The efficacy of early pregnancy monitoring with serial chorionic gonadotropin determinations and real-time sonography in an infertility population

NRAS mutant E132K identified in young-onset sporadic colorectal cancer and the canonical mutants G12D and Q61K affect distinct oncogenic phenotypes

Recent data show a global increase in colorectal cancer (CRC) cases among younger demographics, which portends poorer prognosis. The cause of rising incidence is uncertain, and its mutational landscape remains largely unexplored, including those in genes of the epidermal growth factor receptor pathway. Among these are NRAS mutants where there is paucity of functional studies compared to KRAS. Here, the novel NRAS mutant E132K, identified in three tumor samples from Filipino young-onset, sporadic colorectal cancer patients, was investigated for its effects on different cancer hallmarks, alongside the NRAS canonical mutants G12D and Q61K which are yet poorly characterized in the context of CRC. The novel NRAS mutant E132K and the canonical G12D and Q61K mutants show resistance to apoptosis, cytoskeletal reorganization, and loss of adhesion. In contrast to activating KRAS mutations, including the analogous KRAS G12D and Q61K mutations, all three NRAS mutants have no apparent effect on cell proliferation and motility. The results highlight the need to characterize isoform- and mutation-specific oncogenic phenotypes which can have repercussions in disease management and choice of therapeutic intervention. Further analyses of young-onset versus late-onset CRC datasets are necessary to qualify NRAS E132K as a biomarker for the young-onset subtype.

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

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.

The rate at which serum total beta-subunit human chorionic gonadotropin increases after embryo transfer is a predictor of the viability of pregnancy and an identifier of determinants of pregnancy

OBJECTIVE

To determine whether elements of treatment associated with faster doubling times of total beta-hCG in serum (beta-t2) in pregnant patients are also associated with a higher likelihood of pregnancy in all patients.

DESIGN

Retrospective analysis of beta-t2 values, elements of ovarian stimulation (COH), and outcomes.

SETTING

Private assisted reproductive technology (ART) center.

PATIENT(S)

Initial analysis of data from 432 cycles in which conception occurred after COH and embryo transfer, followed by analysis of pregnancy outcomes after 1,287 cycles of COH/ embryo transfer.

INTERVENTION(S)

No interventions.

MAIN OUTCOME MEASURES

The beta-t2 values initially computed from consecutive serum beta-hCG levels in ongoing pregnancies were correlated with multiple properties of the patients and their treatment cycles.

RESULT(S)

The beta-t2 values during early pregnancy increased exponentially from about 1.6 days at 12 days to about 3.0 days at 24 days after embryo transfer. In those pregnancies which spontaneously aborted, early average beta-t2 values were higher than those for ongoing pregnancies; absolute beta-hCG levels did not differ. Positive correlations were established between beta-t2 values, the number of days of stimulation, and the number of ampules of drug administered per oocyte retrieved. The beta-t2 values were inversely related to average numbers of blastomeres in transferred embryos. Ongoing pregnancy rates (PR) were higher for cycles with lower gonadotropin dosages per oocyte retrieved, and when the average number of blastomeres in transferred embryos was higher.

CONCLUSION(S)

Steeper beta-hCG doubling times in early pregnancy were associated with lower gonadotropin dosages during ovarian stimulation and with higher numbers of blastomeres in transferred embryos. The latter variables were, in turn, associated with a higher likelihood of pregnancy after embryo transfer.

Prediction of early pregnancy outcomes

OBJECTIVE

A prospective study was performed on the conception hormones of early pregnancy in order to examine their sensitivity and predictability for early pregnancy loss.

METHODS

The serum levels of progesterone, estradiol and human chorionic gonadotropin (hCG) were measured and analyzed at 5-8 weeks of gestation in pregnancies occurring both with and without ovarian stimulation.

RESULTS

If a level of < 10 ng/ml of progesterone was chosen as the cut-off value for the prediction of early pregnancy loss, the sensitivity and specificity were 56% and 98%, respectively. The optimal cut-off value was chosen at < 0.5 multiples of the median (MoM) and < 0.4 MoM for estradiol and hCG, respectively. This gave a sensitivity of 80% for estradiol and 85% for hCG, and a specificity of 93% for estradiol and 81% for hCG at week 8 of gestation.

CONCLUSION

The combined determination of conception hormones is an efficacious method of monitoring early pregnancy and may be used for predicting outcome.

Relative operating characteristic analysis in reproductive medicine: comparison of progesterone and human chorionic gonadotropin doubling time as predictors of early gestational normalcy

OBJECTIVE

To directly compare the ability of serum P and hCG doubling time to predict early gestational complications.

