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Coculture techniques on monolayers cells increase the rate of human blastocysts development. The selection of these heavier and more expensive methods should be reserved for cases which this work specifies. The rate of achieved pregnancies seems increased, embryo quality being, at this stage of later development, better estimated, from which a more objective selection. The window of endometrial receptivity to blastocysts implantation seems later than the one defined by the 2/8 cells stage. Last but not least, the cryopreservation of high quality blastocysts favours a high rate of recovery on defreezing.

Uterine artery blood flow was analyzed in 8 menopausal women receiving hormonal replacement therapy consisting of transdermal E2 (0.05 mg/24 h) administered without interruption for 12 weeks in combination with a cyclical supply of Nomegestrol acetate (5 mg/24 h) for the last 13 days of each four week treatment cycle. Uterine artery flow was analyzed using transvaginal pulsed Doppler making semi quantitative measurements of Doppler flow waves by calculation of the pulsatility index (PI). Before treatment (baseline) uterine artery PI was elevated at 3.7 +/- 0.7 (mean +/- SD) and decreased significantly under the influence of E2 to reach 1.9 +/- 0.8 after 2 weeks of treatment. This effect of E2 was not altered by the cyclical addition of Nomegestrol acetate. On the 3rd month of treatment, uterine artery PI values were lower than seen during the first month and no difference was observed between measurements made while receiving E2 (week 10) or E2 and Nomegestrol acetate (week 12). These data indicate that cyclical administration of the progestin Nomegestrol acetate does not interfere with the vascular effects of E2 lowering the uterine artery PI a reflector of the impedance to flow.

Objective: To assess the ability of a GnRH antagonist (Cetrorelix, Asta Medica AG, Frankfurt, Germany) to prevent premature LH surges in an IVF-ET program using a simple protocol with one or two administrations., Design: Controlled ovarian hyperstimulation was carried out in 17 women with three ampules a day of hMG, starting on day 2 of the menstrual cycle. A dose of 5 mg of Cetrorelix was administered when plasma E2 levels were between 150 and 200 pg/mL (conversion factor to Sl unit, 3.671) per follicle of > or = 14 mm. A second injection was performed 48 hours later if the triggering of ovulation was not decided in the meantime., Results: Six patients received one injection and 11 patients received two administrations. Plasma LH levels showed a marked decrease and remained low after the administration of the GnRH antagonist. In six patients, the first administration of Cetrorelix was performed when a significant rise in LH plasma level was present. Even in these patients the GnRH antagonist was able to prevent an LH surge. The tolerance of the product was good. Six clinical pregnancies were obtained, of which four are ongoing (25% per ET). Two ongoing pregnancies were obtained after the transfer of a frozen-thawed embryo (35.3% per retrieval)., Conclusions: The GnRH antagonist Cetrorelix in a simple, unique or dual administration, protocol was able to prevent premature LH surge in all of the 17 patients studied. If these results are confirmed by larger, randomized studies, the good tolerance and efficacy that we observed suggest a bright future for this product is assisted reproductive technologies.

We report a prospective trial of in vitro sperm-mucus penetration test performed in hormonally controlled environment. To enhance the quality of the cervical mucus (CM), prevent spontaneous ovulation and to eliminate the possibility that results may be biased solely because of CM inadequacy, we conceived a 28-day physiological hormonal replacement regimen. For this women received oral estradiol valerate (E2-V) (4 mg/day) from cycle 1 to 28. CM was collected on days 13 (n = 17), 14 (n = 38) or 15 (n = 16), according to patients' individual preferences. The in vitro sperm-mucus penetration test was performed approximately 30 minutes later. On the same day, measurements of P and E2 levels were done to eliminate the possibility of spontaneous ovulation. Plasma E2 on the day of testing were 220 +/- 100 pg/ml (mean +/- SD). In all patients, except 4, P levels were low (< 1 ng/ml) on the day of the test. Our results indicate that a hormonal preparation with E2/P can be clinically useful for preventing spontaneous ovulation and reliably assuring CM quality when sperm/mucus penetration tests are performed.

The recent development of co-culture technique has permitted to cryopreserve human embryos at the blastocyst stage. The aim of the present study was to compare pregnancy rates after transfers of embryos frozen at an early embryo stage (2-8 cell stage, group A; n = 175) with others frozen at blastocyst stage (group B; n = 98). Our results demonstrated that the frozen/thawed blastocyst survival is approximately 100%. In comparison the early embryos survival rate was 59% (P < 0.05). Moreover, pregnancy rates/embryo transfer in group A (16.4%) were significantly improved by comparison to those observed with early embryos (6.2%) (P < 0.05). In conclusion, our results demonstrate that embryo frozen/thawed at the blastocyst stage can be useful for improving pregnancy rates after cryopreservation.

