Plasma concentrations of human chorionic gonadotropin from the time of implantation until the second week of pregnancy

Navigating Pregnancy Testing in Chronic Pain Management for Women of Reproductive Age

Background

Women of childbearing age often require a nuanced and individualized approach to chronic pain management, especially when pregnancy is a possibility. Interventional procedures involving ionizing radiation, such as fluoroscopy-guided injections, raise specific concerns for fetal safety, including risks of embryo death, congenital anomalies, intellectual disability, and microcephaly. Despite national recommendations from organizations like the American College of Radiology (ACR), implementation of pregnancy screening in the pain management context remains limited.

Methods

This review synthesizes current literature and practice guidelines to assess the gaps in pregnancy screening protocols within chronic pain management settings. It highlights challenges in evaluating pregnancy status before initiating pharmacologic or fluoroscopic procedures, and it examines both biological testing limitations and procedural risks.

Results

Fluoroscopically guided procedures may exceed the teratogenic radiation threshold of 50 mGy, underscoring the critical need for reliable pregnancy screening. While urine and serum hCG tests are widely used, both are susceptible to false negatives and positives due to timing, hormone variants, and analytical interferences. Integrating clinical evaluation with menstrual history, point-of-care testing, and serum confirmation may improve diagnostic accuracy and ensure greater protection for the fetus.

Conclusion and Recommendations

To address safety concerns, this review proposes a structured pregnancy screening algorithm tailored for chronic pain practices. Key recommendations include: routine screening of all reproductive-age women prior to procedures involving radiation or teratogenic medications, use of serum hCG testing when uncertainty exists, optimizing radiation exposure strategies, and clear, informed consent processes outlining fetal risks. Adoption of these best practices may improve clinical consistency and enhance patient safety.

Diagnostic utility of clinicodemographic, biochemical and metabolite variables to identify viable pregnancies in a symptomatic cohort during early gestation

A significant number of pregnancies are lost in the first trimester and 1-2% are ectopic pregnancies (EPs). Early pregnancy loss in general can cause significant morbidity with bleeding or infection, while EPs are the leading cause of maternal mortality in the first trimester. Symptoms of pregnancy loss and EP are very similar (including pain and bleeding); however, these symptoms are also common in live normally sited pregnancies (LNSP). To date, no biomarkers have been identified to differentiate LNSP from pregnancies that will not progress beyond early gestation (non-viable or EPs), defined together as combined adverse outcomes (CAO). In this study, we present a novel machine learning pipeline to create prediction models that identify a composite biomarker to differentiate LNSP from CAO in symptomatic women. This prospective cohort study included 370 participants. A single blood sample was prospectively collected from participants on first emergency presentation prior to final clinical diagnosis of pregnancy outcome: LNSP, miscarriage, pregnancy of unknown location (PUL) or tubal EP (tEP). Miscarriage, PUL and tEP were grouped together into a CAO group. Human chorionic gonadotrophin β (β-hCG) and progesterone concentrations were measured in plasma. Serum samples were subjected to untargeted metabolomic profiling. The cohort was randomly split into train and validation data sets, with the train data set subjected to variable selection. Nine metabolite signals were identified as key discriminators of LNSP versus CAO. Random forest models were constructed using stable metabolite signals alone, or in combination with plasma hormone concentrations and demographic data. When comparing LNSP with CAO, a model with stable metabolite signals only demonstrated a modest predictive accuracy (0.68), which was comparable to a model of β-hCG and progesterone (0.71). The best model for LNSP prediction comprised stable metabolite signals and hormone concentrations (accuracy = 0.79). In conclusion, serum metabolite levels and biochemical markers from a single blood sample possess modest predictive utility in differentiating LNSP from CAO pregnancies upon first presentation, which is improved by variable selection and combination using machine learning. A diagnostic test to confirm LNSP and thus exclude pregnancies affecting maternal morbidity and potentially life-threatening outcomes would be invaluable in emergency situations.

Human chorionic gonadotropin promotes murine Treg cells and restricts pregnancy-harmful proinflammatory Th17 responses

An equilibrium between proinflammatory and anti-inflammatory immune responses is essential for maternal tolerance of the fetus throughout gestation. To study the participation of fetal tissue-derived factors in this delicate immune balance, we analyzed the effects of human chorionic gonadotropin (hCG) on murine Treg cells and Th17 cells in vitro, and on pregnancy outcomes, fetal and placental growth, blood flow velocities and remodeling of the uterine vascular bed in vivo. Compared with untreated CD4⁺CD25⁺ T cells, hCG increased the frequency of Treg cells upon activation of the LH/CG receptor. hCG, with the involvement of IL-2, also interfered with induced differentiation of CD4⁺ T cells into proinflammatory Th17 cells. In already differentiated Th17 cells, hCG induced an anti-inflammatory profile. Transfer of proinflammatory Th17 cells into healthy pregnant mice promoted fetal rejection, impaired fetal growth and resulted in insufficient remodeling of uterine spiral arteries, and abnormal flow velocities. Our works show that proinflammatory Th17 cells have a negative influence on pregnancy that can be partly avoided by in vitro re-programming of proinflammatory Th17 cells with hCG.

Hydatidiform Mole Presents As Pregnancy in a 48-Year-Old Perimenopausal Female: A Case Study

Pregnancy should be suspected whenever a woman in her childbearing years misses a menstrual period. Clinical suspicion is increased if she also reports any sexual activity while not using contraception or is inconsistent in her use of contraception. Laboratory findings that aid in the diagnosis of pregnancy include the detection of human chorionic gonadotropin (hCG) in blood or urine. Hydatidiform mole (HM) is part of a group of diseases classified under gestational trophoblastic disease (GTD), which originate in the placenta and have the potential to locally invade the uterus and metastasize. Although molar pregnancies are designated as benign, they have the potential to develop into a malignancy. In this case study, we present a 48-year-old peri-menopausal female patient, with a 1+ year history of irregular menses, who presented to the clinic with signs and symptoms of pregnancy, unprotected sexual activity, and a positive at-home pregnancy test. Upon further workup of the patient, it was diagnosed that the patient had a hydatidiform molar pregnancy. It is interesting to note that benign gestational trophoblastic diseases generally occur in younger women, of “reproductive age” (generally in their twenties to early thirties), and is extremely rare in peri- and post-menopausal women.

Characterizing the Low-Dose Effects of Methylmercury on the Early Stages of Embryo Development Using Cultured Human Embryonic Stem Cells

BACKGROUND

Global concerns of methylmercury (MeHg) exposure have been raised, especially on its effects on pregnant women. Recent epidemiological studies have revealed associations between maternal blood/hair MeHg concentrations, adverse pregnancy outcomes, and developmental deficits. However, the underlying mechanisms remain unclear.

OBJECTIVES

In this study, we characterized the effects of MeHg exposure on undifferentiated human embryonic stem cells (hESCs) and extrapolated the effects to human embryonic development.

