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

Embryo Cryopreservation Strategy May Improve Live Birth for Women Underwent In Vitro Maturation After Early Oocyte Retrieval: A Retrospective Cohort Study

There is limited clinical research investigating the optimal transplantation strategy in early oocyte retrieval cycles. We aimed to assess whether the maturation of oocytes from early oocyte retrieval influenced pregnancy outcomes, and to find the optimal embryo transfer strategy (fresh or frozen-thawed embryo transfers) for patients who had early oocyte retrieval and underwent in vitro maturation (IVM). A retrospective cohort study was conducted in a university-based reproductive medical center. A total of 234 women who underwent single embryo transfer after early oocyte retrieval were included. The primary outcome was live birth rate. The live birth rate (12.5% vs. 27.5%, p = 0.005, adjusted p = 0.010) was significantly lower in IVM cycles compared with no IVM cycles. There was a significant decrease in live birth (3.6% vs. 19.0%, p = 0.008, adjusted p = 0.011) and a markedly elevated early pregnancy loss rate (62.5% vs. 11.1%, p = 0.014, adjusted p = 0.012) for IVM fresh cycles compared with no IVM fresh cycles. However, these findings were not repeated in subgroup analysis when frozen-thaw embryos were transferred. These results indicate that patients who underwent early oocyte retrieval and then IVM-intracytoplasmic sperm injection should be recommended the embryo cryopreservation strategy. Resynchronization of the embryo and the endometrium in frozen-thaw embryo transfer cycles may optimize live birth and decrease early pregnancy loss in IVM-intracytoplasmic sperm injection cycles after early oocyte retrieval.

OUP accepted manuscript

STUDY QUESTION

Can the accuracy of timing of luteal phase endometrial biopsies based on urinary ovulation testing be improved by measuring the expression of a small number of genes and a continuous, non-categorical modelling approach?

SUMMARY ANSWER

Measuring the expression levels of six genes (IL2RB, IGFBP1, CXCL14, DPP4, GPX3 and SLC15A2) is sufficient to obtain substantially more accurate timing estimates and to assess the reliability of timing estimates for each sample.

WHAT IS KNOWN ALREADY

Commercially available endometrial timing approaches based on gene expression require large gene sets and use a categorical approach that classifies samples as pre-receptive, receptive or post-receptive.

STUDY DESIGN, SIZE, DURATION

Gene expression was measured by RTq-PCR in different sample sets, comprising a total of 664 endometrial biopsies obtained 4–12 days after a self-reported positive home ovulation test. A further 36 endometrial samples were profiled by RTq-PCR as well as RNA-sequencing.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A computational procedure, named ‘EndoTime’, was established that models the temporal profile of each gene and estimates the timing of each sample. Iterating these steps, temporal profiles are gradually refined as sample timings are being updated, and confidence in timing estimates is increased. After convergence, the method reports updated timing estimates for each sample while preserving the overall distribution of time points.

MAIN RESULTS AND THE ROLE OF CHANCE

The Wilcoxon rank-sum test was used to confirm that ordering samples by EndoTime estimates yields sharper temporal expression profiles for held-out genes (not used when determining sample timings) than ordering the same expression values by patient-reported times (GPX3: P < 0.005; CXCL14: P < 2.7e−6; DPP4: P < 3.7e−13). Pearson correlation between EndoTime estimates for the same sample set but based on RTq-PCR or RNA-sequencing data showed a high degree of congruency between the two (P = 8.6e−10, R² = 0.687). Estimated timings did not differ significantly between control subjects and patients with recurrent pregnancy loss or recurrent implantation failure (P > 0.05).

LARGE SCALE DATA

The RTq-PCR data files are available via the GitHub repository for the EndoTime software at https://github.com/AE-Mitchell/EndoTime, as is the code used for pre-processing of RTq-PCR data. The RNA-sequencing data are available on GEO (accession GSE180485).

LIMITATIONS, REASONS FOR CAUTION

Timing estimates are informed by glandular gene expression and will only represent the temporal state of other endometrial cell types if in synchrony with the epithelium. Methods that estimate the day of ovulation are still required as these data are essential inputs in our method. Our approach, in its current iteration, performs batch correction such that larger sample batches impart greater accuracy to timing estimations. In theory, our method requires endometrial samples obtained at different days in the luteal phase. In practice, however, this is not a concern as timings based on urinary ovulation testing are associated with a sufficient level of noise to ensure that a variety of time points will be sampled.

WIDER IMPLICATIONS OF THE FINDINGS

Our method is the first to assay the temporal state of luteal-phase endometrial samples on a continuous domain. It is freely available with fully shared data and open-source software. EndoTime enables accurate temporal profiling of any gene in luteal endometrial samples for a wide range of research applications and, potentially, clinical use.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by a Wellcome Trust Investigator Award (Grant/Award Number: 212233/Z/18/Z) and the Tommy's National Miscarriage Research Centre. None of the authors have any competing interests. J.L. was funded by the Biotechnology and Biological Sciences Research Council (UK) through the Midlands Integrative Biology Training Partnership (MIBTP, BB/M01116X/1).

Patterns of sex hormone receptor expression in stimulated endometrium from oocyte donors

In patients with high serum E₂ embryo transfer is often postponed, as high E₂ levels adversely affect embryo transfer outcome. We aimed to determine if stratified serum oestradiol (E₂) and progesterone (P₄) levels differentially affect endometrial histology and endometrial oestrogen and progesterone receptor protein levels. Endometrial biopsies were collected from oocyte donors. Samples were divided based on peak serum E₂ levels into three groups: (i) low-E₂ (n = 33) E₂≤2999pg/mL; (ii) mid-E₂ (n = 40) E₂ 3000-4999 pg/mL; and (iii) high-E₂ (n = 15) E₂≥5000 pg/mL. Oestrogen receptor alpha (ERα) and progesterone receptors A and B (PR) protein levels in endometrial stroma (S), glandular (GE) and luminal (LE) epithelia were assessed by immunohistochemistry. Samples in high-E₂ group demonstrated strongest association with accelerated endometrial maturation (2 (1-2); 2 (1-3); and 3 (2.8-3) median days of advancement of endometrial maturation respectively in low, mid, high-E₂ groups, p = 0.046). There were significant differences in ERα and PR immunoexpression in S, GE and LE among the groups (p < 0.05). Higher E₂ levels were associated with decreased ERα expression (p < 0.017) in GE and LE, and increased PR expression in S and GE (p < 0.011 and p < 0.0001, respectively). Higher serum E₂ levels were associated with impaired endometrial steroid hormone receptor expression, higher serum P₄ and more advancement of endometrial maturation.

