Suppression of ovarian function with the transdermally given synthetic progestin ST 1435.

To study transdermal administration of the synthetic progestin ST 1435 and effectiveness of the steroid in suppression of ovarian function. The effect of transdermal administration of the synthetic progestin ST 1435 in suppression of ovarian function was studied in a short term (17 to 93 days) study in healthy regularly menstruating women. The outpatient clinic of the City Maternity Hospital, Helsinki, Finland. Nine women used the progestin ST 1435 transdermally during a total of 21 menstrual cycles. Treatment was started on the 5th day of the menstrual cycle and continued for 17 to 93 days. Three different daily doses (0.5, 0.8, and 1.0 mg) were tested. The steroid was applied to the periumbical area once a day in a gel. Serum concentrations of ST 1435, progesterone, and estradiol (E2) were determined during the luteal phase of control cycles and in a total of 16 treatment cycles. Bleeding records were kept and side effects registered. Transdermal absorption of the progestin ST 1435 resulted in relatively constant serum concentrations in each subject, depending on the dose used. All doses caused changes in ovarian function. With the 0.5-mg/d dose, inhibition of ovulation was observed in three of five treatment periods. The 0.8-mg/d dose was high enough to inhibit ovulation in 7 of 10 cycles analyzed. With the 1.0-mg/d dose, the serum concentrations of the progestin were high, and anovulation was seen. Serum E2 concentrations were variable in all cases; occasional high peak values were seen, typical of progestin treatment. Bleeding control was variable; irregular bleeding was seen, especially in anovulatory cases. A 0.8-mg dose of the progestin ST 1435 administered transdermally once a day appeared to suppress ovulation, if properly applied, and excessive suppression of ovarian function was not seen. The steroid was well accepted. The synthetic progestin ST 1435 given transdermally represents an effective alternative for inhibition of ovulation and for progestin therapy.


Daily levels of salivary progesterone during menstrual cycle in adolescent girls.

To study the daily levels of salivary progesterone (P) during the menstrual cycles of adolescent girls 14 to 19 years of age and the occurrence of anovulations and defective luteal phases. The salivary P levels were analyzed by radioimmunoassay from three age groups of girls (n = 65) and compared with groups of 20 to 25 years (n = 14) and 25 to 43 years old women (controls, n = 19). One cycle per subject was used in the analyses. The randomly selected healthy schoolgirls were divided into three groups according to their postmenarcheal years: 1 to 2, 3 to 4, and 5 to 6 years (n = 15, 29, and 21, respectively). The youngest group had longer cycles and follicular phases than the older ones, but their mean luteal phase parameters did not differ. Interestingly, signs of temporary derangement of corpus luteum (CL) function (e.g., suppressed P secretion parameters) were observed in the group of 3 to 4 years. In the young adults (20 to 25 years old), the mean P secretion parameters did not differ significantly from the controls. There were more anovulatory cycles in the adolescent groups (25% to 33%) and in young adults (29%) than in controls (0%). About one third of the cycles are anovulatory from the age of 14 and 15 up to 20 to 25 years. In contrast to earlier findings, CL usually functions fully even in the first ovulatory cycles. Transient disturbances in luteal phase P secretion are most common 3 to 4 years after menarche.


The role of blocking factors and antipaternal lymphocytotoxic antibodies in the success of pregnancy in patients with recurrent spontaneous abortion.

To elucidate the role of mixed lymphocyte reaction blocking factors (BF) and complement-dependent antipaternal lymphocytotoxic antibodies on the outcome of pregnancy in unexplained recurrent spontaneous aborters. A controlled study of immunotherapy in which the treated group was immunized with the husband's or a third party donor's lymphocytes and the control group received autologous lymphocytes. Tertiary care institution. Forty-three patients in the control group and 48 patients in the treated group. The before and after immunization levels of BF and antipaternal lymphocytotoxic antibodies were measured. The existence or changing pattern of BF and antipaternal lymphocytotoxic antibodies levels before and after immunization had no influence on the pregnancy outcome in either group of patients. Neither BF nor antipaternal lymphocytotoxic antibodies is essential for successful pregnancy. They probably reflect the immunological response of the mother to exposure to fetal antigens.


Serum androgen and gonadotropin levels decline after progestogen-induced withdrawal bleeding in oligomenorrheic women with or without polycystic ovaries.

To examine the effect of short-term progestogen treatment on androgen, gonadotropin, and sex hormone-binding globulin (SHBG) levels in oligomenorrheic women. Comparative study of changes in hormonal parameters in patients with or without ultrasonographically diagnosed polycystic ovarian disease (PCOD). Open patient clinic of reproductive endocrinology at University Central Hospital of Turku, Finland. Seventy-five oligomenorrheic women with (n = 51) or without (n = 24) PCOD. Serum concentrations of testosterone (T), androstenedione (A), dehydroepiandrosterone sulfate, luteinizing hormone (LH), follicle-stimulating hormone (FSH), and SHBG. The levels of T, A, LH, and the LH:FSH ratios decreased significantly after oral treatment with medroxyprogesterone acetate (10 mg/d for 10 days) in non-PCOD women and in women with PCOD decreasing the frequencies of pathological laboratory findings, in particular elevated levels of LH:FSH ratio and A in PCOD women and of LH:FSH ratio in non-PCOD women. The levels of T, A, and LH as well as the LH:FSH ratio were significantly higher in women with PCOD. Obesity was associated with high free androgen indices, low LH:FSH ratios, and low concentrations of LH, A, and SHBG. The serum samples for hormonal analyses used as an aid in diagnosing PCOD should be obtained without pretreatment with progestogen because it masks the biochemical findings of PCOD.


A unique point mutation in the androgen receptor gene in a family with complete androgen insensitivity syndrome.

To further delineate the diversity of genetic alterations in the gene coding for the androgen receptor in individuals with the androgen insensitivity syndrome and to increase our understanding of the disease at the molecular level. This was a prospective study in which genomic deoxyribonucleic acid (DNA) from individuals with androgen insensitivity were examined through the polymerase chain reaction and DNA sequencing analysis. Eleven complete and four individuals with partial androgen insensitivity syndrome were examined. Exons two through eight were grossly intact in all study subjects. Nucleotide sequence analysis revealed that three of three related family members with complete androgen insensitivity had the same guanine to adenine base substitution in exon five of the steroid-binding domain. The subsequent alanine to threonine amino acid conversion may have resulted in a configurational change of the androgen receptor protein leading to complete androgen insensitivity. This precise alteration has not been previously identified in the human androgen receptor gene in patients with the androgen insensitivity syndrome.


Cutaneous application of an androstenedione gel as an in vivo test of 5 alpha-reductase activity in women.

Assessment of an in vivo test for 5 alpha-reductase activity using serum markers, 5 alpha-androstane-3 alpha,17 beta-diol glucuronide and androsterone glucuronide, after the cutaneous application of androstenedione (A). An A gel was applied for 6 days to the skin of normal women, male volunteers, and hirsute and nonhirsute patients with polycystic ovarian syndrome (PCOS). Blood samples were obtained at baseline and on day 6 of the A gel application. Blood samples were assayed for A, 5 alpha-androstane-3 alpha,17 beta-diol glucuronide, and androsterone glucuronide. In three hirsute women, the protocol was followed before and after receiving an oral contraceptive (OC) and spironolactone 200 mg/d for 3 months. The study was performed in the outpatient clinic of the Division of Reproductive Endocrinology and Infertility, Women's Hospital of the Los Angeles County and University of Southern California Medical Center in Los Angeles, California. A total of eight nonhirsute patients with PCOS, seven hirsute patients with PCOS, and six male volunteers were enrolled in the study. Five normal women served as a control group. Serum A increased after 6 days by a similar magnitude in all groups. Serum androsterone glucuronide showed a significant increase from baseline only in the hirsute group (P < 0.03), whereas the increase in 5 alpha-androstane-3 alpha,17 beta-diol glucuronide was not statistically significant. The ratio of the increases in serum androsterone glucuronide over serum A was significantly higher in the hirsute group (P < 0.02). In the three hirsute patients who were placed on an OC and spironolactone, serum 5 alpha-androstane-3 alpha,17 beta-diol glucuronide and androsterone glucuronide decreased after 3 months and did not increase with application of the gel for another 6 days. The cutaneous application of A provides a useful assessment of in vivo 5 alpha-reductase activity. However, because we found that A absorption varied considerably (30% to 62%), we suggest that this in vivo test may not provide more information than baseline determinations of 5 alpha-androstane-3 alpha,17 beta-diol glucuronide and androsterone glucuronide. It may, however, be useful as a parameter for assessing the effectiveness of various treatment regimens for hirsutism.


11 beta-hydroxyandrostenedione in plasma, follicular fluid, and granulosa cells of women with normal and polycystic ovaries.

To investigate the role of 11 beta-hydroxylase/11 beta-hydroxyandrostenedione (11-OHA) in the ovarian metabolism of androgens in women with polycystic ovaries (PCO) and its associated syndrome (PCOS). Prospective observational study examining the plasma and follicular fluid (FF) concentrations of 11-OHA, testosterone (T), androstenedione (A), and cortisol from women with PCOS and normal women in spontaneous and stimulated cycles. The study was carried out in an infertility department and an endocrine research laboratory of a university hospital. Five groups of women were studied. Blood was taken from 53 women with PCOS and 13 normal controls. Follicular fluid and blood was obtained from 51 women with stimulated cycles undergoing in vitro fertilization embryo-transfer (IVF-ET), 27 of whom had PCO and 24 had normal ovaries. Follicular fluid alone was also taken from 13 women with normal ovaries undergoing laparoscopies. Clear FF was obtained for analysis during oocyte collection. Granulosa cells (GCs) were obtained from seven women with PCO undergoing IVF-ET and were incubated with radiolabeled substrates. Circulating concentrations of T and 11-OHA were higher in women with PCOS compared with women with normal ovaries. In women with PCO receiving exogenous gonadotropin, only 11-OHA concentrations were higher. Concentrations of all steroids measured were higher in FF than plasma, with plasma 11-OHA concentrations 4 to 12 times higher in FF. Significantly lower concentrations of 11-OHA were found in the FF of women with PCO compared with women with normal ovaries. There was no evidence of 11 beta-hydroxylation of A by GCs. Although the raised plasma concentrations of 11-OHA may reflect hyperandrogenism in PCOS and lower 11-OHA concentrations in FF in women with PCO suggest abnormal androgen metabolism, neither can be regarded as a marker for this syndrome.


Interleukin-1: local production and modulation of human granulosa luteal cells steroidogenesis.

