In-vitro cervical mucus-sperm penetration tests and outcome of infertility treatments in couples with repeatedly negative post-coital tests

Cervical fluid pH, electrolytes and osmolarity changes and expression of ion transporters (ENaC, CFTR and AQP) in cervix of women with primary unexplained infertility

BACKGROUND

Unexplained infertility could arise from a defect in the cervix. However, the contribution of abnormal cervical fluid microenvironment to this problem still needs to be identified. Therefore, this study identifies the changes in the cervical fluid microenvironment, i.e., pH, electrolytes and osmolarity as well as expression of ion transporters in the cervix including ENaC, CFTR and AQP in fertile women and in women suffering from primary unexplained infertility.

METHODS

Fertile women and women with unexplained infertility but having regular 28-day menstrual cycles were chosen in this study, Day-22 serum progesterone levels were determined. In the meantime, serum FSH and LH levels were determined on day 2 while, cervical flushing was performed at day 14 to analyse changes in the cervical fluid pH, osmolarity, Na+ and Cl- levels. Meanwhile, cells retrieved from cervical fluid were subjected to mRNA expression and protein distribution analysis for CFTR, AQP and ENaC by qPCR and immunofluorescence, respectively.

RESULTS

No significant changes in serum progesterone, FSH and LH levels were observed between the two groups. However, cervical fluid pH, osmolarity, Na+ and Cl- levels were significantly lower in primary unexplained infertile group when compared to fertile group. Expression of CFTR and AQP (AQP 1, AQP 2, AQP 5 and AQP 7) in endocervical cells was lower and expression of β-ENaC was higher in primary unexplained infertile women (p < 0.05 when compared to fertile group).

CONCLUSIONS

Alterations in the cervical fluid microenvironment linked to the defective ion transporter expression in the cervix might contribute towards the unfavourable condition that accounts for unexplained infertility in women.

Staging, surveillance, and evaluation of response to therapy in renal cell carcinoma: role of MDCT

Renal cell carcinoma is the most common malignant renal tumor in the adults. Significant advances have been made in the management of localized and advanced renal cell carcinoma. Surgery is the standard of care and accurate pre-operative staging based on imaging is critical in guiding appropriate patient management. Besides staging, imaging plays a key role in the post-operative surveillance and evaluation of response to systemic therapies. Both CT and MR are useful in the staging and follow up of renal cell carcinoma, but CT is more commonly used due to its lower costs and wider availability. In this article, we discuss and illustrate the role of multi-detector CT in pre-operative staging, post-operative surveillance, and evaluation of response to systemic therapy in renal cell carcinoma.

Novel MED12 gene somatic mutations in women from the Southern United States with symptomatic uterine fibroids

Although somatic mutations in exon 2 of the mediator complex subunit 12 (MED12) gene have been reported previously in uterine fibroids in women from Finland, South Africa, and North America, the status of these mutations was not reported in the Southern United States women. The aim of this study is to determine the MED12 somatic mutations in uterine fibroids of women from Southern Unites States, which will help to better understand the contribution of MED12 mutations in fibroid tumor biology. Herein, we determined the frequency of MED12 gene exon 2 somatic mutations in 143 fibroid tumors from a total of 135 women from the Southern United States and in 50 samples of the adjacent myometrium using PCR amplification and Sanger sequencing. We observed that the MED12 gene is mutated in 64.33 % (92/143) of uterine fibroid cases in the exon 2 (including deletion mutations). These mutations include 107T > G (4.3 %), 130G > C (2.8 %), 130G > A (7.0 %), 130G > T (2.8 %), 131G > C (2.1 %), 131G > A (20.2 %), and 131G > T (2.1 %). Interestingly, we identified four novel mutations in these patients: 107 T > C (12.8 %), 105A > T (2.1 %), 122T > A (2.1 %), and 92T > A (2.1 %). As expected, we did not observe any mutations in the normal myometrium. Moreover, we found a higher rate of deletion mutations (17.5 %, 25/143) in the above fibroid tumors. Our results clearly demonstrate that the MED12 gene exon 2 is frequently mutated in human uterine fibroids in Southern United States women. These results highlight the molecular pathogenesis of human uterine fibroids with the central role of MED12 somatic mutations.

The role of the cervix in fertility: is it time for a reappraisal?