We report the first case of full-term pregnancy arising from donated oocytes in a 36-year-old woman with chronic myeloid leukemia (CML), 6 years after allogeneic bone marrow transplantation (BMT) following total body irradiation (TBI) (12 Gy) and cyclophosphamide 120 mg/kg. The first attempt at implantation with her own cryopreserved ovocytes was unsuccessful. Thereafter, she became pregnant after donated oocyte implantation using estradiol and progesterone support replacing the defective ovarian function. The baby was normal. Unfortunately, 6 months later, she relapsed in chronic phase of CML.

Two byproducts of in vitro fertilization, transvaginal ultrasonography and hormonal preparation of endometrial receptivity for oocyte donation, have been the source of great progress in endometrial physiology. In practical terms, transvaginal ultrasonography has permitted the assessment of endometrial thickness and more precise echogenicity, the latter being a potential reflector of the secretory changes induced by progesterone. Pulsed and color Doppler ultrasonography have further enhanced the diagnostic performance of transvaginal ultrasonography so that the vascular tone of uterine arteries can be correlated with the hormonal effects on the endometrium and the degree of endometrial receptivity. Because of the excellent pregnancy rates achieved with oocyte donation, estradiol and progesterone replacement regimens have become true experimental models for studying endometrial physiology and physiopathology. Although even extreme alterations in the estradiol-to-progesterone ratio appear to have little effect on endometrial morphology, recent studies suggest an extreme sensitivity of the endometrium to progesterone, particularly early in the luteal phase. The physiology of uterine bleeding and its disorders have been reconsidered in the light of these new findings. In the menstrual cycle, uterine bleeding is triggered by dropping progesterone levels, regardless of estradiol levels.

Objective: To analyze the effects of clomiphene citrate (CC) on cervical mucus (CM) and endometrial morphology independently of hormonal changes encountered when CC is administered for ovulation induction., Design: Volunteers whose ovarian functions were temporarily suppressed (n = 18) by a long-acting GnRH agonist and 6 women of similar age suffering from premature ovarian failure (POF) received E2 and P. Half of the women also received CC (50 mg/d, days 2 to 6)., Setting: Tertiary University Institution, Hôpital A. Béclère., Patients, Participants: Eighteen volunteers suffering from infertility not related to a uterine cause and 6 women of similar age suffering from POF., Main Outcome Measure: Plasma gonadotropins, E2, and P were measured at baseline to confirm that the ovaries were inactive and twice weekly during physiological E2 and P replacement. Cervical mucus was analyzed on day 14 and scored from 0 to 15. Endometrial biopsies were obtained on replacement days 20 and 24 for conventional histology and immunocytochemistry analysis of estrogen receptors and progesterone receptors (PR). Premature ovarian failure women whose results have been previously published served as controls for day 20 biopsies., Results: Cervical mucus scored lower in women who received CC (5.5 +/- 3.2) than in controls (13.6 +/- 4.7, mean +/- SEM). On day 20, endometrial findings were similar in women treated with CC and in controls. On day 24, specimens showed a significant delay in endometrial maturation in women treated with CC. On day 24, only staining for PR selectively persisted in endometrial stroma, and no difference was observed between women who received CC and controls., Conclusion: Our results indicate that CC significantly alters CM quality and late luteal phase endometrial morphology despite physiological levels of plasma E2 and P. Hence, clinicians should monitor E2 levels when using CC, and caution should be exerted when supraphysiological levels of E2 are not present to counterbalance the effects of CC on the CM and the endometrium.

Objective: To determine if an increase in plasma P occurring before hCG administration might impair the outcome of IVF-ET., Design: Five hundred eighty-five IVF-ET cycles were prospectively studied for the occurrence of plasma P elevation before hCG administration., Setting: Tertiary institution, IVF-ET program, Hôpital A. Béclère., Patients: Participating patients included IVF-ET candidates 23 to 42 years of age only, excluding the couples in whom a male factor was a primary or an accessory cause of infertility., Main Outcome Measures: To clarify the practical consequences on IVF-ET outcome of pre-hCG increases in plasma P, we studied 585 consecutive IVF-ET cycles. These were divided into two groups according to plasma P levels observed on the day of hCG administration; plasma P of 0.9 ng/mL (2.9 nmol/L) was taken as an arbitrary cutoff value. Group A included 485 IVF cycles in which plasma P was < or = 0.9 ng/mL (2.9 nmol/L); group B included the remaining 100 cycles in which plasma P was > 0.9 ng/mL (2.9 nmol/L)., Results: The number of mature oocytes retrieved, the oocyte cleavage rate, and the number of embryos obtained were similar in groups A and B. In contrast to this apparent similarity in oocyte quality, a decrease in pregnancy rate (PR) and a trend for a decrease in embryo implantation rate were observed in group B in comparison with group A., Conclusions: The similar fertilization and cleavage rates obtained in groups A and B suggest that pre-hCG elevation in plasma P does not lead to decreased oocyte quality. Yet the lower PR observed when plasma P rises prematurely suggests that the prolonged but discrete elevation in plasma P occurring in these cases might alter endometrium receptivity to embryo implantation.

