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Circulating vascular endothelial growth factor (VEGF) levels in nonhuman primates and women: species differences and relevance to ovarian hyperstimulation syndrome.
Design: Longitudinal. Materials/Methods: Women with 2 normal ovaries, undergoing IVF and considered to be at an increased risk of OHSS because of the presence of ⬎ 20 follicles (n ⫽ 81) were investigated with pre-hCG U/S, colour Doppler imaging (CDI) and serial pre- and post hCG pVEGF. Those with a past history of ovarian disease (including PCO or PCOS) or surgery were excluded. Colour Doppler blood flow imaging was performed with an Acuson 128 XP10 computerised imaging system. A sandwich enzyme immuno-assay (Quantikine™, ELISA) was used to assay free VEGF165. Those who were admitted to hospital with the moderate or severe forms of OHSS, but did not conceive [Group II; n ⫽ 9] were compared with matched controls [Group I; n ⫽ 27]. The VEGF data was not normally distributed and, therefore, required loge transformation. VEGF data are therefore presented as detransformed loge (geometric) means (95%CI). Simple 2-sample t-test was used to compare (geometric) means and analysis of variance was also performed with age, number of follicles; and embryos transferred as co-variates. Results: The peak systolic and time –averaged maximal velocity, pulsatility index, resistance index and S/D ratio of intrafollicular blood flow and pVEGF were similar (p0.05); but the degree of intrafollicular vascularity (FVI) was higher before hCG in the OHSS group (0.38 ⫹ 0.18 vs. 0.69 ⫹ 0.12; p ⬍ 0.001). There was no statistically significant difference in pVEGF between the two groups before hCG and oocyte recovery (OR) (p ⫽ 0.39 and 0.93 respectively). However, following the hCG trigger and oocyte recovery; serial loge mean (95%CI) pVEGF (pg/ml) increased significantly on the days of embryo transfer (DET) [10.00 (4.80,25.30) vs 67.50 (3.14,149.20); p ⬍ 0.01] and DET⫹4 [4.70 (1.90,17.20) vs. 186.10 (70.80,294.70); p ⬍ 0.001] respectively in the OHSS group. Analysis of variance also confirmed that there was no significant increase from day of hCG to OR (p ⫽ 0.76) but significant increases occurred in the OHSS group on DET (p ⫽ 0.010) and DET⫹4 (p ⫽ 0.002) respectively. Conclusions: These results demonstrate that despite higher pre-hCG intrafollicular vascularity, the pVEGF levels are similar to controls before; but increase significantly after hCG in the OHSS group. This may indicate a pre-hCG paracrine effect; genetic differences in VEGF receptivity in the OHSS group; or that other putative angiogenic modulators are involved in the development of pre-hCG intrafollicular vascularity in OHSS. Supported By: A research grant from Wellbeing, the research charity of the Royal College of Obstetricians and Gynaecologists, UK (to OAO).
Wednesday, October 24, 2001 2:15 P.M. O-238 Luteal E2 administration reduces size and improves homogeneity of selectable follicles on cycle-day 3: bases for novel controlled ovarian hyperstimulation (COH) concepts. R. Fanchin, L. Scho¨nauer, J. Cunha Filho, I. Kadoch, P. Cohen-Bacrie, R. Frydman. Hoˆpital Antoine Be´cle`re, Clamart, France; Lab d’Eylau, Paris, France. Objective: In the early follicular phase, selectable follicles show discrepant sizes. This presumably results from the early onset of intercycle FSH elevation during the late luteal phase, 2 to 3 days before menstruation (Roseff et al. JCEM, 1989). Given that larger follicles are more sensitive to FSH (Hillier, Hum Reprod, 1994), only a fraction of the selectable follicular cohort will achieve concomitant maturation during COH. This phenomenon offers plausible explanation for the reduced number of mature follicles obtained in COH with short GnRH agonist and antagonist protocols as compared to long GnRH agonist protocols (Albano et al., Hum Reprod, 2000). As luteal E2 administration effectively suppresses intercycle FSH elevation (de Ziegler et al. Hum Reprod, 1999), we wanted to verify whether administering E2 during the late luteal phase could reduce follicular development and improve homogeneity of follicular sizes on day 3. Design: Prospective, randomized, crossover study. Materials/Methods: 14 women, aged 26-40 years, underwent hormonalfollicular assessment on day 3 in 2 successive menstrual cycles. In control cycles, serum FSH, E2, and inhibin B were measured and the selectable follicular cohort was evaluated, with a 4-6.5 MHz vaginal ultrasound probe equipped with a native harmonic system that improves image resolution. In E2-pretreated cycles, women received micronized 17-E2 (4 mg/day, orally) from day 20 of the preceding cycle up to day 2 of the subsequent cycle. Similar evaluation as in control cycles was performed on day 3.
