R. Margara

Formation and early development of follicles in the polycystic ovary.

BACKGROUND Polycystic ovary syndrome is the most common cause of anovulatory infertility. It has long-term health implications and is an important risk factor for type 2 diabetes. However, little is known about the cause of polycystic ovaries. We have used detailed morphological analysis to assess the hypothesis that there is an intrinsic ovarian abnormality that affects the earliest stages of follicular development. METHODS We took small cortical biopsies during routine laparoscopy from 24 women with normal ovaries and regular cycles and from 32 women with polycystic ovaries, 16 of whom had regular, ovulatory cycles and 16 of whom had oligomenorrhoea. We used computerised image analysis to assess the density and developmental stage of small preantral follicles in serial sections of fixed tissue. FINDINGS Median density of small preantral follicles, including those at primordial and primary stages, was six-fold greater in biopsies from polycystic ovaries in anovulatory women than in normal ovaries (p=0.009). In both ovulatory and anovulatory women with polycystic ovaries, we noted a significant increase in the percentage of early growing (primary) follicles and a reciprocal decrease in the proportion of primordial follicles compared with normal ovaries. INTERPRETATION Our findings indicate that there are fundamental differences between polycystic and normal ovaries in early follicular development, suggesting an intrinsic ovarian abnormality. The increased density of small preantral follicles in polycystic ovaries could result from increased population of the fetal ovary by germ cells, or from decreased rate of loss of oocytes during late gestation, childhood, and puberty.

Mechanical isolation and in vitro growth of preantral and small antral human follicles.

OBJECTIVE To develop a procedure for isolating small human follicles and to determine their growth requirements. DESIGN Preantral and early antral follicles were isolated manually, allocated randomly to experimental groups, and cultured for a few weeks. SETTING Patients giving informed consent in hospitals. PATIENT(S) Women undergoing laparotomy or oophorectomy. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Follicular size, E2, histology. RESULT(S) Human FSH (at a dose of 1.5 U/mL) induced antral growth of follicles, and the addition of human LH (2.5 ng/mL) to human FSH stimulated growth and antral development. Histologic studies showed that most of the early antral follicles did not contain an oocyte and already had begun to undergo atresia before culturing. Levels of E2 increased in the incubation medium as the follicles increased in size, but those levels were significantly greater when the follicles contained oocytes. CONCLUSION(S) It is possible to grow small human follicles after they have been isolated manually. To develop successfully, they require a low concentration of human LH in addition to human FSH. The rate of atresia between the preantral and early antral stages in vivo is very high; therefore, it is worthwhile to develop techniques for isolating and culturing the follicles before the antral stages.

Results of IVF in patients with endometriosis: the severity of the disease does not affect outcome, or the incidence of miscarriage

The literature suggests that the results of in-vitro fertilization (IVF) for patients with endometriosis depend on the stage of the disease, and that patients with severe endometriosis have a higher failure rate. Miscarriage is said to be more prevalent in women treated for endometriosis. In the study reported here, 140 patients with endometriosis underwent 182 cycles of IVF using gonadotrophin-releasing hormone analogues (GnRHa). Patients with endometriosis only were allocated to one group (group 4). The results were compared with those of three other groups of patients undergoing the same treatment within the same period. Group 1 consisted of couples with male factor only (45 cycles), group 2, couples with unexplained infertility (196 cycles) and group 3, couples with a tubal factor only (1139 cycles). The mean age of the patients, mean number of human menopausal gonadotrophin (HMG) ampoules administered, oestradiol concentration on the day of human chorionic gonadotrophin administration, number of days of HMG, mean number of oocytes retrieved and retrieval rate were not significantly different. The fertilization rate was significantly lower in group 1; no difference was observed in the other three groups. The mean number of normally fertilized embryos was not significantly different. The number of transferred embryos in each cycle and the implantation rates were similar in the four groups. The overall pregnancy rate per transfer was 39% in group 1, 48% in group 2, 45% in group 3 and 40% in group 4.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of salpingectomy on ovarian response to superovulation in an in vitro fertilization–embryo transfer program

OBJECTIVE To investigate the effect of salpingectomy on the response of each ovary in patients undergoing an IVF-ET treatment cycle and to compare the results with those of patients who had not had surgery and were undergoing IVF-ET during the same period. DESIGN A prospective study. SETTING Tertiary referral academic IVF unit. PATIENT(S) Twenty-nine ET cycles were evaluated in 29 patients who previously had undergone unilateral salpingectomy because of ectopic pregnancy (study group). Seventy-three patients with unexplained or male factor infertility served as controls. INTERVENTION(S) Ovulation induction and IVF-ET. MAIN OUTCOME MEASURE(S) In the study group, mean ovarian volume, number of follicles, and number of oocytes recovered from each ovary were assessed and compared. The overall results, cycle characteristics, and pregnancy rates of the two groups were compared. RESULT(S) Among the patients who had undergone salpingectomy, significantly fewer follicles developed and consequently fewer oocytes were retrieved from the ovary on the operated side (4.4 versus 8.2 follicles and 3.8 versus 6.0 oocytes). There were no differences in the total numbers of follicles and oocytes recovered from both ovaries, the cycle characteristics, or the pregnancy rates between study and control groups. CONCLUSION(S) Salpingectomy has no detrimental effect on the total ovarian performance during IVF-ET treatment or on the outcome of IVF-ET. However, the ipsilateral ovary could be adversely affected. This could be detrimental in selected patients undergoing IVF-ET, in whom the second ovary already is compromised or missing.