Pinopodes: Recent advancements, current perspectives, and future directions

Successful embryo implantation is a complex and highly regulated process involving precise synchronization between the fetal-derived trophoblast cells and maternal uterine luminal epithelium. Multiple endocrine-driven factors are important for controlling the timely receptivity of the uterus, and this complexity underscores implantation failure as a major cause of recurrent infertility associated with assisted reproductive technologies. One particular cellular structure often hypothesized to promote receptivity is the pinopode or uterodome - a hormonally regulated, large cellular protrusion on the uterine epithelial surface. Recent clinical studies associate pinopodes with favorable fertility outcomes in women, and because they are directly linked to an increase in progesterone levels, the potential utility of these hormone-regulated cell biological structures in predicting or improving implantation in a clinical setting holds promise. In this review, we aim to generate interest in pinopodes from the broader cell biology and endocrinology communities, re-examine methodologies in pinopode research, and identify priorities for future investigation of pinopode structure and function in women's reproductive health.

Delayed frozen embryo transfer failed to improve live birth rate and neonatal outcomes in patients requiring whole embryo freezing

BACKGROUND

Controlled ovarian stimulation (COS) has a negative effect on the endometrial receptivity compared with natural menstrual cycle. Whether it's necessary to postpone the first frozen embryo transfer (FET) following a freeze-all strategy in order to avoid any residual effect on endometrial receptivity consequent to COS was inconclusive.

OBJECTIVE

The purpose of this retrospective study was to explore whether the delayed FET improve the live birth rate and neonatal outcomes stratified by COS protocols after a freeze-all strategy.

METHODS

A total of 4404 patients who underwent the first FET cycle were enrolled in this study between April 2014 to December 2017, and were divided into immediate (within the first menstrual cycle following withdrawal bleeding) or delayed FET (waiting for at least one menstrual cycle and the transferred embryos were cryopreserved for less than 6 months). Furthermore, each group was further divided into two subgroups according to COS protocols, and the pregnancy and neonatal outcomes were analyzed between the immediate and delayed FET following the same COS protocol.

RESULTS

When FET cycles following the same COS protocol, there was no significant difference regarding the rates of live birth, implantation, clinical pregnancy, multiple pregnancy, early miscarriage, premature birth and stillbirth between immediate and delayed FET groups. Similarly, no significant differences were found for the mean gestational age, the mean birth weight, and rates of low birth weight and very low birth weight between the immediate and delayed FET groups. The sex ratio (male/female) and the congenital anomalies rate also did not differ significantly between the two FET groups stratified by COS protocols.

CONCLUSION

Regardless of COS protocols, FET could be performed immediately after a freeze-all strategy for delaying FET failed to improve reproductive and neonatal outcomes.

Transcriptome sequencing of endometrium revealed alterations in mRNAs and lncRNAs after ovarian stimulation

RESEARCH QUESTION

Using RNA-sequencing analysis, we investigated the relationship between ovarian stimulation and endometrial transcriptome profiles during the window of implantation (WOI) to identify candidate predictive factors for the WOI and to optimize timing for embryo transfer.

METHODS

Twelve women with normal basal hormone levels and regular ovulation were randomly assigned into three groups based on sampling time: late-proliferate phase (P group), and receptive phase in natural cycles (LH+7, N group) and stimulated cycles (hCG+7, S group). Transcriptome profiles of mRNAs and long non-coding RNAs (lncRNAs) were then compared among the three groups. Validation was performed using real-time qPCR.

RESULTS

Comparison of transcriptome profiles between the natural and stimulated endometrium revealed 173 differentially expressed genes (DEGs), with a > 2-fold change (FC) and p < 0.05, under the influence of supraphysiological estradiol (E2) induced by ovarian stimulation. By clustering and KEGG pathway analysis, molecules and pathways associated with endometrial receptivity were identified. Of the 39 DEGs common to the three groups, eight genes were validated using real-time PCR. ESR1, MMP10, and HPSE were previously reported to be associated with endometrial receptivity. In addition, three novel genes (IL13RA2, ZCCHC12, SRARP) and two lncRNAs (LINC01060, LINC01104) were new potential endometrial receptivity-related markers.

CONCLUSION

Using mRNA and lncRNA sequencing, we found that supraphysiological E2 levels from ovarian stimulation had a marked impact upon endometrial transcriptome profiles and may result in a shift of the WOI. The precise mechanisms underlying the supraphysiological hormone-induced shift of the WOI require further research.

REGISTRATION NUMBER

ChiCTR180001453.

Molecular Signaling Regulating Endometrium-Blastocyst Crosstalk

Implantation of the embryo into the uterine endometrium is one of the most finely-regulated processes that leads to the establishment of a successful pregnancy. A plethora of factors are released in a time-specific fashion to synchronize the differentiation program of both the embryo and the endometrium. Indeed, blastocyst implantation in the uterus occurs in a limited time frame called the "window of implantation" (WOI), during which the maternal endometrium undergoes dramatic changes, collectively called "decidualization". Decidualization is guided not just by maternal factors (e.g., estrogen, progesterone, thyroid hormone), but also by molecules secreted by the embryo, such as chorionic gonadotropin (CG) and interleukin-1β (IL-1 β), just to cite few. Once reached the uterine cavity, the embryo orients correctly toward the uterine epithelium, interacts with specialized structures, called pinopodes, and begins the process of adhesion and invasion. All these events are guided by factors secreted by both the endometrium and the embryo, such as leukemia inhibitory factor (LIF), integrins and their ligands, adhesion molecules, Notch family members, and metalloproteinases and their inhibitors. The aim of this review is to give an overview of the factors and mechanisms regulating implantation, with a focus on those involved in the complex crosstalk between the blastocyst and the endometrium.

Aberrant endometrial steroid receptor expression in in-vitro maturation cycles despite hormonal luteal support: A pilot study

Clinical outcomes of fresh embryo transfer in non-hCG triggered in vitro maturation (IVM) cycles are inferior compared to vitrified-warmed embryo transfer. This is a prospective observational pilot study in a consecutive cohort of 31 polycystic ovary syndrome (PCOS) patients and 37 normo-ovulatory egg donors who underwent IVM without fresh embryo transfer between July 2009 and June 2014. All subjects received 150 IU of highly purified menotropin (HP-hMG) daily for three days. On cycle day 6, all patients started transdermal oestradiol (E2) at a daily dose of 9 mg. There was no human chorionic gonadotropin (hCG) trigger before oocyte retrieval (OR). Vaginal micronized progesterone was commenced on the evening after OR, at a daily dose of 600 mg. Additional luteal phase support (LPS) was administered as follows: Group A: no additional LPS; Group B: 1500 IU of hCG administered 4 h after OR and Group C: 5000 IU of hCG administered 4 h after OR + an additional injection of 5000 IU of hCG 1 day before endometrial biopsy. Endometrial biopsy for histology and immunohistochemistry (IHC) was performed on day 5 or 6 after OR. Instead of being downregulated, both PR-B and ERα in endometrial glands and stroma were moderately to strongly expressed in all three protocols, suggesting that the mid-luteal histological signature of endometrial receptivity is deficient in a non-hCG-triggered IVM cycle. Poor clinical outcomes after fresh embryo transfer following IVM are probably related to inappropriate endometrial development which may be linked to the short follicular phase of IVM cycles.