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Abstracts
Women randomly started the protocol by control or E2-pretreated cycles. The magnitude of discrepancies in follicular sizes was assessed by the Levene test for equality of variances and the ratio of SD/mean. Statistical differences between both cycles were assessed with the Wilcoxon signedrank test. Results: As shown in table (means ⫾ SD), E2 administration induced a reduction in the size of selectable follicles and in ovarian volume as compared to control cycles. Follicular size discrepancies were attenuated in E2-pretreated as compared to control cycles as confirmed by the Levene test (P⬍ 0.0001) and SD/mean. As expected, in E2-pretreated cycles, serum FSH and inhibin B levels were lower and E2 higher than in control cycles. Effects of luteal E2 administration on hormones and follicles on day 3. Ovarian FSH E2 Inhibit B volume (mIU/mL) (pg/mL) (pg/mL) (mL)
No. of follicles
Size of follicles SD/mean (mm) of sizes
E2-pretreatment 4.6 ⫾ 1.7 116 ⫾ 63 52 ⫾ 31 4.6 ⫾ 2.4 11.8 ⫾ 5.4 3.5 ⫾ 1.0 24% Controls 7.7 ⫾ 4.4 59 ⫾ 28 79 ⫾ 31 5.8 ⫾ 2.4 11.2 ⫾ 4.0 4.9 ⫾ 2.1 41% P ⬍0.01 ⬍0.005 ⬍0.009 ⬍0.01 NS ⬍0.0009 ⬍0.001
Conclusions: 1. Luteal E2 administration reduces size and improves homogeneity of selectable follicles on day 3. 2. Alignment of follicular sizes in the early follicular phase may improve COH outcome by fostering synchronization of follicular development. 3. This approach may be particularly useful to increase the number of mature follicles in GnRH antagonist/ FSH/LH protocols. 4. These preliminary data spur us to conduct prospective randomized investigation on the effectiveness of E2 pretreatment to improve COH results.
Wednesday, October 24, 2001 2:30 P.M. O-239 Circulating vascular endothelial growth factor (VEGF) levels in nonhuman primates and women: species differences and relevance to ovarian hyperstimulation syndrome. T. A. Molskness, P. E. Patton, J. C. Martinez-Chequer, B. N. Klementiev, R. L. Stouffer. Oregon Regional Primate Research Ctr, Oregon Health Science Univ, Beaverton, OR; Oregon Health Science Univ, Portland, OR. Objective: To evaluate the patterns and levels of VEGF in the natural cycle and during CG exposure simulating early pregnancy in natural and controlled ovarian stimulation (COS) cycles in a nonhuman primate, and to compare VEGF levels in COS cycles to those in woman. Design: Prospective observational study. Materials/Methods: Female rhesus monkeys exhibiting regular menstrual cycles received either no treatment or recombinant (r) human gonadotropins (Ares Advanced Technologies, Inc) in one of two protocols (IACUC approved). In protocol 1, animals received increasing doses of r-hCG (15–360 IU, bid, for 6 days) beginning on day 9 of the luteal phase to simulate early pregnancy. In protocol 2, monkeys received r-hFSH (30 IU, tid, 6 days) followed by r-hFSH/r-hLH (30 IU/30 IU, tid, for 2-3 days) beginning at menses to develop multiple preovulatory follicles. The next day, an ovulatory dose of r-hCG (1000 IU) was administered and follicle aspiration performed 27 hours later. Nine days after the hCG bolus, these monkeys also received increasing doses of r-hCG to simulate early pregnancy as described in protocol 1. Daily serum samples were analyzed for estradiol (E; Elecsys 2010), progesterone (P; Elecsys 2010), and free VEGF (Quantikine VEGF ELISA, R&D Systems; validated for macaque, which is identical to human, VEGF using follicular fluid samples). Serum samples were also obtained from women at high risk for OHSS (n ⫽ 11) during COS cycles using recombinant gonadotropins for ART-ET protocols (approved by OHSU IRB) and analyzed for E, P and VEGF. Results expressed as mean ⫾ S.E.M. Significant differences were determined by t-statistics. Results: During natural cycles, monkeys (n ⫽ 8) exhibited typical patterns of circulating E and P; E levels peaked in the late follicular phase at 551 ⫾ 78 pg/ml, whereas P peaked in midluteal phase at 4.4 ⫾ 2.2 ng/ml. CG administration in natural cycles increased P to 12.9 ⫾ 1.3 ng/ml (n ⫽ 4; p ⬍ 0.05). During COS cycles (n ⫽ 5), E levels at late follicular phase (1582 ⫾ 647 pg/ml) and P at midluteal phase (28 ⫾ 11 ng/ml) or in
