Plasma inflammatory cytokines correlate to the ovarian hyperstimulation syndrome

A Dose-Response Study on Functional and Transcriptomic Effects of FSH on Ex Vivo Mouse Folliculogenesis

Follicle-stimulating hormone (FSH) binds to its membrane receptor (FSHR) in granulosa cells to activate various signal transduction pathways and drive the gonadotropin-dependent phase of folliculogenesis. Both FSH insufficiency (due to genetic or nongenetic factors) and FSH excess (as encountered with ovarian stimulation in assisted reproductive technology [ART]) can cause poor female reproductive outcomes, but the underlying molecular mechanisms remain elusive. Herein, we conducted single-follicle and single-oocyte RNA sequencing analysis along with other approaches in an ex vivo mouse folliculogenesis and oogenesis system to investigate the effects of different concentrations of FSH on key follicular events. Our study revealed that a minimum FSH threshold is required for follicle maturation into the high estradiol-secreting preovulatory stage, and such threshold is moderately variable among individual follicles between 5 and 10 mIU/mL. FSH at 5, 10, 20, and 30 mIU/mL induced distinct expression patterns of follicle maturation-related genes, follicular transcriptomics, and follicular cAMP levels. RNA sequencing analysis identified FSH-stimulated activation of G proteins and downstream canonical and novel signaling pathways that may critically regulate follicle maturation, including the cAMP/PKA/CREB, PI3K/AKT/FOXO1, and glycolysis pathways. High FSH at 20 and 30 mIU/mL resulted in noncanonical FSH responses, including premature luteinization, high production of androgen and proinflammatory factors, and reduced expression of energy metabolism-related genes in oocytes. Together, this study improves our understanding of gonadotropin-dependent folliculogenesis and provides crucial insights into how high doses of FSH used in ART may impact follicular health, oocyte quality, pregnancy outcome, and systemic health.

Roles of Different β-Defensins in the Human Reproductive System: A Review Study

Human β-defensins (hBDs) are cationic peptides with an amphipathic spatial shape and a high cysteine content. The members of this peptide family have been found in the human body with various functions, including the human reproductive system. Of among β-defensins in the human body, β-defensin 1, β-defensin 2, and β-defensin 126 are known in the human reproductive system. Human β-defensin 1 interacts with chemokine receptor 6 (CCR6) in the male reproductive system to prevent bacterial infections. This peptide has a positive function in antitumor immunity by recruiting dendritic cells and memory T cells in prostate cancer. It is necessary for fertilization via facilitating capacitation and acrosome reaction in the female reproductive system. Human β-defensin 2 is another peptide with antibacterial action which can minimize infection in different parts of the female reproductive system such as the vagina by interacting with CCR6. Human β-defensin 2 could play a role in preventing cervical cancer via interactions with dendritic cells. Human β-defensin 126 is required for sperm motility and protecting the sperm against immune system factors. This study attempted to review the updated knowledge about the roles of β-defensin 1, β-defensin 2, and β-defensin 126 in both the male and female reproductive systems.

Inflammation in preterm birth: Novel mechanism of preterm birth associated with innate and acquired immunity

Preterm birth (PB) is the most-frequent complication occurring during pregnancy, with a significant impact on neonatal morbidity and mortality. Chorioamnionitis (CAM), the neutrophil infiltration into chorioamniotic membranes, is a major cause of PB. However, several cases of PB have also been reported without apparent pathogenic infection or CAM. Such cases are now attributed to "sterile inflammation." The concept of sterile inflammation has already attracted attention in various diseases, like cardiovascular diseases, diabetes, and autoimmune diseases; recently been discussed for obstetric complications such as miscarriage, PB, gestational hypertension, and gestational diabetes. Sterile inflammation is induced by alarmins, such as high-mobility group box 1 (HMGB1), interleukins (IL-33 and IL-1α), and S100 proteins, that are released by cellular damage without apparent pathogenic infection. These antigens are recognized by pattern-recognition receptors, expressed mainly on antigen-presenting cells of decidua, placenta, amnion, and myometrium, which consequently trigger inflammation. In reproduction, these alarmins are associated with the development of various pregnancy complications, including PB. In this review, we have summarized the development of PB related to acute CAM, chronic CAM, and sterile inflammation as well as proposed a new mechanism for PB that involves innate immunity, acquired immunity, and sterile inflammation.

Obstetric outcomes following ovarian hyperstimulation syndrome in IVF - a comparison with uncomplicated fresh and frozen transfer cycles

Background

We aimed to assess the correlation between ovarian hyperstimulation syndrome (OHSS) in the early course of in vitro fertilization (IVF) pregnancies and obstetric outcomes.

Methods

We identified records of patients admitted due to OHSS following IVF treatment at our institution between 2008 and 2020. Cases were included if pregnancy resulted in a live singleton delivery (OHSS group). OHSS cases were matched at a 1:5:5 ratio with live singleton deliveries following IVF with fresh embryo transfer (fresh transfer group) and frozen embryo transfer (FET group), according to maternal age and parity. Computerized files were reviewed, and maternal, obstetric and neonatal outcomes compared.

Results

Overall, 44 OHSS cases were matched with 220 fresh transfer and 220 FET pregnancies. Patient demographics were similar between the groups, including body mass index, smoking and comorbidities. Gestational age at delivery, the rate of preterm births, preeclampsia and cesarean delivery were similar between the groups. Placental abruption occurred in 6.8% of OHSS pregnancies, 1.4% of fresh transfer pregnancies and 0.9% of FET pregnancies (p=0.02). On post-hoc analysis, the rate of placental abruption was significantly higher in OHSS pregnancies, compared with the two other groups, and this maintained significance after adjustment for confounders. Birthweights were 3017 ± 483, 3057 ± 545 and 3213 ± 542 grams in the OHSS, fresh transfer and FET groups, respectively (p=0.004), although the rate of small for gestational age neonates was similar between the groups.

