Glucocorticoid treatment decreases sera embryotoxicity in endometriosis patients

Effect of low-dose dexamethasone on patients with elevated early follicular phase progesterone level and pregnancy outcomes in IVF-ET treatment: A randomized controlled clinical trial

OBJECTIVE

To evaluate the effect of low-dose dexamethasone on patients with elevated early follicular progesterone levels in IVF-ET treatment.

DESIGN

Randomized controlled trial.

SETTING

In vitro fertilization (IVF) centre.

PATIENT(S)

A total of 459 patients undergoing a first IVF/ICSI cycle.

INTERVENTION(S)

If progesterone concentration exceeded 1.9 nmol/L on days 3-4 of ovarian stimulation, the patients in dexamethasone (DEX) group were treated with oral dexamethasone 0.75 mg/d, and the patients in control group received no extra treatment.

MAIN OUTCOME MEASURE

The cumulative live-birth rate (per cycle started) in 2 years.

RESULTS

The total dose of gonadotropins (1987 ± 536 IU in DEX group vs 2135 ± 701 IU in control group, P = 0.009) and the serum concentrations of progesterone on human chorionic gonadotropin (HCG) day (3.1 ± 1.4 nmol/L in DEX group vs 4.0 ± 1.3 nmol/L in control group, P < 0.001) were both significantly lower in DEX group than that in control. No significant differences between the two groups were observed in the number of oocytes, two pronuclear (2PN) embryos and clinical pregnancy rate. In addition, the cumulative live-birth rate was significantly higher in the DEX group than that in controls (70.0% vs 61.1%, P = 0.029, 95% confidence interval: 1.01-2.19).

CONCLUSION(S)

Progesterone secretion can be suppressed by dexamethasone, and dexamethasone may sensitize the ovary to gonadotropin stimulation in IVF treatment. In addition, the cumulative live-birth rate was significantly higher in the DEX group than in controls, and the obstetric and neonatal outcomes support the safety of DEX treatment in IVF.

Effect of Natural Cycle Endometrial Preparation for Frozen-Thawed Embryo Transfer in Patients with Advanced Endometriosis

Background

The aim of this study was to investigate the effect of natural cycle (NC) endometrial preparation for frozen-thawed embryo transfer (FET) in women with advanced endometriosis.

Material/Methods

This retrospective study included 179 patients with stage III–IV endometriosis who underwent 233 FET cycles at a tertiary care academic reproductive medical center between March 2011 and August 2013 (group A). The control group included 258 patients with tubal factor infertility who underwent 300 FET cycles (group B). Both groups were prepared for FET using a NC protocol. Rates of implantation, clinical pregnancy, live birth, ongoing pregnancy, miscarriage, and pregnancy complication were recorded.

Results

The implantation rate (A: 36.0%, B: 30.4%, P=0.06), the pregnancy rate (A: 50.2%, B: 45.3%, P=0.263), and the live birth rate (A: 39.91%, B: 39.0%, P=0.428) were similar between the stage III–IV endometriosis and tubal factor infertility groups. No differences were observed in ongoing rates of pregnancy, miscarriage, and pregnancy complications, independent of endometriosis severity. No congenital birth defects were found. When high-quality embryos are transferred, pregnancy results were not affected by active endometriosis. Although severe endometriosis did not affect birth rate, higher frequencies of premature delivery (mean gestational age A: 37 weeks, B: 38.3 weeks, P=0.044) and low birth weight were observed (<2500 g A: 26.4%, B: 16.6%, P=0.047).

Conclusions

There was no difference in pregnancy outcomes between patients with endometriosis and those with tubal infertility. Pregnancy outcomes in patients with endometriosis were not affected by endometriosis severity. Pregnancy outcomes were not affected by active endometrial cyst.

