David J. Cahill

Relative influence of serum follicle stimulating hormone, age and other factors on ovarian response to gonadotrophin stimulation

Objective To determine the relative value of the womans age, basal follicle stimulating hormone (FSH), basal luteinising hormone (LH) and menstrual cycle pattern (all denned prior to treatment) in predicting the ovarian response to gonadotrophin stimulation for in vitro fertilisation.

Ovarian Dysfunction in Endometriosis-Associated and Unexplained Infertility

Purpose: The impact of endometriosis and unexplained infertility on follicular function and fertilization of oocytes in cycles totally unperturbed by exogenous gonadotrophins, when compared with controls with tubal damage, were examined.Methods: In natural cycles, without any exogenous gonadotropins, endocrine and ultrasonographic studies of follicular maturation in 18 women with minor endometriosis (41 cycles), 15 women with unexplained infertility (31 cycles), and 34 women with tubal damage (88 cycles) were performed.Results: The endometriosis group had a significantly longer follicular phase (median: 15,13, and 13 days). Both endometriosis and unexplained infertility had significantly reduced LH concentrations in follicular fluid compared with tubal damage (median: 12.1, 11.5, and 15.9 IU/L, respectively). Endometriosis was associated with a significantly reduced fertilization rate compared with unexplained infertility or tubal damage (46, 65, and 69%, respectively).Conclusions: These data show continuing evidence of ovulatory dysfunction leading to reduced fertilization rates in women with minor endometriosis.

Onset of the preovulatory luteinizing hormone surge: diurnal timing and critical follicular prerequisites

OBJECTIVE To determine the diurnal variation in the onset of the preovulatory LH surge in women. DESIGN Prospective open cohort study. SETTING University hospital research program. PATIENT(S) Thirty-five women with infertility resulting from tubal damage that was associated with minor endometriosis or with infertility of prolonged unexplained etiology. INTERVENTION(S) Women underwent transvaginal ultrasonography and serum E2 estimation daily during monitored cycles before unstimulated natural cycle IVF: exogenous gonadotropins were not administered. MAIN OUTCOME MEASURE(S) Serum E2 concentration, follicle diameter, and endometrial thickness. RESULTS Of 169 cycles. 155 progressed to an ovulatory LH surge, of which 146 occurred within 8 hours of assessment of the outcome measures. The relationship between follicle diameter and E2 was weak, but an abnormal value for one always was countered by a normal value for the other. CONCLUSIONS Most women begin the preovulatory LH surge between midnight and 8:00 A.M., but with no particular variation by day of the week. The relationship between follicle size and serum E2 is not sufficiently strong to predict the LH surge confidently on the basis of only one variable, but the LH surge is unlikely to occur before either the follicle diameter has reached 15 mm and/or the serum E2 level has reached 600 pmol/L.

Relationship between midcycle luteinizing hormone surge quality and oocyte fertilization

OBJECTIVE To determine whether alterations in preovulatory follicular fluid (FF) levels of LH, FSH, and steroids are associated with the probability of fertilization. DESIGN Retrospective analysis of prospective study results. SETTING Reproductive medicine clinic of a university teaching hospital. PATIENT(S) Infertile women, with unstimulated, apparently regular cycles in an IVF research program. INTERVENTION(S) Measurement of preovulatory FF levels of LH, FSH, E2, and P and serum LH levels by fluoroimmunometry. MAIN OUTCOME MEASURE Oocyte fertilization. RESULT(S) There were 84 transferable embryos (rate of normal fertilization and cleavage, 67%), and 41 oocytes (33%) failed to fertilize. Analysis of the matched FF showed that the median concentration of FF LH was significantly higher for cleaving embryos than for unfertilized oocytes (14.6 vs. 10.4 IU/L). Serum LH concentrations were similarly higher in cycles with cleaving embryos. There were no statistically significant differences in FF concentrations of FSH, E2, or P in the two groups. CONCLUSION Reduced preovulatory FF LH levels are associated with impaired fertilization of oocytes in vitro, despite normal FF FSH and steroid levels.

Traditional finals and OSCEs in predicting consultant and self‐reported clinical skills of PRHOs: a pilot study

Introduction  As we move from standard ‘long case’ final examinations to new objective structured formats, we need to ensure the new is at least as good as the old. Furthermore, knowledge of which examination format best predicts medical student progression and clinical skills development would be of value.

Essure® for management of hydrosalpinx prior to in vitro fertilisation—a systematic review and pooled analysis

Hydrosalpinges in infertile women reduce the success of in vitro fertilisation (IVF) by 50%. Surgical management of hydrosalpinges before IVF improves outcome but these procedures are often contraindicated in women with dense pelvic adhesions. Tubal occlusion achieved by Essure® via hysteroscopy provides an alternative.

Endometriosis and infertility: The debate continues

A causal relationship between minor endometriosis and infertility or subfertility has not yet been demonstrated, although a significant association is shown by prevalence studies. This article critically reviews the evidence for pituitary-ovarian dysfunction as a cause for subfertility in women with minor endometriosis. The lack of fertile controls with endometriosis presents a methodological problem. Group comparison in studies using tubal infertility cases as controls has demonstrated impaired follicular growth, reduced circulating oestradiol concentrations during the preovulatory phase and oestradiol and progesterone during the early luteal phase, and disturbed luteinizing hormone (LH) surge patterns. LH concentration in preovulatory follicular fluid is also reduced, and granulosa cells collected at the same time have impaired steroidogenic capacity in vitro. However, these findings are not consistent in published studies. Significantly lower oocyte fertilization rates (49%) are found compared with controls (69%), even after maximum stimulation with exogenous follicle-stimulating hormone and human chorionic gonadotrophin (52% versus 69%). The implantation rate is also lower (11% versus 13%). An inherent disorder of follicular function seems likely, and LH surge impairment is probably a secondary effect. Impairment of oocyte fertilization would thus contribute substantially to the natural subfertility associated with endometriosis, but in vitro fertilization is still successful as excess numbers of oocytes are available.

Total Cortisol levels are reduced in the periovulatory follicle of infertile women with minimal-mild endometriosis

PROBLEM: To measure and compare concentrations of total and free glucocorticoids with oocyte fertilizing capacity in the follicular fluid (FF) of women with minimal–mild endometriosis and tubal damage.

The predictive value of the ‘Hull & Rutherford’ classification for tubal damage

Objective  This study explores the predictive value for live birth following tubal reconstructive surgery of the ‘Hull and Rutherford’ (H&R) classification system.

The Practical Implications of a Raised Serum FSH and Age on the Risk of IVF Treatment Cancellation Due to a Poor Ovarian Response

AbstractPurpose: Chronological age, or biological age as indicated by elevated FSH levels, are related to ovarian reserve. This study addresses the likelihood of cancellation of IVF treatment due to a poor ovarian response utilising both basal serum FSH and womans age. Methods: A prospective cohort of 536 infertile but ovulating women were studied in their first cycle of IVF treatment. Standardised methods of pituitary desensitisation and ovarian stimulation prior to IVF treatment were employed. Treatment cycles cancelled due to a poor ovarian response to gonadotrophins were studied. A series of logistic regression models were used to explore the probabilities of cancellation in relation to age and FSH. Results: Both age and basal serum FSH levels were independently associated with the risk of treatment cancellation. A low risk of treatment cancellation was observed in women under the age of 35 irrespective of serum FSH, however in older women the risk of treatment cancellation was most likely in women with a high FSH. Conclusions: In combination both age and FSH may serve as a valuable indicator of poor ovarian response leading to treatment cancellation. However, among older women FSH has particular importance, while less so in younger women with regular menstrual cycles.