Conclusions

OHSS in the early course of IVF pregnancies is associated with an increased risk of placental abruption.

Association of metabolic and inflammatory markers with polycystic ovarian syndrome (PCOS): an update

BACKGROUND

Polycystic ovarian syndrome (PCOS) is the most prevalent metabolic disorder in reproductive-age women. It is indeed a multifactorial condition evidenced by ovarian dysfunction, hyperandrogenaemia, infertility, hormonal imbalance and chronic anovulation. Experimental evidence infers that PCOS women are prone to cardiovascular problems and insulin resistance.

PURPOSE

To furnish the details about the association of inflammatory markers in PCOS.

DESIGN

An extensive literature search on PubMed, science direct and google scholar has been performed for articles about PCOS and inflammation in PCOS. A comprehensive analysis using original articles, reviews, systemic and meta-analysis was conducted for better understanding the relationship between inflammatory cytokines and PCOS.

RESULTS

The inflammatory markers perform a substantial part in managing the functions of the ovary. Any disturbances in their levels can lead to ovarian dysfunction. Inflammatory markers are associated with PCOS pathogenesis. The interplay between inflammatory cytokines in the PCOS ovary strongly implies that inflammation is one of the most potent risk factors of PCOS.

CONCLUSION

Inflammatory markers have a significant role in regulating the ovary. This manuscript highlights the significance of metabolic and inflammatory markers with PCOS. Since PCOS is always considered as a metabolic disorder, researchers can also consider focusing on the relationship between the inflammatory markers in PCOS to establish a new treatment or management of the disease and to improve women's health.

Harmful and beneficial effects of inflammatory response on reproduction: sterile and pathogen-associated inflammation

In reproduction, inflammatory processes play important roles in the development of many pregnancy complications such as preterm labor/birth, recurrent pregnancy loss, recurrent implantation failure, and preeclampsia. Inflammation can be initiated by both microbial and non-microbial causes. Bacterial infection in the feto-maternal interface and uterus can provoke preterm labor/birth, miscarriage, and chronic endometritis. By contrast, inflammation without infection, or 'sterile inflammation,' can also lead to many kinds of complications, such as preterm labor/birth, miscarriage, or preeclampsia. Aberrant inflammation is facilitated by immune cells such as macrophages, dendritic cells, natural killer cells, and invariant natural killer T cells. In addition, cytokines, chemokines, and several kinds of inflammatory mediators are involved. On the other hand, appropriate inflammation is required for a successful offspring during the progression of the entire pregnancy. Herein, we discuss the relation between pregnancy and inflammation with immunological alterations. Understanding the role of inflammation in complications during pregnancy may establish new perspectives of the progress of normal pregnancy as well as treatments during pregnancy complications.

Human β-defensin 1 in follicular fluid and semen: impact on fertility

PURPOSE

β-defensins are antimicrobial peptides expressed at mucosal level of male and female genito-urinary tract, where they exert protective functions against infections, possibly preserving human health and fertility. In our study, we investigated the possible involvement of β-defensins in female and male infertility in Italian infertile couples (i) evaluating the presence of human β-defensin 1 (hBD-1) in follicular fluid (FF) and its correlation with in vitro fertilization (IVF) outcomes; (ii) investigating the relationship between hBD-1 levels in semen and IVF outcomes (comprising correlation with sperm parameters); and (iii) exploring the effect of hBD-1 peptide on spermatozoa motility in vitro.

METHODS

A perspective observational analytic pilot study was conducted. hBD-1 concentration was measured with ELISA assay in FF and semen from 50 couples that underwent assisted procreation technique procedures due to infertility status. Moreover, hBD-1 exogenous peptide was administered to 29 normozoospermic semen and their motility was recorded.

RESULTS

hBD-1 was detected in FF and its levels were significantly higher in women with good fertilization rate (≥ 75%), respect to those with a poor fertilization rate (< 75%). The hBD-1 semen concentrations in oligo-asthenozoospermic subjects were significantly lower than that in normozoospermic men. Instead, hBD-1 level in sperm and FF not correlated with pregnancy rate. Finally, incubation of sperm with exogenous hBD-1 significantly increased progressive motility after 1 h and 24 h.

CONCLUSIONS

Being aware of the relatively small sample size and medium power, our results possibly suggest that hBD-1 could influence oocyte and sperm quality, and could improve, when exogenously added, sperm motility.

Curcumin Protects Skin against UVB-Induced Cytotoxicity via the Keap1-Nrf2 Pathway: The Use of a Microemulsion Delivery System

Curcumin was found to be beneficial in treating several skin pathologies and diseases, providing antioxidant protection due to its reducing properties and its electrophilic properties (the ability to activate the Nrf₂ pathway and induce phase II cytoprotective enzymes). Nevertheless, clinical applications of curcumin are being hampered by its insufficient solubility, chemical instability, and poor absorption, leading to low efficacy in preventing skin pathologies. These limitations can be overcome by using a nanotechnology-based delivery system. Here, we elucidated the possibility of using curcumin encapsulated in a microemulsion preserving its unique chemical structure. We also examined whether curcumin microemulsion would reduce UVB-induced toxicity in skin. A significant curcumin concentration was found in the human skin dermis following topical application of a curcumin microemulsion. Moreover, curcumin microemulsion enhanced the reduction of UV-induced cytotoxicity in epidermal cells, paving the way for other incorporated electrophiles in encapsulated form protecting skin against stress-related diseases.