Intrauterine infusion of human chorionic gonadotropin before embryo transfer in IVF/ET cycle: The critical review

Intrauterine infusion of human chorionic gonadotropin (IUI-hCG) has been proposed to improve the outcome of in vitro fertilization-embryo transfer (IVF-ET), since it plays a critical role in synchronizing endometrial and fetal development. As the early mediator from embryo, hCG promotes the decidualization, angiogenesis, maternal immune tolerance, and trophoblast invasion, favoring successful implantation of embryo. Although multiple clinical trials have been conducted to verify the efficacy of IUI-hCG on IVF-ET outcome in recent years, the findings remained controversial. The difference in study design and population might be the cause to the different consequences after administration of hCG. More importantly, the endometrial receptivity, which might affect the efficacy of IUI-hCG, has not been assessed in women receiving this intervention. Selecting the right population suitable for IUI-hCG based on known etiology would be crucial in enhancing its efficacy and minimize any possible complications. Investigation of optimal indications for IUI-hCG should be highlighted in the future.

Pinopode score around the time of implantation is predictive of successful implantation following frozen embryo transfer in hormone replacement cycles

STUDY QUESTION

Is pinopode measurement of any prognostic value?

SUMMARY ANSWER

Pinopode expression was significantly associated with the occurrence of pregnancy after frozen embryo transfer.

WHAT IS KNOWN ALREADY

Pinopodes are expressed in the endometrium during the implantation period. Pinopode measurement has been proposed as a marker of endometrial receptivity.

STUDY DESIGN, SIZE, DURATION

A prospective cohort study was conducted at the Center of Reproductive Medicine, Sir Run Run Shaw Hospital, between 2014 and 2016, recruiting 172 women with infertility and undergoing frozen embryo transfer following IVF treatment. Among 172 participants, 46 women took part in the first study to quantify the daily changing pattern of pinopodes 3-7 days after the initiation of progesterone therapy in the hormone replacement cycles and the remaining 126 women with infertility participated in a study to examine the relationship between pinopode count and pregnancy outcome following frozen embryo transfer in hormone replacement cycles.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The mean age of participants was 29 years old. All participants received an artificial hormone replacement protocol capable of supporting successful implantation. Endometrial biopsies from 46 women were obtained 3, 4, 5, 6 and 7 days after the initiation of progesterone therapy (P + 3, n = 6; P + 4, n = 6; P + 5, n = 11; P + 6, n = 13; P + 7, n = 10, respectively). Another 126 endometrial biopsies were obtained precisely 6 days after the initiation of progesterone. Scanning electron microscopy was used to capture the pinopode images, followed by use of the image J program to quantify the count and subtype of the pinopodes.

MAIN RESULTS AND THE ROLE OF CHANCE

We found that at least 60 microscopic fields were necessary to achieve a reproducible result. An intra-observer variability study showed good agreement between two measurements regarding the developing pinopode (DP) subtype (r = 0.95) and the fully developed pinopode (FDP) subtype (r = 0.86) but not for the regressing (RP) pinopode subtype (r = 0.39). The proportion of DP/total pinopodes (TP) declined rapidly form day P + 4 to a minimum on day P + 6. The percentage of FDP/TP increased rapidly from day P + 4 to reach a peak on day P + 6. On the other hand, the percentage of RP/TP reached a peak on day P + 7. Participants who conceived had a significantly (P = 0.011) higher percentage of FDP/TP on day P + 6 and significantly (P = 0.005) lower percentage of DP/TP on the same day compared with participants who did not become pregnant. Using a scoring system incorporating the percentages of DP and FDP, it was found that the pregnancy rate and the embryo implantation rate of women with a high pinopode score (82.3%; 63.0%) was significantly (P = 0.001; P = 0.046) higher than that of women with a low pinopode score (53.3%; 46.7%), respectively. There remains a possibility that the observations could have arisen due to chance.

LIMITATIONS, REASONS FOR CAUTION

This study examined pinopode count and subtype in the HRT cycles, and it is uncertain whether the same observations apply to in natural cycles.

WIDER IMPLICATIONS OF THE FNDINGS

Pinopodes have been questioned as a potential marker of endometrial receptivity for many years. Our results suggested that pinopode measurement may be of value in predicting pregnancy.

STUDY FUNDING/COMPETING INTEREST(S)

The study was supported by the grants from the general project of medicine and health in Zhejiang Province of China (2015KYA142; 2018KY106), the Key Research and Development Program of Zhejiang Province (2017C03022) and the National Natural Science Foundation of China (81701514).The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript. We have no competing interests to declare.

TRIAL REGISTRATION NUMBER

ISRCTN26300668.

Changes in Morphology and Presence of Pinopodes in Endometrial Cells during the Luteal Phase in Women with Infertility Problems: A Pilot Study

Objective: To investigate morphological changes in the endometrial epithelial cells of patients with infertility problems. Materials and methods: Endometrial biopsies were obtained from 10 women who have undergone several unsuccessful in vitro fertilisation (IVF) procedures. Endometrial biopsies were performed between luteinizing hormone surge days LH+6 to +10 of the natural menstrual cycle. Each sample was divided into three parts, which were processed for histological, transmission (TEM), and scanning electron microscopy (SEM) investigations. Results: Histological investigations demonstrated significant alterations in the apical part of epithelial cells of one patient; in four patients, the gland maturity was low, not matching the cycle day, and thus a phase lag had developed. By TEM examination, we ascertained changes in secretory and ciliated cells in three patients (decreased amount or missing microvilli, irregular cilia in ciliated cells). SEM examination found pinopodes in five patients: three samples contained fully developed pinopodes-larger and completely smooth, with only some wrinkles; one sample contained regressing small pinopodes, with wrinkled surfaces; and one sample had both developed and regressing pinopodes. Conclusions: To conclude, our study shows that the endometrium of patients with poor IVF outcome has either significant changes in the morphology or the endometrial maturation is inhibited and a phase lag often develops. Our study shows that endometrial pinopodes are found throughout the mid-luteal phase up to day LH+10.