Knowledge regarding the role of the cervix in fertility has expanded considerably over the past 20 years and in this article, we propose that it is now time for its function to be reappraised. First, we review the anatomy of the cervix and the vaginal ecosystem that it inhabits. Then, we examine the physiology and the role of the cervical mucus. The ongoing mystery of the exact mechanism of the sperm-cervical mucus interaction is reviewed and the key players that may unlock this mystery in the future are discussed. The soluble and cellular biomarkers of the lower female genital tract which are slowly being defined by contemporary research are reviewed. Attempts to standardize these markers, in this milieu, are hindered by the changes that may be attributed to endogenous or exogenous factors such as: age, hormonal changes during the menstrual cycle, ectropion, infection, smoking and exposure to semen during sexual intercourse. We review what is known about the immunology of the cervix. With the widespread use of large loop excision of the transformation zone (LLETZ) for treatment of cervical intraepithelial neoplasia, the anatomy of the cervix is changing for many women. While LLETZ surgery has had very positive effects in the fight against cervical cancer, we debate the impact it could have on a woman's fertility.

Assessment of pregnancy-associated, within-woman change in uterine length

OBJECTIVE

To evaluate how absolute uterine length changes as a result of pregnancy.

METHODS

Longitudinal repeated-measures study of all women presenting to a university-affiliated clinic for uterine sounding prior to in vitro fertilization (IVF) who went on to deliver at term and return for repeat measurement from 2002 to 2012. Change in uterine length was assessed by the Wilcoxon signed-rank test.

RESULTS

Among 495 women, mean pregnancy-associated change in uterine length was 0.0 cm (SD ± 0.7, p = 0.84), with 31% of women experiencing no change and 75% of women experiencing a change ≤0.5 cm. Mean uterine lengths at pre-cycle and repeat measurement were 7.2 cm (SD ± 0.7) and 7.2 cm (SD ± 0.7) with medians of 7.0 cm (IQR 7.0-7.5) and 7.0 cm (IQR 6.8-7.8), respectively. Change in uterine length did not vary by gestational number or within time interval between measurements (all p > 0.5).

CONCLUSIONS

There was no difference in uterine length before and after term pregnancy. The finding of minimal variation in uterine length both across and within women suggests uterine length may be relatively stable such that patients undergoing IVF after term IVF pregnancy may not require repeat measurement. Future studies might assess pregnancy-associated sonographic changes in uterine volume and the relationship between uterine length and IVF outcomes.

Dealing with uterine fibroids in reproductive medicine

Women who wish to conceive are nowadays more likely to present with uterine fibroids, mainly because of the delay in childbearing in our society. The relationship between uterine fibroids and human reproduction is still controversial and counselling patients might sometimes be challenging. This paper is to assist those involved in the management of patients of reproductive age presenting with uterine fibroids. The interference of fibroids on fertility largely depends on their location. Submucous fibroids interfere with fertility and should be removed in infertile patients, regardless of the size or the presence of symptoms. Intramural fibroids distorting the cavity reduce the chances of conception, while investigations on intramural fibroids not distorting the cavity have so far given controversial results. No evidence supports the systematic removal of subserosal fibroids in asymptomatic, infertile patients. Myomectomy is still the 'gold standard' in fibroid treatment for fertility-wishing patients. In experienced hands, hysteroscopic myomectomy is minimally invasive, safe, and effective. Abdominal and laparoscopic myomectomy might be challenging, but potential risks could be reduced by new strategies and techniques.

MR imaging evaluation of fibroid clearance following open myomectomy for massive/multiple symptomatic fibroids

PURPOSE

To evaluate the technical success of total fibroid clearance at open myomectomy for massive and/or multiple symptomatic fibroids using MR imaging (MRI) as the imaging modality.

METHODS

The study group comprised 27 women [mean age 37.4 ± 6.9 years (range 27-53)] who underwent open myomectomy for the treatment of massive/multiple symptomatic fibroids at our institution between January 2009 and April 2010. Myomectomy was performed with the intention of achieving complete fibroid clearance. Pre- and postmyomectomy MRI was performed to assess changes in uterine volume and fibroid burden. Periprocedural data (including blood loss and complications) and relief of clinical symptoms at follow-up were also recorded.

