Search

Summary OBJECTIVE This study assessed whether functional ovarian cysts may prevent suppression of serum oestradiol levels even after pituitary desensitization had been achieved with buserelin. PATIENTS OI 288 in-vitro fertilization (IVF) cycles studied 10 patients were found to have cysts with serum oestradiol levels > 200 pmol/l despite 3 weeks of buserelin. DESIGN AND MEASUREMENTS The 10 patients with cysts were given 01 mg GnRH and serum gonadotrophins were measured at time 0, 30 and 60 minutes subsequently. Immediately following the GnRH stimulation test the cysts were aspirated transvaginally under ultrasound guidance. Serum oestradiol levels were again measured 3 days after cyst aspiration. RESULTS Basal LH and FSH levels were < 3 U/I and there was no significant rise in response to GnRH. On the day of cyst aspiration serum oestradiol levels varied between 244 and 1127 pmol/l, and in all cases serum oestradiol levels fell to < 200 pmol/l within 3 days of cyst aspiration. CONCLUSION In the presence of a functional ovarian cyst, failure to suppress the serum oestradiol level does not necessarily imply a failure of pituitary desensitization with a GnRH agonist.

Serum insulin-like growth factor binding protein-1 (IGFBP-1) concentrations were measured at the end of the proliferative phase in infertility patients undergoing normal menstrual cycle frozen embryo transfer, exogenous hormone-supported frozen embryo transfer and in-vitro fertilization (IVF) treatment cycles. These patients were divided into five groups according to their ovarian follicular activity. The exogenous hormone-supported frozen embryo transfer group, who had no ovarian follicles, and the IVF groups (number of follicles ranging from 4-38) showed statistically higher serum IGFBP-1 concentrations when compared to the normal menstrual cycle group (Por = 0.01). There was no significant difference in the serum IGFBP-1 concentrations between the exogenous hormone support frozen embryo transfer group and the poor or normal response IVF groups (number of follicles ranging from 4 to 16). An IVF group that displayed an excessive response to our standard human menopausal gonadotrophin stimulation (20 mature follicles or oestradiol10,000 pmol/l) showed a significantly higher serum IGFBP-1 concentration when compared with the other groups (P = 0.001). This subgroup was subsequently given a modified (follicle-stimulating hormone) stimulation regime which resulted in a significant reduction in serum IGFBP-1 concentrations (P0.05). There was no correlation between serum oestradiol and IGFBP-1 overall or within the patient groups. We conclude that serum IGFBP-1 concentrations in our down-regulated assisted conception cycles did not increase in line with ovarian follicular activity, unless an excessive response was displayed.

This study investigated the development of functional ovarian cysts during pituitary down-regulation prior to in-vitro fertilization (IVF), and identified 16 cases of cysts in 288 IVF cycles studied. Comparing the patients with functional ovarian cysts to the other 272 IVF cycles, there was no significant difference in age or incidence of endometriosis but significantly (P < 0.01) more patients with cysts had ovulatory dysfunction. The serum progesterone was < 5.7 nmol/l in all 16 patients with cysts on day 4 of the IVF cycle, and in eight of these patients the serum progesterone was < 5.7 nmol/l on the day buserelin was commenced. In 10 of the 16 patients with cysts, serum oestradiol concentrations remained elevated despite the prolonged use of buserelin, and the cysts were aspirated. The aspirate in all cases was clear without any suggestion of endometriosis. The cyst aspirates had significantly lower progesterone (P < 0.001), higher androstenedione (P < 0.01) and similar oestradiol concentrations to 10 follicular fluid samples collected at the time of oocyte retrieval. This study suggests that functional ovarian cysts may develop during pituitary down-regulation, and these cysts are follicular cysts rather than persistent corpora lutea or endometriomata.

The results of weekly colposcopy review meetings have been audited for 1 year and cases where there was a discrepancy between the referral cervical smear and the initial colposcopy biopsy have been analysed. New referrals (n = 476) for colposcopy were studied. In the final outcome 80% of 326 women referred for moderate or severe dyskaryosis were found to have cervical intraepithelial neoplasia (CIN) grade II or III or invasive carcinoma. Three women found to have invasive carcinoma had been referred for severely dyskaryotic smears. Twenty women were referred for smears with cell changes suggesting glandular neoplasia: five were found to have adenocarcinoma in situ, whereas eight had CIN and seven had negative biopsies. The results justify the referral policy and demonstrate the need for further investigation when initial colposcopic biopsies are negative.