Vol. 76, No. 3, Suppl. 1, September 2001
simulated early pregnancy (54 ⫾ 21 ng/ml) were further elevated (p ⬍ 0.05); 22 ⫾ 4 oocytes were collected from large follicles at midcycle. Nevertheless, serum concentrations of free VEGF were nondetectable ¨ 32 pg/ml) throughout the menstrual cycle as well as before and after (⫾U CG exposure in natural and COS cycles. In contrast, VEGF was easily detected in women throughout COS cycles; 2-3 days after the ovulatory hCG bolus, VEGF levels averaged 271 ⫾ 42.4 pg/ml. Post-hCG VEGF values did not decline to nondetectable until the time of the luteal-placental shift in pregnancy. Conclusions: Ovarian overproduction of VEGF, particularly in response to the ovulatory bolus of hCG or endogenous secretion of CG in early pregnancy, may be a causative factor in the development of ovarian hyperstimulation syndrome (OHSS) in women during ART protocols. The current results indicate that circulating levels of VEGF and possibly luteal secretion of VEGF during COS cycles in rhesus macaques are low compared to those in women. The low level of endogenous VEGF, combined with the lack of OHSS symptoms, suggest that this macaque could serve as a model for examining the ability of administered VEGF to cause OHSS in natural and COS cycles. Supported By: SCCPRR HD18185, RR00163 and Fogarty Fellowship TWO00668.
Wednesday, October 24, 2001 2:45 P.M. O-240 Comparing the effects of fixed-dose, step-down, and low dose step-up regimens of rFSH on endometrial receptivity in PCOS patients. O. Taskin, G. Akkoyunlu, R. Demir, S. Sadik, A. Onoglu, J. M. Wheeler. Ctr for Women’s Health&Research/Akdeniz Univ, Houston/Antalya, TX; Akdeniz Univ, Antalya, Turkey; SSK Tepecik, Izmir, Turkey; SSK tepecik, Izmor, Turkey; Ctr for Women’s Health & Research, Houston. Objective: To compare the effects of three protocols (Fixed-dose, Stepdown, and Low dose/step-up) of rFSH on endometrial receptivity using immunohistochemical criteria of epithelial integrin expression in PCOS patients. Design: Prospective randomized clinical study. Materials/Methods: Infertile PCOS women who were randomized to Fixed-dose (n:8), Step-down (n:7), and Low dose/step-up(n:9) regimens of rFSH(follitropin beta). Endometrial biopsy was obtained 3 days after oocyte retrieval. Immunohistochemical staining intensity and distribution (HSCORE) of ␣v3 subunit integrins and traditional histologic endometrial dating were compared. Results: There were no significant differences among the groups with respect to baseline characteristics. Although the Low dose/step-up protocol produced better folliculogenesis, the changes in endometrial receptivity as determined by integrin positivity and HSCORE were similar between the groups. Twenty of the 24 endometrial samples were in phase histologically, distributed similarly through the 3 patient groups. Integrin ␣v3 expression was not predicted by in-phase histology, with integrin staining low in all three groups (p ⫽ .25). Just as presence of integrin was not associated with in-phase histology, neither was intensity of integrin staining as measured by the mean HSCORE (p ⫽ 0.67). Conclusions: Although the Low dose/step-up protocol was superior in follicular recruitment in PCOS, endometrial receptivity was not similarly enhanced, and could explain the observation of high miscarriage rates in PCOS patients who conceive. Current studies are underway to further evaluate the role of endometrial receptivity in PCOS patients undergoing various ovarian stimulation protocols. Supported By: Center for Women’s Health & Research.
