Antral follicle assessment as a tool for predicting outcome in IVF--is it a better predictor than age and FSH?

PURPOSE: The purpose of this study is to determine if baseline antral follicle assessment may serve as additional information in predicting in vitro fertilization outcome. METHODS: Prospective, descriptive preliminary study of in vitro fertilization outcome. From July 1998 to July 1999, 224 patients underwent antral follicle assessment (follicle 2-6 mm in diameter) on baseline of the planned, stimulated in vitro fertilization cycle. The outcomes were analyzed with respect to antral follicle assessment (< or = 6 or > 6), basal cycle day 3 follicle stimulated hormone (< or = 10 or > 10 IU/L) and maternal age (< or = 35 or > 35 years). RESULTS: The clinical pregnancy rate was significantly higher in the group with baseline antral follicle > 6 compared to that in the group with antral follicle < or = 6 (51% vs. 19%, respectively). Controlling for patient age, and basal follicle stimulated hormone, the pregnancy rate was significantly higher in the group with antral follicle > 6 compared to that in the group with antral follicle < or = 6. The cancellation rate was significantly increased with advancing maternal age, elevated basal follicle stimulated hormone levels, and baseline antral follicle < or = 6. The cancellation rate was significantly higher in the group with antral follicle < or = 6 compared to that in the group with antral follicle > or = 6 (33% vs. 1%, respectively). CONCLUSIONS: In vitro fertilization outcome is strongly correlated with both maternal ages, basal cycle, day 3 follicle, stimulated hormone, and antral follicle assessment. Antral follicle assessment was a better predictor of in vitro fertilization outcome than were age or follicle stimulated hormone. Antral follicle assessment may provide a marker for ovarian age that is distinct from chronological age or hormonal markers.

Preliminary observations on differing psychological effects of conjugated and esterified estrogen treatments.

During a double-blind comparison of menopausal replacement therapy with estrogen alone compared with estrogen plus methyltestosterone (meT), subjects who had been on conjugated equine estrogen (CEE) said they felt better when placed on esterified estrogen (EE). We, therefore, tested whether these estrogen treatments differed in their neuropsychological effects. Subjects were 34 healthy menopausal respondents to advertisements younger than age 66 who were on CEE at baseline. Each was randomized into the EE condition, either immediately after baseline or after they first took EE plus added meT for 8 weeks. We compared neuropsychological measures between these two conditions. Data included cognitive performance test results and symptom self-ratings. Multivariate techniques were used to adjust for the effects of treatment order. Compared with prior CEE treatment, EE treatment was associated with significantly improved scores on the Zung Self-Rated Depression Scale and on Switching Attention Test performance. Further investigation is warranted to determine if different forms of estrogen replacement induce different neuropsychological effects.

Ovarian steroid and cytokine modulation of human endometrial angiogenesis.

A key mechanism underlying the cyclical growth of the endometrium is its ability to regenerate a vascular capillary network. In normal cycling human endometrium, angiogenesis is influenced by both endocrine and paracrine factors. Hormonal manipulation of the endometrium, such as that occurring during the use of steroidal contraception, appears to result in capillary proliferation and fragility. As a consequence of these vascular changes, contraceptive users may be predisposed to unpredictable uterine bleeding, which is responsible for the high frequency of contraceptive discontinuation. In this paper we address mechanisms responsible for vascular endothelial cell proliferation in normal and contraceptive steroid-exposed endometria. We propose that regulation of endometrial angiogenesis is mediated indirectly, via steroid and cytokine actions on vascular endothelial growth factor (VEGF), and we present data indicating that VEGF expression in normal endometrial stromal cells is increased by oestrogens and progestins. Three proinflammatory cytokines with angiogenic effects in other systems (i.e. interleukin-1beta, tumour necrosis factor-alpha and interferon-gamma) do not appear to up-regulate VEGF expression in normal endometrial stromal cells. Well-characterized in-vitro models in conjunction with immunohistochemistry provide useful experimental systems to study endometrial neovascularization under physiological conditions and in those potentially perturbed via the use of contraceptive steroids.

Transdermal testosterone treatment in women with impaired sexual function after oophorectomy.