In primates, corpus luteum development involves both gonadotrophin stimulation and exposure to low density lipoprotein (LDL) delivered through vascularization of the granulosa cell-derived layer. These regulatory influences were modelled in vitro using granulosa cells obtained during in-vitro fertilization (IVF) cycles controlled with gonadotrophin releasing hormone (GnRH) analogue, human menopausal gonadotrophin (HMG) and human chorionic gonadotrophin (HCG). Granulosa cells were cultured in defined medium on extracellular matrix. Without gonadotrophin or LDL in the medium, progesterone production declined progressively. With LDL alone, there was a short-lived elevation of progesterone output which subsequently declined. Culture with HCG alone resulted in a relatively unchanged rate of steroid production over 5 days despite morphological development. This contrasted with a marked and sustained increase in progesterone output over the same time when granulosa cells were cultured with combined HCG/LDL. Cultures were challenged with combined HCG/LDL on day 5. Where initial incubation included HCG, the challenge resulted in a recovery of progesterone output to values comparable to those of granulosa cells exposed to continuous HCG/LDL. Initial incubation without gonadotrophin led to a reduced response. Results suggest that LDL delivery to granulosa cells of the early corpus luteum causes a short-lived period of progesterone production. Sustained luteinization of granulosa cells and maintenance of gonadotrophin responsiveness requires continued exposure to gonadotrophin in the luteal phase.

The size distribution of marmoset luteal cells was determined on Days 6, 14 and 20 after ovulation in non-pregnant cycles and in early pregnancy. Image analysis was used to estimate the cell diameter of dispersed cells prepared from the marmoset corpus luteum (CL). Steroidogenic cells showed a size distribution consistent with one population of cells. There was a significant increase in mean cell diameter (P less than 0.05) from Day 6 to Day 14 in pregnant and non-pregnant animals with no further increase on Day 20. Micrographs of marmoset luteal tissue showed cells of greater than 10 micron containing the organelles typical of steroid-producing cells, and smaller non-steroidogenic cells surrounding the steroid-producing cells. On the basis of microscopy, there were no areas within the CL where cell composition was noticeably different. In contrast, micrographs of human luteal tissue showed two types of steroidogenic cell; most cells were similar to those in the marmoset CL but a smaller population of smaller cells could be distinguished around the periphery and along vascular septa. It is likely that these smaller and larger types of steroidogenic cells are of theca and granulosa cell origin respectively, the two cell populations differing in the degree of electron density and amount of rough endoplasmic reticulum. A distinguishing feature between marmoset and human luteal cells was the shape of the mitochondrian which were considerably rounder in marmoset luteal cells. The origin of steroidogenic cells in the marmoset CL is unclear, although in marmosets and man the luteal cell types display morphological characteristics distinct from the large and small luteal cells described for CL of the domestic ungulates.

Objective To investigate levels of placental protein 14 (PP14) in in vitro fertilization (IVF) patients with and without exogenous human chorionic gonadotropin (hCG) for luteal support. Design, Patients Thirty-one women undergoing IVF were studied. For 18 women, hCG was administered in the luteal phase, and 12 became pregnant. Five pregnancies occurred in 13 women not receiving exogenous hCG. Setting All the patients attended the University of Southampton/Chalybeate Hospital IVF program. Results There was no change in PP14 levels 2 days after embryo transfer (ET), but small significant rises were noted by day 8 in all patients. Thereafter, levels rose further in pregnant subjects but showed no change in nonpregnant patients. The highest level of PP14 was seen in the group of women on hCG support, but there was no overall statistical difference between those on support and those not. In the nonpregnant group, there was no significant correlation between progesterone (P) and PP14 8 days from ET, whereas a highly significant correlation was noted in the pregnant group. Conclusions Neither hCG nor P are primary factors in the control of endometrial PP14 secretion, but PP14 and P may have common underlying control mechanisms.

Reviewing 780 in-vitro fertilization (IVF) cycles, where buserelin was commenced in the preceding luteal phase and human menopausal gonadotrophin on day 4 of the ensuing menses, 53 cycles were identified with sonolucent cysts (30-50 mm diameter). Of the latter 53 cycles, the serum oestradiol was significantly greater on day 4 in 22 cycles abandoned for poor follicular development than in 31 cycles which proceeded to oocyte retrieval (P less than 0.05). Of the 31 cycles proceeding to oocyte retrieval, nine had a day 4 serum oestradiol greater than 200 pmol/l (95th centile for day 4 oestradiol in patients without apparent cysts), and these cycles produced significantly fewer grade 1 embryos than the cycles with day 4 oestradiol levels less than or equal to 200 pmol/l (P less than 0.05). Six of the 53 cycles with cysts resulted in conception, and all of these cycles had a day 4 serum oestradiol less than 200 pmol/l. Among the 53 cycles with ovarian cysts, the serum progesterone on the day of abandonment in four cycles and on the day of human chorionic gonadotrophin administration in one non-abandoned cycle, was above the range established for 104 cycles without cysts. No significant difference was seen in day 4 serum androstenedione levels, and the day 4 serum progesterone was less than 5 nmol/l in all but one patient. Functional activity of ovarian cysts is associated with an adverse influence on IVF cycles.