To determine the effects of female hormones on peripheral vasculature we studied the brachial artery circulation. Nine young women (27-37 yrs) having inactive ovaries received transdermal estradiol (E2) (0.1-0.4 mg/d) and vaginal progesterone (P) (300 mg/d) to duplicate the menstrual cycle levels of E2 and P. Brachial artery diameter, blood velocity and flow were measured by bidimensional pulsed Doppler in basal conditions, and during hand exclusion by a cuff inflated at suprasystolic pressure. Vascular resistance was calculated by the ratio of mean blood pressure over mean flow. Measurements were obtained before hormonotherapy (d0), on day 14 (d14, after E2), and on day 28 (d28, after E2 and P). The increase of brachial artery diameter began at d14 (3.73 +/- 0.12 mm, vs 3.66 +/- 0.11 mm; NS) to become significant at d28 (3.91 +/- 0.10 mm, p < 0.05). Blood velocity and flow increased at d28 (4.78 +/- 0.55 cm/s, vs 3.55 +/- 0.65 cm/s; P < 0.05 and 35.2 +/- 5.2 ml/mn vs 22.2 +/- 3.6 ml/mn, P < 0.05 respectively). No change was noted in mean blood pressure. The decrease of resistance began at d14, in order to be significant at d28 (158 +/- 17 mmHg/ml/s at d0 vs 263 +/- 31 mmHg/ml/s at d28; P < 0.05). Brachial vasoconstriction during hand exclusion, in response to low flow state disappeared at d14 with estradiol. In conclusion, in women deprived of ovarian function, physiological E2 and P replacement vasodilates small and large arteries, whereas E2 alone attenuates the large artery vasoconstriction in acute response to low flow state.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective: To compare two treatment regimens associating a gonadotropin-releasing hormone agonist (GnRH-a) and human menopausal gonadotropin (hMG) for controlled ovarian hyperstimulation (COH)., Design: A prospective randomized trial., Setting: The outpatient fertility clinic of a university tertiary care center, the Hôpital A. Béclère, Clamart, France., Participants: One hundred eighty-two in vitro fertilization (IVF) candidates undergoing new or repeat IVF cycles at Hôpital A. Béclère over a 4-month period., Treatment: Group 1 (7-day protocol): A short-acting preparation of GnRH-a (Tripteriline 0.1) was administered daily for 7 days, starting on cycle day 2. Ovarian stimulation with hMG was started on cycle day 4. Group 2 (long protocol): A timed release preparation of GnRH-a (Tripteriline 3.75 mg) was administered on cycle day 2. Ovarian stimulation with hMG was started after documented ovarian suppression., Main Outcome Measures: Response to COH, pregnancy rate (PR), tolerance., Results: In the 7-day protocol, the amount of hMG required was markedly lower at 24 +/- 7 than in the long protocol group requiring 42.5 +/- 9.75 vials (75 IU) (mean +/- SD). No elevation of plasma LH occurred in either group. The number of oocytes retrieved was 7.3 +/- 1 and 10.7 +/- 1.2 (mean +/- SD) in the 7-day and long protocols, respectively. Yet, the number of embryos obtained and the PRs were similar in the two treatment groups., Conclusions: We observed that in COH, GnRH-a treatment could be interrupted safely several days before human chorionic gonadotropin administration without risking a premature increase of plasma luteinizing hormone. Moreover, the number of embryos available for fresh transfer and the ongoing PRs were similar in the new 7-day and in the classic long GnRH-a/hMG protocols, despite the smaller number of oocytes suggesting a greater efficiency of the 7-day protocol. The peak estradiol level and the hMG requirement were also lower in the 7-day GnRH-a/hMG protocol.

Unlabelled: Microfertilization technics as SUZI (sub-zonal insemination) can be indicated in cases of repeated in vitro fertilization (IVF) failure. Feminine parameters seem to play however an important role in optimalization of results. We studied 27 couples (32 IVF-SUZI cycles) who had previously presented 2 to 4 in vitro fertilization failures. These 32 cycles were divided in 2 groups according to women's age: group A < or = 35 and group B > 35 years., Results: basal FSH levels were higher in group B (6.6 +/- 3.1 mIU/ml) in comparison to group A (3.7 +/- 1.5 mIU/ml). The amount of hMG necessary to accomplish ovarian stimulation was also higher in group B (39 +/- 21 ampules) than in group A (26 +/- 11 ampules). Maximal plasma estradiol levels were higher in group A (2,775 +/- 872 pg/ml) than in group B (1,824 +/- 559 pg/ml) such as the mean number of oocytes collected and micro-injected: 11.6 +/- 4.5 versus 4.7 +/- 2.2 in groups A and B, respectively. Eight pregnancies (44%), of which 7 were ongoing pregnancies, were obtained in group A. No pregnancy was obtained in group B., Conclusions: SUZI seems to be an available technic for treatment of repeated IVF failures; our results seem to indicate a decrease in SUZI results with age of the women (> 35 years old); they suggest the opportunity of a complete investigation of feminine parameters prior to each SUZI-IVF cycle.