BACKGROUND: The ovaries provide approximately half the circulating testosterone in premenopausal women. After bilateral oophorectomy, many women report impaired sexual functioning despite estrogen replacement. We evaluated the effects of transdermal testosterone in women who had impaired sexual function after surgically induced menopause. METHODS: Seventy-five women, 31 to 56 years old, who had undergone oophorectomy and hysterectomy received conjugated equine estrogens (at least 0.625 mg per day orally) and, in random order, placebo, 150 microg of testosterone, and 300 microg of testosterone per day transdermally for 12 weeks each. Outcome measures included scores on the Brief Index of Sexual Functioning for Women, the Psychological General Well-Being Index, and a sexual-function diary completed over the telephone. RESULTS: The mean (+/-SD) serum free testosterone concentration increased from 1.2+/-0.8 pg per milliliter (4.2+/-2.8 pmol per liter) during placebo treatment to 3.9+/-2.4 pg per milliliter (13.5+/-8.3 pmol per liter) and 5.9+/-4.8 pg per milliliter (20.5+/-16.6 pmol per liter) during treatment with 150 and 300 microg of testosterone per day, respectively (normal range, 1.3 to 6.8 pg per milliliter [4.5 to 23.6 pmol per liter]). Despite an appreciable placebo response, the higher testosterone dose resulted in further increases in scores for frequency of sexual activity and pleasure-orgasm in the Brief index of Sexual Functioning for Women (P=0.03 for both comparisons with placebo). At the higher dose the percentages of women who had sexual fantasies, masturbated, or engaged in sexual intercourse at least once a week increased two to three times from base line. The positive-well-being, depressed-mood, and composite scores of the Psychological General Well-Being Index also improved at the higher dose (P=0.04, P=0.03, and P=0.04, respectively, for the comparison with placebo), but the scores on the telephone-based diary did not increase significantly. CONCLUSIONS: In women who have undergone oophorectomy and hysterectomy, transdermal testosterone improves sexual function and psychological well-being.

The aging ovary.

During reproductive life, ovarian steroid biosynthesis is gonadotropin dependent and occurs in theca and granulosa cells. In the menopausal ovary, there is atresia of ovarian follicles, with sparing of the androgen-producing theca-interstitial cell component. The aging ovary, therefore, produces significantly reduced amounts of estrogen, with continued, though decreased, androgen production. After menopause, ovarian estradiol biosynthesis is minimal, with circulating estrogen being derived principally from peripheral aromatization of ovarian and adrenal androgens. Androgen biosynthesis from the adrenal gland, in addition to that from the ovary, decreases with age. Although ovarian androgen production declines with age, there is not an abrupt decrease as is seen with ovarian estrogen levels at the time of menopause. The biological activity of these steroids, either before or after menopause, depends on the amount of steroid available in the unbound fraction. To this end, sex hormone-binding globulin (SHBG) levels are an important determinant of hormone action. Not only does the concentration of SHBG influence the biological effect of testosterone and estradiol, but these steroids also regulate SHBG concentrations.

Effect of a baseline ovarian cyst on the outcome of in vitro fertilization-embryo transfer.

OBJECTIVE: To determine the significance of prestimulation ovarian cysts on the response to controlled ovarian hyperstimulation and the outcome of IVF. DESIGN: Retrospective study. SETTING: In vitro fertilization unit in an academic center. PATIENT(S): One hundred thirty-seven patients undergoing IVF. INTERVENTION(S): The outcome of 71 patients who had an ovarian cyst of >10 mm detected at ultrasound examination performed on day 3 was compared with that of 66 patients who underwent a similar protocol and did not have an ovarian cyst. MAIN OUTCOME MEASURE(S): Parameters evaluated were the E2 level on the day of hCG administration, the number of follicles, the number of oocytes retrieved, the number of embryos transferred, and the pregnancy rate. RESULT(S): The E2 level on the day of hCG administration and the number of mature oocytes retrieved were lower in the group with a baseline cyst. The pregnancy rate also was significantly lower in the group with a cyst (24% versus 41%). The presence of a baseline ovarian cyst decreases the odds of pregnancy 0.37-fold (95% confidence interval, 0.16-0.87). CONCLUSION(S): A baseline ovarian cyst on cycle day 3 was associated with a poorer outcome after IVF-ET.

