Efficacy and safety of Zi Gui Nv Zhen® capsules used in TCM for fertility preservation in patients with diminished ovarian reserve

OBJECTIVE

To evaluate for the first time whether Zi Gui Nv Zhen^® capsules (ZGNZC), until now used in traditional Chinese medicine (TCM) for menopausal complaints, can increase the fertility of Chinese women with diminished ovarian reserve (DOR).

METHODS

Prospective, randomized, open-labeled 3-monthly study; 109 DOR patients (aged 20-40 years) receiving either ZGNZC (experimental group, n = 75) or not (control group, n = 34). Main outcomes: markers for ovarian function, thickness/type of the endometrium during ovulation, and pregnancy rate. Between-group analysis (A) comparing experimental vs. control group and within-group analysis (B) comparing data at baseline and after study in each of both groups.

RESULTS

(A) Between-group-analysis: patients with ZGNZC had a higher endometrium thickness (0.75 vs. 0.62; p<.05) and higher anti-Müllerian hormone (AMH, 0.50 vs. 0.40; p<.05) than control group. Pregnancy rates were higher in the experimental than the control group (26.7% vs. 14.7%; n.s.). (B) Within-group-analysis: ZGNZC decreased levels of follicle-stimulating hormone (FSH, 11.42 vs. 8.69), increased estradiol-levels (E₂, 56.09 vs. 73.36), and type A endometrium rates (5.3% vs. 39.7%) (all p< .05) and increased antral follicle count (AFC, 2 vs. 3). All hepato-renal biomarkers remained within the norm. The tolerability was good. There were no adverse events.

CONCLUSIONS

In women with DOR who wish to conceive, three months' application of ZGNZC can improve ovarian function and oocyte quality by adjusting the neuroendocrine system, can improve endometrial properties and proliferation, necessary for a healthy pregnancy, and increased the clinical pregnancy rate in our prospective randomized observational study.

Vaginal health, endometrial thickness and changes in bone markers in postmenopausal women after 6 months of treatment with ospemifene in real clinical practice

OBJECTIVE

To assess vaginal health, endometrial thickness, and changes in bone markers in postmenopausal women with vulvovaginal atrophy (VVA) treated with 60 mg/day of ospemifene under routine clinical practice.

METHODS

The AYSEX study is a Spanish observational and prospective study performed in one center in which 5 gynecologists recruited postmenopausal women with VVA in routine clinical practice treated continuously with ospemifene 60 mg/day for 12 months as an appropriate therapeutic option. This article refers to the 3- and 6-months analysis. Vaginal health was assessed by pH and using Vaginal Health Index (VHI) at baseline and 3 months later. Endometrial thickness, measured by vaginal ultrasonography, and bone resorption marker (CTx) were assessed at baseline and 6 months later.

RESULTS

A total of 100 postmenopausal women cytologically and clinically diagnosed with VVA were included in the study. After 3 months of treatment with ospemifene, pH improved from 6.1 to 4.5 (p < .0001), and VHI improved from 10 to 19 points (p < .0001). The percentage of patients with VVA according to VHI decreased from 100% to 5.2% (p < .0001). After 6 months, mean CTx levels decreased from 0.42 pg/ml at baseline to 0.37 pg/ml 6 months later (p = .0018), and mean endometrial thickness changed from 2.24 to 2.15 mm (p = .6066).

CONCLUSIONS

Up to date, this is the only prospective and observational study with ospemifene in routine clinical practice conditions and confirms the results previously reported from randomized controlled clinical trials, improving VVA, not increasing endometrial thickness, and decreasing CTx levels by exerting an anti-resorptive function.

The effect of endometrial thickness and pattern on the success of frozen embryo transfer cycles and gestational age accuracy

OBJECTIVE

To evaluate the relationship between endometrial thickness measured before embryo transfer, and pregnancy outcomes in frozen-thawed embryo transfer (FET).

METHODS

We retrospectively analyzed outcomes of all consecutive FET cycles, from January 2012 to August 2018. Based on ROC analysis for endometrial thickness, we found 8 mm was a reliable cutoff point to predict pregnancy prior to embryo transfer. Accordingly, the cycles were divided into Group A: cycles with endometrial thickness ≤ 8 mm and Group B: > 8 mm.

RESULTS

Group A included 485 FET cycles and group B included 626 cycles. Compared with group A, Group B had significantly higher chemical and clinical pregnancy rates (30.3 vs. 24.6%; p = .046, and 24.0 vs. 18.6%; p = .036), respectively. In multivariate analysis, endometrial thickness and the protocols used were the only parameters influencing the chance to achieve pregnancy, with odds ratio 1.54 (95%CI 1.07-2.22, p = .019) for the endometrium and odds ratio 1.95 (95%CI 1.31-2.9; p = .001) to the protocol used. Endometrial thickness might predict crown-rump length (CRL) discordancy with odds ratio 4.61 (p = .001; 95% CI 1.42-14.92). Compared with group B, Group A had more cases of overt discordancy (13.3 vs. 4%; p = .016).

CONCLUSIONS

For patients undergoing FET cycles, endometrial thickness and treatment protocol may predict the chemical and clinical pregnancy rates, as well as CRL discordancy.

SUMMARY

Endometrial thickness and preparation improved pregnancy rate in FET cycles and significantly greater crown-rump length discordancy was observed with thinner endometria.

Multifactor Prediction of Embryo Transfer Outcomes Based on a Machine Learning Algorithm

In vitro fertilization-embryo transfer (IVF-ET) technology make it possible for infertile couples to conceive a baby successfully. Nevertheless, IVF-ET does not guarantee success. Frozen embryo transfer (FET) is an important supplement to IVF-ET. Many factors are correlated with the outcome of FET which is unpredictable. Machine learning is a field of study that predict various outcomes by defining data attributes and using relevant data and calculation algorithms. Machine learning algorithm has been widely used in clinical research. The present study focuses on making predictions of early pregnancy outcomes in FET through clinical characters, including age, body mass index (BMI), endometrial thickness (EMT) on the day of progesterone treatment, good-quality embryo rate (GQR), and type of infertility (primary or secondary), serum estradiol level (E2) on the day of embryo transfer, and serum progesterone level (P) on the day of embryo transfer. We applied four representative machine learning algorithms, including logistic regression (LR), conditional inference tree, random forest (RF) and support vector machine (SVM) to build prediction models and identify the predictive factors. We found no significant difference among the models in the sensitivity, specificity, positive predictive rate, negative predictive rate or accuracy in predicting the pregnancy outcome of FET. For example, the positive/negative predictive rate of the SVM (gamma = 1, cost = 100, 10-fold cross validation) is 0.56 and 0.55. This approach could provide a reference for couples considering FET. The prediction accuracy of the present study is limited, which suggests that there may be some other more effective predictors to be developed in future work.

The Effects of Endometrial Thickness on Pregnancy Outcomes of Fresh IVF/ICSI Embryo Transfer Cycles: An Analysis of Over 40,000 Cycles Among Five Reproductive Centers in China

OBJECTIVE

To investigate the effects of endometrial thickness (EMT) on pregnancy outcomes on hCG trigger day in fresh in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) cycles.

METHODS

A total of 42,132 fresh cycles between 1 January 2013 and 31 December 2019 were included in this retrospective cohort study. Data were collected from five reproductive centers of large academic or university hospitals in China. All patients were divided into different groups according to their endometrial thickness on hCG trigger day. Multivariate regression analysis, curve fitting and threshold effect analysis were performed.

RESULTS

After adjusting for age, body mass index, infertility type, number of embryos transferred, number of retrieved oocytes and COS (controlled ovarian stimulation) protocols, significant associations were found between endometrial thickness and clinical pregnancy rate (adjusted odds ratio [aOR]: 1.05; 95% confidence interval [CI]: 1.06-1.08, P < 0.0001), live birth rate (aOR: 1.04; 95% CI: 1.03-1.05, P < 0.0001) as well as miscarriage rate(aOR: 0.96; 95% CI: 0.94 - 0.98, P < 0.0001). When the endometrial thickness was less than 12mm, the clinical pregnancy rate and live birth rate were increased significantly by 10% and 9%(OR:1.10; 95%CI: 1.08-1.12, OR:1.09; 95%CI: 1.07-1.11), respectively, along with the increase of each millimeter increment of endometrial thickness. However, when the EMT ranged from 12-15 mm, were stable at the ideal level, that were not significantly associated with EMT growth. Additionally, clinical pregnancy rate and live birth rate were slightly reduced by 6% and 4% when EMT was ≥15mm. Meanwhile, the miscarriage rate was significantly declined by 8% (OR:0.92; 95%CI: 0.90-0.95)with each millimeter increment of EMT. And when EMT was thicker than 12mm, the miscarriage rate didn't change any more significantly.

CONCLUSIONS

Endometrial thickness exhibits a curvilinear relationship with pregnancy outcomes in fresh embryo transfer cycles. Clinical pregnancy rate, live birth rate and miscarriage rate may achieve their optimal level when EMT ≥ 12 mm, but some adverse pregnancy outcomes would be observed when EMT ≥15 mm especially for clinical pregnancy.