Recently, pulsed Doppler has become available on high resolution vaginal ultrasound probes for studying ovarian blood flow. Doppler studies of ovarian blood flow are based on: semiquantitative analysis of Doppler flow waves recorded over the ovarian artery at its entry into the ovary; color Doppler mapping of intraovarian vessels. Semiquantitative analysis of the ovarian artery Doppler flow waves suffers from frequent difficulties at properly identifying the ovarian artery, particularly in multiparous women. Mapping of intraovarian vessels however, appears a most promising feature of vaginal Doppler for studying ovarian blood flow, provided that the proper ultrasound equipment is used. Specifically, transvaginal color Doppler mapping of intraovarian vessels allows for a positive visual detection of the onset of the ovulatory process prior to the actual follicular rupture. Thus, color Doppler mapping of ovarian vessels permits an improved and simplified approach for timing intercourses and inseminations in infertility patients. In controlled ovarian hyperstimulation (COH) used for in vitro fertilization (IVF), mapping of intraovarian vessels by color Doppler offers a fascinating new insight into normal and pathological responses of ovarian follicles to hCG. Finely, color Doppler appears a very promising asset to transvaginal ultrasounds for sorting suspicious ovarian cysts from their benign counter parts. In conclusion, we think that vaginal Doppler should be considered as a marvelous refinement of ultrasounds rather than as a truly new diagnostic tool. Yet vaginal color Doppler carries the potential for markedly improving the sensitivity and the specificity of vaginal ultrasound, particularly for diagnosing benign from potentially malignant ovarian conditions.

Objective: To examine the possible impact of abnormal adrenal steroidogenesis on the ovarian dysfunction seen in polycystic ovarian disease (PCOD)., Design: Prospective analysis of blood sampling monthly for 6 months, then three times weekly for 90 days., Setting: Tertiary institutional outpatient care., Participants: Six anovulatory women with a diagnosis of PCOD., Intervention: Six-month suppression with gonadotropin-releasing hormone agonist (GnRH-a) followed by suppression with dexamethasone (DEX) for 90 days., Main Outcome Measures: Serum levels of testosterone (T), androstenedione (A), dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), cortisol, estradiol (E2), progesterone (P), follicle-stimulating hormone (FSH), luteinizing hormone (LH) and bioactive LH., Results: Gonadotropin-releasing hormone agonist administration suppressed greater than 60% of the circulating levels of T and A, suggesting an ovarian origin. Minimal changes of DHEA, DHEAS, and cortisol were seen. With the addition of DEX, there was greater than 90% suppression of the total circulating A, T, DHEA, DHEAS, and cortisol, supporting the adrenal origin of the non-GnRH-a suppressible androgens. Excessive ovarian T and A secretion returned during the 90-day recovery study period in spite of rises of FSH concentrations that changed the ratio of FSH to LH in all subjects. Four of the six women failed to ovulate. In comparison of the women who did and did not ovulate during recovery, no differences in absolute levels or changes in concentrations of steroids or gonadotropins could be detected., Conclusions: Using sequential and simultaneous administration of GnRH-a and DEX, we were able to delineate the contributions of the ovaries and adrenals to the abnormal steroidogenesis seen in PCOD. Despite prolonged suppression of ovarian and then adrenal steroidogenesis, ovarian dysfunction, evidenced by abnormal androgen production, returned with cessation of agonist administration.

Objective: To report a preliminary study on the efficacy of a gonadotropin-releasing hormone antagonist (Nal-Glu) for preventing premature luteinizing hormone (LH) and progesterone (P) rise in controlled ovarian hyperstimulation using clomiphene citrate (CC) and human menopausal gonadotropin (hMG)., Design: Participants in the study formed two groups. Both groups received CC-hMG and Nal-Glu. Group II differs from group I for receiving human chorionic gonadotropin (hCG) and blood samples for 10 days after the second Nal-Glu injection., Setting: Centre de Fecondation in Vitro, Hôpital Antoine Béclère., Patients: Eleven women 25 to 34 years of age and having normal menstrual cycles using barrier method of contraception not attempting pregnancies participated in the study., Intervention: Daily blood samples, pelvic ultrasound, and CC-hMG/Nal-Glu/hCG administration., Main Outcome Measures: (1) Spontaneous LH surge and P rise, follicular growth, and plasma E2 levels in cycles with CC-hMG/Nal-Glu administration and (2) luteal phase after hCG injection in subjects previously treated with CC-hMG/Nal-Glu., Results: Plasma E2 level increased from 983 +/- 80 pg/mL (mean +/- SEM) on the day of the first Nal-Glu administration to 1,159 +/- 102 and 1,610 +/- 114 pg/mL (mean +/- SEM) 24 and 48 hours later. In 10 women, LH and P remained low for at least 96 hours after the first Nal-Glu administration. In one subject, plasma LH was already elevated at the time of the first Nal-Glu injection. In women who received hCG, plasma E2 and P reached a maximum of 1,258 +/- 313 pg/mL and 50.3 +/- 12.8 ng/mL (mean +/- SEM), respectively, on the 6th day of the luteal phase., Conclusion: Our results suggest that timely Nal-Glu injections can prevent LH and P rise for at least 96 hours, in spite of increasing levels of plasma E2. Moreover, Nal-Glu had no adverse effect on the kinetic of E2 rise, the follicular growth, or on the post-hCG hormonal profile.

