The importance of the follicular phase to success and failure in in vitro fertilization

,e ~t FERTILITY AND STERILITY Copyriht 0 1983 The American Fertility Society Printed in U.SA. The importance of the follicular phase to success and failure in in vitro fertilization Howard W. Jones, Jr., M.D.* Anibal Acosta, M.D. Mason C. Andrews, M.D. Jairo E. Garcia, M.D. Georeanna Seear Jones, M.D. Themis Mantzavinos, M.D. Jeanne McDowell, M.S. Bruce Sandow, Ph.D. Lucinda Veeck, M.L.T. (A.S.C.P.) Theresa Whibley, M.D. Charles Wilkes, M.D. Geore Wriht, Ph.D. Department of Obstetrics and Gynecoloy, Eastern Virinia Medical School, Norfolk, Virinia One hundred seventy-five s in patients with irreparable tubal disease were stimulated by human menopausal onadotropin/human chorionic onadotropin for the purpose of in vitro fertilization. As juded by the heiht of the peripheral estradiol response, the patients were classified as hih, intermediate, or low responders. In addition, the estradiol pattern of the response was found to be separable into six cateories. The prenancy rate was found to be related to the heiht and to the pattern of peripheral response. The overall prenancy rate in this consecutive series was 19% but varied accordin to the heiht and pattern of response from 40% to 0%. Fertil Steril 40:317, 1983 -ility The purpose of this report is to correlate available measures of the follicular phase of menstrual s induced by human menopausal onadotropin (hmg) with success and failure in the Norfolk proram of in vitro fertilization. Specifically, comparisons will be made of the heiht and pattern of the serum estradiol (E 2 ) response to hmg stimulation, the number and type of harvested es, and the subsequent prenancy rate. MATERIALS AND METHODS From September 27, 1981, throuh October 15, 1982 (Norfolk Series 2-6), 175 consecutively in- Received March 28, 1983; revised and accepted May 27, 1983. *Reprint requests: Howard W. Jones, Jr., M.D., Department of Obstetrics and Gynecoloy, Eastern Virinia Medical School, Norfolk, Virinia 23507. duced s of patients with obstructed tubes who had underone laparoscopy for aspiration of es for in vitro fertilization were analyzed. Durin the same time interval, the s of 15 additional patients in couples with other causes of infertility were processed: i.e., 6 with subfertile men, 8' in normal infertile couples, and 1 in a woman with a cervical factor. These 15 patients were not included in the analysis for fear that their special problems would skew the analysis. It should be noted, however, that there were three term prenancies in the 15 excluded patients, one in the roup with subfertile men and two in the normal infertile couples. In addition, eiht other patients were accepted for hmg stimulation but, because of inappropriate responses to stimulation; werecancelled;and-- -----. the s were passed. All patients were stimulated by hmg (Pero... nal, Serono Laboratories Inc., Randolph, MA), Jones et ai. Importance of the follicular phase 317

Fiure 1 Diarammatic representation of the various E2 patterns of response toether with the number of cases in each pattern and the prenancy rate by pattern. monitored, and classified by the heiht of the E2 response accordin to a schedule and analysis previously published. 1 All data were stored in an Apple II computer (Apple Computer Company, Inc., Cupertino, CA), and the various correlations were made by computer analysis. At laparoscopic aspiration, note was made of the number of follicles aspirated and the number and types of es obtained. Es were classified as preovulatory, immature, or atretic, accordin to criteria previously published. 2 Patients were classified as hih, normal (intermediate), or low responders to hmg stimulation by peripheral E2 response at the time hmg was discontinued, as previously described. 