The treatment of infertility associated with endometriosis by in vitro fertilization.

In vitro fertilization and embryo transfer (IVF-ET) was performed on women with tubal disease only (28 women, 40 cycles), endometriosis grade I (15 women, 24 cycles), grade II (25 women, 37 cycles), grade III (26 women, 36 cycles), or grade IV (31 women, 52 cycles). Rates of oocyte recovery and fertilization were not affected by the presence of endometriosis. Pregnancy rates per cycle were similar to that of the tubal group (18%) for women with grade I (13%) or grade II (14%) endometriosis, lower in women with grade III endometriosis (6%) and significantly reduced in women with grade IV (2%, P less than 0.05).

The use of biosynthetic human growth hormone to augment ovulation induction with buserelin acetate/human menopausal gonadotropin in women with a poor ovarian response.

The present study has demonstrated the usefulness of GH in augmenting buserelin acetate/hMG to stimulate the rate of growth of follicles in women regarded as poor responders. The PR achieved was extremely encouraging in a group of patients whose prognosis was otherwise poor. Further studies are required to confirm these preliminary data.

Hormonal profiles and embryo quality in women with severe endometriosis treated by in vitro fertilization and embryo transfer.

A study was undertaken comparing the outcomes of 30 women with infertility due to untreated severe (grade IV) pelvic endometriosis with a comparable series of 28 women whose infertility was caused solely by irreversible tubal disease. There were no significant differences in either the follicular phase or luteal phase hormonal profiles of estradiol and progesterone, but there was a significantly reduced pregnancy rate in those women with severe endometriosis. In part, this was due to the recovery of fewer oocytes from the endometriosis patients (P less than 0.001) despite the fact that the peak estradiol levels and ovarian accessibility were similar in the two groups. However, there were no significant differences in the proportion of oocytes that fertilized or the number that demonstrated normal embryo growth and high-grade embryo quality. There also appears to be an implantation inhibitory factor in patients with severe endometriosis as the pregnancy rate/embryo transferred and number of gestational sacs identified/embryo transferred were significantly reduced (P less than 0.05).

The in vitro fertilization of supernumerary oocytes in a gamete intrafallopian transfer program.

Gamete intrafallopian transfer (GIFT) was performed on a series of 42 couples in whom four oocytes were replaced into the fallopian tubes and the remaining oocytes were inseminated with 100,000 motile spermatozoa. Fertilization in vitro was assessed 16 to 20 hours later. An overall pregnancy rate after GIFT of 40.0% (12/30) in normospermic couples and 16.7% (2/12) in oligospermic couples was seen. Supernumerary oocytes were submitted to in vitro fertilization (IVF) and the findings related to the likelihood of pregnancy. No correlation between IVF and the likelihood of GIFT pregnancies was found in either the oligospermic or normospermic couples. A similar proportion of pregnancies was seen in couples with or without evidence of fertilization of the supernumerary oocytes in both the oligospermic and normospermic couples. However, a high proportion of normospermic couples with no evidence of fertilization had only one oocyte remaining for insemination. These results suggest that the failure of low numbers of supernumerary oocytes to fertilize in vitro after GIFT relates to oocyte selection criteria and does not mean a reduced chance of conception in that treatment cycle.

Early luteal serum progesterone concentrations are higher in pregnancy cycles.

In a consecutive series of 167 patients reaching the stage of embryo transfer after in vitro fertilization and embryo transfer, 19 clinical pregnancies ensued. The serum progesterone (P) levels were significantly greater on the first and second (P less than 0.01) and third (P less than 0.05) postaspiration days for those who conceived. Higher circulating levels of P were achieved on days 1, 2, and 3 (P less than 0.05) by the daily injection of P, 50 mg in oil, given for 5 consecutive days, beginning immediately after follicle aspiration. Both pregnancy and nonpregnancy cycles demonstrated high circulating P levels, but the study implies that relatively higher levels are required for conception, and such levels can be achieved by the use of intramuscular P.

Pregnancies following pronuclear stage tubal transfer.

