Richard P. Marrs

Longitudinal evaluation of patients with untreated prolactin-secreting pituitary adenomas

A group of 43 patients with galactorrhea, hyperprolactinemia, and radiographic evidence of pituitary adenomas were followed from 3 to 20 years. Initial polytomography and computerized tomographic (CT) scans revealed no evidence of extrasellar extension. Serum levels of prolactin (PRL) were measured at 6 month intervals, and visual fields were assessed annually. Polytomograms and CT scans were repeated every 9 to 36 months. During the period of follow-up, CT scans (but not polytomograms) indicated tumor enlargement in two patients, both of whom underwent selective transsphenoidal removal of the tumor. Polytomograms and CT scans did not show any change in the other 41 patients, and three of them have resumed normal menses, are no longer lactating, and have normal PRL levels. The initial results of this ongoing study indicate that most patients with small pituitary adenomas can be followed with annual CT scans with or without medical therapy, and that surgical treatment should be reserved for those patients with large tumors, those with visual-field loss, and those who show signs of enlargement of the tumor.

Correlation of ultrasonic measurement of ovarian follicle size and serum estradiol levels in ovulatory patients following clomiphene citrate for in vitro fertilization

Ovarian follicle development was investigated in 38 normally cycling women who received clomiphene citrate, 150 mg per day for 5 days, to maximize follicular development. Ultrasonic determination of follicle growth was performed on a daily basis with a real-time sector scanner and correlated with daily concentrations of estradiol (E2) in the peripheral serum as measured by rapid radioimmunoassay. Human Chorionic gonadotropin was given to induce ovulation, and the day of injection was considered day 0. Mean concentrations of E2 reached a maximum of 1,150 +/- 65 pg/ml on day 0. Mean diameter of the dominant follicle increased to 22.1 +/- 0.4 on day 0. When peripheral concentrations of E2 were correlated with diameter and total follicular volume it was found that plasma E2 levels varied, depending on the number of follicles seen on ultrasound examination, with a mean E2 value of 459 +/- 18.9 pg/ml per follicle per day. Multiple growth of follicles occur with artificial induction of ovulation; therefore, the use of ultrasound is an important parameter to assess follicular maturation and the timing of ovulation more precisely.

The effect of different methods of ovarian stimulation for human in vitro fertilization and embryo replacement

Many types of medication regimens have been used to produce ovarian stimulation for in vitro fertilization and embryo replacement. However, few comparative studies have been reported. In this investigation, 105 patients were given either clomiphene citrate alone, human menopausal gonadotropins alone, or a combination of these drugs; and the resulting number of oocytes collected, embryos produced, and pregnancies initiated are reported. The data demonstrate optimal follicle development and fertilization rates with combinations of drugs, rather than the use of a single agent. Further studies are needed to determine whether there is a statistically significant difference in pregnancy rates between groups.

Clinical applications of techniques used in human in vitro fertilization research

Human in vitro fertilization-embryo transfer not only provides an opportunity for pregnancy in women who were previously considered to be sterile, but also provides a unique method by means of which basic reproductive physiology can be investigated. From September, 1981, to September, 1982, 71 women with normal cycles who elected to attempt in vitro fertilization-embryo transfer underwent timed laparoscopy for recovery of oocytes. Oocytes were recovered in 60 patients, with embryo transfer resulting in 50 patients, and normal implantation occurred in nine patients. There was a significant correlation between ultrasound observation of follicle size and serum estradiol levels, thus making ultrasound monitoring of follicular growth during stimulation with clomiphene citrate or human menopausal gonadotropin in anovulatory women clinically useful. The technique of sperm washing employed for in vitro fertilization has now been used with good results for intrauterine insemination in patients with infertility due to a cervical factor or oligospermia. Therefore, the techniques used in human in vitro fertilization-embryo transfer are now clinically applicable for couples with infertility due to causes other than tubal disease.

Disappearance of human chorionic gonadotropin and resumption of ovulation following abortion

The disappearance of human chorionic gonadotropin (hCG) and resumption of pituitary ovarian function was investigated in 13 patients following first- and second-trimester abortions. First-trimester abortion patients (with suction curettage) had a mean time of 37.5 +/- 6.4 days for the clearance of hCG to a level of 2 mlU/ml. Second trimester abortions (with prostaglandin) had a mean time of 27.4 +/- 4.8 days. Patients undergoing second-trimester hysterectomy had a mean disappearance time of 39.7 +/- 5.3 days and only 12 days if the hysterectomy was initiated with ligation of the uterine and ovarian vessels. No significant difference in clearance time was found when it was compared on the basis of the baseline hCG levels. Based on a concomitant luteinizing hormone (LH) and follicle-stimulating hormone (FSH) peak, nine of 12 patients resumed normal pituitary function. These LH and FSH peaks were seen even though the serum hCG levels were as high as 35 mlU/ml. Based on serum progesterone levels of greater than 3 ng/ml, all these nine patients ovulated as early as 21 days after abortion. In view of these results, the clearance of hCG after pregnancy termination depends mainly upon the type of procedure used. Moreover, in view of the early time of ovulatory recovery, contraception should be instituted within the first 2 weeks following pregnancy termination.