The effect of endometrial thickness on pregnancy outcomes of frozen-thawed embryo transfer cycles which underwent hormone replacement therapy

Objective

To investigate the impact of endometrial thickness on the embryo transfer(ET) day on the clinical pregnancy outcomes of frozen-thawed embryo transfer cycles which have undergone hormone replacement therapy(HRT-FET).

Methods

A total of 10,165 HRT-FET cycles performed between January 2013 to December 2017 in the Reproductive Medicine Center of Henan Provincial People’s Hospital were studied retrospectively. All patients were grouped according to their endometrial thickness on the ET day (each group having an increment of 1mm between two neighboring groups). Multivariate regression analysis, curve fitting and threshold effect analysis were performed on all data.

Results

After adjusting for the age, duration of infertility, body mass index(BMI), infertility type and number and type of embryos transferred, a significant correlation was observed to be between the endometrial thickness and implantation rates (aOR: 1.08; 95% CI: 1.06–1.10, p < 0.0001), clinical pregnancy rate(aOR: 1.10; 95% CI: 1.07–1.14, p < 0.0001)and live birth rate (aOR: 1.09; 95% CI: 1.06–1.12, p < 0.0001). The numerical value of the cut-off point for the endometrial thickness was 8.7 mm. When the endometrial thickness was less than 8.7 mm, with each additional 1 mm of endometrial thickness, the implantation rate increased by 32%, the clinical pregnancy rate increased by 36%, and the live birth rate increased by 45%.

Conclusions

In the HRT-FET cycles, the optimal live birth rate would be obtained when the endometrial thickness remains within the range of 8.7–14.5 mm. If the endometrium is too thin or too thick, the live birth rate will be reduced.

Clinical value of histologic endometrial dating for personalized frozen-thawed embryo transfer in patients with repeated implantation failure in natural cycles

BACKGROUND

Displacement of the window of implantation (WOI) has been proposed as an important factor contributing to repeated implantation failure (RIF). However, the use of histologic endometrial dating as a diagnostic tool of endometrial receptivity has been questioned.

METHODS

This study is a prospective intervention trial that enrolled 205 infertile patients from July 2017 to December 2017. Endometrial biopsies from 50 patients with good prognoses were conducted on day 3 (n = 6), 5 (n = 6), 7 (n = 26), 9 (n = 6), or 11 (n = 6) post-ovulation (PO + 3/5/7/9/11) of the previous natural cycle before their conventional frozen-thawed embryo transfer (FET) cycle. We conducted endometrial biopsies for 155 RIF patients on day PO + 7.

RESULTS

The verification of the Noyes criteria for endometrial dating was conducted at different times (PO + 3/+ 5/+ 7/+ 9/+ 11) on 41 patients with good prognoses who achieved an ongoing pregnancy in their first conventional FET cycle after endometrial biopsy. The agreement between two pathologists determining endometrial biopsy dating results in infertile patients was determined to be acceptable (weighted kappa = 0.672, P < 0.001). The rate of out-of-phase dating on day PO + 7 was significantly higher in RIF patients than in good- prognosis patients (31.6% vs. 3.8%, P = 0.003). pFET was performed in 47 RIF patients diagnosed to be out of phase, and the cumulative live-birth rate was 61.7%.

CONCLUSIONS

Histologic endometrial dating of RIF patients in natural cycles may be a biomarker for a receptive endometrium in diagnosing WOI displacement.

TRIAL REGISTRATION

NCT03312309 Registered 17 October 2017. NCT03222830 Registered 19 July 2017.

Uterine Luminal Epithelium as the Transient Gateway for Embryo Implantation

The uterine luminal epithelium (LE) is the first maternal contact for an implanting embryo. Intrauterine fluid resorption, cessation of LE proliferation and apoptosis, and LE structural changes are prerequisites for establishing transient uterine receptivity for embryo implantation. Vesicle trafficking in the LE and receptor-mediated paracrine and autocrine mechanisms are crucial both for LE preparation and LE communications with the embryo and stroma during the initiation of embryo implantation. This review mainly covers recent in vivo studies in LE of mouse models from 0.5 days post-coitus (D0.5) to ∼D4 20 h when the trophoblasts pass through the LE layer for embryo implantation. The review is organized into three interconnected sections: preimplantation LE preparation for embryo attachment, embryo-LE communications, and LE-stroma communications.

Measuring the serum progesterone level on the day of transfer can be an additional tool to maximize ongoing pregnancies in single euploid frozen blastocyst transfers

BACKGROUND

Endometrial preparation with hormone replacement therapy (HRT) is the preferred regimen for clinicians due to the opportunity to schedule the day of embryo transfer and for patients due to the requirement of fewer visits for frozen-warmed embryo transfers (FET). The increasing number of FETs raises the question of the serum P levels required to optimize the pregnancy outcome on the embryo transfer day.

METHODS

This prospective cohort study includes patients who underwent single euploid FET. All patients received HRT with oestradiol valerate (EV) and 100 mg of intramuscular (IM) progesterone (P). FET was scheduled 117-120 h after the first IM administration of 100 mg P. The serum P level was analyzed 1 h before the embryo transfer (ET). In all cycles, only embryos that were biopsied on day 5 were utilized for FET. Next generation sequencing (NGS) was used for comprehensive chromosomal analysis.

RESULTS

Overall, the ongoing pregnancy rate (OPR) was 58.9% (99/168). Data were then categorized according to the presence (Group I; n = 99) or the absence (Group II; n = 69) of an ongoing pregnancy. No significant differences regarding, female age, body mass index (BMI), number of previous miscarriages, number of previous live birth, sperm concentration, number of oocytes retrieved, number of mature oocytes (MII), rate of fertilized oocytes with two pronuclei (2PN), trophectoderm score, inner cell mass (ICM) score, endometrial thickness (mm), oestrodiol (E₂) and P levels prior to IM P administration were found between two groups. The P levels on the day of ET (ng/ml) were significantly higher in Group I (28 (5.6-76.4) vs 16.4 (7.4-60) p = 0.039). The P level on the day of ET was a predictor of a higher OPR (p < 0.001 OR: 1.033 95%CI [1.009-1.056]) after multivariate analysis. The ROC curve showed a significant predictive value of serum P levels on the day of ET for OPR, with an AUC (95%CI) = 0.716 (0.637-0.795). The optimal cut-off value for prediction of the OPR was a P level of 20.6 ng/ml (71.7% sensitivity, 56.5% specificity).

CONCLUSIONS

The present study suggests a minimum threshold of the serum P value on the day of ET that needs to be reached in HRT cycles to optimize the clinical outcome. Individualization of the P dosage should be evaluated in further studies.

The impact of endometrial thickness change after progesterone administration on pregnancy outcome in patients transferred with single frozen-thawed blastocyst

BACKGROUND

The aim of this study was to explore the impact of endometrial thickness change after progesterone administration on pregnancy outcome in patients transferred with single frozen-thawed blastocyst.

METHODS

This observational cohort study included a total of 3091 patients undergoing their first frozen-thawed embryo transfer (FET) cycles between April 2015 to March 2019. Endometrial thickness was measured by trans-vaginal ultrasound twice for each patient: on day of progesterone administration, and on day of embryo transfer. The change of endometrial thickness was recorded.

RESULTS

Regardless of endometrial preparation protocol (estrogen-progesterone/natural cycle), female age, body mass index (BMI), and infertility diagnosis were comparable between patients with an increasing endometrium on day of embryo transfer and those without. However, clinical pregnancy rate increases with increasing ratio of endometrial thickness. Compared with patients with Non-increase endometrium, those with an increasing endometrium on day of embryo transfer resulted in significantly higher clinical pregnancy rate (56.21% vs 47.13%, P = 0.00 in estrogen-progesterone cycle; 55.15% vs 49.55%, P = 0.00 in natural cycle).

CONCLUSIONS

In most patients, endometrial thickness on day of embryo transfer (after progesterone administration) increased or kept being stable compared with that on day of progesterone administration. An increased endometrium after progesterone administration was associated with better pregnancy outcome.

Effect of endometrial thickness on birthweight in frozen embryo transfer cycles: an analysis including 6181 singleton newborns

STUDY QUESTION

Does endometrial thickness (EMT) have an impact on singleton birthweight in frozen embryo transfer (FET) cycles?

SUMMARY ANSWER

An EMT <8 mm was associated with a lower mean birthweight and gestational age- and gender-adjusted birthweight (Z-scores) of singletons resulting from FET.

WHAT IS KNOWN ALREADY

Previous studies have examined the impact of EMT on IVF success rates. Little is known, however, regarding the relationship between EMT and neonatal birthweight.