Dexamethasone attenuates the embryotoxic effect of endometriotic peritoneal fluid in a murine model

PURPOSE

The in vitro fertilization (IVF) pregnancy rate of women with advanced stage endometriosis is nearly half that of the general population, suggesting incomplete targeting of the pathophysiology underlying endometriosis-associated infertility. Compelling evidence highlights inflammation as the etiologic link between endometriosis and infertility and a potential target for adjunctive treatment. The objective of this study was to examine the effect of dexamethasone on murine embryos exposed to human endometriotic peritoneal fluid (PF) using the established murine embryo assay model.

METHODS

PF was obtained from women with and without severe endometriosis. Murine embryos were harvested and randomly allocated to five groups of culture media conditions: (1) human tubal fluid (HTF), (2) HTF and 10 % PF from women without endometriosis, (3) HTF and 10 % PF from women with endometriosis (PF-E), (4) HTF with PF-E and 0.01 mcg/mL dexamethasone, and (5) HTF with PF-E and 0.1 mcg/mL dexamethasone. Embryos were cultured in standard conditions and evaluated for blastocyst development.

RESULTS

A total of 266 mouse embryos were cultured. Baseline blastulation rates were 63.6 %. The addition of peritoneal fluid from women with endometriosis decreased the blastocyst development rate to 38.9 % (P = 0.008). The addition of 0.1 mcg/mL of dexamethasone to the culture media restored the blastulation rate to near baseline levels (61.2 %; P = 0.019).

CONCLUSIONS

The results of our in vitro study demonstrate the capacity of dexamethasone to mitigate the deleterious impact of endometriotic PF on embryo development. If confirmed in vivo, dexamethasone may prove a useful adjunct for the treatment of endometriosis-associated infertility.

Endometriosis and Inflammation in Infertility

A wealth of publications proposes that endometriosis and inflammation may have an unfavorable influence on fertility. A recent meta-analysis of assisted reproductive technologies demonstrated that, once confounding factors are controlled for, the pregnancy rate in women with endometriosis is approximately 50% of the rate of women with tubal factor infertility. Peritoneal fluid of women with endometriosis contains elevated amounts of macrophages and their secreted products, such as growth factors, cytokines, and angiogenic factors. Because reproductive organs are bathed in and thus will be influenced by peritoneal fluid, these proinflammatory mediators would affect various aspects of reproduction in women with endometriosis. Advanced stages of endometriosis may have easily understandable factors, such as distortion of the anatomy, causing infertility. On the other hand, in minimal or mild endometriosis mechanisms underlying reproductive failure are subtle and remain controversial. Recent reports suggest that inflammatory factors play a role in this endometriosis-associated reproductive failure. This review provides an overview of recent data on the effects of endometriosis-associated inflammation on fertility.

Eight-hydroxy-2'-deoxyguanosine in granulosa cells is correlated with the quality of oocytes and embryos in an in vitro fertilization-embryo transfer program

OBJECTIVE

To determine the effects of oxidative stress on the quality of oocytes and embryos, 8-hydroxy-2'-deoxyguanosine (8-OHdG) in granulosa cells was quantitatively studied during an in vitro fertilization and embryo transfer (IVF-ET) program.

DESIGN

Immunocytochemical staining of 8-OHdG in granulosa cells was quantitatively estimated using a charge-coupled device camera and analyzed using the National Institute of Health Image (NIH Image) freeware on a computer .

SETTING

Obstetrics and gynecology department in a university hospital.

PATIENT(S)

Ninety-six infertile couples undergoing IVF-ET treatment and intracytoplasmic sperm injection (IVF, n = 72; intracytoplasmic sperm injection, n = 24).

INTERVENTION(S)

Oocytes, granulosa cells, and follicular fluids were collected 35-36 hours after the administration of hCG.

MAIN OUTCOME MEASURE(S)

8-OHdG indices were obtained for mural [8-OHdG index (m)] and cumulus [8-OHdG index (c)] granulosa cells.

