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Alabiad MA, Said WMM, Gad AH, Sharaf ElDin MTA, Khairy DA, Gobran MA, Shalaby AM, Samy W, Abdelsameea AA, Heraiz AI. Evaluation of Different Doses of the Aromatase Inhibitor Letrozole for the Treatment of Ectopic Pregnancy and Its Effect on Villous Trophoblastic Tissue. Reprod Sci 2022; 29:2983-2994. [PMID: 35701686 PMCID: PMC9537218 DOI: 10.1007/s43032-022-00993-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 05/29/2022] [Indexed: 11/26/2022]
Abstract
Letrozole, an aromatase inhibitor, has recently been introduced as a favorable medical treatment for ectopic pregnancy. We aimed at evaluating the effects of different doses of letrozole for termination of ectopic pregnancy and study their effects on villous trophoblastic tissue. Sixty patients with undisturbed ectopic pregnancy were classified into three equal groups. Group I: the control group that contained women who underwent laparoscopic salpingectomy, Group II: patients who received letrozole (5 mg day−1) for 10 days, and Group III: patients who received letrozole (10 mg day−1) for 10 days. Subsequently, the β-hCG levels were determined on the first day and after 11 days of treatment. Group IV consisted of patients of GII and GIII; their β-hCG did not drop below 100 mIU/ml within 11 days, and underwent salpingectomy. Placental tissues from patients undergoing salpingectomy either from the control group or GIV were processed for the evaluation of estrogen (ER) and progesterone (PR) receptors, vascular endothelial growth factor (VEGF), and cleaved caspase 3 (CC-3) expression. Cases exposed to high dose letrozole 10 mg day−1 resulted in a higher ectopic pregnancy resolution rate of 85% (17/20), while the resolution rate of the low dose letrozole-treated group (5 mg day−1) was 65% (13/20), and also showed a significant reduction in β-hCG levels on the 11th day, 25.63 ± 4.29 compared to the low dose letrozole group 37.91 ± 7.18 (P < 0.001), Meanwhile, the letrozole-treated group GIV showed markedly reduced expression of ER, PR, and VEGF and a significant increase in the apoptotic index cleaved caspase-3 compared to the control group (P < 0.001). The utilization of letrozole at a dose of 10 mg day−1 for medical treatment of ectopic pregnancy results in a high-successful rate without any severe side effects. Letrozole depriving the placenta of estrogen that had vascular supporting signals resulted in destroying the vascular network with marked apoptosis.
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Affiliation(s)
- Mohamed Ali Alabiad
- Department of Pathology, Faculty of Medicine, Zagazig University, Zagazig, 44519 Egypt
| | - Warda M. M. Said
- Department of Pathology, Faculty of Medicine, Benghazi University, Benghazi, Libya
| | - Abdalla Hassan Gad
- Department of Gynecology and Obstetrics, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | | | - Dina Ahmed Khairy
- Department of Biomedical Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Mai Ahmed Gobran
- Department of Pathology, Faculty of Medicine, Zagazig University, Zagazig, 44519 Egypt
| | - Amany Mohamed Shalaby
- Department of Histology and Cell Biology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Walaa Samy
- Department of Medical Biochemistry and Molecular Biology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | | | - Ahmed Ismail Heraiz
- Department of Gynecology and Obstetrics, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Zou S, Li X, Feng Y, Sun S, Li J, Egecioglu E, Billig H, Shao R. Comparison of the diagnostic values of circulating steroid hormones, VEGF-A, PIGF, and ADAM12 in women with ectopic pregnancy. J Transl Med 2013; 11:44. [PMID: 23421942 PMCID: PMC3585714 DOI: 10.1186/1479-5876-11-44] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 02/07/2013] [Indexed: 11/17/2022] Open
Abstract