To investigate the possibility of local interleukin-1 (IL-1) and IL-1 inhibitor production by human granulosa and cumulus cells and to assess their direct effects on the steroidogenesis of these cells in vitro. Prospective study. Normal ovulatory women undergoing ovulation induction for in vitro fertilization. Pretreatment of patients with gonadotropin-releasing hormone analogue, human menopausal gonadotropin, and human chorionic gonadotropin (hCG). Retrieval and isolation of granulosa luteal cells and follicular fluid (FF). Granulosa luteal cells and cumulus cells cultured and analyzed by fluorescent activated cell sorter. Follicular fluid separated and bioassayed for IL-1 and IL-1 inhibitory activity. Steroid measurement performed. Interleukin-1 inhibitor purified. Interleukin-1 and IL-1 inhibitor bioassay performed. Statistical analysis made and interpreted. Interleukin-1, but not IL-1 specific inhibitory activity, was found in granulosa and cumulus cell cultures and also in FF, only after its purification on a high-pressure liquid chromatography column. Under nonstimulated conditions, neither IL-1 nor IL-1 inhibitor had any effect on basal progesterone (P) or estradiol (E2) secretion. However, IL-1 inhibitor demonstrated significant (P < 0.01) inhibition of hCG-stimulated P secretion (from 200 to 110 ng/10,000 cells per 24 hours). In addition, IL-1 demonstrated a significant (P < 0.05) and dose-dependent inhibition of hCG-stimulated E2 production (from 6,832 +/- 460 to 4,237 +/- 141 pg/10,000 cells per 24 hours). Interleukin-1 may exert a significant local autocrine regulatory role in the human ovary.


Effect of growth hormone administration on human ovarian function and steroidogenic gene expression in granulosa-luteal cells.

To study the effect of growth hormone (GH) in combination with an ultrashort-term gonadotropin-releasing hormone analogue/human menopausal gonadotropin (hMG)/human chorionic gonadotropin (hCG) regimen in ovarian hyperstimulation for in vitro fertilization (IVF). Prospective randomized placebo-controlled study. University-based IVF program. Fifty-four normally cycling women (27 control and 27 GH-treated) participated in this study. Human recombinant GH (24 IU)/placebo was given intramuscularly on alternate days starting on cycle day 4 until the day of last hMG injection. Serum estradiol (E2) and progesterone (P) concentrations were slightly lower in the GH group than in the placebo group on the day of hCG injection and 1 day thereafter (P < 0.01 to 0.001). Serum luteinizing hormone, follicle-stimulating hormone, prolactin, testosterone (T), and sex hormone-binding globulin did not differ between the groups. The follicular fluid (FF) concentration of T was higher in the GH group than in the placebo group (15.9 +/- 6.0 nmol/L versus 10.2 +/- 4.9 nmol/L, P < 0.005), and no differences were observed in the FF concentrations of E2, P, and insulin-like growth factor I between the groups. In granulosa cells isolated from patients who received GH treatment, the levels of 3 beta-hydroxysteroid dehydrogenase and aromatase messenger ribonucleic acid were significantly higher than in the patients receiving placebo. The number of hMG ampules needed for follicular development and the number of follicles and oocytes recovered were similar in both groups. These results indicate that GH administration modifies ovarian steroidogenic response to gonadotropins in IVF patients, suggesting a role for GH in the regulation of human ovarian function.


Ovarian steroids modulate human monocyte tumor necrosis factor alpha messenger ribonucleic acid levels in cultured human peripheral monocytes.

To determine whether tumor necrosis factor alpha (TNF-alpha) messenger ribonucleic acid (mRNA) levels in human peripheral monocytes are regulated by ovarian steroids. Human granulosa-luteal cells and cultured, activated human peripheral monocytes were subjected to Northern blot analysis for TNF-alpha mRNA. Academic research laboratory. Two human female volunteers of reproductive age and in the luteal phase of the menstrual cycle. Human granulosa-luteal cells produce TNF-alpha mRNA. Physiological levels of progesterone (P) and estradiol (E2) modulate TNF-alpha mRNA from peripheral blood monocytes with an apparent inverse relationship between steroid concentration and TNF-alpha message. Progesterone and E2 at physiological concentrations regulate TNF-alpha mRNA production. The P antagonist mifepristone (RU486) and the E2 agonist/antagonist tamoxifen modulate total TNF-alpha mRNA levels, suggesting involvement of specific receptors.


The effects of spontaneous luteinizing hormone surges on superovulatory cycles.

To determine the effect of a spontaneous luteinizing hormone (LH) surge on the cycle fecundity during superovulation induction. Superovulatory cycles of patients with various diagnoses are retrospectively compared. Reproductive Endocrinology Outpatient Clinic. A total of 1,185 superovulatory cycles from July 1, 1982 until November 1, 1991 are compared. The probability of achieving a pregnancy per treatment cycle. Patients with unexplained infertility and hyperprolactinemia were more likely to have a spontaneous LH surge during superovulation than patients with either endometriosis or polycystic ovarian disease. However, the cycle fecundity rate did not differ whether or not an LH surge occurred, regardless of the diagnosis. Spontaneous onset of an LH surge during superovulation induction does not influence the chances for pregnancy.


A prospective randomized comparison of luteal phase versus concurrent follicular phase initiation of gonadotropin-releasing hormone agonist for in vitro fertilization.

To compare the effects of gonadotropin-releasing hormone agonist (GnRH-a) initiation either preceding or concurrent with controlled ovarian hyperstimulation (COH) in patients undergoing in vitro fertilization-embryo transfer (IVF-ET). Fifty-five patients were prospectively randomized to receive either GnRH-a on cycle day 21 before COH until ovarian suppression was achieved (group I) or GnRH-a concurrently with COH commencing on cycle day 3 (group II). Serum gonadotropin and ovarian steroid hormone levels, as well as fertilization, spontaneous abortion, and live birth rates. Twenty-six patients in group I and 29 patients in group II underwent COH for IVF-ET. Patients in group II had significantly higher serum luteinizing hormone, progesterone, and testosterone levels during stimulation with human menopausal gonadotropins (hMG) before oocyte retrieval (P < 0.05). Despite similar fertilization, biochemical, and clinical pregnancy rates, the spontaneous abortion rate was higher in group II (5/6) compared with group I (1/7) (P < 0.05). Thus, the live birth rate/retrieval for group I was 6 of 24 (25%) as compared with that of group II, which was 1 of 26 (3.8%) (P < 0.05). The initiation of GnRH-a in the follicular phase concurrently with hMG is associated with evidence of premature luteinization, hyperandrogenemia, and poorer pregnancy outcome compared with luteal phase administration of GnRH-a before hMG for IVF-ET.


Nuclear degeneration and meiotic aberrations observed in human oocytes matured in vitro: analysis by light microscopy.

To apply an improved air-dry procedure for the light microscopic identification of both degenerate and aberrant meiotic configurations in cultured human oocytes. MATERIAL AND DESIGN: Meiotically immature, normal appearing human oocytes retrieved after oophorectomy were placed into culture for 9 to 46 hours. Subsequently, oocytes were assessed morphologically and then air dried for light microscopic examination of chromatin configurations. Oocyte chromatin configurations were identified as normal, degenerate, or aberrant and then classified according to meiotic stage. Retrospective analyses were conducted to determine if [1] normal meiotic configurations were associated with morphologically viable oocytes and [2] degenerate or aberrant meiotic configurations were always associated with degenerate oocytes. In addition, for each meiotic stage, the proportion of oocytes exhibiting either degenerate or aberrant chromatin configurations was calculated. Of 101 oocyte chromatin configurations analyzed, 71.3% were normal, 11.9% were degenerate, and 16.8% displayed meiotic aberrations. Retrospective analyses revealed that the majority of both normal and aberrant chromatin configurations were associated with morphologically viable oocytes (93.1% and 88.2%, respectively), whereas all of the degenerate chromatin configurations were associated with morphologically degenerate oocytes. When assessed by stage, nuclear degeneration was observed exclusively at the germinal vesicle and diakinesis stages, whereas meiotic aberrations occurred most frequently after chromosome condensation. These aberrations were manifested either as clumped metaphase I configurations or as two distinct groups of bivalents that appeared to result from bivalent migration along the meiotic spindle without homologue segregation. Slightly > 25% of human oocytes recovered after oophorectomy were incapable of undergoing normal meiotic maturation in culture. The majority of these abnormal oocytes appeared morphologically normal and yet possessed meiotic aberrations. These observations indicate that caution should be taken when using oocytes matured in vitro for application in assisted reproductive technology programs.


Effects of varicocele treatment in adolescents: a randomized study.

To study the effects of varicocele treatment on testicular function in adolescents. A prospective controlled study in 88 randomly selected adolescents. All participants were referred to the fertility outpatient clinic of our university hospital. All participants with a varicocele were randomly assigned into two groups. Group 1 (n = 33) was not treated, whereas group 2 (n = 34) was treated. A similar group of healthy volunteers without a varicocele served as a control group (group 3, n = 21). Testes volumes were measured at intake and during follow-up using an orchiometer. Semen analysis was performed according to standard procedures both at intake and after 1 year of follow-up. Serum hormone levels were determined at intake using a radioimmunoassay. Treatment was performed by means of transcatheter embolization of the left testicular vein. Testes volumes and semen quality at intake and after 1 year of follow-up were compared within and between the three groups. Hormonal parameters were determined at intake only. Before treatment, the mean left testis volume in groups 1 (n = 26) and 2 (n = 27) (20.0 mL; 95% confidence interval [CI]: 18.2 to 21.8 and 21.6 mL; 95% CI: 19.4 to 23.8, respectively) were significantly smaller than those in the control group (n = 19) (24.5 mL; 95% CI: 22.7 to 26.4). During follow-up, left testis volumes of the treated group were comparable with those in the control group (24.2 mL; 95% CI: 22.2 to 26.1 and 24.8 mL; 95% CI: 23.0 to 26.7 respectively) and significantly (P < 0.001) different from the untreated group (20.3 mL; 95% CI: 18.8 to 21.8). A significant increase in left (P < 0.01) as well as right (P < 0.05) testis volume was observed after treatment. Semen parameters before treatment were not significantly different between the three groups. Sperm concentration increased significantly (P < 0.01) from 47.4 x 10(6)/mL (95% CI: 42.5 to 53.3) to 68.9 x 10(6)/mL (95% CI: 50.6 to 87.2) in the treated group, whereas semen quality in the untreated and control groups did not change. Although both testes volumes and sperm concentration improved in the treated group, these phenomena were not consistently correlated to each other. Although not apparent in all adolescents, varicocele correction resulted in an increase in left testis volume and sperm concentration. At this moment, it is not clear if early preventive treatment of varicocele in adolescents, in time, will have a positive effect on testicular function.


Accuracy and precision of the CellForm-Human automated sperm morphometry instrument.

