ESHRE good practice recommendations on recurrent implantation failure

STUDY QUESTION

How should recurrent implantation failure (RIF) in patients undergoing ART be defined and managed?

SUMMARY ANSWER

This is the first ESHRE good practice recommendations paper providing a definition for RIF together with recommendations on how to investigate causes and contributing factors, and how to improve the chances of a pregnancy.

WHAT IS KNOWN ALREADY

RIF is a challenge in the ART clinic, with a multitude of investigations and interventions offered and applied in clinical practice, often without biological rationale or with unequivocal evidence of benefit.

STUDY DESIGN SIZE DURATION

This document was developed according to a predefined methodology for ESHRE good practice recommendations. Recommendations are supported by data from the literature, if available, and the results of a previously published survey on clinical practice in RIF and the expertise of the working group. A literature search was performed in PubMed and Cochrane focussing on 'recurrent reproductive failure', 'recurrent implantation failure', and 'repeated implantation failure'.

PARTICIPANTS/MATERIALS SETTING METHODS

The ESHRE Working Group on Recurrent Implantation Failure included eight members representing the ESHRE Special Interest Groups for Implantation and Early Pregnancy, Reproductive Endocrinology, and Embryology, with an independent chair and an expert in statistics. The recommendations for clinical practice were formulated based on the expert opinion of the working group, while taking into consideration the published data and results of the survey on uptake in clinical practice. The draft document was then open to ESHRE members for online peer review and was revised in light of the comments received.

MAIN RESULTS AND THE ROLE OF CHANCE

The working group recommends considering RIF as a secondary phenomenon of ART, as it can only be observed in patients undergoing IVF, and that the following description of RIF be adopted: 'RIF describes the scenario in which the transfer of embryos considered to be viable has failed to result in a positive pregnancy test sufficiently often in a specific patient to warrant consideration of further investigations and/or interventions'. It was agreed that the recommended threshold for the cumulative predicted chance of implantation to identify RIF for the purposes of initiating further investigation is 60%. When a couple have not had a successful implantation by a certain number of embryo transfers and the cumulative predicted chance of implantation associated with that number is greater than 60%, then they should be counselled on further investigation and/or treatment options. This term defines clinical RIF for which further actions should be considered. Nineteen recommendations were formulated on investigations when RIF is suspected, and 13 on interventions. Recommendations were colour-coded based on whether the investigations/interventions were recommended (green), to be considered (orange), or not recommended, i.e. not to be offered routinely (red).

LIMITATIONS REASONS FOR CAUTION

While awaiting the results of further studies and trials, the ESHRE Working Group on Recurrent Implantation Failure recommends identifying RIF based on the chance of successful implantation for the individual patient or couple and to restrict investigations and treatments to those supported by a clear rationale and data indicating their likely benefit.

WIDER IMPLICATIONS OF THE FINDINGS

This article provides not only good practice advice but also highlights the investigations and interventions that need further research. This research, when well-conducted, will be key to making progress in the clinical management of RIF.

STUDY FUNDING/COMPETING INTERESTS

The meetings and technical support for this project were funded by ESHRE. N.M. declared consulting fees from ArtPRED (The Netherlands) and Freya Biosciences (Denmark); Honoraria for lectures from Gedeon Richter, Merck, Abbott, and IBSA; being co-founder of Verso Biosense. He is Co-Chief Editor of Reproductive Biomedicine Online (RBMO). D.C. declared being an Associate Editor of Human Reproduction Update, and declared honoraria for lectures from Merck, Organon, IBSA, and Fairtility; support for attending meetings from Cooper Surgical, Fujifilm Irvine Scientific. G.G. declared that he or his institution received financial or non-financial support for research, lectures, workshops, advisory roles, or travelling from Ferring, Merck, Gedeon-Richter, PregLem, Abbott, Vifor, Organon, MSD, Coopersurgical, ObsEVA, and ReprodWissen. He is an Editor of the journals Archives of Obstetrics and Gynecology and Reproductive Biomedicine Online, and Editor in Chief of Journal Gynäkologische Endokrinologie. He is involved in guideline developments and quality control on national and international level. G.L. declared he or his institution received honoraria for lectures from Merck, Ferring, Vianex/Organon, and MSD. He is an Associate Editor of Human Reproduction Update, immediate past Coordinator of Special Interest Group for Reproductive Endocrinology of ESHRE and has been involved in Guideline Development Groups of ESHRE and national fertility authorities. D.J.M. declared being an Associate Editor for Human Reproduction Open and statistical Advisor for Reproductive Biomedicine Online. B.T. declared being shareholder of Reprognostics and she or her institution received financial or non-financial support for research, clinical trials, lectures, workshops, advisory roles or travelling from support for attending meetings from Ferring, MSD, Exeltis, Merck Serono, Bayer, Teva, Theramex and Novartis, Astropharm, Ferring. The other authors had nothing to disclose.

DISCLAIMER

This Good Practice Recommendations (GPR) document represents the views of ESHRE, which are the result of consensus between the relevant ESHRE stakeholders and are based on the scientific evidence available at the time of preparation. ESHRE GPRs should be used for information and educational purposes. They should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care, or be exclusive of other methods of care reasonably directed to obtaining the same results. They do not replace the need for application of clinical judgement to each individual presentation, or variations based on locality and facility type. Furthermore, ESHRE GPRs do not constitute or imply the endorsement, or favouring, of any of the included technologies by ESHRE.

P-473 Low radiation affects follicle count in sheep ovaries

Study question

What is the effect of low dose radiation on follicle count in sheep ovaries?

Summary answer

Even low dose radiation has a negative impact on the follicle count in sheep ovaries.

What is known already

Radiotherapy is a corner stone of state-of-the-art cancer treatment, especially in young cancer patients. Survival rates are constantly rising, resulting in long-term survivors with potential child wish. High doses of radiation lead to a permanent damage to the ovaries. Little is known about the damage after low dose radiation to the ovaries including both follicles and stroma.

Study design, size, duration

Prospective ongoing study, including n = 41 sheeps and 942 ovarian punches (Ø 3mm). So far, n = 12 sheep and n = 120 punches were analysed between April 2020 and January 2022. After finishing the experiments with sheep ovarian tissue, we will continue with a mouse model and human ovarian tissue.

Participants/materials, setting, methods

942 cortex punches out of a total of n = 41 sheep were obtained and cryopreserved. After thawing the punches were radiated with a dose of 0.0, 0.5, or 9.0 Gy using a cesium 137 radionuklide source (GSR C1, GammaService Medical GmbH). The punches were fixed in formalin, embedded in paraffin, cut into serial sections of 3-5 µm and stained with Hematoxylin and Eosin for follicle counting as well as Caspase 3 and Ki67.

