High-density lipoprotein metabolism and the human embryo

BACKGROUND

High-density lipoprotein (HDL) appears to be the dominant lipoprotein particle in human follicular fluid (FF). The reported anti-atherogenic properties of HDL have been attributed in part to reverse cholesterol transport. The discoveries of the scavenger receptor class B type I (SR-BI) and the ATP-binding cassette A1 lipid (ABCA1) transporter have generated studies aimed at unraveling the pathways of HDL biogenesis, remodeling and catabolism. The production of SR-BI and ABCA1 knockout mice as well as other lipoprotein metabolism-associated mutants has resulted in reduced or absent fertility, leading us to postulate the existence of a human hepatic-ovarian HDL-associated axis of fertility. Here, we review an evolving literature on the role of HDL metabolism on mammalian fertility and oocyte development.

METHODS

An extensive online search was conducted of published articles relevant to the section topics discussed. All relevant English language articles contained in Pubmed/Medline, with no specific time frame for publication, were considered for this narrative review. Cardiovascular literature was highly cited due to the wealth of relevant knowledge on HDL metabolism, and the dearth thereof in the reproductive field.

RESULTS

Various vertebrate models demonstrate a role for HDL in embryo development and fertility. In our clinical studies, FF levels of HDL cholesterol and apolipoprotein AI levels were negatively associated with embryo fragmentation, but not with embryo cell cleavage rate. However, the HDL component, paraoxonase 1 arylesterase activity, was positively associated with embryo cell cleavage rate.

CONCLUSIONS

HDL contributes to intra-follicular cholesterol homeostasis which appears to be important for successful oocyte and embryo development.

Proceedings from the conference on Reproductive Problems in Women of Color

The purpose of the National Institutes of Health conference on Reproductive Problems in Women of Color that convened on July 25, 2009 was to bring investigators together to examine data related to reproductive health care access and ethnic disparities in reproductive problems, fertility treatments, and pregnancy outcomes. One of the goals discussed at this conference was to initiate a research network of investigators interested in studying these problems through the development of an American Society of Reproductive Medicine special interest group and Society of Assisted Reproductive Technology writing groups.

Racial and ethnic disparities in assisted reproductive technology outcomes in the United States

OBJECTIVE

To evaluate ethnic differences in assisted reproductive technology (ART) outcomes in the United States.

DESIGN

Historical cohort study.

SETTING

Clinic-based data.

PATIENT(S)

A total of 139,027 ART cycles from the Society for Assisted Reproductive Technology Clinic Outcome Reporting System online database for 2004-2006, limited to white, Asian, black, and Hispanic women.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Logistic regression was used to model the odds of pregnancy and live birth; among singletons and twins, the odds of preterm birth and fetal growth restriction. Results are presented as adjusted odds ratios, with white women as the reference group.

RESULT(S)

The odds of pregnancy were reduced for Asians (0.86), and the odds of live birth were reduced for all groups: Asian (0.90), black (0.62), and Hispanic (0.87) women. Among singletons, moderate and severe growth restriction were increased for all infants in all three minority groups (Asians [1.78, 2.05]; blacks [1.81, 2.17]; Hispanics [1.36, 1.64]), and preterm birth was increased among black (1.79) and Hispanic women (1.22). Among twins, the odds for moderate growth restriction were increased for infants of Asian (1.30) and black women (1.97), and severe growth restriction was increased among black women (3.21). The odds of preterm birth were increased for blacks (1.64) and decreased for Asians (0.70).

CONCLUSION(S)

There are significant disparities in ART outcomes according to ethnicity.

Asian ethnicity in anonymous oocyte donors is associated with increased estradiol levels but comparable recipient pregnancy rates compared with Caucasians

OBJECTIVE

To determine if differences exist in ovarian response and pregnancy rates between Asian and Caucasian donors.

DESIGN

Retrospective cohort study.

SETTING

University-based clinic.

PATIENT(S)

Anonymous oocyte donors of self-reported Asian (n=63) or Caucasian (n=156) ethnicity who began ovarian stimulation between February 2000 and March 2008 and their matched recipients.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Recipient pregnancy rates and oocyte donor ovarian responsiveness.

RESULT(S)

Baseline characteristics were similar between Asian and Caucasian donors. Asian donors had peak serum estradiol levels that were 23% higher than their Caucasian counterparts (3715±220 vs. 3013±114 pg/mL). Adjusted estradiol levels per follicle measured and per oocyte retrieved were elevated in Asian donors (17% and 23% higher, respectively), and these differences were unchanged after adjusting for body mass index. No differences were noted in implantation rates (47.4% vs. 40.9%), clinical pregnancy rates (60.3% vs. 62.4%), or live-birth rates (55.5% vs. 59.9%) achieved using Asian vs. Caucasian oocyte donors.

CONCLUSION(S)

In contrast to autologous fresh in vitro fertilization cycles, Asian ethnicity is not associated with a lower pregnancy rate in recipient women using controlled hormone replacement when anonymous donor oocytes are used. Asian donors achieved statistically significantly higher serum estradiol levels during gonadotropin stimulation, suggesting an ethnic difference in steroid production and/or metabolism.

Asian ethnicity is associated with decreased pregnancy rates following intrauterine insemination

Asian ethnicity has been associated with decreased pregnancy outcomes in patients undergoing IVF. The objective of this study was to determine if a difference exists in pregnancy rates between Asian and Caucasian patients undergoing intrauterine insemination (IUI). A retrospective cohort of Asian and Caucasian patients treated with IUI between December 2002 and 2006 was analysed, including 2327 IUI cycles among 814 patients. Baseline characteristics were similar between Asian and Caucasian women. A significantly greater proportion of Asians (43.9%) presented for treatment after more than 2 years of infertility compared with Caucasians (24.6%) (P < 0.0001). Unadjusted analysis showed a trend towards decreased pregnancy rates associated with Asian ethnicity (odds ratio (OR) 0.71, 95% CI 0.50-1.01, not significant). Age, stimulation protocol, differences in gravity and parity, and duration of infertility did not account for this difference (adjusted OR 0.68, 95% CI 0.47-0.98, P = 0.039). Asian ethnicity is associated with lower pregnancy rates in IUI treatment. The increased duration of infertility in Asians does not explain the reduced pregnancy rates.

