Dianne Moore Smith

Ovulation induction in polycystic ovary syndrome with urinary follicle-stimulating hormone or human menopausal gonadotropin*†

In patients with polycystic ovarian disease (PCOD) ovulation was induced with a combination of human menopausal gonadotropin (hMG) and human chorionic gonadotropin (hCG) or with urinary follicle-stimulating hormone (uFSH; Metrodin, Serono Laboratories, Inc., Randolph, MA) alone. hMG/hCG and uFSH resulted in comparable rates of ovulation and conception in patients with PCOD. The incidence of hyperstimulation and the potential for multiple births appeared lower with uFSH. The fact that endogenous ovulation did not occur in hMG patients who had hCG withheld or in 3 of the 11 uFSH patients who had preovulatory levels of estradiol and follicles greater than 15 mm may imply that these similarly derived gonadotropins in some instances block endogenous ovulation.

The temporal relationship between the luteinizing hormone surge and human oocyte maturation

The temporal relationship of oocyte maturation to endogenous luteinizing hormone (LH) in vivo throughout the preovulatory period has not been previously reported. In order to study in vivo oocyte maturation follicular aspiration was carried out from 4 to 38 hours after the onset of the LH surge. Oocytes were obtained in 72% of cases. If oocytes were harvested more than 18 hours after the onset of the LH surge, resumption of meiosis had occurred. Twenty-eight to thirty-eight hours after the onset of the LH surge preovulatory oocytes in metaphase II were obtained. A corpus luteum was found 38 hours after the onset of the LH surge.

The relationship of semen parameters to fertilization in patients participating in a program of in vitro fertilization.

Approximately 80% of the patients in a program of in vitro fertilization (IVF) will fertilize an oocyte. The purpose of this study was to determine which parameters of the semen analysis influence fertilization in vitro. Of 120 patients participating in an in vitro fertilization program, 98 achieved fertilization of at least one mature oocyte and 22 did not. Ovulation induction was standardized and patients whose sperm was exposed to at least one mature oocyte (by light microscopy) were included in the study. Semen washing was accomplished using a “swim-up” technique. Semen parameters were assessed both before (raw) and after washing. Following insemination with 100,000 motile sperm, fertilization was determined by the presence of pronuclei or cleavage. Mean sperm count and motility were higher in patients who fertilized. However, morphology was similar. Fertilization was more likely to occur with a raw density>104 million/ml and a motility>64%, as well as with a density>18 million/ml and a motilkity>86% following washing. Furthermore, washing lowered sperm counts by 75% and increased motility by 25% but had no effect on morphology. This study demonstrates that sperm count and motility, but not morphology, influence fertilization in a program of in vitro fertilization and that patients with higher counts and motility have and greater probability of fertilization.

Effect of steroids on oocyte maturation and atresia in mouse ovarian fragments in vitro.

Ovaries from pubertal mice were dissected into fragments containing 1-4 antral follicles which were cultured on the surface of a chemically defined, modified Eagles Minimum Essential Medium (MEM). After 17-20 h oocytes were released from the cultured follicles and their meiotic status recorded. In the presence and absence of exogenous gonadotrophins, oocytess in these cultures behaved meiotically as expected if they had been studied in vivo. Medium containing progesterone (10 microM), testosterone (100 microM), or androstenedione (100 microM) increased the incidence of oocytes remaining meiotically inactive compared to follicles cultured in steroid-free medium. Lower concentrations of the above steroids or pregnenolone (1-100 microM) did not affect the meiotic status of cultured follicle-enclosed oocytes. Most (61%) of the dictyate oocytes released from steroid-treated follicles resumed and/or completed the first meiotic division when cultured further in steroid-free medium. Progesterone (100 microM) caused atresia of oocytes and follicle cells which increased as the period of follicular exposure to progesterone was increased.

In vitro fertilization and embryo transfer: an individualized approach to ovulation induction

Because of the inherent marked individual responsiveness to ovulatory stimulating agents, a highly individualized approach to ovulation induction for in vitro fertilization has been utilized. The starting time for medication was varied according to the previous mean cycle length. The dose of clomiphene citrate was adjusted to the body weight. The dose and duration of both clomiphene and human menopausal gonadotropin (hMG) were adjusted as early as treatment day 5 in accordance with the ultrasonic findings. The day of human chroionic gonadotropin (hCG) administration was varied according to a combination of ultrasonic findings and plasma estradiol levels. This approach resulted in a mean retrieval of four oocytes per laparoscopy, 75% of which were mature, a fertilization rate of 78%, and a pregnancy rate of 14% of laparoscopies.