1, 3 In addition, six patterns of E2 response in the peripheral blood were reconized. These were iven the arbitrary desination of A, G, B, C, D, 318 Jones et ai. Importance of the follicular phase and E for ease of computer manipulation. The various patterns may be described as follows: A. Daily determinations of serum E2 showed a value hiher than that of the precedin day on each day durin the daily administration ofhmg, on the 2 days after the discontinuation of hmg before the administration of human chorionic onadotropin (hcg), and on the day followin the administration of hcg. The value of E2 had usually fallen on the day of aspiration. G. Daily determinations ofe 2 showed a value hiher than that of the precedin day on each day durin the daily administration ofhmg, on the 2 days after the discontinuation of hmg before the administration of hcg, but a lower value on the day followin the administration of hcg. The value of E2 had usually fallen on the day of aspiration. B. Daily determinations of E2 showed a value hiher than that of the previous day on each day durin the administration of hmg, but lower values on 1 or both days after the discontinuation of hmg before the administration of hcg, but a hiher value on the day followin the administration of hcg. The value of E2 had usually fallen on the day of aspiration. C. Daily determinations ofe 2 showed a value hiher than that of the previous day on each day durin the administration ofhmg, but a lower value on 1 or both days after the discontinuation of hmg before the administration of hcg, and a still lower value on the day followin the administration of hcg. The value of E2 had usually fallen further on the day of aspiration. D. Daily determinations of E2 showed a value hiher than that of the previous day durin the first part of the administration ofhmg, but a lower value on 1 or 2 days while hmg was bein administered, and a still lower value on the days after the discontinuation of hmg prior to the administration of hcg, but a hiher value than the previous day followin the administration of hcg. The value of E2 had usually fallen further on the day of aspiration. E. The same as pattern D except that E2 fell followin the administration of hcg. Table 1. One Hundred Seventy-Five Consecutive Cycles In vitro event A B C D E Laparoscopies Fertilizable es Es fertilized Transfers Prenancies No. 175 146 145 135 33 %A 83 83 77 19 %8 %C %D 99 92 23 93 23 24 Fertility and Sterility

r 1 t f i 1 i,-,f d These various patterns in diarammatic form are shown in Fiure 1. Prenancies were considered confirmed by an elevated serum J3-hCG (> 10 miu) on two or more occasions, plus a concomitant increase in serum values for E2 and proesterone. Prenancies are classified as preclinical abortions, clinical abortions, or viable prenancies. 4 RESULTS OVERALL PREGNANCY RATE Amon the 175 laparoscopics, one or more fertilized es were obtained in 146 s, one or more es were fertilized in 145 s, a transfer occurred in 135 s, and there were 33 s in which prenancies occurred (Table 1). There were three prenancy s in which twin prenancies occurred, for a total of 36 separate concepti. Of the 33 prenancies, there were 8 preclinical abortions and 4 clinical abortions, and 21 patients have either delivered at term or are well alon in the prenancy. EFFECT OF THE HEIGHT OF THE E2 RESPONSE ON THE OOCYTE HARVEST AND THE PREGNANCY RATE Amon the 175 patients who underwent laparoscopy, 26 were classified as hih responders, 109 as intermediate responders, and 40 as low responders. The respective prenancy rates were 23%, 19%, and 15% (Table 2). The total number and the number of preovulatory es harvested per decreased slihtly Table 2. Cycles, Follicles, Es, and Prenancies by Heiht of Response for 175 Consecutive Cycles Hih Normal Low Cycles 26 109 40 Follicles/ 5.5 4.26 4.1 Es/ 3.84 2.76 3.1 Preovulatory es/ 1.69 1.47 1.05 Immature es/ 0.65 0.3 0.55 Es transferred/ 1.57 1.34 1.3 Sinle transfers (%) 30 47 50 Prenancy rate (%)/ 17 17 14 sinle transfer Double transfers (%) 50 38 50 Prenancy rate (%)/ 40 27 14 double transfer Triple transfers (%) 5 14 14 Prenancy rate (%)/ 0 42 50 triple transfer ;;. 