This study identifies a group of 87 patients, who demonstrated a 'poor' response to a standard buserelin/human menopausal gonadotrophin (HMG) regime. The subsequent outcome in 61 of these 'poor' responders when treated with a higher dose of HMG to achieve a satisfactory response was compared with 250 patients, who showed a 'good' response to the standard regime. 'Poor' responders were significantly older than 'good' responders (P less than 0.001), but no significant difference was demonstrated in the indication for in-vitro fertilization (IVF). Even on higher doses of HMG, 'poor' responders took longer for their follicles to achieve maturity than the 'good' responders (P less than 0.01). 'Poor' responders produced 8.9 oocytes per oocyte collection compared to 11.8 in the 'good' responders (P less than 0.01). The fertilization rate was significantly lower in the 'poor' responders compared to the 'good' responders (P less than 0.01). Although there was no significant difference in morphometric grading between 'poor' responder embryos and 'good' responder embryos, the rate of cell division was significantly slower in embryos of the 'poor' responders than the 'good' responders (P less than 0.01). The pregnancy rate per oocyte retrieval was 9% in the 'poor' responders compared to 29% in the 'good' responders (P less than 0.01). The implantation rate in the 'poor' responders was 4.4% compared to 16.1% in the 'good' responders (P less than 0.001).

The circulating levels of placental protein 14 (PP14) and progesterone were measured in three pregnancies resulting from the transfer of cryopreserved embryos. Two of these women had suppressed ovarian activity as a result of pituitary down-regulation with the luteinizing hormone-releasing hormone agonist (buserelin) prior to treatment with exogenous oestradiol and progesterone. After 14 days of oral oestradiol treatment and if the endometrial thickness was greater than 7 mm, progesterone was given intramuscularly for a further 14 days with embryo transfer on the third day of this treatment. On confirmation of pregnancy by human chorionic gonadotrophin analysis, progesterone administration was altered to transvaginal pessaries for maintenance of adequate progesterone levels and endometrial support. In the two women with ovarian suppression, PP14 levels remained below the 2.5th centile of the normal range for pregnancy. In the third pregnancy, embryo transfer was performed 3 days after a spontaneous luteinizing hormone surge in a normal menstrual cycle. In this pregnancy, PP14 levels were within the normal range. Ultrasonic examination confirmed three normal ongoing singleton pregnancies. These results suggest that the majority of PP14 production in normal pregnancy is under ovarian or anterior pituitary control and that the influence of progesterone is of a secondary nature.

The prostaglandins PGE2 and PGF2 alpha and the steroid hormones oestradiol (E2) and progesterone (P) were measured in 345 follicular fluids of patients undergoing ovarian hyperstimulation for in-vitro fertilization (IVF). The measured concentrations were analysed in relation to the outcome of the matched oocyte. Progesterone levels were significantly lower in the unfertilized group (P less than 0.005) compared to the fertilized group but there was no difference between 'pregnancy' and 'no pregnancy'. No differences were shown in either E2 levels or the E2:P ratio. No significant differences were shown among the groups in the concentration of either PGE2 or PGF2 alpha but there were highly significant differences shown when the PGE2:PGF2 alpha ratios were compared. The PGE2:PGF2 alpha ratio fell within a much narrower range for the 'pregnancy' group compared with any of the other groups. The ratio was significantly lower (P less than 0.001) when 'pregnancy' was compared with 'no pregnancy'. The range of the prostaglandin ratio found for the 'pregnancy' group may reflect the moment when conditions are optimal within the follicle for the associated oocyte to go on to establish pregnancy.

Summary. The incidence of early conceptual loss was studied in 27 subfertile women by measuring their serum and urine hCG levels in the luteal phase. Eleven patients eventually had clinically confirmed pregnancies, nine of whom had had significant hCG elevations in previous menstrual cycles. In the remaining 16 patients, who have so far failed to achieve a clinical pregnancy, only three had had elevated hCG results. Thus ‘apparent’ early conceptual loss in non-pregnancy cycles was found to be more often associated with the fertile group of patients.