RESULTS

The mean time to MRI and clinical follow-up was 10 months (range 6-15 months). The mean uterine volume premyomectomy was 795 ± 580 cc and postmyomectomy was 123 ± 70 cc (p < 0.001). The mean percentage reduction in uterine volume was 80.3 % (range 43.0-98.1 %). Of the 10/27 (37.0 %) women with residual fibroids at follow-up: 7 patients had fibroids measuring up to 1 cc in volume, 3 patients had fibroids measuring up to 6 cc. Postoperative adnexal seromas were observed in 6/27 (22.2 %) patients. The clinical success rates of myomectomy amongst the 22/27 (81 %) responders were: 73 % for menorrhagia, 64 % for pain, and 36-64 % for mass-related symptoms.

CONCLUSIONS

Using MRI, we have confirmed that open myomectomy can achieve total or near-total fibroid clearance in the majority of patients with massive and/or multiple fibroids.

Leiomyoma: genetics, assisted reproduction, pregnancy and therapeutic advances

PURPOSE

Uterine leiomyomas are common, benign, reproductive tract tumors affecting a majority of reproductive aged women. They are associated with gynecologic morbidity and detrimentally affect reproductive potential. The etiology of leiomyomas is poorly understood and their diagnosis prior to treatment with Assisted Reproductive Technologies (ART) represents a management dilemma. The purpose of this paper is to review known genetic and molecular contributions to the etiologies of leiomyomas, describe their impact on ART outcomes and reproductive potential, and review alternative therapies and future directions in management.

METHODS

A critical review of the literature pertaining to genetic component of uterine leiomyomas, their impact on ART and pregnancy and leiomyoma therapeutics was performed.

RESULTS

Uterine leiomyomas are characterized by complex molecular mechanisms. Their location and size determines their potential detriment to ART and reproductive function and novel therapeutic modalities are being developed.

CONCLUSION

The high prevalence of uterine leiomyomas and their potential detrimental influence on ART and reproductive function warrants continued well-designed studies to ascertain their etiology, optimal treatment and novel less morbid therapies.

Immunohistochemical characteristics of intramural leiomyomata that enlarge during controlled ovarian hyperstimulation for in vitro fertilization

BACKGROUND/AIMS

This study aimed to determine the immunohistochemical characteristics of intramural leiomyomata that enlarged during controlled ovarian hyperstimulation (COH) for in vitro fertilization (IVF).

METHODS

For this retrospective case-control clinical study and immunohistochemical analysis, 5 patients with enlarged intramural leiomyomata during COH for IVF, who had undergone myomectomy immediately after a failed IVF cycle, were recruited retrospectively. Fifteen consecutive patients who had had myomectomy for intramural leiomyomata <5 cm, but had never undergone any infertility treatment, served as the control group. Histological examinations and immunohistochemical staining with proliferating cell nuclear antigen (PCNA), transforming growth factor-beta (TGF-beta) and fibronectin were performed on all specimens taken from the study and control groups. The main outcome measures were defined as histological and immunohistochemical scores.

RESULTS

Hematoxylin and eosin as well as PCNA staining showed increased mitotic index, cellularity and proliferation index in these growing leiomyomata (study group). There were neither increased mitoses nor cellularity in the leiomyomata of the control group, while PCNA, TGF-beta and fibronectin scores in the study group were significantly higher than those in the control group (p < 0.001).

CONCLUSION(S)

This study is the first to report increased TGF-beta, PCNA, cellularity and mitosis in leiomyomata enlarging during COH for IVF. Further studies with larger sample size are needed to determine the role of TGF-beta, PCNA and fibronectin in the growth of leiomyomata during COH.

Outcomes From Assisted Reproductive Technology

The use of assisted reproductive technology (ART) for treating the infertile couple is increasing in the United States. The purpose of this paper is to review the short-term outcomes after ART. Pregnancy rates after ART have shown nearly continuous improvement in the years since its inception. A number of factors affect the pregnancy rate, with the most important being a woman's age. Certain clinical diagnoses are associated with a poorer outcome from ART, including the presence of hydrosalpinges, uterine leiomyomata that distort the endometrial cavity, and decreased ovarian reserve. Multiple gestations are the major complication after ART. New laboratory techniques, including extended embryo culture, may allow the transfer of fewer embryos to maintain pregnancy rates while reducing the risk of multiple gestations. Although much of the morbidity in children born after ART is the result of multiples, recent analysis suggests that even singletons are at higher risk for perinatal morbidity, including preterm delivery and small for gestational age infants. In vitro fertilization may be associated with a slight increased risk for birth defects. The major short-term complication of ART in women is the development of ovarian hyperstimulation syndrome. This syndrome is difficult to predict, but new treatments are being developed that may limit its frequency. Because of its high pregnancy rate, couples are moving to ART more quickly in the management of their infertility. All outcomes of ART, including pregnancy rates and adverse complications, need to be compared with standard non-ART therapy when deciding the appropriate course of treatment for a given couple.

