P-430 Sperm genomic integrity, telomere dynamics and gene expression in recurrent implantation failure

Study question

Does sperm affect the implantation and early embryogenesis?

Summary answer

Deranged sperm genomic integrity, limited repair mechanisms, aberrant gene expression have the potential to be transmitted to developing embryo and affect implantation and embryonic development.

What is known already

The terminally differentiated, transcriptionally quiscent sperm cells are vulnerable to a host of factors which might affect its function. The spermatozoa with truncated repair mechanisms have the potential to fertilize the oocyte, but eventually result in high rates of pre and post implantation losses. Oxidative stress, deranged genomic integrity, aberrant gene expression in the sperm cell has the potential to affect fertilisation potential, implantation and embryonic viability. This has been seen to be correlated with decreased fertilisation, clevage rates and blastocyst development and thus impaired implantation rates.

Study design, size, duration

A case control study of 75 men from infertile couples who had recurrent implantation failure (RIF) in IVF cycles and 75 fertile controls at AIIMS, New Delhi, India. Study duration was 2 years.

Participants/materials, setting, methods

Semen samples from men from couples who had RIF were analyzed as per WHO 2010. Sperm reactive oxygen species (ROS) and DNA fragmentation index (DFI) was assessed by chemiluminiscence and sperm chromatin structure assay (SCSA) respectively. Relative sperm telomere length was evaluated from sperm DNA by q-PCR analysis. The expression of genes pertinent for early embryonic development was done by qPCR. The relative quantification was done after normalizing with GAPDH and β-actin by 2-ΔΔCt method.

Main results and the role of chance

Seminal ROS levels (RLU/sec/million sperm) were seen to be significantly higher [57.75 (10.1-1186.9)] in cases with respect to controls [16.7(1.15-53.9)] (p < 0.001***). The mean DFI of men undergoing ART was significantly higher (37.7 ± 5.7) vs 23.2 ± 4.6%; p < 0.001***) in cases as compared to controls. ROS and DFI levels correlated negatively with sperm concentration and progressive motility (p < 0.001***). We analyzed the expression of FOXG1, SOX3, STAT4, RPS6, RBM9, RPL10A, RPS17, RPL29, WNT5A, HSP90, TOMM7, EIF5A genes. The expression of SOX3, RBM9, WNT5A, HSP90, TOMM7, and EIF5A showed a significant difference from control levels. The relative sperm telomere length was found to be significantly lower in RIF patients as compared to controls (p < 0.001***).

Limitations, reasons for caution

The current study was a case control study and lacked randomization and also is limited by low sample size. There is a lack of stratification in the enrollment of participants due to difference in specific risk of occurrence and varied clinical history.

Wider implications of the findings

The analysis of spermatozoal gene expression is important for understanding the sperm differentiation, fertilization and early embryonic events. Correlation with oxidative stress, genomic integrity and telomere length may help in regulationof gene expression. It may help in establishing sperm gene expression as a potential biomarker.

Trial registration number

Not applicable

Postoperative flare-up of genital tuberculosis: a clinical reality

We report three cases of flare-up of tuberculosis (TB) following genital surgery. In two cases, both patients developed abdominal distension postoperatively with vomiting and fever following total laparoscopic hysterectomy. Polymerase chain reaction (PCR) analysis of fluid detected and aspirated from the abdomen under ultrasound guidance was positive for Mycobacterium tuberculosis. In another instance, the patient developed abdominal distension with discharge per vaginum following a vaginal hysterectomy. X-ray of the abdomen showed dilated bowel loops and also a pseudo acetabular right hip joint suggestive of TB. PCR analysis of ascitic fluid was positive for TB. All patients responded to anti-tuberculosis treatment.