RESULT(S)

A negative correlation between the fertilization rate and both 8-OHdG indices (c and m) was found. The rate of production of good embryos also showed a negative correlation with the 8-OHdG index (m) and the 8-OHdG index (c). Negative correlations between the 8-OHdG index (c) and E2 levels in follicular fluid were observed. Endometriosis patients showed a higher 8-OHdG index (c) than did patients with other infertility causes, such as tubal, male factor, and unknown.

CONCLUSION(S)

Oxidative stress in granulosa cells lowered fertilization rates and subsequently led to a decrease in the quality of embryos. The quality of oocytes for endometriosis patients was impaired by the presence of 8-OHdG. This might be one causative factor in infertility in endometriosis patients.

Embryotoxicity of peritoneal fluid in women with endometriosis. Its relation with cytokines and lymphocyte populations

BACKGROUND

The goals of the present work were to study the embryotoxic effects of peritoneal fluid (PF) in women with or without endometriosis, and to relate any embryotoxicity to the severity of endometriosis, infertility or achievement of pregnancy, cytokine concentrations and lymphocyte populations.

METHODS

Sixty-six consecutive women of reproductive age, 54 with endometriosis (21 infertile) and 12 infertile without endometriosis, and another 12 fertile women as control group, were included in this study. They all underwent laparoscopy or laparotomy in the second half of the cycle, and PF was collected from the pouch of Douglas. The embryotoxicity of the PF was assessed by means of a mouse embryo assay, and expressed as the number of embryos that did not reach blastocyst stage. Cytokines and lymphocyte populations present in PF were also studied and correlated with embryotoxicity.

RESULTS

PF embryotoxicity was increased in women with endometriosis, but there was little correlation with the severity of the disease. However, although a clear relationship to the presence of infertility was not found, embryotoxicity appeared to be lower in those infertile patients with endometriosis who later became pregnant. We found a significant increase in embryotoxicity in the presence of high cytokine concentrations, especially with interleukin-6, and less so with interleukin-8 (P < 0.05). No good correlation was observed with lymphocyte populations, but CD56 (NK) cells were significantly increased in the PF of women with endometriosis. In general, the correlations for embryotoxicity were better when PF was diluted at 20% (91.4 +/- 17 versus 68.1 +/- 31, P < 0.01).

CONCLUSIONS

These results suggest that alteration in the production of cytokines in the PF, especially IL-6, besides contributing to the endometriosis and its evolution, probably increases embryotoxicity. However, no correlation was found between the latter and associated infertility.

Endometrial quality in infertile women with endometriosis

Several analyses in our infertility (IVF) and oocyte donation programs were carried out to gain clinical knowledge of the factors involved in the etiology of endometriosis-associated infertility. We first compared the IVF outcomes in women with tubal infertility and endometriosis. The results indicated that patients with endometriosis had a poorer IVF outcome in terms of reduced pregnancy rate per cycle, per transfer, and reduced implantation rate per embryo replaced. We then evaluated embryo development in vitro in women with and without endometriosis who underwent IVF and embryo replacement 72 hours after oocyte retrieval. We observed that compared to controls, patients with endometriosis had a significantly reduced number of blastomeres per embryo as well as an increased incidence of arrested embryos in vitro. In subsequent studies we compared fertility parameters in patients receiving donor oocytes. We noted that when donor oocytes came from patients without known endometriosis, embryo development and implantation rates were similar in patients with and without endometriosis. However, when the results of oocyte donation were classified according to the nature of the oocytes donated, patients who received embryos derived from oocytes from women with endometriotic ovaries showed a significantly reduced implantation rate compared to the controls. Taken together, these observations suggest that IVF in patients with endometriosis may be related to alterations within the oocyte, which, in turn, result in embryos of lower quality with a reduced ability to implant.

Effect of hormonal agents on monocyte chemotactic protein-1 expression by endometrial epithelial cells of women with endometriosis

OBJECTIVE

To assess whether hormonal agents used in the medical treatment of endometriosis, such as danazol and GnRH agonist, exert direct regulatory action on monocyte chemotactic protein-1 (MCP-1) expression by endometrial epithelial cells.