METHODS

hESCs were exposed to 0, 1, 5, 10, 50, 100 or 200nM MeHg for 24 h or 6 d. Cell adherence and colony formation and expansion were examined under the microscope. Cell attachment, viability/proliferation, apoptosis, stress response, cell cycle, autophagy, and expression of cell lineage marker genes and proteins were measured at the end of exposures.

RESULTS

Our results indicated that exposure to nanomolar concentrations of MeHg was associated with a) higher levels of reactive oxygen species (ROS) and hemeoxygenase-1 (HO-1), suggesting increased stress and adaptive responses; b) lower cellular adhesion, viability/proliferation, and colony formation and expansion; c) higher levels of apoptosis, reflected by higher cleaved caspase-3 expression and Annexin V binding; d) higher levels of cytoskeleton protein α-tubulin expression; e) higher rates of G1/S phase cell cycle arrest; and f) autophagy inhibition, as shown by a lower LC3BII/LC3BI ratio and accumulation of SQSTM1 (p62). These outcomes were accompanied by higher expressions of self-renewal genes or proteins or both, including OCT4, SOX2, NANOG, and cytokine receptor IL6ST, as well as pluripotency and the cell fate regulator cyclin D1.

DISCUSSION

These results revealed that under the selection pressure of exposure to low doses of MeHg, some hESCs underwent apoptosis, whereas others adapted and survived with enhanced self-renewal gene expression and specific morphological phenotypes. Findings from the present study provide in vitro evidence that low doses of MeHg adversely affect hESCs when exposed during a period of time that models embryonic pre-, during, and early postimplantation stages. https://doi.org/10.1289/EHP7349.

Exposure to perfluorobutane sulfonate and perfluorooctanesulfonic acid disrupts the production of angiogenesis factors and stress responses in human placental syncytiotrophoblast

Poly- and per-fluoroalkyl substances (PFAS) have attracted widespread attention in recent years due to their bioaccumulation, toxicity, and ubiquitous nature. We and others have reported that maternal exposure to PFAS is associated with adverse birth outcomes due to altered placental functions. In this study, we investigated the effects of two major PFAS compounds, perfluorobutane sulfonate (PFBS) and perfluorooctanesulfonic acid (PFOS), on the regulation of the production of angiogenic factors and stress response in placental multinucleated syncytial BeWo cells using qRT-PCR and ELISA. Using this in vitro model, we showed that 1) PFOS or PFBS treatment did not seem to interrupt BeWo cell fusion through syncytins; 2) Exposure to PFOS at 10 μM decreased a potent angiogenic factor PlGF gene expression, which is implicated in preeclampsia; 3) Exposure to either PFOS or PFBS significantly decreased the production of CGB7 and hCG except hCG secretion in PFOS (10 nM) and PFBS (100 nM) treatment groups; 4) Exposure to PFOS (10 μM) increased the gene expression of the stress response molecules CRH while neither PFOS nor PFBS treatment affected a stress mitigation factor 11β-HSD2 expression. Our results demonstrate that exposure to PFOS or PFBS impacts several key pathways involved in placental cell functions. PFOS seems more potent than PFBS. These novel findings provide a potential explanation for the adverse reproductive complications associated with prenatal exposure to PFOS or PFBS, including preeclampsia and contribute to our knowledge of the reproductive toxicity of PFAS, specifically PFOS and PFBS.

A Review of the Actions of Endogenous and Exogenous Vasoactive Substances during the Estrous Cycle and Pregnancy in Rats

Vascular endothelium plays a key role in regulating cardiovascular homeostasis by controlling the vascular tone. Variations in sex hormones during the reproductive cycle of females affect the homeostasis of the cardiovascular system. Also, the evidence shows that estrogens show a cardioprotective effect. On this basis, this study describes some vascular responses induced by vasoactive substances during the estrous cycle in rats. We obtained the information available on this topic from the online databases that included scientific articles published in the Web of Science, PubMed, and Scielo. Many investigations have evaluated the vasoactive response of substances such as acetylcholine and norepinephrine during the estrous cycle. In this review, we specifically described the vascular response to vasoactive substances in rats during the estrous cycle, pregnancy, and in ovariectomized rats. In addition, we discussed the existence of different signaling pathways that modulate vascular function. The knowledge of these effects is relevant for the optimization and development of new treatments for some vascular pathologies.

Longitudinal study of vascular structure and function during normal pregnancy

OBJECTIVE

To examine alterations in maternal vascular structure and function during normal pregnancy.

METHODS

We assessed brachial and central blood pressure, pulse-wave velocity and augmentation index (by pulse-wave analysis and applanation tonometry), common carotid artery structure (by ultrasonography) and endothelial function in the brachial artery (by postischemic hyperemia-induced flow-mediated vasodilatation by glyceryl trinitrate) and in the forearm skin microcirculation (by laser Doppler perfusion imaging during iontophoretic administration of acetylcholine and sodium nitroprusside) in 52 healthy nulliparous women at 14, 24 and 34 weeks' gestation, and at 9 months postpartum.

RESULTS

During pregnancy, brachial and central systolic and diastolic blood pressures initially decreased but subsequently increased (all P < 0.05). Flow-mediated vasodilatation in the brachial artery increased during early pregnancy (P < 0.05), whereas non-specific vasodilatation by glyceryl trinitrate decreased (P < 0.01), indicating improved endothelial function. Thus, endothelial function index (forearm blood flow/glyceryl trinitrate) increased during pregnancy (0.30 ± 0.18 in the non-pregnant state at 9 months postpartum and 0.51 ± 0.19, 0.61 ± 0.39 and 0.49 ± 0.30 in the first, second and third trimesters, respectively) (P < 0.001). Endothelium-dependent skin microvascular reactivity to acetylcholine also increased (P < 0.01). Carotid-femoral pulse-wave velocity decreased during pregnancy (5.88 ± 0.91 m/s in the non-pregnant state and 5.55 ± 0.67, 5.12 ± 0.66 and 5.62 ± 0.74 m/s in the first, second and third trimesters, respectively) (P < 0.001).

CONCLUSION

During normal pregnancy, the blood volume expansion necessary for sufficient fetal growth is accommodated by early and marked changes in the matvascular system. This seems to be dependent on normal adaptive endothelial and vascular function. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Gestational length assignment based on last menstrual period, first trimester crown-rump length, ovulation, and implantation timing

PURPOSE

Understanding the natural length of human pregnancy is central to clinical care. However, variability in the reference methods to assign gestational age (GA) confound our understanding of pregnancy length. Assignation from ultrasound measurement of fetal crown-rump length (CRL) has superseded that based on last menstrual period (LMP). Our aim was to estimate gestational length based on LMP, ultrasound CRL, and implantation that were known, compared to pregnancy duration assigned by day of ovulation.

METHODS

Prospective study in 143 women trying to conceive. In 71 ongoing pregnancies, gestational length was estimated from LMP, CRL at 10-14 weeks, ovulation, and implantation day. For each method of GA assignment, the distribution in observed gestational length was derived and both agreement and correlation between the methods determined.

