P–712 Ovulation induction in type 1 anovulation: a comparative study using gonadotrophins and the GnRH pump

Study question

Is there a difference in treatment outcome between gonadotrophin releasing hormone (GnRH) pump or hMG for women with Type 1 anovulation undergoing ovulation induction?

Summary answer

Treatment with GnRH was more efficient compared to hMG, with fewer number of cycles to pregnancy, fewer days of stimulation and fewer cycle cancellations.

What is known already

Whilst there is a lot of information on ovulation induction in WHO type II anovulation (PCOS), type 1 anovulation is under-represented in research. WHO type 1 anovulation is characterised by low pituitary gonadotrophins and oestradiol. Treatment options used to include induction of ovulation using gonadotrophins (hMG) or the Gonadotrophin hormone releasing hormone (GnRH) pump delivering pulsatile GnRH. Since the withdrawal of GnRH pump, options have become limited. One study reveals that monofollicular cycles are lower and cycle cancellation higher in women with Type 1 anovulation women treated with gonadotrophins. Study design, size, duration: This is a single centre retrospective cohort study. All women with a diagnosis of WHO type 1 anovulation attending the Reproductive Medicine Unit at the University College London Hospital who received ovulation induction treatment using either hMG or GnRH pump between 1993 and 2020 were included in the study

Participants/materials, setting, methods

147 women with WHO type 1 anovulation were included in the study. Diagnosis was based on the presence of primary or secondary amenorrhoea in combination with low gonadotrophins and oestradiol. Demographic and clinical data were obtained by reviewing medical records stored within an electronic database. A total of 599 treatment cycles were identified. Statistical analysis between the groups was performed using the independent T test and chi squared test.

Main results and the role of chance

147 women with WHO type 1 anovulation underwent ovulation induction. hMG was used in 500 cycles (83.5%) and the GnRH pump in 99 cycles (16.5%). Per cycle started the pregnancy rate in the hMG cycles was 107/500 (21.4%) and in the GnRH pump cycles was 19/99 (19.2%) p = 0.36. Cycle cancellation was significantly greater in hMG than GnRH pump cycles (hMG 137/ 500 27.4% vs GnRH pump 17/99 17.2% p = 0.02). Over response was more common in hMG cycles than GnRH pump cycles (66/130 50.8% vs 3/16 18.8% p = 0.01). A total of 363/500 (72.5%) cycles in the hMG and 82/99 (82.8%) cycles in the GnRH pump group reached ovulation. There was no difference in the pregnancy rate after ovulation (hMG 107/363 29.5% vs GnRH pump 19/82 23.2% p = 0.15). The mean number of treatment cycles to achieve pregnancy was significantly fewer with the GnRH pump compared to hMG (1.8 (min 1 – max 3) vs 2.4 ( min 1 – max 8) p = 0.03).The mean days of stimulation required to reach ovulation was also significantly less with the GnRH pump compared to hMG (16.7 (min 8 – max 34) vs 23.4 (min 7 – max 72) p = <0.001).

Limitations, reasons for caution

This is a retrospective cohort study and is reliant on the quality and quantity of the data entry at the time of clinical treatment.

Wider implications of the findings: Ovulation induction for women with type 1 anovulation is now restricted to a single treatment, namely hMG. hMG is not as effective or optimal as GnRH. Reinstating GnRH in routine clinical practice should be promoted to allow more individualised treatment options and prevent the premature need for in vitro fertilisation..

Trial registration number

NA

A novel strategy to reduce very late HIV diagnosis in high-prevalence areas in South-West England: serious incident audit

Background

Very late diagnosis of HIV is a serious public health issue. We used serious incident reporting (SIR) to identify and address reasons for late diagnoses across the patient pathway.

Methods

Cases of very late HIV diagnosis were reported via SIR in two 6-month batches between 2011 and 2012 in Bournemouth, Poole and Bristol. Case notes were reviewed for missed opportunities for earlier diagnosis using a root-cause analysis tool.

