Mary G. Hammond

Increased activation of pelvic macrophages in infertile women with mild endometriosis

Pelvic fluid was collected from 66 women undergoing laparoscopic sterilization or diagnostic laparoscopy for evaluation of infertility. Cells consisting mainly of macrophages were separated, counted, and subjected to histochemical staining for acid phosphatase and myeloperoxidase as markers of cell irritation. Pelvic fluid was analyzed for acid phosphatase, neutral protease, and extractable prostaglandin E2 and F2 alpha. A higher proportion (46% versus 15%) of the macrophages in the group with mild endometriosis exhibited positive staining for acid phosphatase as compared with the fertile group. Pelvic fluid from patients with mild endometriosis had higher acid phosphatase and neutral protease activity than that from fertile patients (p less than 0.05, p less than 0.01). The content of either prostaglandin was not significantly higher in the endometriosis group as compared with the fertile group. The results suggest that mild endometriosis is associated with activation of macrophages and release of active substances into peritoneal fluid that may be responsible for the associated infertility.

Pelvic macrophages in normal and infertile women: The role of patent tubes

The volume of peritoneal fluid and its macrophage content were examined in 80 women undergoing laparoscopy. The amount of pelvic fluid was not dependent on the patency of the fallopian tubes, and no statistical difference in the fluid volume was observed between the infertile groups, including those with endometriosis, as compared to the fertile group. The number of pelvic macrophages in fertile women was extremely high during the menstrual period, and during the rest of the cycle, it remained at a basal level. The number of pelvic macrophages in women with occluded tubes was low. Four of 21 infertile patients with mild endometriosis had very high numbers of pelvic macrophages, even in the luteal phase. These results suggest that the passage of endometrial irritants through the tubes elicits a macrophage response in the peritoneal cavities of both normal women and patients with endometriosis. Although most patients with endometriosis had normal numbers of peritoneal macrophages, it is possible that these macrophages differ qualitatively from normal, and this could explain the associated infertility.

Semen parameters and fertilization of human oocytes in vitro: a multivariable analysis

Semen parameters in 195 couples undergoing in vitro fertilization and embryo transfer were studied using multivariable analysis. Semen parameters that correlated most closely with reduced ability to fertilize apparently mature oocytes were a slow rate of foreward progression of sperm and the presence of excess numbers of white cells in semen. In men with semen parameters within the normal range, the hamster egg penetration assay (HEPA) test did not add additional predictive power. In men with suspected semen abnormalities, however, a low attachment rating added some, but minimal, predictive value. None of the predictive methods reported thus far in this or other studies offers sufficient accuracy to reliably identify the men who will prove infertile for in vitro fertilization treatment.

The effect of growth factors on the proliferation of human endometrial stromal cells in culture

OBJECTIVE Development of ectopic implants of endometriosis is associated with both an inflammatory response by macrophages and endometrial stromal cell proliferation. Macrophages are capable of releasing a variety of inflammatory mediators, including growth factors. To assess the impact of such factors on endometrial tissue, we have studied the effects of recombinant growth factors, fibroblast growth factor, epidermal growth factor, transforming growth factor-alpha, and inflammation mediators transforming growth factor-beta, and tumor necrosis factor-alpha on human endometrial stromal cell proliferation. STUDY DESIGN Increasing concentrations of these compounds were added to cultures of primary, secondary, and long-term stromal cells and the cells were harvested at 24, 48, and 72 hours. RESULTS Epidermal growth factor, transforming growth factor-alpha, transforming growth factor-beta, and fibroblast growth factor induced a statistically significant, dose-dependent increase in stromal cell thymidine uptake of 1.5- to fivefold. The cytokine tumor necrosis factor had no effect alone, but the combination of fibroblast growth factor and tumor necrosis factor had a synergistic effect, increasing cell proliferation 25% to 84% over fibroblast growth factor alone. CONCLUSION The stromal cell response to a wide range of cell growth effectors and the potential of mediators like tumor necrosis factor-alpha to synergize suggest that such macrophage-secretory products may contribute to proliferation of endometrial implants in vivo.