Uterine artery embolization for symptomatic fibroids with imaging follow up

The aim of this study was to determine the effectiveness of uterine artery embolization (UAE) as a primary treatment method in treatment of symptomatic fibroids, whether there are any preembolization MRI characteristics of fibroid predictive of reduction in volume and assess reduction in uterine and dominant fibroid volumes using ultrasound (US) and MRI. Study was carried out in total of 32 patients aged 25-49 years (mean 40.9 years). Uterine and dominant fibroid volume were determined using US and MRI before UAE, MRI and US at 3 months and US alone at 6 and 12 months post-UAE, supplemented by clinical evaluation at interval of 3, 6 and 12 months. Procedure was carried out through unilateral femoral puncture using poly vinyl alcohol (PVA) particles 355-500 microm in size. All 32 patients had successful procedures. Overall, 25 patients responded, giving a clinical success rate of 78.12%. Mean reduction in volume of uterus and fibroid was 33 and 59.7% and 48.9 and 75.5% on US at 3 and 12 months respectively, and 33.3 and 58.6% on MRI at 3 months. Volume reduction on US and MRI at 3 months was highly correlative. There was no statistical difference in size reduction in volume of fibroids, which were hypointense or hyperintense on T2-weighted image (T2WI) on pre-UAE MRI. Uterine artery embolization leads to good technical success and fibroid volume reduction. Ultrasound alone may be used for follow up of patients post-UAE. Preprocedure signal characteristics on T2WI are not predictors of volume reduction after UAE.

Levonorgestrel-releasing intrauterine system vs. transcervical endometrial resection for dysfunctional uterine bleeding

OBJECTIVE

To compare the acceptability, efficacy, adverse effects, and user satisfaction of a levonorgestrel intrauterine system (LNG-IUS) and transcervical resection of the endometrium (TCRE) for the treatment of dysfunctional uterine bleeding.

METHOD

Of 50 women with a pictoral blood loss assessment chart (PBAC) score of 100 or greater, 25 had a LNG-IUS inserted (Mirena; Schering, Berlin, Germany) and 25 underwent TCRE. Procedure-related complications, PBAC score, hemoglobin levels, adverse effects, and rates of acceptability and satisfaction were recorded at 3-month intervals for a period of 12 months.

RESULTS

At the end of 1 year there were a 97% and a 94% reduction in menstrual blood loss in the LNG-IUS and TCRE groups, respectively, and hemoglobin concentration had increased by 5.5% in the LNG-IUS group and 5.2% in the TCRE group. Adverse effects were similar in both groups except for systemic effects, which were seen only in the LNG-IUS group. Satisfaction rates were about 80% in the 2 groups.

CONCLUSION

Both treatments were found to be equally effective but LNG-IUS placement requires less operator skill and entails no operative hazards, and the device provides effective contraception.

Cervical priming with sublingual misoprostol vs. 15-methyl-prostaglandin F2alpha prior to surgical abortion

OBJECTIVE

To compare the efficacy and tolerability of sublingual misoprostol with those of intramuscular 15-methyl-prostaglandin F2alpha (15-M-PG F2alpha) for cervical dilation prior to vacuum aspiration (VA) in first-trimester pregnancy termination.

METHODS

Sixty pregnant women requesting pregnancy termination between the 9th and 12th week were randomized to receive 400 microg of sublingual misoprostol or an intramuscular injection of 125 microg of 15-M-PG F2alpha 2 h prior to vacuum aspiration. Baseline cervical dilation prior to vacuum aspiration was measured using Hegar's dilators. Other variables assessed included procedure duration, intraoperative blood loss, and associated adverse effects. Patient acceptability was assessed by questionnaires completed at the time of discharge from the hospital.

RESULTS

Mean cervical dilation at vacuum aspiration was significantly greater in the misoprostol group than in the 15-M-PG F2alpha group (8.8 vs. 7.6 mm; P<0.01), and preoperative adverse effects were significantly less frequent in the sublingual misoprostol group (P<0.05). However, procedure duration and intraoperative blood loss were similar in both groups. The acceptability rates were 93.3% in the sublingual misoprostol group and 76.6% in the 15-M-PG F2alpha group, respectively; however, 6.6% patients in the sublingual misoprostol group thought that the tablets had an unpleasant taste.

CONCLUSION

Sublingual misoprostol appears to be an effective alternative to intramuscular 15-M-PG F2alpha for cervical dilation prior to vacuum aspiration in first trimester pregnancy. In addition, misoprostol is inexpensive and convenient to use and has higher patient acceptability rates.

Metformin therapy in women with polycystic ovary syndrome

OBJECTIVE

To determine the clinical, biochemical, hormonal, and ultrasonographic effects of 6 months of metformin therapy in women with polycystic ovary syndrome (PCOS) and compare with pretherapy parameters.

