Mary M. Francis

In vitro fertilization in unstimulated cycles: the University of Southern California experience*

OBJECTIVE To describe the clinical experience of our center with in vitro fertilization (IVF) in unstimulated cycles and to provide a comparison to stimulated cycles. DESIGN Spontaneous ovulatory cycles were triggered with human chorionic gonadotropin in the midcycle, and 78 aspirations for IVF were performed, with the remainder of the IVF cycle proceeding in a standard manner. SETTING The IVF program of the University of Southern California and the California Medical Center, Los Angeles, California. PATIENTS Spontaneously ovulatory women (n = 46) with predominantly pelvic factor as their principal cause of infertility, under the age of 40, and no male factor. INTERVENTIONS Human chorionic gonadotropin administration in midcycle, follicle aspiration, IVF, and embryo transfer. MAIN OUTCOME MEASURES Embryo implantation and pregnancy. RESULTS Seventy-eight follicle aspirations resulted in 11 clinical (14%) and 9 ongoing (12%) pregnancies. The per embryo implantation rate was 13% clinical and 11% ongoing. There was no decrease in per cycle pregnancy rates (PRs) for up to three unstimulated cycles. CONCLUSIONS Unstimulated IVF is a viable alternative to stimulated cycles with PRs approximately one half those of stimulated cycles. It is reasonable to offer patients up to three cycles of unstimulated IVF without expecting a decrease in PRs.

Monozygotic twins and triplets in association with blastocyst transfer.

AbstractPurpose: To compare the incidence of monozygotic twins following blastocyst versus day-3 embryo transfer (ET). Methods: A retrospective analysis of the outcome of assisted reproductive technology (ART) cycles utilizing blastocyst ET during 1999–2000 was compared to a similar group of patients undergoing day-3 ET during 1997–1998. Results: Blastocyst ET was used in 75 cycles with 2.0 ± 2 embryos transferred. The comparison group consisted of 90 cycles with day-3 ET and 3.0 ± 2 embryos transferred. Conclusions: High pregnancy rates are maintained with blastocyst ET even though fewer embryos are transferred. The rate of monozygotic twins is higher with blastocyst ET than with day-3 ET. This increase may partially negate the benefit of reduced high-order multiple gestations attributed to blastocyst ET.

Oocyte and pre-embryo donation to women with ovarian failure: an extended clinical trial

The outcome of a series of pre-embryo transfers to 31 women with ovarian failure is described. Twenty six fertile women functioned as nonanonymous donors, providing oocytes for in vitro fertilization after undergoing controlled ovarian hyperstimulation and transvaginal ultrasound directed oocyte aspiration. Recipients, 24 to 44 years of age, received hormone replacement therapy before pre-embryo transfer (ET). A mean of 13.7 +/- 1.1 oocytes were obtained per aspiration resulting in the transfer of 4.5 +/- 0.2 pre-embryos to each recipient couple. Twenty-five of 47 ET resulted in pregnancy (53.2% per ET); 5 preclinical, and 20 clinical, of which 18 are ongoing or delivered. The overall implantation rate per individual transferred fresh pre-embryo was 21.1%. We conclude that oocyte donation is a safe and highly efficient means of achieving pregnancy for women with ovarian failure.

In vitro fertilization in unstimulated cycles : a clinical trial using hCG for timing of follicle aspiration

In vitro fertilization in spsontaneous ovulatory cycles triggered with hCG was associated with a high rate of oocyte retrieval and fertilization, and gave pregnancy rates in the range of national avaerages for stimulated cycles