Background Several peripheral proteins that might be useful for detecting the presence of ectopic pregnancy (EP) have been evaluated, but none have been proven entirely useful in the clinic. We investigated the presence and the possible changes in circulating molecules that distinguish between normal intrauterine pregnancy (IUP) and tubal ectopic pregnancy. Methods Non-pregnant women during the menstrual cycle, women with IUP, and women with tubal EP after informed consent. Serum levels of 17β-estradiol (E2), progesterone (P4), testosterone (T), beta-human chorionic gonadotropin (β-hCG), vascular endothelial growth factor-A (VEGF-A), placental growth factor (PIGF), and a distintegrin and metalloprotease protein 12 (ADAM12) were analyzed. Receiver operating characteristic analysis was used to assess the diagnostic discrimination of EP and gestational age-matched IUP. Results E2, P4, PIGF, and ADAM12 levels increased and β-hCG decreased throughout IUP. E2 and VEGF-A levels were significantly different between women with tubal EP and IUP. However, using a serum β-hCG cut-off of less than 1000 mIU/mL, P4 was significantly lower in women with tubal EP compared to IUP. Although E2 was inversely correlated with VEGF-A in women in the early stages of IUP, E2 was not correlated with VEGF-A in women with EP prior to tubal surgery. There were no significant differences in either PIGF or ADAM12 alone between women with tubal EP or IUP. Although no significant correlations were seen between E2 and PIGF or P4 and ADAM12 in women in the early stages of IUP, E2 was positively correlated with PIGF and P4 was positively correlated with ADAM12 in women with EP prior to tubal surgery. Our studies defined associations but not causality. Conclusions Individual measurements of serum E2 or VEGF-A levels are strongly related to early pregnancy outcomes for women with IUP and EP, and pregnancy-associated E2 and VEGF-A levels provide diagnostic accuracy for the presence of tubal EP. This study demonstrates that correlation analysis of E2/VEGF-A and E2/PIGF serum levels may be able to distinguish a tubal EP from a normal IUP.
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Affiliation(s)
- Shien Zou
- Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai 200011, China
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Kutluer G, Ciçek NM, Moraloğlu O, Ertargın P, Sarıkaya E, Artar I, Erdem O. Low VEGF expression in conceptus material and maternal serum AFP and β-hCG levels as indicators of defective angiogenesis in first-trimester miscarriages. J Turk Ger Gynecol Assoc 2012; 13:111-7. [PMID: 24592019 DOI: 10.5152/jtgga.2012.06] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Accepted: 12/18/2011] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The aims of this study were to assess the relationship between early miscarriages and vascular endothelial growth factor (VEGF) expression and to determine the serum levels of first-trimester maternal alpha-fetoprotein (AFP) and human chorionic gonadotropin (β-hCG) as markers of angiogenesis and predictors of abortion and intrauterine fetal loss. MATERIAL AND METHODS The present study was a prospective, single-center, randomized controlled clinical trial. Ninety-five women who were 6-10 weeks pregnant between May and June 2010 were included in the study. The subjects were divided into three groups, i.e., incomplete abortion (IA) (n=31), intrauterine death (IU-D) (n=32) and control (elective pregnancy termination) (n=32). Feto-placental materials were compared based on immune staining for VEGF in the pathology laboratory, and maternal serum samples were tested in the hormone laboratory. RESULTS Serum β-hCG levels in the patient groups were significantly lower than the controls (p=0.001). The serum AFP level was lower than the controls in the IA group while it was higher than the controls in the IU-D (p=0.016). Immunohistochemistry showed that the cytotrophoblast, syncytiotrophoblast and endometrial gland epithelium were weakly stained for VEGF in the patient groups (IA and IU-D) in comparison to the control group (p=0.06, p=0.028, p=0.006). CONCLUSION Early pregnancy losses are related to insufficient angiogenesis, and maternal serum AFP and β-hCG can be used as markers of angiogenesis in the first trimester.