STUDY DESIGN, SIZE, DURATION

This retrospective study involved singleton live births born to women undergoing frozen-thawed Day 3 embryo transfer during the period from January 2010 to December 2017 at a tertiary care centre.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 6181 women who fulfilled the inclusion criteria were included and were grouped into five groups depending on the EMT: <8 mm, 8-9.9 mm, 10-11.9 mm, 12-13.9 mm and ≥14 mm. EMT between 10 and 11.9 mm was taken as a reference group. Singleton birthweight was the primary outcome measure. A multivariable linear regression analysis was performed to detect a relationship between EMT and newborns' birthweight after controlling for a number of potential confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

A modest but significant decrease in birthweight was observed in the EMT <8 mm group as compared with groups with EMT ≥10 mm, with a mean difference of 89-108 g. Also, singletons from the EMT <8 mm group (0.24 ± 1.04) had a significantly lower birthweight Z-scores than those from the EMT 10-11.9 mm (0.41 ± 1.02; P = 0.032) or EMT 12-13.9 mm (0.46 ± 1.07; P = 0.004) groups. Further, multiple linear regression analyses indicated that parental BMIs, gestational age, newborn gender, pregnancy complications and EMT <8 mm were all independent predictors of neonatal birthweight.

LIMITATIONS, REASONS FOR CAUTION

The present study was limited by its retrospective design. Future prospective studies are required to confirm our findings.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings provided new insight into the relationship between EMT and neonatal outcomes by showing that a thin endometrium is associated with a decrease in singleton birthweight.

STUDY FUNDING/COMPETING INTEREST(S)

National Key Research and Development Program of China (2018YFC1003000); the National Natural Science Foundation of China (81771533, 81571397, 31770989, 81671520); the China Postdoctoral Science Foundation (2018M630456). The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

The association between endometrial thickness and pregnancy outcome in gonadotropin-stimulated intrauterine insemination cycles

BACKGROUND

Intrauterine insemination (IUI) is the first-line treatment for non-tubal infertility. Injectable gonadotropins are often chosen as adjunctive stimulation to promote the growth of ovarian follicles in IUI cycles. The growing follicles produce estrogen, which induces endometrial proliferation and increased endometrial stripe thickness (EST). The association between EST and pregnancy outcome in gonadotropin stimulated IUI is not well studied. The objective of this study is to determine if EST can predict pregnancy outcome in gonadotropin-stimulated IUI cycles.

METHODS

A retrospective review was conducted of all exclusively gonadotropin-stimulated IUI cycles performed between 2012 and 2015 at an academic fertility clinic. Mean endometrial thickness was compared in positive versus negative cycles using Student T-test. Peak EST values were then divided into four groups of < 7 mm, 7.0-10.4 mm, 10.5-13.9 mm, and ≥ 14 mm. Multiple logistic regression analysis adjusted for potential confounders was conducted to assess the impact of peak EST on cycle outcome.

RESULTS

Our sample consisted of 1065 IUI cycles representing 548 patients with a 16.9% clinical pregnancy rate and 20.5% conception rate. No significant differences in mean peak EST were observed between cycles that achieved clinical pregnancy or conception and those that did not. Division of peak EST into four groups showed a non-linear relationship between peak EST and cycle outcome, with highest rates of positive outcomes between 10.5-13.9 mm. The odds of clinical pregnancy and conception increased by 38 and 44% respectively with each subsequent peak EST category up to 10.5-13.9 mm, following which they declined.

CONCLUSION

This is the largest study to date evaluating the effect of peak EST on gonadotropin-stimulated IUI cycles exclusively. The lack of significant difference in peak EST between positive and negative outcomes cycles may be due to the non-linear relationship between cycle outcomes and peak EST. Peak EST in the range of 10.5-13.9 mm was associated with significantly higher conception rates and a trend towards higher clinical pregnancy rates. This non-linearity is likely one of the reasons that EST in isolation was found to be a poor predictor of IUI outcomes, and therefore is not appropriate to be used as the sole indicator for cycle cancellation.

Cytokines and endometrial receptivity after intracytoplasmic sperm injection - A cohort study at Islamabad

OBJECTIVE

To evaluate the role of tumour necrosis factor alpha and interleukin-6 in conception after assisted reproductive treatment.

METHODS

The longitudinal cohort study was conducted from August 2014 to May 2015 and comprised patients undergoing intracytoplasmic sperm injection at the Islamabad Clinic Serving Infertile Couples, Islamabad, Pakistan. During the procedure, endometrial thickness was measured on the day of ovulation induction and serum tumour necrosis factor alpha along with interleukin-6 were measured on the embryo transfer day. Subjects were divided into groups, with non-pregnant females in Group A and those with confirmed foetal cardiac activity in Group B and non-pregnant females were divided into two groups. The difference between the groups and the association of cytokines with endometrial thickness were measured. .

RESULTS

Of the 131 subjects, 79(60%) were in Group A and 52(40%) in Group-B. The mean level of interleukin-6 was 49.65±3.04 in Group B and 104.14±76.03 in Group A, with significant inverse correlation with endometrial thickness (p<0.001). The level of tumour necrosis factor alpha were significantly higher in Group-B compared to Group-A (p<0.001).

CONCLUSIONS

The pro-inflammatory cytokine, tumour necrosis factor alpha, takes part in preparation of endometrial lining for implantation of embryo in assisted reproductive treatment procedures.

Ovarian response is a better predictor of clinical pregnancy rate following embryo transfer than is thin endometrium or presence of an endometrioma

OBJECTIVES

To examine whether endometrial thickness and the presence of endometrioma are independent predictors of clinical pregnancy rate or simply associated with poor ovarian response (POR).

METHODS

This was a retrospective cohort study assessing the first cycle of all women undergoing in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) in a university hospital in Brazil between January 2011 and December 2012. Only the first cycle of each woman within the study period was considered. Women over 40 years of age and those who used clomiphene citrate during controlled ovarian stimulation (COS) or did not undergo embryo transfer were excluded from analysis. POR was defined as ≤ three oocytes retrieved and a thin endometrium was defined as endometrial thickness ≤ 7.0 mm on the day of human chorionic gonadotropin (hCG) administration. We performed a multiple regression analysis to identify which of the following parameters were independent predictors of clinical pregnancy: age, number of oocytes retrieved, endometrial thickness or the presence of endometrioma.

RESULTS

Within the study period, 787 women began COS, but 270 were excluded from analysis. Among the 517 women analyzed, those who achieved pregnancy were younger and yielded more oocytes. The proportion of POR was higher in women with a thin endometrium (17/57 (29.8%) vs 80/460 (17.4%); P = 0.03) and in women with endometrioma (15/39 (38.5%) vs 82/478 (17.2%); P = 0.002). The results of regression analysis showed that only age and the number of oocytes retrieved were independent predictors of pregnancy. Additionally, we observed higher clinical pregnancy rates in women with a thin endometrium from whom ≥ seven oocytes were retrieved (11/25 (44.0%)) compared to women with normal endometrial thickness (99/241 (41.1%)). Considering only women from whom ≥ four oocytes were retrieved, we observed reasonable pregnancy rates in those with a thin endometrium (14/40 (35.0%)) and in those with endometrioma (9/24 (37.5%)).

CONCLUSION

Both a thin endometrium and the presence of endometrioma are associated with POR but are not important independent predictors of clinical pregnancy. Good pregnancy rates can be observed when these conditions are present in women with a good ovarian response.

Elastic shape analysis of cylindrical surfaces for 3D/2D registration in endometrial tissue characterization

We study the problem of joint registration and deformation analysis of endometrial tissue using 3D magnetic resonance imaging (MRI) and 2D trans-vaginal ultrasound (TVUS) measurements. In addition to the different imaging techniques involved in the two modalities, this problem is complicated due to: 1) different patient pose during MRI and TVUS observations, 2) the 3D nature of MRI and 2D nature of TVUS measurements, 3) the unknown intersecting plane for TVUS in MRI volume, and 4) the potential deformation of endometrial tissue during TVUS measurement process. Focusing on the shape of the tissue, we use expert manual segmentation of its boundaries in the two modalities and apply, with modification, recent developments in shape analysis of parametric surfaces to this problem. First, we extend the 2D TVUS curves to generalized cylindrical surfaces through replication, and then we compare them with MRI surfaces using elastic shape analysis. This shape analysis provides a simultaneous registration (optimal reparameterization) and deformation (geodesic) between any two parametrized surfaces. Specifically, it provides optimal curves on MRI surfaces that match with the original TVUS curves. This framework results in an accurate quantification and localization of the deformable endometrial cells for radiologists, and growth characterization for gynecologists and obstetricians. We present experimental results using semi-synthetic data and real data from patients to illustrate these ideas.

Colour analysis of the equine endometrium: comparison of spectrophotometry and computer-assisted analysis of photographs within the L*a*b* colour space system

The aims of this study were to compare two different methods of quantifying the colour of the luminal surface of the equine endometrium and to relate the results to histopathological evidence of inflammation and fibrosis. The mucosal surfaces of 17 equine uteri obtained from an abattoir were assessed using a spectrophotometer and by computer-assisted analysis of photographs. Values were converted into L(*)a(*)b(*) colour space. Although there was significant correlation between the two methods of quantification, variations in 'brightness', 'red' and 'yellow' values were noted. Within a given uterus, measurements using the spectrophotometer did not differ significantly. Using photographic analysis, brightness differed between horns, although no differences in chromaticity were found. Histopathological classification of changes within endometria corresponded to measured differences in colour. Extensive fibrosis was associated with increased brightness and decreased chromaticity using both methods. Inflammation correlated with reduced chromaticity, when measured by spectrophotometry, and with reduced brightness and yellow values, when assessed photographically. For this technique to gain wider acceptance as a diagnostic tool, e.g. for the endoscopic evaluation of uterine mucosae in vivo, standardised illumination techniques will be required so that colours can be compared and interpreted accurately.

