Aspects of Mono- and Multiple Dominant Follicle Development in the Human Ovary

Chapter 1 The introduction of this thesis starts with general information on reproduction, sub­fertility and reproductive medicine. It continues with a brief overview of current knowledge regarding the function of the human ovary, describing ovarian development and early and advanced follicle development. The importance of the threshold/win-dow concept for the selection of a single dominant follicle is stressed in more detail. Furthermore, a description of disturbed follicle development and the classi.cation of anovulatory disorders is offered. After a discussion on management of subfertility and the differences between ovulation induction and ovarian (hyper)stimulation, the study objectives are provided. Chapter 2 Section 2.1 To test whether the administration of low-dose exogenous FSH initiated during the early, mid or late follicular phase can induce multiple dominant follicle development, a prospective, randomized trial was performed in normo-ovulatory women. Forty nor­mal weight women participated. Administration of a .xed dose (75 IU) of recombinant FSH was started on either cycle day 3, 5 or 7 until the induction of ovulation with human chorionic gonadotrophin. Frequent transvaginal ultrasound scans and blood sampling were performed. Multifollicular growth occurred in all groups (overall in 60%), although day 7 starters showed less multifollicular growth. Age, cycle length and initial FSH and inhibin B concentrations were similar between subjects with single or multiple follicle development. However, for all women, the lower the BMI, the more follicles emerged. If multifollicular growth occurred, the length of the luteal phase was reduced and midluteal serum concentrations of LH and FSH were decreased while oestradiol and inhibin A were increased. In conclusion, interference with decremental serum FSH concentrations by administration of low dose FSH starting on cycle day 3, 5 or as late as day 7, is capable of disrupting single dominant follicle selection. The role of BMI in determining ovarian response suggest that differences in pharmacokinetics of exogenous FSH are involved. Multifollicular growth per se has a distinct effect on luteal phase characteristics. Section 2.2 This study was performed to investigate the relationship between serum concentrations of inhibin A, B, and E2 and the number of developing follicles during the administration of FSH in various regimens in normo-ovulatory volunteers and to evaluate if inhibins act as suitable markers for the number of developing follicles during ovarian stimula­tion. To address this issue, serial hormone determinations and assessment of follicle numbers were carried out during unstimulated cycles and during various interventions with exogenous FSH. Subjects were randomized for FSH administration in a single high dose (375 IU: Group A) during the early follicular phase, 5 consecutive low doses starting in the mid follicular phase (75 IU: Group B) or daily low doses (75 IU) during the early to late follicular phase (starting on cycle days 3, 5 or 7: Groups C, D and E, respectively). This study showed that extending the FSH window increases the number of small antral follicles and hence inhibin B serum concentrations. If such an intervention re­sulted in multifollicular growth, mid follicular phase inhibin B (P = 0.001) as well as late follicular phase inhibin B and A levels were signi.cantly (P < 0.05 and P < 0.01, respectively) increased compared to monofollicular cycles or the natural cycle. Although mid follicular inhibin B levels correlated well with the number of small an­tral (P < 0.05) and pre-ovulatory (P < 0.001) follicles in the late follicular phase, mid follicular inhibin A and E2 serum concentrations only correlated with the number of pre-ovulatory follicles (P < 0.001 and P < 0.01, respectively). In conclusion, the present data extend our understanding of the relationship between follicle dynamics, serum inhibins and FSH during ovarian hyperstimulation. However, although mid follicular inhibin B does correlate with the number of developing follicles, it does not facilitate the identi.cation of women at risk for multiple follicle development. Chapter 3 Section 3.1 This section is meant as an introduction to section 3.2. It describes the enormous expansion IVF treatment has undergone since its .rst successful report in the natural cycle. In order to improve success rates of IVF treatment, GnRH agonists were intro­duced to prevent premature luteinisation and ovulation during ovarian hyperstimula­tion. The mechanism of action of GnRH agonists is discussed. Over the years IVF treatment has become extremely complex, expensive, time consuming and not without risks. Recently, serious concerns related to the management of assisted reproductive therapies, like IVF, have been expressed. The clinical availability of GnRH antagonists offers the opportunity to develop alternative approaches to ovarian stimulation, since these compounds are characterized by an immediate suppression of pituitary gonado­trophin release and a rapid recovery after cessation. Section 3.2 Extending the FSH window for multifollicular development by administering FSH from the midfollicular phase onward constitutes a novel, mild protocol for ovarian stimula­tion for IVF based on the physiology of single dominant follicle selection in normo­ovulatory women. To test the outcomes