Steroidogenesis by the human oocyte-cumulus cell complex in vitro

The ability of the human oocyte-cumulus cell complex to synthesize progesterone, androgens and estrogens and to modify its endocrine environment in vitro was investigated. Germinal-vesicle stage oocytes with adhering layers of cumulus cells were recovered from human ovaries and maintained for 40--50 h in vitro in a culture medium with or without antral fluid. The results show that oocyte-cumulus (O-C) cell complexes were capable of synthesizing progesterone, androgens and estrogens. Oocytes with the capacity of resuming meiosis in vitro were part of an O-C complex producing significantly more progesterone than those O-C complexes containing oocytes incapable of resuming meiosis. Irrespective of the stage of oocyte maturation at the end of culture, testosterone and estrone were respectively the major androgen and estrogen produced. It is concluded that the oocyte-cumulus compartment of the antral follicle is a steroidogenically competent unit and that it has the capacity to modify the endocrine microenvironment of the follicle.

Laparoscopic Recovery of Mature Human Oocytes

This report provides a detailed description of a method by which mature or maturing human oocytes can safely be recovered by follicular aspiration during laparoscopy. By combining gonadotropin administration with laparoscopic recovery, oocytes which have resumed or completed meiotic division can be obtained for study without subjecting the patient to more hazardous surgical procedures. Fifteen oocytes were obtained from sixteen patients. On electron microscopic examination, four were found to have extruded polar bodies and were therefore classified as mature. Daily rather than intermittent administration of HMG, larger HMG dose, longer HCG aspiration intervals, and controlled aspiration pressures appeared to be the factors which produced the best yield of mature oocytes.

The effect of clomiphene citrate on human preovulatory oocyte maturation in vivo

Sixty-four infertile women underwent diagnostic laparoscopy in the periovulatory period at time-bracketed intervals following their endogenous luteinizing hormone (LH) surge. Forty-eight of these women were studied during natural cycles and 16 had mild oligoovulation and were administered clomiphene citrate (CC) to regulate their cycles. No patient received human chorionic gonadotropin. No patient was undergoing either in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT). Follicle puncture was performed and the oocytes were observed immediately for stage of maturation. Oocytes obtained from follicles exposed to CC were found to require an increased interval of time to reach metaphase I compared to oocytes obtained from natural cycles (27.75±2.2 vs 22.5 hr; mean±SE). Furthermore, the interval of time required for metaphase I oocytes to achieve metaphase II was statistically significantly shortened for CC cycles (2.4 hr for CC vs 10 hr for natural cycles. Nevertheless, there was no difference between natural and CC cycles in the time interval between LH surge onset and ovulation. These in vivo findings suggest a direct effect of CC on human oocyte maturation and may help explain the wellestablished discrepancy between the relatively high ovulation rate and the relatively low conception rate in clomiphene-induced cycles.

Luteal phase serum progesterone levels after follicle aspiration with and without clomiphene citrate treatment

Peripheral serum progesterone (P) levels were studied on random days after the spontaneous luteinizing hormone (LH) surge in women who underwent follicle aspiration. Comparisons were made with ovulatory women treated with clomiphene citrate (CC) undergoing follicle aspiration and women undergoing midcycle general anesthesia and laparoscopy without follicle aspiration. There were no differences in mean P levels in the group of women who underwent follicle aspiration, compared with the group who did not. Women treated with CC showed higher P levels during the first week of the luteal phase. During the second week of the luteal phase P levels were similar, regardless of follicle aspiration alone or in combination with CC use. In the groups not using CC, more individual women had P levels less than 10 ng/ml. Follicle aspiration does not appear to reduce luteal phase P levels in groups of patients in the natural menstrual cycle or receiving CC. Some individual patients, however, appear to be at risk for lower P levels, particularly after follicle aspiration or general anesthesia, in the natural cycle.