A retrospective cross-sectional study: fresh cycle endometrial thickness is a sensitive predictor of inadequate endometrial thickness in frozen embryo transfer cycles

BACKGROUND

The purpose of this study is to assess predictors of inadequate endometrial cavity thickness (ECT), defined as < 8 mm, in frozen embryo transfer (FET) cycles.

METHODS

This is a retrospective cross-sectional study at an academic fertility center including 274 women who underwent their first endometrial preparation with estradiol for autologous FET in our center from 2001-2009. Multivariable logistic regression was performed to determine predictors of inadequate endometrial development in FET cycles.

RESULTS

Neither age nor duration of estrogen supplementation were associated with FET endometrial thickness. Lower body mass index, nulliparity, previous operative hysteroscopy and thinner fresh cycle endometrial lining were associated with inadequate endometrial thickness in FET cycles. A maximum thickness of 11.5 mm in a fresh cycle was 80% sensitive and 70% specific for inadequate frozen cycle thickness.

CONCLUSIONS

Previous fresh cycle endometrial cavity thickness is associated with subsequent FET cycle endometrial cavity thickness. Women with a fresh cycle thickness of 11.5 mm or less may require additional intervention to achieve adequate endometrial thickness in preparation for a frozen cycle.

Do extracts of oral soybean augment the trophic effect of estrogen on the rat uterus?

OBJECTIVE

To evaluate whether soybean extracts and estrogens present additive effects on adult rat uterus.

METHODS

Fifty ovariectomized rats were randomly divided into five equal groups of ten animals: Control, treated with vehicle; SE46 and SE120, treated with 46 and 120 mg/kg soybean concentrated extract (SE), respectively; EE, treated with conjugated equine estrogens (CE) 50 μg/kg; SE120 + EE, treated with 50 μg/kg (CE) plus 120 mg/kg SE. The substances were administered daily by gavage for 21 consecutive days. Thereafter the animals were weighed and killed by decapitation; trunk blood was collected for hormone determinations. Uteri were removed immediately and fixed in 10% formaldehyde, followed by dehydration, embedding in paraffin and 6-m sections staining with hematoxylin and eosin for histomorphometric analyses of myometrium and endometrium. After ANOVA analysis of the data, the study was complemented with the Tukey-Kramer test for multiple comparisons.

RESULTS

The concentrated extract of soybean at high concentration (SE 120 kg/mg) and estrogens proved to have a trophic effect on the uterus (endometrium and myometrium) of castrated rats. In groups SE120, EE and SE120 + EE, all morphometric parameters examined (number of glands, eosinophils, blood vessels and the glandular area) were increased. No significant addictive effects of soybean extract plus estrogens were detected in the SE120 + EE group.

CONCLUSIONS

Our results indicate that soy extract has a trophic effect on rat uterine structures. Treatment of ovariectomized rats with a concentrated soy extract in combination with conjugated estrogens had no addictive effect on the uterine response.

Safety and efficacy of tibolone and menopausal transition: a randomized, double-blind placebo-controlled trial

OBJECTIVE

To evaluate the efficacy, safety and tolerability of Tibolone use during the menopausal transition (MT).

METHODS

Sixty-five healthy women aged 40-55 years (48.5 ± 3.5 years) were recruited for a randomized, double-blind controlled trial. Thirty participants were recruited to receive oral Tibolone 2.5 mg/day - Tibolone Group (TG), and 35 participants were assigned to the Placebo Group (PG), which received one capsule of lactose/day. Both groups were treated for 12 consecutive weeks. The Blatt-Kupperman Menopausal Index (KMI) and the Greene Climacteric Scale (GCS) were used. The glycaemic and lipid profiles, biochemical measures of hepatic function and endometrial thickness were measured for safety. A daily registry of complaints related to the treatment was maintained, and anthropometric measures were obtained to assess tolerability.

RESULTS

A total of 57 women completed the study. After 12 weeks of Tibolone use, the total score and percentage of the KMI and GCS were significantly decreased compared to baseline, which reflected the efficacy of the treatment of climacteric symptoms. The improvement in blood biochemistry, endometrial atrophy and maintenance of the anthropometrical measures reflected the safety of Tibolone use. The absence of serious side effects demonstrated good tolerability for Tibolone use.

CONCLUSIONS

The results showed good efficacy, tolerability and safety of Tibolone use during the MT.

[Comparison of the measurement line cervical and endometrial ultrasound techniques using two]

BACKGROUND

Cervical and endometrial measurement in the gynecological and obstetric patients is of vital importance. There is no consensus for the correct way in which should be made the measurement, more than anything is for an opinion of some experts.

OBJECTIVE

To determine whether there are differences in measurement of endometrial or sagittal cross section of the uterus and cervix in the measurement of fractional linear fashion or along the cervical canal.

MATERIAL AND METHODS

Using a transvaginal ultrasound, was measured in a transverse and longitudinal endometrial lining. And by fractional measuring along the cervical canal and a linear manner from the internal to the external.

RESULTS

We studied a total of 63 patients. The mean endometrial transversal measurement in a cross was 7.1. mm (SD +/- 3.3) The mean endometrial longitudinally measured were: 7.9 mm (SD +/- 3.4). The mean cervical measurement was fractionally 3.3 cm (SD +/- 0.4) Mean cervical linear measurement was 3.9 cm (SD +/- 0.4). Using student's t test where the value of p in the endometrial measurement was 0.0871 and p value in cervical measurement was 0.009, the latter being statistically significant.

CONCLUSIONS

With respect to the measurement of the endometrial lining, there is no significant difference do any of the two different techniques. However, measurement of the cervix, another significant difference (p = 0.009), so it should be further investigated which of these two techniques is the right way to establish more accurate diagnoses.

The effects of metformin and letrozole on endometrium and ovary in a rat model

OBJECTIVE

The effects of metformin and letrozole on endometrium and ovarian reserve were studied in a rat model.

METHODS

Forty female Wistar albino mature rats at 8 weeks, weighing 180-260 g, were used for the study. These rats were randomly divided into four groups. Control group, eight rats, was given no medication by oral gavage. The rats in low-dose metformin group, 10 rats, were given 100 mg/kg/day of oral metformin. The rats in high-dose metformin group, 10 rats, were given 200 mg/kg/day of oral metformin. The rats in letrozole, 10 rats, were given 0.1 mg/kg/day of oral letrozole.

RESULTS

There was statistically significant difference in the endometrial thickness between the treatment groups and control group. The primordial follicle count was comparable in all treatment groups compared with control. Finally, there was no significant difference in total follicle count between the treatment groups and control.

CONCLUSIONS

This study showed that both metformin and letrozole had similar effects on endometrium and ovary in the rat model. Additionally, metformin had a little effect on endometrium than letrozole. Although metformin and letrozole might have tendency to enhance the total follicle count in the rat model, they had comparable effects on ovarian follicles and did not change the ovarian reserve compared with control.

Nomegestrol acetate, a novel progestogen for oral contraception

Nomegestrol acetate (NOMAC) is a potent, highly selective progestogen, which is structurally similar to 19-norprogesterone and characterized as a full agonist at the progesterone receptor, with no or minimal binding to other steroid receptors, including the androgen and glucocorticoid receptors. In animal models, NOMAC demonstrated moderate antiandrogenic activity and strong antiestrogenic activity. In clinical studies, the progestogen was associated with effective suppression of gonadotropic activity and ovulation in premenopausal women, and a neutral impact on hemostasis, lipids, and carbohydrate metabolism. In normal and cancerous human breast tissue, NOMAC has shown favorable effects on estrogen metabolism, and in human breast cancer cell lines in vitro, it does not stimulate cell proliferation. The pharmacologic profile of NOMAC suggested that it would be well suited for combination with a physiologic estrogen in a combined oral contraceptive (COC), with the aim of achieving effective contraception with good cycle control and a favorable safety profile. A monophasic COC containing NOMAC 2.5mg and 17β-estradiol (E2) 1.5mg, administered in a 24/4-day regimen, is currently under clinical investigation. In a phase III study, NOMAC/E2 provided consistent and robust ovulation inhibition, with contraceptive effects that compared favorably with those of drospirenone 3mg/ethinyl estradiol (EE) 30 μg. Investigators for a second phase III study reported less overall impact with NOMAC/E2 on hemostatic, lipid, inflammatory, and carbohydrate metabolism parameters than with levonorgestrel 150 μg/EE 30 μg. These clinical findings are promising; however, full publication of results from the pivotal phase III trials of NOMAC/E2 is pending.