Pronuclear stage tubal transfer (PROST) is a technique that involves in vitro fertilization (IVF) of oocytes, followed by the transfer of pronuclear oocytes into the fallopian tubes. It has been developed for its prognostic value of confirming fertilization in couples with oligospermia or asthenospermia and enabling fertilization in cases with antispermatozoal antibodies (ASAB). PROST has provided useful diagnostic information in the management of couples who have failed to conceive in other treatment programs and has particular advantages over IVF for those receiving fresh donated oocytes for ovarian failure. Fourteen pregnancies resulted from 52 transfers, providing a pregnancy rate of 27% per transfer. The pregnancy rates were higher than a matched IVF series in the male factor and female ASAB groups and reached statistical significance for the ovum donation group. It is anticipated that both pregnancy rates and fetal wastage will be improved over conventional IVF and embryo transfer for the described infertility groups.

The role of gamete intrafallopian transfer (GIFT) in the treatment of oligospermic infertility.

Gamete intrafallopian transfer (GIFT) was used to treat 32 couples where the male partner was oligospermic (less than 12 X 10(6) motile spermatozoa per milliliter of semen). Initially, 100,000 motile spermatozoa were transferred per fallopian tube and no pregnancies were achieved in 11 cases. The technique was then modified so that a maximal number of motile spermatozoa were transferred (range, 0.11 to 0.90 X 10(6) spermatozoa) and 6 of 21 (29%) pregnancies resulted, with 325,000 spermatozoa being the lowest number associated with pregnancy. It appears that the modified GIFT technique, whereby an increased number of motile spermatozoa are replaced with the oocytes, is an effective therapy in the treatment of oligospermic infertility.

Cryopreservation of human embryos at the pronucleate, early cleavage, or expanded blastocyst stages.

Supernumerary embryos following treatment by IVF or GIFT were cryopreserved at the pronucleate, early cleavage or expanded blastocyst stages. The success of embryo cryopreservation at these stages was evaluated in terms of (i) the proportion of embryos surviving the freeze/thaw procedure; (ii) the proportion of patients reaching embryo replacement; and (iii) the incidence of pregnancy per replacement. Significantly more embryos survived when frozen/thawed at the pronucleate (44/61; 72%) or early cleavage stages (48/80; 60%), than at the expanded blastocyst stage (13/34; 38%). A significantly higher proportion of patients had embryo replacements when embryos were frozen/thawed at the pronucleate (17/19; 89%) or early cleavage stages (21/24; 88%), than at the expanded blastocyst stage (9/17; 53%). Following replacement of frozen/thawed pronucleate and early cleavage stage embryos, clinical pregnancy rates of 8/17 (47%) and 3/21 (14%) clinical pregnancies were achieved, respectively. No pregnancies were achieved following replacement of frozen/thawed expanded blastocysts.

External quality assessment for semen analysis and sperm antibody detection: results of a pilot scheme.

The need for quality assurance in the seminology laboratory is clear, as the techniques of semen analysis and sperm antibody detection are just as susceptible to variation as any other routine pathology test. Semen samples were distributed to 20 laboratories on six occasions, four samples per distribution, for sperm concentration and morphology assessment under routine conditions, together with an equal number of serum samples for sperm antibody detection. The semen analysis results showed a wide range of values for any given sample, which did not seem to be related to the methodology used. However, this variation appears to be related to the presence of persistent errors, as most laboratories showed reasonable between-assay and within-assay variation. Detection of sperm antibodies by the tray agglutination, gelatin agglutination or indirect immunobead test showed a consistent discrimination between the intended positive and intended negative samples. However, the use of fluorescent microscopy was unable to do this. This study has shown the feasibility of operating external quality assessment schemes for semen analysis and sperm antibody detection. These schemes provide the opportunity for individual laboratories to fully evaluate their own methods against those of others and to determine the stages at which any errors occur. An increased number of participants will ultimately enable a systematic comparison of different methods.

Clinical value of tests for assessing male infertility.

