Chad I. Friedman

Women with declining ovarian reserve may demonstrate a decrease in day 3 serum inhibin B before a rise in day 3 follicle-stimulating hormone☆

OBJECTIVE To test the hypothesis that women with declining ovarian reserve may demonstrate a decrease in day 3 serum inhibin B levels before a rise in day 3 serum FSH levels. DESIGN Case-control study. SETTING Tertiary care fertility center. PATIENT(S) One hundred nine women with nonovarian infertility (tubal factor or male factor) and 47 women with declining ovarian reserve who underwent assisted reproductive techniques. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Serum inhibin B and FSH levels, number of ampules of gonadotropins administered, E2 levels on the day of hCG administration, number of oocytes retrieved, clinical pregnancy rate, and cycle cancellation rate. RESULT(S) Women who had declining ovarian reserve as demonstrated by an increased gonadotropin requirement, a decreased E2 response, fewer retrieved oocytes, a lower clinical pregnancy rate, and a higher cycle cancellation rate had lower day 3 serum inhibin B levels despite having nonelevated day 3 FSH levels similar to those of women with nonovarian infertility. CONCLUSION(S) Women with declining ovarian responsiveness and clinical outcomes consistent with declining ovarian reserve had decreased day 3 serum inhibin B levels despite having nonelevated day 3 serum FSH concentrations. Declining ovarian reserve may be demonstrated by a decrease in day 3 inhibin B levels before a rise in day 3 FSH levels.

Follicular fluid vascular endothelial growth factor concentrations are elevated in women of advanced reproductive age undergoing ovulation induction

OBJECTIVE(S) To determine whether follicular fluid (FF) from women of advanced reproductive age had a relative deficiency of the angiogenic cytokine vascular endothelial growth factor/vascular permeability factor. Furthermore, we sought to determine whether luteinized granulosa cells secrete vascular endothelial growth factor/vascular permeability factor in response to hypoxia. DESIGN Retrospective cohort study. SETTING University teaching hospital. PATIENTS Women undergoing follicular aspiration after superovulation in preparation for IVF-ET. Women of advanced reproductive age consisted of 21 women > or = 38 years old (range, 38 to 46 years); 15 subjects < or = 30 years served as the control population. INTERVENTION(S) Granulosa cells and FF were collected by transvaginal aspiration 35 hours after hCG. Granulosa cells from two women were cultured for 24 and 48 hours in M199 + 10% fetal bovine serum in 1% O2-5% CO2-94% N2 (hypoxic) or 95% air-5% CO2 (normoxic) without or with 0.1 mol/L cobalt chloride. MAIN OUTCOME MEASURE(S) Pooled FF vascular endothelial growth factor/vascular permeability factor concentrations and media vascular endothelial growth factor/vascular permeability factor accumulation at 24 and 48 hours were determined. RESULT(S) Follicular fluid vascular endothelial growth factor/vascular permeability factor concentrations were higher in advanced reproductive age women compared with younger women (3,735 +/- 2,155 versus 2,205 +/- 952 pg/mL, mean +/- SD). Accumulation of vascular endothelial growth factor/vascular permeability factor at 24 and 48 hours was 391 +/- 54 and 744 +/- 2 pg/mL in media maintained in 5% CO2 and air. Cobalt chloride induced a marked increase in vascular endothelial growth factor/vascular permeability factor (2,008 +/- 52 pg/mL at 24 hours and 3,630 +/- 519 pg/mL at 48 hours). An intermediate but significant increase in vascular endothelial growth factor/vascular permeability factor (733 +/- 35 pg/mL at 24 hours and 2,675 +/- 864 pg/mL at 48 hours) was observed with 1% O2 compared with normoxic controls. CONCLUSION(S) After hMG and hCG administration the FF from women of advanced reproductive age showed increased vascular endothelial growth factor/vascular permeability factor concentrations compared with younger women. Increased vascular endothelial growth factor/vascular permeability factor concentrations could be consistent with a hypoxic environment within follicles of older women.

