G D'Ambrogio

The role of color doppler imaging in the diagnosis of polycystic ovary syndrome

OBJECTIVE Our purpose was to evaluate whether intraovarian and uterine blood flow variations are associated with clinical, ultrasonographic, and endocrine polycystic ovary syndrome findings. STUDY DESIGN Thirty-two hirsute, oligomenorrheic patients and 18 volunteer women underwent in the early follicular phase ultrasonographic evaluation of ovarian volume, echodensity, and follicle number; transvaginal color Doppler measurement of the uterine and intraovarian vessel variations; and radioimmunologic dosage of luteinizing hormone, follicle-stimulating hormone, estradiol, progesterone, testosterone, androstenedione, and other hormonal compartments. RESULTS In the patients with polycystic ovary syndrome (increased luteinizing hormone/follicle-stimulating hormone ratio, elevated androstenedione levels, high number of subcapsular follicles by ultrasonography-augmented ovarian volume and echodensity) (n = 22) we observed, at Doppler analysis, significantly elevated uterine artery pulsatility index values associated with a typical low resistance index of stromal ovary vascularization. The pulsatility index was positively correlated with the luteinizing hormone/follicle-stimulating hormone ratio, and the resistance index was negatively correlated. The elevated uterine artery resistance was correlated with androstenedione levels. CONCLUSION Doppler analysis can be a valuable additional tool for the diagnosis of polycystic ovary syndrome.

Maternal hyperoxygenation in the treatment of intrauterine growth retardation

OBJECTIVE In the current study the efficacy of maternal hyperoxygenation on growth-retarded fetuses was evaluated. STUDY DESIGN Thirty-six pregnant women with intrauterine growth retardation were studied. The patients were divided in oxygen-treated (n = 17) and untreated (n = 19) groups. Doppler analysis of the fetal circulation was performed on the arrival to the hospital, after 12 hours, and thereafter on alternate days until delivery. Fetal blood was sampled by cordocentesis for immediate blood gas analysis at entrance to the study and the day of delivery. RESULTS Significant improvement in Doppler flow patterns in treated patients were found when compared with untreated women. The Doppler variations were associated with complementary modifications in fetal blood gas. These differences resulted in a significant modification in perinatal mortality with an incidence of 29% and 68% (p less than 0.01) in treated and untreated groups, respectively. CONCLUSION Our data suggest a benefit of maternal hyperoxygenation in the treatment of fetal growth retardation.

Uterine and ovarian blood flow measurement. Does the full bladder modify the flow resistance

Doppler ultrasound is a non‐invasive technique for investigating artery blood flow variations. In 39 normoovulatory patients we investigated the correlation between bladder distension and uterine/ovarian blood flow resistance. The patients were scanned transabdominally or transvaginally both with full and emptied bladders. Pulsatility Index was significantly higher iii patient5 with a full bladder than in the same group after they had emptied their bladders. The present study showed that the full bladder modifying pelvic anatomy and/or increasing sympathetic tone is responsible of a high blood flow resistance in the uterine artery.

SOMATOSTATIN AND OXYTOCIN INFUSION INHIBITS THE RISE OF PLASMA β‐ENDORPHIN, β‐LIPOTROPHIN AND CORTISOL INDUCED BY INSULIN HYPOGLYCAEMIA

The present study investigated the possible effect of somatostatin and oxytocin on the basal and stress‐induced rise of beta‐endorphin (β‐END), beta‐lipotrophin (β‐LPH) and cortisol in the human. For this purpose somatostatin (4.1 μg/min for 120 min or oxytocin (0·4 μg/min for 120 min) was infused into two different groups of seven healthy subjects; 30 min after the start of the infusion, placebo or insulin (0·1 IU/kg body weight, B.W.) was injected on two different days. In a third experimental step, an insulin tolerance test was performed during saline infusion to evaluate stress‐related effects on the different hormonal secretions under basal conditions. Plasma levels of β‐END, β‐LPH and cortisol were measured by radioimmunoassay. Extraction and chromatographic procedures preceded the assay for β‐END and β‐LPH. Neither somatostatin nor oxytocin significantly modified basal plasma levels of β‐END, β‐LPH and cortisol. However these treatments blunted the rise of the three hormones seen at 45 and 60 min during insulin‐induced hypoglycaemia (P> 0·01). These results indicate that somatostatin and oxytocin may influence the β‐END, β‐LPH and cortisol increase induced by stress in humans, without affecting their basal secretion.