DESIGN

Primary cultures of epithelial cells isolated from human endometrium were exposed to different concentrations of cytokines and steroid hormone analogs. Expression of MCP-1 was analyzed at the levels of protein and messenger RNA.

SETTING

Gynecology clinic and laboratory of endocrinology of reproduction.

PATIENT(S)

Women presenting for infertility or pelvic pain in whom endometriosis was diagnosed by using laparoscopy.

INTERVENTION(S)

Endometrial tissue biopsy performed at laparoscopy.

MAIN OUTCOME MEASURE(S)

Secretion of MCP-1 protein was measured by using enzyme-linked immunosorbent assay, and mRNA steady-state levels were measured by performing Northern blot analysis.

RESULT(S)

Buserelin acetate, a GnRH agonist (0.1-10 ng/mL), had no significant effect on MCP-1 expression, whereas danazol (10(-7)-10(-5) M), a testosterone analog, and dexamethasone, an anti-inflammatory glucocorticoid hormone (10(-12)-10(-6)M), showed a direct and a dose-dependent inhibitory effect on MCP-1 expression. This effect occurred at the level of protein and mRNA.

CONCLUSION(S)

The findings of the study may affect understanding of the mechanisms by which hormonal treatments act on endometriosis and influence its clinical manifestations.

Moderate and severe endometriosis is associated with alterations in the cell cycle of granulosa cells in patients undergoing in vitro fertilization and embryo transfer

OBJECTIVE

To determine whether folliculogenesis is impaired in patients with endometriosis.

DESIGN

Prospective study.

SETTING

Yamagata University School of Medicine, Yamagata, Japan.

PATIENT(S)

Thirty women participating in an IVF program.

INTERVENTION(S)

The patients were divided into four groups according to the cause of their infertility: tubal factor (T), n = 7; male factor (M), n = 7; idiopathic (I), n = 7; and endometriosis (E), n = 9. Granulosa cells were obtained from the follicular fluid of each patient and analyzed by flow cytometry.

MAIN OUTCOME MEASURE(S)

The percentage of granulosa cells in each cell-cycle stage.

RESULT(S)

The mean (+/- SD) rate of apoptosis in the granulosa cells obtained from the patients with endometriosis was the highest among the four groups (T = 11.7% +/- 3.3%; M = 5.6% +/- 3.8%; I = 9.6% +/- 5.1%; and E = 18.6% +/- 9.6%). The percentage of S-phase granulosa cells was significantly higher in the patients with endometriosis than in all the other patients combined (E = 12.5% +/- 6%; T + M + I = 9.3% +/- 2.9%). The percentage of G2/M-phase granulosa cells was significantly lower in the endometriosis group than in the other three groups combined (E = 2.3% +/- 2.5%; T + M + I = 4.6% +/- 2.1%).

CONCLUSION(S)

Endometriosis impairs the cell cycle in granulosa cells. This phenomenon may have a detrimental effect on folliculogenesis.

Coculture of human embryos with autologous human endometrial epithelial cells in patients with implantation failure

