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Although opioids are known to affect neurogenesis in vivo, it is uncertain the extent to which opioids directly or indirectly affect the proliferation, differentiation or death of neuronal precursors. To address these questions, the intrinsic role of the opioid system in neurogenesis was systematically explored in cerebellar external granular layer (EGL) neuronal precursors isolated from postnatal mice and maintained in vitro. Isolated neuronal precursors expressed proenkephalin-derived peptides, as well as specific mu and delta, but negligible kappa, opioid receptors. The developmental effects of opioids were highly selective. Morphine-induced mu receptor activation inhibited DNA synthesis, while a preferential delta2-receptor agonist ([D-Ala2]-deltorphin II) or Met-enkephalin, but not the delta1 agonist [D-Pen2, D-Pen5]-enkephalin, inhibited differentiation within the same neuronal population. If similar patterns occur in the developing cerebellum, spatiotemporal differences in endogenous mu and delta opioid ligand-receptor interactions may coordinate distinct aspects of granule neuron maturation. The data additionally suggest that perinatal exposure to opiate drugs of abuse directly interfere with cerebellar maturation by disrupting normal opioid signalling and inhibiting the proliferation of granule neuron precursors.

Objective: To study the effect of freezing on early stage embryos derived from intracytoplasmic sperm injection (ICSI) or from IVF., Design: Prospective, controlled clinical study., Setting: Private IVF center., Patient(s): Sixty-seven consecutive patients undergoing frozen-thawed embryo transfer cycles., Intervention(s): Early stage embryos were frozen, thawed, and transferred., Main Outcome Measure(s): Post-thaw survival, implantation and pregnancy rates., Result(s): We noted an 88% post-thaw survival rate, an 18% implantation rate, and a 52% pregnancy rate in the ICSI group and 81%, 11%, and 25%, respectively, with conventional fertilization., Conclusion(s): Early stage embryos (either zygote or 2-4 cells) derived from ICSI can be frozen with confidence and higher post-thaw survival and pregnancy rates can be achieved when compared with those from conventional IVF.

Objective: To study the effect of in vitro culture on the quality of human testicular sperm and the efficiency of intracytoplasmic sperm injection with in vitro cultured testicular sperm., Design: Clinical study., Setting: A private IVF center., Patient(s): Twenty consecutively seen IVF patients undergoing testicular biopsies for ICSI., Intervention(s): The testicular specimens were cultured in vitro for 24 hours and the isolated spermatozoa were microinjected., Main Outcome Measure(s): Preincubation and postculture sperm motility, and fertilization, implantation, and pregnancy rates after intracytoplasmic sperm injection., Result(s): Motility increased from initial nonmotile or twitching sperm to free motile sperm in 18 of 20 cases. The injection of in vitro cultured testicular sperm resulted in a fertilization rate of 58%, an implantation rate of 20%, and a pregnancy rate of 45%., Conclusion(s): A testicular biopsy procedure can be performed the day before egg retrieval. Despite the low initial sperm quality, a high percentage of the prepared testicular sperm showed increased motility after 24 hours of culture. The injection of in vitro cultured testicular sperm into matured oocytes resulted in fertilization, implantation, and pregnancy rates comparable to those obtained with ejaculated sperm.

Objective: The coculture of human embryos with epithelial cells may improve both embryo quality and pregnancy rates. In this current study we tested the efficacy of coculture with the buffalo rat liver cell line on pregnancy rates in women with a potentially poor prognosis for success with in vitro fertilization (previous in vitro fertilization failure, advanced maternal age, increased early follicular follicle-stimulating hormone levels, and anovulation)., Study Design: This prospective controlled study evaluated a total of 203 women (135 coculture, 68 controls) undergoing in vitro fertilization. Implantation rates per embryo, clinical pregnancy rates, and continuing/delivered pregnancy rates were analyzed., Results: Buffalo rat liver cells, which are commercially available, are stable in coculture. Implantation rates (number of sacs with fetal heart motion per embryos transferred) were similar for coculture (19%) and control (18%) embryos. No difference in the rate of continuing/delivered pregnancies per retrieval was noted (17% coculture vs 14% control) in the group with advanced maternal age, but coculture caused a trend toward improved pregnancy rates in the group with ovulatory dysfunction (43% coculture vs 14% control) and the group with previous in vitro fertilization failure (34% coculture vs 28% control)., Conclusion: This is the first published controlled study to our knowledge that reports the use of the buffalo rat liver cell coculture for human in vitro fertilization in a large number of patients. Our data support consideration of buffalo rat liver coculture for in vitro fertilization for women with previous in vitro fertilization failure and possibly for patients with oocyte or ovulatory dysfunction.