from this protocol, 142 IVF patients were randomized to either a GnRH agonist long protocol or one of two GnRH antagonist protocols commencing recombinant FSH on cycle day 2 or cycle day 5. A .xed dose (150 IU/day) of exogenous FSH was used for ovarian stimulation, and GnRH antago­nist co-treatment was initiated on the day when the leading follicle had reached 14 mm diameter. Frequent transvaginal ultrasound scans and blood sampling were performed. This study showed that application of the described mild ovarian stimulation protocol Summary resulted in pregnancy rates per started IVF cycle similar to those observed after pro­found stimulation with GnRH agonist co-treatment despite a shorter stimulation and a 27% reduction in exogenous FSH. A higher cancellation rate before oocyte retrieval was compensated by improved embryo quality concomitant with a higher chance of undergoing embryo transfer. A relatively low number of oocytes retrieved after mild ovarian stimulation distinctly differs from the pathological reduction in the number of oocytes retrieved after profound ovarian stimulation (poor response) associated with poor IVF outcome. The relatively small number of oocytes obtained after mild ovarian stimulation may represent the best of the cohort in a given cycle. Chapter 4 Section 4.1 This section provides an introduction to alternative approaches to the management of anovulatory patients and ovulation induction. WHO 2 group patients represent a very heterogeneous group of patients, which shows a marked variation in ovarian response during ovulation induction. The importance of a more patient tailored approach to this category of patients is stressed. Section 4.2 Elevated LH concentration is a common feature in PCOS. This study was designed to investigate whether elevated LH levels in PCOS might be suppressed to normal range values by the administration of low doses of GnRH antagonist, which subsequently might reverse the anovulatory status of these patients. In order to address this issue, 24 PCOS patients with elevated endogenous LH concentrations were randomized into three different dose groups, receiving either 0.125 mg (group A), 0.250 mg (Group B) or 0.500 mg (Group C) ganirelix sc daily for 7 subsequent days. During the .rst day of treatment, LH and FSH levels were assessed at 20 minute intervals, during 8 hours. Thereafter LH, FSH, androgens, E2 and inhibins were assessed daily and frequent ul­trasound scans were performed for 7 days to record follicle development. The study showed that repeated GnRH antagonist administration induced a sig­ni.cant suppression of LH (and to a lesser extent of FSH) serum levels, which was comparable between the different doses. Six hours after ganirelix administration, en­dogenous LH was suppressed by 49%, 69% and 75%, and endogenous FSH was suppressed by 23%, 19% and 25%, respectively. The decrease in serum LH and FSH levels was transient and lasted for 12 hours, whereafter serum levels returned to base­line levels at 24 hours after drug administration. Only in the highest dose group a suppression of androgen levels after prolonged treatment was observed. E2 levels de­creased signi.cantly (P < 0.001) and suppression was most pronounced in group C. Inhibin B levels did not change during the treatment period. Spontaneous follicle de­velopment or ovulations were not recorded during the course of treatment. In conclu­sion, the present study demonstrated that the GnRH antagonist ganirelix is capable of normalising elevated LH in PCOS patients, in doses similar to the ones previously shown to prevent a premature LH rise during ovarian hyperstimulation for IVF. In addition, the transient suppression of elevated endogenous LH levels per se does not re-establish normal follicle development in PCOS. However, follicle development may be insuf.ciently supported by the accompanied subtle suppression of endogenous FSH. Similarly, a transient decline in E2 levels is not effectively restoring normal pituitary ovarian feedback. Moreover, these results support the contention of a limited role of LH in the pathogenesis of PCOS. Section 4.3 A placebo controlled double blind assessment was performed to assess whether the addition of metformin to gonadotrophin ovulation induction in insulin-resistant, nor­mogonadotrophic, anovulatory women alters ovarian responsiveness to exogenous FSH. After a progestagen withdrawal bleeding patients were randomized for either metformin (n = 11) or placebo (n = 9). In case of absent ovulation, exogenous FSH was subsequently administered to induce ovulation. Only during metformin treatment body mass index and androgen (androstenedione and testosterone) levels decreased, whereas FSH and luteinizing hormone levels increased signi.cantly. In the metformin group a single patient ovulated before the initiation of exogenous FSH. Signi.cantly more monofollicular cycles and lower pre-ovulatory oestradiol concentrations were observed in women receiving metformin next to FSH, compared to FSH alone. In con­clusion, metformin co-treatment in a group of insulin-resistant, normogonadotrophic, anovulatory patients resulted in normalisation of the endocrine pro.le and facilitated monofollicular development during FSH induction of ovulation. Chapter 5 In this chapter the reader is provided an overview of results and conclusions from the preceding studies. These .ndings are discussed in view of existing knowledge and future perspectives