Main results and the role of chance

Follicle loss was already observed after low dose radiation (0.5 Gy). Mean follicle count after 0 Gy, 0.5 Gy, and 9 Gy were 7.5, 2.3 and 1.8, respectively. While after 0 Gy, no signs of degeneration were visible, after radiation with 9 Gy follicles showed strong signs of degeneration including disorganization of granulosa cells, pyknosis and stromal irregularities.

Limitations, reasons for caution

Limitations of our study include the pilot character and therefore small sample size. The presented data only display part of the overall project including also an in-vivo mouse model.

Wider implications of the findings

As even low dose radiation seems to damage ovarian follicles, further in-vivo studies are needed to confirm these results. Moreover, fertility preservation methods need to be offered consequently to young cancer patients receiving radiotherapy.

Trial registration number

25

Evaluation of electrocardiographic repolarization parameters in patients with polycystic ovary syndrome

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Research, Development and Innovation Office

Introduction

Polycystic ovary syndrome (PCOS) is a multifactorial, endocrine disease associated with metabolic disturbances (e.g. hyperinsulinemia, insulin resistance) and increased cardiovascular risk. Recent data strongly suggest that different QT variability parameters characterizing cardiac repolarization instability represent novel markers in proarrhythmic risk assessment.

Purpose

In the present study we investigated ECG repolarization parameters, including QT variability parameters in patients with polycystic ovary syndrome.

Methods

Fifty-five PCOS patients (age: 29±6 years) and 55 age-matched healthy volunteers (age: 29±10 years) were enrolled in the study. Five-minute 12-lead resting electrocardiograms were recorded, the ECGs were digitized and evaluated off-line using the Cardiosys-A01 system (Cardiosys-A01, MDE Heidelberg GMBH, Heidelberg, Germany). The following parameters were determined: the frequency corrected QT interval (QTc) using Bazett’s, Fridericia, Framingham and the Hodges formulas; QT dispersion (QTd) and T wave peak-to-end distance (Tpeak-Tend). Among QT variability parameters we analyzed the QT variance (QTv), the QT variability index (QTVI), the short-term beat-to-beat QT and RR interval variability (STV-QT, STV-RR) based on constructed Poincaré plots and the variability ratio (VR).

Results

The RR interval did not differ significantly in PCOS patients compared to controls (821±129 ms vs. 847±99 ms), however the QT interval (373±30 ms vs. 391±27 ms, p<0.01), the QTc calculated with Bazett’s, Framingham, Fridericia and Hodges correction formulas (QTc Bazett’s: 413±18 ms vs. 426±21 ms, p<0.01) and the Tpeak-Tend intervals were significantly shorter (76±10 ms vs. 83±12 ms, p<0.01). The QTd, QTv, and STV-RR did not differ significantly. However, the VR (0.3±0.4 vs. 0.2±0.2, p<0.05), the QTVI (-0,9±0.5 vs. -1,3±0.4, p<0.001), and importantly, the STV-QT were significantly higher in PCOS patients compared to controls (4.0±0.9 ms vs. 3.2±0.9 ms, p<0.0001).

Conclusion

Some of the alterations in repolarization parameters and the significant increase in the short-term beat-to-beat QT interval variability and the QT variability index may indicate increased repolarization instability in patients with polycystic ovary syndrome compared to age-matched controls, however, further studies are needed to establish the exact relation of this finding to increased arrhythmia propensity in this population.

Evaluation of electrocardiographic repolarization parameters in patients with polycystic ovary syndrome

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Research, Development and Innovation Office

Introduction

Polycystic ovary syndrome (PCOS) is a multifactorial, endocrine disease associated with metabolic disturbances (e.g. hyperinsulinemia, insulin resistance) and increased cardiovascular risk. Recent data strongly suggest that different QT variability parameters characterizing cardiac repolarization instability represent novel markers in proarrhythmic risk assessment.

Purpose

In the present study we investigated ECG repolarization parameters, including QT variability parameters in patients with polycystic ovary syndrome.

Methods

Fifty-five PCOS patients (age: 29±6 years) and 55 age-matched healthy volunteers (age: 29±10 years) were enrolled in the study. Five-minute 12-lead resting electrocardiograms were recorded, the ECGs were digitized and evaluated off-line using the Cardiosys-A01 system (Cardiosys-A01). The following parameters were determined: the frequency corrected QT interval (QTc) using Bazett’s, Fridericia, Framingham and the Hodges formulas; QT dispersion (QTd) and T wave peak-to-end distance (Tpeak-Tend). Among QT variability parameters we analyzed the QT variance (QTv), the QT variability index (QTVI), the short-term beat-to-beat QT and RR interval variability (STV-QT, STV-RR) based on constructed Poincaré plots and the variability ratio (VR).

Results

The RR interval did not differ significantly in PCOS patients compared to controls (821±129 ms vs. 847±99 ms), however the QT interval (373±30 ms vs. 391±27 ms, p<0.01), the QTc calculated with Bazett’s, Framingham, Fridericia and Hodges correction formulas (QTc Bazett’s: 413±18 ms vs. 426±21 ms, p<0.01) and the Tpeak-Tend intervals were significantly shorter (76±10 ms vs. 83±12 ms, p<0.01). The QTd, QTv, and STV-RR did not differ significantly. However, the VR (0.3±0.4 vs. 0.2±0.2, p<0.05), the QTVI (-0,9±0.5 vs. -1,3±0.4, p<0.001), and importantly, the STV-QT were significantly higher in PCOS patients compared to controls (4.0±0.9 ms vs. 3.2±0.9 ms, p<0.0001).

Conclusion

Some of the alterations in repolarization parameters and the significant increase in the short-term beat-to-beat QT interval variability and the QT variability index may indicate increased repolarization instability in patients with polycystic ovary syndrome compared to age-matched controls, however, further studies are needed to establish the exact relation of this finding to increased arrhythmia propensity in this population.

P–423 Lower cytotoxicity: Altered natural killer cell activation in recurrent implantation failure

Study question

Within this prospective study, we aim to differentiate immune cell subpopulations in recurrent implantation failure (RIF) patients and fertile controls.

Summary answer

A misbalanced immune profile of NK cell subpopulations is present in RIF patients and might be a potential risk factor that requires further detailed analysis.

What is known already

So far, there is no conclusive opinion on the prognostic value of testing immune cell populations in women with RIF. Increased numbers of cytotoxic (CD56dimCD16bright) peripheral natural killer (pNK)-cells and CD56brightCD16dim mainly in the uterus occurring NK cells (uNK) seemed to be more prevalent in RIF patients. NK cell cytotoxicity is regulated by a complex interaction of activating and inhibiting receptors, such as the NKGD2 and natural cytotoxicity receptors including NKp46, NKp30 and NKp44. Dysregulated pNK cells could affect the adhesion and implantation of the embryo thereby contributing to RIF.

