Ovarian autoimmunity: greater frequency of autoantibodies in premature menopause and unexplained infertility than in the general population.

The objective of this study was to: (1) assess the relative prevalence of ovarian, thyroid, nuclear, and cardiolipin antibodies associated with premature menopause and unexplained infertility and (2) compare ovarian and thyroid antibodies in premature menopause, unexplained infertility, and the general population. Autoantibodies were evaluated in women with premature menopause (n = 30), unexplained infertility with (n = 38) or without (n = 15) prior gonadotropin-induced ovulation, and normal cycling controls (n = 12) and in a population of women obtained from a blood bank (n = 53). Antibodies to ovary (OVAB), thyroid (THYAB; thyroid peroxidase and thyroglobulin), cardiolipin, and eight nuclear antigens were assessed by enzyme immunoassay. Organ-specific antibodies (ovary and thyroid) were present with significantly greater frequency than non-organ-specific antibodies (nuclear and cardiolipin) in premature menopause and unexplained infertility (60% (50/83) vs 16% (13/83) respectively; P < 0.0001). OVAB (53%, 44/83) were significantly more frequent than THYAB (30%, 25/83) in premature menopause and unexplained infertility (P = 0.0030). THYAB did not differ among all groups (P = 0.78). In premature menopause and treated or untreated unexplained infertility OVAB frequencies were 53, 61, and 33%, respectively, and were significantly more frequent than in the population (17%) (P = 0.0001). In unexplained infertility, individuals with no prior gonadotropin-induced ovulation had a lower frequency of OVAB than treated individuals (P = 0.07). The frequency distribution of optical density values for OVAB was significantly higher for premature menopause and unexplained infertility than for population or normal cycling women (P < 0.0001). Thus, only ovarian antibodies were significantly more frequent than other antibody markers of autoimmunity in premature menopause and unexplained infertility.

The effect of the oviduct, uterine, and in vitro environments on zona thinning in the mouse embryo.

OBJECTIVE: To evaluate the impact of the oviduct, uterine, and in vitro environments on zona pellucida thinning in the mouse embryo. DESIGN: Female mice were stimulated with pregnant mare serum gonadotropin and mated and hCG injection. Unilateral oviduct ligation was performed on day 2 of gestation using the dorsal approach. The mice were divided into equal groups and killed on days 2, 3, 4, 5, and 10 of gestation. In vitro incubated embryos served as controls. Average daily zona thickness measurements were subjected to analysis of variance and paired Student's t-test. SETTING: The laboratory of the assisted reproductive program of Rush University Medical Center. MAIN OUTCOME MEASURE(S): Progressive daily decrease in average zona thickness. RESULT(S): Zona measurements of embryos flushed out of uterine horns, ligated oviducts, and in vitro incubation demonstrated statistically significant decreases in zona thickness, from 9.6 +/- 1.6 microns (day 3) to 6.0 +/- 0.8 microns (day 5), from 11.6 +/- 2.2 microns (day 2) to 6.0 +/- 1.6 microns (day 5), and from 11.1 +/- 2.0 microns (day 2) to 6.0 +/- 1.6 microns (day 5), respectively. There were no differences in average zona thickness for embryos in the same cell stage and same protocol day in all three locations. CONCLUSION(S): Zona thinning seems to be induced primarily by the dividing embryo before implantation. A substantial tubal and uterine contribution to zona thinning was not detected in this mouse embryo model.

Comparison of mouse embryo development in open and microdrop co-culture systems.

Co-culture with numerous cell lines has been shown to improve in-vitro embryo development. It is usually performed in open culture without an oil overlay, or in relatively large volumes of medium (e.g. 0.5 ml) under oil. We compared the efficacy of open and microdrop co-culture systems using human endometrial and tubal cell lines and mouse zygotes. Although the mean pH values of the media from the tubal cell cultures (both open and oil-covered) decreased significantly over 5 days of culture, this did not appear to impair embryo development. Both co-culture and microdrop culture significantly improved blastocyst and hatching blastocyst formation rates. The combination of the two techniques (microdrop and co-culture) demonstrated the highest blastocyst formation and hatching blastocyst formation rates, as well as the highest mean cell numbers in hatching blastocysts. Co-culture in a microdrop is a superior system for mouse embryo culture.

