Richard T. Scott

Follicle-stimulating hormone levels on cycle day 3 are predictive of in vitro fertilization outcome

Cycle day 3 basal levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (E2) were measured in 441 patients in 758 consecutive cycles to determine their predictive value for stimulation quality and pregnancy rates in vitro fertilization (IVF). Patients with low basal FSH levels (less than 15 mIU/ml) had higher pregnancy rates per attempt than those with moderate levels (15 to 24.9 mIU/ml), both of which were higher than those with high FSH levels (greater than 25 mIU/ml). Basal LH and E2 values did not improve the predictive value beyond that provided by FSH. Ongoing pregnancy rates per attempt in the low, moderate, and high FSH groups were 17.0%, 9.3%, and 3.6%, respectively (P less than 0.01). The three groups differed significantly in the percentage of patients having two ovaries, the mean number of follicles aspirated per retrieval, the mean number of preovulatory oocytes obtained, and peak E2 values (P less than 0.01). Cycle day 3 FSH levels are predictive of pregnancy outcome and stimulation characteristics in IVF, and may be useful in counseling patients.

Hemizona assay: assessment of sperm dysfunction and prediction of in vitro fertilization outcome

The hemizona assay (HZA) was used in a prospective, blinded study to assess the relationship between tight sperm binding in the HZA and sperm fertilizing ability in in vitro fertilization (IVF). In each controlled assay, the authors compared sperm binding of proven fertile men with that of patients undergoing IVF. Human oocytes stored in a salt solution were used in the study, and binding results were correlated with the fertilization rate of preovulatory oocytes during IVF. Patients with poor fertilization rates in IVF had significantly lower binding than those cases with successful fertilization (7.3 +/- 1.4 versus 62.1 +/- 10.9, respectively; mean +/- standard error, P less than 0.02). Based on current standards, the HZA was able to predict fertilization accurately in 26 of 28 cases (sensitivity of 83%, specificity of 95%, positive predictive value of 83%). The authors conclude that the HZA is a valuable tool for evaluating dysfunctional sperm-zona pellucida binding, with good predictive value for fertilization in vitro.

Correlation of follicular diameter with oocyte recovery and maturity at the time of transvaginal follicular aspiration

Forty-four consecutive patients undergoing transvaginal follicular aspiration for in vitro fertilization underwent ultrasonic measurement of follicular diameter at the time of oocyte retrieval to determine the correlation of follicular size with recovery rates and oocyte maturity. Based on the results of 412 follicles aspirated, the data were grouped by size (≤11, 12–14, 15–17, 18–20, and ≥21 mm) and oocyte maturity. Recovery rates were significantly higher in 18- to 20-mm follicles (P<0.01) and lower in those ≤11 mm (P<0.001). The probability of retrieving a metaphase I or II oocyte was significantly lower in follicles ≤11 mm (P<0.001), somewhat higher in 12- to 14-mm follicles (P<0.01), and equally high among the other groups. There were no differences in the incidence of fractured zonas. We conclude that follicles ≥15 mm provide the highest probability of retrieving mature oocytes and the low recovery rates of mature oocytes from follicles ≤11 mm suggest that, in selected circumstances, the operating surgeon may choose not to aspirate them.

Transdermal estrogen replacement in ovarian failure for ovum donation

This study examined the efficacy of transdermal estradiol (TE 2 ) replacement versus oral estradiol (OE 2 ) through evaluation of peripheral steroid levels, endometrial morphology, and clinical outcome in six patients with ovarian failure. Patients were begun on sequential E 2 and progesterone replacement with transdermal E 2 patches. Endometrial biopsies were done on day 21 of the first replacement cycle and day 26 of the second cycle. Controls were 28 cycles on a regular 28-day micronized OE 2 protocol. No significant difference was found between E 2 levels throughout the cycle of the two respective stimulation protocols, except for days 12 to 14, when the OE 2 protocol produced significantly lower E 2 than did the TE 2 protocol ( P 1 ) and E 2 values in the OE 2 group (r = 0.92) ( P 2 administration, El was significantly higher than E 2 ( P 1 was not found to be higher than E 2 in the TE 2 group, resulting in a significant difference in the E 2 /E 1 ratio of 1.59 ± 1.6 for TE 2 compared with 0.13 ± .04 for OE 2 ( P 2 revealed glandular components that were dated as day 18.2 ± 1.7, while the stroma was dated as day 21.8 ± 0.8, a statistically significant disparity ( P 2 , the same significant 3-day glandular/stromal disparity was observed ( P 2 and OE 2 groups, respectively. Embryo transfer was performed in six cycles in patients on TE 2 . A viable intrauterine pregnancy was confirmed in three of the six. It would appear that TE 2 is comparable to OE 2 as an agent for estrogen replacement for donor egg recipients with premature ovarian failure.

A prospective randomized comparison of single- and double-lumen needles for transvaginal follicular aspiration

Patients undergoing ultrasound-directed transvaginal follicular aspiration in a large in vitro fertilization (IVF) program were randomized for retrieval with either a single-lumen needle (SLN;N=22) or a double-lumen needle (DLN;N=22) to compare recovery rates and the technical aspects of their use. Two hundred ten and two hundred two follicles were aspirated with each needle, respectively. Follicular diameters were measured ultrasonically at the time of aspiration and recorded. One or more washes were performed when using the DLN and the SLN was withdrawn each time to recover the fluid in the dead space of the needle. The distribution of follicular sizes was the same for both needles. Oocyte recovery rates (SLN=65.7%; DLN=63.9%) and the incidence of fractured zonae (SLN=9.1%; DLN=6.4%) were the same for both needles (α>0.50; β<0.01). Although there were no differences between the two needles in the number of oocytes provided for IVF, there were technical differences. The DLN needle was more flexible and frequently deviated from the projected path as observed by ultrasound. The SLN may be preferable because it is technically easier to use; however, there may remain specific indications for the use of the DLN.