To evaluate the accuracy and precision of the CellForm-Human (CFH) automated sperm morphometry instrument (Motion Analysis Corp., Santa Rosa, CA). Clinical and research andrology and in vitro fertilization laboratories. Individuals undergoing semen evaluation and infertility work-up. Coefficients of variation for repeated measures of the same sperm were 1%. Coefficients of variation of normal sperm measurements were 7.4% to 12.8%, depending on the measure. Of the objects recognized as sperm by the instrument, 6.8% were debris; hence, the sperm recognition algorithms need improvement. Mean values for all CFH measures of normal sperm from specimens clinically classified as having predominantly normal, tapered, or amorphous sperm were not different; hence, the morphometry of normal sperm from normal specimens was similar to normal sperm from specimens with two different abnormalities. The instrument classified sperm as abnormal if their length or width fell outside a critical range of values recommended by the World Health Organization. Using this method, manual and CFH classification agreed unambiguously 60% of the time. When disagreement occurred, length or width marginally exceeded the range by no more than 0.1 microns. In these cases, the technician classified sperm as normal 25% of the time and classified them as abnormal 6% of the time. Because this disagreement between methods is well below the resolution of manual methods, the overall accuracy of CFH was 91% for cell type classification. At its present stage of development, the CFH instrument exceeds the accuracy and precision of most manual approaches. With improvements in sperm recognition and type classification algorithms, it could significantly improve the reliability of morphology assays in clinical and research laboratories.


Poor in vitro fertilization outcome with semen yielding low sperm density "swim-ups" is not because of altered sperm motion parameters.

To examine fertilization, cleavage, and pregnancy rates (PRs) with semen samples yielding numbers of total motile sperm per swim-up ranging from < 1 to > 20 x 10(6) and to correlate the findings with changes, if any, in the sperm motion parameters. Fertilization, cleavage, and pregnancy outcomes in 439 in vitro fertilization (IVF) cycles were correlated with the total number of motile sperm per swim-up and the sperm motion parameters as determined with an automated semen analyzer. A university-based tertiary referral hospital center. Patients undergoing IVF or intrauterine insemination treatments for multiple etiologies. Higher numbers of motile sperm per swim-up, most notably above the value of 3 x 10(6) motile sperm, were associated with improved fertilization rates and viable PRs. Sperm velocity, linearity, amplitude of lateral head displacement, and flagellar beat per cross frequency for sperm from swim-ups with poor or good pregnancy outcome, however, showed no significant differences. As a group, semen samples that yield < or = 3 x 10(6) motile sperm per swim-up are associated with poor fertilization rates, cleavage rates, and PRs. This relationship can not be attributed to differences in sperm motion parameters.


The culture of human epididymal epithelium and in vitro maturation of epididymal spermatozoa.

To promote human sperm maturation in vitro. Spermatozoa from the proximal epididymis were coincubated with epididymal epithelial fragments. Hospital and research institute. Tissue samples were obtained from men undergoing epididymovasostomy procedures or vasectomy. Fragments of epididymal epithelium formed everted epithelial spheres that in the presence of androgen maintained cell integrity. Coincubation for up to 48 hours of caput epididymal spermatozoa with 3-day-old epithelial cultures from the cauda epididymis was undertaken. Morphology of epididymal epithelium was assessed by light and electron microscopy. Pulse labeling of tissue in vitro with 35S-methionine was performed with analysis by sodium dodecyl sulfate-polyacrylamide gel electrophoresis technique and fluorography. Spermatozoa were assessed for progressive motility and their capacity to bind to salt-stored human zona pellucidae. Epididymal fragments formed everted epithelial spheres that maintained cell integrity and functional morphology for 5 to 7 days. Specific proteins were synthesized in culture, in particular, proteins of 20, 22, 40, and 66 kd. Coincubation of caput epididymal spermatozoa with cultures from the cauda epididymis induced a significant increase in progressive sperm motility and sperm binding to salt-stored human zona pellucidae compared with control cultures of epithelium incubated in the absence of androgens or overgrown with fibroblasts. Aspects of human sperm maturation processes can be mimicked in vitro using coculture techniques with epididymal epithelium. This method may be valuable for improving the fertilizing capacity of human spermatozoa retrieved from the proximal region of the excurrent ducts.


Defective function of a nongenomic progesterone receptor as a sole sperm anomaly in infertile patients.

To compare the function of a novel nongenomic progesterone (P) receptor on the human sperm surface (mediating the P-induced acrosome reaction) in spermatozoa from fertile donors and from infertile patients. To examine the possible implication of defective P receptor function as an etiologic factor in unexplained male infertility. Progesterone binding and P effects were assessed in sperm from infertile patients and compared with corresponding parameters for sperm from healthy donors. Private hospital, medical research center, and a university-based andrological laboratory. Sperm samples were from infertile patients (no pathology detected in their wives) attending our infertility clinic and from healthy sperm donors. None. Progesterone binding sites were visualized with a fluorescein-labeled protein-P conjugate. Indo 1-AM (a fluorescent indicator of intracellular free Ca2+) was used to measure P-induced Ca2+ influx. Progesterone-induced acrosome reaction was monitored after acrosomal staining with Pisum sativum agglutinin. Among 8 patient sperm samples with normal spermiogram values (of 53 examined), 5 showed a reduced percentage of P-binding spermatozoa and an abnormal response to the hormone in terms of Ca2+ influx and the acrosome reaction. Defective function of a sperm surface P receptor is described in some cases of male infertility. The observed fluorescence microscopic patterns of hormone binding may be used to further investigate receptor activity in unexplained male infertility.


Effect of abstinence on sperm acrosin, hypoosmotic swelling, and other semen variables.

To compare the variability of sperm acrosin and hypoosmotic swelling to the more standard semen variables in relationship to controlled periods of sexual abstinence using a defined group of men. Ten men abstained sequentially for 1, 2, 3, 4, 5, and 10 days and produced an ejaculate after each time period. The ejaculate variables measured at each time point were sperm acrosin, hypoosmotic swelling, volume, sperm number, sperm concentration, sperm motility, sperm morphology, pH, and white blood cells (WBCs). Comparisons were performed between the values obtained at each abstinence period. The percentage of hypoosmotically reactive spermatozoa did not vary significantly with the abstinence period. Sperm acrosin remained similar up to 5 days of abstinence but decreased almost twofold after 10 days of abstinence. The sperm volume and concentration increased gradually with the length of abstinence, being approximately twofold higher after 10 days of abstinence than after 1 day of abstinence. The total sperm number increased about fourfold from 1 day of abstinence to 10 days of abstinence. The percent normal sperm forms tended to increase until 5 days of abstinence but decreased after 10 days of abstinence. The WBC count showed only a small increase with longer abstinence periods. The pH remained essentially the same. The length of abstinence affects the various semen variables differently. An abstinence period of up to 10 days does not alter the hypoosmotic swelling test results. However, the sperm acrosin values decrease after prolonged abstinence so that the abstinence period needs to be taken into consideration when performing this assay.


Evaluation of acrosomal status using MH61-beads test and its clinical application.

To evaluate the acrosomal status of viable sperm by MH61-beads test and its clinical application. Acrosomal status was evaluated using immunobeads coated with MH61 monoclonal antibody, which is specific for acrosome-reacted sperm. When viable sperm was coincubated with MH61-beads for an appropriate length of time, the formation of a sperm-bead complex was observed with a phase-contrast microscope, and the number of sperm binding to MH61-beads increased with the progression of the acrosome reaction. Using this agglutination, we developed the MH61-beads test to assess sperm function. Department of Obstetrics and Gynecology, Osaka University Hospital. Forty-three volunteers and 20 males in our in vitro fertilization (IVF) and embryo transfer program. The results of MH61-beads test were compared with the percentage of acrosome-reacted sperm detected by Pisium satinum agglutinin staining on 30 volunteers, with the results of sperm penetration assay (SPA) in 43 volunteers, and with the outcome of IVF in 20 patients. The results of MH61-beads test showed good reproducibility and correlated with the results of SPA using zona-free hamster eggs and IVF. The MH61-beads test, the results of which reflect the acrosomal status of sperm, may provide useful information concerning the fertilizing ability of sperm.


Reactive oxygen species generated by human neutrophils inhibit sperm motility: protective effect of seminal plasma and scavengers.

To investigate whether activated poly-morphonuclear neutrophils (PMN) can affect sperm motility and to assess the capacity of seminal plasma and of scavengers of reactive oxygen species to prevent any loss of motility. Blood PMN were isolated, and their capacity to generate reactive oxygen species was investigated. The effect of activated PMN was tested on the motility of Percoll-washed spermatozoa in the presence and absence of reactive oxygen species scavengers or seminal plasma (whole or fractionated). Fertile volunteers and patients attending the Infertility Clinic at the Royal Victoria Hospital. The production of reactive oxygen species by activated PMN occurred in the 1st hour after stimulation and was linearly correlated with the concentration of PMN. Percoll-washed spermatozoa had reduced motility in the presence of PMN, and the drop in motility was more severe as the concentration of PMN was increased. Catalase and dimethylsulfoxide reduced the toxic effect of PMN on sperm motility, whereas superoxide dismutase was without effect. Seminal plasma (50%, vol/vol) allowed a highly variable protective effect against the loss of sperm motility that appeared to originate predominantly from the low molecular weight (< 10 kd) fraction but also from the high molecular weight (> 12 kd) fraction of seminal plasma. These data suggest that [1] the presence of PMN, even at 0.6 x 10(6) cells/mL, in semen can be hazardous for spermatozoa, [2] H2O2 and .OH are responsible for the loss of motility, and [3H] seminal plasma confers a variable protection due to high and low molecular weight factors.


Evaluation of interceed(TC7) for reduction of postoperative adhesions in rabbits.

To evaluate the effectiveness of Interceed(TC7) (Johnson and Johnson, New Brunswick, NJ) in the prevention of postoperative adhesions in a rabbit uterine horn model. Interceed(TC7) was tested in the presence and absence of absorbable suture. Forty-one New Zealand white rabbits had lesions created on bilateral uterine horns at laparotomy. Lesions were randomly allocated to treatment with Interceed(TC7) or control. The effect of Interceed(TC7) was evaluated on sutured lesions (4-0 polyglactin 910; Ethicon, Inc., Somerville, NJ) as well as on open cut lesions (no sutures applied). Adhesion formation, using a grading system ranging from 0 to 3. Interceed(TC7)-treated animals in the sutured group (average adhesion score +/- SD = 2.15 +/- 1.3) did not differ from controls (average score +/- SD = 2.35 +/- 0.93) in adhesion formation, P = 0.47. Rabbits with open cut lesions treated with Interceed(TC7) (average adhesion score +/- SD = 1.89 +/- 1.1) did not differ from control animals (average score +/- SD = 1.83 +/- 1.2), P = 0.88. Interceed(TC7) was not an effective adhesioprophylactic agent in the presence or absence of nonreactive absorbable suture.