Virtual Ontogeny of Cortical Growth Preceding Mental Illness

Background: Morphology of the human cerebral cortex differs across psychiatric disorders, with neurobiology and developmental origins mostly undetermined. Deviations in the tangential growth of the cerebral cortex during pre/perinatal periods may be reflected in individual variations in cortical surface area later in life. Methods: Interregional profiles of group differences in surface area between cases and controls were generated using T1-weighted magnetic resonance imaging from 27,359 individuals including those with attention-deficit/hyperactivity disorder, autism spectrum disorder, bipolar disorder, major depressive disorder, schizophrenia, and high general psychopathology (through the Child Behavior Checklist). Similarity of interregional profiles of group differences in surface area and prenatal cell-specific gene expression was assessed. Results: Across the 11 cortical regions, group differences in cortical area for attention-deficit/hyperactivity disorder, schizophrenia, and Child Behavior Checklist were dominant in multimodal association cortices. The same interregional profiles were also associated with interregional profiles of (prenatal) gene expression specific to proliferative cells, namely radial glia and intermediate progenitor cells (greater expression, larger difference), as well as differentiated cells, namely excitatory neurons and endothelial and mural cells (greater expression, smaller difference). Finally, these cell types were implicated in known pre/perinatal risk factors for psychosis. Genes coexpressed with radial glia were enriched with genes implicated in congenital abnormalities, birth weight, hypoxia, and starvation. Genes coexpressed with endothelial and mural genes were enriched with genes associated with maternal hypertension and preterm birth. Conclusions: Our findings support a neurodevelopmental model of vulnerability to mental illness whereby prenatal risk factors acting through cell-specific processes lead to deviations from typical brain development during pregnancy

Twenty-three unsolved problems in hydrology (UPH) – a community perspective

This paper is the outcome of a community initiative to identify major unsolved scientific problems in hydrology motivated by a need for stronger harmonisation of research efforts. The procedure involved a public consultation through on-line media, followed by two workshops through which a large number of potential science questions were collated, prioritised, and synthesised. In spite of the diversity of the participants (230 scientists in total), the process revealed much about community priorities and the state of our science: a preference for continuity in research questions rather than radical departures or redirections from past and current work. Questions remain focussed on process-based understanding of hydrological variability and causality at all space and time scales. Increased attention to environmental change drives a new emphasis on understanding how change propagates across interfaces within the hydrological system and across disciplinary boundaries. In particular, the expansion of the human footprint raises a new set of questions related to human interactions with nature and water cycle feedbacks in the context of complex water management problems. We hope that this reflection and synthesis of the 23 unsolved problems in hydrology will help guide research efforts for some years to come

Low-dose exogenous FSH initiated during the early, mid or late follicular phase can induce multiple dominant follicle development

This prospective, randomized trial in normo-ovulatory women was designed to test whether administration of low-dose exogenous FSH initiated during the early, mid to late follicular phase can induce multiple dominant follicle development. Forty normal weight women (age 19-35 years, cycle length 25-32 days) participated. A fixed dose (75 IU/day) of recombinant FSH was started on either cycle day 3 (n = 13), 5 (n = 13) or 7 (n = 14) until the induction of ovulation with human chorionic gonadotrophin. Frequent transvaginal ultrasound scans and blood sampling were performed. Multifollicular growth occurred in all groups (overall in 60%), although day 7 starters showed less multifollicular growth. Age, cycle length and initial FSH and inhibin B concentrations were similar between subjects with single or multiple follicle development. However, for all women the lower the body mass index (BMI), the more follicles emerged (r = -0.44, P = 0.007). If multifollicular growth occurred, the length of the luteal phase was reduced (P = 0.002) and midluteal serum concentrations of LH (P = 0.03) and FSH (P = 0.004) were decreased and oestradiol (P = 0.002) and inhibin A (P = 0.01) were increased. In conclusion, interference with decremental serum FSH concentrations by administration of low dose FSH starting on cycle day 3, 5 or as late as day 7, is capable of disruptin

Development of a research agenda for general practice based on knowledge gaps identified in Dutch guidelines and input from 48 stakeholders