Activin a stimulates meiotic maturation of human oocytes and modulates granulosa cell steroidogenesis in vitro

OBJECTIVE To test the hypothesis that activin A promotes in vitro human oocyte meiotic maturation while inhibiting steroid secretion by nonluteinized antral granulosa cells. DESIGN Prospective randomized controlled study. SETTING A university medical center. PATIENT(S) Nine women ranging in age from 31-44 years who were undergoing oophorectomy for nonovarian pathology. INTERVENTION(S) Analysis of meiotic maturation of oocytes and steroid secretion by granulosa cells cultured in the presence or absence of activin A. MAIN OUTCOME MEASURE(S) Germinal vesicle breakdown (GVBD) and attainment of metaphase II (MII) in oocytes, and progesterone and E2 secretion by granulosa cells. RESULT(S) Activin A significantly enhanced GVBD (91% vs. 65%) for control and maturation to MII (56% vs. 35% for control) of immature oocytes. Activin A significantly suppressed basal, and inhibin A-and FSH-stimulated progesterone and E2 secretion by nonluteinized granulosa cells. CONCLUSION(S) Activin A is a promoter of oocyte maturation in vitro and a modulator of granulosa cell steroidogenesis in culture.

Vascular Endothelial Growth Factor Stimulates Preantral Follicle Growth in the Rat Ovary

Abstract The regulation of preantral follicle growth in mammals is poorly understood. The availability of an adequate vascular supply to provide endocrine and paracrine signals may be important during the early states of follicle growth as well as the later states of follicle selection and dominance. The objective of the present study was to investigate whether vascular endothelial growth factor (VEGF) plays a role in preantral follicular development in the rat ovary. Immature (age, 21 days) Sprague-Dawley rats were injected with 500 ng of VEGF in saline or 50 μg of diethylstilbestrol (DES) in oil under the bursa of one ovary. The contralateral ovary was injected with a corresponding volume of vehicle. Rats were killed 48 h later, and the ovaries were removed and analyzed histologically. Intrabursal administration of VEGF significantly increased the number of primary and small secondary, but not of large secondary, preantral follicles in the ovary, similar to the effect of DES (P < 0.05). The VEGF stimulated preantral follicle growth in a time- and dose-dependent manner. Subcutaneous DES administration increased the number of primary and secondary follicles, and both s.c. and intrabursal estrogen administration stimulated VEGF protein expression in the rat ovary. These data indicate that VEGF stimulates preantral follicular development in the rat ovary, is regulated by estrogen, and may be one of the factors that participate in the regulation of early follicle growth in the rat.

Local peritoneal factors: Their role in infertility associated with endometriosis

In order to detect peritoneal abnormalities that could account for infertility associated with endometriosis, 122 infertile individuals were studied at the time of laparoscopy for diagnostic purposes or for in vitro fertilization. Four groups were defined: group 1, laparoscopy without endometriosis; group 2, laparoscopy with endometriosis; group 3, in vitro fertilization without endometriosis; and group 4, in vitro fertilization with endometriosis. Mean peritoneal fluid volume was greater, although not significantly so, in group 4 (29.0 +/- 6.6 ml, mean +/- SEM) than in group 3 (18.2 +/- 2 ml). The concentration and total number of pelvic macrophages were similar for groups 1 and 2. The total number of pelvic macrophages was increased in group 4 (16.9 +/- 4.2 x 10(6)) versus group 3 (10.0 +/- 1.8 x 10(6)) (p = 0.08). The mean sperm phagocytosis in vitro did not differ among the four groups studied. Interleukin 1 activity within the peritoneal fluid and the in vitro interleukin 1 production rate did not differ between individuals with and without endometriosis. Peritoneal fluid and macrophage supernatants from individuals with endometriosis were not embryotoxic when studied in an in vitro mouse embryo system.

Elevated level of follicular fluid vascular endothelial growth factor is a marker of diminished pregnancy potential

OBJECTIVE To evaluate whether differences in follicular fluid vascular endothelial growth factor (FF VEGF) concentrations are observed between women achieving a clinical pregnancy and those failing to conceive. DESIGN Retrospective chart review and analysis of FF VEGF concentrations. SETTING University teaching center. PATIENT(S) Fifty-seven women < or =42 years of age undergoing follicular aspiration in preparation for IVF or GIFT. INTERVENTION(S) Analysis of FF VEGF concentrations and chart review of a single IVF or GIFT cycle. MAIN OUTCOME MEASURE(S) Follicular fluid VEGF concentrations, clinical pregnancy rate, age, ampules of gonadotropins used, oocytes retrieved, peak estradiol serum concentrations, day 3 FSH levels, and fertilization rate. RESULT(S) Women who did not conceive had higher FF VEGF concentrations than women achieving a clinical pregnancy (4.409 + 2,387 versus 2.793 +/- 1,180 pg/mL: P < .001). A negative correlation was observed between FF VEGF concentrations and peak estradiol levels and number of oocytes retrieved. A positive correlation was found for FF VEGF and patients age and ampules of gonadotropins used. CONCLUSION(S) Elevated FF VEGF concentrations are associated with poor conception rates after IVF or GIFT.