Vectorial secretion of vascular endothelial growth factor by polarized human endometrial epithelial cells.

OBJECTIVE: To analyze directional vascular endothelial growth factor (VEGF) secretion in polarized human endometrial epithelial cell cultures. VEGF has distinct distribution patterns in human endometrium. Stromal cells are diffusely positive for VEGF messenger RNA and protein, whereas glandular epithelium shows focal VEGF immunostaining at the apical surface. The epithelial distribution suggests that VEGF is secreted into gland lumina, potentially influencing the nutrition and/or apposition of the developing blastocyst. DESIGN: Controlled in vitro study of protein secretion by polarized endometrial epithelial cells established on polyethylene filters. SETTING: University hospital. PATIENT(S): Endometrial biopsies were obtained from healthy, ovulatory women undergoing elective surgery. INTERVENTION(S): Primary endometrial epithelial cells were cultured. MAIN OUTCOME MEASURE(S): VEGF mRNA and protein production were measured in polarized cells. The vectorial secretion of VEGF was determined. RESULT(S): VEGF production by endometrial epithelial cells was verified by Northern blotting and immunoassays of conditioned media. The mean (+/-SD) apical secretion of VEGF was 3.9 +/- 1.4 ng per 10(5) cells every 48 hours and the mean (+/-SD) basal secretion was 0.8 +/- 0.2 ng per 10(5) cells every 48 hours. In contrast, the apical and basal secretion of a soluble cellular isoform of fibronectin were 2.76 +/- 0.96 ng per 10(5) cells every 48 hours and 2.64 +/- 1.79 ng per 10(5) cells every 48 hours, respectively. CONCLUSION(S): VEGF is secreted preferentially into the lumina of endometrial glands. Apical VEGF may be an endometrial signal for blastocyst development or implantation.

Corticotropin regulates vascular endothelial growth factor expression in human fetal adrenal cortical cells.

The human adrenal cortex has a complex vasculature that is essential for growth, organ maintenance, and access of secreted hormones to the circulation. Growth and function of the adrenal cortex are regulated by corticotropin (ACTH), the actions of which are in part mediated by locally produced growth factors. As cortical growth and vascularization must increase in a coordinated manner, we hypothesized that ACTH also influences adrenal cortical angiogenesis by stimulating the local expression of specific angiogenic factors. Vascular endothelial growth factor (VEGF) is a potent endothelial cell-specific angiogenic peptide, the expression of which has been detected in adrenal cortical cells. Therefore, we examined the localization of VEGF expression in the midgestation (16-20 weeks) human fetal adrenal cortex and determined whether VEGF expression and secretion by isolated human fetal adrenal cortical cells are regulated by ACTH. By immunohistochemical analysis, strong cytoplasmic staining for VEGF was detected in scattered clusters of fetal zone (inner cortical compartment) cells. In contrast, cells in the outer, definitive zone of the cortex stained only weakly for VEGF. The predominant staining for VEGF in the fetal zone correlated with the extensive vasculature of this zone as detected by immunohistochemical staining for von Willebrand factor, which is specific for endothelial cells. In primary cultures of human fetal adrenal cortical cells, ACTH (1 nmol/L) and forskolin (10 micromol/L) increased the abundance of messenger ribonucleic acid transcripts encoding VEGF, as assessed by Northern and slot blot analyses. The stimulatory effect of ACTH and forskolin on VEGF gene expression occurred within 2 h of agonist exposure and persisted for at least 24 h. ACTH and forskolin also increased VEGF protein secretion by fetal adrenal cortical cells, as assessed by enzyme-linked immunosorbent assay for VEGF in fetal adrenal cortical cell-conditioned medium. A significant (P < 0.05) increase in VEGF secretion was detected as early as 8 h after ACTH or forskolin treatment. By 24 h after the addition of ACTH or forskolin, VEGF secreted from isolated human fetal adrenal cells was increased 5- to 6-fold. These data demonstrate that the human fetal adrenal cortex, particularly the cells of the inner fetal zone, express VEGF and that VEGF expression and secretion by these cells are directly regulated by ACTH and the activation of adenylate cyclase. Thus, VEGF may be a local regulator of adrenal cortical angiogenesis and an important mediator of the tropic action of ACTH, ensuring the coordination of ACTH-stimulated cortical growth and vascularization.