Optimizing tubal epithelial cell growth promotes mouse embryo hatching in coculture.

PURPOSE: This study investigates the relationship between human tubal epithelial cell growth characteristics and mouse embryonic development to determine which cellular requirements should be preferentially provided in a coculture system. METHODS: Cell growth and viability were assessed for 5 days in alpha-minimal essential medium or human tubal fluid supplemented with 10% human serum or 10% synthetic serum. Two-cell mouse embryo development to blastocyst and hatching blastocyst stages was also assessed with or without coculture. RESULTS: Both epithelial cell growth and embryo development were dependent on serum supplementation with better cell viability and growth rates in human serum and better blastocyst development in synthetic serum. The highest proportion of hatching blastocysts was found in alpha-minimal essential medium and human serum with coculture. CONCLUSIONS: Culture conditions which improve tubal epithelial cell growth also improve the hatching rate of mouse embryos in coculture. This indicates that by meeting the metabolic and nutritional demands for epithelial cell growth, the beneficial effects of coculture on embryo development may be optimized.

Sonographically monitored ovarian stimulation for assisted reproduction: a prospective, blind study.

OBJECTIVE: To assess prospectively the appropriateness of follicular sonography alone for monitoring ovarian stimulation and to compare it to ovarian monitoring with both follicular sonography and hormone level determinations. STUDY DESIGN: Prospective, blind, clinical study in which the investigator made cycle management decisions based on follicular sonography only. RESULTS: Follicular sonography alone predicted 88% of the decisions made by the combination of follicular sonography, luteinizing hormone (LH), estradiol (E2) and progesterone measurements. Follicular sonography was unable to predict abnormal E2 patterns in eight (8%) of the patients' scans. Follicular sonography did not detect three (3%) patients with a premature LH surge. CONCLUSION: Follicular sonograms alone performed during ovarian stimulation predicted 88% of cycle decisions. One could argue that hormone measurements could be either reduced or eliminated during ovarian stimulation for assisted reproductive technology and that follicular sonography only would be a cost-effective compromise. The effect of such simplified monitoring on pregnancy rates would require further prospective evaluation.

Luteal phase estradiol and pregnancy outcome in gonadotropin releasing hormone agonist/human menopausal gonadotropin-treated gamete intrafallopian transfer cycles.

To correlate luteal estradiol (E2) levels with pregnancy outcome, 36 consecutive conceptions resulting from gamete intrafallopian transfer in gonadotropin releasing hormone agonist/human menopausal gonadotropin (GnRH-a/hMG) cycles were analyzed. GnRH-a was initiated during the preceding luteal phase. HMG was adjusted individually. Human chorionic gonadotropin (hCG), 5,000 IU, was administered when E2 was > 500 pg/mL and the leading follicle > 17 mm (day 0). The luteal phase was supported by (1) hCG, 1,500 IU in three doses from day 5 and (2) progesterone (P) from day 7. E2 and P levels were analyzed in three groups of patients: normally progressing pregnancy (NPP), abortion (AB) and preclinical abortion (PAB). No significant differences in mean E2 levels were seen between the groups from day 0 through day 5 after hCG. Midluteal E2 levels were significantly different between the groups (P < .05). Late luteal E2 values were significantly higher for NPP than for either AB or PAB (P < .05). There were no significant differences in luteal P values between the NPP, AB and PAB groups. Decreased luteal E2 appears to be associated with early pregnancy wastage; this may be due to inadequate endometrial support.

Evaluation of co-culture and alternative culture systems for promoting in-vitro development of mouse embryos.

The goal of this study was to compare mouse embryo development in a defined synthetic medium (human tubal fluid) against the same medium supplemented with a defined synthetic serum (SS), co-culture on human tubal epithelium (TECC), and culture on human fibronectin (FN) with and without SS. After 48 h, TECC, SS and FN + SS cultures demonstrated accelerated development with > 70% achieving > or = 8-cell stage. After 72 h, these culture conditions also significantly increased the proportion of embryos reaching the blastocyst stage but only TECC significantly increased the number of hatching blastocysts. Nuclei of the trophectoderm of unhatched and hatched blastocysts were stained with propidium iodide before fixing and labelling both the trophectoderm and inner cell mass with bisbenzimide. Blastocysts from the TECC contained a significantly higher total cell number (TCN) and trophectoderm and inner cell mass cell numbers than all other groups. These findings indicate equivalent improvements in mouse embryo development to the blastocyst stage in response to TECC, SS and FN and an enhanced number of cells and rate of hatching found only with TECC.