Diverse endometrial mRNA signatures during the window of implantation in patients with repeated implantation failure

High endometrial receptivity in the window of implantation (WOI) is essential for successful implantation. However, a diagnostic tool with high specificity for impaired endometrial receptivity remains to be developed. We collected endometrium specimens during the WOI from patients with RIF and women who conceived after one IVF/ICSI attempt. We conducted mRNA microarray on the samples followed by relevant comparative and functional analysis. Microarray analysis revealed 357 dysregulated mRNAs between the two groups. The majority of these mRNAs were found to encode membrane proteins by Gene Ontology (GO) analysis. The major functional biological pathways associated with the down-regulated mRNAs were cytokine-cytokine receptor interaction, the p53 signalling pathway and the complement and coagulation cascades. Up-regulated mRNAs were found mainly to participate in pathways such as PPAR signalling, hematopoietic cell lineage, phosphatidylinositol signalling system, ECM-receptor interaction and notch signalling. AQP3, DPP4 and TIMP3 whose expression patterns were down-regulated in RIF patients both by microarray and real-time PCR had a high correspondence with previous studies demonstrating that these genes may contribute to the defects in endometrial receptivity in RIF patients. Overall, these RIF-associated mRNAs may help devise new diagnostic tools for endometrial receptivity.

Effect of the initiation of progesterone supplementation in in vitro fertilization-embryo transfer outcomes: a prospective randomized controlled trial

OBJECTIVE

To analyze the influence of the start point of luteal support on clinical pregnancy rate, implantation rate, and live birth rate of in vitro fertilization and embryo transfer (IVF-ET) cycles.

DESIGN

Single-center prospective randomized controlled trial.

SETTING

University-affiliated IVF unit.

PATIENT(S)

Women ≤35 years of age with day 3 FSH levels <15 mIU/mL, who were undergoing their first IVF-ET cycles and received ovarian stimulation with the use of a GnRH agonist long protocol.

INTERVENTION(S)

The patients were randomized on the day of hCG trigger to receive luteal phase support either 1 day after oocyte retrieval (group A) or on the day of oocyte retrieval (group B).

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate, implantation rate, miscarriage rate in the first trimester of pregnancy, and live birth rate per embryo transfer cycle.

RESULT(S)

Two hundred thirty-three patients were enrolled in this study: 117 were assigned to group A and 116 to group B. The clinical pregnancy rate (group A vs. group B: 55.3% vs. 51.5%), implantation rate (38.4% vs. 38.0%), and miscarriage rate (7.7% vs. 7.5%) were similar between the two groups. The live birth rate also did not significantly differ between the two groups (45.7% vs. 46.6%).

CONCLUSION(S)

Our study indicated that the initiation of progesterone supplementation 1 day after oocyte retrieval did not decrease the clinical pregnancy rate, implantation rate, or live birth rate in women undergoing IVF-ET cycles with the use of the GnRH agonist long protocol.

CLINICAL TRIAL REGISTRATION NUMBER

ChiCTR-IPR-14005293.

The effect of laser-assisted hatching on pregnancy outcomes of cryopreserved-thawed embryo transfer: a meta-analysis of randomized controlled trials

It is well known that laser-assisted hatching (LAH) is the most popular and ideal embryo hatching technology, but the relevance to pregnancy outcomes of cryopreserved-thawed embryo transfer (ET) is controversial. The purpose of this meta-analysis was to evaluate the effects of LAH on pregnancy outcomes of cryopreserved-thawed ET. We searched for relevant studies published in the PubMed, EMBASE, and Cochrane Central databases up to March 2017. This meta-analysis was primarily used to evaluate the effect of laser-assisted hatching on assisted reproductive outcomes: clinical pregnancy, embryo implantation, multiple pregnancy, miscarriage, and live birth. Using the Mantel-Haenszel fixed effects model and random effects model, we determined the summary odds ratios (OR) with 95% confidence intervals (CIs). There were 12 randomized controlled trials (more than 2574 participants) included in our analysis. The rates of clinical pregnancy (OR = 1.65, 95% CI = 1.24-2.19, I ² = 49), implantation (OR = 1.59, 95% CI = 1.06-2.38, I ² = 82%), multiple pregnancy (OR = 2.30, 95% CI = 1.30-4.07, I ² = 33%), miscarriage (OR = 0.86, 95% CI = 0.50-1.48, I ² = 0%), and live birth (OR = 1.09, 95% CI = 0.77-1.54, I ² = 0%) revealed comparable results for both groups. In summary, this meta-analysis demonstrates that LAH is related to a higher clinical pregnancy rate, embryo implantation rate, and multiple pregnancy rate in women with cryopreserved-thawed embryos. However, LAH is unlikely to increase live birth rates and miscarriage rates. Due to the small sample evaluated in the pool of included studies, large-scale, prospective, randomized, controlled trials are required to determine if these small effects are clinically relevant.

Effect of Acupuncture on Endometrial Angiogenesis and Uterus Dendritic Cells in COH Rats during Peri-Implantation Period

This study was to explore the mechanism of acupuncture on regulating the endometrial angiogenesis and uterus dendritic cells (uDCs) during the peri-implantation period. Rats, in early pregnancy, were randomized into five groups: normal (N), model (M), acupuncture (A), progesterone (P), and A + P groups. The COH model was established using pregnant mare serum, combined with human chorionic gonadotrophin. Endometrium was collected on days 4, 6, and 8 (D4, D6, and D8) of gestation. Compared with group M, both VEGF and FGF-2 protein and mRNA levels were significantly lower on D4 and higher on D6 and D8 (P < 0.05), except for VEGF of group P on D8; the proportion of uterus dendritic cells (uDCs) in the endometrium was significantly lower on D4 and D6 and higher on D8 (P < 0.05). In vitro, except for the proliferation of group P on D8, proliferation, tube formation, and migration of uDCs were significantly decreased on D4 and increased on D8 (P < 0.05). In addition, acupuncture or progesterone regulated the secretion levels of VEGF, IL-15, and IL-18 secreted by uDCs instead of soluble sFLT-1. In conclusion, acupuncture may regulate angiogenesis of the endometrium and the number and roles of uDCs after COH, and the specific mechanism may be different with progesterone.

Non-invasive prediction of implantation window in controlled hyperstimulation cycles: Can the time from the menstrual day at embryo transfer to expected menstrual cycle give a clue?

Objective:

The aim of this study was to assess whether the time from the menstrual day at embryo transfer to expected menstrual cycle (TETEMC) is associated with the implantation in women with regular cycles or not.

Materials and Methods:

Forty women with successful implantation and forty women without implantation with regular cycles were randomly selected from prospectively collected database of assisted reproductive technology clinic of Zeynep Kamil Women And Children’s Health Training and Research Hospital. TETEMC was calculated for each case to assess relationship with the successful implantation.