Monitoring techniques for improved pregnancy rates during clomiphene ovulation induction

Despite the introduction of new ovulation-inducing agents, CC remains the drug of choice for most anovulatory patients. Before initiating therapy, patients should be evaluated to determine the cause of anovulation. Patients with ovarian failure, hyperprolactinemia, hypothyroidism, or forms of CAH should be treated with the appropriate replacement therapy. Evaluation of male factor and tubal patency should be obtained. Once CC therapy is initiated, careful monitoring should be continued. Confirmation of ovulation by endometrial biopsy or serum P levels is essential. CC doses should be increased monthly until normal luteal function is demonstrated. If the patient does not conceive in three ovulatory cycles, her treatment should be further evaluated by postcoital testing, repeat serum P measurement, and review of her endocrine findings. Patients with poor cervical mucus may benefit from midcycle estrogen. Patients with elevated T may benefit from prednisone suppressive therapy. Patients with abnormal HSGs should have laparoscopy and surgical correction if feasible. After six ovulatory cycles without conception, all patients should undergo laparoscopy. If laparoscopy is normal, therapy can be continued for a total of 10 to 12 cycles. Patients with reduced fecundability (male factor, minimal endometriosis, or minimal tubal adhesions) may require a longer time to conceive.

Factors affecting pregnancy rates in a donor insemination program using frozen semen

The results of therapy of 226 women receiving frozen and fresh donor semen are reported. Overall, 45.6% of patients conceived with a monthly fecundability of 0.102. The effect of a variety of factors on fertility rates was analyzed in life-table analysis of 1000 cycles. Optimal pregnancy rates were obtained in couples with azoospermia (0.17) or no female infertility factors (0.2). Patients with ovulatory dysfunction treated with clomiphene also had optimal pregnancy rates (0.17 per cycle). Endometriosis reduced fecundability significantly (0.04 per cycle). There was no significant difference in pregnancy rates per cycle between fresh (0.12) and frozen (0.09) semen. Acceptable pregnancy rates were obtained with frozen semen therapy and in patients with treated ovulatory dysfunction.

Positive correlation between body weight, length of human menopausal gonadotropin stimulation, and oocyte fertilization rate *

One hundred four normally cycling women were treated with fixed low-dose human menopausal gonadotropin (hMG) (2 ampules/day) in preparation for oocyte aspiration for in vitro fertilization. The response rate was related to age, weight, and the ratios weight/height2 and weight/height. The required dose of hMG was related to total body weight, but not to age or either of the weight/height ratios. In patients who required fewer than 5 days of hMG (rapid responders), a significantly higher number (P less than 0.02) of oocytes were harvested, compared with slow responders. However, a smaller percentage of the oocytes from rapid responders fertilized (P less than 0.003) and resulted in a reduced rate of embryo transfer. The difference in pregnancy rates was not statistically significant. The results of the study suggest that patients undergoing in vitro fertilization who weigh less than 55 kg may benefit from treatment with a lower dose of hMG to prolong the stimulation cycle.

Diurnal variations in midluteal serum progesterone measurements

The utility of a single midluteal phase progesterone (P) value has been questioned by studies that document pulsatile P secretion. In this study, fluctuations of P values during clinical sampling times were investigated. Significant differences were found between morning and afternoon mean P values and in the timed occurrence of clinically relevant P values. Despite reported pulsatile secretion, the impact of clinically significant fluctuations may be minimized by the use of timed sampling.

Effect of therapy on infertile couples with antisperm antibodies

One hundred seventy-eight couples with positive antisperm antibody titers in serum and genital secretions were offered treatment with prednisone. Of 60 couples who received prednisone only, 43% conceived. Of 25 who had no therapy, 48% conceived. Fifty-four patients treated with prednisone received additional therapy and 31% conceived. Ten of 39 patients not treated with prednisone but receiving other therapies conceived. Cytotoxic antibodies were reduced in 30% to 42% of serum samples and in 24% to 33% of genital secretion samples. In those couples with decreased cytotoxic antibodies pregnancy rates were 40% to 60% compared with 0% to 23% in those with decreased hemagglutinating antibody titers. Our data suggest that prednisone did not improve overall pregnancy rates; pregnancy rates were comparable in both groups treated with other therapies; donor insemination was the most successful of the alternative therapies; reduction of cytotoxic antibody titers after prednisone treatment was associated with increased pregnancy rates.

Analysis of deoxyribonucleic acid distribution in noncleaving oocytes from patients undergoing in vitro fertilization

The purpose of this study was to describe the quantity and distribution of deoxyribonucleic acid (DNA) in oocytes that did not fertilize or did fertilize and failed to cleave, from patients who underwent in vitro fertilization. Patients were selected with at least one cleaving egg, so that the sperm population was known to be fertile, and failure of fertilization or cleavage in the remaining oocytes could be attributed to nonspermatozoan factors. The noncleaving oocytes were classified into five categories, the majority of which (71%) lacked a polar body and any morphologically identifiable nucleus or germinal vesicle. Three general defects were found: failure to replicate the DNA properly; failure to package the DNA properly; and failure to organize the nuclear material properly after sperm penetration. It is concluded that either altered stimulation protocols or altered in vitro maturation conditions are needed to increase the average number of normal embryos available for transfer.