Wednesday, October 24, 2001 3:00 P.M. O-241 Beneficial effects of residual LH levels after GnRH agonist on ovarian response to rFSH, embryo quality, and IVF-ET outcome. R. Fanchin, L. Scho¨nauer, C. Righini, F. Olivennes, J. Taieb, R. Frydman. Hoˆpital Antoine Be´cle`re, Clamart, France.
FERTILITY & STERILITY威
Objective: By the mid-follicular phase of the menstrual cycle, progressive LH secretion parallels the acquisition of LH receptors by the granulosa cells, a phenomenon that may assist final oocyte-follicular maturation and ovulation. In COH, GnRH agonist pretreatment often leads to extensive suppression of endogenous LH activity. By definition, defective LH activity is not subsequently compensated by FSH-only recombinant preparations and such an unbalanced endocrine milieu may alter oocyte-follicular quality. Yet, previous studies addressing this issue have led to divergent conclusions (Scott Sills et al., Hum Reprod, 1999; Fleming et al., Hum Reprod, 1998). Hence, to clarify this point, we assessed possible differences in ovarian response to COH, embryology data, and IVF-ET outcome in women having consistently low or high residual LH levels after pretreatment with GnRH agonist. Design: Prospective, cohort study. Materials/Methods: 229 women, aged 24-43 years, undergoing 261 GnRH-a/rFSH/hCG cycles for IVF-ET were studied. Leuprolide acetate (0.5 mg/day, S.C.) was initiated on day 21 of the cycle preceding COH and rFSH (225 IU/day, S.C.) was started on day 3 of the subsequent cycle. Both hormones were continued up to hCG administration. To attenuate as far as possible the confounding effect of LH pulsatility on our analysis, serum LH levels were considered simultaneously on days 6 and 9 of rFSH administration. Cycles were then sorted into 3 groups: consistently low LH (ⱕ2 mIU/mL on days 6 and 9; n ⫽ 95), consistently high LH (2 mIU/mL on days 6 and 9; n ⫽ 77), and a mixed group in which LH exceeded 2 mIU/mL on days 6 or 9 (remaining cases, n ⫽ 89). Good embryo quality was determined by uniform blastomeres, no ooplasmic granularity, and fragmentation ⱕ10%. Results: Patients were similar in regard to ages and ovarian reserve in the 3 groups. Results of the mixed group were in between the two opposite groups (not displayed). As shown (means ⫾ SE), rFSH treatment course lasted shorter, led to higher E2 levels, more oocytes and available embryos, with a higher prevalence of good quality embryos, in the high LH as compared to the low LH group. In line with this, IVF-ET outcome was improved in the high LH group.