RESULTS

Median ovulation and implantation days were 16 and 27, respectively. The gestational length based on LMP, CRL, implantation, and ovulation was similar: 279, 278, 276.5 and 276.5 days, respectively. The distributions for observed gestational length were widest where GA was assigned from CRL and LMP and narrowest when assigned from implantation and ovulation day. The strongest correlation for gestational length assessment was between ovulation and implantation (r = 0.98) and weakest between CRL and LMP (r = 0.88).

CONCLUSIONS

The most accurate method of predicting gestational length is ovulation day, and this agrees closely with implantation day. Prediction of gestational length from CRL and known LMP are both inferior to ovulation and implantation day. This information could have important implications on the routine assignment of gestational age.

Human Decidual Stromal Cells as a Component of the Implantation Niche and a Modulator of Maternal Immunity

The human decidua is a specialized tissue characterized by embryo-receptive properties. It is formed during the secretory phase of menstrual cycle from uterine mucosa termed endometrium. The decidua is composed of glands, immune cells, blood and lymph vessels, and decidual stromal cells (DSCs). In the process of decidualization, which is controlled by oestrogen and progesterone, DSCs acquire specific functions related to recognition, selection, and acceptance of the allogeneic embryo, as well as to development of maternal immune tolerance. In this review we discuss the relationship between the decidualization of DSCs and pathological obstetrical and gynaecological conditions. Moreover, the critical influence of DSCs on local immune cells populations as well as their relationship to the onset and maintenance of immune tolerance is described.

Reference ranges and determinants of total hCG levels during pregnancy: the Generation R Study

Human chorionic gonadotropin (hCG) is a pregnancy hormone secreted by the placental synctiotrophoblast cell layer that has been linked to fetal growth and various placental, uterine and fetal functions. In order to investigate the effects of hCG on clinical endpoints, knowledge on reference range (RR) methodology and determinants of gestational hCG levels is crucial. Moreover, a better understanding of gestational hCG physiology can improve current screening programs and future clinical management. Serum total hCG levels were determined in 8195 women participating in the Generation R Study. Gestational age specific RRs using ‘ultrasound derived gestational age’ (US RRs) were calculated and compared with ‘last menstrual period derived gestational age’ (LMP RRs) and a model-based RR. We also investigated which pregnancy characteristics were associated with hCG levels. Compared to the US RRs, the LMP RRs were lower, most notably for the median and lower limit levels. No considerable differences were found between RRs calculated in the general population or in uncomplicated pregnancies only. Maternal smoking, BMI, parity, ethnicity, fetal gender, placental weight and hyperemesis gravidarum symptoms were associated with total hCG. We provide gestational RRs for total hCG and show that total hCG values and RR cut-offs during pregnancy vary depending on pregnancy dating methodology. This is likely due to the influence of hCG on embryonic growth, suggesting that ultrasound based pregnancy dating might be less reliable in women with high/low hCG levels. Furthermore, we identify different pregnancy characteristics that influence total hCG levels considerably and should therefore be accounted for in clinical studies.

Predicting Embryo Presence and Viability

Pregnancy establishment, followed by birth of live offspring, is essential to all mammals. The biological processes leading up to pregnancy establishment, maintenance, and birth are complex and dependent on the coordinated timing of a series of events at the molecular, cellular, and physiological level. The ability to ovulate a competent oocyte, which is capable of undergoing fertilization, is only the initial step in achieving a successful pregnancy. Once fertilization has occurred and early embryonic development is initiated, early pregnancy detection is critical to provide proper prenatal care (humans) or appropriate management (domestic livestock). However, the simple presence of an embryo, early in gestation, does not guarantee the birth of a live offspring. Pregnancy loss (embryonic mortality, spontaneous abortions, etc.) has been well documented in all mammals, especially in humans and domestic livestock species, and is a major cause of reproductive loss. It has been estimated that only about 25-30% of all fertilized oocytes in humans result in birth of a live offspring; however, identifying the embryos that will not survive to parturition has not been an easy task. Therefore, investigators have focused the identification of products in maternal circulation that permit the detection of an embryo and assessment of its well-being. This review will focus on the advances in predicting embryonic presence and viability, in vivo.

Impact of ovulation and implantation timing on first-trimester crown-rump length and gestational age

OBJECTIVE

To determine the impact of ovulation and implantation timing on first-trimester crown-rump length (CRL) and the derived gestational age (GA).

METHOD

One hundred and forty-three women who were trying to conceive were recruited prospectively. The timing of ovulation and implantation and the ovulation to implantation (O-I) interval were established in 101 pregnancies using home urinary tests for luteinizing hormone and human chorionic gonadotropin. In 71 ongoing pregnancies, GA determined by measurement of fetal CRL at 10-14 weeks' gestation was compared with GA based on ovulation and implantation day. First-trimester growth was determined by serial ultrasound scans at 6-7, 8-9 and 10-14 weeks.

RESULTS

The median ovulation and implantation days were 16 and 27, respectively, with an O-I interval of 11 days. GA estimated from CRL at 10-14 weeks was on average 1.3 days greater than that derived from ovulation timing. CRL Z-score was inversely related to O-I interval (ρ= -0.431, P=0.0009). There was no significant relationship between CRL growth rate and the difference between observed CRL and expected CRL based on GA from last menstrual period (ρ=0.224, P=0.08).

CONCLUSIONS

Early implantation leads to a larger CRL and late implantation to a smaller CRL at 10-14 weeks, independent of CRL growth rate. Implantation timing is a major determinant of fetal size at 10-14 weeks and largely explains the variation in estimates of GA in the first trimester derived from embryonic or fetal CRL.

Early Maternal Serum β-human Chorionic Gonadotropin Measurements After ICSI in the Prediction of Long-term Pregnancy Outcomes: A Retrospective Cohort Analysis

Background

Initial low maternal serum β-human chorionic gonadotropin (β-hCG) is a good predictor of early pregnancy demise. Our objective was to determine its predictive value in determining the long-term outcome in ICSI pregnancies.

Methods

A retrospective cohort study was designed at the Saudi Center for Assisted Reproduction. Two hundred and sixty-one women with ICSI pregnancies were followed up from initial β-hCG level determination till the end of pregnancy. Accuracy of early β-hCG in predicting the occurrence of a live-birth, ongoing pregnancy, late miscarriage, ectopic pregnancy and early miscarriage following ICSI was measured.

Results

β-hCG levels were significantly different in pregnancies that reached the stage of an ongoing pregnancy and live-birth as compared to early pregnancy loss. The ROC curves demonstrated a high sensitivity for identifying patients with ectopic pregnancies and early miscarriage (100% and 93.33% respectively). The remaining results ranged from a sensitivity of 69% to 79% and specificity of 62% to 75%.

Conclusions

In ICSI pregnancies, a single early β-hCG may help to identify pregnancies that will reach full-term and delivery.