Results:

Comparison of groups revealed significant differences with regard to TETEMC and the menstrual period (p<0.05).

In ROC analyses both the TETEMC (AUC=0.824, p<0.001) and the menstrual period (AUC=0.797, p<0.001) were significant predictors for clinical pregnancy. Cut off value for the menstrual period was found to be 27.5 days with 82.6% sensitivity and 65% specificity. Cut off value for TETEMC was 11.5 days with 75% sensitivity and 63.2% specificity.

Conclusion:

Longer menstrual cycle and the TETEMC seem to be associated with the implantation failure.

The effect of a high progesterone concentration before oocyte retrieval on the peri-implantation endometrium

In this single-centre, prospective cohort study, the effect of high progesterone level before oocyte retrieval on endometrial morphology and uterine natural killer cell (uKN) count in the peri-implantation period was investigated. A total of 106 women undergoing IVF treatment who did not proceed to fresh embryo transfer were included. Endometrial samples were obtained 7 days after HCG administration. Multiple regression analysis was used to identify factors affecting the results of histological staging and uNK cell count. Progesterone level on the day after HCG administration was the only significant variable associated with the results of histological staging (P = 0.004). Endometrial development in women with high progesterone level was significantly (P < 0.001) more advanced than that of women with normal progesterone; progesterone level on the day of HCG administration was the only significant variable associated with uNK cell count. The median (range) of uNK cell count of 9.6% (2.3-21.6%) in women with high progesterone was significantly (P < 0.001) higher than the median (range) of uNK cell count of 5.7% (1.4-18.7%) in women with normal progesterone. High progesterone level before oocyte retrieval was correlated with advancement in endometrial development as well as increased uNK cell count.

Progesterone elevation on the day of human chorionic gonadotropin administration adversely affects the outcome of IVF with transferred embryos at different developmental stages

BACKGROUND

The effect of progesterone elevation (PE) on the day of human chorionic gonadotropin (hCG) administration on the pregnancy outcomes of in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) cycles is a matter of ongoing debate. The replacement of cleavage-stage embryos with blastocyst-stage embryos for transfer was proposed to avoid the possible impairment of PE in fresh cycles. This study aimed to assess the association between PE on the day of human chorionic gonadotropin (hCG) administration and clinical pregnancy rates (CPRs) in IVF/ICSI cycles with embryos transferred at different developmental stages (cleavage and blastocyst). Moreover, a secondary aim was to determine the thresholds at which PE has a detrimental effect on CPRs.

METHODS

This single-center retrospective cohort study included more than 10,000 patients undergoing day 3 cleavage-stage embryo transfer (ET) and 1146 patients undergoing day 5 blastocyst-stage embryo transfer (ET) using gonadotropin and GnRH agonist for controlled ovarian stimulation.

RESULTS

Serum PE was inversely associated with CPRs in both cleavage- and blastocyst-stage ET cycles. In the day 3 ET cycles, CPRs (progesterone levels < 0.5 ng/ml, 49.2 %) significantly declined when the progesterone concentration reached 1.0 ng/ml (45.5 %) and decreased further when the progesterone concentration increased to 1.5 ng/ml (36.2 %). In the day 5 blastocyst-stage ET cycles, patients with serum progesterone levels ≥1.75 ng/ml had significantly lower CPRs (31.3 % VS. 41.4 %, p < 0.001) compared to patients with serum progesterone levels <1.75 ng/ml. The negative association of PE with CPRs was noted in both ET groups, even after adjusting for confounders. Furthermore, the developmental stage of the transferred embryos was not linked to the effect of PE on CPRs because the interaction between the developmental stage of the transferred embryos and PE was not significant.

CONCLUSIONS

PE on the day of hCG administration is associated with decreased CPRs in GnRH agonist IVF/intracytoplasmic sperm injection (ICSI) cycles regardless of the developmental stage of the transferred embryos (cleavage versus blastocyst stage).

Differential expression of vascular endothelial growth factor angiogenic factors in different endometrial compartments in women who have an elevated progesterone level before oocyte retrieval, during in vitro fertilization-embryo transfer treatment

OBJECTIVE

To investigate the relationship between endometrial expressions of angiogenic factors around the time of embryo implantation and P level before oocyte retrieval during IVF-ET treatment.

DESIGN

Retrospective study.

SETTING

University Assisted Reproductive Unit.

PATIENT(S)

Forty patients were recruited, 20 women with an elevated P level, and 20 women with a normal P level, into cancelled embryo transfer (ET) cycles.

INTERVENTION(S)

Endometrial biopsy samples were obtained from women who had an elevated or normal P level 7 days after human chorionic gonadotropin administration. The protein expression levels of VEGF-A, VEGF-C, and PLGF were examined using immunohistochemistry.

MAIN OUTCOME MEASURE(S)

A semiquantitative analysis was performed using histochemical-score analysis of staining intensity in the luminal epithelium, glandular epithelium, and stroma, separately.

RESULT(S)

Luminal epithelial expression of vascular endothelial growth factor (VEGF)-A, VEGF-C, and PLGF did not significantly differ in women with elevated or normal P levels before oocyte retrieval. Glandular epithelial expression of VEGF-A, VEGF-C, and PLGF was higher in women with elevated P levels, compared with those with normal P levels. A significantly higher stromal expression of VEGF-A and PLGF was found in women with elevated P levels.

CONCLUSION(S)

A high P level before oocyte retrieval was associated with expression of VEGF angiogenic factors in glandular epithelium and stromal compartment around the time of embryo implantation. Our findings suggest that the lower implantation rates observed in this group of women may relate to decreased endometrial receptivity arising from altered expression of angiogenic factors.

A comparison of biochemical pregnancy rates between women who underwent IVF and fertile controls who conceived spontaneously†

STUDY QUESTION

Does IVF affect the biochemical pregnancy rate?

SUMMARY ANSWER

The likelihood of an early pregnancy loss may be lower and is certainly not higher in IVF cycles when compared with published rates of biochemical pregnancy in fertile women ≤42 years old.

WHAT IS KNOWN ALREADY

The use of gonadotrophins to stimulate multi-folliculogenesis alters endometrial expression of genes and proteins, compared with unstimulated cycles. Exogenous estrogen and progesterone taken for endometrial preparation in frozen embryo transfer cycles, also cause changes in endometrial gene and protein expression .These endometrial alterations may compromise the ability of embryos to develop once implanted, possibly increasing the biochemical pregnancy rate.