We have developed a coculture system with autologous human endometrial epithelial cells (AEEC) that retained many features of human endometrial epithelium. Implantation failure (IF; >3 previous cycles failed with 3-4 good quality embryos transferred) is a distressing condition in which 2-day embryo transfer repetition is the routine option. The objective of this study was to investigate the basics and to evaluate prospectively the clinical value of embryo coculture on AEEC and blastocyst transfer with their own oocytes [in vitro fertilization (IVF) patients] or with donated oocytes (oocyte donation patients) compared to a routine day 2 embryo transfer for patients with IF. Scanning electron microscopy and mouse embryo assays demonstrate that EEC from fertile and IF patients were morphologically and functionally similar; similar findings were observed in EEC obtained from fresh or frozen endometria. Clinically, 168 IVF cycles were performed in 127 patients with 3.8+/-0.2 previously failed cycles, and 80 cycles were performed in 57 patients undergoing oocyte donation with 3.0+/-0.2 previously failed cycles. Twenty IVF patients and 15 ovum donation patients with 3 previously failed cycles in whom a 2-day embryo transfer was performed were used as controls. In 88% of ovum donation cycles, at least 2 blastocysts were available for transfer, with 60.1% blastocyst formation; 2.2+/-0.1 blastocysts were transferred/cycle, and 36 pregnancies (determined by fetal cardiac activity) were obtained (32.7% implantation and 54.5% pregnancy rates). In 168 IVF cycles, 8.1+/-0.2 embryos/cycle started coculture, resulting in 49.2% blastocyst formation; 2.3+/-0.2 blastocysts were transferred/cycle, and 29 clinical pregnancies were obtained (11.8% implantation and 20.2% pregnancy rates). Fifteen cycles were canceled (9%). In oocyte donation patients with IF undergoing 2-day embryo transfer, implantation and pregnancy rates were significantly lower (4.5% and 13.3%; P < 0.01) than with coculture; however, in IVF patients with IF, results with day 2 transfer (10.7% and 35%) were similar to those with coculture. The present study demonstrates that coculture of human embryos with AEEC and blastocyst transfer is safe, ethical, and effective and constitutes a new approach to improve implantation in patients with IF undergoing ovum donation, but not in IVF patients.

Intraperitoneal and subcutaneous treatment of experimental endometriosis with recombinant human interferon-alpha-2b in a murine model

OBJECTIVE

To determine the effect of human interferon (IFN)-alpha-2b on experimental endometriosis in rats.

DESIGN

Experimental, controlled, double-blind randomized study.

SETTING

Experimental surgery laboratory in a university department.

ANIMAL(S)

Ninety-six Wistar rats with endometriosis, induced by transplanting four endometrial fragments into the peritoneal cavity.

INTERVENTION(S)

One third of the animals served as controls (group A). The others were randomly divided into two groups and were given IFN-alpha-2b either as a single intraperitoneal dose (group B) or as three SC doses (on alternate days) (group C).

MAIN OUTCOME MEASURE(S)

Laparotomy was performed to measure the size of each implant at various times (days 0, 6, 12, 20, and 120 after treatment).

RESULT(S)

There were no differences among the groups in the size of the average implants before IFN was administered (17.3+/-6.7, 19.7+/-7.8, and 18.1+/-9.2 mm for groups A, B, and C, respectively). These values were significantly smaller after treatment in group B (14.9+/-8.0 mm) and group C (14.0+/-9.5 mm) than in the control group (17.6+/-7.5 mm) (P<.05). Intraperitoneal IFN produced an initial maximum decrease in the size of the implants (40% reduction on day 6), which diminished until day 20 (20%) and then was maintained on a plateau until day 120 (25%). By contrast, group C showed an initial minimal reduction (13% at day 6), which increased up to day 20 (19%), after which a plateau was reached (23% at day 120). Thus, the effects in both treatment groups were similar in the long term.

CONCLUSION(S)

Two short regimens of human IFN-alpha-2b reduced the size of experimental endometriosis in rats.

Ovarian fecundity in patients with endometriosis can be estimated by the incidence of apoptotic bodies

OBJECTIVE

To investigate the incidence of apoptotic bodies in membrana granulosa in patients with endometriosis.

DESIGN

Retrospective analysis.

SETTING

Yamagata University Hospital.

PATIENT(S)

Fifty-eight normoovulatory women with endometriosis and 45 patients with male factor infertility underwent ovulation induction for IVF-ET with GnRH analogues and gonadotropins.

INTERVENTION(S)

Patients underwent follicle aspiration after the administration of hCG.