Impact of varying stages of endometriosis on the outcome of in vitro fertilization-embryo transfer.

PURPOSE: The impact of severity of endometriosis on the outcome of in vitro fertilization (IVF) was analyzed in an uncontrolled, retrospective study in an academic IVF program. METHODS: Sixty-one patients with a primary diagnosis of endometriosis undergoing 85 cycles of IVF were included in the study. Patients were divided according to the severity of disease based on the revised American Fertility Society (AFS) classification into groups A (stages I/II, or minimal/ mild) and B (stages III/IV, or moderate/severe). Group A included 32 patients undergoing 45 IVF-embryo transfer (ET) cycles; group B included 29 patients undergoing 40 IVF cycles. Exclusion criteria were age older than 40 years, basal day 3 follicle stimulating hormone (FSH) greater than 20 IU/L, male-factor infertility, assisted hatching, and gamete intrafallopian transfer cases. Stimulation for IVF cycles was standard using pituitary down-regulation with gonadotropin-releasing hormone agonist in a midluteal protocol. Controlled ovarian hyperstimulation (COH) was achieved using a combination of FSH and human menopausal gonadotropin. Outcomes assessed included response to COH and number, maturity, and quality of oocytes retrieved. Fertilization, implantation, and pregnancy rates after IVF-ET were also analyzed. RESULTS: The response to COH and the number, maturity, and quality of the oocytes was comparable between patients with varying severity of endometriosis. Fertilization rates for oocytes of patients in group B (stages III/IV) were significantly impaired compared to those in group A (stages I/II) (P = 0.004). The rates for implantation, clinical pregnancy, and miscarriage were comparable between the two groups. CONCLUSIONS: The reduced fertilization potential of the oocytes obtained from patients with severe endometriosis in the absence of male-factor infertility suggests an adverse biological impact of the advanced disease on the oocytes. The outcome of IVF-ET, however, is unaffected by increasing severity of endometriosis. This suggests that IVF may compensate for or overcome this reduction in the biological potential of the oocytes associated with severe disease, thus accounting for a comparable outcome irrespective of the severity of endometriosis.

Outcome of IVF in DES-exposed daughters: experience in the 90s.

PURPOSE: The outcome of in vitro fertilization (IVF) in a group of infertile women with a history of in utero exposure to diethylstilbestrol (DES) was analyzed. Records from an academic IVF program were retrospectively reviewed. METHODS: Seventeen infertile women with a self-reported history of exposure to DES in utero, attending the IVF unit at Massachusetts General Hospital (MGH) for assisted reproductive technology (ART), underwent 27 IVF cycles. Analysis of the outcome of IVF including implantation and ongoing pregnancy rates was performed. The data were compared with results from a group of 20 infertile patients with idiopathic infertility undergoing 27 IVF cycles at MGH during the same period. The patients in the two groups were matched for age, basal day 3 levels of follicle stimulating hormone and serum estradiol, and the number and quality of embryos transferred. RESULTS: The response to controlled ovarian hyperstimulation was comparable in the two groups. Significantly lower implantation and ongoing pregnancy rates following IVF and embryo transfer were seen in the utero DES-exposed group compared to the control patients. CONCLUSIONS: Infertile patients with a history of in utero exposure to DES exhibit a significantly impaired implantation rate following IVF, and the outcome of ART remains poor.

Angiogenesis and macrophage activation in endometriosis.