Keywords

ICSI; Human chorionic gonadotropin; Outcome; Pregnancy

Home pregnancy test compared to standard-of-care ultrasound dating in the assessment of pregnancy duration

OBJECTIVE

To determine the level of agreement between the Clearblue Digital Pregnancy Test with Conception Indicator home pregnancy test and standard-of-care ultrasound in assessing pregnancy duration in a real-life, observational setting encompassing routine, clinical care.

RESEARCH DESIGN AND METHODS

This was a prospective observational study of non-pregnant women seeking conception. Women collected daily urine samples from day 1 of their next menstrual cycle. If any volunteer became pregnant, daily urine samples continued to be collected for 43 days after the LH surge. Samples from day -7 to day +28 relative to the expected period (LH surge + 15 days) were tested using the home pregnancy test. This categorised any resulting pregnancies into one of three groups: 1-2 weeks, 2-3 weeks, and 3+ weeks since conception. Information from the standard UK ultrasound dating scan was also recorded by the midwife, including the expected delivery date according to ultrasound and the expected delivery date according to LMP.

MAIN OUTCOME MEASURES

Full data were available from 52 pregnant women who had conceived naturally. During the study analysis, 4786 urine samples were cross-compared with 52 routine 12-week NHS ultrasound assessments and the level of agreement between home pregnancy testing and standard-of-care ultrasound in determining pregnancy duration was calculated.

RESULTS

The agreement between the gestational age as calculated by the home pregnancy test result and the exact midwife-recorded gestational age using ultrasound was 82.3%. However, when a ± 5-day range was applied to the ultrasound reading (as per routine UK clinical practice), the level of agreement was 98%.

CONCLUSIONS

The home pregnancy test provides a significantly high (98%) level of agreement with standard-of-care ultrasound when assessing pregnancy duration in a real-life, observational setting which closely mirrors daily clinical practice.

Novel use of a urine pregnancy test using whole blood

We present the case of a 35-year-old woman with hypotension and abdominal tenderness after acute vomiting and syncope. The patient had been breast-feeding since the birth of a child 8 months earlier, was not yet menstruating, and felt that she was having a reaction to sushi. She was unable to provide a urine sample during initial evaluation, and a drop of whole blood was therefore applied to a qualitative urine human chorionic gonadotropin point-of-care test. This test result was positive for pregnancy, ultrasound revealed free fluid in the abdominal cavity, and emergency laparotomy by our gynecologists confirmed ruptured ectopic pregnancy. Often, patients are too unstable or dehydrated to provide a urine sample; and serum human chorionic gonadotropin testing may be difficult to obtain in a timely fashion. This use of the point-of-care urine qualitative test has not been previously described and may be valuable in cases where rapid diagnosis is critical.

Ectopic pregnancy treatment by laparoscopy, a short glimpse

Ectopic pregnancy is a life-threatening emergency, the incidence of which is increasing globally. There are a number of factors predisposing to this condition; today, the most common of these is salpingitis. Due to advancements in diagnostic technology it is possible to diagnose this condition early and thus try to achieve a favourable outcome for the patient. Treatment options in the form of medical and surgical modalities are widely available. As minimally invasive therapy techniques are rapidly advancing, laparoscopic treatment has become the most popular and preferred method for treating ectopic pregnancy. Both salpingotomy as well as salpingectomy can be performed through the laparoscope. This paper gives a short glimpse at the predisposing factors and the diagnostic investigations available for ectopic pregnancy and an insight into its laparoscopic treatment. It also reviews the pregnancy outcome and laparoscopic treatment of cases at the Department of Obstetrics and Gynaecology, Campus Kiel, University Hospitals Schleswig-Holstein.

Serum biomarkers of tubal ectopic pregnancy: current candidates and future possibilities

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.

Case report: elevated serum beta human chorionic gonadotropin in a woman with osteosarcoma

Human chorionic gonadotropin is a glycoprotein hormone normally synthesized by placental syncytiotrophoblast cells. It also is secreted by gestational trophoblastic tumors, gonadal tumors, and even various nongonadal tumors, including bone and soft tissue sarcomas, as a paraneoplastic syndrome. The literature contains one case report of beta human chorionic gonadotropin production from a primary bone sarcoma occurring in a male patient. We report a woman of childbearing age who presented with a distal femur lytic lesion, clinical symptoms suggestive of pregnancy, and elevated serum beta human chorionic gonadotropin. Although the clinical diagnosis of a sarcoma was never in doubt, we present this case to emphasize a need to exclude pregnancy in women of childbearing age to avoid delay in biopsy and subsequent management. Positive immunohistochemical staining of the biopsy specimen established the tumor cells as the source of beta human chorionic gonadotropin.

Urinary hCG patterns during the week following implantation

BACKGROUND

Human chorionic gonadotrophin (hCG) is used to monitor pregnancy status. Yet the pattern of hCG excretion in the first week following implantation has not been adequately described. Therefore the aim of this study was to describe the average profile of hCG and its variability during the 7 days following estimated implantation in a population of naturally conceived pregnancies.

METHODS

We measured daily hCG concentrations in first-morning urine for 142 clinical pregnancies from women with no known fertility problems. Mixed-effects regression models were used to estimate the hCG trajectory and its variability in relation to pregnancy outcomes.

RESULTS

hCG rose 3-fold between the day of detection and the next day (95% CI = 2.7-3.4). The relative rate of rise decreased thereafter, reaching 1.6-fold (95% CI = 1.5-1.8) between days 6 and 7. HCG levels followed a log-quadratic trajectory, and the patterns of rise were unrelated to number of fetuses, risk of spontaneous abortion or sex of the baby. Later implantations (after 10 luteal days) produced slower rates of increase.

CONCLUSIONS

Although mean hCG follows a log-quadratic trajectory during the first week of detectability, there is high variability across pregnancies. Later implantation may reflect characteristics of the uterus or conceptus that slow hCG production.

Human chorionic gonadotropin profile for women with ectopic pregnancy

OBJECTIVE

To analyze serial human chorionic gonadotropin (hCG) levels in women presenting to the emergency department who were ultimately confirmed to have ectopic pregnancies.

METHODS

Human chorionic gonadotropin levels were obtained over time until definitive diagnosis. To be included, women had to have at least 2 hCG measurements. Human chorionic gonadotropin curves were characterized and their slopes calculated.

RESULTS

Two hundred women received diagnoses of ectopic pregnancy with the help of serial hCG values and were included in the study. No curve adequately characterized the pattern of hCG values so attention was focused on the initial 2 values. The median slope of log hCG among all subjects was 0.11 (25% increase in 2 days). However, 60% of subjects had an initial rise in hCG, and 40% had an initial fall. The rise in hCG for women with ectopic pregnancies (0.28; 75% increase in 2 days) was slower than the mean increase reported for a viable intrauterine pregnancy. The decline in hCG for women with ectopic pregnancies (-0.225; 27% decline in 2 days) was slower than the mean reported for completed spontaneous abortion. However, 20.8% of women presented with a rise in hCG values similar to the minimal rise for women with a viable gestation, and 8% of women presented with a fall in hCG values similar to women with a completed spontaneous abortion.

