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The Development and Influence of Functional Ovarian Cysts During in Vitro Fertilisation Cycles

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The Development and Influence of Functional Ovarian Cysts During in Vitro Fertilisation Cycles UNIVERSITY OF SOUTHAMPTON Thesis of Julian Michael Jenkins The development and influence of functional ovarian cysts during in vitro fertilisation cycles. Submitted December 1992 for the Degree; Doctor of Medicine lire development and tnfhience of functional ovanan cysts Contents dttnng IVt cycles. List of Tables n List of Figures iv Abstract viii Acknowledgements ix Publications and Presentations related to this thesis x Abbreviations xii Introduction - outline of Chapter 1 1 Prelude 2 Chapter 1 Literature review 6 Hypotheses and objectives 45 Methods - outline of Chapters 2 & 3 48 Chapter 2 Southampton IVF Programme 51 Studies on functional ovarian cysts Study 1; Methods 59 Study 2; Methods 64 Study 3: Methods 65 Study 4; Methods 67 Chapter 3 Assays 70 Results and Discussions - outline of Chapters 4 to 7 95 Chapter 4 Study 1: The influence of functional ovarian cysts during IVF cycles related to serum steroid levels. 97 Chapter 5 Study 2: The development of functional ovarian cysts during pituitary downregulation Ill Chapter 6 Study 3: Steroid concentrations in functional ovarian cyst fluid 1 23 Chapter 7 Study 4: IVF cycles following aspiration of functional ovarian cysts 133 Conclusion Chapter 8 Concluding remarks and future implications ... 145 References 153 Page i The development and influence of functional ovarian cysts Tables during IVF cycles. Chapter 3 Table 3.1: Specificity of progesterone antiserum (source Amersham laboratories) 73 Table 3.2: Specificity of oestradiol antiserum (source Serono laboratories) 76 Table 3.3: Specificity of androstenedione antiserum (source Egan et aZ. 1989) 79 Table 3.4 Specificity of LH antiserum (source Serono Diagnostics Ltd., Surrey, UK) 90 Table 3.5 Specificity of FSH antiserum (source Serono Diagnostics Ltd., Surrey, UK) 91 Chapter 4 Table 4.1: Age and indication for IVF in cycles with ovarian cysts compared to cycles without apparent ovarian cysts 98 Table 4.2: Comparisons of IVF cycles proceeding to oocyte retrieval related to presence of cysts and day 4 serum oestradiol level 103 Table 4.3 Number of oocytes collected in 27 IVF cycles with unilateral ovarian cysts in relation to day 4 serum oestradiol and side of cyst 104 Chapter 5 Table 5.1 Age and infertility diagnosis for patients who did develop functional ovarian cysts during pituitary downregulation compared to patients who did not develop functional ovarian cysts 112 Page ii The development and influence of functional ovarian cysts I 3uIGS during IVF cycles. Table 5.2 Comparison of the interval between commencement of buserelin and the onset of menses between 16 patients with functional ovarian cysts and 272 patients without functional ovarian cysts 113 Table 5.3 Serum steroid concentrations on the day buserelin commenced in relation to subsequent development of functionally active ovarian cysts 117 Chapter 6 Table 6.1 Steroid concentrations in the aspirates of functional ovarian cysts induced by buserelin(group A) and the aspirates of follicles at the time of oocyte retrieval (group C) 128 Table 6.2 Steroid concentrations in the aspirates of 5 functional ovarian cysts noted prior to commencing buserelin in 3 patients(group B) 128 Chapter 7 Table 7.1 Clinical details of patients having aspiration of functional ovarian cysts 134 Table 7.2 Outcome of IVF cycles follovring aspiration of functional ovarian cysts 138 Page iii The development and influence of fnnctional ovarian cysts • IQUrGS during IVF cycles. Chapter 1 Figure 1.1 Transvaginal ultrasound of functional ovarian cyst . .9 Figure 1.2 Transvaginal ultrasound of endometrioma 9 Figure 1.3 Transvaginal ultrasound of cystic teratoma 10 Figure 1.4 Transvaginal ultrasound of fibroid 10 Figure 1.5 Transvaginal ultrasound of hydrosalpinx 11 Figure 1.6 The diameters of an ovoid are dependent on the plane of measurement. (Measurements of a cross section of an ovoid include a minimum diameter, a maximum diameter and an orthodiametric diameter) 12 Figure 1.7 Diagram of pre-ovulatory follicle illustrating the cellular layers, which must be broken down to allow follicular rupture to take place 17 Figure 1.8 Chemical structure of LHRH in comparison to the LHRH analogue buserelin with the enzymatic inactivation sites indicated by arrows referring to the relevant enzymes shown in italics 23 Figure 1.9 Major pathways of ovarian steroidogenesis. (Steroids are named in plain type alongside their chemical structure. Arrows denote the main steroid pathways with broken lines referring to the relevant enzymes, which are indicated in italics) 27 Page iv riie development and inflnence of functional ovarian cysts iiyUrGS during IVF cycles. Figure 1.10 Diagrammatic representation of predominant steroidogenesis at varying stages of follicular development according to the two cell two gonadotrophin hypothesis 28 Figure 1.11 Diagrammatic illustration of the possible areas of influence of ovarian cysts during IVF cycles 42 Chapter 2 Figure 2.1 Southampton IVF Programme ovarian