Objective: To evaluate the effect of nonselective assisted hatching on pregnancy rate (PR) and to provide an alternative and simplified method for clinical application of assisted hatching., Design: Retrospective analysis of clinical data., Setting: Private infertility practice., Patient(s): Women from 258 consecutive stimulated IVF cycles., Intervention(s): Assisted hatching was performed on each transferred embryo regardless of patient history, embryo morphology, or other selection criteria routinely applied to many IVF programs., Main Outcome Measure(s): Pregnancy, live birth, and implantation rates., Result(s): Of 258 consecutive patients who had nonselective assisted hatching, 109 (42%) had clinical pregnancies, with 93 (36%) live births and 178 (20%) embryos implanted., Conclusion(s): Nonselective assisted hatching resulted in an acceptable PR and provided an alternative and simplified method for clinical application of assisted hatching.

Endometrial biopsies for evaluation of the luteal phase should be taken within 2 days of the onset of menses. When these guidelines are followed and patients present at least 12 days after the thermogenic shift on BBT, the ICON pregnancy test is extremely rapid, sensitive, specific, and has predictive values close to 100%. If a biopsy is undertaken before this time there may be an increased risk of false negative results (i.e., a decreased sensitivity). The improved technology in urine pregnancy tests has now made it feasible to obtain accurate urine pregnancy tests before endometrial instrumentation with an increased level of confidence. It is recommended that this technology be used in the management of patients undergoing endometrial biopsies in the late luteal phase.

The effect of the CO2 laser and microelectrocautery on postoperative intraperitoneal adhesions was examined in 31 female rabbits. Standard injuries were performed and/or repaired with each technique on the uterine peritoneum, the right uterine horn, and the left ovary. The animals were sacrificed 5 weeks later, and the adhesions were graded at each site. No significant differences were found between the two techniques for each site or all sites collectively (P greater than 0.05). The ovary had more extensive adhesions than the other soft tissue site (P less than 0.01) with both techniques. The present study suggests that there is no apparent difference between CO2 laser and conventional microelectrocautery on adhesion formation, and that the ovary seems particularly prone to adhesion formation with either technique.

In patients with prolactin (PRL)-secreting tumors, plasma PRL concentrations after discontinuation of bromocriptine therapy have been used clinically as an index of tumor activity. To investigate the pattern of PRL response under these conditions, seven women on chronic bromocriptine therapy for PRL-producing pituitary tumors were followed with serial PRL determinations for 2 months after bromocriptine withdrawal. In these patients, peak PRL concentrations were achieved 28.1 days (mean; range, 14 to 49 days) after bromocriptine discontinuation. However, PRL concentrations did not usually plateau until at least 40 days after cessation of therapy, and the pattern of PRL response was highly variable. Because of the inconsistent pattern of serum PRL response during the first 40 days after discontinuation of bromocriptine, decisions regarding tumor activity based on PRL concentrations should not be made until at least 6 weeks after withdrawal of the drug.

Adhesiolysis was evaluated in 82 women who had 129 laparoscopies for in vitro fertilization and embryo transfer (IVF-ET). Fifty-five women (67%) had lysis during the first laparoscopic attempt, and 20 of the 129 laparoscopies (16%) required lysis for identification and aspiration of follicles. In 11 women who had a second laparoscopy, 69% of the ovaries had improved access. With the use of laparoscopic lysis, only 3 of 82 women (4%) had insufficient ovarian access, preventing recovery of at least one oocyte. The findings support the efficacy of laparoscopic adhesiolysis and indicate that it has an important role in a program of IVF-ET in assuring initial access for oocyte recovery and in improving access for subsequent attempts.