DESIGN

We analyzed differences in P concentrations and hCG doubling times between spontaneously conceived normal and abnormal pregnancies (abortions and tubal pregnancies) during the first 49 days of pregnancy. Multiple 2 x 2 contingency tables were constructed that compared pregnancy outcome within discriminatory serum P concentrations or hCG doubling time. From these tables relative operating characteristic curves were generated for P concentration and hCG doubling times. The area under the curves were estimated and compared by the critical z score.

RESULTS

Calculation of the areas under the curve for hCG doubling time and P concentration yielded values of 0.799 +/- 0.056 and 0.780 +/- 0.051 (mean +/- SEM), respectively. Critical z testing did not reveal a significant difference between the two curves.

CONCLUSION

Serum P and hCG doubling times equally predict early gestational normalcy. Thus, a single serum P may be just as valuable in estimating risks of early pregnancy complications as repeated hCG measurements.

Serum progesterone predicts abnormal gestations in clomiphene citrate conception cycles as well as in spontaneous conception cycles

OBJECTIVE

To determine if a "discriminatory" P concentration could be established that predicted abnormal early pregnancies in clomiphene citrate (CC)-conceived cycles.

DESIGN

Progesterone concentrations of gestations between 28 and 49 days from last menstrual period in both spontaneously conceived and CC-stimulated cycles were analyzed using a relative-operating characteristic (ROC) curve.

INTERVENTIONS

Serum P concentrations were measured in 222 pregnant patients from the first 49 days of gestation. One hundred sixteen patients conceived in a spontaneous cycle and 106 patients conceived in CC-treated cycles. Two by two contingency tables were used to calculate the true-positive (sensitivity) and false-positive rates at 20 specific P at 20 specific P concentrations. A ROC curve was then generated by plotting the sensitivity of the test against the percent of normal patients incorrectly classified (false positive) at each P level. The best discriminatory value was estimated in each curve at a point of high sensitivity associated with a minimal false-positive value. The areas under the curve and SE were calculated for each group and compared by the critical ratio z-test.

RESULTS

The best discriminatory P concentration was 10 ng/mL (32 nmol/L) for spontaneously conceived pregnancies and 30 ng/mL (95 nmol/L) for CC-treated pregnancies. The area under each ROC curve was significantly predictive. Comparison of the two curves indicated that the ability of P measurements to predict gestational complications was independent of follicular stimulation.

CONCLUSIONS

Follicular stimulation with CC increases the discriminatory P value that predicts gestational normalcy but does not alter the clinical utility of the test.

Hormonal profiles of early gestations with abnormal karyotype

OBJECTIVE

To describe the hormonal profiles of chromosomally abnormal pregnancies during the first trimester.

DESIGN

A prospective study from 1984 through 1990 in which infertility patients who conceived were monitored weekly with serum E2, P, and beta-hCG levels.

SETTING

The infertility practice at Rush-Presbyterian-St. Luke's Medical Center in Chicago, Illinois.

PATIENTS

Study included 15 women who had dilatation and curettage for first trimester fetal losses with confirmed abnormal karyotype, 6 women with chromosomally normal male abortuses, and 60 consecutive women whose pregnancies yielded normal term infants.

RESULTS

After natural conception, E2 demonstrated a moderate rise in both normal and chromosomally abnormal pregnancies to approximately 300 pg/mL by day 29 (6 weeks of gestation). In normal gestations, E2 continued a steady increase to exceed the level of 1,000 pg/mL by day 64 (11 weeks of gestation). In chromosomally abnormal pregnancies, the mean E2 plateaued and remained at approximately 200 pg/mL until fetal demise was noted. In stimulated conceptions, the rise of E2 was sharp and early (1,200 pg/mL by day 29); in normal pregnancies, E2 steadily increased to an average of 1,400 pg/mL by the end of the first trimester, whereas in karyotypically abnormal gestations, E2 declined to approximately 200 pg/mL by day 64. In pregnancies yielding a male abortus, a sharp decline and plateau at 800 pg/mL by day 56 (10 weeks of gestation) was observed. In both natural and stimulated normal pregnancies, hCG levels first demonstrated a linear rise, followed by a curvilinear increase from day 29 until day 56, with a peak of approximately 110,000 mIU/mL. The beta-hCG in chromosomally abnormal pregnancies, as well as in pregnancies yielding a male abortus, was characterized by a slow and gradual rise to a maximum of 40,000 mIU/mL, which remained relatively linear until day 64 when fetal demise was detected in all cases. Progesterone level data were excluded from analysis because of frequent P supplementation.