stimulation regime 1988 - 1990 53 Figure 2.2 Diagram illustrating the technique of transvaginal ovarian cyst aspiration 63 Chapter 3 Figure 3.1 Outline of procedure for progesterone assay 72 Figure 3.2 Outline of procedure for oestradiol assay 75 Figure 3.3 Outline of procedure for androstenedione assay 78 Figure 3.4 Demonstration by parallelism of the suitability of 10% albumin for dilution of functional ovarian cyst fluid prior to oestradiol measurement 82 Figure 3.5 Demonstration by parallelism of the suitability of 5% albumin for dilution of functional ovarian cyst fluid prior to progesterone measurement 83 Page v Ihe development ami influence of fiincttonal ovarian cysts Figures (Umng IVt cycles. Figure 3.6 Serum progesterone versus serum oestradiol on day of HCG administration in 35 conception IVF cycles without apparent ovarian cysts 86 Figure 3.7 Serum progesterone versus serum oestradiol on day of HCG administration in 70 non-conception IVF cycles without apparent ovarian cysts 86 Figure 3.8 Outline of procedure for LH assay 89 Chapter 4 Figure 4.1 Serum oestradiol level on day 4 of IVF cycle in 53 cycles with ovarian cysts grouped according to outcome, with 95th centile for 727 IVF cycles without apparent cysts 99 Figure 4.2 Serum androstenedione level on day 4 of IVF cycle in 53 cycles with ovarian cysts grouped according to outcome, with median and absolute range shown for 20 patients without apparent cysts. 100 Figure 4.3 Serum progesterone level on day 4 menses of the IVF cycle in 53 cycles with ovarian cysts grouped according to outcome, with median and absolute range shown for 20 patients without apparent cysts 100 Figure 4.4 Serum progesterone level on the day of HCG or abandonment in 53 cycles with ovarian cysts grouped according to outcome with median and absolute range shown for 104 patients without apparent ovarian cysts on the day of HCG 101 Page vi The development and influence of functional ovarian cysts FlQUr6S during IVF cycles. Chapter 5 Figure 5.1 Comparison of serum oestradiol and serum progesterone between the day buserelin commenced and the fourth day of the subsequent menses in 16 patients, who developed functional ovarian cysts ^ Figure 5.2 Frequency histograms of serum progesterone on the day buserelin was commenced in patients developing functional ovarian cysts and patients not developing functional ovarian cysts 115 Figure 5.3 Scatterplot of serum progesterone against serum oestradiol on day buserelin commenced in 16 patients who subsequently developed functional ovarian cysts, and 272 patients who did not develop functional ovarian cysts 116 Chapter 6 Figure 6.1 Comparison of serum oestradiol and progesterone levels at the time of aspiration and the aspirate concentrations from functional ovarian cysts and ovarian follicles 125 Figure 6.2 Scatterplots of aspirate concentrations of progesterone, oestradiol and androstenedione for 9 functional ovarian cysts and 10 ovarian follicles 126 Chapter 7 Figure 7,1 LH and FSH response to an intravenous bolus of LHRH in patients with functional ovarian cysts and serum oestradiol >200 pmol/1 on buserelin for at least 3 weeks 136 Figure 7.2 Fall in serum oestradiol following aspiration of functional ovarian cysts 137 Page vii UNIVERSITY OF SOUTHAMPTON ABSTRACT FACULTY OF MEDICINE OBSTETRICS AND GYNAECOLOGY Doctor of Medicine THE DEVELOPMENT AND INFLUENCE OF FUNCTIONAL OVARIAN CYSTS DURING IN VITRO FERTILISATION CYCLES. by Julian Michael Jenkins The thesis studied the development of functional ovarian cysts during pituitary downregulation, and the influence of functional ovarian cysts during IVF cycles in relation to steroidogenic activity. Reviewing 780 IVF cycles with buserelin commenced in the luteal phase and human menopausal gonadotrophin administered from day 4 of the ensuing menses 53 cycles with ovarian cysts were identified. Of the 53 cycles with cysts day 4 serum oestradiol concentrations were significantly (p<0.05) higher in cancelled cycles than cycles proceeding to oocyte retrieval, but no significant difference was seen in day 4 serum progesterone and androstenedione concentrations. Twenty three of the latter 53 cycles had a day 4 serum oestradiol >200 pmol/l (95th centile for cycles without apparent cysts). These 23 cycles had a significantly higher cancellation rate (p<0.05) and fewer grade 1 embryos per oocyte retrieval (p<0.05) than the other 30 cycles with cysts. Of a further 288 IVF cycles studied, functional ovarian cysts (with day 4 serum oestradiol >200 pmol/l) developed in 16 cycles during pituitary downregulation. Cysts were aspirated in 10 of the latter 16 cycles. Oestradiol, androstenedione and progesterone concentrations were measured in 9 of the latter cyst aspirates. The cyst aspirates had significantly lower progesterone (p<0.001), higher androstenedione (p<0.01) and similar oestradiol concentrations compared to 10 follicular fluid samples collected at the time of oocyte retrieval. Further support that the cysts were follicular cysts came from a significant (p<0.01) rise in serum oestradiol concentrations despite a significant (p<0.01) fall in serum progesterone concentrations from the day buserelin had been commenced to day 4 of the IVF cycle.
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