Immature oocyte retrieval: lessons from unstimulated IVF cycles

OBJECTIVE To describe retrieval of immature oocytes during unstimulated IVF and assess the in vitro maturation and fertilization rates. DESIGN Retrospective analysis. SETTING The USC program for assisted reproduction. PATIENT(S) Spontaneously ovulatory women with predominantly pelvic factor as their principal cause of infertility, under the age of 40, and no male factor. INTERVENTION(S) HCG administration in mid-cycle, aspiration of all visible follicles, in vitro maturation of immature oocytes in culture media versus 50% follicular fluid in media, IVF, and embryo transfer. MAIN OUTCOME MEASURE(S) Rates of in vitro maturation, fertilization, and implantation after embryo transfer. RESULT(S) A total of 101 immature oocytes were obtained during 59 follicle aspirations. Thirty percent of prophase I oocytes matured to metaphase II in vitro compared with 44% of metaphase I oocytes. Fertilization rates for matured prophase I oocytes were 62% for those cultured in standard culture media (controls) and 87% for follicular fluid culture media. Two pregnancies resulted from the transfer of embryos derived from immature oocytes when no other embryos were transferred. CONCLUSION(S) Immature oocytes may be retrieved successfully during the mid-cycle aspiration of the dominant follicle in unstimulated IVF cycles. Maturation of immature oocytes in vitro with follicular fluid results in similar maturation and fertilization rates as for control incubation. Immature oocytes thus retrieved contribute to the overall pregnancy success of unstimulated IVF cycles. It may be better to retrieve immature oocytes during unstimulated cycles than during the follicular phase of natural cycles.

Successful pregnancy in a 63-year-old woman

OBJECTIVE To report the occurrence of an unusual case of successful pregnancy achieved by oocyte donation in a woman > 60 years of age. DESIGN Case report. SETTING University-based assisted reproductive technology program. PATIENT(S) Sixty-three-year old nulligravida, married for 16 years to her 60-year-old husband. Throughout her infertility treatment, the patient was believed to be 10 years younger, as she claimed. She revealed her true age of 63 only upon being referred for obstetric care at 13 weeks of gestational age. INTERVENTION(S) Oocyte donation, IVF, embryo cryopreservation, and ET. MAIN OUTCOME MEASURE(S) Attainment of pregnancy and subsequent delivery. RESULT(S) The patient underwent two cycles of oocyte donation. During the second attempt, the fresh transfer resulted in a clinical miscarriage at approximately 8 weeks of gestational age. A subsequent transfer of three frozen-thawed embryos resulted in an ongoing singleton gestation. The pregnancy was complicated by gestational diabetes (controlled by diet) and mild pregnancy-induced hypertension. Delivery by cesarean section at 38 weeks of gestational age resulted in the birth of a healthy female infant weighing 2,844 g with Apgar scores of 9 and 9. CONCLUSION(S) This case demonstrates that the uterus is capable of supporting nidation and subsequent gestation for many years beyond natural menopause. It shows that other aspects of human physiology are capable of adapting to the stresses and changes of pregnancy sufficiently well to achieve a normal birth at the age of 63 years. This case also exemplifies the difficulty in attempting to regulate the age of recipients in oocyte donation. As in other aspects of human life, when age limits are applied to the provision of certain services, human beings whose age falls outside of these limits become motivated to deceive the providers of those services to avail themselves of the services.

Preovulatory follicular fluid steroid levels in stimulated and unstimulated cycles triggered with human chorionic gonadotropin.

The purpose of this study was to analyze follicular fluid (FF) samples for steroid levels from stimulated and unstimulated cycles triggered with human chorionic gonadotropin (hCG) and to assess the influence of controlled ovarian hyperstimulation and luteinizing hormone/hCG on these levels. Spontaneous ovulatory cycles were monitored with serial ultrasound examinations, and hCG 10,000 IU was given when the lead follicle was mature. Fourteen FF samples yielding fertilizable oocytes were compared with 13 FF samples from controlled ovarian hyperstimulation cycles. Progesterone (P) was higher in controlled ovarian hyperstimulation than in unstimulated cycles (9.0 +/- 1.2 micrograms/mL versus 4.4 +/- 0.6 microgram/mL; mean +/- SEM), whereas estradiol (E2) was lower (0.8 +/- 0.1 microgram/mL versus 1.3 +/- 0.2 microgram/mL), resulting in a higher P:E2 ratio (15.5 +/- 3.3 versus 4.4 +/- 0.7). Androstenedione (A), testosterone (T), and T:E2 ratios were all higher in unstimulated than controlled ovarian hyperstimulation cycles. We conclude that controlled ovarian hyperstimulation is associated with increased FF P, decreased FF E2, T, and A levels, and decreased T:E2 ratios, suggesting altered steroidogenesis and enhanced follicular aromatase activity.