Electroacupuncture decreases the progression of ovarian hyperstimulation syndrome in a rat model

This study aimed to elucidate the effect of electroacupuncture treatment on preventing early ovarian hyperstimulation syndrome (OHSS) and the potential mechanisms involved using an induced rat model. The ovarian response was examined by measuring ovary weight, vascular permeability, levels of inflammation (interleukin-6), tumour necrosis factor alpha, chemokine ligand 2 (also known as monocyte chemoactic protein 1), vascular endothelial growth factor and hormone concentrations (oestradiol, progesterone, testosterone and prolactin). Sprague-Dawley female rats underwent ovarian stimulation to induce OHSS. Hyperstimulated rats received consecutive electroacupuncture treatment from 3 days before the beginning of pregnant mare serum gonadotrophin treatment or the time point of pregnant mare serum gonadotrophin treatment respectively, and last until 3 days after HCG administration. Electroacupuncture treatment reduced ovary weight and vascular permeability in hyperstimulated rats. Electroacupuncture treatment also reduced the levels of serum steroid hormones (progesterone and testosterone), inflammatory cytokines (interleukin-6, tumour necrosis factor alpha and monocyte chemotactic protein 1 and vascular endothelial growth factor in hyperstimulated rats. The results indicate that electroacupuncture can modulate endocrine hormone secretion and affect the secretion of inflammatory cytokines and vascular endothelial growth factor, and thus prevent the progress of OHSS. Electroacupuncture may provide a simple and effective method for the prevention and treatment of OHSS.

Immunological and hemostasiological disorders in women with ovarian hyperstimulation syndrome

To assess the markers of destabilization of homeostasis in women with ovarian hyperstimulation syndrome (OHSS), the investigation of the levels of cortisol, markers of renin-angiotensin-aldosterone system, endothelin, proinflammatory cytokines, acute phase proteins, and parameters of hemostasis was performed. Our survey involved 105 women who became pregnant after IVF: 21 women with symptoms of the early moderate and severe OHSS, 28 women with the late moderate and severe OHSS, and 56 pregnant women undergoing IVF without symptoms of OHSS. It was found significant increase of levels of cortisol, interleukins, the number of leucocytes, concentration of fibrinogen and D-dimers in patients with early and late OHSS. The development of late OHSS is associated with the lower level of IL-8 and ceruloplasmin. The OHSS is characterized by leukocytosis, higher level of IL-6, TNF-α, fibrinogen, D-dimers, thus reflecting the homeostasis imbalance. The determination of the level of fibrinogen, D-dimers, leukocytes can be an important screening test of the intensity of the inflammatory process in patients with OHSS.

A potential novel strategy, inhibition of vasopressin-induced VEGF secretion by relcovaptan, for decreasing the incidence of ovarian hyperstimulation syndrome in the hyperstimulated rat model

OBJECTIVE

To investigate the effects of V1A receptor antagonist through inhibition of vasopressin-induced VEGF secretion in an experimental model.

STUDY DESIGN

Thirty rats were randomly divided into five groups. Four groups were given 10IU pregnant mare serum gonadotropin/day (sc) at 8:00-8:30am on days 22-25 of life. They were administered 30IU hCG at 8:00-8:30am on day 26 of life. On days 26 and 27 of life at 8:00am and 4:00pm, (ip) per animal, 50μg/kg/day GnRH antagonist in the GnRH antagonist group, 0.3mg relcovaptan in the high dose relcovaptan group, and 0.15mg relcovaptan in the low dose relcovaptan group were administered. The control group was given the same dosage of 0.9% saline solution (ip) on days 22-26 day of life. The main outcomes were weight gain, ovarian weights, peritoneal fluid VEGF values, corpus luteum count, and atretic follicle count.

RESULTS

Weight gain was highest in the OHSS group; it was almost twice as much in the OHSS group than it was in the control group. Ovarian weights were significantly lower in all treatment groups (p=0.03). There was no statistically significant difference in ovarian weights between the GnRH antagonist and relcovaptan groups (p=0.176). The evaluation of peritoneal fluid VEGF-A levels revealed statistically significant differences between levels in the treatment groups and in the OHSS group (p=0.005). Atretic follicle count in the OHSS group was significantly lower (p=0.048). In all treatment groups, CL counts were prominently lower than they were in the OHSS group (p=0.002).

CONCLUSION

Relcovaptan may be a novel strategy for decreasing risk of OHSS by inhibition of vasopressin-induced VEGF secretion through V1A receptor antagonist.

Persistent ascites resolving with gonadotropin-releasing-hormone-agonist 18 months after hospitalization for severe ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is a life- threatening complication of controlled ovarian stimulation. One of the main symptoms of OHSS is ascites. Treatment is symptomatic with resolution of the symptoms over days to weeks. We report a case of severe OHSS with persistent ascites 18 months after the diagnosis. Persistent ascites secondary to OHSS was diagnosed and single dose leuprolide acetate depot 11.25 mg was administered. At follow-up, no ascites was observed.

Miscarriage and clinical correlates of leukocyte count in patients with ovarian hyperstimulation syndrome

SUMMARY

This study was conducted to determine the pregnancy outcome in women with ovarian hyperstimulation syndrome and leukocytosis. From a total of 944 women who underwent IVF-ET, 89 (9.4%) developed OHSS, of whom 67 underwent embryo transfer. The criteria of the study were met by 53 women and underwent WBC count and haematological, hormonal and biochemical tests were performed on the day of HCG administration. Statistical comparison was made between women with a WBC count of >15,000 and those with a WBC count of <15,000. Patients with WBC count of >15,000 at the time of HCG administration (n = 24) had significantly increased rate of early pregnancy loss than women who had WBC count of <15,000 (n = 29). No other blood, chemical and hormonal parameters were different between the two groups. It is concluded that women with ovarian hyperstimulation syndrome in an IVF-ET cycle are more likely to miscarry if they have a WBC count of >15,000 on the day of HCG administration.