Low LH High LH P
Low LH High LH P
Day of hCG
Peak E2 levels (pg/mL)
Total oocytes
Available embryos
11.5 ⫾ 0.2 10.7 ⫾ 0.2 ⬍0.0004
1,879 ⫾ 81 2,400 ⫾ 98 ⬍0.0001
8.1 ⫾ 0.4 9.5 ⫾ 0.5 ⬍0.03
4.3 ⫾ 0.3 5.6 ⫾ 0.4 ⬍0.004
Good quality embryos
Transf. embryos
30% 51% ⬍0.0003
2.5 ⫾ 0.5 2.6 ⫾ 0.1 NS
Ongoing Implant. PRs/cycle PRs/cycle rates 20% 34% ⬍0.03
12% 27% ⬍0.01
8% 17% ⬍0.002
Conclusions: 1. The shorter rFSH treatment course in the high LH group indicates that LH may accelerate the pace of follicular development. 2. The larger number of oocytes and good quality embryos and the improved IVF-ET outcome in the high LH group indicate that sufficient residual LH levels are required to achieve adequate oocyte-follicular maturation and embryo quality in COH. 3. Our results prompt to verify whether additional LH activity administered to a selected subset of women, who present profoundly suppressed peripheral LH levels by GnRH agonists (and possibly by GnRH antagonists), might improve their ovarian responsiveness to COH and IVF-ET outcome.
Wednesday, October 24, 2001 3:45 P.M. O-242 Follicular dynamics and ovarian stimulation influence meiotic spindle integrity during human IVF. D. Frankfurter, W. Wang, R. Oldenbourg, L. Meng, R. Hackett, D. L. Keefe. Women & Infants Hosp, Brown Univ Sch of Medicine, Providence, RI; Marine Biology Lab, Woods Hole, MA. Objective: IVF cycle management relies on follicular dynamics, yet their effects on egg and embryo development remain unclear. As spindle integrity
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Wednesday, October 24, 2001 2:15 P.M. O-238 Luteal E2 administration reduces size and improves homogeneity of selectable follicles on cycle-day 3: bases for novel controlled ovarian hyperstimulation (COH) concepts. R. Fanchin, L. Scho¨nauer, J. Cunha Filho, I. Kadoch, P. Cohen-Bacrie, R. Frydman. Hoˆpital Antoine Be´cle`re, Clamart, France; Lab d’Eylau, Paris, France. Objective: In the early follicular phase, selectable follicles show discrepant sizes. This presumably results from the early onset of intercycle FSH elevation during the late luteal phase, 2 to 3 days before menstruation (Roseff et al. JCEM, 1989). Given that larger follicles are more sensitive to FSH (Hillier, Hum Reprod, 1994), only a fraction of the selectable follicular cohort will achieve concomitant maturation during COH. This phenomenon offers plausible explanation for the reduced number of mature follicles obtained in COH with short GnRH agonist and antagonist protocols as compared to long GnRH agonist protocols (Albano et al., Hum Reprod, 2000). As luteal E2 administration effectively suppresses intercycle FSH elevation (de Ziegler et al. Hum Reprod, 1999), we wanted to verify whether administering E2 during the late luteal phase could reduce follicular development and improve homogeneity of follicular sizes on day 3. Design: Prospective, randomized, crossover study. Materials/Methods: 14 women, aged 26-40 years, underwent hormonalfollicular assessment on day 3 in 2 successive menstrual cycles. In control cycles, serum FSH, E2, and inhibin B were measured and the selectable follicular cohort was evaluated, with a 4-6.5 MHz vaginal ultrasound probe equipped with a native harmonic system that improves image resolution. In E2-pretreated cycles, women received micronized 17-E2 (4 mg/day, orally) from day 20 of the preceding cycle up to day 2 of the subsequent cycle. Similar evaluation as in control cycles was performed on day 3.