Elevated follicular fluid angiotensin II and pregnancy outcome.

OBJECTIVE: To assess whether a relationship exists between follicular fluid (FF) angiotensin II (AII) concentration and pregnancy outcome or earlier fecundity parameters and whether correlations exist among FF AII concentrations and P, E2, T, androstenedione (A), or various ratios of these. DESIGN: Retrospective study in which hormone concentrations in FF samples were measured. SETTING: In vitro fertilization clinic-Assisted Reproductive Technology Program, Rush Medical Center. PATIENTS: Twenty-six female patients underwent ovarian stimulation for IVF. INTERVENTION: Leuprolide acetate was combined with hMG and FSH for ovarian stimulation. MAIN OUTCOME MEASURE: Follicular fluid aspirates were collected and oocytes were recovered 34 to 36 hours after hCG injection. The patients proceeded to undergo IVF and ET. Follicular fluid hormones were measured using standard RIA. Angiotensin II and steroid hormone concentrations in FF were compared for pregnant versus nonpregnant women using the Student's t-test and rank-sum test. Pearson multiple-correlation analysis was performed to calculate correlation coefficients among AII concentrations and steroid concentrations in FF aspirates. RESULTS: Mean FF concentration of AII was significantly lower in samples from women showing clinical pregnancies (112.2 +/- 13.9 pg/mL [107.3 +/- 13.3 pmol/L]) compared with samples from women who did not achieve pregnancy (217.1 +/- 23.8 pg/mL [207.5 +/- 22.7 pmol/L]) (mean +/- SE). A negative correlation was observed between FF concentrations of AII and P. Correlations of AII with E2, T, A, or with ratios of these did not show significance. CONCLUSION: These data suggest that high AII concentration at time of oocyte recovery may indicate poor pregnancy outcome in women undergoing ovarian stimulation for IVF. These data corroborate previous results in animal models showing that AII predisposes follicles to undergo atresia-like conditions.

Effects of induced hyperprolactinemia on in vitro fertilization cycles.

OBJECTIVE: To investigate the effect of induced endogenous hyperprolactinemia on the luteinization process, as expressed by the shift in the P:E2 ratio after hCG injection in IVF cycles. PATIENTS AND INTERVENTIONS: Serum PRL, E2, and P levels were measured in 49 IVF patients (leuprolide acetate and hMG protocol) on the day of hCG injection. Estradiol and P also were measured on the day after hCG. Serum P:E2 ratios were calculated for two groups of patients; group I (control): PRL < or = 20 ng/mL (conversion factor to SI unit, 1.00); group II (hyperprolactinemia): PRL > 20 ng/mL. Estradiol and P also were measured in follicular fluid (FF) and the gamete performance was compared between groups. RESULTS: Data analysis showed no significant differences in the mean +/- SD serum peak E2 (pg/mL; conversion factor to SI unit, 3.671) between groups: group I, 1,769 +/- 843; group II, 2,333 +/- 1,194; the mean FF E2 (pg/mL) group I, 351 +/- 221; group II, 370 +/- 186; or the mean FF P (ng/mL; conversion factor to SI unit, 3.180) group I, 8,357 +/- 3,127; group II, 11,354 +/- 12,888. No significant differences were found between groups in the P:E2 ratios on days 1 or 2: group I, 78 +/- 48 and 209 +/- 137; group II, 70 +/- 47 and 224 +/- 197, respectively. The magnitude of the P shift also showed no significant difference between the two groups; the mean +/- SD shift in the P level was 2.9 +/- 2.2 for group I, and 4.3 +/- 5.1 for group II. The serum PRL level had no effect on the fertilization rate (60% for group I and 70% for group II) or on the pregnancy rate (17% for group I and 23% for group II). CONCLUSION: These findings suggest that mild endogenous hyperprolactinemia induced by ovarian stimulation does not affect granulosa cell luteinization and gamete performance in humans.

The paternal inheritance of the centrosome, the cell's microtubule-organizing center, in humans, and the implications for infertility.