Hysteroscopic treatment of congenital uterine malformations causing hemihematometra: a report of three cases.

To our knowledge, this is the first case report of hysteroscopic treatment of congenital uterine malformations with one-sided occlusion causing hemihematometra. This rare form of uterine anomaly should be considered when symptoms such as increasing pelvic pain start with menarche. A 9-mm resectoscope was used for dissecting the way into the occluded part of the uterine body. There the endometrium was ablated for prevention of recurrence of hemihematometra. By this endoscopic approach the disadvantages of laparotomy could be avoided in three adolescent patients.


Canalization failure of the müllerian tract.

A patient is described with canalization failure of the müllerian system. This patient presented with primary amenorrhea and absence of the vagina. At the time of laparotomy, a uterus of normal size and shape was found with two small areas of canalization. This syndrome, associated with absence of the vagina, appears to result from a defect occurring later in development than does classical müllerian aplasia. Pathological examination of the patient's uterus supports the tenant that canalization begins after fusion and at various places along the line of fusion.


Ovarian cyst aspiration: a therapeutic approach to ovarian hyperstimulation syndrome.

Ultrasonographically guided transvaginal aspiration of ovarian cysts in women with severe OHSS after GIFT or IVF was safe and has resulted in immediate relief of symptoms, a shorter disease process, and outpatient treatment. The patients were allowed to go back to normal activity after the procedure. The progression of the disease was interrupted and six of seven patients carried beyond 20 weeks' gestation.


The value of repeat hysteroscopic evaluation in patients with failed in vitro fertilization transfer cycles.

One hundred ten women with normal initial hysteroscopy who failed to conceive during three or more IVF-ET cycles underwent repeat hysteroscopic evaluation. In 20 patients (18.2%), visualization revealed uterine abnormalities, mainly newly added endometrial lesions, i.e., hyperplasia, polyps, endometritis, and synechiae. Our results indicate that repeat hysteroscopic evaluation, in cases of recurrent IVF-ET failure, is an important adjunctive method for further evaluating and possibly optimizing the IVF-ET procedure.


Pregnancy after subzonal insertion of cryopreserved spermatozoa from a patient with testicular seminoma.

The first pregnancy established after subzonal insertion of frozen-thawed sperm obtained from a patient with seminoma and severe oligoasthenospermia is reported. A total of 800,000 sperm with a poor progressive motility were recovered after thawing. Three to seven motile spermatozoa were injected into the perivitelline space of each of 10 oocytes, and seven sibling oocytes were coincubated and inseminated with 200,000 motile sperm/mL. Only 1 of the manipulated oocytes fertilized and was transferred to the uterus 65 hours after insemination at the eight-cell stage. A healthy boy weighing 3,600 g was delivered spontaneously at 38 weeks of pregnancy. This report gives hope to patients with testicular malignancy and severely impaired sperm function to maintain their reproductive potential through sperm banking and assisted fertilization techniques.


Assessment of sperm for cryopreservation using the hypoosmotic viability test.

In summary, the hypoosmotic viability parameter was significantly correlated with the outcome of the thawed sperm motility. The prefreeze supravital staining for sperm viability and the hypoosmotic sperm swelling test were not predictive of the thawed sperm total motility. The hypoosmotic viability parameter was not correlated to the postwarmed sperm motility after refrigeration. The results indicated that the integrity of the sperm membranes at the head were more important than the tail membrane.


Very late return of spermatogenesis after chlorambucil therapy: case reports.

Two men were treated for a nephrotic syndrome with high-dose chlorambucil therapy; 6.5 and 14 years later, respectively, both were azoospermic with high plasmatic FSH values. Both patients showed active spermatogenesis, 15 and 19 years after the end of the treatment. This suggests that a return of spermatogenesis can occur even after very high cumulative doses of chlorambucil (between 3,000 and 6,500 mg) and after a very long time.


Allergic reactions to penicillin during in vitro fertilization and intrauterine insemination.

Two cases are reported in which hypersensitivity reactions occurred after intrauterine placement of spermatozoa or embryos. Because the cells were processed and transferred in antibiotic-containing media, these reactions were suspected to be because of penicillin allergy. One patient had no prior penicillin allergy but was found to be penicillin allergic by skin testing. The other had a history of allergy to oral penicillin. In both cases, the allergy symptoms did not occur during subsequent cycles when antibiotics were removed from the transfer media. These reports suggest that in patients known to be penicillin sensitive, penicillin should not be used during transfer of gametes and embryos for assisted reproductive procedures. In addition, the routine use of antibiotics in these procedures should be scientifically evaluated.


Digital road mapping image--a novel fluoroscopic real-time guide for selective transcervical catheterization in the treatment of proximal tubal obstruction.

Ten infertile women 20 to 40 years of age, with a standard HSG diagnosis of unilateral proximal tubal obstruction, underwent a transvaginal catheterization and recanalization of the fallopian tubes. To set a fluoroscopic real-time guidance technique for improving the results of transvaginal catheterization and recanalization of the fallopian tubes and to increase its marginal safety, catheterization was performed under digital road mapping guidance. Transcervical catheterization resulted in an immediate patency of the obstructed tube in all 10 women. Three women conceived 2 to 3 months after the procedure. The improved catheterization technique enables good results in the diagnosis and treatment of proximal tubal obstructions.


The linear everting catheter: a nonhysteroscopic, transvaginal technique for access and microendoscopy of the fallopian tube.

The linear everting catheter is a new technology that allows for nonhysteroscopic, transvaginal access, and microendoscopy of the fallopian tube. Initial results indicate that this approach is safe, successful, and offers a number of unique advantages relative to the available alternatives. Studies are in progress to explore several of the many possible applications of this system in the diagnosis and treatment of infertile patients.


Penetration of zona-free hamster oocytes using human sperm aspirated from the epididymis of men with congenital absence of the vas deferens: comparison with human in vitro fertilization.

To assess the ability of sperm aspirated from the epididymis of men with congenital absence of the vas deferens to penetrate zona-free hamster oocytes. To directly compare the performance of human epididymal sperm in the zona-free hamster oocyte sperm penetration assay (SPA) with the results of human in vitro fertilization (IVF). Sperm penetration assay was carried out with epididymal sperm retrieved microsurgically, and with ejaculated sperm obtained from fertile donors (internal controls). For direct comparison, SPA was performed with the same epididymal sperm sample used for IVF. Men with congenital absence of the vas deferens undergoing sperm aspiration as part of their infertility treatment and control donors who provided ejaculated sperm. Epididymal sperm penetrated SPA with a score of 0% to 30%. The SPA scores for internal controls using ejaculated sperm was 30% to 71%. Linear regression analysis of the association between penetration scores in SPA and fertilization rate in IVF indicated a positive correlation that was highly significative. These findings using SPA confirm previous reports on the fertilizing potential of human epididymal sperm and its ability to produce normal pregnancies. The good correlation between SPA and human IVF using epididymal sperm suggest that SPA is an excellent bioassay to test laboratory experimental conditions for improving fertilizing capacity of human epididymal sperm.


Relationship of epididymal sperm antibodies to their in vitro fertilization capacity in men with congenital absence of the vas deferens.

To test, using the immunobead binding technique, for the presence of antisperm antibodies on epididymal sperm, in epididymal fluid, and in serum of men with congenital absence of the vas deferens. To evaluate the in vitro fertilization (IVF) capacity of human epididymal sperm in the presence of antisperm antibodies. Prospective. At the time of oocyte insemination, sperm from the proximal caput epididymis or vasa efferentia were tested by direct immunobinding technique. The epididymal fluid and serum were tested by indirect immunobinding technique. Center for Reproductive Health, University of California-Irvine. Forty-five patients with congenital absence of the vas deferens participating in the microsurgical epididymal sperm aspiration and IVF program. Incidence of antisperm antibodies to epididymal sperm and their relationship with IVF results. Sixteen men (35%) tested positively to the direct immunobead test on epididymal sperm; 7 (16%) were positive in epididymal fluid and 13 (29%) were positive in serum. Five pregnancies (31%) occurred in the positive group of which two were from patients who had sperm binding of 100% for immunoglobulin (Ig)G (all over sperm surface) and 90% (midpiece, tail) and 50% (tail, tiptail), respectively, for IgA. Five pregnancies (18%) were obtained in the negative group. No statistical difference was observed in the overall fertilization rate between the two groups. Human epididymal sperm and epididymal fluid retrieved from men with congenital absence of the vas deferens can react positively to immunobead test. However, the presence of antisperm antibodies do not seem to impair the IVF capacity of epididymal sperm.


Characterization of human sperm antigens and antisperm antibodies in infertile patients.

To identify which sperm antigens may elicit the production of functionally important antisperm antibodies. Immunoblot analysis was performed on 69 serum and 9 seminal plasma samples from infertile patients, using detergent extracts of pooled donor sperm as the antigen source. Serum and seminal plasma had been previously tested by an indirect immunobead binding test (IBT); 61 IBT-positive and 17 IBT-negative samples were included in the study. Proteins recognized by IBT-positive but not IBT-negative samples were most likely to be cell surface antigens, whereas proteins recognized by both IBT-positive and IBT-negative samples were probably intracellular. Antibodies directed toward surface antigens would be most likely to affect fertilization. Characterization of sperm surface proteins on both acrosome-intact and -reacted sperm used labeling of cell surface proteins with an N-hydroxysuccinimide ester of biotin, fractionation of sperm heads and tails, and lectin binding to determine glycosylation. Specific immunoreactivity (with respect to IBT results) was observed to 35K, 40 to 45K, 57K, 66K, and 88 to 90K MW proteins. Characterization studies identified an 88K MW glycosylated plasma membrane protein, a 66K MW inner acrosomal membrane protein, a 34K MW inner acrosomal membrane protein, and a 35K MW prominent tail protein. Immunological infertility may involve several antigens characterized in this study. Further studies are necessary to determine if antibodies to these specific proteins interfere with sperm function.


Custom cryopreservation of human semen.

