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

AKT, p-AKT, ERK1/2 and p-ERK1/2 in Mural Granulosa Cells Are Not Correlated to Different Ovarian Stimulation Protocols in Patients Undergoing Assisted Reproductive Treatment

(1) Background: In this paper we aim to study the relationship between the expression levels of molecules involved in apoptotic/survival pathways, considered as molecular markers of oocyte competence (i.e., AKT, p-AKT, ERK1/2, and p-ERK1/2) in mural granulosa cells (MGCs) and the administration of r-FSH alone or combined with exogenous r-LH, in ovarian stimulation protocol. Moreover, we aim to evaluate oocyte competence by comparing normally cleaved embryos that were transferred in the uterus, with embryos that were arrested during in vitro culture. (2) Methods: The study included 34 normo-responder women undergoing ICSI procedures. All subjects were divided into two groups. Group A consisted of 18 women stimulated with r-FSH and used as a control group; Group B consisted of 14 women stimulated with r-FSH combined with r-LH. The MGCs were obtained from individual follicles. Immunoblot analyses were carried out to analyze the AKT, p-AKT, ERK1/2, and p-ERK1/2 levels in MGCs and to correlate them with the ovarian stimulation protocol. Furthermore, the oocyte competence was evaluated, for each follicle, according to the development of the embryo during in vitro culture and the pregnancy outcome. (3) Results: We found no significant difference in the levels of molecules in isolated MGCs between groups A and B. These results, in light of our previous research, suggest for the first time, to our knowledge, that cumulus cells and mural granulosa cells in the same follicle show different expression levels of molecules involved in the apoptotic mechanism. (4) Conclusions: Our results could clarify some controversial data in the literature where cumulative cell pools of cumulus and granulosa were analyzed, described as ovarian follicle cells, and used as markers of oocyte competence. In this paper, we found evidence that cumulus and granulosa cells need to be analyzed separately.

Impact of endometriosis on the ovarian follicles

A significant body of evidence has supported a negative impact of endometriosis on ovarian follicles; however, the origin and relevance of this ovarian impairment in endometriosis is still a matter of debate. The ovarian damage can be caused by endometriosis itself or by surgeries aiming to remove endometriotic lesions. In this review, we summarized the existing knowledge on the mechanisms by which endometriosis can impact the ovarian follicles, from molecular to clinical points of view. From a molecular standpoint, the presence of endometriosis or its consequences can induce oxidative stress, inflammation, aberrant mitochondrial energy metabolism and inappropriate steroid production in granulosa cells, phenomena that may impair the quality of oocytes to variable degrees. These alterations may have clinical relevance on the accelerated exhaustion of the ovarian reserve, on the ovarian response to gonadotrophin stimulation in IVF cycles and on the competence of the oocytes. Critical points to be considered in current clinical practices related to fertility issues in endometriosis are discussed.

Decreased oocyte quality in patients with endometriosis is closely related to abnormal granulosa cells

Infertility and menstrual abnormalities in endometriosis patients are frequently caused by aberrant follicular growth or a reduced ovarian reserve. Endometriosis typically does not directly harm the oocyte, but rather inhibits the function of granulosa cells, resulting in a decrease in oocyte quality. Granulosa cells, as oocyte nanny cells, can regulate meiosis, provide the most basic resources required for oocyte development, and influence ovulation. Endometriosis affects oocyte development and quality by causing granulosa cells apoptosis, inflammation, oxidative stress, steroid synthesis obstacle, and aberrant mitochondrial energy metabolism. These aberrant states frequently interact with one another, however there is currently relatively little research in this field to understand the mechanism of linkage between abnormal states.

Effect of Endometriosis on Cumulus ATP, Number of Mitochondria and Oocyte Maturity in Cumulus Oocyte Complex in Mice

OBJECTIVE

 Endometriosis causes a decrease in oocyte quality. However, this mechanism is not fully understood. The present study aimed to analyze the effect of endometriosis on cumulus cell adenosine triphosphate ATP level, the number of mitochondria, and the oocyte maturity level.

METHODS

 A true experimental study with a post-test only control group design on experimental animals. Thirty-two mice were divided into control and endometriosis groups. Cumulus oocyte complex (COC) was obtained from all groups. Adenosine triphosphate level on cumulus cells was examined using the Elisa technique, the number of mitochondria was evaluated with a confocal laser scanning microscope and the oocyte maturity level was evaluated with an inverted microscope.

RESULTS

 The ATP level of cumulus cells and the number of mitochondria in the endometriosis group increased significantly (p < 0.05; p < 0.05) while the oocyte maturity level was significantly lower (p < 0.05). There was a significant relationship between ATP level of cumulus cells and the number of mitochondrial oocyte (p < 0.01). There was no significant relationship between cumulus cell ATP level and the number of mitochondrial oocytes with oocyte maturity level (p > 0.01; p > 0.01). The ROC curve showed that the number of mitochondrial oocytes (AUC = 0.672) tended to be more accurate than cumulus cell ATP level (AUC = 0.656) in determining the oocyte maturity level.

CONCLUSION

 In endometriosis model mice, the ATP level of cumulus cells and the number of mitochondrial oocytes increased while the oocyte maturity level decreased. There was a correlation between the increase in ATP level of cumulus cells and an increase in the number of mitochondrial oocytes.

Evaluation of endometrioma size effect on ovarian reserve, embryo quality and pregnancy outcome after in vitro fertilization cycle; a cross-sectional study

INTRODUCTION

Investigation of endometrioma size and its laterality on the quality of the embryo in patients with endometrioma compared to healthy subjects.

MATERIALS AND METHODS

In this retrospective and cross-sectional study, 70 patients with unilateral and bilateral endometrioma were recruited and compared with 70 age-matched infertile patients as the control group in terms of AMH before ovum pick-up, embryo quality as well as pregnancy outcome. Additionally, in the case group, we divided both unilateral (n = 32) and bilateral endometrioma patients (n = 38) into three groups based on the size of endometrioma. (1-3 cm, 3-6 cm, 6-10 cm) RESULTS: There was no difference in terms of age, BMI, parity, and age of menarche between the case and control groups. Moreover, no significant difference was observed in the baseline level of AMH between the case 2.96 ± 2.72 ng/dl (0.21-11.3) and control 2.73 ± 2.39 (0.21-12.8) groups. (P = 0.59) There was also no significant difference concerning AMH level between unilateral 3.58 ± 3.20 ng/dl (0.21-12.8) and bilateral endometrioma 2.45 ± 2.14 (0.21 - 0.20) groups. In terms of the quality and number of embryos, there was no significant difference between the case and control groups. (P = 0.30) Although the AMH level decreased with the increase in endometrioma size, this difference was not statistically significant. (P = 0.07) There was no significant difference in terms of the embryo quality between the groups based on the size of endometrioma. (P = 0.77) In addition, no significant difference was observed between the case and control groups in the terms of birth weight and pregnancy complications, such as premature delivery, cesarean section rate, neonatal respiratory distress, jaundice, as well as hospitalization rate. Head circumference of the newborns was higher in the endometrioma group while their Apgar score was lower in the case compared to the control group.

CONCLUSION

The presence of endometrioma by itself does not affect the main result of IVF procedures, including the number and quality of embryos and pregnancy outcome. Thus, IVF and embryo preservation and even pregnancy before surgery seem to be reasonable for endometriotic patients.

Conventional IVF performs similarly in women with and without endometriosis

PURPOSE

A reduced oocyte competence has been claimed as one of the factors underlying infertility in women with endometriosis. This idea has justified the hypothesis that intracytoplasmic sperm injection (ICSI), rather than conventional IVF (c-IVF), may overcome oocyte impairment and ensure better assisted reproduction technology (ART) outcomes; however, data from the literature are controversial. Thus, the aim of this study was to compare ART success rates following (c-IVF) between women with and without endometriosis in the presence of normozoospermic partners.