Successful fertilization in humans, achieved when parental chromosomes intermix at first mitosis, requires centrosome restoration and microtubule-mediated motility. Imaging of inseminated human oocytes reveals that the sperm introduces the centrosome. The centrosome then nucleates the new microtubule assembly to form the sperm aster--a step essential for successful fertilization. Oocytes from some infertile patients failed to complete fertilization because of defects in uniting the sperm and egg nuclei, indicating that failure to properly effect the cytoplasmic motions uniting the nuclei results in human infertility. These discoveries have important implications for infertility diagnosis and managing reproduction.

Preoperative serum CA-125 and CA-72 in predicting endometriosis in infertility patients.

CA-125, a high-molecular-weight glycoprotein antigen, has been identified as a possible marker for endometriosis, with discrepant results. CA-72, another glycoprotein antigen, is expressed by a variety of adenocarcinomas, including endometrial carcinoma. This controlled, prospective study evaluated serum CA-125 and CA-72 levels in 35 consecutive patients with endometriosis of varying stages and in patients without endometriosis. Serum CA-125 and CA-72 were measured with immunoradiologic methods prior to diagnostic laparoscopy for infertility evaluation. Endometriosis, scored by American Fertility Society guidelines, was identified in 19 patients, and 16 patients had normal pelvic findings. CA-125 and CA-72 levels were not different between patients with no pelvic disease (controls) and women with stage I-IV endometriosis. The positive predictive value of CA-125 was 0%; the negative predictive value was 47%. The positive predictive value of CA-72 was 5%; the negative predictive value was 53%. CA-72 and CA-125 are not helpful in the routine workup of the infertile woman to determine the likelihood that she has pelvic endometriosis.

Human chorionic gonadotropin levels in conception cycles after uterine and tubal embryo transfer.

OBJECTIVE: To describe the rate of rise of beta-hCG levels in normal single gestations after uterine and tubal embryo transfer. DESIGN: A prospective study from 1991 through 1992 in which infertility patients who conceived after ovulation induction and ET were monitored with serum beta-hCG levels. SETTING: Infertility unit at Rush-Presbyterian-St. Luke's Medical Center in Chicago, Illinois. PATIENTS: Ninety-eight women conceived after ovarian stimulation and ET. This study included only patients who conceived after uterine ET (n = 12) and tubal ET (n = 25) and had an exponential rise of beta-hCG levels and sonographic evidence of an intrauterine gestation. RESULTS: The rate of rise of mean beta-hCG levels after ET preceded that of tubal ET by 24 hours until day 14 when the two approximate each other. CONCLUSION: There appears to be a unique interaction between the trophoblast and endometrial surface that may account for the early detection of beta-hCG after uterine versus tubal ET.

Selective salpingography for the diagnosis and treatment of early tubal pregnancy.

OBJECTIVE: To determine whether selective salpingography can accurately diagnose and treat patients with early ectopic pregnancies (EPs). DESIGN: Prospective clinical case study. SETTING: Selective salpingography was performed in an outpatient setting under i.v. sedation. PATIENTS: Selective salpingography was performed in 10 women who had clinical presentation suggestive of EP, two consecutive abnormal hCG measurements < 2,000 mIU/mL, and inconclusive vaginal probe sonogram. INTERVENTION: Selective salpingography was performed under fluoroscopy. A cervical cannula was placed, and the tubal ostium was cannulated with a curved selective salpingography catheter (Bard Gynecology and Radiology, Covington, GA). Methotrexate (MTX) (25 or 50 mg) was injected into the affected tube through the selective salpingography catheter. MAIN OUTCOME MEASURE: The accuracy of selective salpingography in the diagnosis of early EP was determined by the rate of fluoroscopic imaging of an ampullary radiolucency upon injection of contrast material through the selective salpingography catheter. Resolution of the EP after injection of MTX into the tube was detected by serial declining hCG measurements. RESULTS: Selective injection of contrast material into the fallopian tubes detected seven ampullary pregnancies in 10 patients. Two patients demonstrated neither tubal pregnancy nor intrauterine pregnancy. One patient with apparent bilateral proximal cornual occlusions on selective salpingography underwent laparoscopy, followed by salpingostomy of an ampullary pregnancy. All 7 patients who received MTX through the selective salpingography catheter completely resolved the EP. Four patients demonstrated patent fallopian tubes on hysterosalpingograms performed 3 to 6 months later. CONCLUSION: Selective salpingography may diagnose early tubal pregnancies of some patients with equivocal clinical, laboratory, and sonographic findings. These patients can be successfully treated at the same time with a single dose of MTX delivered into the affected tube. Selective salpingography reduced the need for laparoscopy and operative intervention. Selective salpingography is a simple and relatively inexpensive diagnostic and therapeutic alternative in patients with suspected early tubal pregnancy.