Study design, size, duration

Within this prospective study between March 2018 and August 2020 immune diagnostics of pNK cells and subpopulations as well as regulatory T-cells in RIF patients (defined as ≥ 3 failed fresh or frozen embryo transfers of good quality embryos (Istanbul criteria) and non-pregnant controls (nulli- and multipara) were performed using flow cytometry analysis.

Participants/materials, setting, methods

In total, n = 42 RIF and n = 85 controls were included. Absolute numbers and percentages of total lymphocytes of CD56dimCD16bright, CD56brightCD16dim NK cells, CD45+CD25+FoxP3+-regulatory T-cells and activation markers (CD57+, CD62L+, NKGD2+, NKp46+) were measured in patients and controls (n = 60 nulligravida, n = 25 para) in the mid-luteal phase. Statistical analysis was performed using SPSS Version 26 considering p < 0.05 statistically significant.

Main results and the role of chance

RIF patients showed significantly lower numbers and percentages of CD56dimCD16bright pNK cells (mean±SD per µl: 187,5±113,3 vs. 281,9±163,4 p = 0.001;%: 87,4±8,8 vs. 90,6±6,0 p = 0.017) and higher levels of CD56brightCD16dim pNK cells (mean±SD per%: 10,5±8,3 vs. 7,6±5,5 p = 0.021) compared to controls. Further, lower percentages of CD56dimCD16brightCD62L + (mean±SD per%: 23,5±11,1 vs. 32,0±14,0 p = 0.001), CD56dimCD16brightNKGD2 + (mean±SD per%: 94,0±6,8 vs. 96,4±4,2 p = 0.014) and CD56dimCD16brightNKp46 + (mean±SD per%: 65,8±19,5 vs. 76,1±14,0 p = 0.001) were observed in RIF patients (p < 0.05). A different activation of pNK cells represented by high levels of CD62L+, NKGD2+, NKp46+ surface markers in controls and higher levels of CD56brightCD16dim pNK cells in RIF patients could contribute to RIF. No difference was present in levels of CD45+CD25+FoxP3+-regulatory T-cells within the study population.

Limitations, reasons for caution

As controls composed out of not only nulli- but also multipara, higher levels of pNK cells in controls, could be induced by fetal microchimerism in multiparas, however, results remained significant after removing multipara from statistical analysis.

Wider implications of the findings: These findings condense into the assumption of a non-linear association between NK cytotoxicity and successful pregnancy. A lower NK cytotoxicity in RIF patients could potentially lead to an altered immune environment impeding a successful implantation process.

Trial registration number

Drks00020803

O-128 Intra-cycle alterations of the uterine microbiota in patients with recurrent miscarriage or recurrent implantation failure and healthy controls

Study question

Uterine microbiota: are there differences within three major time points of the menstrual cycle in healthy controls, recurrent miscarriage (RM) and recurrent implantation failure (RIF) patients?

Summary answer

Compared to controls, RM and RIF patients showed an altered uterine microbiota throughout the menstrual cycle, with a lower dominance of lactobacilli.

What is known already

In contrast to the former notion of a sterile womb, bacterial colonization in the uterus and the placenta has been demonstrated. Studies showed that Lactobacillus-dominated endometrial microbiota correlate with reproductive success. Moreover, the presence of non-Lactobacillus-dominated microbiota, especially with detection of Gardnerella and Streptococcus in the endometrial fluid, seems to be associated with lower implantation-, ongoing pregnancy- and live birth-rates. However, intra-cycle variations in healthy women as well as possible alterations in patients with RM or RIF remain unknown.

Study design, size, duration

In total, n = 20 RM patients (≥ 3 consecutive miscarriages), n = 20 RIF patients (≥3 fresh or frozen embryo transfers with negative serum hCG, good quality embryos) and n = 10 healthy controls (no pregnancy) were included in this study. All patients had a 28 day menstrual cycle. During follicular, ovulatory and luteal-phase, after a thorough cleaning of the cervix, a flexible catheter was introduced into the uterine cavity and a uterine flushing with 1ml of NaCl was performed.

Participants/materials, setting, methods

Bacterial DNA was extracted using a QIAamp DNA kit (Qiagen) in combination with a PrecellysR24 homogenizer (Peqlab, Erlangen, Germany) according to the manufacturer’s instructions. The V3-V4 region of the bacterial 16S rRNA gene was amplified. Samples were pooled in equimolar ratios and progressed to pyrosequencing using an Illumina MiSeq se-quencer with MiSeq Kit V2 (250 bp paired-end). Analysis of 16S rRNA data, including alpha- and beta-diversity, were calculated using the phyloseq package in R.

Main results and the role of chance

For the Shannon index (species richness and evenness) a significant decrease during the ovulation period was shown in the control group, indicating a more uniform microbiota (p < 0.05). This loss of diversity was not shown in RIF and RM patients. Overall, we could observe a higher similarity in taxonomic distribution in RM compared to the RIF patients. Longitudinal dynamics included increases in Firmicutes (CTRL and RM only) and a concomitant loss of Proteobacteria. Notably, significant amounts of bacteroides were only detected in the RIF patients. Actinobacteria were more frequent in both, RM and RIF as compared to controls.

Limitations, reasons for caution

To minimize the impact of a potential contamination, we performed pre-experiments with paired samples both from the vaginal fornix and the endometrial cavum and could show a significant difference in overall microbiome configuration. However, the route of sample can still be prone to contamination.

Wider implications of the findings

For the first time, we were able to show cycle-dependent alterations in the endometrial microbiome. These findings underline the role of an altered endometrial microbiome as a cause for RM and RIF and can contribute to the future establishment of therapeutic strategies in cases of a dysbalanced microbiome.

Trial registration number

Drks00020803

P–088 Sexual functioning is impaired in cancer survivors after cancer therapy

Study question

Is impaired sexual functioning correlated to sperm quality in cancer survivors?

Summary answer

Erectile dysfunction affects 25.0% of cancer survivors, independent of sperm quality. 22.9% of patients show symptoms consistent with a reduced testosterone level.

What is known already

Gonadotoxic treatment in male cancer patients can end up in reversible or permanent impaired spermatogenesis, testosterone insufficiency, and sexual dysfunction.

Study design, size, duration

In this prospective single-center study, sexual functioning was assessed in male cancer survivors, who underwent sperm cryopreservation at the Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck, Austria from 01/2010 to 12/2018. Sexual functioning was assessed between 03–12/2020 via two questionnaires: Aging Male Score (AMS) and International Index of Erectile Function (IEEF-EF).