Meiotic recombination in human oocytes

Studies of human trisomies indicate a remarkable relationship between abnormal meiotic recombination and subsequent nondisjunction at maternal meiosis I or II. Specifically, failure to recombine or recombination events located either too near to or too far from the centromere have been linked to the origin of human trisomies. It should be possible to identify these abnormal crossover configurations by using immunofluorescence methodology to directly examine the meiotic recombination process in the human female. Accordingly, we initiated studies of crossover-associated proteins (e.g., MLH1) in human fetal oocytes to analyze their number and distribution on nondisjunction-prone human chromosomes and, more generally, to characterize genome-wide levels of recombination in the human female. Our analyses indicate that the number of MLH1 foci is lower than predicted from genetic linkage analysis, but its localization pattern conforms to that expected for a crossover-associated protein. In studies of individual chromosomes, our observations provide evidence for the presence of "vulnerable" crossover configurations in the fetal oocyte, consistent with the idea that these are subsequently translated into nondisjunctional events in the adult oocyte.

Fibroids and reproductive outcomes: a systematic literature review from conception to delivery

We examined the published relationship between uterine fibroids and reproductive outcomes. Submucosal fibroids had the strongest association with lower ongoing pregnancy rates, odds ratio, 0.5; 95% confidence interval, 0.3-0.8, primarily through decreased implantation. Cumulative pregnancy rates appeared slightly lower in patients with intramural fibroids 36.9% vs 41.1%, which may reflect biases in the literature; however, patients with intramural fibroids also experienced more miscarriages, 20.4% vs 12.9%. Adverse obstetric outcomes are rare and may reflect age or other differences in fibroid populations. Increased risk of malpresentation (odds ratio, 2.9; 2.6-3.2), cesarean (odds ratio, 3.7; 3.5-3.9), and preterm delivery (odds ratio, 1.5; 1.3-1.7) are reported; however, the incidence of labor dystocia was low (7.5%). There was no conclusive evidence that intramural or subserosal fibroids adversely affect fecundity. More prospective, controlled trials are needed to assess the effects of myomectomy. Good maternal and neonatal outcomes are expected in pregnancies with uterine fibroids.

Bed rest after embryo transfer: a randomized controlled trial

OBJECTIVE

To determine whether bed rest after embryo transfer leads to improved pregnancy rates (PR).

DESIGN

Randomized controlled trial.

SETTING

University reproductive health clinic.

PATIENT(S)

Women undergoing IVF.

INTERVENTION(S)

Patients undergoing 164 cycles of IVF were randomized to 30 minutes of bed rest after embryo transfer or immediate discharge from the clinic.

MAIN OUTCOME MEASURE(S)

Clinical PR defined by visualized fetal heart beat and ongoing PR defined by viable intrauterine gestation beyond 11 weeks.

RESULT(S)

The clinical and ongoing PR for both groups were 50% and 46.3%, respectively, with no statistically significant difference between the two groups.

CONCLUSION(S)

Thirty minutes of bed rest after embryo transfer does not improve PR.

The effect of fibroids without cavity involvement on ART outcomes independent of ovarian age

BACKGROUND

The effect of fibroids that do not distort the endometrial cavity on pregnancy rate (PR) and implantation rate (IR) is controversial. Use of oocyte donor-derived embryos offers an ideal patient population to study the effect of fibroids in patients utilizing assisted reproductive technologies (ARTs).

METHODS

We conducted a retrospective cohort study of patients undergoing oocyte donor recipient (ODR) IVF cycles at two tertiary care fertility centres. We examined medical records for the presence of non-cavity-distorting fibroids and evaluated subsequent PR and IR.

RESULTS

Three hundred and sixty-nine patients, 94 with fibroids, underwent oocyte donor recipient transfer cycles with fresh embryos. There was no statistical difference in IR (36 versus 38%) or clinical PR (47 versus 54%) between patients with or without fibroids. Neither the location (subserosal versus intramural) and the presence of multiple myomas nor the size of the myomas affected outcomes. Fibroids were more likely to be present in patients with increasing recipient age.

CONCLUSIONS

Clinical PR and IR are not affected by the presence of non-cavity-distorting leiomyomata. This evidence does not support myomectomy before ART in patients with asymptomatic fibroids that do not significantly distort the endometrial cavity or cause abnormal uterine bleeding.

Oocyte degeneration after intracytoplasmic sperm injection: a multivariate analysis to assess its importance as a laboratory or clinical marker

OBJECTIVE

Oocyte degeneration has historically been associated with the intracytoplasmic (ICSI) technique. We sought to determine whether oocyte degeneration rates were associated with the technician performing the procedure, the baseline characteristics of the patient, and/or ovarian stimulation variables. We also evaluated whether the degeneration rate could serve as a surrogate marker for implantation potential.

DESIGN

Cohort study.

SETTING

Academic medical center.

PATIENT(S)

Couples undergoing ICSI.

INTERVENTION(S)

Six thousand six hundred fifty-three injected oocytes were analyzed to determine whether the degeneration rate was technician dependent. Two hundred thirty first-entry down-regulated cycles were examined to identify predictors associated with oocyte degeneration. Multivariate analyses were performed using generalized linear model routines.

MAIN OUTCOME MEASURE(S)

Oocyte degeneration rates and implantation rates.

RESULT(S)

Neither the ICSI technician nor the stripping technician was associated with the oocyte degeneration rate. However, the day 3 FSH, number of mature oocytes retrieved, and E2 levels on the day of hCG were significant independent predictors of degeneration rate. Physician-adjustable ovarian stimulation variables were not associated with the degeneration rate. The degeneration rate did not appear to be associated with the implantation rate.

CONCLUSION(S)

These data suggest that oocyte degeneration is not technician or physician dependent. Degeneration is likely a function of the inherent oocyte quality in women who underwent ovarian stimulation. However, the remaining cohort of retrieved oocytes appears to be unaffected by virtue of an uncompromised implantation rate.