The usefulness of a short-interval second-look laparoscopy (SLL) after ovarian surgery was examined. In 23 infertile women who had either bilateral wedge resection (BWR) of polycystic ovaries, an oophorocystectomy (OC), or resection of endometriomata (RE), adhesions were graded before and after surgery and before and after laparoscopic lysis for each ovary. At SLL, periovarian adhesions involving at least one ovary were observed in all women. Of the 22 women who wanted to become pregnant, 3 of 3 with BWR, 1 of 3 with OC, and 6 of 16 with RE conceived. In the women with residual adhesive disease in both or the only remaining adnexa after SLL, there were no pregnancies; whereas 67% of the women with at least one adnexa free of disease became pregnant (P = 0.005). This preliminary study indicates that ovarian surgery does result in significant adhesion formation and that SLL offers an opportunity to reassess the pelvis, to lyse adhesions, and to establish a postoperative prognosis.

Twenty-seven patients underwent ultrasonographic and clinical monitoring of a spontaneous cycle so that human chorionic gonadotropin administration could be timed in an attempt to schedule the screening laparoscopy at the optimal time for oocyte aspiration. Inadequate ovarian access was encountered in only 2 of 26 laparoscopies. Seven patients had ovulated by the time of scheduled laparoscopy. Nine mature, seven immature, and three postovulatory oocytes were obtained, and seven embryo transfers were accomplished. The number of eggs obtained per laparoscopy was 0.73. The attempt to control the time of ovulation was unpredictable, few mature oocytes were obtained, and the procedure offered little ultimate benefit to the patient.

The choice of clomiphene citrate (CC) and human menopausal gonadotropin (hMG) protocols for stimulation of ovarian follicular maturation has traditionally not been made with regard to the anatomic status of the pelvis. To evaluate whether hormone production and/or follicular development vary based on the number of ovaries and/or the method of stimulation, 117 cycles were reviewed. Forty-five women received CC, 29 with two ovaries and 16 with one ovary. Seventy-two women received hMG, 50 with two ovaries and 22 with one ovary. Among women receiving CC, those with two ovaries tended to have higher initial estradiol levels and a greater number of large (greater than or equal to 15 mm) follicles. Among women receiving hMG, those with two ovaries tended to have higher estradiol levels, but the number of large follicles (greater than or equal to 15 mm) was similar. With either stimulation protocol, women with two ovaries developed a higher total number of follicles than women with one ovary. The total number of follicles in women with one ovary was similar for hMG and CC stimulations. The number of oocytes recovered at laparoscopy was greater in women with two ovaries who received hMG in comparison with CC, but did not significantly vary between women with one or two ovaries who received CC nor between women with one or two ovaries who received hMG. The number of oocytes was also similar for the women with one ovary regardless of stimulation protocol.

Because of the failure to conceive after the first cycle of in vitro fertilization (IVF), many couples often undergo repeated attempts. However, choosing the best stimulation protocol in successive cycles of IVF in the same individual is hindered by the lack of information regarding outcome in successive cycles following utilization of the same or different stimulation protocols. Examination of repeated cycles of the same stimulation protocol in 33 women demonstrated that comparing women with an initial "A" estradiol (E2) pattern (daily E2 levels that continued to rise throughout the stimulation) and those with non-A E2 patterns (failure to have continually rising E2 levels throughout the stimulation), the former were significantly less likely to have a subsequent passed cycle (P = 0.007) and tended to be more likely to have a subsequent A cycle (P = 0.079). Changing the stimulation protocol resulted in a different E2 pattern in 15 of 20 subsequent cycles. Thus, it is suggested that after a cycle with an acceptable E2 pattern, successive cycles be performed with the same stimulation protocol. However, after an initial unacceptable E2 pattern, it may be more efficacious to utilize an alternate stimulation protocol.