Participants/materials, setting, methods

Thirty-five cancer survivors (testicular cancer: n = 16 [45.7%], hematological malignancies: n = 15 [42.9%], others: n = 4 [n = 11.4%]) filled in two questionnaires (AMS and IEEF-EF) during routine follow-up visit at the Department of Gynecological Endocrinology and Reproductive Medicine, Medical University Innsbruck and the Department of Urology, Medical University Innsbruck, Austria. Moreover, sperm quality was assessed and normozoospermia was defined in accordance with the 2010 WHO criteria (sperm concentration ≥15 million/mL, progressive motility ≥32%, and ≥4% normal morphology).

Main results and the role of chance

Mean age at sperm cryopreservation and follow-up visit was 25.1±4.2 and 31.9±6.3 years, respectively with a mean follow-up time of 81.4±12.5 months. Rate of erectile dysfunction was low (75.0% no dysfunction, 15.6% low dysfunction, 3.1% low-moderate dysfunction, 3.1% moderate, 3.1% severe dysfunction). Moreover, AMS score indicated no, low, moderate and severe symptoms consistent with a low testosterone level in 77.1%, 8.6%, 2.9%, and 2.9% of patients, respectively. Oligozoospermia was observed in up to 48% of the patients with TM and in only 23% patients with HM. Patients with TM showed significantly reduced sperm count (18.7 × 106/mL [5.3–43.0]) and total sperm count (42.4 × 106/ejaculate [13.3–108.5]) compared to HM (p = 0.03). There was no difference in sexual functioning between patients with HM or TM. Sexual functioning did no correlate with sperm count, progressive motility or morphology.

Limitations, reasons for caution

Although the study may be limited by its small sample size, it is the first to assess a correlation of sperm quality and sexual dysfunction in cancer survivors.

Wider implications of the findings: As every fourth male cancer patient suffers from impaired sexual functioning after gonadotoxic treatment, this important topic should be addressed in clinical and scientific future. Future studies should focus on both, somatic and psychosomatic reasons for sexual dysfunction.

Trial registration number

none

Definition, diagnostic and therapeutic options in recurrent implantation failure: an international survey of clinicians and embryologists

STUDY QUESTION

What is the global variability in recurrent implantation failure (RIF) definition, investigation and therapy, currently offered to patients undergoing IVF?

SUMAMRY ANSWER

Definitions, diagnostic investigations and treatments offered to RIF patients differ widely amongst assisted reproduction healthcare professionals and clinical guidelines on RIF are urgently needed.

WHAT IS KNOWN ALREADY

RIF affects around 10% of patients undergoing IVF worldwide. There is no consensus on the definition of RIF, its diagnostic investigations or the therapeutic options, which leads to inconsistencies in clinical practice.

STUDY DESIGN, SIZE, DURATION

A cross-sectional study of clinicians and embryologists was conducted between May and June 2020. The survey included 43 questions aimed at understanding participants' background and their current practice with regards to defining, investigating and managing RIF. The questions were designed by the European Society of Human Reproduction and Embryology (ESHRE) Special Interest Group (SIG) on implantation and early pregnancy following three consensus meetings.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 8579 ESHRE members from 6916 IVF centers were invited to participate using two global email calls based on their pre-specified interest in implantation and early pregnancy. SurveyMonkey and SPSS were used for data collection and analysis, respectively. Furthermore, differences were reported in the answers of European and non-European professionals, as well as between public and private settings and among clinicians clustered according to the average number of RIF patients treated per year.

MAIN RESULTS AND THE ROLE OF CHANCE

The final data set included 735 clinicians and 300 embryologist or IVF-biologists. The majority defines RIF based on the number of failed embryo transfers (ETs) with the most common threshold adopted being three ETs both fresh and frozen. More than two-thirds take lifestyle factors into account, mainly drugs, smoking and BMI. The highest consensus on which diagnostic investigations should be performed was reached for anatomical malformations and gynecological aspects focusing on hydrosalpinx, Asherman's syndrome, endometrial thickness and endometriosis. Concerning treatment of RIF patients, the highest consensus was reached for preconceptional therapies, including BMI adjustment, smoking and endometritis followed by therapies during IVF procedures.

LIMITATIONS, REASONS FOR CAUTION

The response rate was relatively low, but comparable to other surveys.

WIDER IMPLICATIONS OF THE FINDINGS

A consensus on definition, diagnosis and treatment of RIF would help to reduce costly, time-consuming and poorly validated approaches.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used. B.T. received support from Bayer for Clinical trials concerning endometriosis and Ferring for clinical trials concerning ovarian stimulation. She received reimbursement for travel expenses from Astropharm, Ferring. Dr Kade and is a shareholder of Reprognostics. She is a board member of the Austrian Society for Obstetrics and Gynecology (OEGGG), the associate head of the 'Reproduktionsmedizinische Zentren Baden-Württemberg' (RZBW), a member of guideline group of the German Society for Obstetrics and Gynecology (DGGG) and an editorial board member of the following journals: American Journal of Reproductive Immunology (AJRI), Archives of Gynecology and Obstetrics. All the other authors declare no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

Bedeutung der Fertilitätschirurgie bei Kinderwunsch

Die Bedeutung der Fertilitätschirurgie bei Kinderwunsch kann vielfach aufgrund fehlender eigener Erfahrung während der Facharztweiterbildung nicht erfasst werden, da nur an wenigen Zentren eine spezifische operative Ausbildung erfolgt. Neben der Abklärung anatomischer Fehlbildungen mittels Hysteroskopie bzw. Laparoskopie gehört die operative Myom- und Endometriosebehandlung zu den Standardverfahren der Fertilitätschirurgie. Hier ist die Erfahrung der Reproduktionsmediziner gefragt, damit unter maximaler Schonung der Ovarreserve ein bestmöglichstes Ergebnis hinsichtlich Endometriosesanierung bzw. Myomenukleation erreicht wird. Die Abklärung der Tubendurchgängigkeit mit Chromopertubation ist nach wie vor Goldstandard, auch wenn im ambulanten Sektor vorwiegend nichtoperative Verfahren zum Einsatz kommen. Die diagnostische und gegebenenfalls operative Hysteroskopie dient der Beurteilung des Endometriums und erlaubt den Ausschluss von Entzündungsprozessen oder dem Vorliegen von Polypen.