4 transfers (%) 15 1 7 Prenancy rate (%)/ 33 0 50 ;;. 4 transfers Prenancy rate (%)/ 23 19 15 as the heiht of the E2 response decreased from hih to intermediate to low. There was a lesser decrease in the number of es transferred, but the number of sinle e transfers per increased slihtly with a decrease in the heiht of the response (Table 2). EFFECT OF THE PATTERN OF THE E2 RESPONSE ON THE OOCYTE HARVEST AND THE PREGNANCY RATE There were 75 patients with an A type of response. Twenty of these became prenant, for a a a 's 1- Table 3. Cycles, Follicles, Es, and Prenancies by of Response for 175 Consecutive Cycles A G B C D E Cycles 75 57 25 12 3 3 Follicles/ 4.48 4.09 5.4 3.75 3.67 3.66 Es/ 3.26 2.75 3.52 2.25 1.66 1.33 Preovulatory es/ 1.57 1.36 1.56 0.92 0.33 0 Immature es/ 0.56 0.44 1.04 0.5 0.67 0 Es transferred/ 1.46 1.29 1.8 0.83 0.33 0 Sinle transfers (%) 42 51 35 57 100 0 Prenancy rate (%)/ 15 23 0 25 0 0 sinle transfer Double transfers (%) 45 30 30 43 0 0 Prenancy rate (%)/ 38 15 17 0 0 0 double transfer Triple transfers (%) 11 14 20 0 0 0 Prenancy rate (%)1 57 33 25 0 0 0 triple transfer ;;. 4 transfers (%) 2 5 15 0 0 0 Prenancy rate (%)/ 100 0 33 0 0 0 ;;. 4 transfers Prenancy rate (%)/ 27 16 12 8 0 0 ity Jones et al. Importance of the follic/!-lar phase 319

q 25 5 2 l'il 20 4 o--~ Prenancy Rate a: _. Transfers..., ~ 15 11 3, c, l'il E a, 10 ;i2 ~ " a.. If< 5 1 0 0 '''' A G BCD E..A./'./"'...-' ~r-... Fiure 2 The prenancy rate and the number of concepti transferred per by pattern of E2 response. prenancy rate of 27%. There were 57 patients with a G type of response. Nine of these patients became prenant, for a prenancy rate of 16%. There were 25 patients with a B type of response. Three of these patients became prenant, for a prenancy rate of 12%. There was only one other prenancy amon the various other types of response (Table 3). If the number and type of es and the resultin transfers are examined by E2 response pattern, there is very little difference between types A, G, and B as compared with the substantial difference in the prenancy rate (Fi. 2). If the prenancy rate by each transferred conceptus is examined by stimulation patterns, it is necessary to consider 36 individual prenancies, because 3 of the prenancies were twin prenancies. For each transferred conceptus from the A pattern, the prenancy rate was 20%; from the G pattern, 14%; and from the B pattern, 7% (Table 4). EFFECT OF THE HEIGHT AND PATTERN OF THE E. RESPONSE ON THE PREGNANCY RATE If both the heiht and the pattern of the E2 response are considered, the numbers become small, but prenancies occurred in the hih responders only if they exhibited an A pattern. In the small roup of A pattern hih responders, there was a 40% prenancy rate. Intermediate responders with A and G patterns also had a ood prenancy rate (Table 5). DISCUSSION The data support the concept that the events of the follicular phase have a critical influence on 320 Jones et al. Importance of the follicular phase the prenancy rate. Whether this is due to variation in the quality of oocytes obtained or to the influence of the follicular phase on events of the luteal phase, i.e., environment, cannot be stated with certainty. The reason different patients respond differently with respect to the heiht of peripheral serum E2 levels is probably multifactorial. It is clearly not a dose-related phenomenon, because a previous study showed that hih responders received fewer ampules ofhmg than low responders. 