MAIN OUTCOME MEASURE(S)

Recovered granulosa cells (GCs) were examined by fluorescence microscopy, and the incidence of apoptotic bodies was tabulated. These data and the other parameters associated with IVF results were analyzed on the basis of both the revised American Fertility Society (AFS) classification of endometriosis and the existence of chocolate cysts.

RESULT(S)

The incidence of apoptotic bodies in membrana granulosa of patients with endometriosis was significantly higher than that of the control (male factor infertility) group and increased as the stage of the revised AFS classification advanced. The incidence of apoptotic bodies in membrana granulosa was significantly higher in patients with chocolate cysts than in those without chocolate cysts. The patients with endometriosis had smaller numbers of developed follicles (> or = 15 mm), harvested oocytes, and mature oocytes than the male factor infertility patients. The existence of chocolate cysts corresponded with a reduced number of both harvested oocytes and mature oocytes.

CONCLUSION(S)

Through the apoptosis of GCs, the existence of endometriosis may have negatively affected the follicle development and oocyte quality.

Peritoneal cellular immunity and endometriosis

PROBLEM

An immunologic basis has long been considered to be very important in the pathogenesis of endometriosis. Interactions of the peritoneal cells, which comprise macrophages, B cells, T cells, natural killer (NK) cells, and retrograde endometrial cells, are critical, but remain controversial, for exploring the pathogenesis of endometriosis.

METHOD OF STUDY

Accumulated data from the literature were reviewed, and our data were analyzed.

RESULTS

The data show that peritoneal macrophages are activated by the recurrent reflux of menstrual shedding. Humoral and local endometrial autoantibodies are detected in patients with endometriosis, but B cells are not quantitatively increased. There is decreased NK cell activity in the peritoneal cavity and peripheral blood, and this decreased activity may be related to the failure to clear out the ectopic endometrial tissue. Peritoneal T cells are predominant by Th1 inflammatory cells, and these cells are impaired because of a decrease in activation (especially HLA-DR+CD4+CD3+ population) and in the production of interleukin-2. Inflammatory cytokines such as interleukin-1, interleukin-6, and tumor necrosis factor-alpha are elevated in the peritoneal fluid of women with endometriosis.

CONCLUSIONS

The peritoneal NK and T lymphocytes are suppressed in women with endometriosis, but whether these immunologic deviations are the cause or the result of endometriosis is still unclear. Further studies are required to determine what role immunologic factors play in the pathophysiology of endometriosis.

The effect of endometriosis on implantation: results from the Yale University in vitro fertilization and embryo transfer program

OBJECTIVE

To investigate the effect of endometriosis on implantation.

DESIGN

Case-control study from Yale University IVF-ET program.

PATIENTS

Two hundred eighty-four consecutive IVF cycles were analyzed retrospectively. Patients with endometriosis only (n = 35; 89 cycles) were compared with an age-matched control group with tubal infertility (n = 70; 147 cycles) and also to a group with unexplained infertility (n = 15; 48 cycles). Data from the endometriosis group was analyzed further in subgroups of minimal-mild (43 cycles) and moderate-severe (46 cycles).

RESULTS

No difference was found in the number and the quality of oocytes retrieved and fertilization rates between the endometriosis, the tubal infertility, and the unexplained infertility groups. The quality and the number of embryos transferred in each group were comparable. A trend toward reduced pregnancy rate per transfer (14.8%) in the endometriosis versus tubal or unexplained infertility groups (25.7% and 23.3%, respectively) was observed. Implantation rate (gestational sac per transferred embryo) was significantly lower in the endometriosis versus the tubal infertility group (3.9% versus 8.1%; unexplained infertility group, 7.2%). Analysis of first cycles only across all groups revealed that the implantation rate also was significantly lower in the endometriosis versus the tubal infertility group (3.1% versus 9%; unexplained infertility group, 6.7%). Within the endometriosis group, although the pregnancy rate per cycle and per transfer were similar in subgroups, patients with minimal-mild endometriosis had the lowest implantation rate.