METHOD

50 Indian women with PCOS, 25 unmarried and 25 married, infertile women, were enrolled in this prospective clinical study. After a baseline workup, including body mass index (BMI), waist hip ratio (WHR), Ferriman Gallwey hirsutism scoring, menstrual pattern, levels of fasting insulin, lipids, oral glucose tolerance test (OGTT), serum gonadotropins, estradiol (E2), testosterone, androstenedione, sex hormone binding globulin (SHBG), and dehydroepiandrosterone sulphate (DHEAS), patients were given 1000 gm of metformin for 6 months and then reevaluated.

RESULT

In 41 of 50 women who completed treatment, significant improvement in BMI, WHR, menstrual cyclicity (80.5%), ovulation rate (66%), and pregnancy rate (28%) was noted. Statistically significant decrease in lutenising hormone (LH) and LH/FSH ratio with an increase in follicle stimulating hormone (FSH) levels were seen. Levels of high-density lipoprotein (HDL) cholesterol (Chol) increased along with a decrease in total cholesterol. Improvement was noted in ovarian volume, stromal thickness, and number of follicles. There was no change in hirsutism, acne, levels of other sex steroid hormones, and lipids.

CONCLUSION

A 6-month course of metformin therapy may improve menstrual cyclicity and fertility in women with PCOS.

Sublingual misoprostol versus methylergometrine for active management of the third stage of labor

OBJECTIVE

To compare the efficacy and side effects of sublingual misoprostol and intravenous methylergometrine for active management of third stage of labor.

METHOD

One hundred twenty low risk pregnant women at term with spontaneous onset of labor were included in the study. The women were randomized to receive either two tablets of misoprostol (200 microg/tablet) sublingually or 1 ml of methylergometrine (200 microg) intravenous injection, after the delivery of the anterior shoulder of the baby. The main outcome measures were: need for additional oxytocic drugs, blood loss >or=500 ml, change in hemoglobin levels and side effects.

RESULTS

Postpartum hemorrhage as defined by hemorrhage >or=500 ml occurred in 3.1% of the women in the sublingual misoprostol group but none of the women in the methylergometrine group (P > 0.05). There was a need for additional oxytocic drugs in 5.0% and 8.3% after methylergometrine and misoprostol, respectively (P > 0.05). The change in hemoglobin levels at 24 h postpartum were 0.8 and 0.7 gm% in methylergometrine and misoprostol group, respectively(P > 0.05). In the misoprostol group, 6.6% women developed fever >or=38 degrees C and 21.6% had shivering while in methylergometrine group none experienced these side effects. However, the incidence of other side effects like nausea, vomiting, headache and giddiness were similar in both groups.

CONCLUSION

Sublingual misoprostol appears to be as effective as intravenous methylergometrine in the prevention of postpartum hemorrhage. However, larger randomized studies are needed to advocate its routine use.

A randomized comparison of sublingual and vaginal misoprostol for cervical priming before suction termination of first-trimester pregnancy

This randomized trial compares the efficacy and side effects of sublingual and vaginal misoprostol for cervical priming before first-trimester pregnancy termination. One-hundred pregnant women between 6 and 12 weeks of gestation opting for termination of pregnancy by suction evacuation were included in this study. The women were randomly allocated into two groups. Group 1 received 400 microg of sublingual misoprostol and group 2 received 400 microg of vaginal misoprostol 2 h prior to suction evacuation. The abortion was carried out by suction evacuation using a Karman's cannula attached to an electrically operated suction machine under intravenous analgesia. Baseline cervical dilatation, duration of the procedure, operative blood loss, side effects and complications were noted in both groups. There was a significant difference between the sublingual and vaginal misoprostol groups with respect to mean cervical dilatation (8.6 mm vs. 6.8 mm, p < 0.05). However, the duration of the procedure (3.03 min vs. 3.16 min) and the amount of blood loss (29 mL vs. 31.2 mL) were not significantly different between the two groups. The women in the sublingual group experienced significantly more shivering and preoperative vaginal bleeding (68% vs. 56%, p < 0.05). None of the women in the two groups had either uterine perforation or excessive hemorrhage. In our study, sublingual misoprostol (400 microg) was significantly more effective in facilitating cervical dilation prior to surgical abortion than vaginal misoprostol.