3 In a study by ultrasound of some of this same material by Mantzavinos et al.,5 the level of the response could not be correlated with the diameter of the larest follicle, but could be correlated in part with the number of developin follicles. There are probably other unidentified factors responsible for the variation in the level of the E2 response. The explanation for the various patterns of response must be speculative. The lowerin of peripheral serum E2 probably reflects a diminished output ofe2 by the most dominant follicle or follicles. This, in tum, would seem to be a reflection of the termination of proressive oocyte maturation. Thus, with time, a downturn in peripheral E2 must be rearded as an unfavorable sin, indicatin follicles with atretic oocytes. On the other hand, an increase in serum E2 after heg, i.e., patterns A and B, is accompanied by the harvest of a relative increased number of immature oocytes. The prenancy rate was found to be proressively lower per oocyte transferred, or preovulatory oocyte transferred, from patients with the A, G, or B patterns, in that order. It is difficult to Table 4. Prenancies by Concepti Transferred by Stimulation for 175 Consecutive Cycles A G B C D E Cycles 75 57 25 12 3 3 Total concepti trans- 110 74 45 10 1 0 ferred Concepti from preovu- 86 58 29 7 1 0 latory es transferred Concepti from imma- 24 16 16 3 0 0 ture es transferred Prenancies 22 10 3 1 0 0 Chance of prenancy 20 14 7 10 0 0 (%)/conceptus Chance of prenancy 26 16 10 14 0 0 (%)/preovulatory conceptus Prenancy rate (%)1 27 16 12 8 0 0 Fertility and Sterility

Table 5. Prenancies by Heiht and of Response (Number of Prenancies/Number of Cycles) for 175 Consecutive Cycles of response Heiht of response Hih Intermediate Low Total A 6/15 11/49 3/11 20175 G 017 8/38 1112 9/57 B 0/2 1114 2/9 3/25 C 0/2 118 0/2 1112 D 0/0 0/0 0/3 0/3 E 0/0 0/0 0/3 0/3 Total 6/26 21/109 6/40 33/175 escape the conclusion that oocytes obtained from follicles in patients with the A pattern who are hih responders are of better quality than oocytes obtained from patients who exhibit other patterns. This seems to be true in spite of the fact that there is no morpholoic distinction between the various oocytes and no morpholoic distinction between the concepti transferred arisin from oocytes from patients with the various stimulation patterns. A study of the luteal phases related to the heiht and pattern of the E2 response is in proress and will be the subject of a separate report, but a survey of these luteal phase data seems to indicate that factors other than the observed luteal phase variations must be operational to explain the differences. From the data presented, it seemed to be desirable durin a stimulation effort with hmgihcg to attempt to obtain serum E2 patterns which apparently indicate continuin maturation of the oocyte, Le., those of hih or intermediate responders with the A or G patterns. As an alternative, if this is impossible, serious consideration should be iven to passin the patients whose patterns of E2 response correspond to those which in the past have yielded oocytes that seemed, for whatever reason, to be incapable of producin prenancies. REFERENCES l. Garcia JE, Jones GS, Acosta AA, Wriht G Jr: Human menopausal onadotropinihuman chorionic onadotropin follicular maturation for oocyte aspiration: Phase II, 1981. Fertil Steril 39:174, 1983 2. Veeck LL, Wortham JWE Jr, Witmyer J, Sandow BA, Acosta AA, Garcia JE, Jones GS, Jones HW Jr: Maturation and fertilization of morpholoically immature human oocytes in a proram of in vitro fertilization. Fertil Steril 39:594, 1983 3. Garcia JE, Jones GS, Acosta AA, Wriht G Jr: Human menopausal onadotropinihuman chorionic onadotropin follicular maturation for oocyte aspiration: Phase I, 1981. Fertil Steril 39:167, 1983 4. Jones HW Jr, Acosta AA, Andrews MC, Garcia JE, Jones GS, Mantzavinos T, McDowell J, Sandow BA, Veeck L, Whibley TW, Wilkes CA, Wriht GL: What is a prenancy? A question for prorams of in vitro fertilization. Fertil Steril. In press 5. Mantzavinos T, Garcia JE, Jones HW Jr: Ultrasound measurement of ovarian follicles stimulated by human onadotropins for oocyte recovery and in vitro fertilization. Fertil Steril. In press ty Jones et al. Importance of the follicular phase 321