Melvin L. Taymor

Emotional aspects of infertility

The psychologic aspects of infertility in men and women are reviewed, neuroendocrinologic factors thought to affect reproduction physiologically are described, and awareness of the stresses that infertility places on a couples relationship is encouraged. Studies have found infertile women to be more neurotic, dependent, and anxious than fertile women, experiencing conflict over their femininity and fear associated with reproduction. In contrast to these reports, a double blind study could not determine the difference in the psychologic makeup of women who were infertile because of demonstrated somatic causes and those women in whom no somatic cause could be found and who were considered infertile on an emotional etiologic basis. Other studies have similarly come to negative conclusions regarding the relationship between psychologic factors and infertility. The 1st set of studies failed to consider the stress that infertility itself places on the couple. Emotional factors may negatively affect fertility in the male. Up to 10% of infertile males have had improvement in their semen analysis after cessation of all treatment for a prolonged period of time. The concept that emotional stress might lead to oligospermia was further supported in a report describing testicular biopsies obtained from men awaiting sentencing after raping and impregnating women. A more obvious effect of the emotional stress infertility places on the male is the occurrence of impotence. It has been estimated that up to 10% of infertilty may be partially or completely explained on the basis of male sexual dysfunction. The gradual unraveling of the complexities of neuroendocrinology have permitted increased understanding of the role that stress might play in infertility. Catecholamines, prolactin, adrenal steroids, endorphins, and serotonin all affect ovulation and in turn are all affected by stress. Such stress might result from infertility or habitual abortion. Infertility is frequently perceived by the couple as an enormous emotional strain, and counseling may prove helpful as a part of the initial infertility evaluation, an adjunctive measure during treatment, or a final measure to help patients cope with acceptance of their infertility problem. Although statistical evidence is overwhelmingly against the relationship of adoption and subsequent conception, it does appear that a small percentage of patients do achieve pregnancy following adoption. Possibly this can be explained by a reduction in stress, and subsequently, alterations in the neuroendocrinologic characteristics of the infertile couple.

The impact of embryo quality and quantity on implantation and the establishment of viable pregnancies

The role of cleavage rates, number of embryos transferred, and some other variables in pregnancy outcome in 222 human embryo transfers was studied. Pregnancy rates were significantly higher in a group of 117 patients receiving at least one embryo that had reached the four-cell stage at 40 hr postinsemination (26% total pregnancies/transfer and 18% ongoing pregnancies/transfer) than in the 105 patients receiving embryos developing at a slower rate (7% total pregnancies/transfer and 2% ongoing pregnancies/transfer). Of the 23 ongoing or term pregnancies produced, 21 came from transfers of at least one embryo that had reached four-cell stage by 40 hr postinsemination. Pregnancy rates were unaffected in either the fast-cleaving or the slower-cleaving embryos by culturing in vitro for an additional 24 hr. The presence of anucleate cell fragments also had no effect on pregnancy rates. Pregnancy rates increased progressively with the transfer of more embryos per transfer. These results suggest that procedures to improve ovulation induction and in vitro embryo culture technique may better the success of in vitro fertilization by providing a high number of rapidly cleaving embryos for transfer.

The effectiveness of danazol on subsequent fertility in minimal endometriosis

Sixty-five patients with minimal endometriosis were studied for the purpose of prospectively comparing conservative medical management in the form of danazol with no therapy in the treatment of this disease. After completion of the basic infertility evaluation and correction of additional factors affecting fertility, a diagnostic laparoscopy, dilatation and curettage (D and C), and tubal lavage were performed. A randomly selected cord determined whether the patient received no treatment for 6 months or danazol for 6 months followed by no treatment for 6 months. The dosage of danazol was 800 mg daily for the first 2 months, 600 mg daily for the next 2 months, and 400 mg daily for the final 2 months. The mean age of both the danazol-treated group and the group that received no danazol was 31 years. Conception occurred in 30% of the danazol-treated patients and 50% of the untreated patients. These results suggest that infertile patients with minimal endometriosis should be given an opportunity to conceive after laparoscopy, D and C, and tubal lavage. This would seem particularly true in older patients where a 6-month delay in permitting attempts at conception represents a significant interval of time.

Simultaneous intrauterine and tubal pregnancies following ovulation induction

Abstract Two cases of simultaneous intrauterine and tubal pregnancies resulting from the administration of human menopausal gonadotropin (HMG) in one instance and clomiphene citrate in the other are described. No vaginal bleeding or spotting was observed, and dilatation and curettage were not performed around the time the tubal pregnancies were excised; consequently, the intrauterine pregnancy was salvaged in each instance.

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.

Reversal of persistent anovulation in polycystic ovarian disease by administration of chronic low-dose follicle-stimulating hormone

Low doses of follicle-stimulating hormone (FSH) were administered once daily to two consecutive patients with polycystic ovarian disease (PCOD) for therapy of infertility. Serial blood samples were obtained for gonadotropins and ovarian steroid determinations during the period of FSH administration. Exogenous FSH resulted in an initial and concomitant decrease in serum androstenedione (A), estrone (E1), and luteinizing hormone (LH), with an increase in estradiol (E2) and FSH. Subsequent changes in the above-mentioned hormonal levels were typical of a normal ovulatory cycle, with the exception of FSH, which continued to rise in the second half of the follicular phase. This was attributed to the exogenous administration of FSH. Both patients became pregnant in their first induced ovulatory cycle by administration of chronic low-dose FSH. These preliminary data demonstrate (1) a correction of the biochemical imbalance characteristic of PCOD, (2) successful ovulation induction, and (3) restoration of fertility in PCOD treated with chronic low-dose FSH.

The role of ultrasound in ovulation induction: a critical appraisal *

Twenty-five cycles induced by human menopausal gonadotropin (hMG) were serially studied by ultrasound. The developing follicles were observed up to and beyond human chorionic gonadotropin (hCG) administration. Ovulation as determined by subsequent pregnancy or a sustained elevation of basal temperature was seen in 18 of these cycles. Among these patients the follicular size ranged between 24 and 13 millimeters. No pregnancies occurred where the follicular size was below 15 mm. A shortened luteal phase was noted in three cycles where the follicular size was either 13 or 14 mm. Multiple follicles greater than 10 mm were observed in 14 of the ovulating cycles, but in no case did a multiple pregnancy occur. Fifteen millimeters is therefore suggested as a minimum size for satisfactory ovulation, but it does not appear that an optimum size exists. We conclude that ultrasound can play an important role in the monitoring of ovulation induction but does not replace the present methods.

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.

THE PREVENTION OF POSTOPERATIVE PELVIC ADHESIONS FOLLOWING CONSERVATIVE OPERATIVE TREATMENT FOR HUMAN INFERTILITY

A combination of Decadreon (dexamethasone) and Phenergan (promethazine) was tested in this collaborative study of 240 infertility patients as a means of preventing postoperative adhesion formation after simple pelvic surgery. 24 patients were lost to follow-up. The overall pregnancy rate among the 240 patients was 51.7% (124): 49% with primary infertility and 58% with secondary infertility conceived after surgery. 90 full-term deliveries were recorded, 27 spontaneous abortions occurred, and 7 ectopic gestations were conceived. In all, 31 cases were reinspected for various reasons after the drug treatment postsurgery; 42% showed no adhesions, 23% showed minimal adhesions, and 35% had significant adhesions. Complications coincident with use of the combined medication were seen in 2.2% (11 of 240) patients. Though this study lacked controls, the authors feel thta the use of corticosteroids postoperatively after pelvic intervention may control the numbers of adhesions which form postoperatively.