The biological activity of deglycosylated human chorionic gonadotrophin (hCG) prepared by treatment of the native hormone with anhydrous hydrogen fluoride was evaluated using suspensions of dispersed cells from biopsies of human corpus luteum obtained during the luteal phase of normal menstrual cycles. A reproducible pattern of response to hCG in terms of progesterone production by luteal cells was established for a range of luteal ages. Deglycosylation of hCG led to a diminished level of maximum response to the hormone. Co-incubation of luteal cells with a level of hCG just sufficient to elicit a maximum response and increasing concentrations of deglycosylated hCG led to a progressive inhibition of the hormonal response; at a concentration of 103 ng deglycosylated hCG/ml (a tenfold excess of deglycosylated hCG over the native hormone), hCG-induced progesterone production was reduced by about 50%. Deglycosylated hCG therefore acts as a partial antagonist for the action of hCG on human luteal cells. J. Endocr. (1984) 101, 327–332

An accelerated double antibody method has been developed for the radioimmunoassay of pregnancy-associated plasma protein A (PAPP-A) in serum. The workable range for the assay was 0·04–1·8 mg/l of serum. PAPP-A levels were determined in single serum samples from 110 women with prospective normal pregnancies of between 7 and 14 weeks' gestation. The level of pregnancy specific β1 glycoprotein (SP1) was also measured in these samples and normal ranges for PAPP-A and SP1 were constructed from the results obtained.

Summary. Serum concentrations of human chorioni gonadotrophin (hCG). schwangerschaftsprotein l(SPl), progesterone and oestradiol were measured in 116 pregnant women experiencing varying degrees of nausea and vomiting or no nausea at all at between 9 and 16 weeks gestation. The patients were categorized into four groups, namely asymptomatic, nausea alone, nausea and vomiting and hyperemesis gravidarum. The distribution of levels for each group were examined in relation to the calculated normal ranges. Statistically higher hCG levels were found in out-patients with nausea alone or nausea and vomiting than in the asymptomatic women. No significant differences were found between the groups for any of the other measured variables, including the progesterone/oestradiol concentration ratio.

OBJECTIVE--To evaluate the effect of support with human chorionic gonadotrophin in the luteal phase in women taking part in an in vitro fertilisation programme after buserelin and human menopausal gonadotrophin were used to hyperstimulate their ovaries. DESIGN--Controlled group comparison. SETTING--Outpatient department of a private hospital. PATIENTS--115 Women with indications for in vitro fertilisation, all of whom had at least one embryo transferred. INTERVENTIONS--After suppression of the pituitary with buserelin the ovaries of all the women were stimulated with human menopausal gonadotrophin on day 4 of the luteal phase. Human chorionic gonadotrophin (10,000 IU) was given to induce ovulation, and oocytes were recovered 34 hours later. Embryos were transferred 46 to 48 hours after insemination. Women who had received the 10,000 IU of human chorionic gonadotrophin on a date that was an uneven number (n = 61) were allocated to receive support doses of 2500 IU human chorionic gonadotrophin three and six days after that date. The remaining 54 women did not receive hormonal support. END POINT--Determination of the rates of pregnancy. MEASUREMENTS and main results--Support with human chorionic gonadotrophin did not significantly alter the progesterone or oestradiol concentrations in the early or mid-luteal phase. The mean (range) progesterone concentrations in the late luteal phase in women who did not become pregnant were, however, significantly higher in those who received support (16(9-110) nmol/l nu 8(4-46) nmol/l), and the luteal phase was significantly longer in this group (14 days nu 12 days). The rate of pregnancy was significantly higher in the women who received support than in those who did not (25/61 nu 8/54). CONCLUSIONS--When buserelin and human menopausal gonadotrophin are used to hyperstimulate ovaries support with human chorionic gonadotrophin in the luteal phase has a beneficial effect on in vitro fertilisation.

SummaryFollowing induction of ovulation by clomiphene at Southampton Subfertility Clinic between 1971 and 1977. 149 pregnancies were identified and studied. Either 100 or 150 mg taken on days 2–6 induced 78 per cent of the clomiphene pregnancies. Fifty-six per cent conceived within 3 cycles of clomiphene treatment and 78 per cent within 6 cycles. In 28 per cent of cases mid-cycle oestrogen was used to improve the cervical mucus. Three per cent of pregnancies occurred when HCG had been given in addition to clomiphene.The 149 conceptions resulted in 19 per cent abortions, 75 per cent singleton pregnancies and 8 per cent multiple pregnancies. The perinatal mortality rate for singleton pregnancies (37 per 1000 births) was higher than the overall rate at Southampton General Hospital.