Predictive factors of intrauterine insemination success of women with infertility over 10 years

OBJECTIVE

The relationship between maternal age, duration of infertility, pre-ovulatory follicles, endometrial thickness and motile sperms with intra uterine insemination (IUI) success in women with infertility over 10 years was surveyed.

METHODS

We performed a descriptive - cross sectional study among couples (n=26) with a history of infertility for more than 10 years who were treated with IUI. The data was collected between 2000 and 2007 in the fertility ward of Amiralmomenin Hospital of Semnan University of Medical Sciences. Patients underwent a basic fertility workup and the ovarian hyperstimulation was done with clomiphene citrate (CC) and human chorionic gonadotrophin (hMG) alone or in combination. A volume of 0.3-0.4 ml suspension of processed spermatozoa (after swim-up procedure) was introduced into the uterine cavity 36h after human chorionic gonadotrophin (hCG) administration. The comparison between variables was performed by chi-square and student's test on SPSS (Version 10.0).

RESULTS

The total number of women with infertility over 10 years referring to fertility ward was 26. Seven of them became pregnant after treatment (27%). Majority of these pregnancies (87.5%) were achieved in the first cycle. Pregnant cases were 30-37 years of age with a history of infertility for up to ten years. The comparison of data between two groups showed that maternal age (P<0.03) and number of motile sperms (P<0.05) had a significant relationship with the results of treatment.

CONCLUSION

Number of motile spermatozoa and women age are factors with the highest impact on pregnancy after IUI treatment in women with infertility for over 10 years.

Effect of estrus induction on prostaglandin content and prostaglandin synthesis enzyme expression in the uterus of early pregnant pigs

Prostaglandins (PGs) play a pivotal role in maternal recognition of pregnancy and implantation in pigs. In the present study, PGE(2), PGF(2alpha), and PGFM (PGF(2alpha) metabolite) content, as well as PGE(2) synthase (mPGES-1) and PGF(2alpha) synthase (PGFS) expression was investigated in early pregnant gilts with natural (n=21) and PMSG/hCG-stimulated (n=19) estrus. Endometrial tissue samples, uterine luminal flushings (ULFs), and blood serum were collected on days 10-11, 12, and 15 after insemination. Additionally, day 15 conceptuses were collected for mPGES-1 and PGFS protein expression. Effect of estrus induction was observed on day 15 of pregnancy, when the content of PGE(2) in the uterine lumen was fourfold lower in gonadotropin-stimulated gilts in comparison to controls (P<0.001). Decreased PGE(2) content in ULFs of gonadotropin-treated pigs was preceded by lower endometrial mPGES-1 gene expression in hormonally-stimulated animals in comparison to control gilts (P<0.01). On the other hand, estrus induction with PMSG/hCG resulted in higher PGE(2) accumulation in the endometrial tissue on day 15 of pregnancy (P<0.01). Furthermore, PGF(2alpha) content in the endometrium and PGFM levels in blood serum were lower in gonadotropin-treated gilts, especially on day 12 after insemination when compared to control gilts (P<0.01). Finally, PGFS expression in day 15 conceptuses was decreased in animals with hormonally-induced estrus. We conclude that PMSG/hCG stimulation of prepubertal gilts to induce estrus results in changes of PG production and secretion during early pregnancy, which, in turn, may affect conceptus development, implantation, and the course of pregnancy.

Contraceptive efficacy and safety of a low-dose oral contraceptive, (0.03 mg ethinyl oestradiol and 2 mg chlormadinone acetate) Belara®, over three medication cycles

OBJECTIVE

To describe the modulation of ovarian function during three medication cycles with 0.03 mg ethinyl oestradiol (EE) and 2 mg chlormadinone acetate (CMA), leading to inhibition of conception in healthy women.

METHODS

Phase II, single-centre, open, non-controlled trial. The main outcome measure was inhibition of ovarian activity, assessed by frequent monitoring of the presence, size and persistence of follicle-like structures using ultrasonography. Secondary parameters included: cervical reaction score (CRS-probability of fertilization), endometrial thickness (probability of nidation), and serum levels of the sex hormones oestradiol, progesterone, luteinizing hormone and follicle stimulating hormone. Safety was primarily assessed by monitoring the occurrence of adverse events.

RESULTS

Thirty-three subjects were eligible for the trial and were included in the efficacy assessment (per protocol analysis, PPA). All subjects ovulated during the pretreatment cycle, but none during the three medication cycles. Follicular growth was profoundly suppressed during the medication phase, with residual ovarian activity occurring in only 12/83 (14.5%) treatment cycles. The CRS was negative during each medication cycle and endometrial thickness was suppressed on each medication day, with median values of 4.0-6.0 mm. EE/ CMA was well tolerated, with few adverse events reported; most were typically cycle-related and included headache, breast discomfort, nausea and vomiting.

CONCLUSION

During the administration of EE/CMA follicular development, cervical reaction and endometrial thickness are profoundly suppressed, resulting in unfavourable conditions for fertilization, implantation and, thus, pregnancy.

The impact of endometrial thickness and texture on intracytoplasmic sperm injection outcome

OBJECTIVE

To determine the impact of endometrial thickness and texture on clinical pregnancy, implantation and miscarriage rates in intracytoplasmic sperm injection (ICSI) and embryo transfer cycles.

STUDY DESIGN

A total of 758 consecutive infertile women (n = 1,087 cycles) undergoing ICSI and embryo transfer (ET) because of severe male factor infertility were retrospectively enrolled in Hacettepe University, Faculty of Medicine. Three groups of patients undergoing ICSI were identified based on endometrial thickness on the day of human chorionic gonadotropin (hCG) administration: < 7 mm (group A: 26 patients, 42 cycles), 7-14 mm (group B: 663 patients, 956 cycles) and > 14 mm (group C: 69 patients, 89 cycles).

RESULTS

Although there was a trend of lower clinical pregnancy rate per embryo transfer in group A (35.0%) compared with group B (43.1%), it did not reach statistical significance; however, it was significantly higher in group C (59.1%), (p < 0.05). The respective figures for implantation rates were 37.6%, 10.4%, and 23.0% (p < 0.01).

CONCLUSION

Endometrial thickness < 7 mm on the day of hCG is associated with lower pregnancy rate when compared with 7-14 mm and > 14 mm; however, a clinical pregnancy rate of approximately 35% still warrants not abandoning fresh embryo transfer in such cases.

Endometrial thickness, Caucasian ethnicity, and age predict clinical pregnancy following fresh blastocyst embryo transfer: a retrospective cohort

BACKGROUND

In-vitro fertilization (IVF) with blastocyst as opposed to cleavage stage embryos has been advocated to improve success rates. Limited information exists on which to predict which patients undergoing blastocyst embryo transfer (BET) will achieve pregnancy. This study's objective was to evaluate the predictive value of patient and cycle characteristics for clinical pregnancy following fresh BET.

METHODS

This was a retrospective cohort study from 2003-2007 at an academic assisted reproductive program. 114 women with infertility underwent fresh IVF with embryo transfer. We studied patients undergoing transfer of embryos at the blastocyst stage of development. Our main outcome of interest was clinical pregnancy. Clinical pregnancy and its associations with patient characteristics (age, body mass index, FSH, ethnicity) and cycle parameters (thickness of endometrial stripe, number eggs, available cleaving embryos, number blastocysts available, transferred, and cryopreserved, and embryo quality) were examined using Student's T test and Mann-Whitney-U tests as appropriate. Multivariable logistic regression models were created to determine independent predictors of CP following BET. Receiver Operating Characteristic analyses were used to determine the optimal thickness of endometrial stripe for predicting clinical pregnancy.

RESULTS

Patients achieving clinical pregnancy demonstrated a thicker endometrial stripe and were younger preceding embryo transfer. On multivariable logistic regression analyses, Caucasian ethnicity (OR 2.641, 95% CI 1.054-6.617), thickness of endometrial stripe, (OR 1.185, 95% CI 1.006-1.396) and age (OR 0.879, 95% CI 0.789-0.980) predicted clinical pregnancy. By receiver operating characteristic analysis, endometrial stripe >or= 9.4 mm demonstrated a sensitivity of 83% for predicting clinical pregnancy following BET.

CONCLUSION

In a cohort of patients undergoing fresh BET, thicker endometrial stripe, Caucasian ethnicity, and younger age are positive predictors of clinical pregnancy after fresh BET. These findings may be useful in clinical management of infertile patients undergoing fresh BET cycles.

The effect of endometrial thickness on in vitro fertilization (IVF)-embryo transfer/intracytoplasmic sperm injection (ICSI) outcome

The value of measuring the endometrial thickness and studying the endometrial receptivity in the context of assisted conception remains a contentious issue. A prospective analysis was carried out to determine the effect of endometrial thickness on IVF - embryo transfer/ICSI outcome in dedicated Assisted Reproductive Technology (ART) units in Abuja and Rivers State, Nigeria. Two hundred and fifty one patients who met the inclusion criteria were analysed. They were grouped on the basis of endometrial thickness into 3 groups; <7 mm, 7 - 14 mm and >14 mm. The main outcome measure was clinical pregnancy. There were significantly more pregnancies in the 7 - 14 mm endometrial thickness group compared to the <7 mm and >14 mm groups, p=0.004 and p<0.0001 respectively. The findings suggest that following IVF/ICSI, significantly more pregnancies occurred when the endometrial thickness was between 7 and 14 mm.