To design a protocol to evaluate individual variability in human semen cryoprotection by native seminal plasma. Post-thaw motility from the frozen semen of pregnancy-proven donors (n = 10) and patients referred for infertility screening (n = 10) was examined in three equal aliquots (per original ejaculate) that comprised varying ratios of native seminal plasma to TES and Tris (TEST)-yolk buffer (Irvine Scientific, Irvine, CA) in a dose-titration curve format. All aliquots from the same ejaculate contained final vol/vol 6% glycerol, had equal sperm density, and had undergone centrifugation for 5 minutes at 600 x g before buffer:semen ratio adjustment and standard precooling protocol for submersion in liquid nitrogen. Post-thaw measurement of percent original motility preserved (post-thaw percent motility/original percent motility x 100) was used for standardization of results. In 14 of 20 specimens (70%), the maximal yield of original motility was obtained in 50% seminal plasma, with an average post-thaw motile yield of 50%. In 6 of 20 specimens (30%), the best preservation of original motility was noted at 100% seminal plasma, with an average post-thaw motile yield of 58%. No specimen had a greatest percent motility preserved at 0% seminal plasma. Donor specimens have equal preference for either 50% or 100% seminal plasma, whereas patient specimens have a preference for 50% seminal plasma (P < 0.05). Native seminal plasma has variable cryoprotectant qualities for which custom cryopreservation can compensate. A simple two-point dose-titration test of cryopreservation buffer:seminal plasma ratio (i.e., 50:50 versus 0:100) can determine the optimal mixture for cryopreservation of a given individual's semen.


Semen cryobanking for men with cancer--criteria change.

To summarize pregnancies and births after the use of pretherapy cryobanked semen from men with cancer and to reassess the clinical role of semen cryobanking for these patients. Survey of pregnancies and births that have occurred after the use of cryobanked semen from pretherapy cancer patients. Survey of the literature and of nine semen banks. Men with testicular cancer, Hodgkin's diseases, non-Hodgkin's lymphoma, and other types of cancer who cryobanked their semen specimens before therapy. Pregnancies and births resulting from the use of cryobanked semen after artificial insemination by husband (AIH) or other assisted reproductive technology (ART) procedures. The use of AIH and other ART procedures have resulted in 117 documented pregnancies and 115 livebirths. Cryobanking of semen should be offered to all men diagnosed with cancer because such a procedure provides the only reasonable chance of establishing a pregnancy after therapy that is detrimental to fertility potential. Existing criteria for pretherapy semen cryobanking, therefore, should be revised in view of successful pregnancies even with the use of semen with low spermatozoal densities and motilities, as well as other realized clinical efficacies of ART. Conceptions have occurred after in vitro fertilization (IVF) with < 1 x 10(6) motile spermatozoa. Semen cryobanking should be offered by the attending physician as a viable option for any pretherapy male patient who has any motile sperm and considers the future possibility of having children.


Assessment of testicular cytology by fine needle aspiration as a diagnostic parameter in the evaluation of the oligospermic subject.

To investigate whether testicular cytology by fine needle aspiration may be considered a diagnostic parameter in the evaluation of the oligospermic subject. Cytologic smears were obtained using a 23-gauge needle, stained with May-Grünwald-Giemsa stain and examined under a light Orthoplan microscope (Wild Leitz, Wetzlar, Germany) for qualitative and quantitative analysis. One hundred sixty-six oligospermic patients were analyzed, and the findings were compared with those obtained from 40 normozoospermic infertile subjects used as controls. At least 200 spermatogenic cells were counted per slide and classified at the various steps of spermatogenesis. Because the number of Sertoli cells may be considered as a constant per unit of tubular length, Sertoli cells:spermatogenic cells ratio (termed Sertoli index) provided further elucidation and more comprehensible results. The procedure provided no sign of traumatization. The cytologic analysis permitted identification of different classes of oligospermic subjects, characterized by the following specific cytologic pictures: [1] bilateral or [2] unilateral germ depopulation (hypospermatogenesis), associated with maturation abnormalities of the first steps of spermatogenesis on both testes; [3] difficult maturation of the immature germ cells (spermatogonial or spermatocytic arrest); [4] ineffective spermiogenesis (spermatidic arrest); [5] normal maturation of the germ line in the presence of oligospermia, resulting from a transient acute damage on the spermatogenic line. Plasma levels of FSH and the testicular volumes agree with the cytologic picture of each group of patients. The results support use of fine needle aspiration of the testis as a minimally invasive diagnostic parameter for the assessment of oligospermic subjects.


Effect of ascorbic acid supplementation on the sperm quality of smokers.

To determine the effect of ascorbic acid supplementation on the sperm quality of heavy smokers. Microscopic examination of semen for 1 month during supplementation with placebo or ascorbic acid at dose levels of 200 or 1,000 mg/d. Department of Obstetrics and Gynecology, The University of Texas Medical Branch. Seventy-five men (20 to 35 years old) randomly divided into one of three supplementation groups: placebo, 200 mg and 1,000 mg of ascorbic acid. Improvement in sperm quality as compared with presupplementation levels and between the three treatment groups. The placebo group showed no improvement in sperm quality. The groups receiving ascorbic acid showed improvement in sperm quality with most improvement in the 1,000-mg group. Pearson's correlation showed statistically significant relationships between the weekly group means of serum and seminal plasma ascorbic acid levels and sperm qualities. Ascorbic acid supplementation of heavy smokers in excess of 200 mg/d results in improved sperm quality.


Deoxyribonucleic acid flow cytometry and semiquantitative histology of spermatogenesis: a comparative study.

To compare deoxyribonucleic acid (DNA) flow cytometry with a semiquantitative histologic method for the assessment of spermatogenesis and to investigate the influence of various preparative techniques on the results of DNA measurements. Testicular tissue from 52 autopsies was examined for spermatogenesis by DNA flow cytometry and by conventional semiquantitative histology. Flow cytometry was performed on single nuclei suspensions from fine needle aspiration biopsies, resuspended imprints, as well as on specimens obtained by mechanical disaggregation of surgical biopsies of the same testis. In all cases, flow cytometry revealed a characteristic distribution pattern of haploid (n), diploid (2n), and tetraploid (4n) cells independent of the preparation technique used. The percentage of haploid cells of the testes showed statistically highly significant correlations (P = 0.0002) with the results of semiquantitative histology. Fine needle aspiration biopsy always contained more haploid cells compared with resuspended imprints and mechanically disaggregated samples. Our results confirm the suitability of DNA flow cytometry as a fast and reliable quantitative method for the assessment of spermatogenesis and demonstrate its optimal feasibility in combination with fine needle aspiration biopsy.


Differentiation of round cells in semen by means of monoclonal antibodies and relationship with male fertility.

To differentiate round cells in semen samples of subfertile men and evaluate the clinical significance during infertility investigation. One hundred and eight randomly chosen couples with a median duration of infertility of 4 (range, 1 to 20) years presenting at the outpatient infertility clinic of the University of Heidelberg, Germany. Differentiation of round cells in semen by means of monoclonal antibodies (mABs) and a streptavidin-biotin system for staining. Correlation of results with medical history, outcome of clinical examination, sperm analysis, microbial screening of both partners, evaluation of sperm functional capacity in vivo by means of the postcoital test (PCT) and in vitro with the standardized crossed sperm-cervical mucus penetration test (SCMPT) and the subsequent fertility in a prospective study. The method used for differentiation of round cells proved to be practical and suitable for routine use. The percentage of leukocytes ranged from 0% to 58% with a median of 3%. Number of round cells and percentage of leukocytes did not differ markedly with regard to andrologic history, clinical findings, for example, varicocele, results of standard sperm analysis, and microbial colonization of semen samples. However, high rates of leukocytes of the round cells correlated with reduced sperm count and morphology and results of PCT. Leukocyte-positive (> 15% leukocytes) specimens were also significantly more frequent in case of inadequate SCMPT and reduced sperm penetration ability in vitro. In asymptomatic patients (in terms of genital tract infection), the majority of round cells consist of immature germ cells and < 5% are white blood cells. The streptavidin-biotin system and the mABs used in this study proved to be useful to identify patients with elevated rates of leukocytes in semen possibly reflecting subclinical genital tract infection with influence on sperm functional capacity and subsequent fertility. Thus the procedure can be recommended to be included in a comprehensive evaluation of male fertility.


Autotransfusion of the ascitic fluid in the treatment of severe ovarian hyperstimulation syndrome.

Three cases of severe OHSS were treated by transvaginal aspiration of the ascitic fluid and autotransfusion of the aspirated fluid. Marked improvement of the symptoms, general condition, and urine output followed the aspiration shortly. No reactions were noticed during or after the autotransfusion. The blood parameters were corrected, and the general condition and urine output continued to improve. The procedure is simple, safe, and straightforward that showed a striking physiological success in correcting the maldistribution of fluid and proteins without the use of heterogeneous biological material.


Isolated prolactin deficiency: a case report.

A 36-year-old woman, with lifelong oligomenorrhea and immeasurable serum PRL levels, conceived and had normal deliveries after ovulation induction with CC. Alactogenesis followed both deliveries. Evaluation of other pituitary hormones were within normal limits, and attempted stimulation of PRL levels by TRH was unsuccessful. The clinical significance of isolated hypoprolactinemia is discussed.


Magnetic resonance imaging using "fat-saturation" technique is useful for diagnosing small endometrioma: a case report.

Preoperative MRI using fat-saturation technique was performed in a patient with endometriosis. Endometrial implants as small as 3 mm were accurately diagnosed by MRI. The fat-saturation technique is useful for diagnosing small endometrioma.


Radiologic evaluation of incremental intrauterine instillation of contrast material.

In view of the contradictory results of IUI reported in the literature, the present study was undertaken to determine whether the volume of material injected into the uterus can affect the delivery site of the sperm. Ten infertile women scheduled for HSG were submitted to intrauterine injection of different volumes of radiopaque dye (0.2 mL to 1.0 mL) before the procedure to mimic IUI. An x ray taken immediately after injection showed that volumes of > or = 0.4 mL reached the uterus and tubes, whereas the 0.2-mL volume did not reach the tube. These data show that volume injected is an important variable in IUI.


Transcervical tubal cannulation: a comparison of two techniques.

Transcervical tubal cannulation using tactile guidance has a similar rate of successful cannulation compared with that with US guidance (78% versus 73%) but takes less time to perform (2.3 +/- 1.8 minutes versus 8.7 +/- 6.2 minutes, mean +/- SD) and is associated with less pain and bleeding. This appears to be because of the design of the Labotect tubal cannulation set that uses a special speculum and tenaculum to straighten the uterus before insertion of the guide cannula and a less traumatic ball-tipped guide catheter.


Cytogenetics of human spermatozoa: correlations with sperm morphology and age of fertile men.

Sperm chromosomes from 15 fertile men were analyzed after fusion of their spermatozoa with zona-free hamster eggs. The total proportion of abnormal metaphases as well as the proportions of aneuploidy and structural aberrations were calculated for every man and examined for linear correlations with [1] sperm morphology and [2] the age of the persons studied. A positive correlation between the cytogenetic parameters and the percentage of abnormal sperm morphology was not evident, suggesting that assessment of sperm morphology cannot be used as an indicator of chromosomal damage in human spermatozoa. In contrast, there was a more distinct positive correlation between the age of donors and the three cytogenetic parameters studied.