Pregnancy with Chronic Kidney Disease: Outcome in Indian Women

BACKGROUND

Fetal survival and the risk of accelerated renal damage are the two major concerns with pregnancies complicated by chronic kidney disease. Although fetal survival has increased significantly due to improved antenatal and neonatal services, the maternal and neonatal morbidity is still considerable.

METHODS

This retrospective analysis of 51 pregnancies was conducted at a tertiary care center in India to estimate the risk of obstetrical complications, perinatal morbidity and mortality, and the effect of pregnancy on renal function in women with different types and severity of renal disease.

RESULTS

The type of renal disease and the degree of renal insufficiency did not have a significant effect on the chances of successful pregnancy outcome once the pregnancy had progressed beyond the first trimester. The risk of prematurity was significantly increased when the diastolic blood pressure was >/= 90 mm Hg at conception (OR 8.3, CI 1.6-41.5). All patients with a diastolic blood pressure > 100 mm Hg delivered preterm. Hypertension worsened in 16 (35.5%) women during pregnancy, of which 13 had to be terminated preterm because of uncontrolled blood pressure. Serum creatinine deteriorated during pregnancy in 32.5%, the percentage increase showing a significant inverse correlation to the baseline creatinine clearance.

CONCLUSIONS

Hypertension at conception was a significant independent factor influencing the gestational age at delivery. The baseline renal function did not correlate with the risk of acceleration of hypertension during pregnancy. However, the deterioration of renal function during pregnancy had a significant inverse correlation to basal creatinine clearance.

Prediction of perinatal asphyxia with nucleated red blood cells in cord blood of newborns

OBJECTIVE

To determine normal level of nucleated red blood cells (NRBC) per 100 white blood cells (WBC) in cord blood of term non-asphyxiated newborns and to investigate variations in NRBC counts in perinatal asphyxia.

METHODS

A total of 75 cases were studied. Levels of NRBC per 100 WBC in umbilical venous blood were compared between 26 asphyxiated newborns (group I) and 49 non-asphyxiated newborns (group II). Correlation with neonatal outcome was also evaluated.

RESULTS

The mean (+/-S.D.) NRBC per 100 WBC level in umbilical blood of newborns in group I was 16.5+/-6.4, range 3-25; whereas that in group II was 8.6+/-7.01, range 1-26. This difference was statistically significant (P<0.001). A statistically significant negative correlation existed between NRBC level and markers of acute intrapartum asphyxia, Apgar score and umbilical arterial pH (r=-0.50, P<0.001 and r=-0.48, P<0.001, respectively). Positive correlation was demonstrated with evidence of chronic antepartum asphyxia, presence of pregnancy induced hypertension and intrauterine growth restriction (r=2.66, P=0.02). A high NRBC count in umbilical blood correlated with poor early neonatal outcome.

CONCLUSIONS

The level of NRBC per 100 WBC correlates both with acute as well as chronic antepartum asphyxia. Further, it can be used as a reliable index of early neonatal outcome.

Fetal gastrointestinal malformations

In an audit to evaluate fetal gastrointestinal (GIT) malformations, case sheets of all mothers who gave birth to newborns with GIT malformations were analysed regarding the maternal history, prenatal ultrasound and the postnatal structural malformations and perinatal management. In 1999, eleven babies were born with gastrointestinal malformations, one was a still birth. Nine had associated malformations of other systems, two had trisomy 21. Eight babies were operated in the immediate newborn period, 5 survived. Ultrasound was not very accurate in the diagnosis of GIT anomaly in this series. In view of associated chromosomal and structural anomaly a fetal ECHO and genetic amniocentesis is warranted. Most of these babies require immediate surgery after birth, so they need to be delivered in a centre which is equipped with good neonatal and pediatric surgery care.

Species-specific prevalence of vaginal candidiasis among patients with diabetes mellitus and its relation to their glycaemic status

OBJECTIVES

Non- C. albicans Candida species are increasingly being recognized as the cause of vulvo-vaginal candidiasis. These species are often less susceptible to antifungal agents. Patients with diabetes mellitus are at risk for vulvo-vaginal candidasis. We assessed the species-specific prevalence rate and risk of candidiasis in patients with diabetes mellitus and healthy controls.

