Clinical reproduction and fertility最新文献

The characteristics and attitudes of 37 semen donors in six New Zealand AID programmes are reported. Donors were found to be highly educated and, as a result, in predominantly professional and technical fields. The major reason for being a donor was altruism--a desire to help infertile couples, although financial considerations were a factor for almost one-quarter of the respondents. The attitude of donors towards payment differs markedly from the attitudes of specialists providing AID services. Personal knowledge of infertile couples was found to be a factor leading one-quarter of the donors to offer their services. There is a wide variation in the number of times that some donors are asked to donate, with some specialists operating outside the guidelines produced by the Royal New Zealand College of Obstetricians and Gynaecologists. Donors are almost equally divided on the issue of the child's right to know of the nature of her/his conception. Almost one-quarter of donors would still donate if there was a possibility that they could be traced in the future and a further 30% were unsure. These findings challenge some of the traditionally accepted views about the need for donor anonymity. It was found that 39% of donors expressed an interest in knowing the outcome of their donations. The results of the study have implications for policy and practice issues associated with the psychosocial aspects of AID. One implication is that it seems important that the psychosocial needs of donors be considered and that programmes should be flexible in responding to the differing attitudes, expectations, and needs of donors.

Five patients with carefully defined polycystic ovarian disease (PCOS) were treated with pure follicle stimulating hormone (FSH) to induce ovulation. Serum levels of androstenedione and testosterone were measured daily and noted to rise dramatically, reaching a maximum at the time of ovulation. However, despite the rise in androgens, ovulation occurred in each case and three patients conceived. Contrary to the traditional concept, it is concluded that elevated androgen levels in patients with PCOS do not interfere with ovulation induction using pure FSH.

The introduction of rapid semiquantitative methods using monoclonal antibodies to measure urinary LH has application to the management of the infertile couple. The interpretation of the colour change end-point has however been subjective and thus liable to misinterpretation with resultant problems in clinical management. This short communication describes the use of a modified reflectance meter to overcome these problems.

The incidence of endometriosis appears to be increasing, but is possibly due simply to the more widespread use of diagnostic laparoscopy. Whilst a clear pathogenetic role for endometriosis resulting in tubo-ovarian distortion and infertility is obvious, a causal role for mild endometriosis in infertility has not been established. Any one of several factors may result in both endometriosis and infertility. Nevertheless, endometriosis is best treated at the time of diagnosis in order to limit progression of the disease. The preferred method of treatment is medical, with surgery being reserved for those endometriotic lesions not responding to medical treatment. Conservative surgery will not eradicate microscopic foci, and it is possible that the surgery itself may result in adhesion formation. The choice of medication should be individualized, as the side-effects may not be readily tolerated by some women. Maintenance of amenorrhoea may not be essential to therapeutic efficacy, as normally sited and ectopically sited endometrial tissue may respond to hormonal manipulation in different ways.

Administration of pulsatile LHRH (14.4 microgram/pulse per 90 min) from day 5 to 9, or day 7 to 11 of the cycle following clomiphene pretreatment on days 2-6 induced multiple follicular growth for oocyte recovery for in vitro fertilisation. Administration of LHRH without clomiphene pretreatment failed to induce multiple follicular development. The same group of patients treated with clomiphene alone had fewer numbers of mature follicles, fewer oocytes recovered and less pre-embryos for transfer than when treated with clomiphene and LHRH in combination. Peak gonadotrophin release following commencement of LHRH was seen within the first 24 h of administration with a gradual fall in both LH and FSH toward baseline pretreatment values by the fourth day of administration. A discernible LH increment to LHRH was still present on the fourth day of LHRH treatment, but in many individuals no FSH increment was observed. The preovulatory oocytes recovered were predominantly mature with fertilisation rates of 70% and 85.7% for the two regimens. No pregnancy occurred in the six patients who underwent pre-embryo transfer.

One or more semen analysis results were available for 195 men whose wives responded to ovulation induction with gonadotrophins performed at The Royal Women's Hospital since 1963. Fifty-three men (27%) has subnormal semen analyses by conventional criteria: sperm concentration less than or equal to 20 X 10(6)/ml, motility less than or equal to 40% or normal morphology less than or equal to 50%. The lifetable pregnancy rates were not significantly different for those with subnormal and normal semen (chi 2 = 0.169), by six cycles 64% (s.e.m. = 7) with subnormal semen had conceived compared with 59% (s.e.m. = 5) with normal semen. It appears that lower limits of semen quality could be relaxed for women needing ovulation induction with gonadotrophins.

Indirect evidence of the occurrence of ovulation, which is generally accepted, is an increase in plasma or serum progesterone. Pelvic ultrasonography can estimate the probable time of ovulation within 12 h. There is a close association between the rise in progesterone, luteinizing hormone (LH) and oestrogen peaks and ovulation. A WHO study reported that ovulation occurred at a median time of 8 h after the rise in plasma progesterone, 15 h after the LH peak and 24 h after the oestrogen peak. The basal body temperature (BBT) method is the most effective in determining the premenstrual infertile period, but it is unreliable for an accurate determination of ovulation and the postmenstrual infertile period. Nor is BBT an effective method of predicting ovulation during postpartum lactational amenorrhoea. Therefore, BBT is usually used as a secondary indicator of ovulation and is combined with more reliable indicators. Observed changes in cervical mucus patterns can be used to define the probable fertile period, although this method produces a wide range of days. The peak mucus symptom is closely correlated with ovulation. Mucus symptoms can be used as a guide for the timing of blood or urine samples for estimation of LH, oestrogen and progesterone or their metabolites. Symptothermal methods incorporate other symptoms such as cervical changes, intermenstrual pain, breast tenderness and backaches, but these are secondary signs of ovulation and are recommended to be used in conjunction with mucus and BBT.

The gonadotrophin responses to the negative and positive feedback effects of orally administered ethinyl oestradiol in 12 women with minimal endometriosis were compared with those in six normal women of proven fertility. Basal concentrations of LH, FSH and oestradiol did not differ between the two groups. LH and FSH concentration declined within 12-24 h of starting treatment and there was no difference between minimum values, which occurred in both groups after 12-48 h. In five women with minimal endometriosis, LH concentrations subsequently increased above basal values to maximum values indistinguishable in magnitude and timing from those in the control group. An exaggerated LH response to oestrogen positive feedback occurred in one subject. In the remaining six women LH concentrations increased above levels which could be attributed to episodic variation in basal LH secretion but maximum LH values were below control limits. There was no relationship between previously documented progesterone secretion nor LH concentrations during the early luteal phase of the cycle and the LH response to oestrogen positive feedback. These data suggest that minor abnormalities of hypothalamopituitary function may contribute to infertility associated with minimal endometriosis.