Absence of nuclear receptors for oxysterols liver X receptor induces ovarian hyperstimulation syndrome in mice

Ovarian hyperstimulation syndrome is a frequent complication occurring during in vitro fertilization cycles. It is characterized by a massive ovarian enlargement associated with an accumulation of extra vascular fluid. Here we show that liver X receptor (LXR)-alpha and LXR-beta deficient mice present many clinical and biological signs of ovarian hyperstimulation syndrome: ovarian enlargement, hemorrhagic corpora lutea, increased ovarian vascular permeability, and elevated estradiol. Ovulation stimulation resulted in excessive ovarian response to exogenous gonadotropins because follicle number and estradiol production were higher in transgenic mice. LXR deficiency also leads to perturbations in general inflammatory status, associated with ovarian il-6 deregulation. Upon treatment with the synthetic LXR agonist T09101317, serum estradiol and expression of star and cyp11a1 genes were markedly increased in wild-type mice, showing that LXRs are key regulators of ovarian steroidogenesis. These results suggest that LXRs control the ovulation by regulating endocrine and vascular processes.

Patients with severe ovarian hyperstimulation syndrome can be managed safely with aggressive outpatient transvaginal paracentesis

OBJECTIVE

To describe our experience with aggressive outpatient transvaginal paracentesis to manage ovarian hyperstimulation syndrome (OHSS).

DESIGN

Retrospective case series.

SETTING

Private, academically affiliated IVF center.

PATIENT(S)

Women undergoing assisted reproductive technologies (ART) and having a diagnosis of OHSS.

INTERVENTION(S)

Management of OHSS with hospitalization or outpatient transvaginal paracentesis between 1999 and 2007.

MAIN OUTCOME MEASURE(S)

Grade and stage of OHSS, need for hospitalization, and adverse events.

RESULT(S)

From 1999 to 2007, we identified 183 patients with OHSS. We began performing outpatient transvaginal paracentesis to treat OHSS in 2002. We have performed 146 outpatient transvaginal paracenteses in 96 patients with no procedure-related complications. With the implementation of early, aggressive, outpatient paracentesis, the number of patients requiring hospitalization for OHSS decreased. From 2006 to 2007, 29 patients were diagnosed with severe OHSS and 25 (86%) were managed as outpatients with transvaginal paracentesis with no complications.

CONCLUSION(S)

This report represents one of the largest series of patients with OHSS managed with outpatient transvaginal paracentesis. Although there continues to be a small percentage of patients with OHSS who require hospitalization, the vast majority of patients with severe OHSS at our center in the past 2 years had their condition successfully managed as outpatients with use of aggressive transvaginal paracentesis.

Lysophosphatidic acid up-regulates expression of interleukin-8 and -6 in granulosa-lutein cells through its receptors and nuclear factor-kappaB dependent pathways: implications for angiogenesis of corpus luteum and ovarian hyperstimulation syndrome

CONTEXT

Lysophosphatidic acid (LPA) was found at significant amounts in follicular fluid of preovulatory follicle. The lysophospholipase D activity of serum from women receiving ovarian stimulation was higher than women with natural cycles. Angiogenic cytokines, including IL-6, IL-8, and vascular endothelial growth factor, increased in plasma and ascites of patients with ovarian hyperstimulation syndrome. The role of LPA in ovarian follicles is unclear.

OBJECTIVE

Our objective was to investigate the expression of LPA receptors and function of LPA in granulosa-lutein cells.

DESIGN

Granulosa-lutein cells were obtained from women undergoing in vitro fertilization. We examined the expression of LPA receptors using RT-PCR. The effects of LPA on the expression of IL-6, IL-8, and vascular endothelial growth factor were examined. Signal pathways of LPA were delineated. The functions of secretory angiogenic factors were tested using human umbilical vein endothelial cells.

RESULTS

The LPA1, LPA2, and LPA3 receptors' mRNA was identified in granulosa-lutein cells. LPA enhanced IL-8 and IL-6 expressions in a dose- and time-dependent manner. LPA functioned via LPA receptors, Gi protein, MAPK/ERK, p38, phosphatidylinositol 3-kinase/Akt, and nuclear factor-kappaB, and transactivation of epidermal growth factor receptor. LPA induced IL-8 and IL-6 through different pathways. LPA-induced IL-8 and IL-6 increased permeability of human umbilical vein endothelial cell monolayer.

CONCLUSIONS

LPA induces IL-8 and IL-6 expressions through LPA receptors and nuclear factor-kappaB dependent pathways in granulosa-lutein cells. The LPA in preovulatory follicles may play a role in the angiogenesis of corpus luteum. Large amounts of LPA-induced IL-8 and IL-6 from multiple corpora luteae of stimulated ovaries may be one of the pathophysiological causes of ovarian hyperstimulation syndrome.