Suspensions of luteal cells were prepared from samples of human corpora lutea obtained during the luteal phase of menstrual cycles. Addition of oxytocin (1 μmol/l) to the various cell preparations had no effect on either basal production of progesterone or on steroidogenic responses to a range of concentrations of gonadotrophin. J. Endocr. (1985) 104, 149–151

Progesterone production was assessed following short-term incubations of luteal cell suspensions prepared from tissue samples of human corpora lutea obtained at specific times throughout the luteal phase of the menstrual cycle. Luteal cells responded rapidly and sensitively to human chorionic gonadotrophin (HCG; concentration required for 50% maximum response, 0·1–1·0 i.u./ml) with a maximum level of response (five- to tenfold higher than basal production) similar to that elicited by human LH or N6,02-dibutyryl cyclic AMP. In the absence of gonadotrophin or in the presence of sub-maximal (but not maximal) concentrations of HCG, progesterone production by mid-luteal phase cells was stimulated by prostaglandin F2α (1 μmol/l), an effect not observed during the late-luteal phase. l-Adrenaline and l-isoprenaline failed to elicit significant increases in the level of progesterone production.

Cell suspensions were prepared from tissue samples of human corpora lutea obtained during the mid- and late-luteal phase of the menstrual cycle. Both oestradiol and progesterone production by dispersed cells were stimulated by similar concentrations of human chorionic gonadotrophin (hCG). As the degree of stimulation of production by hCG was greater for progesterone than for oestradiol (five- to tenfold compared with two- to threefold higher than basal production), the ratio of progesterone to oestradiol produced varied according to the level of trophic stimulation. A comparison of cell suspensions prepared from mid- and late-luteal phase corpora lutea, exposed to the same concentration of hCG (10 i.u./ml) in vitro, did not reveal a shift to oestradiol production in the late-luteal phase. Provision of additional testosterone during incubation raised the level of oestradiol production by dispersed luteal cells. At an optimum concentration of testosterone (1 μmol/l), oestradiol synthesis was not raised further in the presence of hCG or N6, O2-dibutyryl cyclic AMP, suggesting a lack of induction or activation of the aromatase system by gonadotrophin in short-term cultures. Basal and stimulated levels of progesterone production were not significantly impaired in the presence of testosterone.

Human granulosa cells were prepared from follicular aspirates obtained during oocyte collection for in-vitro fertilization. Following several days in culture, cells were washed and then progesterone output was measured in 2-h incubations. After culture for 3 days, incubated cells responded well to human chorionic gonadotrophin (hCG) and prostaglandin (PG) E2 with similar levels of maximum response. Exposure of cultured cells to epidermal growth factor (EGF) for 2 days (days 3–5) led to substantial increases both in basal production and in responses to hCG and PGE2 during subsequent incubations. These effects of EGF were not accompanied by measurable increases in DNA levels in cultures over this time. Results may point to a possible paracrine role for EGF-like factors modulating the activity of cells forming the early corpus luteum. Journal of Endocrinology (1989) 121, 397–402

Pregnancy-associated plasma protein-A (PAPP-A) and Schwangerschaftsprotein 1 (SP1) levels were measured in single serum samples from 60 patients admitted with vaginal bleeding in the first 14 weeks of pregnancy. When based on ultrasound diagnoses the prediction of non-viability (the predictive value) was 97% for SP1 and 84% for PAPP-A. Whereas the prediction of viability (above -2SD of the normal range) with SP1 was 88% the value with PAPP-A was only 57%; the poorer result obtained with PAPP-A probably reflects its longer half-life. Pregnancy outcome is not related to the duration of bleeding.

We used a pregnancy specific-beta 1-glycoprotein (SP1) radioimmunoassay to monitor 72 menstrual cycles of 38 apparently subfertile women who were trying to become pregnant. Blood samples were taken up to day 42 from the start of the previous menstrual cycle. Using serum SP1 levels greater than 6 micrograms/1 as indicative of pregnancy, we obtained 16 positive results of which 11 were later confirmed by a human chorionic gonadotrophin haemagglutination pregnancy test. Three of the five women whose pregnancies were not confirmed had a subsequent history of spontaneous abortion.

SUMMARY There was no diurnal variation in plasma oestriol and diet, exercise and rest did not affect plasma oestriol levels in pregnant women. The 30-min, 3-h and day-to-day coefficients of variation compared favourably with that of 48-h urinary excretion.