CONCLUSION

There is no single way to characterize the pattern of hCG for ectopic pregnancy. The number of women with ectopic pregnancy who experience an increase in hCG values is approximately equal to the number of those who experience a decrease. The hCG profile in women with ectopic pregnancy can mimic that of an intrauterine pregnancy or a completed spontaneous abortion in approximately 29% of cases.

LEVEL OF EVIDENCE

II-2.

Early serum β-human chorionic gonadotropin in pregnancies after in vitro fertilization: contribution of treatment variables and prediction of long-term pregnancy outcome

OBJECTIVE

Low initial serum beta hCG is a good predictor of early pregnancy failure. We sought to determine the contribution of treatment variables and the predictive value of early serum beta hCG after IVF on long-term pregnancy outcome.

DESIGN

A retrospective case-control study.

SETTING

An academic IVF unit.

PATIENT(S)

Five hundred thirty-three IVF cycles performed between 1999 and 2004, which resulted in a positive serum beta hCG level (> 10 mIU/mL) on day 13 after embryo transfer (ET).

INTERVENTION(S)

The study group included 281 pregnancies with initial beta hCG < or = 150 mIU/mL on day 13 after ET. Randomly selected 252 IVF cycles with initial beta hCG > 150 mIU/mL comprised the control group. Characteristics of the patients and the treatment protocols were analyzed using logistic regression, Pearson's chi-square, and Fisher's exact test.

MAIN OUTCOME MEASURE(S)

Primary pregnancy outcome was defined as favorable when a fetal pulse was detected, testifying to a viable gestation. Unfavorable outcome referred to chemical or ectopic pregnancies, as well as spontaneous abortions. Additionally, the two groups were followed throughout gestation. Secondary pregnancy outcome was based on the following parameters: gestational age at delivery, method of delivery, and birth weight.

RESULT(S)

Poor primary pregnancy outcome was encountered in 64.8% of the study group and in 22.2% of the control group. Predictors of unfavorable primary pregnancy outcome were older age, use of a short protocol, and shorter than anticipated crown-rump length. No difference was found in the secondary pregnancy outcome between the groups. Preterm labor was more prevalent in the study group, but the difference did not reach statistical significance.

CONCLUSION(S)

Pregnancy viability can be predicted by measuring serum beta hCG as early as on day 13 after ET. Older age, use of a short protocol, and shorter than anticipated crown-rump length are associated with early pregnancy loss. Of those who reach delivery, no significant adverse outcome is anticipated in IVF pregnancies with low initial serum beta hCG.

Cryopreserved embryo transfers suggest that endometrial receptivity may contribute to reduced success rates of later developing embryos

OBJECTIVE

To evaluate viability and implantation potential of cryopreserved blastocysts according to the day of blastocyst expansion and cryopreservation.

DESIGN

Retrospective study.

SETTING

Private ART center.

PATIENT(S)

Three hundred and seventy-five patients undergoing embryo transfer with cryopreserved blastocysts.

INTERVENTION(S)

Blastocyst cryopreservation on day 5, 6, or 7 after oocyte retrieval according to the day of blastocyst expansion and subsequent embryo transfer.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate (PR) per embryo transfer.

RESULT(S)

Clinical PRs were similar between blastocysts cryopreserved on day 5 and blastocysts cryopreserved on day 6 (32% vs. 28%). The clinical PR was lower for blastocysts cryopreserved on day 7 (15%), but this difference was not statistically significant after accounting for the number of embryos per transfer (P=.15).

CONCLUSION(S)

Viability and implantation potential are similar for day 5 and day 6 blastocyst cryopreservation. Viability may be reduced for blastocysts cryopreserved on day 7, but not to the extent suggested by reports of fresh transfers. These results suggest that reduced success rates associated with fresh transfers of later developing blastocysts may be the result of asynchrony with endometrial receptivity instead of poorer embryo quality.

The classification, functions and clinical use of different isoforms of HCG

HCG is composed of two subunits, HCGalpha and HCGbeta. During early pregnancy, HCG stimulates progesterone production in the corpus luteum, and injection of HCG is widely used to induce ovulation in assisted reproduction treatment (ART). Under experimental conditions, the free subunits have been shown to exert functions other than those of HCG, but the relevance of these remains to be determined. Intact HCG, free subunits and degraded forms of these occur in biological fluids, and determinations of these are important for diagnosis and monitoring of pregnancy, pregnancy-related disorders and several types of cancer. Development of optimal methods for the various forms has been hampered by lack of appropriate standards and expression of the concentrations of the various forms in units that are not comparable. Furthermore, the nomenclature for HCG assays is confusing and in some cases misleading. These problems can now be solved; a uniform nomenclature has been established, and new standards are available for HCG, its subunits HCGalpha and HCGbeta, the partially degraded or nicked forms of HCG and HCGbeta, and the beta-core fragment. This review describes the biochemical and biological background for the clinical use of determinations of various forms of HCG. The clinical use of HCG and studies on HCG vaccines are briefly reviewed.

Application of redefined human chorionic gonadotropin curves for the diagnosis of women at risk for ectopic pregnancy

OBJECTIVE

To validate recently characterized curves of hCG rise and fall that are seen in viable and nonviable pregnancies in a population of women who have pregnancies of unknown location.

DESIGN

Historical cohort study.

SETTING

University hospital.

PATIENT(S)

One thousand two hundred forty-nine women with symptomatic early pregnancies.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Comparison of observed hCG values to predicted hCG values; time to diagnosis of ectopic pregnancy; accuracy of diagnosis.

RESULT(S)

Of the 1,249 patients included in this study, 196 had ectopic pregnancy (EP); 261, intrauterine pregnancy (IUP); and 792, spontaneous abortion (SAB). By determining the rate of change in hCG values from two consecutive visits and comparing them with a minimal rise of 35% in 2 days (the bound that is defined by the 99.9% confidence interval [CI] for the rise of hCG in an IUP) or a minimal fall of 21%-35% (the bound that is defined by the 90% CI for the fall of hCG in an SAB), we were able to make the diagnosis of EP an average of 2.5 days sooner than by standard clinical practice. Only 12% of patients had an EP go undiagnosed by using these rules, because the curve of rise or fall of their hCG mimicked that of a non-EP gestation.

CONCLUSION(S)

Recently redefined curves of rise and fall in hCG for IUP and SAB are valid for clinical use on the basis of our application to this large cohort of patients. Using them can shorten the time needed to make the diagnosis of EP. Use of a more conservative cutoff for minimal rise in hCG, one as slow as 35% over 2 days, to characterize a potentially viable gestation would minimize potential interruption of a desired pregnancy.