Hydrogynecography: a new technique enables vaginal sonography to visualize pelvic adhesions and other pelvic structures.

Vaginal ultrasonography, done after the transcervical injection of isotonic saline into the cul-de-sac, is a new technique we named hydrogynecography. This was prospectively used in patients suffering from infertility and pelvic pain. In 84% of patients we were able to identify pelvic adhesions confirmed by laparoscopy. In 16% the procedure provided false-negative results.


Laparoscopic removal of 46XY gonads located within the inguinal canals.

Male pseudohermaphrodites require gonadectomy for the prevention of gonadal malignancy. Laparoscopic gonadectomy has been performed in patients with intra-abdominal gonads and can also be performed in patients whose gonads are located within the inguinal canals.


A microwell sperm penetration assay.

Egg penetration rates in a modified SPA using microwells in tissue typing plates were comparable with those in a standard assay. This technique allows sperm penetrating ability to be determined using single zona-free hamster eggs and as few as 10,000 spermatozoa.


Neural tube defects after infertility treatment: a review.

To investigate whether an association exists between ovulation induction and neural tube defects (NTDs). Risk estimations in the medical literature were identified through Medline, and validity and power were assessed. Large in vitro fertilization-embryo transfer (IVF-ET) registries represent another source of information. The total number of NTDs and the total number of fetuses were computed from five registries. These data were expressed as proportions and compared with data from the general population. Only one study could be identified as both valid and powerful, through literature review. This case-control study concluded there was no association between ovulation induction and NTDs. The pool of IVF-ET registry data represents another powerful epidemiologic tool. Analysis of the registry data confirms the findings of the case-control study. Ovulation induction does not seem to represent a risk factor for NTDs in the offspring.


The routine use of gonadotropin-releasing hormone agonists prior to in vitro fertilization and gamete intrafallopian transfer: a meta-analysis of randomized controlled trials.

To assess the efficacy of gonadotropin-releasing hormone agonists (GnRH-a) used in ovulation induction for in vitro fertilization and embryo transfer (IVF-ET) and gamete intrafallopian transfer (GIFT). Meta-analysis of 10 trials comparing treatment cycle outcomes after GnRH-a (n = 914) with other ovulation induction protocols (n = 722) and 7 trials comparing outcomes after short flare-up (n = 368) with longer suppression (n = 476) GnRH-a protocols. The outcome of primary interest was clinical pregnancy rate (PR) per treatment cycle commenced. Data describing the amount of gonadotropin used, cycle cancellation rate, clinical pregnancy per ET, and multiple pregnancy and abortion rates were also analyzed. Clinical PR per cycle commenced was significantly improved after GnRH-a use for IVF (common odds ratio [OR] 1.80, 95% confidence interval [CI] 1.33 to 2.44) and GIFT (common OR 2.37, 95% CI 1.24 to 4.51). Clinical PR per embryo transfer was also significantly improved with GnRH-a use (common OR 1.40, 95% CI 1.01 to 1.95). Cycle cancellation was decreased (common OR 0.33, 95% CI 0.25 to 0.44), whereas spontaneous abortion rate was similar with and without GnRH-a use. Cycle cancellation and PRs after short flare-up and longer suppression protocols were similar between groups. This meta-analysis supports the routine use of GnRH-a for IVF and GIFT. Further research is needed, however, to assess the potential for increased rates of multiple pregnancy and ovarian hyperstimulation syndrome, which may be associated with this treatment.


Color Doppler ultrasonography assessment of tubal patency: a comparison study with traditional techniques.

To compare the results of color Doppler ultrasonic hysterosalpingography (color US-HSG) and x-ray-HSG with chromoperturbation at the time of laparoscopy. Open, uncontrolled study of women seeking evaluation for infertility from August 1989 to July 1991. Clinical environment. Two hundred thirty-eight infertile women. Saline was administered transcervically during transvaginal color Doppler sonography in 238 women. Traditional x-ray-HSG was performed in 89 women. Laparoscopy with chromoperturbation was done in 121 women. Forty-nine women had all three procedures performed. The frequency of diagnosis of bilateral tubal patency, bilateral tubal occlusion, and unilateral tubal patency after color US-HSG and x-ray-HSG was compared with chromoperturbation. The diagnostic efficacy of color US-HSG and x-ray-HSG was compared with chromoperturbation. Correlation between color US-HSG and x-ray findings with chromoperturbation occurred in 81% versus 60% (P = 0.0008) of all women studied. In 49 women who had all three procedures performed, color US-HSG results correlated with chromoperturbation more often than x-ray-HSG (82% versus 57%, P = 0.0152). Color US-HSG is an alternative technique to x-ray-HSG in diagnosing tubal occlusion as a cause of infertility.


Fallopian tubes and ultrasonography: the Sion experience.

To compare the accuracy of three new ultrasonographic methods of detecting tubal patency and pathology with established methods like hysterosalpingography (HSG) and laparoscopy. Sixty-seven cases were evaluated by performing the Sion test using endosonography to check for tubal patency. The Sion procedure includes filling up the pouch of Douglas with approximately 300 mL of sterile normal saline to elucidate not only the patency but visualize the motility, the fimbriae, and peritubal adhesions, if present. We have compared the accuracy of this procedure with HSG and laparoscopy in 24 infertile women. Color-coded duplex Doppler sonography was used in 38 patients to check for tubal patency. Our experience at the Sion Hospital using the three new ultrasonographic techniques for evaluating the status of the fallopian tubes is very encouraging. The accuracy with the three modes shows agreement in > 90% of cases with established investigative modalities such as HSG and laparoscopy. These three new investigative modalities are offered not as substitutes for HSG, laparoscopy, hysteroscopy, or salpingoscopy but as office-screening procedures that would be complementary to the armamentarium of infertility investigations already available.


Gonadotropin-releasing hormone-associated peptide gene sequences in women with hyperprolactinemia.

To determine if mutations in the structural gene for gonadotropin-releasing hormone (GnRH)-associated peptide are present in women with hyperprolactinemia. Patients with hyperprolactinemia and controls were studied retrospectively for GnRH-associated peptide gene mutations. Patients seen in a clinical setting were studied at a medical school laboratory setting. Fifteen women with hyperprolactinemia and two fertile controls with normal prolactin levels were studied. Genomic deoxyribonucleic acid (DNA) was extracted from each patient and subjected to Southern blot analysis and polymerase chain reaction (PCR). For Southern blot analysis, DNA was digested with EcoRI, XbaI, BglII, PstI, and BamHI and hybridized to two DNA probes for GnRH-associated peptide. Exons II to IV, which encode for the structural gene, were amplified by PCR. Fragment sizes from autoradiographs were compared among patients and controls. Amplified PCR products of exons II to IV of the GnRH-associated peptide were also compared. No large deletions, insertions, or polymorphisms were identified in women with hyperprolactinemia or controls by Southern blotting. Each of the exons was present and of normal size by PCR in the study patients and controls. No large deletions of the GnRH-associated peptide gene appear to be present in our patients with hyperprolactinemia. Small deletions, insertions, or point mutations are not excluded by this analysis.


Absence of effect of adjuvant growth hormone therapy on follicular responses to exogenous gonadotropins in women: normal and poor responders.

To examine the effects of growth hormone (GH) on ovarian responses to exogenous gonadotropins after pituitary desensitization in normal and poor responder patients undergoing in vitro fertilization. A prospective study with comparison of control and GH-treated cycles. Poor responder patients (n = 10) required > 44 ampules of human menopausal gonadotropin (hMG) to achieve criteria for administration of human chorionic gonadotropin (hCG) on day 0 or cancellation in control cycles, and normal responder patients (n = 10) required < 45 ampules. Ovarian responses to hMG assessed by duration of stimulation required to achieve first significant estradiol (E2) response and hCG criteria. Total doses and duration of hMG, follicular development and E2 concentrations on day 0, and embryology were also assessed. Growth hormone showed no effect on any of the parameters studied in either patient group. Follicular recruitment, E2 secretion by mature follicles, and oocyte yield and quality were uninfluenced by GH treatment.


Deep endometriosis: a consequence of infiltration or retraction or possibly adenomyosis externa?

To analyze the incidence and occurrence of subtypes of deep endometriosis. Deep endometriotic lesions (> 5 mm) were retrospectively analyzed, using our data base and slides taken systematically during surgery. University Hospital Gasthuisberg (University of Leuven) which is a referral center for infertility and endoscopic surgery. All women with deep endometriosis (n = 136) were selected from a consecutive series of 1,252 laparoscopies for infertility, pain, or both. Deep endometriosis was excised by CO2 laser and the depth of infiltration and the pelvic area measured. As part of an ongoing study, most lesions were photographed. Deep endometriosis is suggested to contain three subgroups. Type I is conical shaped and suggested to be formed by infiltration. Type II is deeply located and covered by extensive adhesions and probably formed by retraction. Type III is a spherical nodule with its largest dimension under the peritoneum. Types I, II, and III are found in 4.1%, 0.8%, and 0.9% of women with infertility (n = 759) and in 10.4%, 3.2%, and 3.2% of women with pelvic pain (n = 374). Types I, II, and III are most frequently found in the revised American Fertility Society classes II, III to IV, and I, respectively. Three subtypes of deep endometriosis can be distinguished. Type III, which is a spherical nodule located in the recto vaginal septum is the most severe and largest lesion. This is, however, easily missed clinically because these lesions are generally scored as revised American Fertility Society class I.


Early endometriosis invades the extracellular matrix.

To investigate whether the aminoterminal propeptides of type III procollagen are increased in patients with early endometriosis and to demonstrate that the subtle lesion of endometriosis is an active stage of the disease. Aminoterminal propeptide of type III procollagen was determined in serum and peritoneal fluid (PF) of 100 consecutive patients undergoing laparoscopy. Academisch Ziekenhuis Maastricht, The Netherlands, a tertiary care center. Aminoterminal propeptide PF levels were significantly higher in women with early lesions of endometriosis compared with levels in two groups of controls, i.e., fertile, cycling, women without the disease (P = 0.019) and women on oral contraceptives without the disease (P = 0.036). No difference was found in aminoterminal propeptide PF levels when comparing patients with early lesions of endometriosis and patients with unexplained infertility, the third control group. Aminoterminal propeptide PF levels of patients with endometriosis without early lesions were not different from PF levels in controls. The early lesion is an active stage of endometriosis, invading the extracellular matrix. In women with unexplained infertility active, microscopic endometriosis may be present.


Tumor necrosis factor alpha in the human ovary: presence in follicular fluid and effects on cell proliferation and prostaglandin production.