Follicular stimulation for in vitro fertilization using pituitary suppression and human menopausal gonadotropins

Multiple follicular stimulation is a prerequisite to the efficient use of in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT). For some individuals, however, this stimulation may be difficult using standard superovulation protocols because of dominant follicle formation, suboptimal estradiol response, or premature luteinizing hormone surge. A group of such individuals with several previous failed attempts at superovulation were studied. Follicular stimulation was accomplished using a long-acting agonist of gonadotropin-releasing hormone (GnRH) for pituitary suppression followed by human menopausal gonadotropin (hMG) for follicular stimulation. Fourteen cycles (12 IVF, 2 GIFT) were completed in 12 individuals. There were no cycle cancellations. Mean number of prior cycle cancellations per patient was 3.1 +/- 0.4. Mean number of mature oocytes recovered was 3.9 +/- 0.5. Two pregnancies resulted. Pituitary suppression with a long-acting agonist of GnRH followed by hMG appears to be an effective adjunct to current superovulation regimens.

Serum testosterone concentrations in the evaluation of androgen-producing tumors

During a 5-year study period 18 women with a serum testosterone concentrations of greater than 2 ng/ml were evaluated for a possible androgen-producing tumor. All subjects were hirsute and had menstrual irregularities, with the exception of one postmenopausal woman. The majority of the women were obese and 72% were greater than 50% over ideal body weight. Only two of 11 women undergoing operative and histologic evaluation of the ovaries were found to have an androgen-producing neoplasm. Seven additional women with serum testosterone concentration of greater than 2 ng/ml have been followed for over 1 year with no additional evidence of an androgen-producing neoplasm. The poor predictive value of a serum concentration of greater than 2 ng/ml in identification of an androgen-producing neoplasm is partially explained by the apparent prevalence of high testosterone concentrations in chronically anovulatory, hyperandrogenic obese women and by the large coefficient of variation observed in this study when analyzing testosterone concentrations were analyzed over an 8-hour interval (range, 3% to 42%). In the absence of an adnexal mass or rapidly progressive virilization, it is suggested that the use of venography or operative exploration to diagnose an androgen-producing neoplasm be reserved for women with a mean testosterone concentration derived from three daily samples that is at least 2.5 times greater than the upper range of normal in the given laboratory.

Obesity and its effect on reproductive function

This article reviews current knowledge of the effect of obesity on ovulation and reproductive potential. Although only a minority of obese women are affected, it seems certain that there is a link between obesity and anovulation. This interrelationship is suggested by the apparent effectiveness of weight reduction in suppressing the hyperandrogenemia observed with obesity and restoring ovulation. The increased aromatase activity and hyperinsulinemia observed in obese women is believed to play a major role in causing the hyperandrogenemia, either by stimulating luteinizing hormone secretion or directly stimulating the ovary. In addition to ovarian hyperandrogenemia, pituitary hypothalamic dysfunction has been observed in response to obesity. Inadequate central serotonin stimulation, excessive dopamine stimulation, and insensitivity to endorphins may all be involved in the pituitary hypothalamic dysfunction, as well as resistance to weight reduction. Few data are available on the efficacy of weight loss in restoring ovulatory function in obese women; nonetheless, weight reduction should be regarded as a central component of any attempt to induce ovulation. In terms of fertility, even a short-term weight loss can be beneficial. Ileal jejunal bypass surgery to effect weight reduction appears to place a fetus at risk; thus, avoidance of pregnancy for at least 2 years after such surgery is advised.

Intraluminal urethral pressure measurements in the female baboon: effects of hormonal manipulation

Four female baboons underwent cystometry and simultaneous urethral pressure profilometry (UPP) in a hypoestrogenic castrate state, after estrogen treatment, and after concurrent testosterone and estrogen treatment. Studies were performed under general anesthesia both before and after skeletal muscle paralysis. The results provide objective evidence that estrogen replacement enhances the urethral sphincter mechanism in the castrate female baboon by significantly increasing the paralyzed and nonparalyzed urethral length as well as the paralyzed total UPP area and the paralyzed UPP area to maximum urethral closure pressure (MUCP). The area increases reflected both the increase in functional urethral length as well as increases in mean urethral pressure. Muscle paralysis significantly reduced MUCP in all three hormonal states. The addition of testosterone had no significant effect on the UPP measurements. These findings are discussed in light of conflicting human studies regarding objective evidence for the role of hormonal modulation of urethral function and the role of estrogen therapy for stress urinary incontinence.