Results

A total of 33 patients (aged 30-67 years, 66% male) were diagnosed very late. Although the majority were white British (n = 17), Black African (n = 9) and Eastern European (n = 4) ethnicities were over-represented. Twenty-four (73%) patients had clinical indicator conditions for HIV, 30 (91%) had a risk factor for HIV acquisition, with 13 (39%) having 2 or more (men-who-have-sex-with-men (n = 11), partner HIV positive (n = 11), from high-prevalence area (n = 12)). Actions resulting from SIR included increasing awareness of indicator conditions, HIV education days within primary care, and initiatives to increase testing within hospital specialities.

Conclusions

SIR allowed identification of reasons for very late HIV diagnosis and provided an impetus for initiatives to address them. SIR may be part of an effective strategy to prevent late diagnosis of HIV which would have important benefits for individual and population health.

Multi-Center Evaluation of the Fully Automated PCR-Based Idylla™ KRAS Mutation Assay for Rapid KRAS Mutation Status Determination on Formalin-Fixed Paraffin-Embedded Tissue of Human Colorectal Cancer

Since the advent of monoclonal antibodies against epidermal growth factor receptor (EGFR) in colorectal cancer therapy, the determination of RAS mutational status is needed for therapeutic decision-making. Most prevalent in colorectal cancer are KRAS exon 2 mutations (40% prevalence); lower prevalence is observed for KRAS exon 3 and 4 mutations (6%) and NRAS exon 2, 3, and 4 mutations (5%). The Idylla™ KRAS Mutation Test on the molecular diagnostics Idylla™ platform is a simple (<2 minutes hands-on time), highly reliable, and rapid (approximately 2 hours turnaround time) in vitro diagnostic sample-to-result solution. This test enables qualitative detection of 21 mutations in codons 12, 13, 59, 61, 117, and 146 of the KRAS oncogene being clinically relevant according to the latest clinical guidelines. Here, the performance of the Idylla™ KRAS Mutation Assay, for Research Use Only, was assessed on archived formalin-fixed paraffin-embedded (FFPE) tissue sections by comparing its results with the results previously obtained by routine reference approaches for KRAS genotyping. In case of discordance, samples were assessed further by additional methods. Among the 374 colorectal cancer FFPE samples tested, the overall concordance between the Idylla™ KRAS Mutation Assay and the confirmed reference routine test results was found to be 98.9%. The Idylla™ KRAS Mutation Assay enabled detection of 5 additional KRAS-mutated samples not detected previously with reference methods. As conclusion the Idylla™ KRAS Mutation Test can be applied as routine tool in any clinical setting, without needing molecular infrastructure or expertise, to guide the personalized treatment of colorectal cancer patients.

Guidelines for the measurement of BCR-ABL1 transcripts in chronic myeloid leukaemia

Molecular testing for the BCR-ABL1 fusion gene by real time quantitative polymerase chain reaction (RT-qPCR) is the most sensitive routine approach for monitoring the response to therapy of patients with chronic myeloid leukaemia. In the context of tyrosine kinase inhibitor (TKI) therapy, the technique is most appropriate for patients who have achieved complete cytogenetic remission and can be used to define specific therapeutic milestones. To achieve this effectively, standardization of the laboratory procedures and the interpretation of results are essential. We present here consensus best practice guidelines for RT-qPCR testing, data interpretation and reporting that have been drawn up and agreed by a consortium of 21 testing laboratories in the United Kingdom and Ireland in accordance with the procedures of the UK Clinical Molecular Genetics Society.

Transchromosomic cell model of Down syndrome shows aberrant migration, adhesion and proteome response to extracellular matrix

Background

Down syndrome (DS), caused by trisomy of human chromosome 21 (HSA21), is the most common genetic birth defect. Congenital heart defects (CHD) are seen in 40% of DS children, and >50% of all atrioventricular canal defects in infancy are caused by trisomy 21, but the causative genes remain unknown.

Results

Here we show that aberrant adhesion and proliferation of DS cells can be reproduced using a transchromosomic model of DS (mouse fibroblasts bearing supernumerary HSA21). We also demonstrate a deacrease of cell migration in transchromosomic cells independently of their adhesion properties. We show that cell-autonomous proteome response to the presence of Collagen VI in extracellular matrix is strongly affected by trisomy 21.