Gonadotropin stimulation demonstrates a ceiling effect on in vitro fertilization outcomes

OBJECTIVE

To determine the effect of number of oocytes retrieved and number of 2PN embryos developed on in vitro fertilization (IVF) outcomes.

DESIGN

Retrospective data analysis.

SETTING

University practice.

PATIENT(S)

Reproductive-aged women (n = 467).

INTERVENTION(S)

First fresh nondonor cycle of IVF.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate

RESULT(S)

Clinical pregnancy rates increase until age 30 (odds ratio (OR) 1.72 per year (95% confidence interval 1.19-2.49)) before demonstrating a linear decline. In subjects < 37 years old, maximal clinical pregnancy rates are seen when 20 oocytes were retrieved (OR 1.03 (0.96-1.11)), five 2-pronuclei (2PN) embryos developed (OR 1.91 (1.29-2.87)), and no more than two embryos transferred (OR 0.72 (0.56-0.92) for each additional embryo transferred > 2). In subjects > or = 37 years old, maximum clinical pregnancy rates were achieved in subjects who had ten oocytes retrieved (OR 1.09 (1.01-1.18)), 20 2PN embryos developed (OR 1.29 (1.03-1.62)), and no more than two embryos transferred (OR 0.72 (0.56-0.92) for each additional embryo transferred > 2).

CONCLUSION(S)

The odds of achieving a successful clinical pregnancy with IVF are greatest with retrieval of approximately 20 oocytes, transfer of no more than 2 embryos, and the development of about five 2PN embryos in women < 37 years old and ten 2PN embryos in women > or = 37 years old.

Day 2 transfer improves pregnancy outcome in in vitro fertilization cycles with few available embryos

OBJECTIVE

Delaying ET to day 3 to optimize embryo selection is well accepted. However, in cases where there are not enough embryos to perform selection, it is not clear whether there is a difference in clinical outcomes with the day of ET.

DESIGN

Cohort study.

SETTING

Academic medical center.

PATIENT(S)

Two hundred forty-two fresh IVF/intracytoplasmic sperm injection (ICSI) cycles from 2002-2004, where all generated embryos were transferred irrespective of quality because of an extremely low number of available embryos.

INTERVENTION(S)

In time period 1, ET was on day 3. In time period 2, ET was on day 2.

MAIN OUTCOME MEASURE(S)

Patient response to stimulation was analyzed along with pregnancy outcome and implantation rate.

RESULT(S)

Miscarriage rates were decreased, and ongoing pregnancy rates were increased with a day 2 ET in patients <40 years of age.

CONCLUSION(S)

In women <40 years of age, the day of transfer is a significant predictor of clinical outcome in cases in which a low number of embryos are available for transfer. The evidence suggests that limiting embryo culture to only 2 days reduces the incidence of miscarriage and increases ongoing pregnancy rates.

Triploidy formation after intracytoplasmic sperm injection may be a surrogate marker for implantation

OBJECTIVE

Triploidy after intracytoplasmic sperm injection (ICSI) is due mostly to retention of the second polar body. Our interest was to determine the predictors of triploidy and to determine whether the presence of triploidy can serve as a surrogate marker of implantation for the remaining cohort of zygotes.

DESIGN

Cohort study.

SETTING

Academic research center.

PATIENT(S)

Infertile couples undergoing IVF/ICSI.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Triploid zygote (3PN) rate, implantation rate.

RESULT(S)

The 3PN rate is a significant predictor of implantation rate for the remaining cohort of zygotes. The starting and total dose of gonadotropins administered and the total days of stimulation are independent predictors of the 3PN rate.

CONCLUSION(S)

In couples with a normal semen analysis undergoing IVF/ICSI, the 3PN rate may serve as a surrogate marker of oocyte quality and may be altered by adjusting the stimulation protocol.

In vivo feasibility of image-guided transvaginal focused ultrasound therapy for the treatment of intracavitary fibroids

OBJECTIVE

To determine the feasibility of uterine tissue ablation in vivo using a transvaginal focused ultrasound applicator guided by ultrasound imaging.

DESIGN

Randomized in vivo animal study.

SETTING

Academic research environment.

ANIMAL(S)

Healthy anesthetized sheep.

INTERVENTION(S)

Uterine treatment location was determined using a computerized targeting system. Five sonications 10 seconds in duration and averaging 2,000 W/cm(2) of focal ultrasound intensity were applied in each animal's uterus. Animals were euthanized either immediately or 2, 7, or 30 days post-treatment.

MAIN OUTCOME MEASURE(S)

Gross and microscopic analysis of the dissected uterus was used to quantitatively and qualitatively determine the ablated region and treatment side effects.

RESULT(S)

Treatments resulted in coagulative necrosis. Histopathological analysis showed that over 7 days, inflammatory cells appeared and smooth muscle bundles regenerated. By day 30, treated tissues healed and scar tissue formed. None of the animals showed abnormal behavior or medical problems. Complications in three animals were damage to the vaginal wall and colon, possibly due to inadequate applicator cooling and an empty bladder during treatment.

CONCLUSION(S)

Transvaginal image-guided high-intensity focused ultrasound has potential for treating uterine fibroids. Further safety testing of this treatment will prepare it for human use.

Treatment of uterine fibroid tumors in an in situ rat model using high-intensity focused ultrasound

OBJECTIVE

To determine the efficacy and safety of high-intensity focused ultrasound (HIFU) for the treatment of uterine fibroid tumors in an in situ animal model.

DESIGN

High-intensity focused ultrasound was applied intraoperatively to uterine fibroid tumors in rats.

SETTING

Department of Bioengineering, and Applied Physics Laboratory, University of Washington, Seattle, Washington.

ANIMAL(S)

Thirty-five tumors in 27 Eker rats that had spontaneous in situ uterine fibroids were randomly assigned into two groups receiving HIFU (n = 29) or sham (n = 6) treatments.