METHODS

This is a retrospective, matched case-control study of 314 patients who underwent c-IVF cycles between January 2014 and December 2020. Women with endometriosis were matched in a 1:1 ratio with patients undergoing ART for other indications, considering age (± 6 months), number of oocytes retrieved (± 1), and study period. The main outcome measures included total fertilization failure, fertilization rate, embryo quality, cumulative clinical pregnancy, and live birth rates.

RESULTS

The fertilization rate and the proportion of women with total fertilization failure did not differ between women with and without endometriosis. Similarly, all other embryological variables did not also differ, except for the number of top-quality cleavage stage embryos which was higher in the endometriosis group. Cumulative clinical pregnancy and live birth rates were similar between women with and without endometriosis.

CONCLUSION

A diagnosis of endometriosis does not negatively affect the performance of c-IVF; thus, c-IVF can be efficiently used in women affected, unless a male factor is also involved. This issue holds clinical relevance to help operators on their insemination technique decision-making.

Endometriosis: A Review of Clinical Diagnosis, Treatment, and Pathogenesis

Endometriosis is a condition that affects women of reproductive age, and it is distinguished by the development of endometrial-like tissue outside the uterine cavity. It is frequently accompanied by persistent pelvic discomfort and infertility. This investigation looks into recent findings on clinical manifestation to help doctors and improve women's health. PubMed and Google Scholar were used to review on clinical diagnosis of endometriosis. The search strategy contained the terms “endometriosis” and “clinical diagnosis.” All research articles published between 1960 and 2021 were included in the search. The findings were then categorized to summarize the evidence. There was a total of 29 instances of endometriosis discovered. The patients' ages varied from 20 to 45 years old, with a median of 28.8 years and a mean of 29.4±7.7 years. Dysmenorrhea is a common disorder among adolescent girls experiencing various physical and emotional symptoms which have a detrimental influence on their quality of life. In this study, scar endometriosis was shown to be the more common variety of endometriosis, with 50% of cases predominantly developing at the lower segment cesarean section (LSCS) scar site. As a result, women with endometriosis are more likely to have miscarriages, and the quality of their embryos declines as a result.

Dysregulated sphingolipid metabolism and autophagy in granulosa cells of women with endometriosis

We evaluated metabolic profiles between cumulus cells (CCs) and mural granulosa cells (MGCs) derived from women with endometriosis to identify their correlations with oocyte quality. CCs and MGCs were collected from women with and without endometriosis undergoing in vitro fertilization/intracytoplasmic sperm injection treatment. The metabolomics of CCs and MGCs were measured by liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS) followed by a quantitative polymerase chain reaction to further confirm the genes involved in the metabolic results. LC-MS/MS analysis revealed differences in 24 metabolites of CCs and 71 metabolites of MGCs between groups. Among them, five metabolites were upregulated and 19 metabolites were downregulated in CCs with endometriosis, whereas three metabolites were upregulated and 68 metabolites were downregulated in MGCs with endometriosis. Metabolites related to sphingolipid metabolism, which included palmitic acid (PA) and docosahexaenoic acid, increased significantly only in CCs with endometriosis, whereas sphingosine and PA were significantly downregulated in MGCs with endometriosis compared with CCs and MGCs without endometriosis. Gene expression involved in ceramide synthesis (CERS1, SPTL1, and SMPD1) and autophagy (BECN1, LAMP, and PC3) were significantly higher in CCs with endometriosis according to FASN, BECN1, and LAMP protein expressions. However, gene expression involved in ceramide synthesis (SPHK1, ASAH1, and SGPP1) and autophagy (BECN1, LAMP, and PC3) were significantly lower in MGCs with endometriosis, whereas CERS1 and UGCG expression increased. There are differences in sphingolipid metabolites in CCs and MGCs with endometriosis compared with women without endometriosis. These differences seem to be involved in the regulation of autophagic cell death in preovulatory follicles.

Novel therapeutic targets to improve IVF outcomes in endometriosis patients: a review and future prospects

BACKGROUND

Patients with endometriosis often experience infertility and have poor IVF outcomes, with low fertilization and pregnancy rates. Although many theories have tried to explain the mechanisms underlying infertility in these patients, none of them is conclusive.

OBJECTIVE AND RATIONALE

In this review, we discuss the pathologic mechanisms through which endometriosis likely leads to infertility along with the therapeutic options used to date to treat endometriosis-related infertility and, thereby, to improve IVF outcomes in patients with endometriosis.

SEARCH METHODS

We performed a comprehensive literature search of clinical outcomes in endometriosis and the molecular mechanisms contributing to oocyte quality using the PubMed database to identify human and animal studies published from 1992 until September 2020. In total, 123 manuscripts were included.

OUTCOMES

While some theories propose that endometriosis patients may have fertility problems as a result of decreased endometrial receptivity, others reinforce the idea that infertility could be associated with oocyte alterations and lower implantation rates. Single-cell RNA sequencing of oocytes from patients with endometriosis has identified dysregulated mechanisms involved in steroid metabolism and biosynthesis, response to oxidative stress and cell cycle regulation. Dysregulation of these mechanisms could result in the poor IVF outcomes observed in patients with endometriosis. Further, impaired steroidogenesis may directly affect oocyte and embryo quality. Increased oxidative stress in patients with endometriosis also has a detrimental effect on the follicular microenvironment, inducing cell cycle dysregulation in oocytes, poor oocyte quality, and infertility. Moreover, granulosa cells in the context of endometriosis undergo increased apoptosis and have an altered cell cycle that could adversely affect folliculogenesis, oocyte and embryo quality, and IVF outcomes. Endometriosis is also associated with inflammatory damage and impaired angiogenesis, which could be directly correlated with poor IVF outcomes. While therapeutic options using GnRH analogues, progestins and aromatase inhibitors do not improve endometriosis-related infertility, anti-inflammatory agents and antioxidant supplementation could improve oocyte quality as well as implantation and clinical pregnancy rates in patients with endometriosis.

WIDER IMPLICATIONS

Endometriosis is a heterogeneous disease whose pathogenesis is complex and could affect fertility by altering a collection of molecular mechanisms in oocytes. Thus, a single model is not sufficient to describe endometriosis-related infertility. Dysregulation of steroidogenesis, oxidative stress, cell cycle progression, inflammation and angiogenesis in the follicular environment and oocytes in individuals with endometriosis are all possible contributors to endometriosis-related infertility. Therefore, treatments targeting these mechanisms could be therapeutic alternatives to improve IVF outcomes for these patients.

The impact of endometrioma on in vitro fertilisation/intra-cytoplasmic injection IVF/ICSI reproductive outcomes: a systematic review and meta-analysis

Background

Assisted reproductive technologies (ART) such as in vitro fertilisation (IVF) and intra-cytoplasmic sperm injection (ICSI) are often used to aid fertility in women with endometrioma; however, the implications of endometrioma on ART are unresolved.

Objective

To determine the effect of endometrioma on reproductive outcomes in women undergoing IVF or ICSI.

Methods

A systematic review and meta-analysis was conducted to identify articles examining women who had endometrioma and had undergone IVF or ICSI. Electronic searches were performed in PubMed, BIOSIS and MEDLINE up to September 2019. The primary outcome was live birth rate (LBR). Secondary outcomes included clinical pregnancy rate (CPR), implantation rate (IR), number of oocytes retrieved, number of metaphase II (MII) oocytes retrieved, number of embryos and top-quality embryos and the duration of gonadotrophin stimulation and dose.

Results

Eight studies were included. Where significant heterogeneity between studies was identified, a random-effects model was used. The number of oocytes (weighted means difference; WMD-2.25; 95% CI 3.43 to − 1.06, p = 0.0002) and the number of MII oocytes retrieved (WMD-4.64; 95% CI 5.65 to − 3.63, p < 0.00001) were significantly lower in women with endometrioma versus controls. All other outcomes, including gonadotrophin dose and duration, the total number of embryos, high-quality embryos, CPR, IR and LBR were similar in women with and without endometrioma.

Conclusion

Even though women with endometriomas had a reduced number of oocytes and MII oocytes retrieved when compared to women without, no other differences in reproductive outcomes were identified. This implies that IVF/ICSI is a beneficial ART approach for women with endometrioma.