Elevated oestradiol concentrations are not associated with increased first trimester miscarriage rates of singleton gestations conceived by assisted conception treatment

The study evaluated the impact of elevated oestradiol concentrations on pregnancy loss during the first trimester in singleton gestations conceived via ovarian stimulation and intracytoplasmic sperm injection (ICSI). Following determination of oestradiol concentrations during 6478 ICSI cycles, patients were assorted by oestradiol percentile. Hyper-responders were defined as patients having peak oestradiol concentrations over the 90th percentile (>4200 pg/ml, 685 cycles), moderate responders were defined as patients having peak oestradiol concentrations between the 75th and 90th percentiles (3250-4200 pg/ml, 958 cycles) and normal responders were defined as patients having peak oestradiol concentrations between the 25th and 75th percentiles (1350-3250 pg/ml, 3325 cycles). The relationship between first trimester miscarriage rates and oestradiol percentiles was analysed in 1184 singleton gestations. Pregnancy rate was significantly lower in normal responders (54.4%) than in moderate (58.8%, P = 0.02) and hyper-responders (60.9%, P = 0.003), but there were no intergroup differences in miscarriage rate (19.6%, 17.1%, and 16.8%, respectively). Although women with severe ovarian hyperstimulation syndrome had a miscarriage rate of 40%, this rate did not differ significantly from the miscarriage rates of the other groups. The findings suggest that high oestradiol concentrations during ovarian stimulation do not expose singleton pregnancies to an increased risk of miscarriage during the first trimester.

Obesity and the role of gut and adipose hormones in female reproduction

Reproductive function declines at both extremes of human energy balance. The relationship between obesity and reproductive function is complex and incompletely understood. The literature has established the negative impact of excess energy stores on ovulatory function and investigated the mechanisms whereby this occurs. Furthermore, weight loss in obese anovulatory women increases ovulation and conception. Obesity and anti-obesity therapy effects on the endometrium, implantation and early fetal development have received less attention. The discovery of adipokines and enterokines greatly expands the ability to investigate the relationship between obesity, therapies to produce weight loss and reproductive function. In this review, we discuss select adipose and enteric signals. We focus on in vitro, animal and human data that lend biological plausibility to adipokines and enterokines as mediators of obesity and reproduction. Very little published work exists that directly addresses adipocyte and enteric signals in this specific role; therefore, much of this review is on the basis of a synthesis of the literature in three areas: (i) in vitro and in vivo evidence regarding the reproductive effects of these signals; (ii) adipokine and enterokine changes that occur with weight-loss therapies, focusing on hypocaloric diets, bariatric surgery and drugs that target adipocyte or enteric signals and (iii) reproductive changes produced by these weight-loss therapies.

Hyperstimulation and a gonadotropin-releasing hormone agonist modulate ovarian vascular permeability by altering expression of the tight junction protein claudin-5

We investigated the mechanism by which a GnRH agonist (GnRHa) affects ovarian vascularity, vascular permeability, and expression of the tight junction protein claudin-5 in a rat model of ovarian hyperstimulation syndrome (OHSS). Hyperstimulated rats received excessive doses of pregnant mare serum gonadotropin (PMSG; 50 IU/d) for 4 consecutive days, from d 25 to 28 of life, followed by 25 IU human chorionic gonadotropin (hCG) on d 29. Control rats received 10 IU PMSG on d 27 of life, followed by 10 IU hCG on d 29. GnRHa (leuprolide 100 microg/kg.d) was administered to some hyperstimulated rats either on d 29 and 30 (short-term GnRHa treatment) or from d 25 to 30 (long-term GnRHa treatment). Ovarian vascular density (vessels per 10 mm(2)) and vessel endothelial area (percent) were assessed by immunohistochemical analysis of the distribution of von Willebrand factor, whereas vascular permeability was evaluated based on leakage of Evans blue. High doses of PMSG and hCG significantly increased ovarian weight, vascular permeability, vascular density, and the vessel endothelial area and significantly reduced expression of claudin-5 protein and mRNA. All of these effects were significantly and dose-dependently inhibited by administration of GnRHa. This suggests that reduced expression of claudin-5 plays a crucial role in the increased ovarian vascular permeability seen in OHSS and that its expression can be modulated by GnRHa treatment. Indeed, preventing redistribution of tight junction proteins in endothelial cells and the resultant loss of endothelial barrier architecture might be the key to protecting patients against massive extravascular fluid accumulation in cases of OHSS.

Serum inhibin A, VEGF and TNFα levels after triggering oocyte maturation with GnRH agonist compared with HCG in women with polycystic ovaries undergoing IVF treatment: a prospective randomized trial

BACKGROUND

We aimed to examine the serum levels of inhibin A, vascular endothelial growth factor (VEGF), tumour necrosis factor alpha (TNFalpha), estradiol (E2) and progesterone levels after triggering of final oocyte maturation with GnRH agonist compared with HCG in patients with polycystic ovaries (PCO) and to investigate the relationship between these markers and ovarian hyperstimulation syndrome (OHSS).

METHODS

Twenty-eight patients with PCO, undergoing controlled ovarian hyperstimulation with FSH and GnRH antagonist for IVF-embryo transfer treatment, were randomized for triggering of final oocyte maturation with GnRH agonist (GnRH agonist group, n = 15) or HCG (HCG group, n = 13). Blood samples were obtained on the day of randomization and thereafter every 2-7 days. Serum levels of inhibin A, VEGF, TNFalpha, E2 and progesterone, the incidence of OHSS, ovarian size and pelvic fluid accumulation were evaluated.

RESULTS

Serum inhibin A, E2 and progesterone levels were significantly lower in the GnRH agonist group compared with the HCG group, particularly on the day of embryo transfer (P < 0.0001). Serum VEGF and TNFalpha levels were similar between the two groups. Four patients in the HCG group developed severe OHSS, whereas no patient had any symptoms or signs of OHSS in the GnRH-agonist group (P < 0.05).

CONCLUSIONS

In patients with PCO treated with FSH/GnRH antagonist, final oocyte maturation with GnRH agonist instead of HCG reduces significantly inhibin A, E2 and progesterone levels during the luteal phase. This phenomenon reflects the inhibition of the corpus luteum function and may explain, at least in part, the mechanism of OHSS prevention in high-risk patients. Our results do not support a crucial role for VEGF or TNFalpha in OHSS.