Revascularization decisions in patients with stable angina and intermediate lesions: results of the second International Survey on Interventional Strategy (ISIS-2)

Background

ISIS-1 survey (conducted in 2012–2013) demonstrated a significant disconnect between guideline recommendations on invasive functional and imaging assessment of coronary stenosis severity and effective intention to adoption in patients with chronic coronary syndromes (CCS). Ever since, more evidences and new indexes/tools have become available, supposedly resulting into a simplified adoption. Therefore, six years later the second survey was repeated (ISIS-2) with the aim to evaluate a possible evolution in the intended adoption of invasive diagnostic tools.

Methods

ISIS-2 was conducted via a web-based platform from June to December 2019. Here, five complete angiograms were provided, presenting only focal intermediate stenoses. FFR and quantitative coronary angiography (QCA) values were known and kept concealed to the participants. Estimation of stenosis significance was asked for each lesion. In case of uncertainty, the most appropriate adjunctive invasive diagnostic method among QCA, intravascular ultrasound, optical coherence tomography, or invasive functional test (i.e. with FFR or a non-hyperemic index) was to be selected. Primary endpoint of the study was the rate of requested adjunctive functional or imaging assessment, as indicated by guideline recommendations. Secondary endpoint was the rate and accuracy of purely angiography-based decisions.

Results

A total of 411 participants performed 3749 lesion evaluations in ISIS-2: 2237 (60%) decisions were taken solely on angiogram and expressed no need for further evaluation with adjunctive tools. This rate of angiographic reliance was significantly reduced in ISIS-2 as compared with ISIS-1 (3139 [71%]; p<0.001). Here the decision (significant or non-significant) was discordant with the known functional significance in 870 (39%) cases, markedly less as in ISIS-1 (1459, 46%; p<0.001). In ISIS-2, participants expressed the need for either invasive functional assessment or intravascular imaging in 1110 (29%) and 379 (11%) cases, respectively. These rates were significantly higher as compared with ISIS-1 (928 [21%]; p<0.001 and 354 [8%]; p<0.001, respectively).

Conclusions

ISIS-2 survey suggests an evolving pattern over 6 years in the intention to integrate coronary angiography with invasive coronary physiology and imaging testing in patients with CCS.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Unrestricted grant from Abbott Medical

OP0233 EFFICACY, SAFETY, AND PHARMACODYNAMIC EFFECTS OF THE BRUTON’S TYROSINE KINASE INHIBITOR, FENEBRUTINIB (GDC-0853), IN MODERATE TO SEVERE SYSTEMIC LUPUS ERYTHEMATOSUS IN A PHASE 2 CONTROLLED STUDY

Background:

Fenebrutinib (GDC-0853, FEN) is an oral, non-covalent, and selective inhibitor of Bruton’s tyrosine kinase (BTK) in clinical development for autoimmune diseases.

Objectives:

This was a randomized, placebo-controlled, multi-center study to evaluate the efficacy, safety, and pharmacodynamic effects of FEN in patients with moderate-to-severe systemic lupus erythematosus (SLE) activity.

Methods:

Patients who met SLICC or revised ACR SLE criteria, had ≥1 serologic marker of SLE, SLEDAI ≥8, and were on ≥1 standard of care (SOC) therapy were included; patients with renal or CNS involvement, or exposure to B cell depleting or calcineurin inhibitor therapy were excluded. Patients were randomized to placebo (PBO), FEN 150 mg QD, or FEN 200 mg BID, for 48 weeks. A corticosteroid taper was recommended, with burst and taper permitted from Week 0 (W0) to W12 and W24 to W36. The primary endpoint was SRI-4 at W48. Post hoc subgroup analyses were conducted based on patient baseline disease characteristics.

Results:

This study enrolled 260 patients, with the majority recruited in Latin America, USA, and Western Europe. At W48, the SRI-4 response rates for FEN 150 mg QD and FEN 200 mg BID were 51% (95% CI: -8.5, 21.2; p value 0.37) and 52% (95% CI: -7.3, 22.4; p value 0.34), respectively, compared to 44% for PBO (Table 1). Post-hoc analysis showed larger responses in subgroups of patients with higher baseline disease activity (Table 1). Safety results were similar between FEN and PBO arms, although more serious adverse events were observed in the FEN 200 mg BID arm. Study discontinuations were balanced across the 3 arms (24-26%). FEN treatment significantly reduced levels of CD19+ B cells, anti-dsDNA autoantibodies, IgG, and a BTK-dependent RNA signature highly expressed in plasmablasts by W48 compared to PBO; C4 levels modestly improved with FEN vs. PBO (Table 2).

Table 1.

SRI-4 Response (%) at W48 in Primary Analysis and in Post-hoc Patient Subgroups

PBOFEN 150 mg QDFEN 200 mg BIDSRI-4 Response (%) at W4844n=8451n=8752n=88SRI-4 Response (%) in Baseline Subgroups At least 1 BILAG A48n=4254n=3959n=46 At least 1 BILAG A and SLEDAI increased DNA binding37n=1953n=1765n=26 SLEDAI arthritis with at least 4 swollen joints39n=5750n=5457n=54 SLEDAI arthritis with at least 4 tender joints39n=7153n=7059n=69 CLASI >=1021n=1436n=1131n=16Table 2.

Key Biomarker Results

PBOFEN 150 mg QDFEN 200 mg BIDMedian (%) Change from Baseline at W48 Plasmablast signature-19.7%n=52-54.3%*n=53-51.7%*n=57 CD19+B cells (cells/µl)-0.50n=38-57.0*n=49-57.5*n=48 Anti-dsDNA#(IU/ml)+6.9n=31-38.3*n=36-75.7*n=33 Total IgG (g/L)-0.20n=65-1.25*n=64-1.56*n=64 C3 (g/L)-0.02n=65+0.01n=67-0.01n=66 C4 (g/L)0.00n=65+0.02*n=67+0.01*n=66

#Patients who were positive at baseline (>30 IU/mL)

*Denotes significant vs. PBO; Kruskal-Wallis false-discovery rate controlled two sided (p-value ≤0.05)

Conclusion:

The primary endpoint of SRI-4 for FEN was not met despite evidence of strong BTK target and pathway inhibition. FEN had an acceptable safety profile. Several disease activity subgroups were suggestive of a greater treatment effect on SRI-4 compared to PBO

Disclosure of Interests:

David Isenberg Consultant of: Study Investigator and Consultant to Genentech, Richard Furie Grant/research support from: AstraZeneca, Biogen, Consultant of: AstraZeneca, Biogen, Nicholas S. Jones Shareholder of: Genentech/Roche, Employee of: Genentech/Roche, Pascal Guibord Shareholder of: Roche, Employee of: Roche, Joshua Galanter Shareholder of: Genentech/Roche, Employee of: Genentech/Roche, Chin Lee Shareholder of: Genentech/Roche and Eli Lilly, Employee of: Genentech/Roche, Anna McGregor Employee of: Genentech/Roche, Balazs Toth Shareholder of: Genentech/Roche, Employee of: Genentech/Roche, Julie Rae Shareholder of: Genentech/Roche, Employee of: Genentech/Roche, Olivia Hwang Shareholder of: Genentech/Roche, Employee of: Genentech/Roche, Armend Lokku Shareholder of: Roche, Employee of: Roche, Pedro Miranda Consultant of: Study Investigator for Genentech, Viviane de Souza Consultant of: Study investigator for Genentech, Juan Jaller-Raad Consultant of: Study investigator for Genentech, Anna Maura Fernandes Consultant of: Study investigator for Genentech, Rodrigo Garcia Salinas Consultant of: Study investigator for Genentech, Leslie Chinn Shareholder of: Genentech/Roche, Employee of: Genentech/Roche, Michael J. Townsend Shareholder of: Genentech/Roche, Employee of: Genentech/Roche, Alyssa Morimoto Shareholder of: Genentech/Roche, Employee of: Genentech/Roche, Katie Tuckwell Shareholder of: Genentech/Roche, Employee of: Genentech/Roche

Manifestation of migraine in adolescents: Does it change in puberty?

PURPOSE

To analyze the association between pubertal stage, menstrual cycle and migraine attacks in girls with migraine. In addition, headache frequency, accompanying symptoms, duration and onset in relation to the specific phase of the cycle were investigated.

METHODS

Girls between 7 and 18 years old, diagnosed with headaches that met "International Classification of Headache Disorders II" diagnostic criteria for migraine without aura, kept a daily headache and menstrual cycle diary over 8 weeks. Ovulatory cycles were identified by weekly progesterone saliva tests.

RESULTS

47 girls participated in the study and were divided into three groups according to Tanner stage and onset of regular menstruation: pre- (n = 16), peri- (n = 19) and post-pubertal (n = 12). A significant difference in migraine frequency was found between pre- and post-pubertal girls (p = 0.005). No significant differences with regard to headache characteristics were detected. Interestingly, a higher frequency of attacks in follicular phase occurred compared to luteal phase in peri- and post-pubertal girls (p = 0.030).

CONCLUSION

During puberty, migraine patterns in girls change to a typical adult pattern of migraine in a stepwise manner not clearly related to menarche. The first sign of this transition phase could be the higher frequency of migraine attacks in post-pubertal girls.

Evaluation of the exposure, dose-response and fate in the lung and pleura of chrysotile-containing brake dust compared to TiO2, chrysotile, crocidolite or amosite asbestos in a 90-day quantitative inhalation toxicology study - Interim results Part 1: Experimental design, aerosol exposure, lung burdens and BAL

This 90-day repeated-dose inhalation toxicology study of brake-dust (BD) (brakes manufactured with chrysotile) in rats provides a comprehensive understanding of the biokinetics and potential toxicology in the lung and pleura. Exposure was 6 h/d, 5d/wk., 13wks followed by lifetime observation (~20 % survival). Control groups included a particle control (TiO₂), chrysotile, commercial crocidolite and amosite asbestos. Aerosol fiber distributions of the chrysotile, crocidolite and amosite were similar (fibers L > 20 μm/cm³: chrysotile-Low/High 29/72; crocidolite 24; amosite 47 fibers/cm³; WHO-fibers/cm³: chrysotile-Low/High 119/233; crocidolite 181; amosite 281 fibers/cm³). The number of particles/cm³ in the BD was similar to that in the chrysotile, crocidolite & amosite exposures (BD 470-715; chrysotile 495-614; crocidolite 415; amosite 417 particles/cm³). In the BD groups, few fibers L > 20 μm were observed in the lungs at the end of exposure and no fibers L > 20 μm at 90d post exposure. In the chrysotile groups, means of 204,000 and 290,000 fibers(L > 20 μm)/lung were measured at 89d. By 180d, means of 1 and 3.9 fibers were counted on the filter corresponding to 14,000 and 55,000 fibers(L > 20 μm)/lung. In the crocidolite and amosite groups mean lung concentrations were 9,055,000 and 11,645,000 fibers(L > 20 μm)/lung at 89d. At 180d the means remained similar with 8,026,000 and 11,591,000 fibers(L > 20 μm)/lung representing 10-13% of the total lung fibers. BAL determined the total number of macrophages, lymphocytes, neutrophils, eosinophils, epithelial-cells and IL-1 beta, TNF-alpha and TGF-beta. At the moderate aerosol concentrations used in this study, neutrophil counts increased ~5 fold in the amphibole asbestos exposure groups. All other groups and parameters showed no important differences at these exposure concentrations. The exposure and lung burden results provide a sound basis for assessing the potential toxicity of the brake dust in comparison to the TiO2 particle control and the chrysotile, crocidolite and amosite asbestos control groups. The BAL results provide an initial indication of the differential response. Part 2 presents the presentation and discussion of the histopathological and confocal microscopy findings in this study through 90 days post exposure.

Evaluation of the dose-response and fate in the lung and pleura of chrysotile-containing brake dust compared to TiO2, chrysotile, crocidolite or amosite asbestos in a 90-day quantitative inhalation toxicology study - Interim results Part 2: Histopathological examination, Confocal microscopy and collagen quantification of the lung and pleural cavity

The interim results from this 90-day multi-dose, inhalation toxicology study with life-time post-exposure observation has shown an important fundamental difference in persistence and pathological response in the lung between brake dust derived from brake-pads manufactured with chrysotile, TiO₂ or chrysotile alone in comparison to the amphiboles, crocidolite and amosite asbestos. In the brake dust exposure groups no significant pathological response was observed at any time. Slight macrophage accumulation of particles was noted. Wagner-scores, were from 1 to 2 (1 = air-control group) and were similar to the TiO₂ group. Chrysotile being biodegradable, shows a weakening of its matrix and breaking into short fibers & particles that can be cleared by alveolar macrophages and continued dissolution. In the chrysotile exposure groups, particle laden macrophage accumulation was noted leading to a slight interstitial inflammatory response (Wagner-score 1-3). There was no peribronchiolar inflammation and occasional very slight interstitial fibrosis. The histopathology and the confocal analyses clearly differentiate the pathological response from amphibole asbestos, crocidolite and amosite, compared to that from the brake dust and chrysotile. Both crocidolite and amosite induced persistent inflammation, microgranulomas, and fibrosis (Wagner-scores 4), which persisted through the post exposure period. The confocal microscopy of the lung and snap-frozen chestwalls quantified the extensive inflammatory response and collagen development in the lung and on the visceral and parietal surfaces. The interim results reported here, provide a clear basis for differentiating the effects from brake dust exposure from those following amphibole asbestos exposure. The subsequent results through life-time post-exposure will follow.