Pathophysiological Basis of Endometriosis-Linked Stress Associated with Pain and Infertility: A Conceptual Review

Women with endometriosis are often under stress due to the associated pain, infertility, inflammation-related and other comorbidities including cancer. Additionally, these women are also under stress due to taboos, myths, inter-personal troubles surrounding infertility and pain of the disease as well as due to frequent incidences of missed diagnosis and treatment recurrence. Often these women suffer from frustration and loss of valuable time in the prime phase of life. All these complexities integral to endometriosis posit a hyperstructure of integrative stress physiology with overt differentials in effective allostatic state in women with disease compared with disease-free women. In the present review, we aim to critically examine various aspects of pathophysiological basis of stress surrounding endometriosis with special emphasis on pain and subfertility that are known to affect the overall health and quality of life of women with the disease and promising pathophysiological basis for its effective management.

Laparoscopic management of massive recurrent endometrioma with atypical presentation: A case report

Endometriosis affects 10%–15 % of reproductive age group population. Pelvic endometriosis usually involves ovaries, and it is reported to involve both ovaries in one-third to one-half of cases. Ovarian endometriomas rarely exceed 10–15 cm in diameter. Our case is that of a 31-year-old P1L1 who presented with increasing abdominal girth, and imaging revealed a huge cystic mass extending till the diaphragm around 29 × 24 × 19 cm3 which was later found to be a case of recurrent endometriosis. This was managed by laparoscopy, and the volume of the chocolate fluid evacuated was approximately 11,300 mL. It is rare for endometriomas to grow up to such a large size. This case stresses the importance of suspicion of recurrent endometrioma even in atypical presentations and the need for follow-up in known cases of endometriosis to identify early recurrence.

Relationship between apoptosis and survival molecules in human cumulus cells as markers of oocyte competence

To select from a single patient the best oocytes able to reach the blastocyst stage, we searched for valuable markers for oocytes competence. We evaluated the DNA fragmentation index (DFI) and the level of some survival molecules, such as AKT, pAKT and pERK1/2, in individual cumulus cell-oocyte complexes (COC). The study included normo-responder women. The average age of the patients was 34.3. DFI in cumulus cells was evaluated using the terminal deoxynucleotidyl transferase (TdT) dUTP nick-end labelling (TUNEL) assay in situ. AKT, pAKT and pERK1/2 were measured by immunological assay and densitometric analysis of fluorescent signals using NIS-Elements BR 3.10 image software. Statistical analysis was performed using STATA SE/14.1. The study focused on 53 patients involved after informed consent. Out of 255 MII oocytes, 197 were fertilized and the derived embryos had the following evolution: 117 completed the development to blastocyst and were transferred to uterus; 57 were vitrified at the blastocyst stage; and 23 were arrested during in vitro culture at different stages of cleavage. We found a significant statistical difference between the DFI of cumulus cells of the arrested embryos and the transferred blastocysts (P = 0.004), confirming that DFI could be considered as a valuable marker of oocyte competence. In addition, the pAKT/DFI ratio was higher in cumulus cells of oocytes able to produce blastocysts, indicating that DFI is significantly lower when pAKT is higher (P = 0.043). This study demonstrates for the first time that the relationship between apoptosis and survival molecules can be used as a marker to select the best oocytes.

Is the oocyte quality affected by endometriosis? A review of the literature

Endometriosis is an estrogen-dependent chronic inflammatory condition that affects women in their reproductive period causing infertility and pelvic pain. The disease, especially at the ovarian site has been shown to have a detrimental impact on ovarian physiology. Indeed, sonographic and histologic data tend to support the idea that ovarian follicles of endometriosis patients are decreased in number and more atretic. Moreover, the local intrafollicular environment of patients affected is characterized by alterations of the granulosa cell compartment including reduced P450 aromatase expression and increased intracellular reactive oxygen species generation. However, no comprehensive evaluation of the literature addressing the effect of endometriosis on oocyte quality from both a clinical and a biological perspective has so far been conducted. Based on this systematic review of the literature, oocytes retrieved from women affected by endometriosis are more likely to fail in vitro maturation and to show altered morphology and lower cytoplasmic mitochondrial content compared to women with other causes of infertility. Results from meta-analyses addressing IVF outcomes in women affected would indicate that a reduction in the number of mature oocytes retrieved is associated with endometriosis while a reduction in fertilization rates is more likely to be associated with minimal/mild rather than with moderate/severe disease. However, evidence in this field is still far to be conclusive, especially with regards to the effects of different stages of the disease and to the impact of patients’ previous medical/surgical treatment(s).

Impact of ovarian endometrioma on ovarian responsiveness and IVF: a systematic review and meta-analysis

In this systematic review and meta-analysis, the effect of ovarian endometrioma on ovarian responsiveness to stimulation and on assisted reproduction outcomes was evaluated. Nine published studies (1039 cases) were included. The number of oocytes retrieved (mean difference [MD] -1.50; 95% CI, -2.84 to -0.15, P = 0.03), metaphase II (MII) oocytes retrieved (MD -3.61; 95% CI -4.44 to -2.78, P < 0.00001) and total embryos formed (MD -0.66; 95% CI -1.13 to -0.18, P = 0.007) were significantly lower in women with ovarian endometrioma than the control group. Gonadotrophin dose, duration of stimulation, number of good-quality embryos, implantation rate, clinical pregnancy rate and live birth rate were similar. Comparisons between ovaries with endometriomas and healthy ovaries of the same individuals were also made. Number of oocytes retrieved, MII oocytes retrieved and total embryos formed were not statistically significantly different between the affected ovaries and contralateral normal ovaries. Observational studies showed that ovarian endometrioma was associated with fewer oocytes retrieved, fewer MII oocytes retrieved and fewer total formed embryos. Clinical pregnancy rate and live birth rates were not affected. Intra-patient comparisons in women with unilateral endometrioma suggested the number of oocytes retrieved, MII oocytes retrieved and total embryos formed were similar.

Endometriosis may be associated with mitochondrial dysfunction in cumulus cells from subjects undergoing in vitro fertilization-intracytoplasmic sperm injection, as reflected by decreased adenosine triphosphate production

OBJECTIVE

To determine whether endometriosis is associated with mitochondrial dysfunction in cumulus (granulosa [GC]) cells of subjects undergoing IVF-intracytoplasmic sperm injection (ICSI).

DESIGN

Prospective cohort study.

SETTING

An IVF clinic in a tertiary academic care center.

PATIENT(S)

Eleven women with endometriosis and 39 controls.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Cumulus cell adenosine triphosphate (ATP) levels, mitochondrial DNA (mtDNA), and genomic DNA (gDNA) number.

RESULT(S)

Cumulus cell ATP content was 65% lower in subjects with surgically proven endometriosis (median 312.5 attomoles/ng total DNA, interquartile range = 116.0-667.8) compared with controls (median 892.4 attomoles/ng total DNA, interquartile range = 403.0-1,412.2). There was no significant difference in mtDNA:gDNA ratio. There were no significant differences in age, body mass index (BMI), basal serum FSH level, total oocyte number, metaphase II (M2) oocyte number, metaphase I oocyte number, percentage of M2 oocytes, fertilization rate, implantation rate, or pregnancy rate (PR). Multivariate regression analysis showed significant positive correlations between ATP and [1] M2 oocyte number (r = 0.307) and [2] pregnancy (r = 0.332). There were also trends toward positive correlations between ATP and [3] age (r = 0.283), [4] total number of oocytes (r = 0.271), [5] percentage of M2 oocytes (r = 0.249), and [6] implantation rate (r = 0.293). There were no statistically significant correlations between mtDNA:gDNA ratio and any demographic factors or clinical outcomes measured.

CONCLUSION(S)

Surgically confirmed endometriosis may be associated with cumulus cell mitochondrial dysfunction in subjects undergoing IVF-ICSI for infertility, as reflected by decreased ATP production.