Absent or reversed end-diastolic flow in umbilical artery and severe intrauterine growth retardation: An ominous association

Uteroplacental insufficiency is a major cause of perinatal mortality and postnatal morbidity. Doppler velocimetry has been used to assess well‐being of the fetus for several years. In the present study we evaluated the perinatal outcome of growth retarded fetuses with presence or absence of diastolic flow in umbilical artery at Doppler analysis. Forty‐six pregnant women with intra‐uterine‐growth‐retardation were studied. Ultrasound assessment of amniotic fluid was performed on alternate days until parturition. A weekly ultrasound measurement of fetal abdominal circumference was done. Doppler analysis of fetal/maternal circulation was performed upon arrival of the patient in hospital and thereafter on alternate days until delivery. Fetal blood was sampled by cordocentesis for immediate blood‐gas analysis. In the group (/i = 26) with absent or reversed diastolic flow in the umbilical artery, we observed a correspondingly worse blood‐gas analysis; a reduced time interposed between the diagnosis and the delivery; a reduced birth weight associated with an increased fetal risk and with a perinatal mortality approaching 60%. Our data suggest that absent or reversed diastolic flow in umbilical artery of growth‐retarded fetuses, associated with alterations in other vessels, are ominous signs of serious fetal compromise.

Correlation between the amount of follicle-stimulating hormone administered and plasma and follicular fluid vascular endothelial growth factor concentrations in women undergoing in vitro fertilization

Vascular endothelial growth factor (VEGF) is a powerful mediator for vessel permeability and it is strongly implicated in angiogenesis, stimulating endothelial cell proliferation as well as capillary permeability. We studied 30 women undergoing in vitro fertilization (IVF) programs and evaluated, on the day of oocyte retrieval, VEGF levels in plasma and follicular fluid and related such concentrations to the amount of follicle-stimulating hormone (FSH) administered. Furthermore, the correlation between the number of oocytes retrieved and the VEGF concentrations both in plasma and in follicular fluid were also investigated. Results indicate that follicular fluid VEGF concentrations and the amount of pure FSH administered were directly proportional (p < 0.05). On the day of oocyte retrieval, the VEGF plasma concentrations and the number of oocytes collected were directly proportional (p < 0.05). VEGF plasma levels increased after human chorionic gonadotropin (hCG) administration (30.37 +/- 18.60 pg/ml up to 52.62 +/- 43.63 pg/ml). In conclusion, this study demonstrates that the doses of pure FSH administered to women undergoing IVF cycles have a crucial role in hCG-dependent VEGF production.

Interrelationships between follicle stimulating hormone and the growth hormone--insulin-like growth factor--IGF-binding proteins axes in human granulosa cells in culture.

As it has been hypothesized that IGF-binding proteins (IGFBPs) may have a role as autocrine/paracrine factors in regulating the local actions of the insulin-like growth factors (IGFs) in the ovary, we studied the production of the IGFBPs by human granulosa cells (GC) in culture and the role of IGFBP-3 in the modulation of ovarian cell responsiveness to IGF-I and FSH. To this purpose, human luteinizing GC were cultured in serum-free conditions for 24 h and subsequently submitted to increasing concentrations (2–8 nmol/l) of recombinant non-glycosylated or partially glycosylated IGF-BP-3 for 48 h, in the presence or absence of IGF-I, des(1–3)IGF-l - a truncated analog of human IGF-I with markedly reduced binding ability to IGFBPs - and FSH (5–20 mlU/ml). The results demonstrate that human GC release IGFBP-1-2 and -3 into the medium, and that FSH is able to inhibit this release, while GH is clearly inhibitory on IGFBP-1 and stimulatory on IGFBP-3. Both IGF-I and des(1–3)IGF-l significantly (p<0.001) stimulate E2 production by human GC in culture in a manner comparable to that of FSH in the dose range used. Preincubation for 2 h at 22 C with IGFBP-3, to allow the formation of the IGF-IGFBP complex, drastically reduced the stimulatory effect of IGF-I but not that of des(1–3)IGF-l. IGFBP-3 was also able to inhibit the stimulatory effect of FSH. These data show that: i) the IGF peptide is less active when bound to IGFBP-3; ii) as IGFBP-3 does not affect the potency of des(1–3)IGF-l, its inhibitory action is exerted upstream of the membrane receptor binding; iii) as the action of IGFBP-3 is exerted by binding the IGF peptide, its inhibitory effect on FSH points out the role of the locally produced IGF-II in potentiating the FSH action on human GC.