Complete cervical canal obstruction is a rare complication of cone biopsy and may result in retrograde menstrual flow, hematometria and infertility. We treated a patient who had postconization obstruction and ultimately a successful pregnancy after combined vaginal and abdominal reconstruction of the cervical canal.

Ninety-one pregnancies were monitored prospectively with serial human chorionic gonadotropin (hCG) determinations and real-time sonography. The monitoring process included an initial hCG doubling time (DT) followed by sonographic examination for fetal heart motion at 7 to 8 weeks in the asymptomatic patient. In women with an abnormal DT or who developed symptoms, repeat hCG determinations and/or sonography were performed. A single DT correctly identified 95% of the successful pregnancies (58) and 64% of the abnormal pregnancies (25 abortions and 8 ectopic gestations) in asymptomatic women. With repeat hCG determinations and/or sonography, 88% of the spontaneous abortions (before aborting) and 100% of the ectopic pregnancies (before tubal rupture) were identified. As a result of the early diagnosis, conservative surgery was performed in six of eight women with tubal pregnancies. The presence of fetal heart motion was a reliable indicator that an intrauterine pregnancy will progress to viability in both the symptomatic (89%) and asymptomatic patient (93%). We conclude that the combined use of serial hCG determinations and real-time sonography provides efficacious monitoring of the early high-risk pregnancy.

Polyspermy is a potential complication of attempts at in vitro fertilization. Nine polyspermic oocytes were identified among 169 oocytes obtained from 67 cycles stimulated by human menopausal gonadotropin. Cleavage to the 2-, 3-, and 4-cell stage was observed. Four polyspermic oocytes were identified among 85 oocytes obtained from 47 cycles stimulated by clomiphene citrate. Cleavage was not observed. Careful dispersion of cumulus cells at 15 to 18 hours and examination of the oocytes for polyspermy is essential, because the condition may not be apparent at 40 hours from insemination, when normal-appearing cleavage stages may be observed.

In an attempt to minimize the infectious morbidity of hysterosalpingography, the efficacy of oral doxycycline prophylaxis was examined. The records and hysterosalpingograms of 278 consecutive women (group 1) were reviewed to correlate the radiologic findings and the development of acute pelvic inflammatory disease (PID) after hysterosalpingography. Four women (1.4%) developed PID and all four had tubal dilatation. The overall frequency of PID in women with dilated tubes was 4/35 (11%). Subsequently, 56 of 326 women (group 2) with tubal dilatation received oral doxycycline prophylaxis. No cases of PID were observed in the 56 women who had antibiotic prophylaxis (p less than 0.02) or in group 2 as a whole. The study suggests that the risk of infection after hysterosalpingography is very low when nondilated tubes are present (0/398 women of groups 1 and 2). The relative risk of PID in women with peritubal disease or proximal tubal occlusion, although apparently low, remains to be determined. Furthermore, in the highest-risk group of women with dilated tubes, doxycycline prophylaxis was effective in reducing infection after hysterosalpingography.

Compartmental ovarian steroidogenesis in vitro was investigated in polycystic ovary syndrome. Basal estrogen secretion by granulosa cells ranged from 60 to 284 pg/micrograms cell protein for 24 hours and progesterone secretion from 24 to 1646 pg/micrograms cell protein for 24 hours. In three of four specimens, the addition of either 10(-5)M testosterone or androstenedione significantly increased estrogen production, demonstrating the presence of aromatase activity. Treatment with human follicle-stimulating hormone (100 ng/mL) or human chorionic gonadotropin (100 ng/mL) significantly increased the progesterone production in three of four specimens. The thecal compartment of every patient secreted significantly more testosterone and androstenedione than the capsule and stroma and more estrogen in tissue from two of the four women. The androgen/estrogen ratio was significantly greater for the theca (16.9) than the capsule (1.1) or stroma (1.7). These data demonstrate that in polycystic ovary syndrome a portion of the follicles possess the qualitative characteristics of developing follicles, granulosa cell aromatase activity and gonadotropin responsiveness, and that the theca is likely the principal site of ovarian androgen synthesis. These findings suggest that the small follicles characteristic of polycystic ovary syndrome consist of a mixed population of developing and atretic follicles and that the peripheral androgen excess is attributable to the large mass of the thecal compartment from both follicle populations.