Objective: To determine if controlled preparation of the endometrium with exogenous estradiol (E2) and progesterone (P) could be achieved in women retaining their ovarian function without requiring prior ovarian suppression with a long-acting agonist of gonadotropin-releasing hormone (GnRH-a)., Design: Prospective feasibility study of a new simplified hormone regimen for preparation of endometrium receptivity. Six volunteer women received transdermal E2 and vaginal P without prior suppression of their ovarian function with GnRH-a. The control group consisted of previously reported cases receiving GnRH-a and E2 and P., Setting: Academic tertiary care institution., Patients: Six volunteer women., Main Outcome Measures: Participants received transdermal E2 and P after a regimen designed to duplicate the plasma E2 and P levels seen in the menstrual cycle., Intervention: Endometrial biopsy., Results: Plasma luteinizing hormone increased to surge levels in one woman on day 11, in two on day 12, and on day 14 in the remaining three women. No follicular growth was noticed on ultrasound, and no increase in plasma P occurred before the onset of P administration on day 15. Day 20 endometrium specimens showed early secretory changes as previously reported in women deprived of ovarian function receiving similar hormonal treatment., Conclusions: Our results indicate that controlled preparation of the endometrium can be achieved with exogenous E2 and P without prior ovarian suppression with a GnRH-a in women having functioning ovaries. Hence, administration of exogenous E2 and P appears to be a viable simpler alternative to the combined administration of GnRH-a and exogenous E2 and P, which avoids the side effects and the cost of GnRH-a.

To determine if reproductive hormones played a role at physiological levels on vascular resistance of uterine arteries, we studied young women having inactive ovaries who received exogenous estradiol (E2) and progesterone (P). Six women, ages 27 to 36 with absent or nonfunctioning ovaries, received transdermal E2 and vaginal P after a 28-day replacement regimen duplicating E2 and P levels seen in the menstrual cycle. Vascular resistance of uterine arteries was evaluated before treatment (baseline), on days 13 to 14 and on days 26 to 27, using transvaginal pulsed Doppler combined with real-time imaging. Doppler waveforms were analyzed by the pulsatility index (PI). Baseline evaluation showed narrow systolic Doppler flow waves with a PI of 5.2 +/- 0.4, mean +/- SEM. On cycle day 13, Doppler waveforms showed a marked broadening with uninterrupted diastolic flow indicative of a profound decrease in vascular resistance. This was reflected by a significant decrease in PI to 1.3 +/- 0.3, mean +/- SEM. Doppler measurements made on days 26 to 27 showed no significant change. Our results indicate that at physiological levels, E2 affects vascular resistance of uterine arteries. This represents a new parameter of estrogen action, readily measurable by a noninvasive technique that, in the future, may help for assessing the efficacy of various estrogenic treatments.

Uterine oestrogen (ER) and progesterone (PR) receptors are subject to fine hormonal control by oestradiol and progesterone. In order to assess the role of ER and PR measurement in the evaluation of endometrial maturation, both receptors were studied by immunocytochemical techniques using monoclonal antibodies during the menstrual cycle, and in women with inactive ovaries treated by different regimens of hormonal substitution with oestradiol and progesterone. During the normal menstrual cycle, the concentrations and distribution of ER and PR changed markedly. During the mid follicular period (days 7-8), a small proportion of stromal and glandular cells stained positively for PR while staining for ER was more intense and more frequent. During the late follicular phase and early luteal period (days 9-19), the staining for PR increased markedly in glandular cells. During the mid and late luteal phase (days 21-27), ER and PR staining disappeared in glandular cells. Thus, while oestradiol increases the staining for ER and PR in both glands and stroma, progesterone decreases ER and PR staining in the glands in a dramatic fashion. These variations, especially the disappearance of PR under the effect of progesterone, are potentially useful for studying the cumulative effect of progesterone on endometrial maturation. This was confirmed in anovulatory women, where a late luteal phase aspect was observed, i.e. the absence of a reduction in ER and PR in glandular cells. In women with ovarian failure, the disappearance of ER and PR in glandular cells is correlated with the duration of progesterone therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Combined intra-uterine and ectopic gestations are uncommon. Heterotopic gestations in which the ectopic pregnancy is located in the ovary are exceptional. We are reporting a 22 week heterotopic gestation with two live fetuses, one fetus was developing in the uterus and one in the ovary. Surgical excision of the ovarian pregnancy was conducted without disturbing the intra-uterine live fetus who was ultimately delivered uneventfully at term.