S90
Abstracts
Women randomly started the protocol by control or E2-pretreated cycles. The magnitude of discrepancies in follicular sizes was assessed by the Levene test for equality of variances and the ratio of SD/mean. Statistical differences between both cycles were assessed with the Wilcoxon signedrank test. Results: As shown in table (means ⫾ SD), E2 administration induced a reduction in the size of selectable follicles and in ovarian volume as compared to control cycles. Follicular size discrepancies were attenuated in E2-pretreated as compared to control cycles as confirmed by the Levene test (P⬍ 0.0001) and SD/mean. As expected, in E2-pretreated cycles, serum FSH and inhibin B levels were lower and E2 higher than in control cycles. Effects of luteal E2 administration on hormones and follicles on day 3. Ovarian FSH E2 Inhibit B volume (mIU/mL) (pg/mL) (pg/mL) (mL)
No. of follicles
Size of follicles SD/mean (mm) of sizes
E2-pretreatment 4.6 ⫾ 1.7 116 ⫾ 63 52 ⫾ 31 4.6 ⫾ 2.4 11.8 ⫾ 5.4 3.5 ⫾ 1.0 24% Controls 7.7 ⫾ 4.4 59 ⫾ 28 79 ⫾ 31 5.8 ⫾ 2.4 11.2 ⫾ 4.0 4.9 ⫾ 2.1 41% P ⬍0.01 ⬍0.005 ⬍0.009 ⬍0.01 NS ⬍0.0009 ⬍0.001
Conclusions: 1. Luteal E2 administration reduces size and improves homogeneity of selectable follicles on day 3. 2. Alignment of follicular sizes in the early follicular phase may improve COH outcome by fostering synchronization of follicular development. 3. This approach may be particularly useful to increase the number of mature follicles in GnRH antagonist/ FSH/LH protocols. 4. These preliminary data spur us to conduct prospective randomized investigation on the effectiveness of E2 pretreatment to improve COH results.
Wednesday, October 24, 2001 2:30 P.M. O-239 Circulating vascular endothelial growth factor (VEGF) levels in nonhuman primates and women: species differences and relevance to ovarian hyperstimulation syndrome. T. A. Molskness, P. E. Patton, J. C. Martinez-Chequer, B. N. Klementiev, R. L. Stouffer. Oregon Regional Primate Research Ctr, Oregon Health Science Univ, Beaverton, OR; Oregon Health Science Univ, Portland, OR. Objective: To evaluate the patterns and levels of VEGF in the natural cycle and during CG exposure simulating early pregnancy in natural and controlled ovarian stimulation (COS) cycles in a nonhuman primate, and to compare VEGF levels in COS cycles to those in woman. Design: Prospective observational study. Materials/Methods: Female rhesus monkeys exhibiting regular menstrual cycles received either no treatment or recombinant (r) human gonadotropins (Ares Advanced Technologies, Inc) in one of two protocols (IACUC approved). In protocol 1, animals received increasing doses of r-hCG (15–360 IU, bid, for 6 days) beginning on day 9 of the luteal phase to simulate early pregnancy. In protocol 2, monkeys received r-hFSH (30 IU, tid, 6 days) followed by r-hFSH/r-hLH (30 IU/30 IU, tid, for 2-3 days) beginning at menses to develop multiple preovulatory follicles. The next day, an ovulatory dose of r-hCG (1000 IU) was administered and follicle aspiration performed 27 hours later. Nine days after the hCG bolus, these monkeys also received increasing doses of r-hCG to simulate early pregnancy as described in protocol 1. Daily serum samples were analyzed for estradiol (E; Elecsys 2010), progesterone (P; Elecsys 2010), and free VEGF (Quantikine VEGF ELISA, R&D Systems; validated for macaque, which is identical to human, VEGF using follicular fluid samples). Serum samples were also obtained from women at high risk for OHSS (n ⫽ 11) during COS cycles using recombinant gonadotropins for ART-ET protocols (approved by OHSU IRB) and analyzed for E, P and VEGF. Results expressed as mean ⫾ S.E.M. Significant differences were determined by t-statistics. Results: During natural cycles, monkeys (n ⫽ 8) exhibited typical patterns of circulating E and P; E levels peaked in the late follicular phase at 551 ⫾ 78 pg/ml, whereas P peaked in midluteal phase at 4.4 ⫾ 2.2 ng/ml. CG administration in natural cycles increased P to 12.9 ⫾ 1.3 ng/ml (n ⫽ 4; p ⬍ 0.05). During COS cycles (n ⫽ 5), E levels at late follicular phase (1582 ⫾ 647 pg/ml) and P at midluteal phase (28 ⫾ 11 ng/ml) or in