Activated protein C and the ovarian hyperstimulation syndrome: Possible therapeutic implications

Given the efficacy and safety of recombinant human activated protein C (rhAPC) in the systemic inflammatory response syndrome (SIRS), this study was designed to review the evidence for rhAPC as a possible therapeutic option in the treatment of severe ovarian hyperstimulation syndrome (OHSS). SIRS, like OHSS, is a proinflammatory and prothrombotic disorder whose cornerstone is endothelial dysfunction in which protein C deficiency is a frequent occurrence. Recently, the use of rhAPC has been shown to be of benefit with a reduction in mortality and an improvement in indicators of inflammation and coagulation. OHSS is typically an iatrogenic disorder resulting from ovarian stimulation as a component of infertility treatment. The pathogenesis of OHSS, like sepsis, is related to endothelial dysfunction and inflammation and can result in significant morbidity including end organ hypoperfusion, disseminated intravascular coagulation (DIC), thrombosis, and occasionally, death. We have performed a review of the literature to identify similarities between these disease processes to develop a theoretical basis for the use of rhAPC in patients with moderate to severe OHSS. Use of rhAPC in this group may attenuate the disease process and reduce the potential morbidity associated with this iatrogenic disorder.

Hyperstimulation ovarienne : place de la chirurgie

Ovarian hyperstimulation syndrome is a iatrogenic complication that could happen during ovulation induction. Metabolic modifications can lead to a third sector and organic failure. Medical treatment, undertaken in first line, may be insufficient. In these cases, invasive treatment, using surgical techniques, in association with reanimation principles becomes necessary. From the simple drainage to final measures for the patient's rescue, this review describes the different solutions and their respective place. Several means exist, but serious evaluation is lacking. Their use should be indicated specifically. Medico-surgical associations seemed to offer interesting results.

Understanding ovarian hyperstimulation syndrome

The ovarian hyperstimulation syndrome (OHSS) is a potentially life-threatening complication of ovarian stimulation treatments. Severe forms are characterized by a massive ovarian enlargement with the formation of multiple ovarian cysts associated with extravascular fluid shifts resulting in the development of ascites, pleural and/or pericardial effusion. The pathophysiology of the syndrome has not been completely elucidated yet. The vascular fluid leakage is thought to result from an increased capillary permeability of mesothelial surfaces under the action of one or several vasoactive ovarian factor(s) produced by the multiple corpora lutea. The paper focuses on the recent identification of mutations in the FSH receptor gene that display an increased sensitivity to hCG and are responsible for the development of spontaneous OHSS occurring during pregnancy. These findings have shed light for the first time on the molecular basis of the pathophysiology of the spontaneous form of the syndrome. As spontaneous and iatrogenic OHSS share similar pathophysiological sequences including massive recruitment and growth of ovarian follicles, extensive luteinization provoked by hCG, and oversecretion of vasogenic molecules by the corpora lutea, they have also opened new research perspectives for the understanding of the much more frequent iatrogenic OHSS.

Serum leptin concentrations in patients with severe ovarian hyperstimulation syndrome during in vitro fertilization–embryo transfer treatment

OBJECTIVE

To investigate the changes in serum leptin concentration in the conception cycle of severe ovarian hyperstimulation syndrome (OHSS).

DESIGN

Prospective longitudinal study of 66 IVF-ET cycles between May 2000 and June 2002.

SETTING

Infertility outpatient clinic at a Japanese medical school.

PATIENT(S)

Infertile patients undergoing IVF-ET cycles at the infertility outpatient clinic were divided into three groups consisting of group 1 (conception-cycle patients with severe OHSS, n = 9), and group 2 (conception cycle, non-OHSS, n = 28), and group 3 (nonconception cycle, non-OHSS, n = 29).

INTERVENTION(S)

Blood samples were collected at five different periods. Period I, on the first day of ovarian stimulation with FSH; period II, at hCG administration before oocyte retrieval; period III, 7 days after oocyte retrieval; period IV, 14 days after oocyte retrieval; and period V, 21 days after oocyte retrieval.

MAIN OUTCOME MEASURE(S)

Serum leptin concentration.

RESULT(S)

The serum leptin concentration was low in the OHSS group compared with that of the non-OHSS groups in all serum samples, with significant levels at periods III (vs. groups 2 and 3; P<.05) and IV (vs. group 3; P<.01). A twofold increase of leptin concentration from period I to period II (P<.05) was observed in all groups.

CONCLUSION(S)

The change pattern in serum leptin concentration might provide a great contribution to the pathophysiology development of OHSS patients during assisted reproductive treatment.

The effects of ovulation induction during infertility treatment on gingival inflammation

BACKGROUND

Ovulation induction is the most common method of infertility treatment in which the ovaries are stimulated to produce multiple follicles. The aim of this study was to assess the effects of three drug protocols of ovulation induction: clomiphene citrate (CC) alone, CC combined with follicle stimulating hormone (FSH), and CC combined with human menopausal gonadotropin (HMG) on the gingival tissues of women who were undergoing infertility treatment.

METHODS

Study population was composed of 18 women using CC for three menstrual cycles or less and 16 women using CC for more than three cycles; 21 women using CC-FSH; and 24 women using CC-HMG who had at least four cycles of CC alone the previous year. All subjects were clinically examined for plaque levels (plaque index), gingival inflammation (gingival index), bleeding on probing, and gingival crevicular fluid volume. The results were compared with a control group of 20 women matched for age, educational and professional level, and oral habits and who had never used ovulation drugs.