Transvaginal ultrasonography and the assessment of luteal phase endometrium.

OBJECTIVE: The goal of this study was to determine if ultrasonography of the endometrium could be used to identify in a noninvasive manner patients with luteal phase defects. STUDY DESIGN: Patients underwent midluteal transvaginal ultrasonography with photographing of the endometrial image, an endometrial biopsy, and two serum hormonal profiles. The ultrasonographic images were graded and compared with the histologic results and the serum hormonal profiles. RESULTS: There was a trend toward a higher grade image being associated with normal histologic studies. There was no significant difference between the mean hormonal profiles in patients with normal and those with abnormal biopsy specimens. There was no significant difference between the hormonal values drawn before and those drawn after the biopsies. CONCLUSIONS: Although the endometrial appearance on ultrasonography appears to reflect secretory transformation, it cannot replace endometrial biopsy for full evaluation of luteal endometrial development. Short-term variability in serum concentrations of midluteal hormones was not demonstrated.

Hormonal profiles of early gestations with abnormal karyotype.

OBJECTIVE: To describe the hormonal profiles of chromosomally abnormal pregnancies during the first trimester. DESIGN: A prospective study from 1984 through 1990 in which infertility patients who conceived were monitored weekly with serum E2, P, and beta-hCG levels. SETTING: The infertility practice at Rush-Presbyterian-St. Luke's Medical Center in Chicago, Illinois. PATIENTS: Study included 15 women who had dilatation and curettage for first trimester fetal losses with confirmed abnormal karyotype, 6 women with chromosomally normal male abortuses, and 60 consecutive women whose pregnancies yielded normal term infants. RESULTS: After natural conception, E2 demonstrated a moderate rise in both normal and chromosomally abnormal pregnancies to approximately 300 pg/mL by day 29 (6 weeks of gestation). In normal gestations, E2 continued a steady increase to exceed the level of 1,000 pg/mL by day 64 (11 weeks of gestation). In chromosomally abnormal pregnancies, the mean E2 plateaued and remained at approximately 200 pg/mL until fetal demise was noted. In stimulated conceptions, the rise of E2 was sharp and early (1,200 pg/mL by day 29); in normal pregnancies, E2 steadily increased to an average of 1,400 pg/mL by the end of the first trimester, whereas in karyotypically abnormal gestations, E2 declined to approximately 200 pg/mL by day 64. In pregnancies yielding a male abortus, a sharp decline and plateau at 800 pg/mL by day 56 (10 weeks of gestation) was observed. In both natural and stimulated normal pregnancies, hCG levels first demonstrated a linear rise, followed by a curvilinear increase from day 29 until day 56, with a peak of approximately 110,000 mIU/mL. The beta-hCG in chromosomally abnormal pregnancies, as well as in pregnancies yielding a male abortus, was characterized by a slow and gradual rise to a maximum of 40,000 mIU/mL, which remained relatively linear until day 64 when fetal demise was detected in all cases. Progesterone level data were excluded from analysis because of frequent P supplementation. CONCLUSIONS: There were significant differences in the hormonal profiles of chromosomally normal and abnormal pregnancies. Serial measurements of serum E2 and beta-hCG from the 6th week of gestation may be useful in predicting an abnormal karyotype sooner than other current diagnostic tests.

Acrosin activity in human spermatozoa in relation to semen quality and in-vitro fertilization.