Most oocyte donation programs have experienced higher pregnancy rates than usually seen in regular in vitro fertilization (IVF), suggesting that the quality of either the oocytes or the endometrium is superior. To clarify this issue we analyzed the results of transfers of 136 cryopreserved embryos originating either from donated oocytes (18 transfers) or from regular IVF (118 transfers). Transfers of embryos originating from donated oocytes took place after administrating oral estradiol (E2) valerate and vaginal micronized progesterone (P) following a regimen designed to mimic the serum levels of E2 and P observed during the menstrual cycle. Transfers of embryos originating from regular IVF took place either in the natural cycle (53 transfers) or after suppressing ovarian function with a single injection of a gonadotropin-releasing hormone agonist (GnRH-a), Decapeptyl-Retard 3.75 mg, and administering the same hormone replacement regimen (E2/P) used in oocyte donation (65 transfers). Eighteen transfers involving 24 embryos originating from donated oocytes were affected, resulting in six pregnancies (4 ongoing). The ongoing pregnancy rate per transfer was 22%. Seventy-nine embryos originating from regular IVF were transferred (53 transfers) in the natural cycle resulting in six pregnancies (2 ongoing). One hundred three other embryos originating from regular IVF were transferred (65 transfers) after administration of GnRH-a and E2/P resulting in four pregnancies. The pregnancy rate after transfers of embryos originating from regular IVF was 9% per transfer. This was significantly less than the pregnancy rate of 33% per transfer seen after the transfers of embryos originating from donated oocytes.(ABSTRACT TRUNCATED AT 250 WORDS)

A successful triplet gestation in a 45,X/46,XY woman is presented. A previously hypoplastic uterus was prepared for implantation by exogenous hormone replacement. Conception was achieved through in vitro fertilization of donor oocytes and transfer of four embryos into a hormonally primed endometrium. This case illustrates that some women with 45,X/46,XY karyotype can have a successful triplet pregnancy. Therefore, a conservative approach during gonadectomy in patients with a Y chromosome may be warranted.

A new protocol was developed to provide participants of our oocyte donation program with oocytes donated by donors who were not financially rewarded, were anonymous, and fertile. Each participant provided an oocyte donor selected among fertile friends or family members. The retrieved oocytes were anonymously exchanged between phenotypically matched donor-recipient pairs. In the first 30 months of activity, we obtained 111 embryos suitable for transfer or cryopreservation from 52 retrievals, and 40 embryo transfers (ETs) were performed. Recipients received oral Estradiol-valerate and vaginal micronized progesterone. Fifteen embryos were transferred in 8 ETs conducted after donor-recipient synchronization. This resulted in four pregnancies, all ongoing (ongoing pregnancy rate 50% per transfer). Of the 96 cryopreserved embryos, 82 were thawed for ET, and 45 surviving embryos were transferred in 32 ETs. This resulted in eight pregnancies, with six ongoing or delivered (ongoing pregnancy rate 19% per transfer). The overall ongoing pregnancy rate of 25% per transfer indicates that our approach is a viable method for obtaining donated oocytes while respecting the ethical guidelines that recommended that donation of human gametes should be free, and from anonymous and fertile donors. Furthermore, guaranteeing anonymous oocyte donation had practical importance because, for many volunteer donors, it played a crucial role in their decision to donate.

Nine clomiphene citrate-resistant polycystic ovarian disease (PCOD) patients received intravenous gonadotropin-releasing hormone (GnRH) pulses before and immediately after 1 month of GnRH agonist (GnRH-a) therapy. Circulating gonadotropin and ovarian steroid levels, as well as follicular development, were measured throughout therapy. Results were compared with those obtained from five hypogonadotropic patients treated with GnRH pulses only who ovulated during six of seven treatment cycles. Only two PCOD patients ovulated normally with GnRH pulses before GnRH-a therapy. Aberrant gonadotropin and ovarian steroid secretory patterns were noted in the others. After GnRH-a, gonadotropin and ovarian steroid hormone levels were similar to those of the hypogonadotropic patients. Subsequent secretory responses to GnRH pulses were partially normalized. However, only two additional PCOD patients ovulated.

Modeled on our successful experience with oocyte donation, we present a novel, viable approach to cryopreserved-thawed embryo transfers (ETs) in women with recalcitrant ovarian dysfunction: gonadotropin-releasing hormone agonist and exogenous estradiol and progesterone (GEEP). After attainment of ovarian suppression, seven such women received physiological steroidal replacement regimens with cryopreserved-thawed ETs prospectively synchronized with the 4th day of progesterone administration and two conceived. These GEEP cycles and cryopreserved-thawed ETs were prospectively compared with cryopreserved-thawed ETs performed on the 4th day of exposure to progesterone in 20 spontaneous cycles and in 5 oocyte donation-steroidal replacement cycles. Pregnancies occurred after three cryopreserved-thawed ETs in each of these groups. We conclude that GEEP constitutes a successful preparation for cryopreserved-thawed ETs, at the least, in women with ovulatory dysfunction.