CONCLUSION

We conclude that, in patients with endometriosis, implantation rate is low. Abnormal implantation, which may be secondary to endometrial dysfunction or embryotoxic environment, is a factor in endometriosis-associated subfertility.

Increased incidence of aberrant morphological phenotypes in human embryogenesis--an association with endometriosis

PURPOSE

After noticing specific aberrant forms of development in preimplantation embryos from women with endometriosis, we embarked upon this study in order to examine the frequency of these events as compared with controls.

METHODS

A total of 235 embryos representing 30 women undergoing 56 cycles of in vitro fertilization were retrospectively analyzed on videotape and placed into categories based upon the incidence of specific morphological criteria found during observations made on the first and second days following oocyte retrieval.

RESULTS

Several of the aberrant nuclear and cytoplasmic events were found to be statistically increased in the group of embryos from women with endometriosis.

CONCLUSIONS

The incidence of defined aberrant phenotypes in embryos from women with laparoscopically documented endometriosis may allow us to identify specific embryotoxic events with reference to endometriosis and other diagnoses.

Validation of an embryotoxicity assay

PROBLEM

Culture of mouse blastocysts has served as a tool for identifying various embryotoxic factors in human serum. While inactivated, sera from recurrently aborting women inhibit mouse blastocyst development in vitro. Variation in results from individual serum samples has limited the usefulness of this assay in establishing a new classification of idiopathic recurrent spontaneous abortion (RSA).

METHOD

Two-cell embryos were collected from superovulated mated CB6F1/J mice and cultured in Ham's F-10 media supplemented with 10% fetal bovine serum (FBS) or tested human serum at 37 degrees C with 5% CO2 and high humidity. Each sample was assayed in triplicate using three mice with at least five embryos from the same mouse per dish. Development was evaluated at 72 h and the frequency of atretic embryos was recorded.

RESULTS

Intrasample (interassay) variation yielded a coefficient of variation of 9%. When repeated, samples from a given individual were evaluated and the coefficient of variation was 8.7%. Interoperator variability was 4% interassay and 2% intrassay. Atresia of embryos was 23% when incubated with FBS (N = 122), 21% in FC (N = 122), and in the sera of patients with RSA 34.6% (N = 95). Results of percentage of atresia from the fertile control group had a nonparametric distribution. Using 2.2 multiples of the median to determine the 95% confidence interval, a threshold at 44.0% of atresia was established.

CONCLUSIONS

The critical step in maintaining low variability in this bioassay is to control mouse variability by averaging the percentage atresia from different mice as embryo donors for each tested serum. A subgroup of 24% (23/95) RSA patients who displayed embryotoxic activity was identified with a specificity of 95% and positive predictive value of 83%, P = 0.001.

Endometriosis: the host response

There is abundant evidence of altered immune function in endometriosis. The task that remains is to attempt a synthesis from the accumulated data, to try to make some sense of the observed phenomena and to fit them into a conceptual framework; this might permit the formulation and testing of hypotheses. Evidently, eutopic endometrium does not engender an immune response in normal subjects, otherwise the endometrium would be subject to autoimmune destruction. It has also been established that the overwhelming majority of women regurgitate menstrual debris into the peritoneal cavity. Why does this lead to endometriosis in some, but not in others? There are several possible explanations. The uterus might act as a privileged site, i.e. be exempt from immune effector mechanisms. This would certainly be conducive to the reproductive goal, the survival of the fetal allograft. Endometrium would then not enjoy the immunologic tolerance of most other tissues, and upon leaving the uterus and entering an immunocompetent environment would be subject to immune attack. In normal subjects, this could consist of elimination of menstrual debris without further sequelae. An altered response, characterized by the production of antibody that could mask receptors for cytotoxic or phagocytic effector cells, would permit persistence of ectopic endometrium. The alternative to this hypothesis is that the uterus is not a privileged site, and that the organism is normally tolerant to endometrial antigens. Menstrual debris would be eliminated intraperitoneally without loss of tolerance due to the presence of homeostatic mechanisms including suppressor T cells and suppressive cytokines. In endometriosis, this tolerance breaks down, as is the case in several autoimmune disorders, causing a chronic inflammatory response with the release of toxic factors and, eventually, peritoneal scarring. Finally, the role of cell adhesion molecules, including the integrins, is only just being explored. The behaviour of these molecules in ectopic endometrium differs from that in eutopic endometrium, and it remains to be seen whether regurgitated endometrial debris from normal subjects is different from that of endometriosis sufferers. It seems that this will be an area of intense investigation in the immediate future.