[Treatment with isoflavones replaces estradiol effect on the tissue fat accumulation from ovariectomized rats]

OBJECTIVE

Isoflavones (ISO) present in soybean are named phytoestrogens because they show estrogen effect. The use of isoflavones has beneficial effect in disturbance of post-menopause, which is characterized by ovarian function suppression. Decreasing of estrogen secretion and consequent morphologic and metabolic disarrangements are observed in female hormonal decline. The aim of present work was to investigate the effect of ISO on the fat accretion of uterine endometric tissue, and HDL and glucose blood concentration from ovariectomized rats (OVX).

METHODS

Female Wistar rats with 60 days-old were submitted a surgery to remove bilaterally the ovarium. After 8-day recovery period the animals were distributed into three groups: sham operate (GC); OVX ISO untreated (GI) and OVX supplemented with ISO (G II). Total uterus mass, uterus fat and retroperitoneal fat pad, were removed, washed and weighted. Samples of uterus were histological processed to measure endometrium thickness. Blood samples were also collected to analyze the concentration of HDL and glucose. The OVX caused endometric atrophy, decrease of uterus weight and HDL reduction. The treatment with ISO provoked decrease of uterine and retroperitoneal fat pad. HDL increase and glycemia reduction were also observed. However, there was no uterotrophic effect.

CONCLUSIONS

ISO treatment causes decrease in tissue fat accretion from ovariectomized rats.

A comparison of the effects of clomiphene citrate and the aromatase inhibitor letrozole on superovulation in Asian women with normal ovulatory cycles

OBJECTIVE

To compare the effect of the aromatase inhibitor letrozole and clomiphene citrate (CC) on superovulation in women with normal ovulation.

METHODS

A cross-over randomized study of 22 women with normal ovulation, divided randomly into two equal cohorts, was carried out. Each group of 11 women was randomly allocated to take letrozole or CC for one cycle. After washing out for one cycle, the alternative drug was administered in the subsequent cycle. The number and size of mature follicles, endometrial thickness, and estradiol and progesterone levels were monitored.

RESULTS

The number of mature follicles and estradiol levels on ovulation day were significantly lower in the letrozole group than the CC group (p < 0.05 for both). However, no differences between the two groups in endometrial thickness and pattern were observed. Progesterone levels showed ovulation in all cycles.

CONCLUSIONS

The administration of 50 mg CC on days 3-5 was superior to 2.5 mg letrozole for superovulation induction in women with normal ovulation.

[Sonographic evaluation of the uterus in Holstein-Friesian cows without and with disturbances of the puerperium during the first 14 days postpartum]

The aim of this study was to investigate if, compared with transrectal manual palpation, B-mode sonography provides additional information about the uterine structures and contents of Holstein-Friesian cows without and with disturbances during the early puerperal phase, that lead to a more precise diagnosis. The examinations were carried out once per cow either during the first four days p. p. (contraction phase, KPH) or on days 5 to 10 (desquamation phase, DPH) or on days 11 to 14 (regeneration phase, RPH) in 57 cows with undisturbed (UP) and 69 with disturbed puerperal phases (GP). The mean size of the uterus measured by transrectal palpation was 0.94 to 1.51 points (on a 6-point scale, p < 0.05) larger throughout the examination period and the fluctuation was 1.29 and 0.92 points (on a 4-point scale, p < 0.05) higher in GP cows compared with UP cows during the KPH and RPH, respectively. During the KPH, contractility of the uterus was 0.56 points (on a 3-point scale, p < 0.05) lower in GP cows compared with UP cows. Sonographically the cross sectional area of the most caudally located caruncle was 0.47 to 3.53 cm2 bigger (p < 0.05) in GP cows than in UP cows. The GP cows showed in the KPH a 0.21 cm thinner (p < 0.05) endometrium compared with the UP cows. In the DPH and RPH, the echogenicity was 1.63 and 1.04 points (on a 4-point scale, p < 0.05) higher and the intraluminal diameter of the uterine body was 0.49 to 0.67 cm greater (p < 0.05) in GP cows compared with UP cows, respectively. By means of dicriminant analysis 96.7% and 91.7% of the animals of the GP and UP group, respectively, where classified correctly during the DPH, whereas in the other two phases these proportions were between 70.0% and 87.5%. The results show that B-mode sonography is an additional valuable method for a more accurate differentiation of uterine involutionary processes between cows without and with disturbances of the puerperal phase.

Open interfaces in initial lymphatics: a methodological artifact?

Castenholz, Hauck, and other authors--including myself--have previously described initial lymphatics and the existence of open interfaces in tongue, mesentery as well as in uterus. These structures were supposed to represent an additional entrance into the initial lymphatic pathway and the open interfaces were proposed to act as pressure relief valves in some organs in case of increased volumes of tissue fluid. The methodological approaches used by these authors were interstitial and retrograde fillings of the lymphatic system, and often an endothelium-lined structure was seen connecting initial lymphatics with the interstitial space and ending free in connective tissue. Further research of my group in basic lymphology has led to new and surprising insights, and we now demonstrate that most of these so called "open-interfaces" are methodological artifacts.

Tibolone histology of the endometrium and breast endpoints study: design of the trial and endometrial histology at baseline in postmenopausal women

OBJECTIVE

To address the endometrial safety of tibolone.

DESIGN

The Tibolone Histology of the Endometrium and Breast Endpoints Study (THEBES) is a randomized, double-blind, parallel-group trial of tibolone compared with continuous combined conjugated equine estrogen (CEE) and medroxyprogesterone acetate (MPA).

SETTING

Multi-country, multi-center ambulatory care setting.

PATIENT(S)

A total of 5,185 subjects were screened, and biopsies were obtained from 4,446 women.

INTERVENTION(S)

Participants were randomized in a 1:1:2 ratio, to tibolone (1.25 or 2.5 mg/d) or CEE-MPA.

MAIN OUTCOME MEASURE(S)

The one-sided 95% confidence intervals for the incidence of hyperplasia or cancer were evaluated for tibolone compared with CEE-MPA.

RESULT(S)

Endometrial biopsy results at baseline: atrophic (87.29%), inactive (0.25%), proliferative (6.12%), secretory (2.86%), menstrual type (0.40%), and hyperplasia (0.18%). Only subjects with atrophic or inactive endometrium were eligible for this study, and 3% of the women at screening either had no tissue (0.18%) or had an amount of tissue that was insufficient for diagnosis (2.72%). Three thousand two hundred forty postmenopausal women with a mean (+/-SD) age of 54.4 +/- 4.4 years and a mean time since menopause of 4.5 +/- 3.6 years were randomized.

CONCLUSION(S)

The Tibolone Histology of the Endometrium and Breast Endpoints Study is a prospective, randomized clinical trial, designed to provide evidence of the endometrial safety of tibolone compared with estrogen and progestogen. Screening endometrial histology shows a low prevalence of endometrial hyperplasia (0.18%) and no carcinoma.

The role of Pipelle® Mark II sampling in endometrial disease diagnosis

OBJECTIVE

To evaluate the feasibility and accuracy of Pipelle Mark II sampling (designed for combined cytology and histology testing) in the diagnosis of endometrial disease.

MATERIALS AND METHODS

A 97 women with abnormal uterine bleeding or intrauterine lesions on ultrasound examination underwent Pipelle Mark II endometrial sampling, followed by diagnostic hysteroscopy. The adequacy of endometrial samples obtained for cytological and histological analysis was assessed. A correlation was established between endometrial cytology, histology and diagnostic hysteroscopy results. Where discrepancies were found, they were compared with the histological results obtained from operative hysteroscopy.

RESULTS

The tissue samples obtained for cytological and histological diagnoses were insufficient in 14.4% and 11.3% of patients, respectively. The opposite was found in the group of postmenopausal women (N=52): the tissue samples for cytological and histological diagnoses were insufficient in only 3.8% and 15.4% of cases, respectively. The cytological results corroborated diagnostic hysteroscopy findings and histological results in all cases but 3 (3.6%). Only two cases of endometrial carcinoma were reported in this group of patients, and they were both detected by all three methods. The rate of false positives with endometrial cytological sampling was 3.6%. There were no false negatives.

CONCLUSION

Pipelle Mark II endometrial sampling is feasible. It provides adequate samples for histological and/or cytological analysis and reliable results. It reduces the rate of false negative results for endometrial cancer. Pipelle Mark II sampling is particularly useful in postmenopausal women and in women with endometrial atrophy. Other larger studies are necessary to evaluate the efficiency of Pipelle Mark II.