Angiotensin II (AII) modulation of steroidogenesis by luteinized granulosa cells in vitro

PurposeThe purpose of the present study was to evaluate the effect of angiotensin II and its inhibitor, saralasin, on steroid production by luteinized human granulosa cells in vitro. Granulosa cells were obtained from follicular fluid aspirations from human in vitro fertilization. Cultures were established in supplemented Hams F-10 medium. Human chorionic gonadotropin and angiotensin II were added to culture media and the effect on steroid production was measured.ResultsHuman chorionic gonadotropin alone stimulated production of progesterone, estradiol, and testosterone. The addition of angiotensin II resulted in a dose-dependent increase in progesterone production (428% increase compared to baseline). No effect was seen on estradiol or testosterone. However, a large increase (700%) in estradiol was seen with the addition of the competitive inhibitor of angiotensin II, saralasin.ConclusionWe conclude that angiotensin II modulates progesterone production by human luteinized granulosa cells in vitro. The observed enhancement of estradiol production by angiotensin blockade suggests a tonic inhibition of estradiol secretion by endogenous angiotensin II.

The significance of elevated early follicular-phase follicle stimulating hormone (FSH) levels: Observations in unstimulated in vitro fertilization cycles

AbstractObjective: Our objective was to determine the effect of elevated early follicular-phase serum follicle stimulating hormone (FSH) levels on follicle growth and oocyte maturity in unstimulated in vitro fertilization (IVF) cycles. Study Design: We compared cycles with elevated day 3 FSH levels (>20 mIU/ml) to subsequent cycles in the same patients when day 3 FSH returned to normal and to cycles among women with normal day 3 FSH levels. Patients: Seven cycles in seven patients had an elevated day 3 FSH (high-FSH group). These were compared to 11 subsequent cycles in which there was a return to a normal baseline FSH and to 13 cycles in 13 patients that entered the unstimulated protocol with a normal baseline day 3 FSH. Results: The day of human chorionic gonadotropin (hCG) administration was similar in all groups as were the serum estradiol (E2) levels. Although the high-FSH group tended to have smaller maximum follicular diameters, the difference was not statistically significant. The highest FSH level on cycle day 3 in a completed cycle was 56.2 mIU/ml. The total number of oocytes aspirated and the number of embryos obtained was similar in all groups. Whereas there were no pregnancies in the high-FSH group, 2 of the subsequent 11 normal day 3 FSH cycles resulted in clinical pregnancies. Two of the 13 patients in the normal day 3 FSH values also achieved pregnancies. Conclusions: We conclude that cycle day 3 serum FSH levels as high as 56.2 mIU/ml may be associated with apparently normal follicular growth, oocyte fertilization, and embryo cleavage in unstimulated cycles. However, pregnancies are not observed. In addition, FSH levels vary widely from cycle to cycle and elevated levels in one cycle do not necessarily imply that pregnancy may not occur in a subsequent cycle when FSH levels return to normal.

The effect of leuprolide acetate on steroidogenesis by granulosa and theca cells in vitro

Enhancement of follicular response to controlled ovarian hyperstimulation for human in vitro fertilization (IVF) has been suggested following pretreatment with leuprolide acetate (LA). However, additional human menopausal gonadotropin (hMG) is required to achieve follicle maturity in the presence of LA. We studied the effect of LA on steroidogenesis of granulosa and theca cells in vitro. Human granulosa cells obtained from IVF follicular fluid aspirations were cultured for 14 days in the presence and absence of human chorionic gonadotropin (hCG). hCG significantly enhanced progesterone (P) and estradiol (E2) production by the cells, however, the addition of LA in concentrations of 10, 100, and 1000 ng/ml had no effect. Porcine granulosa cells were cultured for 48 hr in the presence and absence of follicle stimulating hormone (FSH) with the addition of LA at the same doses. LA did not affect the FSH-induced increase in P production. Porcine theca cells were cultured for 48 hr in the presence and absence of hCG. The addition of LA did not affect androstenedione (A) production by these cells. We conclude that in this dynamic model in vitro, LA does not inhibit or stimulate P or E2 production by granulosa or A production by theca cells.