A series of 10 patients with benign androgen-secreting neoplasms is presented. Nine tumors were ovarian, and one adrenal. In an attempt to correctly diagnose the presence of tumor and to accurately localize the lesion to a specific gland, steroid hormones in peripheral, ovarian, and adrenal vein serum were analyzed by radioimmunoassay. Little correlation was made in this series with those levels of testosterone (greater than 2 ng/ml) or dehydroepiandrosterone sulfate (greater than 7000 ng/ml) that have been widely used to predict the presence of such tumors. Peripheral testosterone levels were less than 2 ng/ml in 50% of our patients, and the dehydroepiandrosterone sulfate level was greater than 7000 ng/ml in only a single patient with an ovarian lipoid cell tumor. Pelvic ultrasonography was found to be of limited value in evaluating nonpalpable tumor because of the small size (less than 2 cm3) of the majority of these neoplasms. The use of selective retrograde venous catheterization to demonstrate significant effluent-peripheral vein androgen gradients served to accurately localize androgen-secreting tumors in all six patients in which it was used. Our data emphasize the potential pitfalls that exist in the preoperative evaluation of patients with these fascinating neoplasms and the importance of a high degree of suspicion on the part of the physician caring for these women.

Five women with prior suboptimal ovarian stimulation for in vitro fertilization and embryo transfer (IVF-ET) were pretreated with a long-acting gonadotropin-releasing hormone (GnRH) agonist beginning in the midluteal phase of the preceding menstrual cycle. The four women with normal luteal function had castrate estrogen levels following regression of the corpus luteum, whereas one woman with an abnormal luteal phase and perimenopausal levels of gonadotropins had an agonistic response. In the three women with adequate stimulation, 20 oocytes were obtained and one women became pregnant. Initiation of GnRH agonist therapy during the luteal phase of a normal menstrual cycle may be an efficient way of obtaining ovarian suppression without an agonistic response.

Two cell types isolated and purified to homogeneity from human decidua obtained at 8-17 weeks of gestation were shown immunocytochemically to correspond to decidual and epithelial cells in the tissue of origin. The decidual cells reacted with antihuman PRL antiserum, and epithelial cells reacted with antiserum against keratin, an epithelial cell marker. Decidual and epithelial cells were cultured separately to determine their abilities to release PRL to the medium. Decidual cells released 140-410 ng PRL/mg protein in 24 h, whereas no PRL was detectable in cultures of isolated epithelial cells. These homogeneous preparations provide an excellent system with which to study the regulation of PRL production and other biochemical properties of decidual components.

Persistent suppression of gonadotropin and ovarian steroid production can be achieved in women with polycystic ovarian disease (PCO) by daily administration of a long-acting GnRH agonist (GnRHa). This study was designed to determine the patterns of recovery of clinical responses and hormonal secretion after chronic GnRHa administration in women with PCO. Six women with PCO were treated with daily sc injections of [D-His6(imBzl),Pro9-NEt]GnRHa (100 micrograms) for 6 months. Blood samples were obtained at the time of and three times weakly for 90 days after discontinuation of agonist therapy. In five women who did not ovulate, the suppressed serum FSH levels rose to pretreatment values within 10 days. In contrast, a gradual and progressive increase in serum LH (as measured by bioassay and immunoassay) was apparent by day 18. The LH increase coincided with progressive increases in serum estrone (E1), androstenedione, and testosterone. Serum estradiol (E2) began to rise on day 28. All hormones returned to their pretreatment baseline values within the 90-day recovery interval, with the exception of E2. Trend analysis of the slopes of recovery revealed that the incremental secretion patterns of E1, E2, androstenedione, and testosterone differed significantly from that of FSH, but not from those of bioactive or immunoactive LH. Serum progesterone, dehydroepiandrosterone sulfate, and cortisol did not change after withdrawal of GnRHa. One woman ovulated spontaneously on day 52 before which her hormone secretion patterns were indistinguishable from those of the other women. In summary, 1) during recovery after discontinuation of chronic GnRH agonist therapy the patterns of FSH and LH release suggested resumption of endogenous GnRH action on the pituitary with greater release of FSH than LH, a pattern that would be expected in the absence of ovarian steroid influence; 2) the lack of early estrogen production despite the increase in serum FSH concentrations suggests inadequate FSH secretion, abnormal ovarian responsiveness to FSH, or impaired FSH bioactivity; 3) androgen secretion was provoked by the increase in LH secretion; 4) per unit LH measured by bioassay, greater ovarian androgen secretion was stimulated in PCO than ovulatory women; and 5) the likelihood of spontaneous ovulation during recovery was minimal.

The responses of the blood coagulation and related systems were studied in 23 postmenopausal women, all of whom received, in randomized order, therapy with conjugated oral estrogens (0.625 and 1.25 mg daily) and transdermally administered estradiol in doses of 25, 50, 100, and 200 micrograms/24 hr. Neither plasma fibrinopeptide A determinations nor plasma fibrinogen chromatographic findings were altered; thus there is no evidence of accelerated fibrinogen turnover with either form of therapy. However, alpha 1-antitrypsin and plasminogen concentrations were significantly increased with the higher dosage of oral but not with transdermally administered estrogen. Similarly, ceruloplasmin concentration was significantly elevated with both oral doses but was unchanged by transdermal therapy.