INTERVENTION(S)

Animals were anesthetized, and tumors were exposed surgically. The HIFU was applied at 3.5 MHz in 10-second bursts to produce coagulative necrosis lesions (3 mm by 10 mm), spaced 5 mm apart. Sham treatments consisted of exposing the tumors, and handling them similarly to those in the HIFU treatment group, but HIFU was not applied.

MAIN OUTCOME MEASURE(S)

Tumor volume was measured every week transabdominally using B-mode ultrasound imaging. Gross examination and histological analysis were performed after euthanasia.

RESULT(S)

More than half of the tumors in the HIFU treatment group showed significant tumor volume reduction. The average tumor volume in the sham treatment group increased 40-fold. Gross and histological analysis showed coagulative necrosis of tumor cells in the HIFU treatment group.

CONCLUSION(S)

The HIFU may provide an effective and safe method of treating uterine fibroid tumors.

An image-guided high intensity focused ultrasound device for uterine fibroids treatment

A high intensity focused ultrasound (HIFU) device was developed for treating uterine fibroid tumors. This prototype device enables image-guided therapy by aligning a commercially available abdominal ultrasound image probe to a vaginal HIFU transducer so the HIFU focus is in the image plane. The device was designed based on anatomical constraints of the female pelvic structures. HIFU was generated using a 3.5 MHz PZT-8 crystal, 25.4 mm in diameter, bonded to an aluminum lens. Computer simulations were performed to ensure that effective focusing was achievable at a fixed focal depth of 40 mm. Transducer efficiency was empirically determined to be 58%, and the half pressure maximum focal dimensions were 11 mm in length and 1.2 mm in width. A water-filled latex condom surrounding the transducer provided acoustic coupling, a stand-off, and allowed water circulation for transducer cooling. In vitro experiments in a tissue-mimicking gel phantom and in turkey breast demonstrated ultrasound image-guided lesion formation, or tissue necrosis, at the focus due to HIFU induced thermal and cavitation effects. The HIFU treatment site appeared as a hyperechoic spot on the ultrasound image at intensities above 1250 W/cm2. The results of in vitro experiments and in vivo ergonomic testing in six human volunteers indicated that the device has the potential of providing a nonsurgical approach for uterine fibroid treatment. Future in vivo studies in large animal models and fibroids patients are planned.

Treatment of uterine leiomyosarcoma in a xenograft nude mouse model using high-intensity focused ultrasound: a potential treatment modality for recurrent pelvic disease

OBJECTIVE

The objective was to test the efficacy of high-intensity focused ultrasound (HIFU) for treatment of uterine leiomyosarcoma in a Xenograft nude mouse model.

METHODS

A total of 65 athymic nude mice were inoculated subcutaneously with 5 to 7 x 10(6) ELT-5B cells, a uterine leiomyosarcoma cell line derived from the Eker rat. Thirty animals showed tumor growth. The tumor volume was measured transcutaneously once a week. Animals were randomly assigned to three groups: HIFU treatment (n = 17), sham treatment (n = 7), and control (n = 6). A HIFU device, operating at a frequency of 2.0 MHz and an intensity of 2000 W/cm(2), was used for treatment.

RESULTS

Within 3 weeks of a single HIFU treatment, 100% reduction in tumor volume was observed in all animals, except one. A second HIFU treatment was applied to that animal, resulting in 100% reduction in tumor volume. The tumors in the sham-treated animals continued to grow at a similar rate to that of the control group to approximately 500% of the tumor volume at the time of treatment. All animals were monitored for a maximum of 3 months. No metastasis was observed in the HIFU-treated animals. Histological examination confirmed a complete tumor disappearance after HIFU treatment.

CONCLUSION

We have shown that HIFU can effectively treat uterine leiomyosarcoma tumors inoculated in Xenograft nude mice, demonstrating HIFU's potential use for treatment of recurrent uterine leiomyosarcoma.

Factors influencing pregnancy rates with a combined clomiphene citrate/gonadotropin protocol for non-assisted reproductive technology fertility treatment

OBJECTIVE

To determine the effectiveness of a combined clomiphene citrate/gonadotropin protocol in a general infertility population and to evaluate factors influencing pregnancy rates obtained with this protocol.

DESIGN

A retrospective chart review. SETTING; University-based infertility clinic.

PATIENT(S)

Two hundred forty-eight patients undergoing 658 cycles of minimal stimulation (MS) protocol from 1996-2000.

INTERVENTION(S)

Patients underwent treatment with clomiphene citrate and gonadotropin, often followed by intrauterine insemination.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rates.

RESULT(S)

Overall, the clinical pregnancy rate was 7.1% per cycle (n = 248 patients and 658 cycles). The age range of the patients was 24-47 years (mean +/- SD = 36.5 +/- 4.9) with 8.7% noted to have ovulatory dysfunction. Pregnancy rates varied significantly (P<.05) with patient age (9.3% in women <40 years vs. 2.4% in women > or =40), duration of infertility (9.0% in women with < or =3 years of infertility vs. 2.2% in women with >3 years of infertility) and number of follicles produced during stimulation (9.1% in women with > or =3 follicles vs. 4.6% in women with <3 follicles).

CONCLUSION(S)

The effectiveness of the MS protocol in a general infertility population with a predominantly ovulatory status is much less than that previously reported in a younger patient population with a significant rate of ovulatory dysfunction. This protocol does not appear to lead to pregnancy rates higher than that reported for clomiphene citrate/intrauterine insemination (IUI) cycles. The clinical pregnancy rates using a minimal stimulation protocol are particularly compromised in women over 40, those with a longer duration of infertility or those who produce few follicles during stimulation.

Attenuation coefficient and sound speed in human myometrium and uterine fibroid tumors

OBJECTIVE

To develop a noninvasive method for treatment of uterine fibroid tumors using high-intensity focused ultrasound. Optimal high-intensity focused ultrasound treatment would be dependent on quantitative information about ultrasonic tissue characteristics.

METHODS

Ultrasonic attenuation and the sound speed of fresh human fibroid tumors and myometrium were measured as a function of frequency (1-3 MHz) by using a pulse transmission technique before and after in vitro high-intensity focused ultrasound treatment (3.5 MHz at an intensity of 2,000 W/cm2).