Nine cases of heterotopic pregnancies in 4 years of in vitro fertilization

The incidence of simultaneous intrauterine and extrauterine pregnancy increased after wider use of ovulation induction and the advent of techniques of assisted reproduction. Nine cases of heterotopic pregnancies are reported after in vitro fertilization (IVF) and embryo transfer (ET) between September 1984 and November 1988. The incidence of heterotopic pregnancies in clinical IVF pregnancies was 9 of 312 (2.9%). Superovulation and IVF-ET appear to predispose to heterotopic pregnancy, particularly after tubal disease.

Inhibition of oestradiol production by epidermal growth factor in human granulosa cells of normal and polycystic ovaries.

Anovulation in women with polycystic ovary syndrome results from a disorder of FSH‐mediated follicular maturation which may involve paracrine modulation of FSH action by intra‐ovarian factors. Epidermal growth factor (EGF) is a potent inhibitor of FSH‐stimulated oestradiol production in the rat and has also been shown to inhibit aromatase activity in human granulosa cells obtained after superovulation. The purpose of this study was to investigate the action of EGF on granulosa cell function in human ovaries which had not been previously exposed to treatment with exogenous gonadotrophins and to compare the responses in tissue obtained from normal and from polycystic ovaries. Granulosa cells were obtained from antral follicles <10 mm in diameter after dissection of unstimulated normal or polycystic ovaries (PCO). Cells were pooled, washed, plated and incubated for 48h in the presence of 10‐7 M testosterone and various doses of human FSH. FSH dose responses were obtained with or without the addition of purified EGF (50 pg/ml). Testosterone in the absence of FSH resulted in a fourfold (range 2–7.5) increase in oestradiol accumulation in the medium after incubation of granulosa cells from both normal and polycystic ovaries. This increase was reversed by addition of EGF. FSH treatment stimulated a dose‐related increase in oestradiol regardless of the origin of the granulosa cells. The peak E2 response to FSH, obtained at a dose of 1–2.5 ng/ml was a 20‐fold increase above testosterone alone (range 4–55) in cells from PCO compared to sixfold (2–5.13) in cells from normal ovaries. The concurrent addition of EGF at 50 pg/ml caused an average 57% inhibition of the peak response to FSH. EGF also caused a dose‐dependent inhibition of oestradiol production stimulated by a fixed dose of FSH in cells from both normal and PCO. These data indicate that EGF inhibits FSH‐inducedoestradiol production by granulosa cells of both normal and polycystic ovaries and suggest that EGF, or its analogue, transforming growth factor α, which is known to be synthesized by theca cells, may have a role in human ovarian function.

Microsurgical salpingostomy is not an obsolete procedure

Objective— A review of the results of microsurgery for bilateral distal tubal blockage.

A review of complications following transvaginal oocyte retrieval for in-vitro fertilization

Transvaginal ultrasound guided oocyte retrieval (TVOR) during in vitro fertilization (IVF) treatment was first described in 1985. By virtue of its simplicity and effectiveness, it has gained widespread popularity and has now become the gold standard for IVF therapy. Nevertheless, despite the advantages, the aspiration needle may injure the adjacent pelvic organs and structures leading to serious complications. The most common complications are haemorrhage, trauma and injury of pelvic structures, and pelvic infection. Other complications described include adnexal torsion, rupture of endometriotic cysts, anaesthetic, and even vertebral osteomyelitis. In the last two decades, several reports have described the complications associated with this technique, and tried to address the risk factors and safety issues. However there is wide variation in the way this common procedure is performed, with room for improvement through published guidelines. This article reviews the most common complications reported in literature, summarizes the recommendations made to minimize their occurrence, and raises some of the controversial issues related to the procedure especially that of pelvic infection. Conflict of interest: none

Pregnancy outcome is not affected by antiphospholipid antibody status in women referred for in vitro fertilization

OBJECTIVE To determine the prevalence of antiphospholipid (aPL) and anti-beta 2 glycoprotein I (anti-beta2-GPI) antibodies in women referred for IVF and to prospectively evaluate the effect of these antibodies on IVF outcome. DESIGN Prospective observational study. SETTING A university hospital and IVF unit. PATIENT(S) Three hundred eighty consecutive women referred for IVF. INTERVENTION(S) Blood samples taken before commencement of IVF cycles were tested for the presence of aPL (lupus anticoagulant [LA], anticardiolipin [aCL], and antiphosphatidyl serine antibodies [aPS]) and anti-beta2-GPI antibodies. MAIN OUTCOME MEASURE(S) Antibody prevalence, pregnancy rates, and live birth rates. RESULT(S) Of the total 380 women, 89 tested persistently positive for aPL (23.4%). None of 176 women tested for IgG aPS antibodies had a positive titer. Only 3.3% (11 of 329) tested positive for anti-beta2-GPI antibodies. Pregnancy rate, live birth rate, gestational age at delivery, and birth weight were not affected by aPL status. CONCLUSION(S) Although women referred for IVF have a high prevalence of aPL, these antibodies do not affect the outcome of treatment. Screening women undergoing IVF for aPL is not justified.

MUC 1: a genetic susceptibility to infertility?

In man and some animals regulation of embryo implantation by endometrial expression of the highly polymorphic MUC 1 mucin has been suggested. We assessed the polymorphism of MUC 1 in women known to be fertile and those with infertility due to suspected failure of embryo implantation. The median of the lower allele size in the infertile group was only 2.5 kb compared with 3.4 kb in the fertile group (p=0.0029, difference 0.9, [95% CI 0.1-1.3]). Women with unexplained infertility might have a genetic susceptibility to failure of embryo implantation due to small MUC 1 allele size.