STUDY DESIGN, SIZE, DURATION

This is a retrospective study, involving 1636 fresh and 188 frozen, single embryo transfer (SET) IVF cycles performed between August 2008 and December 2012. The biochemical pregnancy rate of the 1824 combined IVF and frozen cycles were compared with fertile controls, derived from the three prospective studies in the medical literature that evaluate this rate.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Subjects ≤42-years old, who underwent a SET, as part of a fresh or thawed IVF cycle were considered for inclusion. Each subject is represented only once. The biochemical pregnancy rates were compared with those of historical standard, fertile populations with spontaneous conceptions.

MAIN RESULTS AND THE ROLE OF CHANCE

The pregnancy rates per transfer for fresh and frozen IVF cycles were similar at 39 and 40%, respectively. There was also no significant difference in the likelihood of pregnancy outcomes (clinical, biochemical and ectopic pregnancy) between fresh IVF and frozen cycles (85.4 versus 85.6%, 13.8 versus 14.8%, 0.5 versus 0%, P = 0.82). However, pregnancy rates decreased in older patients when compared with younger ones P < 0.0001. The biochemical pregnancy rate for fresh and frozen IVF cycles combined was 13.8% of all pregnancies. IVF and frozen cycles were combined as the IVF group treated with hormones for further comparison with the fertile control group. The biochemical pregnancy rate (14%) in the IVF group was lower than the rate based on the total fertile group (18%), P = 0.01 and differed significantly from the rate in two out of the three studies used to establish the normative rate. The age ranges of the IVF and fertile controls were 21-42 years. The mean age in the IVF population was 34.8 years, as compared with 29 years, 29, 4 years and 30.6 years (Zinaman) in the three published studies (mean: 29.4 years).

LIMITATIONS, REASONS FOR CAUTION

This is a retrospective study and it was impossible to recruit an in-house biochemical pregnancy control population.

WIDER IMPLICATIONS OF THE FINDINGS

Lower early pregnancy wastage after IVF may be due to the opportunity to select the embryo for transfer. This finding should be confirmed in further studies but supports the idea that embryo selection is an important step.

STUDY FUNDING/COMPETING INTERESTS

None.

Follicular progesterone elevations with ovulation induction for IVF

The purpose of this review is to analyse the sources and effects of follicular progesterone elevations during ovarian stimulation, with the underlying mechanisms and preventive strategies on the in vitro fertilisation pregnancy outcome. In the early follicular phase, a flare-up effect of gonadotrophin releasing hormone (GnRH) agonists and incomplete luteolysis in GnRH antagonist regimens can result in significant elevations of progesterone. In the late follicular phase, progesterone elevations in GnRH analogue cycles are the result of the ovarian stimulation itself, driven by high follicle stimulating hormone dosage, estradiol levels, the number of follicles and oocytes. It seems that progesterone elevations (> or = 1.5 ng/mL or 4.77 nmol/L) have a detrimental effect on the outcome of pregnancy, accelerating the endometrial maturation. The most appropriate choice to avoid the negative effects of follicular progesterone elevations is to cancel fresh embryo transfer and to transfer frozen-thawed embryos in natural cycles. To prevent follicular phase elevations it might be preferable to use milder stimulation protocols, earlier trigger of ovulation in high responders and single-blastocyst transfer on day 5. The optimal GnRH analogue protocols during the entire stimulation period appear to be the long agonist as well as "long" and long GnRH antagonist regimens.

Clinical rationale for cryopreservation of entire embryo cohorts in lieu of fresh transfer

Recent dramatic increases in success rates with frozen-thawed embryo transfer (FET) are encouraging, as are numerous findings of several reduced risks with FET when compared with fresh transfer. These reduced risks include low birth weight and prematurity, among others. However, FET is also associated with increased risks of macrosomia and large for gestational age. There have been reports of greater implantation and pregnancy rates with FET than with fresh autologous embryo transfer, suggesting superior endometrial receptivity in the absence of ovarian stimulation. As cryo-technology evolves, there is potential for further increase in FET success rates, but for now it may be best to follow an individualized approach, balancing fresh transfer and embryo cohort cryopreservation options while considering patient characteristics, cycle parameters, and clinic success rates.

Administration of corifollitropin alfa on Day 2 versus Day 4 of the cycle in a GnRH antagonist protocol: a randomized controlled pilot study

STUDY QUESTION

Does the initiation of corifollitropin alfa administration on cycle day 4 instead of cycle day 2 result in a reduced total rFSH consumption in a GnRH antagonist protocol?

SUMMARY ANSWER

Initiation of corifollitropin alfa on cycle day 4 compared with day 2 results in significantly reduced total rFSH consumption at the end of the follicular phase.

WHAT IS KNOWN ALREADY

In vitro fertilization treatment is associated with significant physical, psychological and emotional stress in infertile patients. This notion has fuelled the search for simplified treatment approaches that may reduce the treatment burden. The introduction of corifollitropin alfa has provided a more patient-friendly treatment protocol because it obviates the need for daily hormonal injections. In addition, postponing the initiation of hormonal stimulation should also reduce the total gonadotrophin consumption and the number of injections needed.

STUDY DESIGN, SIZE, DURATION

A prospective randomized controlled pilot study was conducted in a university centre in Belgium. Between December 2011 and March 2013, 59 patients were randomized in the study and 52 of these patients received the allocated intervention.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All patients were randomly assigned to the control group (CD2), with initiation of corifollitropin alfa on cycle day 2, or to the study group (CD4) with initiation of stimulation on day 4. The GnRH antagonist was administered from cycle day 7 onwards in both treatment arms. The main outcome measure was the total rFSH consumption at the end of the follicular phase after corifollitropin alfa treatment.

MAIN RESULTS AND THE ROLE OF CHANCE

The total dose of rFSH at the end of the follicular phase was significantly reduced in the CD4 group compared with the CD2 group (324 (276) IU in the CD2 group versus 173 (255) IU in the CD4 group, P = 0.015, mean difference -151, 95% confidence interval (CI) -301 to -1). A significant reduction of total duration of rFSH stimulation in the CD4 group was also observed (8.6 (1.4) days in CD2 group versus 7.8 (1.2) days in the CD4 group, P = 0.008, mean difference -0.8, 95% CI -1.6 to -0.1). The number of cumulus-oocyte-complexes was comparable in both treatment groups (12.8 (7.3) in CD2 group versus 14.7 (8.8) in the CD4 group, P = 0.461, mean difference 1.8, 95% CI -2.7 to 6.4). Ongoing pregnancy rates of 48% in the CD2 group and 41% in the CD4 group were achieved (P = 0.60, relative risk (RR) 0.85, 95% CI 0.46-1.56). Final oocyte maturation was triggered with GnRH agonist instead of hCG in two patients in the CD2 group and in eight patients in the CD4 group, because of an increased risk of ovarian hyperstimulation syndrome (P = 0.078, RR 3.7 (95% CI 0.88-15.8).