Fibroids and infertility: a systematic review of the evidence

A systematic literature review was performed to determine whether leiomyomata are associated with decreased fertility rates, and whether surgical removal increases fertility rates postoperatively. Meta-analysis was conducted when multiple studies addressed a single issue and were sufficiently homogeneous. Data were analyzed for effect of any fibroid upon fertility, as well as specific fibroid location. Results of studies comparing women with infertility and fibroids versus infertile controls showed widely disparate results. Subgroup analysis failed to indicate any effect on fertility of fibroids that did not have a submucous component. Conversely, women with submucous myomas demonstrated lower pregnancy rates (RR 0.30; 95% confidence interval [CI] 0.13--0.70) and implantation rates (RR 0.28; 95% CI 0.10--0.72) than infertile controls. Results of surgical intervention were similar. When all fibroid locations were considered together, myomectomy results were again widely disparate. However, when women with submucous myomas were considered separately, pregnancy was increased after myomectomy compared with infertile controls (RR 1.72; 95% CI 1.13--2.58) and delivery rates were now equivalent to infertile women without fibroids (RR 0.98; 95% CI 0.45--2.41). The current data suggest that only those fibroids with a submucosal or an intracavitary component are associated with decreased reproductive outcomes, and that hysteroscopic myomectomy may be of benefit.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader will be able to summarize the data on the role of fibroids and infertility, describe the effect of myomectomy on fertility, and list the methods used to evaluate intracavitary fibroids.

Traditional surgical approaches to uterine fibroids: abdominal myomectomy and hysterectomy

Abdominal myomectomy and hysterectomy remain the traditional treatment of large symptomatic uterine myomas. The preoperative indications for abdominal myomectomy or hysterectomy must be clearly evaluated and delineated avoid unnecessary intervention. There appears to be an increasing trend toward expectant management for asymptomatic uterine myomas. Women should consider the options of myomectomy and hysterectomy when their symptoms are severe enough to warrant intervention and the benefits of intervention outweigh the risks. The advantages and disadvantages of preoperative medical also must be addressed before intervention. The factors influencing the choice of therapy seem to be strongly dependent on both the patient and physician preferences. A clinical approach to abdominal myomectomy in patients with infertility and repetitive miscarriage has been presented in this chapter. The rapid development and use of minimally invasive innovations and adjunctive medical therapies has provided clinicians with a wealth of alternatives. A practical and cost-effective approach based on the data currently available have been presented; however, there remains a paucity of prospective randomized data to evaluate and compare the effectiveness and safety of these alternative treatments to abdominal myomectomy and hysterectomy. Future studies should help define the optimal candidates for traditional surgical treatment with abdominal myomectomy and hysterectomy.

Comparison of human cervical mucus and artificial sperm penetration media

The cervical mucus penetration tests aid research and determine the clinical importance of positive sperm antibody tests. Limited availability and variability of human cervical mucus have instigated the search for mucus substitutes for these tests. This study compares sperm migration in cervical mucus with that in artificial media including hyaluronate solution, egg white and albumin Tyrode solution. Results were quantified by measuring the migration distance (the maximum distance of capillary migration from a semen reservoir by spermatozoa after 1 h) and the sperm concentration at half the migration distance. The mean of both measures for cervical mucus and hyaluronate solution were equivalent [4.4 +/- 1.1 (SD) versus 4.3 +/- 1.0 cm and 118 +/- 51 versus 111 +/- 44x10(3)/ml], and higher than in egg white and albumin Tyrode solution. Antisperm antibodies impaired sperm penetration in cervical mucus and hyaluronate solution in a similar manner (r = 0.92). These results suggest that hyaluronate solution sufficiently resembles human cervical mucus in terms of penetrability that it may be used as a substitute for mucus in capillary tube tests of sperm function. The higher penetrability of cervical mucus and hyaluronate solution is probably related to a channelling effect due to their polymeric structure.