To examine the concentration of tumor necrosis factor alpha (TNF alpha) in human follicular fluid (FF) and its effects on cultured human granulosa-lutein cells. The concentration of TNF alpha in FF from hyperstimulated cycles and in conditioned media from cultured granulosa-lutein cells was measured by radioimmunoassay (RIA) and bioassay using L929 cells. The effects of recombinant human TNF alpha (rTNF alpha) on proliferation and production of progesterone (P) and prostaglandin (PG, PGE2, and PGF2 alpha) by cultured human granulosa-lutein cells were assessed. In vitro fertilization and embryo transfer (IVF-ET) program at Reproductive Medicine Unit, The Queen Elizabeth Hospital, Woodville, South Australia, Australia. Twenty-five women undergoing IVF-ET for tubal factor infertility. The concentration of immunoreactive TNF alpha in FF was 0.36 +/- 0.02 microgram/L, and there were no significant correlations between levels of TNF alpha and steroids or FF volume. Bioactivity for TNF alpha was considerably less. Immunoreactive or bioactive TNF alpha was not detected in conditioned media from granulosa-lutein cell culture. Recombinant human TNF alpha dose-dependently stimulated proliferation of cultured granulosa-lutein cells as measured by incorporation of 3H-thymidine, but in contrast to earlier reports, we were not able to demonstrate any effect of rTNF alpha on basal or human chorionic gonadotropin-stimulated P accumulation during culture periods of up to 72 hours. The accumulation of both PGE2 and PGF2 alpha was dose-dependently increased by rTNF alpha during a 48-hour incubation period. Time course studies revealed that maximal levels of both PGE2 and PGF2 alpha were reached within 12 hours of culture. Immunoreactive and bioactive TNF alpha is present in FF. Tumor necrosis factor alpha may have a physiological role in stimulating proliferation of follicular cells and PG production at the time of ovulation and formation of the corpus luteum.


Inhibitory effect of interferon and tumor necrosis factor on human luteal function in vitro.

To investigate whether immunological mechanisms may be involved in human luteal function. The effects of the cytokines, interferon-alpha (IFN-alpha), interferon-gamma (IFN-gamma) and tumor necrosis factor alpha (TNF-alpha) on steroidogenesis by human luteal cells were examined in vitro. The dispersed human luteal cells, obtained from a total of 17 women at laparotomy, were cultured separately in the presence or absence of human chorionic gonadotropin (hCG) and IFNs/TNF-alpha with the medium being replaced at 48 hours. The medium was collected at 48 and 96 hours for steroid assays. The IFN-alpha had no significant effect on the production of estradiol or progesterone (P), whereas a dose-related inhibition of basal, as well as hCG-stimulated P formation, was observed after the addition of IFN-gamma (10 to 1,000 U/mL). Progesterone production was inhibited to about 45% of the control at 48 hours and even lower at 96 hours (n = 6, P < 0.001). The combination of IFN-gamma and low doses of TNF-alpha induced a further significant inhibition, whereas there was no effect of TNF-alpha alone. This inhibitory effect of IFN-gamma could be completely neutralized with a monoclonal antibody to IFN-gamma. Incubation with the antibody alone increased the production of P from luteal cells in culture, suggesting a local tonic inhibitory action of endogenous IFN-gamma. Interferon-gamma and TNF-alpha, whose function classically is known as antiviral, also may play a role in human luteal regression by inhibiting luteal P production.


Antisperm antibodies in women: variability in antibody levels in serum, mucus, and peritoneal fluid.

To look for patterns of antisperm antibody expression in women by exploring the levels of antisperm antibodies in different body fluids. This was achieved by studying sequential serum samples from individual patients and by comparing the levels of antisperm antibodies in serum from a number of patients with the levels of antisperm antibodies in cervical mucus or peritoneal fluid (PF). Prospective studies were performed on sequential serum samples within a menstrual cycle. Retrospective studies were done to compare antisperm antibodies in serum and mucus or PF. The immunobead assay was used to measure antisperm antibodies in these fluids. Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. A random sample of patients undergoing evaluation for infertility. The levels of antisperm antibodies in sera drawn from patients at different points in a menstrual cycle stimulated by the presence of exogenous hormones did not change during the follicular phase of the menstrual cycle. Also, in many samples, the antisperm antibody level in serum did not correlate with the antisperm antibody levels in mucus or PF. The data suggest that measurement of antisperm antibodies at a single point in time or from a single fluid is not sufficient when evaluating a woman for immunological infertility. The data also suggest that numerous and complex factors contribute to the expression of antisperm antibodies in women.


Differential effects of transdermal estradiol and sequential progestogens on impedance to flow within the uterine arteries of postmenopausal women.

To investigate the relationship between estradiol (E2), progestogen, and impedance to blood flow in the uterine artery. Twelve postmenopausal women treated for two cycles with transdermal E2, 0.05 mg/d, with either norethindrone acetate, 0.7 mg, or medroxyprogesterone acetate, 10 mg added sequentially. Transvaginal ultrasonography and color flow imaging were used to measure the pulsatility index in the uterine arteries before and during the E2-only and combined E2/progestogen phases. The mean pulsatility index fell to 53% of its pretreatment value within 12 days E2 administration (P < or = 0.0001) and was 66% of its pretreatment value in the combined phase (P < 0.005). Similar changes were seen in cycle 2. Time since menopause was correlated with the pretreatment pulsatility index (r = 0.674, P < 0.05) and change in pulsatility index on treatment (r = 0.856, P < 0.001). Gonadal hormones have a profound effect on arterial tone in postmenopausal women; this action may help explain some of the beneficial effects of estrogen on arterial disease risk.


Further study and characterization of the yellow pigments in follicular fluid that are related to oocyte quality.

To characterize the 455-nm (yellow) absorbing pigments in human follicular fluid (FF). Serum and FF samples obtained from patients undergoing in vitro fertilization were analyzed for carotenoids, bilirubin, and beta-glucuronidase concentrations. Spectrophotometric analysis in the visible spectrum was performed on FF samples, and the delta OD455 absorbance was calculated. Thin-layer chromatography confirmed the presence of beta-carotene and bilirubin in FF. The mean (+/- SD) contribution of bilirubin and carotenoids to the FF delta OD455 absorbance was 64% +/- 9.6% and 22.7% +/- 12.1%, respectively. Bilirubin fractions in serum and FF samples were then compared. The median unconjugated bilirubin concentration in FF was lower than that in the serum (0.130 versus 0.288 mg/dL; P < 0.0001). The median conjugated bilirubin concentration was higher in the FF when compared with the serum (0.129 versus 0.101 mg/dL; P = 0.0018). beta-Glucuronidase levels in the FF were significantly lower when compared with serum concentrations. Bilirubin is the major contributor to the FF 455-nm spectrophotometric peak. The higher levels of conjugated bilirubin noted in the FF could in part be explained by the lower levels of beta-glucuronidase.


Human embryo biopsy on the 2nd day after insemination for preimplantation diagnosis: removal of a quarter of embryo retards cleavage.

To assess any reduction in viability and development in vitro after biopsy of a quarter of the cells of human embryos on day 2 after insemination. A prospective study in which normally fertilized surplus embryos of good morphology with two to eight cells approximately 48 hours after insemination were randomly allocated to a control or biopsied group, respectively. In vitro fertilization (IVF) unit and laboratories of the Hammersmith Hospital, Institute of Obstetrics and Gynaecology, London University. One hundred twenty-nine embryos from 28 infertile IVF patients. Follicular aspiration by ultrasound-guided transvaginal puncture and embryo biopsy by micromanipulative procedures. Pyruvate uptake and cell number at the blastocyst stage. Embryo biopsy did not have an adverse effect on either the proportion developing to the blastocyst stage (50% [32 of 64] and 47.7% [31 of 65] for the control and biopsied groups, respectively) or embryo viability, measured indirectly through pyruvate uptake. However, the proportion of embryos that reached the morula stage after day 4 (retarded embryos) was significantly higher (44%, 11 of 25 versus 8.7%, 2 of 23) in the biopsied group. The total number of cells (29.6 +/- 3.1 versus 62.4 +/- 4.7), numbers of inner cell mass (7.7 +/- 2.2 versus 24.5 +/- 1.4) and trophectoderm (24.0 +/- 5.2 versus 45.0 +/- 6.4) cells, and the inner cell mass:trophectoderm ratio (34.7 +/- 7.9 versus 59.5 +/- 11.7) were strikingly reduced at the blastocyst stage in the biopsied group. This reduction was greater in embryos that reached the morula stage after day 4. More investigation is needed to assess whether the detrimental effects observed were because of the biopsy method used in this study or to a high sensitivity of human embryos at early stages to manipulation in vitro.


Freezing cocultured human blastocysts.

To determine the possibility of obtaining good pregnancy rates (PRs) after freezing and thawing cocultured blastocysts. Human blastocysts were frozen first according to a protocol available from literature. Two other protocols including the addition of glycerol were designed to improve the results. All the patients were under clinical management at the Institut Rhonalpin pour l'Etude de la Reproduction Humaine in Lyons, France. Patients involved in the in vitro fertilization program have had their supernumerary embryos frozen according to the three protocols presented here. Embryo recovery after freezing and thawing. Clinical and ongoing pregnancies after embryo transfer (ET). A protocol including sucrose addition and reduction of steps in the preparation of the blastocysts for freezing gave us a 21% PR per transfer (15 ongoing) of 101 transfers (106 thawings). Freezing of cocultured human blastocysts allow good PRs. This can represent an alternative for repeated failures of ETs at early stages.


Effects of smoking on ovulation induction for assisted reproductive techniques.

To determine the effects of smoking on ovulation induction for assisted reproductive techniques. Matched, retrospective, cohort study. Outpatient University endocrine/infertility program. Eighteen smokers and 36 nonsmokers: 2 nonsmokers matched to each smoker for age, weight, and history of ovarian surgery. During a stimulation cycle, the serum estradiol (E2) level, number of follicles, number of oocytes, number of embryos, and ampules of gonadotropins used were compared in the smoking versus the nonsmoking groups by Wilcoxon's signed rank test for paired data. Follicular fluid (FF), testosterone (T), androstenedione (A), E2, A:E2 ratios, and T:E2 ratios were measured and compared between groups by Mann-Whitney U-tests. Smokers had significantly lower serum E2 levels, fewer follicles, fewer oocytes retrieved, and fewer embryos per cycle than nonsmokers, despite equal amounts of gonadotropin administration. Follicular fluid obtained from mature follicles had a higher A:E2 ratio and a higher T:E2 ratio in smokers compared with nonsmokers. Smoking adversely affects ovulation induction parameters and alters the FF hormonal milieu.


The relative success of gonadotropin-releasing hormone analogue, clomiphene citrate, and gonadotropin in 1,099 cycles of in vitro fertilization.