Follicular fluid steroid and epidermal growth factor content, and in vitro estrogen release by granulosa-luteal cells from patients with polycystic ovaries in an IVF/ET program

The follicular fluid (FF) content of androgens, estrogens and epidermal growth factor (EGF) has been evaluated in a group of patients with policystic ovary disease (PCO) and in one of normally-ovulating infertile women (NOW) in an IVF/ET program. The in vitro response to follicle-stimulating hormone (FSH) has been also evaluated in granulosa luteal cells from the same patients. PCO patients showed significantly higher FF androstenedione (delta 4) and testosterone (T) and similar FF estrone (E1) and 17 beta-estradiol (E2) levels compared to controls. In vitro production of E1 and E2 by granulosa luteal cells from PCO patients and from controls were overlapping and their response to FSH was similar. These data indicate a normal intrinsic potential aromatase activity in ovaries from PCO patients stimulated with gonadotropins and suggest that PCOs do not derive from inherent ovarian aromatase deficiency. Increased FF androgen content following gonadotropin stimulation may result from theca cell hyperactivity and androgen accumulation in the follicular antrum of rescued hyperandrogenic follicles as well as from inhibitory factors that may inhibit aromatase activation in vivo, partially counteracting the effect of gonadotropins. FF EGF levels were significantly higher in the group of PCO patients compared to those of NOW. EGF may play a role in blunting the in vivo response of granulosa cells to gonadotropins.

Corticotropin-Releasing Factor-Binding Protein: Origins and Possible Functions

Corticotropin-releasing hormone-binding protein (CRFBP) is a 37-kD protein of 322 amino acids, containing one putative N-glycosylation site and 11 cysteines, 10 of which remain in the mature molecule (298 amino acids) and result essential for the action. CRFBP protein gene has been cloned and mapped to the distal region of chromosome 13 and loci5q in the mouse and human genomes. CRFBP is the only example of a neuropeptide-binding protein. It is produced in human and rat brain, and in human liver and placenta. In brain, the central distribution of CRFBP shares some regional overlap with CRF receptor-bindings sites. Additionally, in hypothalamic and limbic structures, CRFBP has been identified in association with CRF-expressing cell groups. CRFBP has been also demonstrated in the human placenta and related membranes. Indeed, amniotic epithelium, chorionic cytotrophoblast, and maternal decidua also show intense positive CRFBP mRNA signals. Circulating CRFBP levels in healthy nonpregnant individuals show the same range values as in maternal plasma collected during the first and second trimesters of pregnancy. A rise in CRFBP levels at 30-35 weeks of pregnancy with a dramatic decrease at 38-40 weeks have been shown. At postpartum, CRFBP levels in maternal plasma reach the nonpregnant concentrations. Recombinant and native CRFBP neutralize the ACTH-releasing activity of human CRF in cultured pituitary or placental cells and, additionally, may block the activity of CRF on human pregnant endometrium prostaglandin release and on human myometrium contractility in vitro. These findings suggest that CRFBP may play a role in modulating the functions of CRF in human pregnancy.

Serum vascular endothelial growth factor levels before starting gonadotropin treatment in women who have developed moderate forms of ovarian hyperstimulation syndrome

The study aims to evaluate whether serum vascular endothelial growth factor (VEGF) levels, before treatment with gonadotropins, may be considered a predictive marker of moderate ovarian hyperstimulation syndrome (OHSS). At the University of Pisa hospital infertility unit we have retrospectively selected 10 patients who developed moderate forms of OHSS and 30 control patients who presented a normal response to ovarian stimulation among 400 women undergoing in vitro fertilization (IVF). Serum samples were collected before starting pFSH administration (150-300 IU/day). VEGF levels in serum were measured. No statistically significant difference was found between the serum VEGF levels of patients who developed moderate forms of OHSS and women without any symptoms of the syndrome. Further, serum VEGF concentrations were not significantly correlated with the age of the patients, the number of international units of FSH administered during the cycle of stimulation, the follicle and oocyte numbers counted on the day of the egg retrieval or estradiol levels detected on the same day. This study demonstrates that serum VEGF levels, before starting gonadotropin treatment, are not predictive of the subsequent development of moderate forms of ovarian hyperstimulation syndrome.