion of cytokines, because FF IL-1 beta, IL-6, and TNF-alpha levels after COH were higher than during natural cycles.

Strategies for ovulation induction and oocyte retrieval in the lowland gorilla.

PURPOSE: Ovulation induction and oocyte retrieval were performed in a lowland gorilla in an attempt to propagate and potentially cryopreserve embryos from an infertile animal and to advance techniques to help preserve this endangered species. RESULTS: Following 34 days of leuprolide acetate suppression, human menopausal gonadotropins were administered for 14-days in a 32-year-old wild-born lowland gorilla. Ten oocytes were retrieved by transrectal ultrasound-guided aspiration. Other approaches to oocyte recovery were not feasible in this case. A serum estradiol concentration of 4700 pg/ml at the time of human chorionic gonadotropin administration did not induce ovarian hyperstimulation. Mature oocytes were recovered from follicles measuring 14 to 24 mm in diameter, with a corresponding average serum estradiol concentration of approximately 300 pg/ml for each mature follicle. Cryopreservation of a gorilla embryo was effected from cryopreserved gorilla spermatozoa. CONCLUSIONS: Parameters for monitoring ovulation induction in the gorilla appear to be similar to those for humans. The results indicate that the use of a gonadotropin releasing hormone agonist and higher doses of gonadotropins than previously used in gorillas appear to improve oocyte recovery.

Current practices of commercial cryobanks in screening prospective donors for genetic disease and reproductive risk.

OBJECTIVE: To determine how the screening practices of commercial semen banks vary from published guidelines, which factors influence cryobanks to exclude prospective semen donors for genetic reasons, and the current role of clinical geneticists/genetic counselors in evaluating prospective semen donors. DESIGN: The genetic screening of prospective donors by commercial semen banks was evaluated using written questionnaires completed by bank directors. Responses were analyzed to determine exclusion criteria, adherence to published guidelines, and contribution of genetic professionals. SETTING AND PARTICIPANTS: Semen banks were selected on the basis of membership in the American Association of Tissue Banks and commercial use of semen for artificial insemination by donor. MAIN OUTCOME MEASURE: Semen bank practices as reported by commercial semen bank directors. RESULTS: Of 37 eligible banks, 16 responded. All screen prospective donors by medical/family history and physical examination, 94% have upper age limits; 63% examine for minor physical defects; 56% routinely karyotype; 81% screen men of ethnic groups at risk for Tay Sachs disease, sickle cell disease and thalassemia; 19% screen all donors; 25% screen all donors for cystic fibrosis and 50% only screen if family history positive. Donor rejection was based on three criteria: mode of inheritance of familial disorder, severity of disease, and availability of carrier/confirmatory testing of donor genotype. Ten of 16 banks have no genetic professional on staff. CONCLUSION: Commercial semen banks primarily rely on family history as the major exclusion criterion in genetic screening of donors. Considerable differences exist among semen bank practices in accordance with guidelines published by national agencies. Genetic professionals have a minimal effect overall on evaluation of semen donors.

A practical approach to hirsutism.

Women often express concern about what they consider to be excess body or facial hair. This surplus of hair may be normal or it may signal hypertrichosis or hirsutism. Hirsutism may be idiopathic, secondary to increased responsiveness of hair follicles to normal circulating levels of androgens, or it may result from an excess of androgens, which may be exogenous, or of ovarian or adrenal origin. The evaluation of hirsutism must include the identification, or exclusion, of androgen-producing tumors, but other extensive evaluation is controversial. Treatment includes local measures, antiandrogenic therapy and treatment focused on the underlying source of excess androgen.

Attempting pregnancy after miscarriage and curettage--what is the minimum interval?

We describe a normal pregnancy that was conceived less than 3 weeks following curettage for a blighted ovum. A delay between curettage and subsequent pregnancy is often recommended. Evidence supporting such a delay is examined.

Absolute male factor infertility. A useful model for evaluating the efficacy of cryopreserved semen.

Cryopreserved semen generally results in diminished pregnancy rates when used for donor insemination. However, coexisting female subfecundity may significantly confound the pregnancy outcome. Therefore, in order to determine the efficacy of cryopreserved semen, 43 consecutive women with absolute male factor infertility (single women or wives of azoospermic men) were inseminated with cryopreserved spermatozoa using cervical caps. Life table analysis of the results revealed a cumulative probability of conception of 84% with a monthly fecundability rate of 19% after eight insemination cycles. These results are similar to those reported using fresh semen, suggesting that the efficacy of cryopreserved semen may be higher than previously believed.

