Jairo E. Garcia

Human intraovarian interleukin-1 (IL-1) system: highly compartmentalized and hormonally dependent regulation of the genes encoding IL-1, its receptor, and its receptor antagonist.

To delineate the scope of the human intraovarian IL-1 system we used a solution hybridization/RNase protection assay to test for expression of the genes encoding IL-1, its type I receptor (IL-1R), and its receptor antagonist (IL-1RA). IL-1 transcripts were not detected in whole ovarian material from days 4 or 12 of an unstimulated menstrual cycle but transcripts (IL-1 beta much greater than IL-11 alpha) were detected in preovulatory follicular aspirates from gonadotropin-stimulated cycles. Concurrently obtained peripheral monocytes did not contain IL-1 beta transcripts but macrophage-depleted follicular aspirates did, thus implicating the granulosa cells as the site of IL-1 expression. IL-1R transcripts were detected in RNA from whole ovaries and follicular aspirates but not in RNA from peripheral monocytes. IL-1RA transcripts were detected in whole ovarian material as well as in macrophage-free follicular aspirates. Cultured human granulosa and theca cells did not contain mRNA for IL-1 beta or IL-1RA but did contain mRNA for IL-1R. Treatment of cell cultures with forskolin (25 microM) induced IL-1 beta transcripts in granulosa but not theca cells. Forskolin also increased the basal levels of IL-1R transcripts in both granulosa and theca cells but did not induce IL-RA transcripts in either cell type. Taken together, these findings reveal the existence of a complete, highly compartmentalized, hormonally dependent intraovarian IL-1 system replete with ligands, receptor, and receptor antagonist.

Effect of maternal age and number of in vitro fertilization procedures on pregnancy outcome

Five hundred twelve patients underwent 1,101 oocyte retrievals for in vitro fertilization (IVF) from July 1, 1985 to June 30, 1988. Eighty-four percent of all oocyte retrievals went on to transfer. The mean number of oocyte retrievals was 2.2 per patient, and the mean number of embryo transfers (ET) was 1.8 per patient. The pregnancy rate was 23% per retrieval, 27% per ET, and 49% per patient. There were 77 (31%) spontaneous abortions and five (2%) ectopic pregnancies. Linear regression analysis of the effect of womens age on the ongoing pregnancy rate per ET showed a highly significant negative linear correlation between age and ongoing pregnancy rate (P less than 0.005). Ongoing pregnancy rate per ET for patients younger than 30 years of age was 26%, as compared with 9% for patients aged 37 years (P less than 0.01). Patients aged 40 years or greater had a 50% miscarriage rate, compared with 29% in patients under the age of 40 (P greater than 0.05). The clinical pregnancy rate per ET for patients undergoing one to seven attempts was 25%, 29%, 28%, 33%, 35%, 30%, and two out of five, respectively. We conclude that womens age has a negative effect on IVF success that is more pronounced after the age of 36, and the pregnancy rate per ET is similar for at least seven attempts.

Follicular phase gonadotropin-releasing hormone agonist and human gonadotropins: a better alternative for ovulation induction in in vitro fertilization

Leuprolide acetate was used in 189 in vitro fertilization (IVF) cycles. Patients were allocated prospectively into two groups: In group A (96 cycles), leuprolide acetate was started on the 2nd menstrual cycle day of the actual IVF attempt. In group B (93 cycles), leuprolide acetate was started on the 3rd luteal phase day of the preceding IVF cycle. Ovulation was induced with a combination of pure follicle-stimulating hormone (FSH) and human menopausal gonadotropins (hMG), starting on or before the 5th cycle day, respectively. Leuprolide acetate and gonadotropins were continued until the day of human chorionic gonadotropin (hCG) administration. Follicular aspiration was carried out either by laparoscopy or by transvaginal ultrasound guidance. Group A required a lower number of FSH and hMG ampules than group B; nevertheless, there was no difference in the number of follicles, percentage of preovulatory oocytes or fertilization rate between the groups. The number of embryos transferred was 3.3 and 3.4, respectively. A significantly higher pregnancy rate was observed in group A (40.6% versus 27.7%) and a lower miscarriage rate (22.8% versus 36%) than in group B. In short, this study suggests that there is no need to administer leuprolide acetate routinely during the luteal phase of the preceding IVF cycle.