The laboratory assessment of the male partner of an infertile couple is an important aspect of the overall investigation of that couple. The laboratory tests are designed essentially to determine whether (a) the semen samples contain adequate numbers of normal motile sperm, and the sperm are able (b) to migrate to the site of fertilization and (c) to fertilize oocytes. Within this framework, tests can be viewed as being either descriptive, in terms of describing the ejaculate and sperm, or assessing functional qualities of the sperm. Irrespective of the nature of the test, it must satisfy simple criteria, namely being reproducible and able to discriminate between the fertile and infertile populations reliably. External quality assurance programmes now exist for semen analysis and allied techniques to help laboratories to standardize their reporting and to identify the source of possible errors.

Internal quality control and external quality assurance in the IVF laboratory.

The existence of internal quality control programmes and external quality assurance schemes is important in enabling the maintenance of good service to patients. All aspects of our work in laboratories involved in the diagnosis and treatment of human infertility can benefit from such programmes and schemes, moving the work from being a subjective art form to an objective science. Equally, many clinical procedures are amenable to such scrutiny. Acceptance and introduction of such schemes and programmes will rely initially on the self-motivation of the laboratories themselves and then pressure brought to bear by accrediting authorities.

The influence of infertility etiology on the outcome of IVF-ET and GIFT treatments.

The present report examines retrospectively the success rates of both in-vitro fertilization and embryo transfer (IVF-ET) and gamete intrafallopian transfer (GIFT) in relation to the underlying infertility disorder. Reduced fertilization rates were seen when the male partner was oligospermic or had both IgA and IgG in his semen, or the female partner had elevated LH concentrations during the follicular phase. In IVF-ET, the chance of pregnancy was reduced in women with elevated LH concentrations or endometriosis. Pregnancy rates for patients treated in the GIFT program were significantly better (P less than .001) than for those treated by IVF-ET. Of special interest was the finding of an improved chance of pregnancy for patients with severe endometriosis treated by GIFT (P less than .001). With oligospermia, pregnancies were only achieved in the GIFT program when the insemination number was increased. The pregnancy outcome was similar in both programs, with approximately 70% of pregnancies delivering beyond 20 weeks' gestation. However, there was a high rate of ectopic pregnancy, particularly in cases with underlying tubal disease. These findings have led to revised guidelines for the accurate counseling of patients, and provide further insight into the possible mechanism of various disorders contributing to infertility.

Aromatase activity in ovarian follicles of the golden hamster.

The aromatizing ability of recombined granulosa and thecal cells in culture, isolated from hamsters 72-78 h and 96-102 h after PMSG-stimulation, was assessed by the addition to the culture medium of androstenedione, testosterone, dehydroepiandrosterone (DHEA) or 5 alpha-dihydrotestosterone (DHT), and measuring the output of oestradiol 4 h later. The cells from all follicles taken after 96-102 h had a reduced oestradiol output compared to those isolated after 72-78 h (P less than 0.02). Recombined cells from the unluteinized follicles at 96-102 h (Group I) showed similar oestradiol output in the presence of androstenedione, testosterone and DHEA to the cells from follicles taken at 72-78 h. However, the recombined cells from the luteinized follicles (Group II) showed a reduced output of oestradiol in the presence of androstenedione, testosterone and DHEA when compared to the recombined cells from the previous period cultured with the corresponding C19 steroid. The results show that a reduced oestradiol output can be caused by (1) the reduced availability of aromatizable substrate and (2) a reduced potential aromatase activity.

Early pregnancy wastage after gamete manipulation.

The outcome of 1034 pregnancies in women who conceived after referral for infertility management in seven treatment groups is detailed. The mean early pregnancy wastage (before 20 weeks gestation) was 27% and ranged from 18% after AID (artificial insemination by donor semen) to 33% after IVF-ET (in-vitro fertilization and embryo transfer). These differences were not due to maternal age which was similar in all groups (means between 29.7 and 32.7 years). Excluding the AID group, there was a high rate of ectopic pregnancy which was significantly higher after GIFT (gamete intrafallopian transfer) and was only partly related to underlying tubal disease. Blighted ova was the main category of early pregnancy loss and was highest after AIH (artificial insemination by husband's semen). There was a higher rate of biochemical pregnancies after GIFT, PROST (pronuclear stage tubal transfer) and IVF-ET. Our findings confirm a high pregnancy wastage rate in subfertile women and highlight deficiencies in the sperm separation, gamete handling and IVF/embryo culture techniques.