Conclusion

This set of experiments establishes a new model system for genetic dissection of the specific HSA21 gene-overdose contributions to aberrant cell migration, adhesion, proliferation and specific proteome response to collagen VI, cellular phenotypes linked to the pathogenesis of CHD.

83 CHANGES IN BLASTOCYST LINEAGE DIFFERENTIATION AND NUTRIENT SENSING ARE MEMORIZED IN RESPONSE TO MATERNAL LOW-PROTEIN DIET

Studies have consistently shown that conditions experienced during the periconceptional period including culture in vitro and maternal diet composition can profoundly alter the development of the embryo/fetus and can result in adult diseases such as obesity, hypertension, and cardiovascular disease. This programming occurs during the pre-implantation period. Here, we have examined blastocyst phenotype changes in response to maternal protein undernutrition during the pre-implantation period and determined whether such adaptations are stable through a change in environment. Embryos were flushed at Day 3.25 to 3.75 from naturally mated MF1 mice fed either a control (NPD) or low-protein diet (LPD) from day of plug. Blastocysts were differentially labeled using the TNBS-anti-DNP-complement method with propidium iodide and Hoechst, and cells were counted on z-series with overlays using Metamorph software (Molecular Devices, Sunnyvale, CA). For outgrowths, blastocysts flushed from LPD or NPD mothers were placed into KSOM supplemented with 10% FCS and amino acids at uterine fluid concentrations (Porter et al. 2003 Pediatr. Res. 53, 46A abst). Outgrowths were cultured for an additional 96 h and scored daily with final 4′,6-diamidino-2-phenylindole (DAPI) nuclei counts. Neither total cell numbers nor lineage divergence was affected by maternal diet until just before implantation (Day 3.75) when blastocysts from LPD mothers had significantly more total cells due to an increase in trophectoderm (TE) compared with NPD blastocysts (ANOVA; Table 1). Upon outgrowth, LPD embryos spread over a greater area although with similar nuclei numbers compared with NPD blastocysts. Moreover, inhibition of the mTOR signaling pathway with rapamycin (rapa) showed the expected dose-responsive decrease of spreading in NPD but not in LPD outgrowths (Table 1). Our data suggest a compensatory upregulation of the TE lineage after mild maternal protein undernutrition. This response becomes evident just before implantation and is, together with altered nutrient sensing and signaling sensitivity, sustained throughout peri-implantation development in vitro regardless of culture environment. Thus, we show that adaptations evident by the blastocyst stage and induced by maternal environment can subsequently be memorized and are likely to contribute to long-term programming of phenotype independent of that environment. Table 1.Blastocyst and peri-implantation development respond to maternal diet Funding by DOHaD, Gerald Kerkut Trust, and NICHD are gratefully acknowledged.

Chromosome instability is a predominant trait of fibroblasts from Li-Fraumeni families

Previous work has indicated a role for p53 in cell cycle control, genomic stability and cellular responses to DNA-damaging agents. However, few data are available for human fibroblasts heterozygous for defined germline mutations in TP53. We report studies on 25 strains derived from 12 families with Li-Fraumeni syndrome (LFS) and 18 strains from normal volunteers. The families include three that are classical LFS families, but in whom no TP53 mutation has been found. In the families with mutations, increased longevity and resistance to low-dose-rate ionizing radiation showed a statistically significant association with the presence of TP53 mutations. However, not all heterozygotes had increased longevity or were radioresistant, and fibroblasts from cancer-affected members of LFS families without TP53 mutations showed no significant increase in either of these end points. In contrast, all mutation-carrying strains showed evidence of genomic instability, expressed as aneuploidy, and accumulated structural chromosome aberrations in up to 100% of cells, usually accompanied by loss of the wild-type TP53 allele, immediately before senescence. Levels of aneuploidy higher than in normal cells were also observed in fibroblasts from families without TP53 mutations, suggesting that chromosome instability is a major factor in determining the cancer proneness of these families.