Impact of endometriosis and its staging on assisted reproduction outcome: systematic review and meta-analysis

OBJECTIVE

To evaluate whether the presence or severity of endometriosis affects the outcome of assisted reproductive techniques (ART).

METHODS

In this systematic review, all studies comparing the outcome of ART in women with and those without endometriosis, or at different stages of the disease, were considered eligible. We used either risk ratio (RR) or mean difference (MD) and their 95%CIs for comparisons. The primary outcome was live birth; the secondary outcome was clinical pregnancy. Miscarriage and the number of oocytes retrieved were examined as additional outcomes.

RESULTS

We included 92 studies in the review and 78 in the meta-analysis: 20,167 women with endometriosis were compared with 121,931 women without endometriosis, and 1703 women with Stage-III/IV endometriosis were compared with 2227 women with Stage-I/II endometriosis. The following results were observed for the comparison of women with endometriosis vs women without endometriosis: live birth, RR = 0.99 (95%CI, 0.92-1.06); clinical pregnancy, RR = 0.95 (95%CI, 0.89-1.02); miscarriage, RR = 1.31 (95%CI, 1.07-1.59); number of oocytes retrieved, MD = -1.56 (95%CI, -2.05 to -1.08). The following results were observed for the comparison of women with Stage-III/IV vs Stage-I/II endometriosis: live birth, RR = 0.94 (95%CI, 0.80-1.11); clinical pregnancy, RR = 0.90 (95%CI, 0.82-1.00); miscarriage, RR = 0.99 (95%CI, 0.73-1.36); number of oocytes retrieved, MD = -1.03 (95%CI, -1.67 to -0.39).

CONCLUSIONS

Women with endometriosis undergoing ART have practically the same chance of achieving clinical pregnancy and live birth as do women with other causes of infertility. No relevant difference was observed in the chance of achieving clinical pregnancy and live birth following ART when comparing Stage-III/IV with Stage-I/II endometriosis. The quality of the evidence for the additional examined outcomes was very low, not allowing meaningful conclusions to be drawn.

Expression of antiapoptosis gene survivin in luteinized ovarian granulosa cells of women undergoing IVF or ICSI and embryo transfer: clinical correlations

BACKGROUND

The purpose of the study was to determine the incidence of survivin gene expression in human granulosa cells during ovarian stimulation in Greek women with normal FSH levels, undergoing IVF or ICSI and to discover any correlation between levels of gene expression and clinical parameters, efficacy of ovulation or outcomes of assisted reproduction.

METHODS

Twenty nine women underwent ovulation induction for IVF or ICSI and ET with standard GnRH analogue-recombinant FSH protocol. Infertility causes were male and tubal factor. Cumulus-mature oocyte complexes were denuded and the granulosa cells were analyzed for each patient separately using quantitative reverse transcription polymerase chain reaction analysis for survivin gene expression with internal standard the ABL gene.

RESULTS

The ABL and survivin mRNA were detected in granulosa cells in 93.1%. The expression levels of survivin were significantly lower in normal women (male infertility factor) compared to women with tubal infertility factor (p = 0.007). There was no additional statistically significant correlation between levels of survivin expression and estradiol levels or dosage of FSH for ovulation induction or number of dominant follicles aspirated or number of retrieved oocytes or embryo grade or clinical pregnancy rates respectively.

CONCLUSIONS

High levels of survivin mRNA expression in luteinized granulosa cells in cases with tubal infertility seem to protect ovaries from follicular apoptosis. A subpopulation of patients with low levels of survivin mRNA in granulosa cells might benefit with ICSI treatment to bypass possible natural barriers of sperm-oocyte interactions.

Association of endometriosis-related infertility with age at menopause

OBJECTIVE

The influence of past history of infertility, which is closely associated with reproductive factors, on menopause has not been clarified. The purpose of this study was to clarify the association of reproductive factors, including past history of infertility, with menopause in Japanese women.

STUDY DESIGN

This study was a cross-sectional analysis of the Japan Nurses' Health Study (JNHS) baseline survey. The JNHS is a nationwide prospective cohort study on the health of Japanese women, and the baseline survey was conducted between 2001 and 2007.

MAIN OUTCOME MEASURE

We analyzed data for 24,153 pre- and postmenopausal women who were enrolled in the JNHS at the ages 40-59 years. The main outcome measure was menopause.

RESULTS

Reproductive factors influencing the onset of natural menopause were past history of infertility [relative risk (RR) (age-adjusted odds ratio and 95% confidence interval): 1.28 (1.10-1.48)], past history of endometriosis: 1.32 (1.07-1.64), age at menarche: 0.919 (0.886-0.953) and number of pregnancies: 0.943 (0.911-0.976). Endometriosis as the cause of infertility was significantly associated with earlier onset of menopause (3.43 [2.17-5.44]) after adjustment for age. The strong association of past history of infertility related to endometriosis was still significant after multivariate adjustment.

CONCLUSION

Menopause in women who have a past history of infertility, especially in those who have suffered from endometriosis, is significantly earlier than that in women without such a history.

[Follicular atresia: Its features as predictive markers for the outcome of assisted reproduction]

The mammalian ovary is an extremely dynamic organ in which excessive or defective follicles are rapidly and effectively eliminated continuously throughout reproductive life. More than 99 % of follicles disappear, due to apoptosis of granulosa cells, and only one or few of the surviving follicles successfully complete the path to ovulation. The balance between signals for cell death and survival determines the destiny of the follicles. In this review, we provide a short overview of the role of programmed cell death essentially in adult folliculogenesis. We highlight molecules involved in regulation of granulosa cell apoptosis. We further discuss the potential use of scores for apoptosis in granulosa cells and characteristics of follicular fluid as prognostic markers for predicting the outcome of assisted reproduction.

Endometrioma and ART: Does the Needle Work?

Aim and Objectives

The aim of this study was to see if the fertility outcome improved when IVF/ICSI was done after administration of GnRH analogs and cyst aspiration in comparison with patients in whom either only cyst aspiration or only GnRh analogs were administered.

Materials and methods

This was a prospective study done in a tertiary level ART center which included 30 patients over a span of 5 years from 2004 to 2009. All of them had endometriomas and underwent assisted reproductive techniques (ART) either after cyst aspiration with or without GnRH analog pretreatment or only GnRH analog pretreatment.

Depending on the pretreatment received, they were classified into three groups:

• Group B: Both GnRH analog and cyst aspiration

• Group C: Only cyst aspiration

• Group G: Only GnRH analog.

The patients were not randomized.

The number of days required for stimulation, total dose of stimulation required, number of oocytes obtained, quality of embryos, and the pregnancy rates for each group were tabulated for comparison.

Statistical analysis

The significance of the difference in ART outcome after the different modalities of pretreatment, which was estimated in terms of pregnancy rates was evaluated by calculating the p-value.

Observations and results

Significant difference was observed between the pregnancy rates in the three groups, with the maximum pregnancy rate in group B, followed by the group G and then the group C. The p-value showed a trend, though not statistically significant, indicating the need for larger prospective studies with greater number of subjects.

Conclusion

Pretreating endometriomas by aspirating the cysts and administering three doses of GnRH analog depot preparation prior to IVF/ICSI seems to be better than administering GnRH analog depot preparation alone or aspirating the cysts alone in terms of the number of days required for stimulation, the number of oocytes obtained, and the clinical pregnancy rates.

Survivin gene expression in granulosa cells from infertile patients undergoing in vitro fertilization–embryo transfer

OBJECTIVE

To evaluate survivin gene expression in granulosa cells from infertile patients and examine the relationship between survivin gene expression and infertile clinical background.

DESIGN

Prospective study.

SETTING

IVF-ET program at Osaka Medical College.

PATIENT(S)

Twenty-eight patients underwent ovulation induction for IVF-ET performed because of tubal infertility, male factor infertility, or endometriosis.

INTERVENTION(S)

Granulosa cells obtained at oocyte retrieval were examined for survivin gene expression by quantitative reverse transcription-polymerase chain reaction.