Recent studies suggest that the symptoms associated with endometriosis are the result of local peritoneal inflammation. Increased concentrations of activated pelvic macrophages and lymphocytes and the elevated levels of specific cytokines and growth factors reviewed above support this hypothesis. The precise roles of these soluble factors are currently unknown, but we propose that a complex network of endometrial cytokines are normally regulated by hormones produced during the ovulatory cycle. Ectopic endometrial implants also are subject to these same endocrine cues. The secretion of these proinflammatory proteins by endometriosis lesions into the peritoneal microenvironment appears to cause a recruitment of capillaries and activated inflammatory cells to the implant. Future therapeutic strategies directed to ameliorate the inflammatory reaction associated with endometriosis should not ignore the likely physiological actions of many of the same bioactive molecules in normal eutopic endometrial function.

Differential expression of members of the bcl-2 gene family in proliferative and secretory human endometrium: glandular epithelial cell apoptosis is associated with increased expression of bax.

Glandular epithelial cells of the human endometrium initiate apoptosis in the secretory phase of the cycle. To better understand the regulation of apoptosis in this paradigm of endocrine-regulated cell turnover, we studied the expression of the cell death regulatory genes, bax, bcl-2, and bcl-x, in human proliferative and secretory endometria relative to the absence or presence of apoptosis. As assessed by immunohistochemistry, levels of BAX protein were modest in proliferative endometrium and increased dramatically in the secretory phase when apoptosis was most prevalent. Expression of BAX was predominantly localized to epithelial cells of the functionalis layer of the secretory endometrium. In contrast, BCL-2 immunoreactivity was maximal during the proliferative phase and decreased in the secretory phase. Moreover, BCL-2 was topographically concentrated in the basalis layer. Immunoreactive BCL-X protein was observed mostly in glandular epithelial cells of the human endometrium. Compared with proliferative endometrium, secretory endometrium showed stronger BCL-X staining, especially in the functionalis layer. By Western blotting we confirmed that both proliferative and secretory endometrium expressed the long or antiapoptosis form as well as the short or proapoptosis form of the BCL-X protein. Taken together, our results demonstrate a coordinated pattern of expression of bcl-2 gene family members in human endometrium during the menstrual cycle, with a shift toward greater levels of the proapoptosis protein, BAX, occurring in glandular epithelial cells during the secretory phase of the cycle. Therefore, we conclude that cyclic changes in endometrial growth and regression may be precisely regulated by shifts in the ratio or balance of BCL-2 and related proteins in glandular epithelial cells.

Ovarian steroid regulation of vascular endothelial growth factor in the human endometrium: implications for angiogenesis during the menstrual cycle and in the pathogenesis of endometriosis.

The human endometrium undergoes a complex process of vascular and glandular proliferation, differentiation, and regeneration with each menstrual cycle in preparation for implantation. Vascular endothelial growth factor (VEGF) is an endothelial cell-specific angiogenic protein that appears to play an important role in both physiological and pathological neovascularization. To investigate whether VEGF may regulate human endometrial angiogenesis, we examined VEGF messenger ribonucleic acid (mRNA) and protein throughout the menstrual cycle and studied the regulation of VEGF by reproductive steroids in isolated human endometrial cells. By ribonuclease protection analysis, VEGF mRNA increased relative to early proliferative phase expression by 1.6-,2.0-, and 3.6-fold in midproliferative, late proliferative, and secretory endometrium, respectively. In histological sections, VEGF mRNA and protein were localized focally in glandular epithelial cells and more diffusely in surrounding stroma, with greatest VEGF expression in secretory endometrium. Consistent with these in vivo results, the treatment of isolated human endometrial cells with estradiol (E2), medroxyprogesterone acetate (MPA), or E2 plus MPA significantly increased VEGF mRNA expression over the control value by 3.1-, 2.8-, and 4.7-fold, respectively. The VEGF response to E2 was rapid, with steady state levels of VEGF mRNA reaching 85% maximum 1 h after the addition of steroid. E2 also caused a 46% increase in secreted VEGF protein, and the combination of E2 and MPA caused an 18% increase. VEGF expression in endometriosis, an angiogenesis-dependent, estrogen-sensitive disease was similar to that seen in eutopic endometrium. Peritoneal fluid concentrations of VEGF were significantly higher in women with moderate to severe endometriosis than in women with minimal to mild endometriosis or no disease. VEGF, therefore, may be important in both physiological and pathological angiogenesis of human endometrium, as it is an estrogen-responsive angiogenic factor that varies throughout the menstrual cycle and is elevated in women with endometriosis.