LIMITATIONS, REASONS FOR CAUTION

Before general implementation can be advised, this trial should be validated in a much larger randomized trial. WIDER IMPLICATIONS OF THE FINDINGS If the approach of starting ovarian stimulation on Day 4 of the cycle could be implemented in a large population of infertile patients, it would result in a significant reduction of gonadotrophin consumption.

STUDY FUNDING/COMPETING INTEREST(S)

No external finance was involved in this study. C.B and N.P.P. have received fees from MSD. Otherwise the authors declare no conflict of interest regarding this study.

TRIAL REGISTRATION NUMBER

The trial was registered at clinicaltrials.gov (NCT01633580).

Premature formation of nucleolar channel systems indicates advanced endometrial maturation following controlled ovarian hyperstimulation

STUDY QUESTION

Is there a shift in the timing of nucleolar channel system (NCS) formation following controlled ovarian hyperstimulation (COH)?

SUMMARY ANSWER

NCSs appear prematurely following COH compared with natural cycles.

WHAT IS KNOWN ALREADY

During natural cycles, NCSs of endometrial epithelial cell (EEC) nuclei are exclusively present during the window of implantation and are uniformly distributed throughout the upper endometrial cavity.

STUDY DESIGN, SIZE, DURATION

Prospective two-cohort study. Cohorts I and II each consisted of seven volunteers for the duration of three menstrual study cycles that were separated by at least one wash-out or rest cycle, between December 2008 and May 2012.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were recruited from a pool of healthy oocyte donors. Consecutive endometrial biopsies were obtained during the same luteal phase on cycle days (CD) 16, 20 and 26 for Cohort I, and on CD14, 22 and 24 for Cohort II, following random assignment to a natural cycle group, a COH cycle group (using a GnRH antagonist), or a COH cycle group receiving luteal phase hormonal supplementation (COH + S). The day of oocyte retrieval was designated CD14 in COH cycles and the day of the LH surge was designated CD13 in natural cycles. Prevalence of NCSs in the nuclei of EECs was quantified using indirect immunofluorescence with an antibody directed against a subset of related nuclear pore complex proteins that are major constituents of NCSs. Progesterone and estradiol levels were measured on the day of each endometrial biopsy.

MAIN RESULTS AND THE ROLE OF CHANCE

The natural cycle group exhibited peak NCS prevalence on CD20 [53.3%; interquartile range (IQR) 28.5-55.8], which rapidly declined on CD22 (11.8%; IQR 6.3-17.6), CD24 (2.5%; IQR 0.0-9.2) and CD26 (0.3%; IQR 0.0-3.5), and no NCSs on CD14 and 16 defining a short NCS window around CD20. In contrast, in COH and COH + S cycles, NCS prevalence was high already on CD16 (40.4%; IQR 22.6-53.4 and 35.6%; IQR 26.4-44.5, respectively; P = 0.001 compared with CD16 of the natural cycle group, Mann-Whitney), whereas no significant difference in NCS prevalence was detected on any of the other five CDs between the three groups (P > 0.05).

LIMITATIONS, REASONS FOR CAUTION

The cohort size was small (n = 7) but was offset by the all-or-none presence of NCSs on CD16 in natural versus COH and COH + S cycles and the fact that each subject served as her own control.

WIDER IMPLICATIONS OF THE FINDINGS

Premature appearance of NCSs and hence maturation of the endometrium following COH is consistent with previous studies based on histological dating but contradicts studies based on mRNA expression profiling, which reported a lag in endometrial maturation. However, this is the first study of this kind that is based on consecutive endometrial biopsies within the same cycle and that reports such clear-cut differences: no versus robust NCS presence on CD16. Our observation of advanced endometrial maturation following COH may contribute to the reduced implantation rates seen in fresh compared with frozen and donor IVF-embryo transfer cycles. Therefore, the NCS window could serve as a sensitive guide for timing of embryo transfer in frozen and donor cycles.

STUDY FUNDING/COMPETING INTEREST(S)

The study was supported by the March of Dimes Birth Defects foundation (1-FY09-363 to U.T.M.); Ferring Pharmaceuticals, Parsippany, NJ; East Coast Fertility, Plainview, NY and the CMBG Training Program (T32 GM007491 to M.J.S.). We report no competing interests.

Preovulatory progesterone rise during ovarian stimulation for IVF

The aim of this review is to analyze the relationship between the preovulatory progesterone (P) rise and the in vitro fertilization (IVF) pregnancy outcome. It also investigates the sources and effects of P level increase, including the underlying mechanisms and potential strategies in preventing its elevation during ovarian stimulation. The origin of production of P in the early follicular phase is adrenal which shifts toward the ovaries prior to the ovulation. Several factors contribute to the etiology of P level increase including the number of multiple follicles, the overdose of gonadotropins and poor ovarian response. Nowadays, the influence of the preovulatory P rise on IVF outcome remains controversial. Several authors have failed to demonstrate any negative impact, while others reported a detrimental effect associated with the rise of P. It seems that P rise (≤ 1.5 ng/ml or 4.77 nmol/l) may have deleterious effects on endometrial receptivity, namely, accelerating the endometrial maturation process that subsequently narrows the time-frame for implantation and thus decreases pregnancy rates. To prevent a P rise, it might be preferable to use milder stimulation protocols, earlier trigger of ovulation, cryopreservation of all embryos and transfer in the natural cycle.

Low birth weight: is it related to assisted reproductive technology or underlying infertility?

Since 1978, we have witnessed a successful evolution of assisted reproductive technology (ART), with improvement of the pregnancy rates and a growing demand. However, in recent years, there has been increasing concern regarding its safety due to the potential health impact on its infants. The raise of the developmental origins of adult disease has positioned low birth weight (LBW) as a significant health issue. Although multiple studies have associated ART with LBW, the etiology of this association remains largely unknown. We review the potential association between different components of ART and infertility with LBW, while acknowledging the limitations of interpretation of the existing literature.