The treatment of infertility by the high intrauterine insemination of husband's washed spermatozoa.

A total of 345 couples with non-tubal infertility on an IVF waiting list underwent 702 treatment cycles involving daily intrauterine inseminations of husband's washed spermatozoa (AIH) over 3 days of the periovulatory period, following ovarian stimulation. Pregnancy rates achieved were dependent upon the underlying infertility disorder, with similar rates noted in those with a negative post-coital test (15.8%) or where antispermatozoal antibodies were present in either the male (18.5%) or female (17.1%) partner. These rates were significantly higher than for couples with poor cervical mucus (4.7%), asthenozoospermia (0%), endometriosis (mild, 7.7%; severe, 4.1%) or unexplained infertility (8.5%), while discrete oligozoospermia showed mid-range results (10.3%). Pregnancy outcome revealed a high level of early wastage (33.3%), mainly in the blighted ovum category, however congenital abnormalities (5.6%) were not significantly increased. It is concluded that the procedure of AIH should be considered for infertility due to poor sperm--mucus interaction, antispermatozoal antibodies and simple oligozoospermia, prior to IVF-related treatments.

Effect of LH on steroidogenesis by hamster follicles isolated at defined stages of development.

Multiple follicular growth was stimulated in groups of immature female hamsters by the administration of PMSG. The ovaries were removed 72-78 or 96-102 h later. The animals at 96-102 h were subdivided according to whether the concentration of plasma progesterone was within the range of the concentrations found at the previous period (0.45-13.18 nmol/l; Group I) or above (Group II). Thecal and granulosa cells from batches of isolated follicles (591-740 micron) were cultured together in the presence or absence of LH and the products of steroidogenesis were measured in the culture fluid. The results showed that there was a significant increase in the production of progesterone and 17 alpha-hydroxyprogesterone in follicles from Groups I and II at 96-102 h. In the presence of LH there was a significant increase in the yield of progesterone and 17 alpha-hydroxyprogesterone over the control values at all time periods. There were, however, reductions in the yields of 17 alpha-hydroxyprogesterone and androstenedione in the presence of LH at 96-102 h compared with 72-78 h and in Group II compared with Group I, although the concentrations of 17 alpha-hydroxyprogesterone were approximately 40-fold those of androstenedione. In addition, the production of oestradiol decreased significantly in follicles from both groups at 96-102 h and was reduced further in the presence of LH. It is concluded that the major rate-limiting step of steroidogenesis in hamster follicles undergoing the oestrogen-progestagen shift involves the side-chain cleavage of 17 alpha-hydroxyprogesterone.

The effects of frequent ejaculation on seminal spermatozoal number and calculation of daily spermatozoal output.

Spermatozoal depletion of the extra-gonadal reserve (EGR) has been monitored in 14 men by analysing ejaculates collected daily for 5 days. It has been concluded that EGR is stabilized within 2 days and that an estimate of daily spermatozoal output can be obtained either by averaging the values from days 3 to 5 or by using the day 5 value alone. This latter parameter may prove useful clinically.

The UK Human Fertilisation and Embryology Act 1990--how well is it functioning?

The Human Fertilisation and Embryology Act became law in the UK in 1990, and a statutory body, the Human Fertilisation and Embryology Authority, was established to administer the Act. The opinions of those persons responsible for licensed activity under the Act were canvassed anonymously to assess the initial effect of the Act on their activities, and the administration of the Act by the 'Authority'. The views expressed reflect the opinions of 80% of the 'responsible persons' and are thus likely to be of value to those responsible for administration of the Act and also those planning legislation in this field of human endeavour.