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Affiliation(s)
- Gülşen Kutluer
- Department of Perinatology and Family Planning, Zekai Tahir Burak Women's Health Resource and Education Hospital, Ankara, Turkey
| | - Nedim Mahmut Ciçek
- Department of Perinatology and Family Planning, Zekai Tahir Burak Women's Health Resource and Education Hospital, Ankara, Turkey
| | - Ozlem Moraloğlu
- Department of Perinatology and Family Planning, Zekai Tahir Burak Women's Health Resource and Education Hospital, Ankara, Turkey
| | - Pervin Ertargın
- Department of Perinatology and Family Planning, Zekai Tahir Burak Women's Health Resource and Education Hospital, Ankara, Turkey
| | - Esma Sarıkaya
- Department of Perinatology and Family Planning, Zekai Tahir Burak Women's Health Resource and Education Hospital, Ankara, Turkey
| | - Ishak Artar
- Department of Perinatology and Family Planning, Zekai Tahir Burak Women's Health Resource and Education Hospital, Ankara, Turkey
| | - Ozlem Erdem
- Department of Pathology, Faculty of Medicine, Gazi University, Ankara, Turkey
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Reid S, Casikar I, Barnhart K, Condous G. Serum biomarkers for ectopic pregnancy diagnosis. ACTA ACUST UNITED AC 2012; 6:153-65. [DOI: 10.1517/17530059.2012.664130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Ugurlu EN, Ozaksit G, Karaer A, Zulfikaroglu E, Atalay A, Ugur M. The value of vascular endothelial growth factor, pregnancy-associated plasma protein-A, and progesterone for early differentiation of ectopic pregnancies, normal intrauterine pregnancies, and spontaneous miscarriages. Fertil Steril 2009; 91:1657-61. [DOI: 10.1016/j.fertnstert.2008.02.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2007] [Revised: 02/04/2008] [Accepted: 02/04/2008] [Indexed: 11/16/2022]
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Cartwright J, Duncan WC, Critchley HOD, Horne AW. Serum biomarkers of tubal ectopic pregnancy: current candidates and future possibilities. Reproduction 2009; 138:9-22. [PMID: 19321656 DOI: 10.1530/rep-09-0060] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ectopic pregnancy remains a considerable cause of maternal morbidity and mortality worldwide. Currently, it is diagnosed using a combination of transvaginal ultrasound and serial serum beta-human chorionic gonadotrophin levels. Diagnosis is often delayed and these tests are time-consuming and costly, both psychologically to the patient and financially to health services. The development of a biomarker that can differentiate a tubal ectopic from an intrauterine implantation is therefore important. In the pre-genomic era, a one-by-one scientific approach has revealed over 20 candidate biomarkers that could be used as a test to diagnose ectopic pregnancy although at present their clinical utility is very limited. These biomarkers cluster into themes: markers of abnormal embryo/trophoblast growth, markers of abnormal corpus luteum function, markers of a growing pregnancy in the Fallopian tube, markers of inflammation and peritoneal irritation, and uterine markers of normal implantation. It is likely that this thematic approach will facilitate the identification of newer biomarkers using microarray technology and inform the development of investigative paradigms using multiple markers at the time of presentation.
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Affiliation(s)
- Joanna Cartwright
- Division of Reproductive and Developmental Sciences, Simpson Centre for Reproductive Health, The University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SB, UK
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Abstract
The incidence of ectopic pregnancies is increasing, which may be related to better diagnostic tools as well as the increasing use of assisted reproductive technologies. However, the signs and symptoms of ectopic pregnancy can be similar to other complications of early pregnancy such as miscarriage. Diagnosis often requires serial human chorionic gonadotropin levels along with ultrasound and, in some cases, dilation and curettage. Once a diagnosis has been made, treatment options include medical therapy with methotrexate and surgery, which can often be performed via the laparoscope. Fertility rates after therapy are similar for both medically and surgically treated patients.