MAIN OUTCOME MEASURE(S)

Hormone environment, number of oocytes, fertilization rate, high-quality embryo rate, pregnancy rate, and expression of survivin genes.

RESULT(S)

Survivin gene expression was detected in all granulosa cells. The gene expression levels of survivin in patients with endometriosis were significantly lower than those in patients with male factor infertility. The gene expression levels of survivin in total pregnant patients were higher than those in total nonpregnant patients and than those in the male factor infertility group, and there was no correlation between gene expression level and serum E(2) level.

CONCLUSION(S)

Survivin may be used as an indicator of the success of IVF-ET, and the existence of endometriosis may elevate the apoptosis of granulosa cells.

Glutathione S-transferase theta 1 expressed in granulosa cells as a biomarker for oocyte quality in age-related infertility

OBJECTIVE

The goal of this study was to identify a reliable biomarker for age-related infertility.

DESIGN

Laboratory study.

SETTING

ART laboratory.

PATIENT(S)

Patients undergoing intracytoplasmic sperm injection or IVF cycles.

INTERVENTION(S)

Expression of Glutathione S-transferase (GST) mRNA and protein in mural and cumulus granulosa cells obtained from infertile patients were examined by reverse transcriptase-polymerase chain reaction and immunofluorescence.

MAIN OUTCOME MEASURE(S)

Correlation between the expression of GST theta 1 (GSTT1) in granulosa cells and oocyte quality was a main outcome measure.

RESULT(S)

Expression of GSTT1 in granulosa cells from male factor patients was positively correlated with age and negatively with cumulus-oocyte complex maturity. When samples with high and low GSTT1 in granulosa cells were extracted from the other infertility factors, cumulus-oocyte complex maturity in the high GSTT1 group was significantly lower than that in the low GSTT1 group (high: 27.2% vs. low: 51.3%). The developmental capacity of oocytes in the high GSTT1 group was likely to be lower (high: 26.4% vs. low: 43.9%). Up-regulation of GSTT1 during aging may be promoted by FSH and H(2)O(2), determined by an in vitro model.

CONCLUSION(S)

GSTT1 is a good indicator for age-related infertility.

La stérilité par endométriose

From the literature, the crucial knowledge were drawn among endometriosis related infertility. Endometriosis is an important factor of infertility in minimal or light stages and a major one in mild or moderate stages. Thus, a laparoscopy must be performed to confirm endometriosis when suggestive clinical or biological signs exist. In absence of them, laparoscopy can be delayed after intra-uterine inseminations (IUI). The first line treatment is laparoscopic surgery. Its efficacy is proven. It is useless to prescribe a post-operative medical treatment (GnRH analogues). Surgery leads to 25 to 40% of deliveries. It is dependant on age, infertility duration, tubo-ovarian adhesion and tubes involvement. But, surgery can be avoided and the patient is directly referred to In Vitro Fertilization (IVF) when the lesions extension is so important that surgery exposes to complications or when there is a permanent other indication for IVF (severe male infertility). When infertility persists 6 to 12 months after surgery and without patent recurrence, ovulation stimulations and IUI are performed as the second line treatment. After IUI failure, or in case of recurrence, IVF must be applied. A second surgery is not recommended. The IVF results are not impaired by the presence of endometriosis and even of endometriomas. Thus, it is useless to operate again endometriosis before IVF. In opposition, in severe stages or in cases of recurrence, a pre-IVF medical treatment (GnRH analogues) improves the results. IVF do not increased the risk of endometriosis acute growth. In case of infertility and pain, infertility is considered as the first target. But medical treatment can be prescribed between the IVF attempts.

Regulated upon activation, normal T cell expressed and secreted (RANTES) and monocyte chemotactic protein 1 in follicular fluid accumulate differentially in patients with and without endometriosis undergoing in vitro fertilization

OBJECTIVE

To compare the amount of regulated upon activation, normal T cell expressed and secreted (RANTES) and monocyte chemotactic protein 1 (MCP-1) in follicular fluid (FF) of patients with and without endometriosis and to determine their oocyte fertilization and pregnancy rates.

DESIGN

Case-control study.

SETTING

Department of Obstetrics and Gynecology, University Hospital Schleswig-Holstein, Campus Luebeck, Germany.

PATIENT(S)

Thirty-two women with endometriosis stages I-IV and 28 women without endometriosis, both groups surgically and histologically confirmed.

INTERVENTION(S)

Diagnostic laparoscopy, IVF-ET.

MAIN OUTCOME MEASURE(S)

RANTES and MCP-1 levels in follicular fluid, measured by ELISA, and oocyte fertilization and pregnancy rates.

RESULT(S)

Follicular response and days of gonadotropin stimulation were similar between the two groups. The levels of RANTES in FF from patients with endometriosis were significantly higher (460.4 +/- 90.3 pg/mL) compared with concentrations in patients with tubal infertility (243.8 +/- 70.9 pg/mL; P<.05). In contrast, MCP-1 concentrations in FF from women with endometriosis (330.0 +/- 29.2 pg/mL) were lower than in women with tubal infertility (420.5 +/- 46.6 pg/mL; P<.05). Oocyte fertilization rates in the endometriosis group (54%) were significantly lower than those of the tubal infertility group (73%; P<.05), as were the pregnancy rates (19% vs. 35%, respectively; P<.01).

CONCLUSION(S)

Women with endometriosis-associated infertility have a poor IVF outcome. Immune cell recruitment into the ovary might affect follicular function and lead to impaired oocyte quality.

The importance of folate, zinc and antioxidants in the pathogenesis and prevention of subfertility

Current treatments of subfertile couples are usually empiric, as the true cause of subfertility often remains unknown. Therefore, we outline the role of nutritional and biochemical factors in reproduction and subfertility. A literature search was performed using MEDLINE, Science Direct and bibliographies of published work with both positive and negative results. The studies showed that folate has a role in spermatogenesis. In female reproduction, folate is also important for oocyte quality and maturation, implantation, placentation, fetal growth and organ development. Zinc has also been implicated in testicular development, sperm maturation and testosterone synthesis. In females, zinc plays a role in sexual development, ovulation and the menstrual cycle. Both folate and zinc have antioxidant properties that counteract reactive oxygen species (ROS). Thiols, such as glutathione, balance the levels of ROS produced by spermatozoa and influence DNA compaction and the stability and motility of spermatozoa. Oocyte maturation, ovulation, luteolysis and follicle atresia are also affected by ROS. After fertilization, glutathione is important for sperm nucleus decondensation and pronucleus formation. Folate, zinc, ROS and thiols affect apoptosis, which is important for sperm release, regulation of follicle atresia, degeneration of the corpus luteum and endometrial shedding. Therefore, the concentrations of these nutrients may have substantial effects on reproduction. In conclusion, nutritional and biochemical factors affect biological processes in male and female reproduction. Further research should identify pathways that may lead to improvements in care and treatment of subfertility.

L'apoptose des cellules de la granulosa peut-elle être considérée comme un marqueur prédictif du succès de la fécondation in vitro ?

During in vitro fertilization (IVF) morphological criteria are the only means usable today to select embryos before their uterine transfer in order to obtain pregnancy with the best chances of success. Since several years many attempts have been made to find more functional means. Quantification of apoptosis of granulosa cells has been proposed for this purpose. The aim of this review is to take stock of our knowledge on apoptosis and its mechanisms in granulosa cells and to analyse how quantification of these apoptotic cells could be a reliable and predictive marker of success for an attempt of an IVF in terms of pregnancy.

Usefulness of intraovarian artery pulsatility and resistance indices measurement on the day of follicle aspiration for the assessment of oocyte quality

OBJECTIVE

To examine the correlation between the pulsatility and resistance indices (PI and RI) of the intraovarian artery on the day of follicle aspiration and the oocyte quality, intrafollicular oxidative stress, and luteinization. Pulsatility index and RI on the day of hCG administration also were measured.

DESIGN

Prospective study.

SETTING

Obstetrics and gynecology department of a university medical school in Japan.

PATIENT(S)

Thirty-five patients in an IVF-ET program.