Human chorionic gonadotropin triggers angiogenesis via the modulation of endometrial stromal cell responsiveness to interleukin 1: a new possible mechanism underlying embryo implantation

Deep functional changes occurring within the endometrium during implantation are orchestrated by embryonic and maternal signals. Human chorionic gonadotropin (hCG), a major embryonic signal, plays a critical role in the initiation and maintenance of pregnancy. Interleukin (IL) 1, one of the earliest embryonic signals, appears to exert a direct impact on the receptive endometrium and to induce major molecular changes that are essential for embryo implantation. Herein we investigate whether hCG can modulate endometrial stromal cell (ESC) receptivity to IL1 during the implantation window and assess the impact on angiogenesis in vitro. Primary cultures of ESCs from normal fertile women during the implantation window were treated for 24 h with different concentrations of hCG (0-100 ng/ml) and stimulated for 24 h with IL1B (0-0.1 ng/ml). IL1 receptors (IL1Rs), IL1R antagonist (IL1RA), and monocyte chemotactic protein (MCP) 1 were analyzed by real-time PCR, ELISA, and Western blotting. The angiogenic activity in vitro was studied using human microvascular endothelial cell line, scratch wound assay, and cell proliferation via BrdU incorporation into DNA. Human CG induced a dose-dependent imbalance in ESC receptivity to IL1 by significantly upregulating the functional signaling IL1R1 and concomitantly downregulating the decoy inhibitory IL1R2 and IL1RA upon subsequent exposure to IL1B. Prior exposure to hCG amplified MCP1 secretion by ESCs in response to IL1B and triggered the release of angiogenic activity in vitro in which MCP1 appeared to play a significant role. Overexpression of IL1R2 using cell transfection inhibited IL1 and hCG/IL1B-mediated MCP1 secretion. These findings suggest that hCG coordinates embryonic signal interaction with the maternal endometrium, and point to a new possible pathway by which it may promote embryonic growth.

Expression and activation of the membrane-cytoskeleton protein ezrin during the normal endometrial cycle

OBJECTIVE

To examine total ezrin expression (ezrin and phospho-ezrin) through the normal endometrial cycle and to correlate ezrin activation and localization with cytologic changes.

DESIGN

Experimental laboratory study.

SETTING

University medical centers.

PATIENT(S)

Reproductive-age women.

INTERVENTION(S)

A total of 36 samples of normal early, mid-, and late proliferative- and secretory-phase endometrium were studied for immunoreactive total ezrin (ir-T-ezrin) and phospho-ezrin (ir-p-ezrin) expression by histology, immunohistochemistry, and Western blotting.

MAIN OUTCOME MEASURE(S)

Total ezrin and phospho-ezrin expressions through the normal endometrial cycle.

RESULT(S)

Throughout the cycle ir-T-ezrin is present in the epithelium. The intensity and localization of both ir-ezrin and ir-p-ezrin vary greatly throughout the cycle. The main findings include the following: lateral localization of ir-ezrin/ir-p-ezrin in association with membrane specializations; dense staining around secretory vacuoles (secretory phase); dense staining of the apical surfaces, including microvilli and pinopodes of epithelial cells, especially during the mid- to late secretory phases; and the presence of ezrin in the glandular secretions. Immunoreactive total ezrin and ir-p-ezrin were not expressed by stromal fibroblasts.

CONCLUSION(S)

Ezrin is a prominent protein in the cycling endometrium. The most striking findings were the gravitation of ir-ezrin/ir-p-ezrin to the periphery of secretory vacuoles, localization on apical surfaces of the luminal epithelium, dense ezrin staining in secretory-phase epithelial cell plumes, and the presence of ir-ezrin/ir-p-ezrin in secretory-phase luminal secretions. These findings may have functional implications, especially for implantation biology.

Ongoing pregnancies from early retrieval of prematurely developing antral follicles after DHEA supplementation

Two patients with severely diminished ovarian reserve who were refractory to aggressive ovarian stimulation conceived with oocytes from prematurely developing antral follicles after dehydroepiandrosterone supplementation. The first patient had 11 and 14.5 mm, and the second patient had 13 mm antral follicles on cycle days 2 and 3 respectively. In the first case, no ovarian stimulation was performed, while the second case received one dose of gonadotrophins with a gonadotrophin-releasing hormone antagonist. Following very early human chorionic gonadotrophin (HCG) triggering on cycle day 5, when antral follicles reached 15 and 18.5 mm in the first case, and 19 mm in the second case, IVF intracytoplasmic sperm injection treatment resulted in pregnancies in both cases, which are currently ongoing at 35 and 14 weeks of gestation. The results in these patients show that pregnancy can be achieved in poor responder patients with prematurely developing antral follicles following early HCG triggering based on follicle size rather than cycle day, with no or minimal stimulation. Whether DHEA supplementation had any impact on the success of these cycles remains to be determined.

Effect of estradiol on oocyte development

OBJECTIVE

To determine whether elevated serum estradiol (E(2)) concentrations in oocyte donors affect assisted reproduction outcome.

METHOD

In a retrospective cohort study of 58 consecutive oocyte donation cycles, donors were stratified into 2 groups according to E(2) concentration, group 1 (n=32; E(2)2000 pg/mL [range, 2062-6957 pg/mL]). Data were analyzed using the t test and chi(2) test.

RESULTS

Donors in group 1 produced significantly less oocytes than donors in group 2 (19.3+/-1.7 vs 12.0+/-1.4; P<0.001), and recipients of oocytes from group 1 had significantly fewer numbers of embryos available for transfer (10.4+/-1.1 vs 6.4+/-0.8; P=0.003). However, the mean number (3.3) of embryos transferred and the pregnancy rate were the same in both groups.

CONCLUSION

Elevated estradiol concentration in oocyte donors did not affect pregnancy outcome, suggesting that estradiol levels in donors do not affect oocyte development.

Prospective cohort study of three- versus two-dimensional ultrasound for prediction of oocyte maturity

OBJECTIVE

To determine whether three-dimensional follicular ultrasound (3-D) measurements are better predictors of optimal timing of hCG administration than two-dimensional (2-D) images, the current standard.

DESIGN

Prospective, cohort study.

SETTING

Tertiary referral center.

PATIENT(S)

Seventy-six patients undergoing IVF.

INTERVENTION(S)

Seventy-six consecutive patients undergoing serial follicular monitoring during IVF had an additional daily 3-D volume scan of their ovaries once lead follicles had reached 16 mm diameter.

MAIN OUTCOME MEASURE(S)

Number of mature oocytes retrieved.

RESULT(S)

The 2-D follicular diameter measurements predicted 25.4% of the observed variance in the number of mature oocytes retrieved. The 3-D follicular volume measurements were more predictive of outcome, accounting for 29.2% of the observed variance in number of mature oocytes retrieved. Follicles >22 mm diameter and 5 mL volume were associated with fewer mature oocytes reflecting an undesired postmature state. Follicles measuring 11 to 15 mm had a 50% chance of yielding a mature oocyte.

CONCLUSION(S)

Three-dimensional follicular volume measurements have a stronger correlation with the number of mature oocytes retrieved than 2-D measurements. As 3-D technology improves, this parameter may replace 2-D measurements in the optimal timing of hCG before oocyte retrieval.