The impact of previous live births on peripheral and uterine natural killer cells in patients with recurrent miscarriage

BACKGROUND

Peripheral and uterine natural killer cells (pNK and uNK cells) are key players in the establishment and maintenance of pregnancy and are disturbed in patients with recurrent miscarriage (RM). Different immunologic risk factors have been proposed between patients with primary RM (pRM, no previous live birth) and secondary RM (sRM, ≥ 1 previous live birth). However, so far, the study populations mainly consisted of small subgroups. Therefore, we aimed to analyse pNK and uNK cells in a large, well defined study population within a prospective study.

METHODS

In total, n = 575 RM patients (n = 393 pRM, n = 182 sRM) were screened according to a standard protocol for established risk factors as well as pNK and uNK cells. Peripheral blood levels of CD45⁺CD3^-CD56⁺CD16⁺ NK cells were determined by flow cytometry and uterine CD56⁺ NK cells by immunohistochemistry in mid-luteal non-pregnant RM patients. Exclusion of patients with ≥1 established risk factor revealed n = 248 idiopathic RM patients (iRM, n = 167 primary iRM (ipRM), n = 81 secondary iRM (isRM)).

RESULTS

Patients with pRM and ipRM showed significant higher absolute numbers and percentages of pNK cells compared to sRM and isRM patients (pRM/ipRM vs sRM/isRM, mean ± SD /μl: 239.1 ± 118.7/244.9 ± 112.9 vs 205.1 ± 107.9/206.0 ± 105.6, p = 0.004/ p = 0.009; mean ± SD %: 12.4 ± 5.5/12.8 ± 5.4 vs 11.1 ± 4.6/11.1 ± 4.3, p = 0.001; p = 0.002). Only patients with isRM showed significantly higher uNK levels compared to patients with ipRM (mean ± SD /mm² 288.4 ± 239.3 vs 218.2 ± 184.5, p = 0.044).

CONCLUSIONS

The demonstrated differences in pNK and uNK cells in RM patients depending on previous live birth might indicate differences in NK cell recruitment and potentially different underlying immune disorders between pRM and sRM. As there is an overlap in the distribution of the NK cell results, further studies with focus on NK cell function are needed in order to clearly identify RM patients with distinct immune abnormalities. The clinical relevance of our findings should be interpreted cautiously until specificity and sensitivity are further evaluated.

Exploring Differential Connexin Expression across Melanocytic Tumor Progression Involving the Tumor Microenvironment

The incidence of malignant melanoma, one of the deadliest cancers, continues to increase. Here we tested connexin (Cx) expression in primary melanocytes, melanoma cell lines and in a common nevus, dysplastic nevus, and thin, thick, and metastatic melanoma tumor progression series involving the tumor microenvironment by utilizing in silico analysis, qRT-PCR, immunocyto-/histochemistry and dye transfer tests. Primary melanocytes expressed GJA1/Cx43, GJA3/Cx46 and low levels of GJB2/Cx26 and GJC3/Cx30.2 transcripts. In silico data revealed downregulation of GJA1/Cx43 and GJB2/Cx26 mRNA, in addition to upregulated GJB1/Cx32, during melanoma progression. In three melanoma cell lines, we also showed the loss of GJA1/Cx43 and the differential expression of GJB1/Cx32, GJB2/Cx26, GJA3/Cx46 and GJC3/Cx30.2. The dominantly paranuclear localization of connexin proteins explained the ~10–90 times less melanoma cell coupling compared to melanocytes. In melanocytic tumor tissues, we confirmed the loss of Cx43 protein, fall of cell membrane and elevated paranuclear Cx32 with moderately increased cytoplasmic Cx26 and paranuclear Cx30.2 positivity during tumor progression. Furthermore, we found Cx43, Cx26 and Cx30 proteins upregulated in the melanoma adjacent epidermis, and Cx43 in the tumor flanking vessels. Therefore, differential connexin expression is involved in melanocytic tumor progression where varying connexin isotypes and levels reflect tumor heterogeneity-related bidirectional adaptive interactions with the microenvironment.

Psychometric characteristics of the FertiQoL questionnaire in a German sample of infertile individuals and couples

BACKGROUND

FertiQoL is a questionnaire internationally developed to measure fertility-specific quality of life. It has been validated with infertile populations in many countries and used in several studies focusing on the psychosocial consequences of infertility in Europe, Asia, and North America.

METHODS

Over a period of two years, 596 infertile women and men took part in the study conducted at three German fertility clinics. Psychometric properties of FertiQoL were tested by performing confirmatory factor analyses, calculating average variance extracted values, reliability and correlation coefficients. Hierarchical regression analyses were conducted to determine the relations between FertiQoL subscales and both sociodemographic and medical variables. Individual and cross-partner effects were tested for.

RESULTS

The confirmatory factor analyses conducted on our FertiQoL data supported the original four-factor solution for both women and men but, resulted in some unsatisfactory indices. Family and friends' support items loaded weakly on the Social subscale of FertiQoL (.27 and .34 in women, .32 and .19 in men). The Emotional and Mind/Body subscales revealed a strong intercorrelation (r = .77, p < .001 in women, r = .74, p < .001 in men). Women scored lower than men on the Emotional and Mind/Body subscales only, and they reported better fertility-specific relational QoL. In women, the perceived cause of infertility and already mothering a child related significantly to individual FertiQoL scores, while in men, age, educational level, and the duration of their wish for a child had an impact on the FertiQoL subscales (all p < .05). The men's educational level, the women's educational level, and the subjective perceived medical cause of fertility problems exerted cross-partner effects on QoL (all p < .05).

CONCLUSIONS

Our study results represent a contribution both to research and clinical practice. The findings suggest the importance of considering the personal experience of infertility in different cultural and gender specific settings and that the strong connections between the emotional, physical, and cognitive aspects of an individual's fertility-specific quality of life should be regarded as a more coherent system.

TRIAL REGISTRATION

DRKS: DRKS00014707 . Registered 1 May 2018 (retrospectively registered).