INTERVENTION(S)

The PI and RI of the intraovarian artery were measured by transvaginal color ultrasonographic pulsed wave Doppler on the day of hCG administration and the day of follicle aspiration. Follicular fluids and the granulosa cells were collected at follicle aspiration.

MAIN OUTCOME MEASURE(S)

The PI and RI of the intraovarian artery blood flow on the day of hCG administration and of follicle aspiration, as well as the rate of development of mature oocytes, follicular fluid steroid levels, and the incidence of apoptosis in the granulosa cells.

RESULT(S)

The PI and RI on the day of follicle aspiration were correlated positively with the rate of mature oocytes retrieved (PI: r = 0.429; RI: r = 0.348), were correlated negatively with the incidence of apoptotic mural (PI: r = -0.383; RI: r = -0.459) and cumulus (PI: r = -0.378; RI: r = -0.469) granulosa cells, and were negatively correlated with the concentration of P in the follicular fluid (PI: r = -0.429; RI: r = -0.359). The PI and RI on the day of hCG administration were negatively correlated only with the total number of retrieved oocytes (PI: r = -0.393; RI: r = -0.374).

CONCLUSION(S)

The PI and RI of the intraovarian artery blood flow measured on the day of follicle aspiration may be good indicators of the follicle luteinization and oxidation as well as of oocyte quality.

Levels of apoptosis in human granulosa cells seem to be comparable after therapy with a gonadotropin-releasing hormone agonist or antagonist

OBJECTIVE

To compare levels of apoptosis in granulosa cells from women treated with the gonadotropin-releasing hormone (GnRH) agonist triptorelin or the GnRH antagonist cetrorelix.

DESIGN

Randomized, prospective study.

SETTING

University hospital.

PATIENT(S)

Thirty-two women undergoing assisted reproduction techniques after ovulation induction with recombinant follicle-stimulating hormone (FSH) plus GnRH agonist or antagonist.

INTERVENTION(S)

Granulosa cells were isolated from follicular aspirates after oocyte removal.

MAIN OUTCOME MEASURE(S)

Apoptosis was assessed with Annexin V binding assay, terminal deoxynucleotidyl transferase (TdT)-mediated nick-end labeling (TUNEL) assay, flow cytometric analysis of DNA, and ultrastructural analysis of cell morphology in transmission electron microscopy. Serum and follicular hormonal levels were also determined.

RESULT(S)

Annexin V binding and TUNEL assays revealed comparable percentages of apoptosis in the two groups under investigation. Analysis of DNA histograms revealed a similar cell cycle distribution in the two groups. Ultrastructural analysis only occasionally displayed patterns of chromatin margination in apoptotic cells. The mean concentrations of all the follicular fluid steroid hormones evaluated (E2, T, and P) were significantly lower in the GnRH antagonist-treated group.

CONCLUSION(S)

Therapy with a GnRH agonist or antagonist is associated with comparable levels of apoptosis in granulosa cells.

Long-term pituitary down-regulation before in vitro fertilization (IVF) for women with endometriosis

BACKGROUND

Women with endometriosis who are treated with in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) have a lower pregnancy rate compared to women with tubal factor infertility. It has been suggested that the administration of gonadotrophin releasing hormone (GnRH) agonists for a few months prior to IVF or ICSI increases the pregnancy rate.

OBJECTIVES

To determine the effectiveness of administering GnRH agonists for three to six months prior to IVF or ICSI in women with endometriosis.

SEARCH STRATEGY

We used computer searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the National Research Register (NRR) and the MDSG Specialised Register of controlled trials. We handsearched proceedings of annual meetings of the American Society for Reproductive Medicine (ASRM) and the European Society for Human Reproduction and Embryology (ESHRE). We reviewed lists of references in original research and review articles. We contacted experts in various countries to identify unpublished trials.

SELECTION CRITERIA

We included randomised controlled trials using any GnRH agonist prior to IVF or ICSI to treat women with any degree of endometriosis diagnosed by laparoscopy or laparotomy

DATA COLLECTION AND ANALYSIS

Two independent review authors abstracted data (HNS and JGV). We sent e-mails to investigators to seek additional information. We assessed the validity of each study using the methods suggested in the Cochrane Handbook. The data were checked by the third review author (SD) and any disagreement was resolved by arbitration with the fourth review author (AA). We generated 2 x 2 tables for principal outcome measures. The Peto-modified Mantel-Haenszel technique was used to calculate odds ratios (OR) and assess statistical heterogeneity between studies.

MAIN RESULTS

Three randomised controlled trials (with 165 women) were included. The live birth rate per woman was significantly higher in women receiving the GnRH agonist compared to the control group (OR 9.19, 95% CI 1.08 to 78.22). However, this was based on one trial reporting "viable pregnancy" only. The clinical pregnancy rate per woman was also significantly higher (three studies: OR 4.28, 95% CI 2.00 to 9.15). The information on miscarriage rates came from two trials with high heterogeneity and, therefore, results of the meta-analysis were doubtful. The included studies provided insufficient data to investigate the effects of administration of GnRH agonists on multiple or ectopic pregnancies, fetal abnormalities or other complications.

AUTHORS' CONCLUSIONS

The administration of GnRH agonists for a period of three to six months prior to IVF or ICSI in women with endometriosis increases the odds of clinical pregnancy by fourfold. Data regarding adverse effects of this therapy on the mother or fetus are not available at present.

Impact of ovarian endometrioma on assisted reproduction outcomes

The effects of ovarian endometrioma on fertility outcomes with IVF and embryo transfer have been causally related to poor outcomes. The objective of this meta-analysis was to evaluate the ovarian reserve and ovarian responsiveness to ovarian stimulation and assisted reproduction outcomes in patients with ovarian endometrioma. The odds for clinical pregnancy were not affected significantly in patients with ovarian endometrioma compared with controls, with an overall odds ratio of 1.07 from three studies [95% CI: (0.63, 1.81), P = 0.79]. The overall pregnancy rate was similar with an estimated odds ratio of 1.17 [95% CI: (0.85, 1.60), P = 0.34]. Decreased ovarian responsiveness to ovarian stimulation in patients with ovarian endometrioma may be due to a reduced number of follicles in these patients compared with controls (P = 0.002). Prospective randomized controlled trials are needed to assess whether surgical treatment versus no surgical treatment improves pregnancy outcomes in patients with ovarian endometrioma undergoing assisted reproduction cycles.

Predictive value of cumulus cell apoptosis with regard to blastocyst development of corresponding gametes

OBJECTIVE

To test if a high degree of apoptosis in cumulus cells could indicate diminished oocyte quality and developmental competence.

DESIGN

Prospective analysis.

SETTING

Public hospital and university.

PATIENT(S)

Thirty seven women who gave written consent to participate in this study.

INTERVENTION(S)

Cumulus-oocyte complexes were denuded separately and the resulting cumulus cell suspensions were analyzed for presence of apoptosis using a terminal deoxynucleotidyl transferase-mediated digoxigenin-dUTP nick-end labeling (TUNEL) assay detection kit.

MAIN OUTCOME MEASURE(S)

Percentage of apoptotic cumulus cells and blastocyst formation rate.

RESULT(S)

Younger patients (< or = 35 years) showed significantly fewer apoptotic cumulus cells than older ones. In all patients gamete maturity was shown to be highly correlated to the rate of apoptosis in cumulus cells. At zygote and cleavage stages (days 1 to 4) no morphologic features were related to the degree of programmed cell death. However, blastocyst development was predictable taking into account the percentage of apoptosis in associated somatic cells. In addition, there was a trend toward better quality blastocysts from follicles with a lower rate of apoptotic cells. No influence on pregnancy and implantation rate was observed.

CONCLUSION(S)

Apoptotic processes within follicles seem to impair oocyte maturation. Though not manifested in the morphologic appearance, gametes and embryos derived from cumulus complexes with no or minor apoptosis have an increased chance of giving rise to optimal blastocysts.