RESULTS

The ranges of the attenuation coefficients, before and after high-intensity focused ultrasound treatment, were 0.9 to 2.2 and 1.8 to 3.9 dB/cm2, respectively, for fibroid tumors and 0.5 to 1.6 and 1.7 to 3.3 dB/cm2, respectively, for myometrium. Although the sound speed appeared to be independent of frequency (1,611 to 1,616 m/s at 1 to 3 MHz) in both types of tissues, a slight increase of approximately 4 to 14 m/s was observed after high-intensity focused ultrasound treatment.

CONCLUSIONS

The results of this study represent our first reported values of the attenuation coefficient and sound speed in fibroid tumors and myometrium before and after high-intensity focused ultrasound treatment.

Bacteria in the transfer catheter tip influence the live-birth rate after in vitro fertilization

OBJECTIVE

To assess the impact of individual bacteria isolated from the vagina and tip of the embryo transfer catheter on live-birth rates.

DESIGN

Prospective clinical study.

SETTING

Infertility outpatient clinic of a university hospital.

PATIENT(S)

Ninety-one women undergoing IVF-ET.

INTERVENTION(S)

Cultures were obtained from the vagina for aerobic and anaerobic bacteria at the time of both sonographic egg retrieval and embryo transfer and from the tip of the embryo transfer catheter. Doxycycline treatment was started after egg retrieval.

MAIN OUTCOME MEASURE(S)

The live birth of one or more neonates.

RESULT(S)

Doxycycline had no substantial impact on the recovery of individual vaginal bacteria or on bacterial vaginosis. An increase in live-birth rate was associated with the recovery of hydrogen peroxide-producing Lactobacillus from the vagina (P=0.01) and from the embryo transfer catheter (P=0.01). In contrast, a reduction in live-birth rate was associated with recovery of Streptococcus viridans (S. viridans) from the embryo transfer catheter tip (P=0.04).

CONCLUSION(S)

In the setting of IVF-ET, prophylactic doxycycline had little effect on vaginal bacteria. Specific bacteria recovered from the embryo transfer catheter appear associated with a detrimental or beneficial effect or with no effect on live-birth rates.

Treatment of uterine fibroid tumors in a nude mouse model using high-intensity focused ultrasound

OBJECTIVE

The purpose of this study was to investigate the potential efficacy of high-intensity focused ultrasound for the treatment of uterine fibroid tumors in a nude mouse model.

STUDY DESIGN

A total of 60 female athymic nude mice were inoculated subcutaneously with 3 to 5 x 10(6) ELT-3 cells, a uterine fibroid tumor cell line. Tumor size was monitored with transcutaneous caliper measurements. The high-intensity focused ultrasound probe was a concave, single-element, high-power transducer that operated at a frequency of 3.5 MHz. The tumors were treated for 30 to 60 seconds using a high-intensity focused ultrasonic intensity of 2000 W/cm(2), depending on the tumor size.

RESULTS

A single high-intensity focused ultrasonic treatment resulted in an average reduction in tumor volume of 91% within 1 month of the treatment. Histologic analysis of tumors treated with high-intensity focused ultrasound showed coagulation necrosis and nuclear fragmentation of tumor cells.

CONCLUSION

High-intensity focused ultrasound effectively reduced uterine fibroid tumor size in a nude mouse model. Further studies are needed to assess the in situ response of uterine fibroids to high-intensity focused ultrasonic treatment.

Late-onset hematometra and hematosalpinx in a woman with a noncommunicating uterine horn. A case report

BACKGROUND

Noncommunicating uterine horns are rare, occasionally presenting with functional endometrial cavities. Surgical removal of the noncommunicating horn is commonly performed to prevent endometriosis in these patients.

CASE

A 41-year-old woman with a unicornuate uterus and noncommunicating uterine horn presented with a three-month history of right-sided pelvic pain. She had previously undergone multiple assisted reproductive technique attempts with superovulation and supraphysiologic serum estradiol levels and no apparent symptomatology or evidence of hematosalpinx during laparoscopy. Shortly after completing a donor oocyte recipient cycle, she developed acute right-sided pelvic pain. Diagnostic laparoscopy and subsequent laparotomy confirmed a right hematosalpinx and hematometra of the noncommunicating horn, with stage III endometriosis.

CONCLUSION

Consideration of prophylactic resection of a noncommunicating uterine horn with a cavity should be considered in an asymptomatic, reproductive-age patient with this rare müllerian anomaly.

Interferon-gamma and activin A promote insulin-like growth factor-binding protein-2 and -4 accumulation by human luteinizing granulosa cells, and interferon-gamma promotes their apoptosis

Insulin-like growth factor (IGF)-binding proteins (IGFBPs) antagonize IGF and gonadotropin actions on granulosa cells. Human atretic follicles express IGFBP-2 in granulosa cells more strongly and contain higher levels of IGFBP-2 and IGFBP-4 than healthy follicles. We studied the effects of interferon-gamma (IFN gamma) and activin A, which decrease progesterone accumulation, on granulosa cell IGFBP production and apoptosis. Conditioned media from luteinizing granulosa cells cultured with IFN gamma or activin A and/or LH were subjected to ligand blotting; northern blots of total ribonucleic acid (RNA) from these cells were probed for IGFBP-2 and -4. Apoptosis was measured by in situ DNA end labeling. LH decreased medium IGFBP-2 to 21% of the control value. Although IFN gamma did not alter basal medium IGFBP-2, in the presence of LH it increased IGFBP-2 3.4-fold, with parallel changes in messenger RNA levels. Activin A also tended to increase medium IGFBP-2 in LH-treated cultures. In conditioned medium, IGFBP-4 was consistently decreased by LH, whereas both IFN gamma and activin A increased IGFBP-4 and decreased IGFBP-4 protease activity. Both LH and IFN gamma modestly stimulated IGFBP-4 messenger RNA levels. Follistatin antagonized the action of activin A, but not that of IFN gamma. IFN gamma, but not activin A, increased granulosa cell apoptosis. In conclusion, IFN gamma produced by activated lymphocytes may decrease endogenous IGF activity through stimulation of IGFBPs and may promote apoptosis of granulosa-lutein cells in vivo and, thus, luteal regression. Activin A similarly promotes IGFBP accumulation, but it does not promote apoptosis.