Optimizing hCG cut-off values: a single determination on day 14 or 15 is sufficient for a reliable prediction of pregnancy outcome

OBJECTIVE

Optimizing the cut-off level for a single serum hCG determination around day 15 after oocyte retrieval or ovulation.

STUDY DESIGN

Retrospective data analysis.

RESULTS

204 hCG samples >5 IU/L between March and October 1999 taken on day 14, 15 or 16 after oocyte retrieval in 204 patients undergoing IVF or ICSI were analyzed. ROC-curves and optimal cut-off levels to discriminate between viable and non-viable pregnancies were calculated for each day separately. Cut-off levels were found at 76, 142 and 223 IU/L for day 14, 15 and 16, respectively, and were verified by 487 hCG samples >5 IU/L taken between January 2000 and June 2004.

CONCLUSIONS

A single serum hCG determination on day 14 or 15 is sufficient to discriminate viable pregnancies accurately from non-viable pregnancies.

Endometrial receptivity: Clinical assessment in relation to fertility, infertility, and antifertility

Fertility in humans and other mammalian species depends absolutely on synchronous events that render the developing blastocyst and the receiving uterus competent for implantation. Endometrial receptivity is defined as the period during which the endometrial epithelium acquires functional, but transient, ovarian steroid-dependent status supportive to blastocyst acceptance and implantation. Once inside the uterus, the blastocyst is surrounded by an intact luminal epithelium, which is considered to act as barrier to its attachment, except for this short period of high endometrial receptivity to blastocyst signal(s). Its transport and permeability properties, in conjunction with cellular action of the endometrium and the embryo, have been suggested to influence creation and maintenance of informational and nutritional status of uterine luminal milieu. This period, also termed as the 'window of implantation,' is limited to days 20-24 of menstrual cycle in humans. However, establishment of endometrial receptivity is still a biological mystery that remains unsolved despite marked advances in our understanding of endometrial physiology following extensive research associated with its development and function. This review deals with various structural, biochemical, and molecular events in the endometrium coordinated within the implantation window that constitute essential elements in the repertoire that signifies endometrial receptivity and is aimed to achieve a better understanding of its relationship to fertility, infertility, and for the development of targeted antifertility agents for human use and welfare.

Effect of fetal gender on maternal serum human chorionic gonadotropin levels throughout pregnancy

OBJECTIVES

Maternal serum human chorionic gonadotropin (MshCG) levels are higher in pregnant women with female fetuses than in pregnant women with male fetuses in the third trimester of pregnancy. Our aim was to examine the effect of fetal sex on MshCG levels throughout the pregnancy.

MATERIALS AND METHODS

Twenty-nine uncomplicated pregnancies (14 had male fetus and 15 had female fetus) were included in the study. MshCG levels were measured four times between 8-12, 14-18, 24-28 and 32-36 weeks of pregnancy.

RESULTS

MshCG levels were significantly higher in both sexes between 8-12 weeks than the other three measurement periods. At 8-12 and 14-18 weeks measurements, there were no sex related differences in the MshCG levels. At 24-28 (P<0.004) and 32-36 (P<0.001) weeks MshCG levels were significantly higher in pregnancies bearing female fetuses than those bearing male fetuses.

CONCLUSIONS

Fetal gender has a significant effect on MshCG levels in the third trimester of pregnancy. Accordingly, no correlation seems to exist in the first and second trimesters.

Intact HCG, free HCG beta subunit and HCG beta core fragment: longitudinal patterns in urine during early pregnancy

BACKGROUND

Detecting and monitoring early pregnancy depend on the measurement of HCG. Little is known about how production of various forms of HCG may evolve over the earliest weeks of pregnancy, particularly in naturally conceived pregnancies.

METHODS

We describe the daily excretion of three urinary HCG analytes during the first 6 weeks post-conception in 37 naturally conceived pregnancies ending in singleton birth. We assayed daily first morning urine samples for intact HCG, free beta subunit and beta?core fragment, plus the combined measurement of these HCG forms. We calculated doubling times for each analyte and the inter- and intra-subject day-to-day variation.

RESULTS

Intact HCG and the free beta subunit were initially the predominant forms of HCG, with the beta core fragment emerging as the predominant form in the fifth week after conception. Intact HCG and the free beta subunit showed the most day-to-day variability, and were transiently undetectable even 10 days after detection of pregnancy. The most stable estimate of doubling time was provided by the combined measurement of all these forms.

CONCLUSIONS

Although intact HCG is usually regarded as the main analyte for detection and monitoring of early pregnancy, it can fluctuate markedly during early pregnancy. This variability could affect pregnancy test results based on early pregnancy urine, and may distort estimates of doubling time. Assays that combine several forms of HCG may be more reliable.

Decline of serum human chorionic gonadotropin and spontaneous complete abortion: defining the normal curve

OBJECTIVE

We sought to estimate a standard curve of serum human chorionic gonadotropin (hCG) decline that characterizes spontaneous abortion.

METHODS

Data were extracted from a clinical database of women with symptomatic early pregnancies and nondiagnostic ultrasonography who required follow-up with serial hCG levels. The evaluation was restricted to women who had a pregnancy of unknown location, a decrease in serum levels, and who were ultimately diagnosed with miscarriage (a decrease in serum hCG to < 5 mIU/mL in the absence of surgical intervention or confirmation of products of conception after dilation and curettage). The starting point of the curve was the hCG concentration at presentation, with serial levels plotted until the time of definitive diagnosis. Semiparametric statistical techniques were used to characterize the shape of the curve. We present slopes for the decrease in log hCG levels and the projected rate of fall.

RESULTS

Of the 1,543 patients, 710 were diagnosed with miscarriage. A quadratic curve for log hCG with a steeper rate of decline for large initial hCG values best described the pattern of change. One curve could not fully estimate the decline because the rate was dependent on the initial hCG level. In other words, more rapid decline was associated with a higher starting concentration. The rate of decline ranged from 21% to 35% at 2 days and 60% to 84% at 7 days, depending on initial hCG value.

CONCLUSION

The rate of hCG decrease in spontaneous abortions is described by a quadratic profile, with a faster decline in hCG value with higher presentation levels. A rate of decline less than 21% at 2 days or 60% at 7 days suggests retained trophoblasts or an ectopic pregnancy.

Symptomatic patients with an early viable intrauterine pregnancy: HCG curves redefined

OBJECTIVE

To analyze the change in serial human chorionic gonadotropin (hCG) levels in women symptomatic with pain or bleeding who presented with nondiagnostic ultrasonography but were ultimately confirmed to have a viable intrauterine pregnancy.

METHODS

The rise in serial hCG measures were modeled over time, with the start point defined in 2 ways: by last menstrual period and by date of presentation for care. Both semiparametric (spline) curves and linear random-effects models were explored. The slope and projected increase of hCG were calculated to define 99% of viable intrauterine pregnancies.