Increased natural killer cell subsets with inhibitory cytokines and inhibitory surface receptors in patients with recurrent miscarriage and decreased or normal subsets in kidney transplant recipients late post-transplant

Patients with recurrent miscarriage (RM) show up-regulated cytotoxic natural killer (NK) cells that are suspected to play a causal role in abortion. In the present study, we investigated counter-regulating inhibitory mechanisms and compared the results in RM patients with those of healthy controls (HC), patients with end-stage renal disease (ESRD) and kidney transplant recipients late post-transplant (TX). NK, NK T and T cell subsets were analysed in the peripheral blood of 31 RM, 14 female ESRD and nine female TX patients as well as 21 female HC using eight-colour fluorescence flow cytometry. Compared with HC, RM patients showed significantly higher absolute numbers of CD56⁺ NK cells co-expressing the phenotype interferon (IFN)-γR⁺ , IL-4⁺ , transforming growth factor (TGF)-β⁺ , IL-4⁺ human leucocyte antigen D-related (HLA-DR)⁺ , TGF-β⁺ HLA-DR⁺ , IL-4⁺ TGF-β⁺ , IL-4⁺ TGF-β^- , IFN-γ⁺ and/or IL-10^- IFN-γ⁺ (all P ≤ 0·01), more IL-17⁺ CD56^bright (P = 0·028) NK cells and more CD56^dim CD16⁺ NK cells co-expressing IFN-γR, IFN-γ, IL-4 and/or TGF-β (all P ≤ 0·01). When the same cell subsets were analysed in ESRD or TX patients, cytokine-producing NK cell subsets were not significantly different from those of HC. RM patients showed significantly higher absolute numbers of CD158a⁺ , CD158b⁺ , CD158a^- CD158e⁺ (all P < 0·05), NKG2D⁺ NKG2A⁺ , NKG2D ⁺ NKG2A^- , NKG2D⁺ and/or NKG2A⁺ (all P ≤ 0·01) CD56⁺ NK cells and higher CD158a⁺ , CD158b⁺ (all P < 0·05), NKG2D⁺ and/or NKG2A⁺ (all P < 0·01) CD56^dim+ CD16⁺ NK cells than HC. In contrast, ESRD patients had normal and TX recipients had lower CD158a⁺ and NKG2D⁺ NKG2A^- CD56⁺ NK cells and lower CD158a⁺ CD56^dim+ CD16⁺ NK cells (all P < 0·05) than HC. RM patients have abnormally high circulating NK cells expressing inhibitory cytokines and inhibitory surface receptors which might contribute to the pathogenesis of RM.

Lack of Carcinogenic Effects of Isonicotinic Acid Hydrazide in the Syrian Golden Hamsters

Isonicotinic acid hydrazide (INH) was administered as a 0.3 % solution for 42 weeks intermittently and as a 0.2 and 0.1 % solutions continuously in the drinking water for the lifespan of adult Syrian golden hamsters. 0.3 % INH solution was found to be too toxic, therefore it had to be given periodically and finally the treatment had to be stopped, while 0.2 and 0.1 % INH solutions were relatively well tolerated during the entire life of the animals. The consumption of INH resulted in no detectable tumorigenic effect in the treated hamsters.

It is concluded that the drug is apparently no carcinogenic in this species. In view of the fact that the tumor producing capability of INH was shown by numerous studies in mice, the matter of selective neoplastic response in the various species is discussed and emphasized.

Investigatin on the Tumor Producing Effect of Isonicotinic Acid Hydrazide in ASW/Sn Mice and MRC Rats

Administration of 0.1% isonicotinic acid hydrazide in drinking water to 9 week old ASW/Sn mice and to 5 week old MRC rats for the remainder of their lifetime resulted in an enhanced incidence of pulmonary tumors in the former species. It rose from 34 to 68% in the females as compared with the controls, while in the males, the treatment did not affect the development of these lesions nor did it increase the incidences of other types of tumors. In rats, the compound was also without any apparent carcinogenic effect.

The possible role of this chemical in tumorigenesis is discussed in light of the obtained results.

A Toxicity Method with Calcium Cyclamate for Chronic Carcinogenesis Experiments

An experimental approach for determining the maximum tolerated dose of chemicals administered continuously or repeatedly ad libitum for the lifespan of animals is described. Five dose levels of calcium cyclamate were given in the drinking water for 35 days to Swiss mice, 8 animals in each group. By taking into account 4 parameters — survival rates, body weights, chemical consumption figures and histological changes — this method enables one to choose with certainty the proper dose, which is prerequisite to designing a chronic carcinogenesis experiment.

Ovarian and Other Timor Induction by 7,12-Dimethylbenz(a)Anthracene in the Syrian Golden Hamster

Two or three weekly repeated intravenous injections of 7,12-dimethylbenz(a)-anthracene (DMBA) in 15% fat emulsion were given to adult randomly bred Syrian golden hamsters. The treatments resulted in the induction of ovarian tumors in the females with incidence of 77% and 85% in the twice and three times injected animals respectively. Out of the 45 ovarian tumors found in the treated groups, 23 were the granulosa cell type, 6 were the theca cell type, 15 were the granulosa-theca cell type (mixed) and one was a hilar cell tumor. In 35 animals the tumors occurred bilaterally and in 10 unilaterally.

Additionally, a significant percentage of animals of both sexes developed dermal melanocytomas, tumors of forestomach, breast, intestines, skin, subcutis, lymphoreticular tissue, etc.

The induction of ovarian tumors with high incidence by a chemical carcinogen in the hamster provides a model by which the factors involved in the pathogenesis of this neoplasm could be studied.

Health-related quality of life in patients with polycystic ovary syndrome: validation of the German PCOSQ-G

PURPOSE

Patients with polycystic ovary syndrome (PCOS) report a decreased health-related quality of life (HRQOL) and higher levels of psychological distress. Validated questionnaires are necessary to assess the impact of PCOS on patients' lives. The aim of the present study was to evaluate the German "Polycystic Ovary Syndrome Questionnaire" (PCOSQ-G).

METHODS

The psychometric properties of the PCOSQ-G were investigated in PCOS patients with item-total correlation, internal consistency and test-retest reliability. Correlations with the Short-Form-36 Health Survey (SF-36) and the Hospital Anxiety and Depression Scale (HADS-D) were calculated to evaluate the validity of the PCOSQ-G. Discriminatory validity was investigated through a receiver operating characteristic curve and independent sample t tests compared with healthy controls.

RESULTS

Good psychometric properties were found for most items. Acceptable to high internal consistency was found for the total score (α = 0.94-0.95) and all subscales (α = 0.70-0.97). High test-retest reliability was found for the total score (0.86) and all subscales (0.81-0.90). The validity analyses showed that the PCOSQ-G total score was positively correlated with both SF-36 summary scales and was negatively correlated with both HADS subscales. Patients reported significantly lower values for the PCOSQ-G total score (p < 0.001) and all subscales, and the PCOSQ-G discriminated well between patients and healthy controls (AUC = 0.81, p < 0.001).

CONCLUSIONS

PCOSQ-G is a reliable and valid tool to assess the HRQOL in patients with PCOS and can be used in future clinical research. Patients with PCOS exhibited an impaired HRQOL, which indicates the need for psychosomatic counseling.