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Affiliation(s)
- Jennifer L Kulp
- University of Pennsylvania Medical Center, Penn Fertility Care, Department of Obstetrics and Gynecology, 3701 Market St. Suite 810, Philadelphia, PA 19104, USA
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Early serum interleukin-8 evaluation may prove useful in localizing abnormally implanted human gestations after in vitro fertilization. Fertil Steril 2008; 90:2068-72. [DOI: 10.1016/j.fertnstert.2007.10.063] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2007] [Revised: 10/08/2007] [Accepted: 10/08/2007] [Indexed: 11/19/2022]
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Kirk E, Bourne T. Predicting Outcomes in Pregnancies of Unknown Location. WOMENS HEALTH 2008; 4:491-9. [DOI: 10.2217/17455057.4.5.491] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A pregnancy of unknown location (PUL) is a descriptive term used to classify a woman when she has a positive pregnancy test but no intra- or extra-uterine pregnancy is visualized on transvaginal sonography. Expectant management has been shown to be safe for the majority of women with a PUL. Serum progesterone and human chorionic gonadotrophin levels as well as mathematical models play a role in predicting the final outcomes of PULs, which include intrauterine pregnancy, failing PUL and ectopic pregnancy. Other possible predictors of outcome have been studied, but currently no factor has been identified that combines accuracy with reproducibility and simplicity. This article discusses the various aspects of the management of women with PULs. Future work should be aimed at prospectively testing current models in order to predict the outcome of a PUL and minimizing follow-up.
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Affiliation(s)
- Emma Kirk
- Early Pregnancy & Gynaecology Ultrasound Unit, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK, Tel.: + 44 79 7421 4125; Fax: +44 20 8725 0094
| | - Tom Bourne
- Early Pregnancy & Gynaecology Ultrasound Unit, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK, Tel.: + 44 79 7421 4125; Fax: +44 20 8725 0094
- Department of Obstetrics & Gynaecology, University Hospital Gasthuisberg, KU Leuven, Belgium
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Coppus SFPJ, van der Veen F, Bossuyt PMM, Mol BWJ. Quality of reporting of test accuracy studies in reproductive medicine: impact of the Standards for Reporting of Diagnostic Accuracy (STARD) initiative. Fertil Steril 2006; 86:1321-9. [PMID: 16978620 DOI: 10.1016/j.fertnstert.2006.03.050] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2005] [Revised: 03/28/2006] [Accepted: 03/28/2006] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the extent to which test accuracy studies published in two leading reproductive medicine journals in the years 1999 and 2004 adhered to the Standards for Reporting of Diagnostic Accuracy (STARD) initiative parameters, and to explore whether the introduction of the STARD statement has led to an improved quality of reporting. DESIGN Structured literature search. Articles that reported on the diagnostic performance of a test in comparison with a reference standard were eligible for inclusion. For each article we scored how well the 25 items of the STARD checklist were reported. These items deal with the study question, study participants, study design, test methods, reference standard, statistical methods, reporting of results, and conclusions. We calculated the total number of reported STARD items per article, summary scores for each STARD item, and the average number of reported STARD items per publication year. SETTING Not applicable. PATIENT(S) Not applicable. INTERVENTION(S) Not applicable. MAIN OUTCOME MEASURE(S) Quality of reporting. RESULT(S) We found 24 studies reporting on test accuracy in reproductive medicine in 1999 and 27 studies in 2004. The mean number of reported STARD items for articles published in 1999 was 12.1 +/- 3.3 (range 6.5-20) and 12.4 +/- 3.2 (range 7-17.5) in 2004, after publication of the STARD statement. Overall, less than half of the studies reported adequately on 50% or more of the STARD items. The reporting of individual items showed a wide variation. There was no significant improvement in mean number of reported items for the articles published after the introduction of the STARD statement. CONCLUSION(S) Authors of test accuracy studies in the two leading fertility journals poorly report the design, conduct, methodology, and statistical analysis of their study. Strict adherence to the STARD guidelines should be encouraged.