Addition of serum to culture medium during washing of sperm was shown to significantly improve sperm motility upon subsequent 24-hour incubation, distinct from the beneficial effects of adding serum after washing. Commercial sources of human and bovine albumen tested did not preserve motility as well as serum, but addition to serum showed that the lesser effect was probably due to toxic contaminants. One of the most commonly available disposable plastic syringes was found to be markedly toxic to sperm. The materials found to have sperm toxicity also manifested toxicity to mouse embryos. These findings show that a similar degree of caution is advisable in testing of materials contacting sperm in vitro to that which has become standard practice for culture of human embryos.

During the first 2 1/2 years of operation of the University of California at Los Angeles in vitro fertilization-embryo transfer program, 47 clinical pregnancies were achieved in 154 laparoscopies for oocyte aspiration (31%). Two of these pregnancies were achieved through transfer of cryopreserved embryos when ongoing pregnancy did not result from embryo transfer in the stimulated cycle. An increase in clinical implantation was noted with a reduction of transfer volume and proportion of air, with 34% of laparoscopies being followed by clinical pregnancy over the last 18 months. No difference in the rate of clinical pregnancy was noted relative to uterine depth or position. The high rate of multiple implantation (47%) suggested a high level of embryo quality. The success rate was attributed to a strong ovarian, human menopausal gonadotropin stimulation, accurate timing of human chorionic gonadotropin, a high oocyte retrieval rate, meticulous laboratory technique, atraumatic, high-fundal transfer of embryos, and initiation of embryo cryopreservation.

Human placentas were perfused in vitro through fetal vessels of a single cotyledon with a solution of tritiated androstenedione (A) or tritiated testosterone in oxygenated Krebs-Ringer bicarbonate buffer containing glucose. The same buffer, without labeled steroids, was used to perfuse the maternal side of the placenta. Fractions of unrecycled "fetal" and "maternal" perfusates were collected to estimate the steady-state rates of output into each perfusate of labeled estrone (E1) and estradiol (E2), formed by aromatization of the perfused androgens. An unequal distribution of the two estrogens was observed, i.e., a significantly larger proportion of E2 than of E1 was released to the maternal perfusate. Addition of unlabeled A or ethinyl estradiol (10(-5)M) to the fetal perfusion buffer resulted in a redistribution of the E2 output toward the fetal perfusate. These in vitro results are similar to the findings of Walsh and McCarthy, who detected by tracer experiments an unequality in the in vivo fetomaternal distribution of the output of placentally produced E1 and E2 in rhesus monkeys. These results also support the possibility of the existence of saturable specific E2 carriers in the syncytiotrophoblast, postulated by the same authors to explain their findings. However, an extrasyncytial conversion of E2 to E1 could also account for the disproportion in the relative output of the estrogens toward mother and fetus. The perfusion system used in these studies may be useful for the elucidation of factors determining the relative rates of placental secretion of steroids toward mother and fetus.

Previously, we reported that short term administration of a highly potent GnRH agonist (GnRHa) for 1 month to patients with polycystic ovarian disease (PCO) resulted in complete suppression of ovarian steroidogenesis without measurable effects on adrenal steroid production. This new study was designed to evaluate the effects of long term GnRHa administration in PCO patients with respect to their hormone secretion patterns and clinical responses. Eight PCO patients and 10 ovulatory women with endometriosis were treated daily with sc injections of [D-His6-(imBzl]),Pro9-NEt]GnRH (GnRHa; 100 micrograms) for 6 months. Their results were compared to hormone values in 8 women who had undergone bilateral oophorectomies. In response to GnRHa, PCO and ovulatory women had rises of serum LH at 1 month, after which it gradually declined to baseline. In both groups FSH secretion was suppressed throughout treatment. Serum estradiol, estrone, progesterone, 17-hydroxyprogesterone, androstenedione, and testosterone levels markedly decreased to values found in oophorectomized women by 1 month and remained low thereafter. In contrast, serum pregnenolone and 17-hydroxypregnenolone were partially suppressed, and dehydroepiandrosterone, dehydroepiandrosterone sulfate, and cortisol levels did not change. Clinically, hyperplastic endometrial histology in three PCO patients reverted to an inactive pattern, and proliferative endometrium in two other PCO patients became inactive in one and did not change in the other. Regression of proliferative endometrial histology occurred in all ovulatory women. Vaginal bleeding occurred in all women studied during the first month of GnRHa administration, after which all but one PCO patient became amenorrheic. Hot flashes were noted by all ovulatory women and by four of eight PCO patients. All PCO patients noted subjective reduction of skin oiliness, and five had decreased hair growth. We conclude that in premenopausal women: 1) chronic GnRHa administration results in apparently complete persistent suppression of ovarian steroid secretion; 2) adrenal steroid secretion is not influenced directly or indirectly; and 3) its use may be helpful in the treatment of endometrial hyperplasia and ovarian androgen excess in women with PCO.