The straw swim-up: a simple method to evaluate the effects of additives, media, or toxicants on sperm motility.

We describe a new method for evaluating potential toxicants, spermicides, and motility enhancers. Cryopreservation straws filled with media plus additive are emersed below the surface of an unprocessed donor ejaculate. After incubation, the sperm found within the first 4 cm of the straw are expelled and analyzed. The effects of media containing glycerol and albumin were examined. Survivability and sperm migration into the media occur independently and can be differentiated in this assay. This method allows for the use of unprocessed semen and includes an evaluation of the semen and media interaction.

Heterotopic pregnancy with discordant ultrasonic appearance of fetal cardiac activity.

In an interesting experiment of nature, we observed the discordant onset of fetal cardiac activity between the two gestations of a heterotopic pregnancy. After initially detecting cardiac activity only in the tubal gestational sac, we later observed cardiac activity in the intrauterine sac 6 days after laparoscopic salpingectomy. This case illustrates the variable onset of cardiac activity. We advise expectant management of the intrauterine pregnancy in a heterotopic gestation when cardiac activity is not detected initially in the intrauterine sac.

Luteal insufficiency: correlation between endometrial dating and integrated progesterone output in clomiphene citrate-induced cycles.

Midluteal phase endometrium was histologically dated with midcycle luteinizing hormone surge time in 29 cycles from 10 parous women during untreated cycles (control) and treatment with clomiphene citrate 50 mg and 150 mg daily on days 5 through 9. Integrated progesterone output for 7 days after luteinizing hormone surge calculated from the daily plasma progesterone levels was 66.6 +/- 9.8 ng/ml in the control group compared with 117.5 +/- 18.6 ng/ml for clomiphene citrate 50 mg treatment and 152.1 +/- 11 ng/ml for clomiphene citrate 150 mg treatment (p less than or equal to 0.05). Only one cycle (clomiphene citrate 150 mg) had an out-of-phase endometrium and a significantly reduced integrated progesterone output of 28 ng/ml. All other cycles showed synchronous endometrial maturation. We conclude that luteal insufficiency as a result of clomiphene citrate treatment in ovulatory women is infrequent and is more likely to be a result of functional outcome of a relative lack of luteal phase progesterone output.

Peri-implantation phase endometrial estrogen and progesterone receptors: effect of ovulation induction with clomiphene citrate.

The effects of clomiphene citrate on endometrial nuclear estradiol receptors and progesterone receptors were examined in 10 normal women during an untreated cycle (control) and during treatment with 50 mg clomiphene citrate and 150 mg clomiphene citrate daily on days 5 through 9. Concentrations and binding constants of the receptors were determined in endometrium obtained 8 to 12 days after midcycle luteinizing hormone surge. Scatchard plots for both estrogen receptors and progesterone receptors were linear, indicating only one type of high-affinity binding sites. In control cycles, estrogen receptor levels (mean +/- SEM) were 199.6 +/- 23.1 fmol/mg deoxyribonucleic acid, (n = 8) and were not significantly different from either 50 mg clomiphene citrate (180.5 +/- 19.1 fmol/mg deoxyribonucleic acid, n = 6) or 150 mg clomiphene citrate (194.3 +/- 35.2 fmol/mg deoxyribonucleic acid, n = 4). Similarly, the dissociation constants were unaffected by clomiphene citrate treatment. The concentrations of progesterone receptors in the control cycles (613 +/- 31 fmol/mg deoxyribonucleic acid, n = 5) and treatment cycles (50 mg clomiphene citrate -652.8 +/- 121 fmol/mg deoxyribonucleic acid, n = 6; 150 mg clomiphene citrate -592.6 +/- 31 fmol/mg deoxyribonucleic acid, n = 7) were also not significantly different. Clomiphene citrate also did not affect dissociation constants for progesterone receptors. Therefore, ovulation induction with clomiphene citrate apparently did not affect peri-implantation phase endometrial estrogen receptors and progesterone receptors or their respective binding constants.