Laparoscopic management of selected cases of tubal pregnancy may be an alternative to the conventional approach, laparotomy. Twenty-seven patients were managed with this technique; each had a readily accessible unruptured ampullary pregnancy less than 4 cm in diameter. All but one went home by the second hospital day. One suffered an immediate postoperative hemorrhage that required laparotomy to control. Six of eight patients tested from three to ten months after the operation had tubal patency. Five of eight patients attempting conception have become pregnant, with one repeat ipsilateral tubal pregnancy. In five patients, serum beta-human chorionic gonadotropin remained elevated for more than 30 days after laparoscopy with no untoward effect. Although insufficient data exist to compare reproductive outcome after this technique with that after laparotomy, in properly selected cases operative laparoscopy seems to be safe and effective conservative therapy, decreasing the need for laparotomy and the duration of hospitalization.

There is transferrin-like protein present in the follicular fluid of stimulated ovarian cycles. The transferrin concentration correlates with the follicular morphologic maturity and steroidogenesis, varies among follicles, and often exceeds serum concentrations. An intermediate range of transferrin concentration is associated with the highest likelihood of oocyte fertilization in vitro. The biological significance of these observations may relate to an optimum degree of follicle maturation.

Clinical and laboratory evaluations of nine hirsute women were performed for determination the efficacy of combination drug therapy. Each patient had previously failed to respond to single drug therapy with oral contraceptives (OC), dexamethasone (DEX), or spironolactone (S) and received S (100 to 150 mg) and either an OC (mestranol, 0.05 to 0.08 mg, and norethindrone, 1 mg) or DEX (0.5 mg) daily. Total testosterone, dehydroepiandrosterone sulfate, free testosterone, and sex-hormone-binding globulin were measured before therapy and 4 to 6 weeks after initiation of therapy and were compared with the responses to OC (n = 7), DEX (n = 8), and S (n = 6). A satisfactory clinical response in the rate of hair growth was defined as at least a doubling of the time interval between adjunctive therapies (electrolysis, shaving, or bleaching) and patient satisfaction with treatment. The responses of the androgenic parameters were not statistically different between combination and single drug therapy. Although all patients noted a subjective improvement in hair growth, eight of nine fulfilled the criteria for a clinical response (P less than 0.001). Transient diuresis was the only side effect noted. The study suggests that combination drug therapy is an efficacious and well-tolerated approach to the management of unresponsive hirsutism.

The oral route of progesterone administration has long been considered impractical because of poor absorption and short biologic half-life. Recent reports suggest that micronization of progesterone enhances absorption and increases serum and tissue levels of progesterone. This study checks serum progesterone levels before and 0.5, 1, 2, 3, 4, and 6 hours after oral administration of 200 mg of progesterone in seven subjects. Progesterone was plain milled, micronized, plain milled in oil, micronized in oil, or micronized in enteric-coated capsules. All patients exhibited a significant increase in serum progesterone levels after oral progesterone administration. Mean peak progesterone levels (30.3 +/- 7.0 ng/ml) (p less than 0.005) were achieved with micronized progesterone in oil at 2.0 +/- 0.3 (p less than 0.05) hours after administration. Four types of oral progesterone had equivalent mean peak elevations and mean times to peak: plain milled, 9.6 +/- 2.5 ng/ml at 4.0 +/- 0.5 hours; micronized 13.2 +/- 2.4 ng/ml at 3.2 +/- 0.4 hours; plain milled in oil, 11.3 +/- 3.0 ng/ml at 4.0 +/- 0.5 hours; and micronized in enteric-coated capsules, 11.2 +/- 3.0 ng/ml at 4.1 +/- 0.7 hours. Contrary to traditional teaching, these data show that significant serum progesterone levels can be achieved by oral administration. Absorption can be significantly improved by the physical characteristics of the progesterone and the vehicle used with oral administration.