RESULTS

A total of 287 subjects met inclusion criteria and contributed 861 measurements of hCG. On average, these subjects contributed 3.00 observations and were followed up for 5.25 days. A linear increase in log hCG best described the pattern of rise. Curves derived from last menstrual period and day of presentation do not differ substantially. The median slope for a rise of hCG after 1 day was 1.50, (or a 50% increase); 2.24 after 2 days (or a 124% rise), and 5.00 after 4 days. The fastest rise was 1.81 at 1 day, 3.28 at 2 days, and 10.76 at 4 days. The slowest or minimal rise for a normal viable intrauterine pregnancy was 24% at 1 day and 53% at 2 days.

CONCLUSION

These data define the slowest rise in serial hCG values for a potentially viable gestation and will aid in distinguishing a viable early pregnancy from a miscarriage or ectopic pregnancy. The minimal rise in serial hCG values for women with a viable intrauterine pregnancy is "slower" than previously reported, suggesting that intervention to diagnosis and treat an abnormal gestation should be more conservative.

Luteal phase treatment with mifepristone and misoprostol for fertility regulation

Emergency contraception (EC) with 10 mg mifepristone can prevent pregnancy up to 5 days after a single act of unprotected intercourse. No methods have been shown to be effective when treatment is administered more than 5 days after a single unprotected act or after several unprotected acts. Therefore, we tested, among 699 Chinese women requesting EC and exposed to the risk of pregnancy described, the potential of 100 mg mifepristone followed 2 days later by 0.4 mg misoprostol orally, when administered in the luteal phase of the cycle. At the time of treatment urinary pregnancy test had to be negative. Despite treatment, 25 women (2.7%) became pregnant. Among women with treatment delayed more than 5 days, the pregnancy rate was related to the number of acts of intercourse before treatment, being 1.4% with one episode and increasing to 6.5% when the number of episodes was two or more (relative risk = 4.62, 95% CI: 1.06-20.18). Side effects within a week after treatment were mild, and most women (57.2%) had menstruation within 3 days as expected. An occasional treatment with mifepristone in combination with misoprostol could provide an option for preventing unwanted pregnancies in women who are late for EC.

Physiological range of human chorionic gonadotropin for support of early human pregnancy

OBJECTIVE

To determine the physiological range of hCG in early pregnancy.

DESIGN

Retrospective study of patient charts.

SETTING

Magee-Women's Hospital IVF clinic, Monroeville, Pennsylvania.

PATIENT(S)

Sixty patients with successful, singleton birth outcomes.

INTERVENTION(S)

Serum hCG measurements on days 12-16 post-oocyte retrieval (OR).

MAIN OUTCOME MEASURE(S)

Lowest values, highest values, mean values, quartile mean values, and 48-hour doubling times for days 12-16 post-OR.

RESULT(S)

The average production of hCG in successful pregnancies is roughly 4-fold greater than the lowest amount observed in successful pregnancies, suggesting that a considerable excess of hCG is normally produced. Additionally, the average doubling time is almost 2-fold greater than the slowest doubling rate.

CONCLUSION(S)

The data from this study provide a set of values for the minimum and maximum threshold of hCG for days 12-16 post-OR that may be physiologically required, although not entirely predictive, for a successful IVF pregnancy outcome.

Corpus luteum response to exogenous HCG during the mid-luteal phase of the menstrual cycle

OBJECTIVE

To assess a range of exogenous HCG regimes designed to simulate the endocrine environment occurring in biochemical, single and multiple pregnancies and to study the response of the corpus luteum to those regimes.

DESIGN

Prospective clinical study.

PATIENTS

Twenty-five normally cycling women aged 24-35 years were given one of four regimes of HCG injections designed to mimic the HCG concentrations found following spontaneous implantation. Regimes A, B, C and D were designed with starting HCG doses of 60, 140, 250 and 1000 iu, respectively. The daily HCG injections were then increased to give a doubling concentration every 30 h for regime A, every 27 h for regime B, every 24 h for regimes C and D. HCG administration was started on either days 7 or 8 after the LH peak.

MEASUREMENTS

Plasma HCG and progesterone concentrations.

RESULTS

Subjects given regime A failed to demonstrate any rescue of the corpus luteum despite low-detectable amounts of HCG in the circulation equivalent to those seen in some biochemical pregnancies. In contrast, subjects given regimes B and C demonstrated prompt increases in progesterone secretion immediately after the first HCG injection achieving HCG and progesterone concentrations in plasma similar to those seen in normal singleton pregnancies. Subjects given regime D also showed rapid rescue of the corpus luteum but this time achieved plasma HCG concentrations in the range normally seen in multiple pregnancies. All subjects in regimes B, C and D secreted significantly higher amounts of progesterone than those in regime A (P<0.001). However, despite the greater amounts of HCG used in regime D, the amount of progesterone produced was not significantly different from regimes B or C.

CONCLUSIONS

The exogenous HCG regimes used in this study successfully mimicked the hormonal environment found in biochemical, single and multiple pregnancies and elicited appropriate corpus luteum responses.

An update on the medical treatment of ectopic pregnancy

Medical treatment of ectopic pregnancy with methotrexate has been shown to be effective and safe in appropriate patients. When considering medical management, the definitive diagnosis of an ectopic pregnancy and the assurance that the patient is a candidate are of paramount concern. An understanding of the mechanism of action and pharmacokinetics of methotrexate allows the clinician to better inform patients, recognize and treat side effects, and be cognizant when treatment is unsuccessful. Two common protocols, the "multi-dose" and the "single-dose" protocols, have excellent success rates; however, neither one of these is completely effective. The "multi-dose" protocol appears to have a higher success rate than the "single-dose" protocol.

The roles of clinical assessment, human chorionic gonadotropin assays, and ultrasonography in medical abortion practice

The clinical assessment of patients who request early medical abortion includes confirmation of the diagnosis of pregnancy and estimation of gestational age. Accurate gestational dating is essential, because the efficacies of medical abortion regimens decline as pregnancy advances. Whereas medical abortion researchers in the United States have relied on routine ultrasonography for gestational dating, abortion providers experienced with mifepristone and prostaglandin regimens outside the United States have reported high efficacy and safety primarily with clinical dating parameters. Diligent follow-up of patients allows clinicians to confirm that complete abortion has occurred without complications. In cases of uncertain outcome or suspected ectopic pregnancy, transvaginal ultrasonography and beta-human chorionic gonadotropin assays can assist in prompt diagnosis and management. As medical abortion with mifepristone and misoprostol becomes more prevalent in the United States, studies will be needed to further evaluate the effects of these modalities on medical abortion outcomes.