Contains fulltext : 203568.pdf (publisher's version ) (Open Access)BACKGROUND: Several funding organizations using different agendas support research in general practice. Topic selection and prioritization are often not coordinated, which may lead to duplication and research waste. OBJECTIVES: To develop systematically a national research agenda for general practice involving general practitioners, researchers, patients and other relevant stakeholders in healthcare. METHODS: We reviewed knowledge gaps from 90 Dutch general practice guidelines and formulated research questions based on these gaps. In addition, we asked 96 healthcare stakeholders to add research questions relevant for general practice. All research questions were prioritized by practising general practitioners in an online survey (n = 232) and by participants of an invitational conference including general practitioners (n = 48) and representatives of other stakeholders in healthcare (n = 16), e.g. patient organizations and medical specialists. RESULTS: We identified 787 research questions. These were categorized in two ways: according to the chapters of the International Classification for Primary Care (ICPC) and in 12 themes such as common conditions, person-centred care and patient education, collaboration and organization of care. The prioritizing procedure resulted in top 10 lists of research questions for each ICPC chapter and each theme. CONCLUSION: The process resulted in a widely supported National Research Agenda for General Practice. We encourage both researchers and funding organizations to use this agenda to focus their research on the most relevant issues in general practice and to generate new evidence for the next generation of guidelines and the future of general practice

The clinical significance of the retrieval of a low number of oocytes following mild ovarian stimulation for IVF: a meta-analysis

Background: milder ovarian stimulation protocols for in vitro fertilization (IVF) are being developed to minimize adverse effects. Mild stimulation regimens result in a decreased number of oocytes at retrieval. After conventional ovarian stimulation for IVF, a low number of oocytes are believed to represent poor ovarian reserve resulting in reduced success rates. Recent studies suggest that a similar response following mild stimulation is associated with better outcomes. Methods: this review investigates whether the retrieval of a low number of oocytes following mild ovarian stimulation is associated with impaired implantation rates. Three randomized controlled trials comparing the efficacy of the mild ovarian stimulation regimen (involving midfollicular phase initiation of FSH and GnRH co-treatment) for IVF with a conventional long GnRH agonist co-treatment stimulation protocol could be identified by means of a systematic literature search. Results: these studies comprised a total of 592 first treatment cycles. Individual patient data analysis showed that the mild stimulation protocol results in a significant reduction of retrieved oocytes compared with conventional ovarian stimulation (median 6 versus 9, respectively, P &lt; 0.001). Optimal embryo implantation rates were observed with 5 oocytes retrieved following mild stimulation (31%) versus 10 oocytes following conventional stimulation (29%) (P = 0.045). Conclusions: the optimal number of retrieved oocytes depends on the ovarian stimulation regimen. After mild ovarian stimulation, a modest number of oocytes is associated with optimal implantation rates and does not reflect a poor ovarian response. Therefore, the fear of reducing the number of oocytes retrieved following mild ovarian stimulation appears to be unjustified

Effects of pesticides used in soybean crops to the egg parasitoid Trichogramma pretiosum Efeitos dos agroquímicos utilizados na cultura da soja ao parasitóide de ovos Trichogramma pretiosum

This research aimed to study the effects of different insecticides, herbicides and fungicides on eggs, larvae and pupae of Trichogramma pretiosum. The results showed that studied pesticides had different impact on T. pretiosum. Esfenvalerate 7.5 and spinosad 24.0 grams ha-1 were classified as harmfull (class 4) while clorfluazuron 10.0, methoxyfenozide 19.2, lactofen 165.0, fomesafen 250.0, fluazifop 125.0, glyphosate 960.0 (Gliz® and Roundup Transorb®), azoxistrobin + ciproconazol 60.0 + 24.0, azoxistrobin 50.0 and myclobutanil 125.0 grams ha-1 were chemicals classified as harmless to all imature T. pretiosum stages. All the other chemicals evaluated had different impact on T. pretiosum being classified from harmless (class 1) to harmful (class 4) varying the impact accordingly to the different parasitoid stage. Then, less noxious products should be chosen whenever possible to be used in a soybean IPM program.<br>Este trabalho teve como objetivo estudar os efeitos de diferentes inseticidas, herbicidas e fungicidas em ovos, larvas e pupas de Trichogramma pretiosum. Os resultados mostraram que os pesticidas estudados tiveram efeitos diferentes sobre T. pretiosum. Esfenvalerato 7,5 e espinosade 24,0 gramas ha-1 foram classificados como nocivos (classe 4), enquanto que clorfluazurom 10,0, metoxifenozida 19,2, lactofem 165,0, fomesafem 250,0, fluazifope 125,0, glifosato 960,0 (Gliz® e Roundup Transorb®), azoxistrobina + ciproconazole 60,0 + 24,0, azoxistrobina 50,0 e miclobutanil 125,0 gramas ha-1 foram classificados como seletivos (classe 1) para todas as fases imaturas de T. pretiosum. Todos os demais agroquímicos avaliados tiveram diferentes efeitos em T. pretiosum, sendo classificados de seletivo (classe 1) a nocivo (classe 4), variando o impacto de acordo com as diferentes fases do parasitóide. Portanto, produtos menos nocivos aos inimigos naturais devem ser escolhidos, sempre que possível, para serem usados em um programa de MIP-soja