hMG Injection Research Articles

The program for in vitro fertilization at Norfolk

Several aspects of the program of in vitro fertilization (IVF), or, as it is called in Norfolk, the program for the Vital Initiation of Pregnancy (VIP), have been or are in the process of publication. However, because there has been no overall account, it seems appropriate to give a brief report of a general nature covering the period from the beginning of the effort in late February 1980 through December 31, 1981. Although minor changes were constantly made in the protocol, there were two major revisions. Therefore, a discussion of the program during three distinct periods, i.e., 1980, 1981-Phase I, and 1981-Phase II, is necessary. During 1980 and 1981 all patients had either no fallopian tubes or irreparable tubes.The general procedures utilized in the 2 major phases of the Norfolk in vitro fertilization program in 1981 are described. When the program began, it was believed desirable to exploit the natural menstrual cycle instead of a stimulated controlled cycle, to aspirate the single dominant follicle at the last possible moment prior to expected ovulation, since it was believed impossible to further mature an oocyte in vitro; to utilize a reliable method to predict the hour of ovulation; to utilize a proven aspiration technique; to take extreme measures to maintain a special environment for the oocyte; and to provide means of inseminating the egg with the least possible delay. The results for 1980 were disappointing; from 41 laparoscopies only 19 fertilizable ova were obtained, and no pregnancies resulted from in vitro and in vivo attempts. For phase I beginning in 1981, a protocol was adopted calling for stimulated controlled ovulation using human menopausal gonadotropin (hMG). Exogenous human chorionic gonadotropin (hCG) was used to substitute for the midcycle luteinizing hormone (LH) surge. Laparoscopy for follicular aspiration was scheduled 36-38 hours after hCG administration. The use of a realtime sector ultrasonograph to monitor follicular growth became routine, quality control in the laboratory was tightened, and supplementary maturation in vitro of oocytes prior to insemination was initiated. In Phase I, 48 fertilizable eggs were obtained in 26 of 31 cycles; cleavage was obtained in eggs from 12 cycles, and 2 pregnancies occurred. In 1981-Phase II, several changes in procedures were made. Serum E2 values became available on a daily basis, so that hMG injections could be controlled. There were further improvements in laboratory quality control, such as measures to insure a toxin-free water supply. It became possible to incubate morphologically immature oocytes which subsequently accepted fertilization. In 1981 Phase II, fertilizable eggs were obtained in 22 of 24 laparoscopic cycles, eggs were fertilized from 21 of the 22 cycles, transfers were made in 19 cycles, and there were 5 pregnancies. The importance of transferring more than 1 conceptus became evident from the 31 cycles with transfers: the pregnancy rate was 13% with transfer of a single conceptus, 31% with 2, and 50% with 3.

Functional and structural relationships in steroidogenesis in vitro by human ovarian follicles during maturation and ovulation.

To investigate steroidogenic function of human follicles in the light of their structures, eight antral follicles of different sizes were mechanically isolated from ovaries of patients laparotomized in the follicular phase of the menstrual cycle with or without pretreatment with human menopausal gonadotropin (hMG). A portion of each follicle was taken for histology and slices of each follicle were incubated with [1-14C]-acetate. Incorporation into progestins, androgens, and estrogens was assessed by the reverse dilution technique with recrystallization to constant specific activity. A predominant incorporation into 17 beta-estradiol was observed in two maturing follicles, whereas a marked increase in incorporation into 17 beta-estradiol with a concomitant decrease in incorporation into androstenedione was verified in two other mature follicles. Remarkable enhancement in relative incorporation into C21 steroids was commonly noted in four preovulatory follicles. However, with the progress of preovulatory stages toward ovulation, as judged from structural changes of the follicles, actual incorporation into C19 and C18 steroids showed a moderate increase, followed by a drastic decrease around the time of ovulation. hMG injection induced similar relationships between the steroidogenic pattern and the follicle structure of different stages, although overall incorporation was considerably increased. We conclude that marked qualitative and quantitative changes in the steroidogenic function and accompanying corresponding changes in structure occurred over the period of follicular maturation and ovulation.

Role of the hypothalamic-pituitary-ovarian axis in puerperal infertility.

To gain further insight into the mechanisms of postpartum infertility, plasma gonadotropins, prolactin, estradiol, and progesterone were measured following either iv LHRH or im menopausal gonadotropins (Pergonal) to postpartum women. Plasma estradiol and progesterone rose significantly between 24-72 hours following hMG injection. The response was similar in both nursing and non-nursing women throughout the intermediate and late postpartum study interval. No gonadotropin response was observed following LHRH injection in the early puerperium. Beyond five postpartum weeks, a significantly greater response following LHRH was observed in nursing compared with non-nursing women. A subsequent and significant rise in estradiol correlated with the magnitude of the LHRH-induced increment. Basal prolactin levels in nursing women were significantly greater than in non-nursing women but were unchanged after either hMG or LHRH. We conclude that the postpartum ovary is not refractory to either direct exogenous gonadotropin stimulation or to endogenously released gonadotropins, at least as far as estrogen production is concerned. Furthermore, the difference in the pituitary response to LHRH in nursing and non-nursing women may reflect a difference in the hypothalamic-pituitary axis. Elevated prolactin secretion in response to nursing may be involved in postpartum infertility, but the specific role remaine unclear.

The ovarian response in women to large single injections of human menopausal gonadotrophin and human chorionic gonadotrophin.

Summary. A large single dose (3000 i.u.) of human menopausal gonadotrophin (hmg) was injected subcutaneously into each of twelve women. Seven days later, 19,500 i.u. human chorionic gonadotrophin was injected intramuscularly and laparotomy was performed 48 to 96 hr later. The response of the ovaries was determined by assaying urinary oestrogen and pregnanediol, by inspecting the ovaries, and by examining histological sections from multiple ovarian biopsies. Eight of nine women, who were currently having normal menstrual cycles, showed evidence of ovulation, the number of corpora lutea varying from one to seven. In three women, who received injections of hmg on the 14th day of a normal puerperium, there was no evidence of ovulation or of a significant increase in steroidogenesis.

Effect of single and multiple doses of menopausal gonadotropin upon ovarian function

The ability of a large single injection of HMG to stimulate ovulation has been investigated. The positive results reported by Crooke and his co-workers, utilizing human pituitary FSH, could not be confirmed. However, when 3 daily injections were utilized there was evidence of 13 ovulations in 31 cycles. Ovulation was more likely to occur when therapy was initiated after the sixth day of the cycle in subjects with a certain degree of endogenous FSH activity.