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Affiliation(s)
- Sjors F P J Coppus
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, the Netherlands.
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Abstract
Women who present with pain and bleeding in the first trimester are at risk for ectopic pregnancy, a life-threatening condition. Conditions that predispose a woman to ectopic pregnancy are damaged fallopian tubes from prior tubal surgery or previous pelvic infection, smoking, and conception using assisted reproduction. Many women without risk factors can develop an ectopic pregnancy. A diagnostic algorithm that includes the use of transvaginal ultrasonography, human chorionic gonadotropin (hCG) concentrations, and, sometimes, uterine curettage can definitively diagnose women at risk in a timely manner. The absence of an intrauterine pregnancy above an established cut point of hCG is consistent with an abnormal pregnancy but does not distinguish a miscarriage from an ectopic pregnancy. When the initial hCG value is low, serial hCG values can be used to determine whether a gestation is potentially viable or spontaneously resolving. The minimal rise in hCG for a viable pregnancy is 53% in 2 days. The minimal decline of a spontaneous abortion is 21-35% in 2 days, depending on the initial level. A rise or fall in serial hCG values that is slower than this is suggestive of an ectopic pregnancy. Women diagnosed with an unruptured ectopic pregnancy are potential candidates for medical management with methotrexate. Intramuscular injection with methotrexate can be used to safely treat an ectopic pregnancy with success rates, tubal patency rates, and future fertility that are similar to those obtained with conservative surgery. Success rates using methotrexate are inversely rated to baseline hCG values and are higher using "multidose" compared with "single-dose" regimens. Surgical treatment may be conservative or definitive and should be attempted in most cases via laparoscopy.
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Affiliation(s)
- Beata E Seeber
- Department of Obstetrics and Gynecology, Penn Fertility Care, Philadelphia, PA 19003, USA
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Daponte A, Pournaras S, Zintzaras E, Kallitsaris A, Lialios G, Maniatis AN, Messinis IE. The value of a single combined measurement of VEGF, glycodelin, progesterone, PAPP-A, HPL and LIF for differentiating between ectopic and abnormal intrauterine pregnancy. Hum Reprod 2005; 20:3163-6. [PMID: 16055453 DOI: 10.1093/humrep/dei218] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND To evaluate whether serum concentrations of the non-placental markers vascular endothelial growth factor (VEGF), glycodelin (GLY) and progesterone (P) and the novel placental markers pregnancy-associated plasmaprotein A (PAPP-A), human placental lactogen (HPL) and leukaemia inhibiting factor (LIF) differ in ectopic pregnancy (EP) when compared with abnormal intrauterine pregnancy (aIUP). METHODS A prospective clinical study was conducted at the University Hospital of Larissa, Greece. The study included 50 patients admitted with failed pregnancy and suspected ectopic pregnancy that were treated with curettage or laparoscopy and classified as histologically confirmed EPs (n = 27) or histologically confirmed aIUPs (n = 21) (mean gestational age of 7.15 and 7.3 weeks, respectively). Two suspected EPs proved to be normal IUPs and were excluded. VEGF, GLY, P, beta-HCG, PAPP-A, HPL and LIF were measured by enxyme-linked immunosorbent assay (ELISA) methods in a single pre-operative blood sample. RESULTS The median VEGF concentration was 227.2 pg/ml in the EP group versus 107.2 pg/ml in the aIUP group (P < 0.001), with a suggested threshold value of 174 pg/ml for their differential diagnosis. LIF, P, PAPP-A, HPL and GLY serum measurements did not differ significantly between EP and aIUP. CONCLUSION VEGF serum levels might be a useful marker in differentiating between EPs and aIUPs.
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Affiliation(s)
- A Daponte
- Department of Obstetrics and Gynaecology, University of Thessalia, Larissa, Greece
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