Congenital cervical atresia: report of seven cases and review of the literature

OBJECTIVE

Our aim was to evaluate the clinical course and management of congenital cervical atresia.

STUDY DESIGN

This retrospective analysis included 7 patients referred to our clinic and a review of the medical literature.

RESULTS

Including this case series, 58 cases of congenital cervical atresia have been reported in the literature. Forty-eight percent of patients had isolated congenital cervical atresia with a normal vagina whereas the remainder had either complete or partial vaginal atresia ("shortened blind vaginal pouches"). Surgical management has included abdominal hysterectomy or uterovaginal cannulation with or without vaginoplasty. In 59% of patients who underwent uterovaginal canalization procedures (23/39), normal menstrual bleeding was achieved. Four of these patients subsequently became pregnant and were delivered at term.

CONCLUSION

Surgical canalization in selected patients with congenital cervical atresia can be successfully performed to provide patients an opportunity for conservative management, resulting in normal menstrual bleeding, resolution of cyclic pelvic pain, and some potential (albeit limited) for fertility.

Utility of follicle stimulating hormone (FSH), luteinizing hormone (LH), oestradiol and FSH:LH ratio in predicting reproductive age in normal women

The relative efficacy of follicle stimulating hormone (FSH), luteinizing hormone (LH), FSH:LH ratio and oestradiol is evaluated as a predictor of ovarian reserve (reproductive age) in normal women. Serum levels of FSH, LH, oestradiol and FSH:LH ratios were measured during menstrual cycle days 1-4 in younger (20-25 years; n = 23) and older (40-45 years; n = 32) reproductive age women with regular menstruation and normal reproductive function. On days 1-4, mean levels of FSH, oestradiol and FSH:LH ratios were significantly higher in older compared with younger women. FSH increased in concentration across cycle days in both age groups. A significantly lower LH value in younger versus older women was found only on day 1. Oestradiol showed no change across days in the younger group, but increased significantly from day 1 to day 4 in the older group. FSH values on days 1 or 2 were the best single predictor of age differences. However, the best prediction of age differences was obtained by using the combination of FSH and LH (as opposed to the FSH:LH ratio) on day 1 of the menstrual cycle.

Dose-related suppression of serum luteinizing hormone in women by a potent new gonadotropin-releasing hormone antagonist (Ganirelix) administered by intranasal spray

OBJECTIVE

To determine if the GnRH antagonist (GnRH-a) Ganirelix (Syntex Research, Palo Alto, CA), administered by intranasal (IN) spray to normal women, is absorbed into the systemic circulation and suppresses LH secretion.

DESIGN

A single center, open label, nonrandomized, dose-escalation study.

SETTING

Academic research environment.

PATIENT(S)

Normal female volunteers ages 23 to 43 years.

INTERVENTION(S)

Ganirelix was administered as a single dose by IN spray. The administered doses and the number of women receiving each of them were 0.1 mg (n = 1), 0.3 mg (n = 1), 1 mg (n = 2), 3 mg (n = 5), and 6 mg (n = 5). Blood samples were collected from -15 minutes to 24 hours after dosing.

MAIN OUTCOME MEASURE(S)

Serum concentrations of Ganirelix and LH.

RESULT(S)

Ganirelix was absorbed rapidly. The mean time to maximal serum levels in the 3- and 6-mg groups was 0.67 and 0.53 hour, respectively. Mean serum LH levels were suppressed by > or = 35% relative to baseline from 2 to 12 hours after dosing in both groups. The mean maximal percent decrease in serum LH was -62% (at 8 hours after dosing) and -74% (at 6 hours after dosing) in the 3- and 6-mg groups, respectively.

CONCLUSION(S)

Single dose IN administration of 3 or 6 mg of Ganirelix suppressed serum LH levels in women, further enhancing the potential clinical utility of this potent GnRH-a. This is the first clinical report of a GnRH-a reducing the secretion of a pituitary gonadotropin when administered by an IN delivery system. Based on the duration and extent of LH suppression observed in this study, Ganirelix, administered by twice daily IN spray, may be effective for the treatment of gonadal hormone-dependent disorders in women.

Reproductive aging: accelerated ovarian follicular development associated with a monotropic follicle-stimulating hormone rise in normal older women

Women experience a decline in fertility that precedes the menopause by several years. Previous studies have demonstrated a monotropic rise in FSH associated with reproductive aging: however, the mechanism of this rise and its role in the aging process are poorly understood. The purpose of this study was to characterize ovarian follicular development and ovarian hormone secretion in older reproductive age women. Sixteen women, aged 40-45 yr, with regular ovulatory cycles were studied. The control group consisted of 12 ovulatory women, aged 20-25 yr. Serum obtained by daily blood sampling was analyzed for FSH, LH, estradiol (E), progesterone, and inhibin (Monash polyclonal assay). Follicle growth and ovulation were documented by transvaginal ultrasound. Older women had significantly higher levels of FSH throughout the menstrual cycle. E, progesterone, LH, and inhibin levels did not differ between the two age groups when compared relative to the day of the LH surge. Ultrasound revealed normal growth, size, and collapse of a dominant follicle in all subjects. Older women had significantly shorter follicular phase length associated with an early acute rise in follicular phase E, reflecting accelerated development of a dominant follicle. We conclude that older reproductive age women have accelerated development of a dominant follicle in the presence of the monotropic FSH rise. This is manifested as a shortened follicular phase and elevated follicular phase E. The fact that ovarian steroid and inhibin secretion were similar to those in the younger women suggests that elevated FSH in women of advanced reproductive age may represent a primary neuroendocrine change associated with reproductive aging.

The anterior pituitary response to a gonadotropin-releasing hormone challenge test in normal older reproductive-age women

OBJECTIVE

To assess the pituitary responsiveness to GnRH stimulation of premenopausal women relative to age.