Impact of ovarian endometrioma on oocytes and pregnancy outcome in in vitro fertilization

OBJECTIVE

To evaluate the effect of endometriosis and the presence of an ovarian endometrioma on outcomes of conventional in vitro fertilization (IVF).

DESIGN

Retrospective study.

SETTING

Reproductive Unit, Department of Obstetrics and Gynecology, Tokai University Hospital.

PATIENT(S)

Group A: 80 cycles with ovarian endometriomas; group B: 248 cycles with endometriosis but without endometrial cysts at the time of oocyte retrieval; group C: 283 cycles undergoing IVF because of tubal factor without endometriosis.

INTERVENTION(S)

All conventional in vitro fertilization-embryo transfer (IVF-ET) with previous diagnostic laparoscopy. An endometrioma was diagnosed by direct aspiration at the time of oocyte retrieval.

MAIN OUTCOME MEASURE(S)

Retrieved number of oocytes, fertilization rate, embryo quality, implantation rate, pregnancy rate, and live birth rate for all cases. In group A, the number of retrieved oocytes in relation to the volume of the endometrioma and affected laterality.

RESULT(S)

Fewer oocytes were retrieved from groups A and B than from group C (P<.005). The number of retrieved oocytes was not dependent on the volume of endometrial cyst(s). Fertilization rates were similar among the groups. Group A had slightly but not significantly higher rates of morphologically good-quality embryos (group A: 67.2%, group B: 63.0%, group C: 58.1%), implantation (group A: 14.1%, group B: 11.7%, group C: 11.3%), and pregnancy (group A: 25.3%, group B: 22.3%, group C: 23.9%).

CONCLUSION(S)

Endometriosis affects oocyte number but not embryo quality or pregnancy outcome, irrespective of the presence of an ovarian endometrioma.

[Laser vaporization of ovarian endometriomas: the impact on the response to gonadotrophin stimulation]

OBJECTIVE

To evaluate the ovarian response to stimulation for IVF in endometriosis patients who have previously undergone laparoscopic treatment of peritoneal and/or ovarian endometriosis (CO2 laser vaporization).

PATIENTS AND METHODS

Retrospective study of 455 patients undergoing IVF. The study group, made up of 127 endometriosis patients, was divided into 2 subgroups: Ia: 42 women with peritoneal endometriosis, treated by laparoscopy, who underwent 71 IVF cycles; Ib: 85 women with ovarian endometriomas, treated by vaporization of the internal wall, who underwent 187 IVF cycles. The control group, consisting of 328 women, was also divided into 2 subgroups: IIa: 193 women suffering from tubal infertility who underwent 422 IVF cycles; IIb: 135 women with idiopathic infertility who underwent 275 IVF cycles.

RESULTS

The ovarian stimulation parameters (number of gonadotrophin ampoules, number of follicles and mature oocytes, maximum estradiol concentrations) were not significantly different in the various subgroups. The number of embryos obtained and transferred per cycle, the fertilization rates (group Ia: 61.81%; Ib: 60.90%; IIa: 62.48%; IIb: 57.99%), the implantation rates (group Ia: 17.72%; Ib: 15%; IIa: 13.94%; IIb: 18.05%) and the clinical pregnancy rates (group Ia: 32.39%; Ib: 37.40%; IIa: 27.49%; IIb: 30.18%) were not statistically different in the studied subgroups.

DISCUSSION AND CONCLUSION

The theoretical risk of loss of ovarian cortex when treating endometriotic cysts can be eliminated by the technique of vaporization of the internal wall of the endometrioma.IVF outcomes are similar in patients treated for endometriosis and those presenting with unexplained or tubal infertility.

How does endometriosis affect infertility?

Prospective and retrospective clinical trials suggest a decreased oocyte and embryo quality in women with endometriosis. Based on these observations, the authors described an altered intrafollicular milieu in endometriosis, which explains the bad quality oocytes and the resulting embryos with lower capacity to implant. Whether these changes affect the oocytes or are the consequence of genomic alterations manifested by biochemical and chromosomal differences in healthy women is an unresolved issue. If the effects of endometriosis on follicular development are nongenomic in origin, modulation of the process of folliculogenesis may be sufficient to treat the disease and cure infertility associated with endometriosis. A genomic defect needs specific genetic therapy, which currently is not available.

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.

New advances in the understanding of endometriosis related infertility

The association between endometriosis and infertility is complex. Nevertheless, in the absence of tubal distortion considerable evidence suggests four principle factors likely to contribute to subfertility. These include impaired folliculogenesis, decreased fertilization, inflammatory factors in follicular, peritoneal and reproductive tract fluid, and implantation defects. The potential impact of each of these is critically examined. The role of endometriomas, prior surgeries and donor oocytes is also discussed.

Expression and function of 3beta hydroxisteroid dehydrogenase (3beta HSD) type II and corticosteroid binding globulin (CBG) in granulosa cells from ovaries of women with and without endometriosis

PURPOSE

To investigate the secretion of progesterone (P4) and corticosteroid binding globulin (CBG) by granulosa luteal cells (GC) as well as the mRNA levels of CBG and 3beta hydroxisteroid dehydrogenase (3beta HSD), in women with and without endometriosis in vivo and in vitro.

METHODS

Prospective study in a private, university-affiliated assisted reproduction unit, including women with severe endometriosis (n = 14) or without the disease (n = 20) undergoing in vitro fertilization/intracytoplasmic sperm injection and embryo transfer. GC were obtained from each follicle aspirated, pooled for each patient, and follicular and blood contaminating leukocytes depleted through immunomagnetic purification. Secreted P4 and CBG, and mRNA for both 3beta HSD and CBG were determined in vivo and in vitro using RIA and reverse transcription followed by competitive polymerase chain reaction (cRT-PCR).

RESULTS

The pattern of expression of 3beta HSD and CBG mRNAs in vivo and in vitro was similar in both groups. Also, GC from patients with endometriosis produced equal amounts of P4 and CBG than controls without the disease, either in freshly isolated cells or in 24-h cultures.

CONCLUSIONS

The GC function in terms of 3beta HSD and CBG mRNA expression and P4/CBG secretion does not seem to be altered in patients with endometriosis in comparison with those without this condition.

Ovarian response during IVF-embryo transfer cycles after laparoscopic ovarian cystectomy for endometriotic cysts of >3 cm in diameter

BACKGROUND

Ovarian response during IVF cycles after laparoscopic ovarian cystectomy for endometriotic cysts >3 cm is controversial. A retrospective study was designed to study this problem.

METHODS

At laparoscopy, endometriomas >3 cm were treated by ovarian cystectomy, whilst adhesions and peritoneal endometriosis were treated using conventional techniques. Ovarian stimulation was achieved with clomiphene and gonadotrophins or with gonadotrophins after a desensitization with gonadotrophin-releasing hormone agonists. Three groups of patients were retrospectively selected from an IVF-embryo transfer database: patients who underwent laparoscopic ovarian cystectomy for an endometrioma >3 cm (Group A, n = 41), patients with endometriosis without ovarian endometrioma (Group B, n = 139) and patients with tubal infertility (Group C, n = 59).

RESULTS

The groups did not differ in age. In the first IVF cycle, the mean (+/- SD) numbers of oocytes and of embryos were 9.4 +/- 6.2 and 4.7 +/- 3.6 respectively in group A and 11.6 +/- 7.5 and 5.1 +/- 4.9 in group B (not significant). The results did not differ in cycles 2 and 3 or when compared according to age. No difference was found when comparing patients with endometriosis and patients with tubal infertility.

CONCLUSION

The number of oocytes and embryos obtained was not significantly decreased by laparoscopic cystectomy, suggesting that in experienced hands this procedure may be a valuable surgical tool for the treatment of large ovarian endometriomas. However, great care must be taken to avoid ovarian damage.

Expression, production, and secretion of vascular endothelial growth factor and interleukin-6 by granulosa cells is comparable in women with and without endometriosis

OBJECTIVE

To investigate the production and secretion of interleukin (IL)-6 and vascular endothelial growth factor (VEGF) mRNA and protein by granulosa luteal cells (GCs) in vivo and in vitro in women with and without endometriosis.