In the human fetus, vascular endothelial growth factor is expressed in epithelial cells and myocytes, but not vascular endothelium: implications for mode of action.

Vascular endothelial growth factor (VEGF) is potentially an important regulator of angiogenesis, particularly during the extensive tissue growth and remodeling that occur in utero. In the present study, we have investigated the role of VEGF during human fetal development by analyzing the distribution of VEGF messenger RNA as well as the tissue- and cell-specific localization of VEGF peptide in the human midgestation (16-22 weeks) fetus. As a comparison, we conducted parallel studies on several human adult tissues. Messenger RNA encoding VEGF was detected in all fetal tissues studied and was most abundant in human fetal lung, kidney, and spleen; moderately abundant in heart, adrenal, pancreas, intestine, liver, testis, skin, muscle, and brain; and minimally detected in thymus and placenta. VEGF peptide, detected by immunohistochemistry, always was intracytoplasmic and localized principally in epithelial cells and myocytes, including the smooth muscle cells lining blood vessels. VEGF was not detected in vascular endothelial cells. As the cellular localization of VEGF in several human adult tissues was similar to that found in the cognate fetal tissues, VEGF is probably important not only in angiogenesis, but also in the maintenance of existing vessels. As VEGF was localized primarily in epithelial cells and myocytes and not in endothelial cells, these data are consistent with a paracrine mechanism of action whereby VEGF secreted by nonendothelial cells modulates activities in adjacent vascular endothelium.

Human fetal ovaries and uteri: developmental expression of genes encoding the insulin, insulin-like growth factor I, and insulin-like growth factor II receptors.

OBJECTIVE: To study the messenger ribonucleic acid (mRNA) expression of receptors for insulin, insulin-like growth factor I (IGF-I), and insulin-like growth factor II (IGF-II) in human fetal ovaries and uteri at 10, 15, 19, and 22 weeks' gestation. Insulin, IGF-I, and IGF-II are postulated to have paracrine and autocrine functions in the development of fetal tissues, but receptors for these growth factors have never been studied in reproductive organs of the human female fetus. DESIGN: Ribonucleic acid extracted from human fetal reproductive tissues underwent reverse transcription and polymerase chain reaction (PCR) amplification. The amplified complementary deoxyribonucleic acid (cDNA) fragments were analyzed by gel electrophoresis and restriction enzyme mapping. RESULTS: Messenger RNA expression consistent with both known forms of the insulin receptor, the IGF-I receptor, and the IGF-II receptor was observed in human fetal ovaries and uteri at 10, 15, 19, and 22 weeks' gestation. The identity of the PCR amplified ovarian and uterine DNA fragments were confirmed by digestion with the restriction endonucleases AvaII, DdeI, and BamHI, respectively. CONCLUSIONS: This study demonstrates that mRNA for receptors for insulin, IGF-I, and IGF-II are expressed in the fetal human female genital tract. These receptors may have roles in fetal reproductive tract development.

Asystolic cardiac arrest: a rare complication of laparoscopy.

A healthy young woman suffered cardiac arrest during diagnostic laparoscopy; emergent laparotomy was required to release the pneumoperitoneum and reinitiate cardiac rhythm. Several cases of cardiovascular collapse have been described in the literature. Possible causes for such complications include hypercapnia or anoxia from hypoventilation during anesthesia, decreased venous return and cardiac output secondary to elevated intra-abdominal pressure, gas embolism, and a profound vagal response to peritoneal distention. Treatment includes cardiovascular support and rapid release of the pneumoperitoneum.

Placenta membranacea with placenta increta: a case report and literature review.

The pregnancy of a patient with placenta membranacea associated with placenta increta and a live-born infant is described, and the literature covering placenta membranacea is reviewed. A total of 26 cases of placenta membranacea in the second and third trimesters have been reported. The condition appears to have an incidence of 1:20,000-40,000, and there have been 14 reported live births associated with this rare placental anomaly. Antepartum and postpartum hemorrhage were reported to complicate 83 and 50% of the cases, respectively. Approximately 30% of the cases involved some form of abnormal placental adherence.