Computerized staged-freezing technique improves sperm survival and preserves penetration of zona-free hamster ova

Sperm cryosurvival was evaluated after a staged freezing program, compared with standard vapor-cooling. Fifty-nine ejaculates produced by nine proven fertile males were studied before and after preservation with glycerol or dimethylsulfoxide. Spermatozoal survival was assessed by after-thaw motility, mean sperm velocity (MSV) with the use of multiple exposure photography and by the ability to penetrate zona-free hamster ova. A significantly greater reduction in sperm motility was observed with the addition of DMSO in contrast to G (P less than 0.01). All freezing methods resulted in reduced sperm motility, compared with unfrozen samples. The after-thaw sperm motility was significantly lowered when vapor-freezing was used in comparison with the staged process (22.9% +/- 2.6% versus 32.9% +/- 3.4%; P less than 0.01). The MSV was slightly, but not significantly, lower in the after-thaw semen, compared with fresh ejaculates. A significant impairment in sperm penetration ability was evidenced with vapor-freezing, compared with the staged cooling (25.7% +/- 3.1% versus 34.9% +/- 3.0%; P less than 0.01). The programmed freezing process rendered the same sperm efficiency in penetrating zona-free hamster ova as did the fresh samples. This relatively rapid, simple, and reliable computerized cooling technique improves the efficiency of sperm cryostorage and preserves its penetration capacity.

The effect of time of initiation of clomiphene citrate on multiple follicle development for human in vitro fertilization and embryo replacement procedures

Clomiphene citrate has been utilized for ovarian stimulation for human in vitro fertilization and embryo replacement (IVF-ER) procedures quite successfully. The optimal time and the amount of drug necessary for optimal development have not been identified. In this investigation, 58 patients participating in a human IVF-ER program were stimulated with clomiphene citrate, 150 mg/day for 5 days, beginning on day 3, 4, 5, or 7 of the menstrual cycle. Maximal numbers of oocytes recovered, fertilized, and transferred occurred when stimulation was initiated on the fifth day of the cycle. It is concluded that if clomiphene alone is utilized for multiple follicle development, cycle day 5 is optimal for drug initiation.

Factors affecting human sperm penetration of zona-free hamster ova

Abstract The effects of in vivo and in vitro aging of hamster ova, protein supplementation of culture media, sperm concentration, and sperm motility on penetration of zona-free hamster ova by human sperm were investigated. Penetrability of ova was significantly lowered by 2 to 4 additional hours of in vivo aging or by an additional 3 hours of in vitro aging. A comparison was made of the effects of the addition to the media of human preovulatory serum and human serum albumin, and the penetrating ability of human sperm was increased with the addition of 10% human preovulatory serum. Sperm motility was also better maintained in the presence of 10% serum. Maximum penetration occurred after 3 hours of sperm-egg interaction following a 3-hour preincubation period with a sperm concentration of 5 × 10 6 motile sperm per milliliter. When motile sperm concentration was maintained at 1 × 10 7 motile sperm per milliliter, there was no correlation between penetrating ability and percentage of motility. These factors should be controlled to allow reproducible results with the hamster test.

Correlation of ultrasonic and endocrinologic measurements in human menopausal gonadotropin therapy

Ultrasonographic measurement of follicle growth and estradiol concentrations have been shown to correlate well in spontaneous and Clomid-induced ovulatory cycles. However, little is known about these changes during human menopausal gonadotropin (hMG) therapy. Twenty-five women who did not ovulate when treated with clomiphene were treated with hMG during 70 treatment cycles. Eleven patients had withdrawal bleeding after progesterone administration (group 1) and 14 did not bleed (group 2). Follicle growth was monitored with intermittent serum estrogen determinations and daily ovarian ultrasound with an ADR Model 2140 real-time sector scanner. The mean dominant follicle size at the time of human chorionic gonadotropin (hCG) injection was 21.2 mm +/- 0.6 (SEM) and was not different between the two groups. Mean serum estrogen level at the time of hCG injection was 1,121 pg/ml and correlated with follicle volume. At the time of hCG injection in group 2, one dominant follicle was present in 65% and two were present in 35% of the patients. Among those in group 1, two or more dominant follicles were present during all cycles. Mean serum estrogen levels were significantly higher in group 1 patients than those in group 2. This chemical hyperstimulation was induced in order to delay ovulation until adequate follicular size had been achieved. All cycles were ovulatory. Five patients in group 1 and eight in group 2 conceived. The use of ultrasound enables the physician to evaluate follicular growth and development daily and thus to individualize treatment and to reduce the need for estrogen monitoring.

The effect of pregnant mare serum gonadotropin on mouse embryos fertilized in vivo or in vitro

The effect of increasing doses of exogenous gonadotropin stimulation for ovarian hyperstimulation was studied utilizing mouse embryos fertilized in vivo or in vitro. Increased rates of embryo degeneration, fragmentation, and triploidy, increased sister-chomatid exchange, and decreased fertilization rates were observed in high-dose stimulation groups. It appears, therefore, that oocyte and/or embryo quality may be affected by increased amounts of exogeneous gonadotropin stimulation.