RESULTS

Despite similar plaque levels (P>0.05), women using CC for more than three cycles and combined protocols of CC-FSH and CC-HMG had higher levels of gingival inflammation (P<0.01, P<0.001 and P<0.001, respectively), bleeding (P<0.001), and GCF volume (P<0.001) when compared to the control group and to the users of CC for three cycles or less.

CONCLUSIONS

The results of this study have shown that ovulation induction, which is the most common method in the management of infertility, exacerbates gingival inflammation, bleeding, and GCF volume and that the duration of the usage of these drugs is strongly associated with the severity of gingival inflammation.

Interleukin-18 levels correlate with severe ovarian hyperstimulation syndrome

OBJECTIVE

To assess the involvement of interleukin-18 (IL-18) in the pathophysiology of severe ovarian hyperstimulation syndrome (OHSS), and study its use as a marker of disease and its correlation to capillary hyperpermeability.

DESIGN

Prospective controlled study.

SETTING

An IVF unit in a tertiary medical center.

PATIENT(S)

Twenty-four patients with OHSS in an IVF program, two control groups: group 1, 40 healthy age-matched women without ovulation-induction treatment; group 2, 19 women who received the same ovulation-induction regimen without experiencing OHSS.

INTERVENTION(S)

Blood samples were obtained at three times: during acute OHSS, on significant clinical improvement, after complete resolution. Ascitic and pleural fluids were obtained by therapeutic paracentesis. Serum, peritoneal, and pleural fluids were analyzed for IL-18 and IL-6, and blood for hematocrit, white blood cell count, and E(2) levels.

MAIN OUTCOME MEASURE(S)

Hematocrit white blood cell count, serum, peritoneal, pleural fluid levels of IL-18, IL-6, E(2) in severe OHSS.

RESULT(S)

Significantly higher IL-18 levels were detected in serum, peritoneal, and pleural fluids of patients with severe OHSS as compared with both control groups. Serum IL-18 dropped significantly on transition to the diuretic phase and resolution. A statistically significant correlation between serum IL-18 and hyperpermeability characteristics (white blood cell count, hematocrit), serum E(2), and IL-6 levels was recorded.

CONCLUSION(S)

This is the first study suggesting a role of IL-18 as a marker of OHSS, with correlation to capillary hyperpermeability parameters.

Markedly elevated levels of inflammatory cytokines in maternal serum and peritoneal washing during arrested labor

BACKGROUND

The role of inflammatory cytokines in the pathophysiology of arrested labor is currently unknown. We measured levels of inflammatory cytokines in maternal serum and peritoneal washings in arrested first stage of labor to assess the possible involvement of these mediators in this obstetric disorder.

METHODS

This was a prospective, case-control study involving 15 women who underwent cesarean section for arrested cervical dilatation (group I), 15 controls who were operated during active labor for nonreassuring fetal heart-rate tracing (group II) and 15 controls who were operated electively (group III). Blood samples were drawn from all women shortly before the operation. The presence of peritoneal fluid was assessed and peritoneal washings were obtained during the operation. All samples were assayed for the inflammatory cytokines interleukin (IL)-1beta, IL-6, IL-8 and soluble IL-2 receptor (sIL-2R) by solid-phase enzyme-linked immunosorbent assay (ELISA).

RESULTS

All women from group I and one patient (6.7%) from group II had some degree of peritoneal fluid accumulation, while none from group III had any. Serum samples from group I contained significantly higher IL-1beta, IL-6, IL-8 and IL-2R levels than both control groups. Peritoneal washings from group I contained significantly higher IL-1beta, IL-6 and IL-8 but similar IL-2R levels.

CONCLUSIONS

Arrested first stage of labor is associated with peritoneal fluid accumulation and increased levels of inflammatory cytokines in both serum and peritoneal fluids. Inflammatory cytokines may therefore be involved in the pathophysiology of arrested labor.

New insights into the pathophysiology of ovarian hyperstimulation syndrome. What makes the difference between spontaneous and iatrogenic syndrome?

The recent identification of mutations in the FSH receptor gene, which display an increased sensitivity to hCG and are responsible for the development of spontaneous ovarian hyperstimulation syndrome (OHSS), provides for the first time the molecular basis for the physiopathology of spontaneous OHSS. Based on these recent findings, this paper underlines the differences between spontaneous and iatrogenic OHSS and proposes a model to account for the different chronology between the two forms of the syndrome. In the iatrogenic form, the follicular recruitment and enlargement occur during ovarian stimulation with exogenous FSH, while in the spontaneous form, the follicular recruitment occurs later through the stimulation of the FSH receptor by pregnancy-derived hCG. In both forms, massive luteinization of enlarged stimulated ovaries ensues, inducing the release of vasoactive mediators, leading to the development of the symptoms of OHSS.

New concepts in the understanding of the ovarian hyperstimulation syndrome

PURPOSE OF REVIEW

In this review we will evaluate the recent developments in the pathophysiology of the ovarian hyperstimulation syndrome, with special emphasis on mediators of human chorionic gonadotropin action.

RECENT FINDINGS

From all the different molecules investigated, it seems that vascular endothelial growth factor is the key mediator of human chorionic gonadotropin action on the vascular tree. Recent data show that although absolute serum vascular endothelial growth factor values are useless in predicting the occurrence of ovarian hyperstimulation syndrome, individual variations in binding profiles may account for clinical differences. It has been shown that vascular endothelial growth factor is produced, expressed and secreted in the ovary and that it mediates vascular permeability in response to human chorionic gonadotropin in a time-dependent fashion. This effect may be blocked by a synthetic compound (SU5416) developed to inhibit its high-affinity receptor, kinase domain containing receptor signaling in different cancers by avoiding the initial phosphorylation of vascular endothelial growth factor receptor-2.