Vol. 76, No. 3, Suppl. 1, September 2001
simulated early pregnancy (54 ⫾ 21 ng/ml) were further elevated (p ⬍ 0.05); 22 ⫾ 4 oocytes were collected from large follicles at midcycle. Nevertheless, serum concentrations of free VEGF were nondetectable ¨ 32 pg/ml) throughout the menstrual cycle as well as before and after (⫾U CG exposure in natural and COS cycles. In contrast, VEGF was easily detected in women throughout COS cycles; 2-3 days after the ovulatory hCG bolus, VEGF levels averaged 271 ⫾ 42.4 pg/ml. Post-hCG VEGF values did not decline to nondetectable until the time of the luteal-placental shift in pregnancy. Conclusions: Ovarian overproduction of VEGF, particularly in response to the ovulatory bolus of hCG or endogenous secretion of CG in early pregnancy, may be a causative factor in the development of ovarian hyperstimulation syndrome (OHSS) in women during ART protocols. The current results indicate that circulating levels of VEGF and possibly luteal secretion of VEGF during COS cycles in rhesus macaques are low compared to those in women. The low level of endogenous VEGF, combined with the lack of OHSS symptoms, suggest that this macaque could serve as a model for examining the ability of administered VEGF to cause OHSS in natural and COS cycles. Supported By: SCCPRR HD18185, RR00163 and Fogarty Fellowship TWO00668.
Wednesday, October 24, 2001 2:45 P.M. O-240 Comparing the effects of fixed-dose, step-down, and low dose step-up regimens of rFSH on endometrial receptivity in PCOS patients. O. Taskin, G. Akkoyunlu, R. Demir, S. Sadik, A. Onoglu, J. M. Wheeler. Ctr for Women’s Health&Research/Akdeniz Univ, Houston/Antalya, TX; Akdeniz Univ, Antalya, Turkey; SSK Tepecik, Izmir, Turkey; SSK tepecik, Izmor, Turkey; Ctr for Women’s Health & Research, Houston. Objective: To compare the effects of three protocols (Fixed-dose, Stepdown, and Low dose/step-up) of rFSH on endometrial receptivity using immunohistochemical criteria of epithelial integrin expression in PCOS patients. Design: Prospective randomized clinical study. Materials/Methods: Infertile PCOS women who were randomized to Fixed-dose (n:8), Step-down (n:7), and Low dose/step-up(n:9) regimens of rFSH(follitropin beta). Endometrial biopsy was obtained 3 days after oocyte retrieval. Immunohistochemical staining intensity and distribution (HSCORE) of ␣v3 subunit integrins and traditional histologic endometrial dating were compared. Results: There were no significant differences among the groups with respect to baseline characteristics. Although the Low dose/step-up protocol produced better folliculogenesis, the changes in endometrial receptivity as determined by integrin positivity and HSCORE were similar between the groups. Twenty of the 24 endometrial samples were in phase histologically, distributed similarly through the 3 patient groups. Integrin ␣v3 expression was not predicted by in-phase histology, with integrin staining low in all three groups (p ⫽ .25). Just as presence of integrin was not associated with in-phase histology, neither was intensity of integrin staining as measured by the mean HSCORE (p ⫽ 0.67). Conclusions: Although the Low dose/step-up protocol was superior in follicular recruitment in PCOS, endometrial receptivity was not similarly enhanced, and could explain the observation of high miscarriage rates in PCOS patients who conceive. Current studies are underway to further evaluate the role of endometrial receptivity in PCOS patients undergoing various ovarian stimulation protocols. Supported By: Center for Women’s Health & Research.
Wednesday, October 24, 2001 3:00 P.M. O-241 Beneficial effects of residual LH levels after GnRH agonist on ovarian response to rFSH, embryo quality, and IVF-ET outcome. R. Fanchin, L. Scho¨nauer, C. Righini, F. Olivennes, J. Taieb, R. Frydman. Hoˆpital Antoine Be´cle`re, Clamart, France.