DESIGN

Older and younger reproductive-age women underwent the GnRH stimulation test in the early follicular phase of the menstrual cycle.

SETTING

Female subjects in an academic research environment.

PATIENTS

Women aged 21 to 44 years consisting of normal volunteers and infertility patients.

INTERVENTIONS

Gonadotropin-releasing hormone was administered intravenously between days 2 and 4 of the menstrual cycle. Blood samples were collected from -20 minutes before to 120 minutes after administration.

MAIN OUTCOME MEASURE

Luteinizing hormone, FSH, inhibin, and E2 levels.

RESULTS

No significant difference in baseline values existed between older and younger women with regard to LH, inhibin, and E2, but basal FSH levels were higher in older women. A significantly diminished percent of LH and percent FSH change above baseline occurred 30 minutes after GnRH administration in the older women compared with younger women. No change in inhibin or E2 levels could be detected during the sampling period.

CONCLUSIONS

The present study demonstrates marked attenuation of the acute pituitary LH response (sensitivity) to GnRH stimulation in older women when compared with a younger cohort.

Localization and regulation of corticotropin receptor expression in the midgestation human fetal adrenal cortex: implications for in utero homeostasis

Developmental changes in the responsiveness of the fetal adrenals to corticotropin (ACTH) play an important role in the regulation of the fetal hypothalamic-pituitary-adrenal axis. Responsiveness of adrenal cortical cells to ACTH is dependent on the extent of ACTH receptor expression. Therefore, we examined the localization and regulation of ACTH receptor expression in the midgestation (16-24 weeks) human fetal adrenal cortex. In situ hybridization analysis was used to localize messenger RNA (mRNA) encoding the ACTH receptor in sections of human fetal adrenal glands. Messenger RNA encoding the ACTH receptor was localized in cells from all cortical zones; abundance was higher in definitive zone than in fetal zone cells and was least abundant in the more central portions of the cortex. Regulation of ACTH receptor expression was studied using Northern blot analysis of total RNA extracted from primary cultures of fetal and definitive zone cells. Two major (1.5 and 3.5 kilobases) and, upon stimulation with ACTH, 3 minor (4.0, 6.0 and 10.0 kb) ACTH receptor mRNA transcripts were detected in RNA from fetal and definitive zone cells. In both cell types, ACTH-(1-24) increased the abundance of mRNA encoding the ACTH receptor 10- to 20-fold compared with untreated cells. The effects of ACTH-(1-24) on ACTH receptor expression in fetal zone cells were time- and dose-dependent. The ED50 for the stimulation of ACTH receptor expression by ACTH-(1-24) was 1-10 pM, and maximal response to 0.1 nm ACTH-(1-24) was detected after 12-16 h. Eight-bromoadenosine cAMP and forskolin also stimulated ACTH receptor expression in fetal zone cells and closely mimicked the effects of ACTH-(1-24). In contrast, stimulation of protein kinase C with 12-O-tetradecanoyl phorbol 13-acetate had no effect on ACTH receptor expression. Changes in ACTH receptor expression in response to ACTH-(1-24), cAMP and forskolin were paralleled by changes in expression of the P450 cholesterol side chain cleavage (P450scc) enzyme. These data demonstrate that expression of the ACTH receptor by the human fetal adrenal cortex is up-regulated by its own ligand and that this effect is mediated by a cAMP-dependent mechanism. In addition, the coordinate stimulation of ACTH receptor and P450scc expression by ACTH indicates that the gene for the ACTH receptor is one of a specific cohort of genes regulated by ACTH that are required to facilitate fetal adrenal cortical response to ACTH. ACTH regulation of its own receptor may represent a mechanism by which fetal adrenal responsiveness to ACTH is maintained and possibly enhanced during fetal development.

Suppression of follicular phase pituitary-gonadal function by a potent new gonadotropin-releasing hormone antagonist with reduced histamine-releasing properties (ganirelix)

OBJECTIVE

To determine if daily subcutaneous doses of ganirelix will suppress and maintain E2 < or = 30 pg/mL (conversion factor to SI unit, 3.671), the serum profiles of LH and FSH during and after cessation of treatment, the time-course of the resumption of normal ovarian function after ganirelix cessation, and to identify side effects of daily treatment.

DESIGN

Open-label nonrandomized clinical study.

SETTING

Normal human volunteers in an academic research center.

PATIENTS

Women 21 to 45 years of age, with documented ovulatory menstrual cycles.

INTERVENTIONS

Ganirelix was administered subcutaneously daily for 8 days. Blood samples were obtained during dosing as well as before and after cessation of dosing.

MAIN OUTCOME MEASURES

Changes in serum E2, LH, FSH, P, and ganirelix.

RESULTS

Ganirelix treatment rapidly decreased serum levels of gonadotropins and E2 after both 1 and 2 mg administration. Twenty-four hours after the first dose of ganirelix, E2 decreased from a mean +/- SEM of 50 +/- 8 and 67 +/- 11 pg/mL at baseline to 25 +/- 4 and 20 +/- 3 in the 1 mg and 2 mg groups, respectively. Estradiol remained suppressed (mean levels < 26 pg/mL) on all subsequent 7 days of ganirelix dosing in both groups. After the final dose of ganirelix, there was a rapid return of ovarian function in all volunteers. All women had P levels indicative of ovulation in the subsequent cycle, and the mean number of days from the final ganirelix dose to the next menses was 25.8 +/- 2.1 and 27.3 +/- 1.6 in the 1 and 2 mg groups, respectively.

CONCLUSIONS

Daily ganirelix administration is effective in suppressing the pituitary-gonadal axis and has a side effect profile that should be well tolerated.