Oocyte donation in low responders to conventional ovarian stimulation for in vitro fertilization

OBJECTIVE

To analyze endometrial response (endometrial dating and implantation) to exogenous administration of E2-valerate and P in women with low response to gonadotropins undergoing oocyte donation.

DESIGN

Prospective study. A cycle in which endometrial specimens were obtained and subsequent cycles with ET were evaluated. The control group was made up of patients with premature ovarian failure (POF) undergoing the same procedure.

SETTING, PATIENTS

In Vitro Fertilization program at the Instituto Valenciano de Infertilidad. A total of 37 women with low response to gonadotropins in previous cycles and 33 women with POF.

INTERVENTIONS

First artificial cycle with E2-valerate and P in the absence of previous pituitary suppression to determine endometrial adequacy. Successive artificial cycles in which ET was performed on cycle day 17. Oocytes donated from infertile patients undergoing IVF.

MAIN OUTCOME MEASURES

Serum steroid levels were measured during the artificial cycle. Histologic dating of the endometrium on cycle days 15 and 26. Ultrasonographically documented IVF-ET pregnancies.

RESULTS

Postovulatory changes on cycle day 15 were observed in 36.4% of low responders treated with E2-valerate and P in the absence of simultaneous pituitary suppression. Pregnancy rates were higher in women with previous sufficiently (77.8%) or insufficiently (80%) estrogen-primed endometrium than in the cases showing postovulatory changes (37.5%). Pregnancy rates (PRs) per transfer were significantly higher in low responders (63.8%) than in patients with POF (37.2%). Patients with endometriosis had a 71.4% PR per transfer. Embryos derived from oocytes from polycystic ovaries had a 48.3% PR.

CONCLUSIONS

Oocyte donation is a reliable alternative for women with low response to gonadotropins, including those with severe endometriosis. The efficacy of the steroid replacement regimen in controlling ovarian function may influence outcome. Thus, women with functional ovaries despite exogenous steroid replacement might be differently treated. Women with polycystic ovaries are an adequate source of oocyte donation.

Inflammatory reaction in endometriotic tissue: an immunohistochemical study

A panel of monoclonal antibodies specific for macrophage subtypes appearing in early (27E10), down-regulatory (RM3/1) and late (25F9) stages of inflammation had been applied to 20 endometriotic implants of 14 women. Of those patients 9 were in the follicular phase of the cycle, two on danazol, one on LHRH-analogue (buserelin) and another two on oral contraceptives. Beside the macrophage subsets, antibodies against T4, T8 lymphocytes as well as proliferating cells (EN7/44 and Ki67) were examined. In all specimens immunologically competent cells could be detected to a varying degree and within the same implant different stages of inflammation were discernible. Endometriosis presented with signs of early inflammation indicated by 27E10+ macrophages and CD4+ lymphocytes (15 specimens) and with down-regulatory, late inflammatory reactions as shown by RM3/1+, 25F9+ macrophages and CD8+ lymphocytes (19 biopsies). Additionally, in 14 specimens cells of the EN7/44+ and Ki67+ type was detected. These preliminary results showed no significant correlation to either extension of endometriotic implants or adhesions or concomitant therapy and clearly indicate, that there is an immunological dynamic process within the lesion itself in addition to that one of the peritoneal fluid.