Prognostic value of the early serum estradiol response to leuprolide acetate in in vitro fertilization

One hundred in vitro fertilization (IVF)-stimulated cycles were analyzed to evaluate the prognostic value of the early follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (E2) response to the agonist action of leuprolide acetate. Four distinct early E2 response patterns were found. Pattern A (n = 41) showed a prompt elevation of E2, followed by a fall by cycle day 4. Pattern B (n = 16) showed a delayed elevation of E2, followed by a fall by cycle day 6. Pattern C (n = 19) showed a persistent elevation of E2. Pattern D (n = 18) lacked the early E2 response. The clinical pregnancy rates per cycle for patterns A, B, C, and D were 46%, 38%, 16%, and 6%, respectively. A baseline serum FSH level greater than 20 mIU/mL was associated with a lower clinical pregnancy rate, although not statistically significant. Baseline serum LH levels and stimulated FSH and LH levels did not predict IVF outcome. We conclude that the early E2 response pattern to leuprolide acetate is the best early prognostic indicator of IVF outcome.

Deleterious effect of the presence of hydrosalpinx on implantation and pregnancy rates with in vitro fertilization

OBJECTIVEnTo determine the effect of the presence of a unilateral or bilateral hydrosalpinx on the outcome with IVF-ET.nnnDESIGNnRetrospective analysis of clinical and laboratory data.nnnSETTINGnHospital-based private IVF center.nnnPATIENTSnEight hundred forty-six patients with tubal disease younger than age 40 years undergoing 1,766 stimulation cycles. In 118 cycles, a hydrosalpinx was noted sonographically (group I) whereas, in 1,648 cycles, no such image was documented.nnnMAIN OUTCOME MEASURESnPregnancy and implantation rates.nnnRESULTSnGroup I displayed a significantly lower pregnancy rate per transfer than group II (16.84% versus 36.83%) and a lower implantation rate (3.92% versus 11.53%).nnnCONCLUSIONnThe presence of hydrosalpinx adversely affects the outcome of IVF.

High fertilization rate obtained after intracytoplasmic sperm injection with 100% nonmotile spermatozoa selected by using a simple modified hypo-osmotic swelling test

OBJECTIVEnTo report a high fertilization rate after intracytoplasmic sperm injection (ICSI) in patients with 100% nonmotile spermatozoa selected by a simple modified hypo-osmotic swelling test.nnnDESIGNnClinical study.nnnSETTINGnHospital-based IVF center.nnnPATIENT(S)nThree couples with infertility due to asthenospermia.nnnINTERVENTION(S)nThe hypo-osmotic swelling test with 150-mOsm NaCl solution was used to select viable spermatozoa before ICSI. Three patients provided semen samples and one of these three also had a testicular biopsy.nnnMAIN OUTCOME MEASURE(S)nSelection of viable spermatozoa using the hypo-osmotic swelling test with 150-mOsm NaCl solution for ICSI.nnnRESULT(S)nNo motile spermatozoa were found in three ejaculated semen samples and one testicular biopsy. Fifty-seven metaphase-II oocytes were injected with hypo-osmotic swelling test-positive ejaculated or testicular spermatozoa. Fifty-five (96.5%) of these oocytes were intact after injection. Forty-two (76.4%) of 55 oocytes showed two pronuclei, and 40 of the 42 fertilized oocytes cleaved. One patient had all embryos cryopreserved because of the risk of hyperstimulation; two other patients had embryos transferred. One ongoing pregnancy resulted.nnnCONCLUSIONnThis hypo-osmotic swelling test with 150-mOsm NaCl solution is a simple and efficient method for selection of viable spermatozoa. A high fertilization rate can be obtained using ICSI with viable spermatozoa selected by using this hypo-osmotic swelling test.