METHODS

Genital tract examination, direct microscopy and fungal cultures of discharge collected by high vaginal swab were undertaken among 78 consecutive patients with diabetes mellitus (mean (+/-sd) age 32+/-12 years and body mass index (BMI) 22.3+/-5.5kg/m(2)) and 88 age- and BMI-matched healthy females. Glycaemic control in the diabetic cohort was assessed by measuring total glycosylated haemoglobin.

RESULTS

Candida species were isolated in 36 of 78 (46%) subjects with diabetes mellitus and in 21 of 88 (23%) healthy subjects (Chi-squared 9.11, P=0.0025). The predominant Candida species isolated in diabetics with vulvo-vaginal candidiasis were Candida glabrata (39%), C. albicans (26%) and C. tropicalis (17%). In contrast, in the control group, C. albicans, C. glabrata and C. hemulonii comprised 30% each, with none having C. tropicalis infection (for C. tropicalis: diabetic vs. control; 17% vs. nil, P=0. 05). Among the diabetic group, subjects with vulvo-vaginal candidiasis had significantly higher mean HbA1 when compared to those who had no such infection (12.8+/-2.6% vs. 9.7+/-1.7% respectively, P=0.001). The overall accuracy of direct microscopy and clinical examination for predicting vulvo-vaginal candidiasis was only 77% and 51%, respectively, in the diabetic group, and 83% and 65% in the control group.

CONCLUSIONS

Patients with diabetes mellitus had a high prevalence rate (46%) of vulvo-vaginal candidiasis with relative risk of 2.45. The non- C. albicans species such as C. glabrata and C. tropicalis were the predominant species isolated among them. There seems to be a significant link between hyperglycaemia and vulvo-vaginal candidiasis.

Hematometra in postmenarchal adolescent girls: a report of two cases

We report two cases of unicornuate uterus with functioning rudimentary horn to highlight that Mullerian duct anomalies should be considered in the differential diagnosis of severe dysmenorrhoea even in normally menstruating girls.

Uterine arteriovenous malformations: the role of intravenous 'dual-phase' CT angiography

The authors describe the use of dual-phase intravenous CT angiography of the pelvis in two female patients, who presented with ongoing excessive vaginal bleeding, to demonstrate large adnexal and uterine arteriovenous malformations (AVMs). Power Doppler was used as the initial modality to diagnose the AVMs. CT angiography, along with 3-D rendering in the form of maximum intensity projections and shaded surface display, were especially useful for anatomical conceptualization to the gynecologist. This greatly helped in the subsequent management in the form of therapeutic embolization in both patients by reducing the time, radiation dose, and contrast required for the procedure. Subsequent surgery, which was required in both patients (due to failed embolization), was also greatly aided by the demonstration of the exact extent of the AVMs on axial CT images. Thus, CT angiography emerged as an impressive non-invasive imaging modality for the complete evaluation and management of the uterine AVMs.

Can amniotic fluid distribution predict fetal outcome?

OBJECTIVE

This study was designed to determine whether the distribution pattern of amniotic fluid (AF) within the uterine cavity is related to perinatal outcome.

STUDY DESIGN

One-hundred women in labor with intact membranes underwent a real time ultrasound examination to measure the AF index. Patients were divided into two groups based on liquor distribution. Those with > 50% liquor distributed in upper quadrants formed the 'upper greater' group whereas the rest of the patients constituted the 'lower greater' group. Pregnancy outcome was assessed with respect to incidence of fetal heart rate (FHR) abnormalities, operative delivery, meconium stained liquor, Apgar score < 7 at 1 and 5 min and neonatal intensive care unit admissions.

RESULTS

A total of 100 patients were evaluated. The 'upper greater' group had a higher incidence of cesarean for non-reassuring FHR (40.74% vs. 9.6%, P < 0.001), persistent variable deceleration (14.8% vs. 0%, P < 0.001) and bradycardia (25.9% vs. 4.1%, P < 0.001). There was no statistically significant difference in the Apgar score < 7 at 1 min and neonatal intensive care unit admissions in the two groups.

CONCLUSIONS

Distribution of less liquor in the lower quadrants of the uterus predisposed to abnormalities in FHR and hence, cesarean section. The distribution pattern did not have a predictive value for the perinatal outcome.