Endometrial stripe thickness and pregnancy outcome in first-trimester pregnancies with bleeding, pain or both

OBJECTIVE

To determine the association between endometrial stripe (ES) thickness and pregnancy outcome in women with a symptomatic first-trimester pregnancy and to determine how vaginal bleeding, pelvic pain and 1 human chorionic gonadotropin (hCG) level affect ES thickness.

STUDY DESIGN

Data on ES thickness, serum hCG, presence of pain, characterization of vaginal bleeding and ultimate clinical outcome were collected for 576 women presenting to the emergency room.

RESULTS

ES was thinner with increased vaginal bleeding and associated with hCG level and pregnancy outcome. The mean ES for ectopic pregnancies (EPs) was 9.56 +/- 4.87, for intrauterine pregnancies was 12.12 +/- 6.0 and for spontaneous abortion was 10.19 +/- 6.10. Ninety-nine percent of patients with EP had an ES <21 mm, and 100% had one < or =25 mm.

CONCLUSION

There was considerable overlap in ES for the 3 pregnancy outcomes, making it a poor diagnostic test. Nevertheless, ES >21 mm in a woman with no evidence of a gestational sac excludes EP with 96% specificity. A patient with a stripe >25 mm may be expectantly managed.

Three-dimensional endometrial volume and 3-dimensional power Doppler analysis in predicting endometrial carcinoma and hyperplasia

OBJECTIVE

To evaluate the accuracy of endometrial volume measurement and 3-dimensional power Doppler analysis (3D-PDA) in the diagnosis of endometrial carcinoma and endometrial hyperplasia in women with post- and peri-menopausal bleeding.

METHODS

56 women with post-menopausal and 89 with peri-menopausal bleeding were enrolled. All were scheduled for hysteroscopy, dilatation and curettage, endometrial sampling or hysterectomy, and the ultrasound was performed within 24 h before the procedure. Endometrial thickness, endometrial volume, vascularity index (VI), flow index (FI) and vascularity flow index (VFI) were measured. These parameters were compared between the group of women with normal histology (including endometrial polyps) and the pathologic group (carcinoma and hyperplasia with or without atypia).

RESULTS

Ninety women (62%) had normal histology, 26 (17.9%) had an endometrial polyp, 18 (12.5%) hyperplasia and 11 (7.6%) had endometrial carcinoma. Mean endometrial thickness was 11 mm and 15.5 mm in the normal and pathologic groups respectively (p<0.005). The mean endometrial volume was 6.87 cc and 15.5 cc in the two groups respectively (p<0.001). The VI was 2.27% and 2.95% in the two groups respectively (p=0.022). The FI was 18.6 and 23.6 in the two groups respectively (p=0.014). The VFI was 0.68 and 0.89 in the two groups respectively (p=0.018). Using ROC the area under the curve was 0.698, 0.728, 0.621, 0.631, and 0.625 for endometrial thickness, endometrial volume, VI, FI and VFI respectively. The best predictor of endometrial carcinoma was an endometrial volume of 3.56 cc or more (sensitivity 93.1%, specificity 36.2%).

CONCLUSIONS

Endometrial volume and 3D-PDA are good diagnostic tools in predicting endometrial carcinoma and hyperplasia in women with post- and peri-menopausal bleeding.

Wild Fulvous Fruit Bats (Rousettus leschenaulti) Exhibit Human-Like Menstrual Cycle1

We investigated the menstrual cycle of wild fulvous fruit bats (Rousettus leschenaulti), focusing on changes in the endometrial and ovarian structure and pituitary and steroid hormones. The menstrual cycle lasts for 33 days in bats studied in their natural habitat and in captivity. Vaginal bleeding was restricted to a single day (Day 1). A preovulatory follicle was found in the ovary on Day 18 when the levels of LH and FSH reached their maxima, accompanied by a thickened endometrium. On Day 24, serum levels of progesterone and estradiol-17 were also maximal, and uterine glands increased in size. After that, the levels of progesterone dropped precipitously, leading to menstrual bleeding. Both the morphologic and hormonal changes observed in fulvous fruit bats during the menstrual cycle resemble similar changes in humans. Fulvous fruit bats may be useful nonprimate laboratory models to study menstruation and menstrual dysfunction.

Endometrial thickness and pregnancy outcome after intrauterine insemination

OBJECTIVES

To investigate whether endometrial thickness on the day of hCG administration is a predictor of intrauterine insemination (IUI) success.

DESIGN

A retrospective study.

PATIENT(S)

Two hundred forty-nine women undergoing IUI cycles.

SETTING

University hospital-based infertility center.

INTERVENTION(S)

Endometrial thickness on the day of hCG administration, cycle parameters, and sperm quality were compared between pregnant and nonpregnant patients. A similar comparison was made between ongoing pregnancies and those that resulted in a loss.

MAIN OUTCOME MEASURE(S)

Endometrial thickness versus IUI outcome.

RESULT(S)

The overall pregnancy rate was 15%. Mean (+/- standard deviation) endometrial thickness on the day of hCG administration was significantly greater in cycles where pregnancy was achieved (10.1 +/- 3.0 vs. 7.7 +/- 3.5). In the univariate analysis, the following variables affected the pregnancy rate: the woman's age, duration of infertility, the number of IUI cycles, the number of follicles, the diameter of the dominant follicle, the duration of follicle maturation, and sperm count, motility, and morphology. In the multivariate analysis, the strongest predictor of IUI success was the number of IUI cycles. The woman's age was negatively associated with pregnancy outcome, while endometrial thickness and the total motile sperm count were positively associated with pregnancy outcome.

CONCLUSION(S)

The results of the present study suggest that clinicians providing IUI for infertile couples must pay close attention to endometrial development as well as to follicle growth and sperm motility.

[Changes in the sonographic appearance of the endometrium after different premenopausal tamoxifen therapies]

OBJECTIVE

To assess the effect of different schemes of premenopausal tamoxifen therapy on the endometrium.

METHODS

Totally 109 normal premenopausal women positive for high-risk factors of breast cancer were divided into two groups, namely periodic and consecutive tamoxifen treatment groups. Endometrial thickness as examined by vaginal sonography was assessed in relation to duration of tamoxifen use and time from discontinuation of the drug.

RESULTS

After one year of tamoxifen use, the mean endometrial thickness in periodic treatment group was 6.5-/+1.4 mm, and 10.2-/+2.0 mm in consecutive treatment group. Endometrial thickness increased with the duration of tamoxifen use at the rate of 0.51 mm/year in the periodic treatment group, and 0.73 mm/year in consecutive treatment group. After discontinuation of tamoxifen, the endometrial thickness in the former group decreased by 1.29 mm/year, and by 1.33 mm/year in the latter.

CONCLUSIONS

Endometrial hyperplasia is obviously milder in premenopausal women receiving periodic tamoxifen treatment who are at risk for breast cancer than that in women with consecutive treatment. After discontinuation of the drug, the endometrial thickness decreases at a roughly equal slow rate in the two groups.

Effect of implanted Cu/low-density polyethylene nanocomposite on the morphology of endometrium in the mouse

OBJECTIVE

To investigate the damage of endometrium caused by the implanted Cu/low-density polyethylene (LDPE) nanocomposite and the contraceptive effect of this novel copper-containing intrauterine device material.

DESIGN

Experimental animal study.

SETTING

TongJi Medical College of Huazhong University of Science and Technology.

PATIENT(S)

Sixty healthy female mice.

INTERVENTION(S)

Twenty mice received no implants, 20 mice received the Cu/LDPE nanocomposite, and 20 mice received bulk copper.

MAIN OUTCOME MEASURE(S)

Morphologic features of the endometrium, contraceptive effect, and surface condition of the implanted implants.

RESULT(S)

The contraceptive effect of both the Cu/LDPE nanocomposite and bulk copper is 100%, the damage of the endometrium caused by the Cu/LDPE nanocomposite is much less than that caused by bulk copper, and the surface of the implanted Cu/LDPE nanocomposite is much smoother and much softer than that of the implanted bulk copper.

CONCLUSION(S)

The contraceptive effect of the Cu/LDPE nanocomposite is comparable with that of bulk copper, and the damage of the endometrium caused by the Cu/LDPE nanocomposite is much less than that caused by bulk copper. The endometrium injury is related to the surface condition of the implanted intrauterine device material.

Placentation in dolphins from the Amazon River Basin: the Boto, Inia geoffrensis, and the Tucuxi, Sotalia fluviatilis

A recent reassessment of the phylogenetic affinities of cetaceans makes it timely to compare their placentation with that of the artiodactyls. We studied the placentae of two sympatric species of dolphin from the Amazon River Basin, representing two distinct families. The umbilical cord branched to supply a bilobed allantoic sac. Small blood vessels and smooth muscle bundles were found within the stroma of the cord. Foci of squamous metaplasia occurred in the allanto-amnion and allantochorion. The interhemal membrane of the placenta was of the epitheliochorial type. Two different types of trophoblastic epithelium were seen. Most was of the simple columnar type and indented by fetal capillaries. However, there were also areolar regions with tall columnar trophoblast and these were more sparsely supplied with capillaries. The endometrium was well vascularised and richly supplied with actively secreting glands. These findings are consistent with the current view that Cetacea are nested within Artiodactyla as sister group to the hippopotamids.