To evaluate the effectiveness of and analyze the factors influencing the outcome of three ovarian stimulation protocols used during in vitro fertilization (IVF) in a large population. Retrospective file review. In vitro fertilization program in one center during the years 1985 to 1990. PATIENTS AND PROTOCOLS: Three hundred forty-one patients received clomiphene citrate (CC) and human menopausal gonadotropin (hMG), 365 received hMG alone, and 393 received gonadotropin-releasing hormone analogue (GnRH-a) for pituitary suppression followed by hMG stimulation. Rates of cancellation, total pregnancies, and ongoing pregnancies, with breakdown by age of patients. The cancellation rate because of early luteinization following GnRH-a/hMG was significantly reduced compared with the other two protocols: 3.6% versus 9.4% and 13.7% for CC/hMG and hMG, respectively. However, in women over 40 years of age, GnRH-a/hMG resulted in the highest rate of poor ovarian response. Significantly more oocytes were retrieved, fertilized, and cleaved after the use of GnRH-a/hMG compared with the other two protocols. Despite this, clinical pregnancy rate (PR) was the highest with CC/hMG compared with GnRH-a/hMG and hMG:31.4% versus 16.9% and 15.7%, respectively. Ongoing PRs were 20.5%, 9.7%, and 11.6%, respectively. Although the use of GnRH-a for pituitary suppression before ovarian stimulation for IVF reduced the cancellation rate and increased the number of retrieved oocytes, it was not found to result in higher PRs than those achieved by stimulation with CC/hMG. This suggests that treatment by GnRH-a/hMG should be reserved mainly for the prevention of early luteinization.


The comparison of two gonadotropin-releasing hormone agonists in an in vitro fertilization program.

To compare two gonadotropin-releasing hormone agonists (GnRH-a), buserelin acetate and leuprolide acetate [LA], used in combination with gonadotropins in ovarian stimulation for in vitro fertilization (IVF). Randomized prospective study. Assisted Reproduction Unit of the Hospital Clínic i Provincial in Barcelona. Thirty-five pairs of IVF patients who were matched on age, indication, and number of attempts. These women were randomized to receive either buserelin acetate plus gonadotropins (group B) or LA plus gonadotropins (group L). Luteolysis, ovarian response, and IVF outcome. The mean time for total ovarian arrest and the total dose of gonadotropins and estradiol levels on the day of human chorionic gonadotropin administration were similar in the two groups of patients. The number of follicles punctured, the number of oocytes retrieved, and the percentage of mature oocytes in group L were significantly higher. The number of embryos suitable for replacement and cryopreservation was higher in group L compared with group B approaching statistical significance. Our results warrant further studies to compare different GnRH-a as therapeutic tools in IVF.


Intrauterine insemination after ovarian stimulation as a treatment for subfertility because of subnormal semen: a prospective randomized controlled trial.

To determine whether intrauterine insemination (IUI) after ovarian stimulation with human menopausal gonadotropin (hMG) gives a better pregnancy rate (PR) than natural intercourse in couples with subfertility because of subnormal semen. Prospective randomized controlled trial. University based subfertility clinic. Couples with subnormal semen as the only identifiable cause of subfertility. In control cycles, the couples had natural intercourse. In IUI cycles, IUI was performed after ovarian stimulation with hMG and human chorionic gonadotropin. The clinical PRs and complications of IUI cycles and control cycles were compared. There were six clinical pregnancies in the 42 IUI cycles, whereas there was no clinical pregnancy in the 42 control cycles. The clinical PR in IUI cycles (14.3% per cycle) was significantly higher than that in control cycles (0%). Six patients (14.3%) developed moderate degree of ovarian hyperstimulation syndrome in IUI cycles. Intrauterine insemination after ovarian stimulation with hMG is useful in treatment of subfertile couples with subnormal semen.


When are simple flashes and floaters ocular emergencies?

One hundred and seventy patients presented to the Bristol Eye Hospital casualty department with flashes and/or floaters during a six month prospective study. A sight-threatening condition was found in 41 patients (24.1%), the most important of which was a retinal break (16.5%). Although there were no specific symptoms which could be correlated to an increased incidence of retinal breaks, those patients who complained of isolated uniocular floaters had an insignificant incidence of breakage, when compared to asymptomatic fellow eyes. Thus while the majority of patients with flashes and floaters do merit an urgent ophthalmological opinion, those who complain of a single, isolated floater can safely be reviewed as routine outpatients.


A comparison of prophylactic, topical and subconjunctival treatment in cataract surgery.

Prophylactic subconjunctival antibiotics and steroids have been used in cataract surgery since the early 1950s. However despite their widespread acceptance, there has, to date, been no direct comparison of subconjunctival and topical routes of administration. We therefore carried out a prospective comparison of the effects of subconjunctival and topical administration of antibiotics and steroids in sixty patients undergoing elective, uncomplicated, extracapsular cataract extraction and posterior chamber lens implantation. The patients were examined by a single observer on the first and third post-operative days and two and six weeks following surgery. The observer was blinded to the patient treatment group. Significantly higher degrees of conjunctival injection and anterior chamber activity were noted in those who received subconjunctival injections compared with those who received topical treatment. There were no significant differences between the two groups in best corrected visual acuity, central corneal oedema, cystoid macular oedema, intraocular pressure and infection. We conclude that prophylactic subconjunctival therapy in uncomplicated cataract surgery is not necessary.


The uses and limitations of intraocular biopsy.

Based upon the author's considerable experience of trans-scleral resection of malignant melanoma of the choroid, a technique has been developed for the biopsy of tissues of the posterior segment of the eye. Its use in the management of atypical malignancy posing diagnostic difficulty and in the investigation of selected case of acute retinal necrosis, uveitis and retinal pigment epitheliopathy is described. In 34 trans-scleral biopsies of choroid, RPE and in some cases, retina, an adverse result occurred in only one case, this it was thought being due to not including pars plana vitrectomy as part of the biopsy technique. Pars plana vitrectomy is now regarded as an integral part of this form of biopsy.


The safety and efficacy of topical norfloxacin compared with chloramphenicol for the treatment of external ocular bacterial infections. The Norfloxacin-Chloramphenicol Ophthalmic Study Group.

Two hundred and forty-six patients with signs of acute bacterial conjunctivitis and/or blepharitis were randomised to receive either norfloxacin or chloramphenicol for one week in this double-masked parallel group study. Ninety-two per cent of the norfloxacin-treated patients and 93% of the chloramphenicol-treated patients were rated as either clinically improved or cured at the end of the treatment period. Based upon pre-treatment bacteriological cultures, 31.3% of the patients had significant bacterial infection of the lids and/or conjunctiva. All of these culture-positive patients were rated as either clinically improved or cured. Based upon post-treatment cultures, 72 of 82 strains of Gram-positive and Gram-negative bacteria were eradicated or suppressed following treatment with either norfloxacin or chloramphenicol. However six of 41 strains persisted for norfloxacin and four of 41 for chloramphenicol. Two norfloxacin-treated patients and three chloramphenicol-treated patients had adverse experiences, predominantly ocular discomfort, which required cessation of drug therapy. Norfloxacin appears to be an effective and relatively safe agent for the treatment of bacterial infections of the lids and/or conjunctiva. In this study, norfloxacin was clinically and microbiologically similar in activity to chloramphenicol.


Cystoid macular oedema following neodymium:YAG laser capsulotomy a prospective study.

Neodymium:YAG laser capsulotomy was performed in 65 eyes of 65 patients because of vision loss due to posterior capsular opacification or wrinkling following uneventful extracapsular cataract extraction with intraocular lens implantation. Eyes with pre-existing macular pathology were excluded from this study. In all of the eyes the posterior capsule was successfully opened. None developed clinical or angiographic cystoid macular oedema. One eye developed retinal detachment nine months after capsulotomy.


Low contrast visual acuity changes in human immuno-deficiency virus (HIV) infection.

A pilot study of low contrast visual acuity testing using Regan Charts has been undertaken in 34 patients seropositive for Human Immuno-Deficiency Virus and 20 normal control subjects. Low contrast visual acuities of the HIV (+) patients both with and without HIV retinopathy were found to be significantly lower than the age-matched controls (p < 0.01). This finding is probably attributable to pathology related to HIV in the visual pathways/Central Nervous System. Lowest contrast Chart (Chart C) was found to be a useful diagnostic tool for HIV retinopathy and presumed neuropathy.


Do computerised visual fields and automated optic disc analysis assist in the choice of therapy in glaucoma?

The choice of therapy in patients with glaucoma is determined by the presence of damage in the visual field or optic disc or by change in the appearance of the optic disc or visual field over time. Computerised visual fields and automated optic disc analysis can assist in this determination. Automated optic disc analysis permits the measurement of neuroretinal rim area which is more closely related to the presence of pathology than cup/disc ratio. Simple ophthalmoscopic techniques may also be used to estimate the size of the neuroretinal rim area. Automated perimetry allows accurate diagnostic information to be obtained in a reliable manner. This permits easier diagnosis of glaucoma as well as easier long term follow up for change. The availability of automated techniques in ophthalmology has helped the clinician in the choice of therapy. The use of astute clinical judgement remains however of the utmost importance.


Biometry and auto-fluorescence of the anterior ocular segment in diabetics with and without autonomic neuropathy: a case control study.

The biometry and auto-fluorescence of the anterior ocular segment were examined in a case control study of two populations of diabetics. Cases, with diabetic autonomic neuropathy, and controls without neuropathy (forty in each group) were selected from a community based diabetic population and matched individually for age, sex, and type of diabetes. Scheimpflug and auto-fluorescence anterior segment photography were performed and analysed by digital image analysis in a masked fashion. There were differences between the groups in axial lens thickness, front radius of curvature of the lens, anterior chamber depth and lenticular auto-fluorescence. These findings are discussed in the context of the known association between autonomic neuropathy and narrow angle glaucoma, and possible common mechanisms of tissue damage in diabetes.


Changes in light scatter and width measurements from the human lens cortex with age.

Light scatter and width measurements of the anterior cortical layers of the human lens were made in 50 eyes of 50 subjects using computerised linear scanning densitometry of Scheimpflug images. It was demonstrated that the amount of light scatter increased with age in all of the three major zones and that zone C3 showed the most marked increase. Most lens growth occurs in zone C2 with C3 showing little increase in width once it has become established. Zone C1 showed a tendency to decrease in width with age. In addition it was shown that the C3 zone, which is not present at birth and during early childhood, appears as a distinct layer during the second decade of life. Its scattering properties continue to increase throughout life, exceeding all other zones after approximately 30 years of age, in the absence of cataract. Possible explanations for the lens zone pattern are discussed.