SUMMARY

Vascular endothelial growth factor is a promising molecule in the understanding of ovarian hyperstimulation syndrome. Future treatments should be directed to modulate or inhibit its action on the vascular wall.

Hypercoagulability, high tissue factor and low tissue factor pathway inhibitor levels in severe ovarian hyperstimulation syndrome: possible association with clinical outcome

During ovarian gonadotrophin stimulation for ovulation induction or in vitro fertilization, a clinical severe ovarian hyperstimulation syndrome (OHSS) may occur. Only few studies have investigated the mechanism responsible for the alterations of the haemostatic system in women affected by severe OHSS. The aim of the present study was to investigate the correlation between the magnitude of ovarian stimulation and the increase in fibrin formation and degradation in severe OHSS. Twenty-five patients (age range 23-43 years) who were hospitalized for severe OHSS, 25 women undergoing in vitro fertilization who did not develop OHSS (case-control group) and 25 healthy age-matched women (healthy control group) were investigated. On the day of admission a number of haemostatic markers, including D-dimer, thrombin-antithrombin complexes (TAT), prothrombin fragment 1 + 2 (F1 + 2), plasmin-antiplasmin complexes (PAP), tissue factor (TF), tissue factor pathway inhibitor (TFPI) and von Willebrand factor antigen (vWF), were examined. In patients with severe OHSS, TF, D-dimer, TAT, F1 + 2, PAP and vWF antigen plasma levels were significantly higher than those observed both in the case-control group and in healthy controls, whereas TFPI levels were significantly lower (P < 0.005) with respect to both case-controls and healthy controls. D-Dimer levels were related with serum oestradiol levels and oocyte number recovered (r = 0.45, P < 0.001 and r = 0.47, P < 0.001, respectively). D-Dimer and TAT levels were significantly (P < 0.05 and P < 0.005, respectively) higher in OHSS patients with unsuccessful pregnancy outcome (D-dimer, 226.5, 56-1449 ng/ml; TAT, 19.8, 3.1-82.6 microg/l) with respect to those with successful outcome of pregnancy (D-dimer, 145, 29-330 ng/ml; TAT, 5.0, 1.0-19.6 microg/l). Our data indicate that a marked hypercoagulability with alterations of TF and TFPI levels is detectable in patients with severe OHSS and that it is related to the clinical outcome.

Persistent ascites after ovarian hyperstimulation syndrome and administration of mifepristone (RU 486) for the termination of pregnancy

We describe two cases with persistent ascites after ovarian hyperstimulation syndrome (OHSS). Mifepristone (RU 486), an anti-progestin was administered to terminate pregnancy in both cases.

DISCUSSION

To our knowledge, this is the first such report and we discuss the implications.

Ovarian hyperstimulation syndrome is associated with reversible impairment of vascular reactivity

OBJECTIVE

To determine if there is a loss of normal peripheral arteriolar vasoconstrictor reactivity in women with severe ovarian hyperstimulation syndrome (OHSS).

SETTING

Prospective controlled study.

DESIGN

National University Hospital, Singapore.

PATIENT(S)

Forty-three women undergoing treatment in an IVF program: 22 women with severe OHSS and 21 normal women without OHSS.

INTERVENTION(S)

Measurement and quantification of the cutaneous arteriolar vasoconstrictor response using laser Doppler fluximetry.

MAIN OUTCOME MEASURE(S)

Changes in blood flow as an index of vasoconstrictor response before and after treatment for OHSS with albumin.

RESULT(S)

The mean (+/-SE) percentage (%) change in normal control women was -68.3% +/- 4.7. This was significantly different from women with OHSS (-32.3% +/- 11.1). The response in women with OHSS changed significantly after treatment with IV albumin (-60.4% +/- 5.7) and was no different than the control response. The reproducibility of the technique was -13.6% (+/-2.8).

CONCLUSION(S)

Women with OHSS have impaired vascular reactivity when compared with normal women.

Soluble ICAM-1 and E-selectin levels correlate with clinical and biological aspects of severe ovarian hyperstimulation syndrome

OBJECTIVE

To assess the potential involvement of the soluble endothelial cell-leukocyte adhesion molecules E-selectin and intercellular adhesion molecule-1 (ICAM-1) in the pathophysiology of capillary hyperpermeability in the ovarian hyperstimulation syndrome (OHSS).

DESIGN

Controlled clinical study.

SETTING

Women hospitalized for severe OHSS after ovulation induction for IVF at two tertiary medical centers.

PATIENT(S)

Eleven patients with severe OHSS undergoing IVF and 20 controls who had received a similar ovulation induction regimen and did not develop OHSS.

INTERVENTION(S)

Serial serum samples were obtained from all patients with OHSS from admission until discharge. Ascitic fluid was obtained from all patients by therapeutic paracentesis. Serum was obtained from all controls 4-8 days after ET.

MAIN OUTCOME MEASURE(S)

Samples were assayed for soluble E-selectin and soluble ICAM-1 by using enzyme-linked immunosorbent assay and results were correlated with clinical and biological aspects of OHSS.

RESULT(S)

Compared with controls, patients with severe OHSS had higher levels of soluble ICAM-1 and lower levels of soluble E-selectin detected in serum and ascites. Serum levels of soluble ICAM-1 decreased, while soluble E-selectin levels increased along with clinical and biological improvement. Serum soluble ICAM-1 showed significant positive correlation and serum soluble E-selectin showed significant negative correlation with clinical and biological aspects of severe OHSS.

CONCLUSION(S)

Soluble ICAM-1 and soluble E-selectin seem to be involved in the pathophysiology of capillary hyperpermeability in severe OHSS.