Growth hormone deficiency and supplementation at in-vitro fertilisation

INTRODUCTION

This study aims to evaluate the differences in oocyte stimulation, endometrial thickness, fertilisation rate and embryo quality at in-vitro fertilisation (IVF) in patients with documented growth hormone (GH) deficiency, after GH supplementation.

METHODS

This was a retrospective analysis of 20 cases of patients who were pregnant and had GH supplementation during IVF at the Singapore General Hospital between 1993 and 2003. All these patients had previously failed IVF due to poor stimulation, poor egg quality, poor fertilisation at intracytoplasmic sperm injection (ICSI) or failed implantation, and they had documented GH deficiency. These initial cycles were compared with their subsequent IVF cycles with GH supplementation. A non-parametric test was used for statistical analysis.

RESULTS

Embryo quality, determined by scoring the embryos on Day two using morphology, improved significantly after supplementation of GH (p-value is less than 0.001, median embryo score increased from 10.7 to 16). There was also a statistically significant increase in the fertilisation rate for those patients who had ICSI. There was no statistical difference in the number of oocytes retrieved or in the mean endometrial thickness with GH.

CONCLUSION

This study implies that GH supplementation may improve embryo quality in selected patients with GH deficiency. Its role in improving fertilisation rate at ICSI merits further research and evaluation.

Angiogenic factors in normal endometrium and endometrial adenocarcinoma

In the endometrium, angiogenesis plays important roles not only in tumor growth but also in the menstrual cycle. The purpose of the present paper was to investigate immunohistochemically the correlation between angiogenic factor expression and angiogenic score in normal and neoplastic endometrium. Immunohistochemical staining for vascular endothelial growth factor (VEGF), angiopoietin (Ang)-1, Ang2, Tie2, CD34 and CD105 was performed on formalin-fixed and paraffin-embedded tissues from 31 normal endometrium and 85 endometrial adenocarcinoma. VEGF, Ang1, Ang2 and Tie2 expression was localized in the cytoplasm of glandular and tumor cells. The levels of each angiogenic factor were different in the phases of the menstrual cycle and each layer of normal endometrium. In general, VEGF and Tie2 expression was higher in adenocarcinoma than in normal epithelial cells. Conversely, Ang1 and Ang2 expression was higher in normal epithelium than in adenocarcinoma. The angiogenic score (CD105/CD34) tended to be higher in the adenocarcinoma than in the normal epithelium. It is suggested that the angiogenic pathway and the role of these factors seem to differ between normal tissue and carcinoma of the endometrium.

Distribution Patterns of Uterine Glands and Embryo Spacing in the Mouse

To clarify the mechanism of implantation, relationship between positioning of the mouse embryo in the uterus and distribution of uterine glands along the long axis of the uterine horn was examined by three-dimensional remodelling of the uterine endometrium. There were two unique regions in the endometrium. Uterine glands were distributed widely from mesometrial to anti-mesometrial side in one region. It was localized from lateral to anti-mesometrial side in another. These different regions were alternately aligned throughout the uterine horn. The number and position of embryos was consistent with that of the latter region. This study suggests that the type of distribution of uterine glands is closely related to the positioning of the embryo in mice.

Low endometrial volume may predict early pregnancy loss in women undergoing in vitro fertilization

PURPOSE

To evaluate the role of 3-D US measurement of the endometrium during early IVF-pregnancy and before the appearance of gestational sac in the prediction of pregnancies outcome.

METHODS

60 pregnant women following IVF treatment were included in the study. The women underwent transvaginal 3D US measurements of endometrial volume and thickness on day 15-17 post ET. Patients were followed and classified according to pregnancy outcome into 2 further groups. The group with early pregnancy loss and the group with ongoing pregnancy.

RESULTS

While no differences were observed between those who miscarried and those who did not in gestational age, endometrial thickness or volume, spontaneous early pregnancy loss was significantly higher in patients with endometrial volume <2 mL as compared to those with endometrial volume >2 mL.

CONCLUSIONS

3-D US measurement of endometrial volume of less than 2 mL during early IVF pregnancy and prior to the appearance of gestational sac is a powerful predictor of pregnancy loss.

Endometrial thickness and volume by three-dimensional ultrasound one week after embryo transfer to detect pregnancy

PURPOSE

Determine if the evaluation of endometrium one week after embryo transfer can predict pregnancy.

METHODS

Endometrial volume and thickness were evaluated by three-dimensional ultrasound in 40 patients one week after embryo transfer. These results were compared to serum pregnancy test performed one week later.

RESULTS

Eighteen patients have achieved pregnancy. A significant difference was found for endometrial volume: 6.49+/-1.97 mL versus 3.40+/-1.11 mL (pregnant versus not pregnant); and thickness: 11.15+/-2.75 mm versus 9.77+/-1.85 mm. The ROC curve was used to detect the best cutoff values: endometrial volume of 3.48 mL (sensitivity-100%, specificity-68.2%) and endometrial thickness of 10.3 mm (sensitivity-72.2%, specificity-77.3%). The area under curve was significant higher for endometrial volume (0.909 versus 0.745, p=0.027). No pregnancy was achieved in women who had an endometrial volume <3.8 mL (15 patients) or thickness <7.9 mm (3 patients).

CONCLUSIONS

The endometrial volume and thickness were significant higher in pregnant women and this difference was more prominent for endometrial volume.

Lymphangiogenesis of normal endometrium and endometrial adenocarcinoma

BACKGROUND

Information about lymphatics and lymphangiogenesis in the human endometrium is limited. We investigated the distribution of endometrial lymphatic vessels during the normal menstrual cycle and in association with endometrial adenocarcinoma and investigated the expression of lymphangiogenic growth factors, vascular endothelial growth factor (VEGF)-C, VEGF-D and VEGF receptor-3 (VEGF-R3).

METHODS AND RESULTS

Full thickness uterine samples (n = 23 proliferative; n = 23 secretory) and endometrial adenocarcinoma samples (n = 7 grade I; n = 10 grade III) were collected for the study and analysed by immunohistochemistry and western blotting. Lymphatic vessels of the functionalis were significantly reduced compared with basalis (P = 0.001) across the menstrual cycle with lymphatics of the basalis sometimes intimately associated with spiral arterioles. Lymphatic vessels of endometrial adenocarcinomas were located intra-tumoural and peri-tumoural with significant increases in the peri-tumoural lymphatic vessels compared with normal basalis (P = 0.02). Interestingly, high-grade adenocarcinoma vessels containing tumour emboli demonstrated a mixed blood/lymphatic endothelial cell phenotype. VEGF-C and VEGF-D were immunolocalized in glandular epithelium and some stromal cells with the staining intensity of this localization increasing in endometrial adenocarcinoma. Protein analysis identified VEGF-C (58, 41, 31 and 21 kD) and VEGF-D (56, 41, 31 and 21 kD) and VEGF-R3 (148 and 65 kD) peptides in normal endometrium, with significant increases in several of these peptides for VEGF-C and VEGF-D and no changes in protein expression for VEGF-R3 in endometrial adenocarcinoma.

CONCLUSION

Endometrial lymphatics are significantly reduced in the functionalis, and increases in endometrial adenocarcinoma peri-tumoural lymphatics are associated with increases in VEGF-C and VEGF-D peptides.

Poly(ADP-ribose) polymerase (PARP) and DNA-fragmentation factor (DFF45): Expression and correlation in normal, hyperplastic and neoplastic endometrial tissues

This study evaluated the immunohistochemical expression of poly(ADP-ribose) polymerase (PARP) and DNA fragmentation factor 45 (DFF45) in normal endometria (NE, n=13), non-atypical (NAH, n=22) and atypical hyperplasia (AH, n=14), endometrioid carcinoma (EC, n=34), serous carcinoma (SC, n=10), and clear cell carcinoma (CCC, n=2). With regard to quantity and intensity of positively stained cells, immunostaining was scored as negative, low, and strong. Nuclear PARP immunoreactivity was found in all cases. If present, DFF45 immunoreactivity was detected predominantly in the nucleus and to some extent in the cytoplasm. PARP immunoreactivity increased significantly from NE via NAH to AH (P=0.0004), and decreased from AH to endometrial carcinomas (P=0.0054). DFF45 immunoreactivity increased significantly from NE to NAH and to AH (P=0.0009). No significant differences were calculated between AH and endometrial carcinomas (P=0.7495). FIGO stages and tumor grades could not be characterized by PARP and DFF45 immunoexpression (P=1.000 and 0.7383, as well as P=0.3034 and 0.7533, respectively). Pearson correlation revealed significant associations of PARP and DFF45 immunoscores for all diagnostic categories of NE, NAH, AH, EC, and SC/CCC. Immunoexpression of PARP and DFF45 is apparently altered in endometrial carcinomas as compared with non-neoplastic endometrial tissues, indicating impaired mechanisms of apoptosis in the former.