Preliminary results on the role of embryonic human chorionic gonadotrophin in corpus luteum rescue during early pregnancy and the relationship to abortion and ectopic pregnancy

The precise mechanisms by which corpus luteum (CL) function is modulated during early pregnancy are not known. Evidence in failed pregnancies (ectopic, abortions), shows that factors other than human chorionic gonadotrophin (HCG) could be involved in its regulation. The objective of this study was to investigate the dynamics of beta-HCG, progesterone and oestradiol production in early pregnancy and its relation to embryonic quality and topographic localization. Plasma concentrations of progesterone, oestradiol and beta-HCG were studied between days +12 and +21 after an in-vitro fertilization (IVF) embryo transfer in 11 intrauterine pregnancies, 10 intrauterine abortions and seven tubal pregnancies. Tubal pregnancies and abortions were grouped according to doubling time (DT) of HCG. Results showed that oestradiol concentrations were apparently reduced in both ectopic pregnancies and abortions compared with normal pregnancies. The fall in oestradiol concentrations was seen in ectopic pregnancies with an abnormal DT for HCG and in all abortions. When the ectopic pregnancy had a normal DT, oestradiol and progesterone concentrations were normal. In abortions, the fall in oestradiol and progesterone concentrations was less influenced by the DT of HCG. These findings suggest that corpus luteum function depends on an adequate DT of HCG more than an absolute value, and with normal trophoblastic tissue the site of implantation does not affect CL function.

Endometrial estrogen and progesterone receptor and pinopode expression in stimulated cycles of oocyte donors

OBJECTIVE

To study the effect of controlled ovarian hyperstimulation and the ovarian response on several features of endometrial morphology simultaneously.

DESIGN

Prospective controlled study.

SETTING

Academic infertility center.

PATIENT(S)

Twenty-five oocyte donors undergoing COH and 10 ovulatory controls.

INTERVENTION(S)

Endometrial biopsies during the luteal phase and measurement of serum E2 and progesterone levels on days 12, 13, and 18-20.

MAIN OUTCOME MEASURE(S)

Endometrial morphology as judged by histologic dating, pinopode expression, and estrogen and progesterone receptor content.

RESULT(S)

Controlled ovarian hyperstimulation caused the early expression of endometrial features as judged by histologic dating criteria, estrogen and progesterone receptor expression, and the timing of pinopode expression in many of the subjects. A significant correlation within subjects with regard to their particular result on any one measure (e.g., histologic examination) and the others (e.g., estrogen and progesterone receptors, pinopodes) was observed. Those with higher levels of progesterone the day after hCG administration exhibited the most prematurity of morphologic features.

CONCLUSION(S)

Many controlled ovarian hyperstimulation cycles are associated with synchronous early expression of the expected pattern of histologic features, estrogen and progesterone receptors, and pinopodes. The most predictive feature of this premature expression was the level of progesterone the day after hCG administration.

Analysis of implantation in assisted reproduction through the use of serial human chorionic gonadotropin measurements

PURPOSE

Our purpose was to examine implantation of singleton pregnancies achieved following various assisted reproductive technologies (ARTs) through the appearance and rising titers of serum human chorionic gonadotropin (hCG) levels.

METHODS

A total of 114 singleton pregnancies resulting from in vitro fertilization and intrauterine insemination was analyzed. Patients were divided into five groups according to the type of ovarian stimulation protocol [gonadotropin stimulation with/without the use of gonadotropin-releasing hormone agonist (GnRHa), long protocol, or flare-up technique] and to the day of embryo transfer (day 2 or day 3 after oocyte retrieval). Serial serum hCG levels were measured between 10 and 25 days after fertilization and log-transformed. Linear regression analyses were performed and extrapolated to hCG = 10 mIU/ml (hCG10), which was used as an estimate of detectable implantation. The slopes of the regression lines were used to estimate the rising speed of hCG.

RESULTS

There were no significant differences in the days of hCG in maternal serum to reach 10 mIU/ml (implantation) or in the slopes of the regression lines for all five studied groups.

CONCLUSIONS

The appearance of hCG in maternal serum was used to assess the time of clinically detectable implantation. Furthermore, because hCG production is a marker of trophoblastic activity, its serum doubling time was used as an indicator of embryo quality. Results showed that in various ART protocols with and without GnRHa, there were no significant differences in implantation time or embryo quality. Embryo development in early pregnancy follows a preprogrammed-timing schedule and depends mainly on the embryonic age of the healthy, successfully implanted conceptus.

Disappearance of human chorionic gonadotropin and its α- and β-subunits after term pregnancy

We have used high-specificity and precision immunofluorometric assays to measure the elimination half-times of human chorionic gonadotropin (hCG), hCGα, and hCGβ in serum over 21 days after delivery in six women with term pregnancies. Baseline concentrations and half-times were calculated with the use of a curve-fitting algorithm for multiexponential decay. In contrast to the two-component model, a three-component exponential function with baseline provided a fit for which predicted values could not be distinguished from the observed values by analysis of variance. Median half-times were 3.6, 18.0, and 53.0 h for hCG; 1.0, 23.4, and 194 h for hCGβ; and 0.6, 6.2, and 21.9 h for hCGα. The mean ratio of hCGα to hCG decreased rapidly from 36.9% to 3.3% on day 3; thereafter it increased to 64.3% 21 days after delivery because of a higher baseline concentration of hCGα. hCGβ had the slowest total elimination rate, and the ratio of hCGβ to hCG in serum increased from 0.8% before delivery to 26.7% after 21 days. If the metabolism of hCG and hCGβ is similar in patients with trophoblastic disease, the ratio of hCGβ to hCG must be evaluated with caution in samples taken several days after initiating therapy. We conclude that the disappearance of hCGβ from plasma is slower than previously recognized and that the ratios of hCGβ or hCGα to intact hCG vary as a function of postpartum time. Such information may be important in clinical studies of pregnancy disorders.

Human chorionic gonadotropin hormone prevents wasting syndrome and death in HIV-1 transgenic mice

At birth, transgenic mice, homozygous for the HIV-1 provirus pNL4-3, deleted in gag/pol, are normal in appearance and weight. Within several days after birth, the pups develop a syndrome characterized by dry, scaly, hyperkeratotic skin, growth failure, and death. The possibility that the homozygous embryos are being protected during gestation by a maternal factor led us to treat the newborn animals with various pregnancy-related hormones including human chorionic gonadotropin (hCG), estrogen, progesterone, and dexamethasone. Treatment with hCG prevented death, led to normal growth, and markedly reduced skin lesions. In contrast to the skin of the untreated homozygous pups, which expressed high levels of HIV mRNA and proteins (i.e., gp120 and Nef), the skin of the hCG-treated pups showed a marked reduction in both HIV mRNA and proteins. Discontinuation of hCG resulted in the reappearance of HIV transcripts and proteins, skin lesions, and growth failure resulting in death. In addition, HIV transcripts and proteins were reduced significantly in heterozygous mothers during pregnancy, but reappeared after parturition. Similarly, hCG treatment resulted in a decrease of HIV proteins in the skin of nonpregnant heterozygous transgenic mice. These findings suggest that the inhibiting effect of hCG on HIV expression may be clinically useful in the treatment of HIV infections, and may be responsible, during pregnancy, for the low transmission of HIV from infected mothers to their offspring.