DESIGN

Prospective study.

SETTING

A private, university-affiliated assisted reproduction unit and a university center.

PATIENT(S)

Women with severe endometriosis (n = 6) or without the disease (n = 14) after laparoscopy, undergoing in vitro fertilization/intracytoplasmic sperm injection and embryo transfer.

INTERVENTION(S)

GCs were obtained from each aspirate.

MAIN OUTCOME MEASURE(S)

Intracellular and secreted protein, as well as mRNA for both VEGF and IL-6 in GCs.

RESULT(S)

The expression of VEGF and IL-6 mRNAs in vivo and in vitro was similar in both groups. Also, GCs from patients with endometriosis produced and secreted equal amounts of these proteins compared with controls without the disease, either in freshly isolated cells or in 24-hour cultures.

CONCLUSION(S)

The GC function in terms of VEGF and IL-6 production does not seem to be altered in patients with endometriosis in comparison with those without this condition.

Endometriosis and assisted reproductive technologies: are outcomes affected?

The preponderance of recent data suggests that endometriosis does not adversely affect in-vitro fertilization pregnancy rates. However, many studies demonstrate impaired oocyte quality, decreased fertilization, and compromised implantation rates. Such findings give insight into the mechanisms by which endometriosis may impact on fertility, and provide clues as how to focus assisted reproductive technologies in order to overcome these deficiencies. Specifically, extended downregulation protocols, ample use of gonadotropins for ovarian stimulation, and conservative management of endometriomas have all been suggested as means to optimize in-vitro fertilization outcomes for women with endometriosis.

Effects of controlled ovarian hyperstimulation on oocyte quality in terms of the incidence of apoptotic granulosa cells

PURPOSE

The aim was to investigate which ovarian hyperstimulation protocol performed in the same patients causes development of oocytes of good quality.

METHODS

Twenty normo-ovulatory women underwent three different controlled ovarian hyperstimulation protocols for in vitro fertilization-embryo transfer. Patients underwent follicle aspiration after administration of human chorionic gonadotropin (hCG). The total number of retrieved oocytes, the number of mature oocytes, and the rate of mature oocytes were examined. Recovered granulosa cells were stained with Hoechst 33258 and examined by fluorescence microscopy to estimate the incidence of apoptotic cells.

RESULTS

The total number of oocytes and the number of mature oocytes in gonadotropin-releasing hormone agonist (GnRHa) + human menopausal gonadotropin (hMG) + hCG and hMG + hCG cycles were higher than those in the natural cycle (P < 0.0001). The rate of mature oocytes in hMG + hCG cycle was the highest among the three protocols (P < 0.04). In the mural granulosa cells, the incidence of apoptotic cells in the GnRHa + hMG + hCG cycle was significantly higher than those of the natural (P < 0.002) and hMG + hCG cycles (P = 0.0002). The incidence of apoptotic cumulus granulosa cells in the GnRHa + hMG + hCG cycle was significantly higher than those of natural and hMG + hCG cycles (P < 0.002). Moreover, the incidence of apoptotic cumulus granulosa cells in the hMG + hCG cycle was significantly lower than that in the natural cycle (P < 0.01).

CONCLUSIONS

These results indicated that hMG + hCG is the most appropriate controlled ovarian hyperstimulation protocol among the three examined with regard to oocyte quality.

Effects of aging on ovarian fecundity in terms of the incidence of apoptotic granulosa cells

PURPOSE

The objective was to determine the effects of women's age on the ovarian fecundity as assessed by the incidence of apoptotic granulosa cells.

METHODS

Twenty-eight normo-ovulatory women underwent ovulation induction for standard IVF. The husbands of these women showed severe male infertility factors. The women were divided into four groups according to their ages. Women underwent follicle aspiration after the administration of human menopausal gonadotropin plus human chorionic gonadotropin. The nuclei of granulosa cells were examined by using fluorescence microscopy, and the incidence of apoptotic granulosa cells was tabulated.

RESULTS

Granulosa cells in the older women revealed a significant increase in the number of apoptotic cells. The number of total oocytes and the number of mature oocytes obtained significantly decreased with age. However, endometrial thickness and follicular estradiol, progesterone, and free testosterone levels were not significantly different among four different age groups.

CONCLUSIONS

Age increases apoptotic changes in granulosa cells and consequently decreases the ovarian fecundity.

Relatively poor oocyte quality is an indication for intracytoplasmic sperm injection

OBJECTIVE

To determine the relation between the insemination method used and the quality of oocytes and embryos.

DESIGN

Prospective study.

SETTING

Assisted reproductive centers at Yamagata University Hospital and Kuramoto Women's Clinic in Yamagata, Japan.

PATIENT(S)

Forty patients undergoing IVF and 40 patients undergoing intracytoplasmic sperm injection (ICSI).

INTERVENTION(S)

To estimate oocyte quality, the granulosa cells surrounding the oocyte were fixed and stained with a commercial dye in both groups of patients. One thousand granulosa cells were examined under a fluorescence microscope.

MAIN OUTCOME MEASURE(S)

The incidence of apoptotic granulosa cells surrounding each oocyte.

RESULT(S)

The incidence of apoptosis in the granulosa cells enclosing the oocytes that were fertilized by IVF was significantly lower than that in the oocytes that were fertilized by ICSI. Moreover, the incidence of apoptosis in the granulosa cells enclosing the oocytes that grew into good-quality or fair-quality embryos was significantly lower after conventional IVF than after ICSI. With ICSI, the incidence of apoptosis was not significantly different among the granulosa cells surrounding the oocytes that were inseminated, were fertilized, or developed into good-quality or fair-quality embryos. With IVF, the incidence of apoptosis was highest in the granulosa cells surrounding the oocytes that were inseminated and lowest in the granulosa cells surrounding the oocytes that developed into good-quality and fair-quality embryos.

CONCLUSION(S)

A good-quality oocyte is necessary for the development of a good-quality embryo with IVF but not with ICSI. Thus, relatively poor oocyte quality is a good indication for the use of ICSI.

Hyaluronic acid inhibits apoptosis in granulosa cells via CD44

PURPOSE

This study was designed to examine whether hyaluronic acid (HA) inhibits apoptosis in cumulus and mural granulosa cells and to examine whether this effect of HA was mediated through CD44.

METHODS

Mural and cumulus granulosa cells were obtained from in vitro fertilization patients. The cells were cultured with various concentrations of HA or HA plus various concentrations of anti-CD44 antibody without serum supplement. After 24 hr of culture, the cells were fixed and stained with Hoechst 33258. One thousand granulosa cells of each conditions were observed by fluorescence microscopy.

RESULTS

HA inhibited apoptosis in both kinds of granulosa cells, and anti-CD44 antibody prevented this effect of HA.

CONCLUSIONS

The incidence of apoptotic granulosa cells with fragmented condensed nuclei was reduced by HA via CD44.

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.

Chocolate cysts from ovarian follicles

OBJECTIVE

To study the development of chocolate cysts by serial transvaginal ultrasonographic tracking of ovarian follicles.

DESIGN

Retrospective study.

SETTING

Department of Obstetrics and Gynaecology, Sunderland Royal Hospital, Sunderland, United Kingdom.

PATIENT(S)

We reviewed case notes of all patients who underwent laparoscopy for diathermy to endometriosis/ovarian diathermy/aspiration of ovarian cysts from 1989 to 1998. Twelve women with histories of infertility and proven chocolate cysts with documented ultrasonographic findings were included in the study.

INTERVENTION(S)

Serial ultrasonographic tracking of ovarian follicles in the cycle leading to the development of the chocolate cysts, followed by ultrasonographic tracking of cysts for 3 months and laparoscopy.

MAIN OUTCOME MEASURE(S)

Development and formation of chocolate cysts.

RESULT(S)

The diagnosis of chocolate cysts was confirmed laparoscopically in all patients and histopathologically in four. Ultrasound confirmed that they had all developed from follicles.

CONCLUSION(S)

Chocolate cysts can develop from ovarian follicles.