Follistatin antagonizes the effects of activin-A on steroidogenesis in human luteinizing granulosa cells

Activin-A decreases progesterone secretion and aromatase activity in cultured human luteinizing granulosa cells. Follistatin is a binding protein for activin and inhibin produced by granulosa cells and present in follicular fluid. The present study examines the hypothesis that follistatin reverses the actions of activin-A on human granulosa cells. Granulosa cells from women undergoing ovarian stimulation for in vitro fertilization were cultured in defined medium with recombinant human (rh) activin-A and purified porcine follistatin. Follistatin completely reversed the inhibition of basal progesterone production by rh-activin-A, but only when added in a greater than 2:1 molar ratio to activin-A. Although variable effects of activin-A on aromatase activity were observed in these studies, follistatin also antagonized these effects. Follistatin had no effect in the absence of added activin-A. rh-Inhibin-A did not alter steroidogenesis by granulosa cells either with or without added activin-A. Even when added in a 45-fold molar excess, inhibin-A did not displace sufficient activin-A from follistatin to inhibit progesterone secretion. This suggests that the affinity of inhibin-A for follistatin is much lower than that of activin-A, and/or that activin-A bound to follistatin dissociates slowly. alpha 2-Macroglobulin, another activin-binding protein, did not alter the inhibition of progesterone production by activin-A. We conclude that in human granulosa cells, follistatin, but not alpha 2-macroglobulin or inhibin-A, acts to modulate the actions of activin-A. Follistatin and activin may be viewed as components of an autocrine/paracrine system within the human follicle that regulate the differentiated functions of granulosa cells.

Endogenous catecholamines augment the inhibitory effect of opioids on luteinizing hormone secretion during the midluteal phase

OBJECTIVE

Our purpose was to test the hypothesis that endogenous catecholamines may interact with endogenous opioid peptides to influence gonadotropin secretion during the midluteal phase in normal women.

STUDY DESIGN

Normal cycling women studied during the midluteal phase were randomized to one of four treatment groups: (1) alpha-methyl-para-tyrosine, (2) naloxone, (3) alpha-methyl-para-tyrosine and naloxone, and (4) control. Mean treatment luteinizing hormone levels were compared by analysis of variance. Pulse frequency, amplitude, and integrated area under the curve were assessed by CLUSTER analysis and compared by means of nonparametric analyses.

RESULTS

Mean luteinizing hormone levels were significantly higher in the naloxone and alpha-methyl-para-tyrosine plus naloxone groups compared with alpha-methyl-para-tyrosine or placebo. Coadministration of alpha-methyl-para-tyrosine and naloxone caused a significant increase in large-burst luteinizing hormone pulses compared with the group receiving naloxone only.

CONCLUSION

Endogenous catecholamines augment the inhibitory effect of opioids on luteinizing hormone secretion during the midluteal phase in normal cycling women.

Variability of serum prolactin and progesterone levels in normal women: the relevance of single hormone measurements in the clinical setting

In order to delineate factors contributing to variation in hormone levels, progesterone and prolactin (PRL) levels from 28 normal women, obtained daily during one menstrual cycle and every 20 minutes during a midluteal 24-hour admission in a subgroup of five subjects, provided a data base for analysis of these variables. Pulsatile analysis of the 24-hour data was conducted using an adaptive-threshold algorithm, and normal reference ranges were generated from randomly selected daily hormone values. Our data verify that inherent variation can significantly alter single random serum levels of reproductive hormones. These variations included menstrual cycle day, circadian influence, pulsatile secretion, assay error, and biologic heterogeneity. Besides the expected day-to-day change in progesterone levels during the luteal phase, seven of ten women exhibited a significant circadian variation in progesterone; however, the time of day of the peak level was not consistent among women. Prolactin levels did not demonstrate any clinically relevant change over the menstrual cycle, but did have a consistent circadian pattern (nocturnal rise) over the 24-hour study period. Pulsatile variation occurred in both progesterone and PRL levels during the 24-hour admission. Five different reference ranges were generated from randomly selected single daily values from the 28 normal menstrual cycles. Although the mean levels calculated for each reference range were similar, the reference ranges demonstrated considerable variation due to the random sampling. In the five progesterone reference ranges, the lower limit of the range varied from 2.7-6.1 ng/mL, whereas the upper limit varied from 24.2-42.1 ng/mL.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of deglycosylated human chorionic gonadotropin on corpora luteal function in healthy women

Fourteen healthy young women were studied through a control and a treatment menstrual cycle in two series of experiments. In the first series, they were given one of four doses of deglycosylated human chorionic gonadotropin (hCG) as a 24-hour infusion during the mid-luteal phase of the cycle. In these studies, there were no significant alterations of the length of the luteal phase of the treatment cycle, and there was no decrease in serum progesterone (P) during the infusion. In fact, serum P increased during the infusion. In the second series of studies, five subjects were given a 48-hour infusion of normal saline during the control cycle, and a 48-hour infusion of deglycosylated alpha-intact beta-hCG during the treatment cycle, both being administered during the mid-luteal phase. Treatment did not alter luteal phase duration and, again, increased serum P. It is concluded that deglycosylated preparations of hCG are not clinically useful as luteinizing hormone antagonists, probably because of residual agonist activity.

Increased adrenocortical responsiveness to exogenous ACTH in oral contraceptive users

To evaluate the effects of changing steroid milieu on adrenocortical function, basal levels and responses of cortisol, 17-hydroxyprogesterone (17PO), androstenedione (A), dehydroepiandrosterone (DHEA), and testosterone to exogenous synthetic ACTH were investigated in six normal women during the early follicular (EF) and midluteal (ML) phases of the menstrual cycle and in five women on an oral contraceptive (OC) agent (35 micrograms ethinyl estradiol and 1 mg ethynodiol diacetate, Demulen). Baseline serum steroid and cortisol binding globulin (CBG) levels were measured on days 3-7 and 21-23 of the menstrual cycle in the normal subjects and on days 3-7 of OC treatment cycles. ACTH stimulation (10 micrograms m-2 i.v. bolus) was performed following dexamethasone suppression (0.5 mg p.o. q 6 h X 4). Basal levels of cortisol and CBG as well as cortisol responses to ACTH were increased in OC users relative to normal women tested during both the EF and ML phases of the cycle. In addition, 17PO levels were increased during the ML phase both before and following dexamethasone suppression compared to levels present in the EF phase and in OC users, no doubt because of increased ovarian steroidogenesis.