Successful in vitro maturation of human oocytes not exposed to human chorionic gonadotropin during ovulation induction, resulting in pregnancy

OBJECTIVEnTo report a case of successful in vitro maturation of human oocytes not exposed to hCG during ovulation induction, resulting in pregnancy after transfer of a frozen-thawed embryo resulting from intracytoplasmic sperm injection (ICSI) of the in vitro-matured human oocytes.nnnDESIGNnClinical study.nnnSETTINGnHospital-based private IVF center.nnnPATIENT(S)nA couple with infertility due to severe oligospermia.nnnINTERVENTION(S)nFive immature oocytes were retrieved from a patient who failed to use hCG during ovarian stimulation and were cultured for 48 hours in B2 medium containing FSH and hCG. Five oocytes extruded the first polar body and underwent ICSI with frozen-thawed husband spermatozoa.nnnMAIN OUTCOME MEASURE(S)nIn vitro maturation, fertilization after ICSI, embryo development, and pregnancy.nnnRESULT(S)nAll five oocytes extruded the first polar body and were injected using ICSI. Three oocytes were fertilized, but two showed three pronuclei. The remainder, a two-pronuclei embryo subsequently cleaved and was cryopreserved. An ongoing pregnancy was obtained after-the transfer of this frozen-thawed embryo.nnnCONCLUSION(S)nImmature human oocytes at the germinal-vesicle stage that have not been exposed to hCG during ovarian stimulation can be matured in vitro and a normal pregnancy can result from ICSI of the in vitro-matured oocytes.

Effect of human hydrosalpinx fluid on murine embryo development and implantation

OBJECTIVEnTo determine the effect of hydrosalpinx fluid-containing medium on murine embryo development and implantation.nnnDESIGNnThe development of one-, two-, and four-cell mouse embryos in medium containing 5%, 10%, and 20% of human hydrosalpinx fluid was observed. Implantation rates of mouse embryos transferred into the uterine horn with hydrosalpinx fluid-containing media were determined.nnnSETTINGnPrivate hospital-based fertility center and IVF program.nnnMAIN OUTCOME MEASURE(S)nPercentage of embryos continuing cell division and implantation rates after ET.nnnRESULT(S)nHydrosalpinx fluid in culture medium affected embryo development in a dose-dependent fashion. The injection of hydrosalpinx fluid-containing medium into the uterine horn did not affect embryo implantation.nnnCONCLUSION(S)nHydrosalpinx fluid negatively affects murine embryo development, but its presence in the uterine horn at ET did not affect implantation.

Abdominal paracentesis for the ovarian hyperstimulation syndrome with severe pulmonary compromise

Abdominal paracentesis is a well-tolerated therapeutic alternative to relieve the severe pulmonary compromise caused by severe ascites and pleural effusion in the ovarian hyperstimulation syndrome. An improvement in renal function may be another benefit that deserves further investigation.

The Lupron* screening test: tailoring the use of leuprolide acetate in ovarian stimulation for in vitro fertilization†

STUDY OBJECTIVEnTo evaluate the prognostic and therapeutic value of a Lupron (leuprolide acetate; Tap Pharmaceuticals, North Chicago, IL) screening test before ovarian stimulation for in vitro fertilization (IVF).nnnDESIGNnProspective.nnnSETTINGnOutpatient IVF program.nnnPATIENTSnEighty patients exhibited four early estradiol (E2) patterns. Patients with pattern A and B remained on a flare-up ovarian stimulation protocol. Patients with pattern C were randomized to three ovarian stimulation protocols. Patients with pattern D were treated with the flare-up protocol using a high pure follicle-stimulating hormone (FSH) dose.nnnRESULTSnPatterns, A, B, C, and D occurred in 44%, 16%, 25%, and 15% of the patients, respectively. The E2 pattern recurred in 77% of subsequent IVF cycles. Pattern A and B patients achieved a 41% (23/56) and 22% (5/23) ongoing pregnancy rate (PR) per stimulated cycle. An early luteal phase Lupron protocol had the best ongoing PR per stimulated cycle (10/27, 37%) in patients with a pattern C response. Pattern D patients had a 20% (5/25) ongoing PR per stimulated cycle.nnnCONCLUSIONnThe Lupron screening test allows prospective selection of stimulation protocols in ovulatory patients undergoing IVF. Early E2 patterns A and B should be treated with the flare-up protocol. Pattern C patients benefit from the luteal phase Lupron protocol and pattern D patients benefit from a high pure FSH flare-up protocol.