Acrosin, a sperm proteinase released during acrosomal exocytosis, facilitates penetration through the oocyte vestments. The purpose of this investigation was to determine if a correlation exists between the acrosin activity of ejaculated human spermatozoa, before motility enrichment techniques, and in-vitro fertilization (IVF) success using selected (glass wool or swim-up) spermatozoa. Since all the oocytes were retrieved from women receiving exogenous hormonal stimulation and a mixed population of mature and immature oocytes were encountered, only cases with > or = 50% mature oocytes were analysed. Under these conditions, the acrosin activity was significantly greater (P < 0.01) in the ejaculates in which spermatozoa ultimately fertilized > or = 70% of the mature oocytes, than in the ejaculates in which spermatozoa ultimately fertilized < 70% of the mature oocytes. Furthermore, a strong correlation (r = 0.962, P = 0.0001) was detected between pre-IVF acrosin activity and subsequent high (> or = 70%) IVF success. Acrosin activity from normozoospermic and oligo-asthenozoospermic men was also compared and was significantly (P < 0.01) higher for the normozoospermic group. These data suggest that measurement of acrosin activity may be a valuable clinical laboratory assay for assessing the sperm fertilizing potential and that low acrosin activity is associated with abnormal semen characteristics.

Human chorionic gonadotropin rise in normal and vanishing twin pregnancies.

OBJECTIVE: The purpose of the study was to describe and to compare the rate of rise of human chorionic gonadotropin (hCG) in vanishing twin and normally progressing twin pregnancies during the first trimester. DESIGN: All patients with twin pregnancies between 1985 and 1989 were prospectively studied. Human chorionic gonadotropin was measured one to three times per week between days 12 and 52 after luteinizing hormone (LH) surge or day of hCG administration (day 0). Pelvic ultrasound (US) was performed weekly beginning on day 24. SETTING: The study was performed at Rush-Presbyterian-St. Luke's Medical Center in an academic private practice setting of the Section of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology. PATIENTS: Forty patients who conceived after treatment of infertility and who had two gestational sacs on US examination were included in the study after the following criteria were met: (1) both sacs progressed to exhibit a fetal pole and (2) day of LH surge and/or day of hCG administration was known. MAIN OUTCOME MEASURE: The rate of rise of hCG was slower in vanishing twin pregnancies than in normally progressing twin gestations for the entire time period studied (P less than 0.05). RESULTS: A vanishing twin occurred in one third of the twin pregnancies. Forty-six percent of these losses occurred after fetal heart activity had been established. CONCLUSIONS: Vanishing twin phenomenon occurred in a large proportion of twin pregnancies in this infertility population. Fetal heart activity was not a reliable predictor of continuing fetal viability in early twin gestations. Vanishing twin conceptions were characterized by a slower rate of rise of hCG than normally progressing twin pregnancies.

Delayed ovarian response in oligomenorrheic women using gonadotropin-releasing hormone agonist.

Ovarian response to human menopausal gonadotropins (hMG) was studied in the presence or absence of prior ovarian suppression using gonadotropin-releasing hormone agonist in the same oligomenorrheic women. Delayed response, with higher hMG requirements, was observed in cycles with prior ovarian suppression.

Progesterone:estradiol ratios at implantation in ongoing pregnancies, abortions, and nonconception cycles resulting from ovulation induction.

UNLABELLED: The purpose of this study was to compare progesterone (P):estradiol (E2) ratios after ovulation induction at the time of implantation in cycles resulting in ongoing pregnancies or abortions and in nonconception cycles. Material included 43 stimulated conception cycles, 29 with human menopausal gonadotropins (hMG) and human chorionic gonadotropins (hCG), 14 with clomiphene citrate (CC) with or without hCG, and 28 nonconception cycles (13 hMG and hCG, 15 CC with or without hCG). Midluteal P and E2 were measured and expressed in ng/mL. There were no differences in P:E2 ratios (mean +/- SE) for ongoing pregnancies after hMG and hCG (n = 20, 112.6 +/- 14.9), CC and hCG (n = 6, 97.0 +/- 15.9), or CC alone (n = 5, 96.2 +/- 25.5), and the data were pooled. Progesterone:estradiol ratios in 31 ongoing pregnancies and 28 nonconception cycles were 107.0 +/- 10.7 and 115.2 +/- 12.5, respectively, both significantly higher than in 12 abortions (64.5 +/- 13.2). IN CONCLUSION: (1) P:E2 ratios at the time of implantation were similar after CC with or without hCG and hMG and hCG treatment; (2) high luteal P:E2 ratio was associated with ongoing pregnancies; and (3) lower P:E2 ratio was seen in cycles leading to spontaneous abortion.