FERTILITY & STERILITY威
Objective: By the mid-follicular phase of the menstrual cycle, progressive LH secretion parallels the acquisition of LH receptors by the granulosa cells, a phenomenon that may assist final oocyte-follicular maturation and ovulation. In COH, GnRH agonist pretreatment often leads to extensive suppression of endogenous LH activity. By definition, defective LH activity is not subsequently compensated by FSH-only recombinant preparations and such an unbalanced endocrine milieu may alter oocyte-follicular quality. Yet, previous studies addressing this issue have led to divergent conclusions (Scott Sills et al., Hum Reprod, 1999; Fleming et al., Hum Reprod, 1998). Hence, to clarify this point, we assessed possible differences in ovarian response to COH, embryology data, and IVF-ET outcome in women having consistently low or high residual LH levels after pretreatment with GnRH agonist. Design: Prospective, cohort study. Materials/Methods: 229 women, aged 24-43 years, undergoing 261 GnRH-a/rFSH/hCG cycles for IVF-ET were studied. Leuprolide acetate (0.5 mg/day, S.C.) was initiated on day 21 of the cycle preceding COH and rFSH (225 IU/day, S.C.) was started on day 3 of the subsequent cycle. Both hormones were continued up to hCG administration. To attenuate as far as possible the confounding effect of LH pulsatility on our analysis, serum LH levels were considered simultaneously on days 6 and 9 of rFSH administration. Cycles were then sorted into 3 groups: consistently low LH (ⱕ2 mIU/mL on days 6 and 9; n ⫽ 95), consistently high LH (2 mIU/mL on days 6 and 9; n ⫽ 77), and a mixed group in which LH exceeded 2 mIU/mL on days 6 or 9 (remaining cases, n ⫽ 89). Good embryo quality was determined by uniform blastomeres, no ooplasmic granularity, and fragmentation ⱕ10%. Results: Patients were similar in regard to ages and ovarian reserve in the 3 groups. Results of the mixed group were in between the two opposite groups (not displayed). As shown (means ⫾ SE), rFSH treatment course lasted shorter, led to higher E2 levels, more oocytes and available embryos, with a higher prevalence of good quality embryos, in the high LH as compared to the low LH group. In line with this, IVF-ET outcome was improved in the high LH group.
Low LH High LH P
Low LH High LH P
Day of hCG
Peak E2 levels (pg/mL)
Total oocytes
Available embryos
11.5 ⫾ 0.2 10.7 ⫾ 0.2 ⬍0.0004
1,879 ⫾ 81 2,400 ⫾ 98 ⬍0.0001
8.1 ⫾ 0.4 9.5 ⫾ 0.5 ⬍0.03
4.3 ⫾ 0.3 5.6 ⫾ 0.4 ⬍0.004
Good quality embryos
Transf. embryos
30% 51% ⬍0.0003
2.5 ⫾ 0.5 2.6 ⫾ 0.1 NS
Ongoing Implant. PRs/cycle PRs/cycle rates 20% 34% ⬍0.03
12% 27% ⬍0.01
8% 17% ⬍0.002
Conclusions: 1. The shorter rFSH treatment course in the high LH group indicates that LH may accelerate the pace of follicular development. 2. The larger number of oocytes and good quality embryos and the improved IVF-ET outcome in the high LH group indicate that sufficient residual LH levels are required to achieve adequate oocyte-follicular maturation and embryo quality in COH. 3. Our results prompt to verify whether additional LH activity administered to a selected subset of women, who present profoundly suppressed peripheral LH levels by GnRH agonists (and possibly by GnRH antagonists), might improve their ovarian responsiveness to COH and IVF-ET outcome.
Wednesday, October 24, 2001 3:45 P.M. O-242 Follicular dynamics and ovarian stimulation influence meiotic spindle integrity during human IVF. D. Frankfurter, W. Wang, R. Oldenbourg, L. Meng, R. Hackett, D. L. Keefe. Women & Infants Hosp, Brown Univ Sch of Medicine, Providence, RI; Marine Biology Lab, Woods Hole, MA. Objective: IVF cycle management relies on follicular dynamics, yet their effects on egg and embryo development remain unclear. As spindle integrity
S91