Critical Assessment of Sperm Morphology Before and After Double Wash Swim-Up Preparation for in Vitro Fertilization

Critical assessment of sperm morphology using specific and stringent criteria is predictive of the subsequent ability of those sperm to fertilize oocytes in in vitro fertilization (IVF). Previous studies have evaluated sperm morphology prior to sperm preparation and, thus, have not assessed the actual sperm used for insemination. We studied the impact of a double wash swim-up technique used for IVF on sperm morphology using the strict criteria of Kruger et al. [5, 6] in 73 consecutive patients undergoing IVF. Pre- and postswim-up morphological assessments were done in a prospective, randomized, and blinded fashion. The mean percentage of normal forms pre- and postswim-up was 19.8% and 23.4%, respectively, an improvement of 18% (p less than 0.05) with 62 of 73 patients showing improvement. Significantly, analysis of the 27 patients with abnormal morphology on initial assessment (normal forms less than or equal to 14%) revealed an improvement in percentage of normal forms from 9.0% to 21.5%, a mean increase of 239% (p less than 0.005). Eighteen of these 27 patients showed improvement in their percentage of normal forms, eight were unchanged, and only one patient had a decline in their percentage of normal forms. We conclude that the double wash swim-up preparation used for IVF substantially improves the percentage of sperm with normal morphology, and that the benefit is most substantial in those cases where the percentage of normal morphology is abnormal.

Effects of leuprolide acetate on follicular fluid hormone composition at oocyte retrieval for in vitro fertilization

The follicular fluid (FF) in 91 follicles from 17 women treated with leuprolide acetate (LA) before stimulation with gonadotropins for in vitro fertilization were analyzed for estradiol (E2), progesterone (P), androstenedione, prolactin, and human chorionic gonadotropin (hCG) and compared with the concentrations in 128 follicles from 31 women treated with gonadotropins alone. The FF E2 concentration in LA-treated patients was significantly lower than in non-LA patients for all oocyte maturational stages. Follicles containing metaphase II oocytes had significantly lower concentrations of P and hCG in LA-treated patients. These differences persisted when analysis was limited to follicles whose oocytes fertilized normally. These data indicate that in the presence of LA, normal oocyte maturation can occur despite lower intrafollicular concentrations of E2 and P.

The incidence of transient hyperprolactinemia in gonadotropin stimulated cycles for in vitro fertilization and its effect on pregnancy outcome

The incidence of transient hyperprolactinemia and its impact on in vitro fertilization (IVF) were determined in 151 euprolactinemic women with tubal infertility undergoing an identical gonadotropin stimulation for IVF. Prolactin (PRL) levels were measured on the morning of cycle day 3, days of human chorionic gonadotropin (hCG) administration, and peak estradiol (E2), and in the midluteal phase. Women were divided into high (H: peak E2 greater than 1,000 pg/mL, n = 51), intermediate (I:peak E2: 500 to 800 pg/mL, n = 50), or low (L:peak E2 less than 400 pg/mL, n = 50) E2 response groups. There was no difference in the incidence of hyperprolactinemia on cycle day 3 between the response groups (H:16%, I: 12%, and L:8%). However, high responders had a higher incidence of hyperprolactinemia than intermediate or low responders on all other study days. The incidence of hyperprolactinemia was greater than baseline (cycle day 3) only in the high responders on the day of peak E2. Serum prolactin was strongly correlated with peak E2 (r = 0.41). There were no differences in the number of preovulatory oocytes retrieved or fertilized or the pregnancy rates between hyperprolactinemic and euprolactinemic patients in each response group or when all hyperprolactinemic and euprolactinemic patients, regardless of E2 response, were compared. Transient hyperprolactinemia during gonadotropin stimulation for IVF occurs and correlates with E2 response but has no impact on IVF outcome.

The relationship between serum estradiol-17β concentrations and induced pituitary luteinizing hormone surges in postmenopausal women

The present study was designed to evaluate the effect of different serum concentrations of estradiol-17 beta (E2) on pituitary luteinizing hormone (LH) release in postmenopausal women. Serum E2 levels were evaluated in healthy postmenopausal women while they wore two, four, and six transdermal E2 delivery systems. The mean serum E2 levels at 48 hours after application of the devices were 185.5, 338.9, and 520.5 pg/mL, respectively, which were significantly different from each other. Serum E2 levels were stable throughout the first 48 hours of patch application but declined by a mean of 54% between 48 and 72 hours. Pituitary LH surges were induced with all three serum concentrations of E2 but were present more often with the higher serum values. There were no significant differences between the mean interval of device utilization and initiation, height, or duration of the induced pituitary LH surge at any of the three serum E2 concentrations studied.

Oocyte Donation—State of the Art 1989

In the past, infertility due to absent, inaccessible, or abnormal gametes in females was considered to be irreversible. Women who could not provide their own oocytes were forced to adopt if they wanted to have a family. However, the absence or inaccessibility of normal oocytes does not preclude implantation of an embryo derived from a donated oocyte or embryo. Although egg donation is analogous to sperm donation in couples where the male had abnormal or absent gametes, there are significant technical differences. While male gametes are available on demand in large numbers, and can be easily cryopreserved and stored, the same is not true for female gametes. Thus a number of approaches for egg and embryo donation have been proposed.