CONCLUSIONS

There were significant differences in the hormonal profiles of chromosomally normal and abnormal pregnancies. Serial measurements of serum E2 and beta-hCG from the 6th week of gestation may be useful in predicting an abnormal karyotype sooner than other current diagnostic tests.

Further observations on the doubling time of human chorionic gonadotropin in early asymptomatic pregnancies

The doubling time (DT) of human chorionic gonadotropin (hCG) in serum was investigated retrospectively using serial serum hCG values that had been obtained from asymptomatic pregnant women with a prior history of infertility. The DT of hCG did not increase significantly as pregnancy advanced during the period in gestation when the serum hCG concentration was less than 10,000 mIU/mL (International Reference Preparation). Serum hCG concentrations increased subnormally in 2 of 60 women with normal intrauterine pregnancies, 5 of 8 women with asymptomatic ectopic pregnancies (EPs), and in 2 of 8 asymptomatic women who subsequently aborted their pregnancies. Neither the sensitivity nor the specificity of serial hCG testing for EP was enhanced by adopting different test criteria at different serum hCG concentrations.

Some endocrinological events associated with early pregnancy failure

Serial measurements of serum progesterone, oestradiol, human chorionic gonadotrophin (hCG) and human placental lactogen (hPL) have been determined in 33 women experiencing early pregnancy failure and compared with the values of the same hormones in 72 healthy women having uncomplicated pregnancies. Steroid production by the corpus luteum seemed similar in both groups up to 6 weeks gestation but thereafter placental steroidogenesis was not evident in those women in whom spontaneous pregnancy losses occurred. Placental production of the two protein hormones, hCG and hPL, did take place, and whereas the circulating levels were not as high as in normal pregnancies, levels did usually increase before clinical evidence of miscarriage occurred. hCG was not a sensitive discriminator of subsequent failure. In these women there were no significant hormone differences between those with evidence of a fetus and those without.

Transvaginal ultrasonography for the diagnosis of ectopic pregnancy

The transvaginal (TVU) and transabdominal (TAU) ultrasound approaches were compared in their ability to identify by direct visualization the adnexal mass of ectopic pregnancy. There were 22 patients who had a surgically proven ectopic pregnancy. The TAU approach identified the adnexal mass in 50% and the TVU approach in 91% of the patients (P less than 0.01). Below both previously reported threshold titers for the expected TAU intrauterine sac visualization, at 6500 mIU and 3600 mIU, respectively, the TVU approach allowed the identification of significantly more ectopic adnexal masses than the TAU approach. The results of the present study demonstrate the increased efficacy of TVU over TAU in the direct identification of the adnexal mass associated with ectopic gestation.

Serum beta-human chorionic gonadotropin levels relate poorly with the size of a tubal pregnancy

Ectopic implantation usually begins with relatively normal growth of trophoblast and serum beta-hCG progression. However, the trophoblast eventually erodes into vessels and a variable degree of bleeding and hematoma compromises its growth. The serum beta-hCG level then usually begins to demonstrate some degree of abnormal progression. For our patients, the length of the ectopic pregnancy varied widely, depending mainly on when the individual patient chose to seek medical treatment. Infertility patients followed from the moment of conception would thus be expected to show a better correlation between early beta-hCG levels and the size of the tubal pregnancy. Preconditions for the operative laparoscopic management of a tubal pregnancy usually include that the tube be unruptured, less than 3 cm in diameter, and readily accessible via the laparoscopic approach. Ackerman et al. suggested there was a general correlation between the serum beta-hCG level and tubal rupture, and the present data demonstrate an overall positive correlation between the size of the tubal pregnancy and the serum level. However, the range of levels is so broad for any given size of mass or tubal status that this correlation is not meaningful clinically. A reliable method to determine the size and status of a tubal pregnancy before laparoscopy would be valuable. Unfortunately, we did not find the preoperative serum beta-hCG level to be useful for making this prediction.

First-trimester serum levels of the beta-subunit of human chorionic gonadotropin in a tubal molar pregnancy

A woman is described in whom the levels of the beta-subunit of human chorionic gonadotropin were rising in a pattern consistent with a tubal pregnancy. A tubal molar pregnancy was found. Thus an early ectopic molar pregnancy is not distinguishable from a nontrophoblastic tubal pregnancy on the basis of human chorionic gonadotropin levels.