Retrospective cohort study comparing success of medical management of early pregnancy loss in pregnancies conceived with and without medical assistance

OBJECTIVE

To compare the success rates of medical management using a combined mifepristone and misoprostol protocol in cases of early pregnancy loss (EPL) between women who conceived without medical assistance and those who conceived through in vitro fertilization (IVF), after fresh or frozen embryo transfer, and evaluate for the predictive factors of success, time to first passage of tissue, and time to complete resolution of pregnancy.

DESIGN

Retrospective cohort study.

SETTING

University hospital.

PATIENT(S)

Women who presented with EPL below 13 weeks of gestation between June 2013 and July 2021 who were managed medically with mifepristone 200 mg orally and misoprostol 800 mcg vaginally were included in the study.

INTERVENTION(S)

Medical management with mifepristone and misoprostol; conception without medical assistance vs. post-IVF, after fresh or frozen embryo transfer.

MAIN OUTCOME MEASURE(S)

We evaluated overall success and performed subgroup analysis according to the mode of conception and compared fresh vs. frozen-thawed embryo transfers for IVF pregnancies. In all groups, we also calculated success according to gestational age and compared the time to first passage of tissue. The potential predictive factors of treatment success were analyzed. The side effects and complications of treatment were recorded.

RESULT(S)

A total of 930 women were included in the study, 99 (11%) of whom achieved pregnancy after IVF. The overall success of medical treatment was 89% with no statistically significant difference according to the mode of conception (89% vs. 89%) or type of transfer (fresh 89% vs. frozen 89%). Only lower gestational age by sonography was independently predictive of treatment success, showing a negative regression coefficient of β = -0.333 and an odds ratio of 0.717. The mean time to first passage of tissue was 5.0 ± 2.1 hours. Altogether, 666 women (72%) showed pregnancy resolution on the day of medication administration, an additional 110 women at 1-week follow-up, and a further 74 women after ≥4 weeks on ultrasound.

CONCLUSION(S)

Medical management of EPL with mifepristone and misoprostol is a highly successful treatment option that results in completed abortion in a timely fashion in both pregnancies conceived without medical assistance and those conceived after IVF.

Does endometriosis inflict harm on embryos? A systematic review of embryo morphokinetics analysed by time lapse monitoring in women with endometriosis

Endometriosis has been shown to be associated with unfavorable development and maturation of oocytes, as well as aberrancies in embryonal development, including arrest after fertilization, following in vitro fertilization (IVF). Time-lapse monitoring (TLM) enables continuous and non-invasive monitoring of embryo morphokinetics during the IVF process and might be useful in the assessment of embryos from women with endometriosis. In this review, five eligible studies were evaluated to determine if embryo morphokinetics assessed under TLM differ in patients with endometriosis and subsequently predict blastocyst quality, implantation and success of pregnancy. The studies showed overall inferior morphokinetic parameters of embryos from endometriosis patients when compared to controls, independent of the severity of endometriosis. Embryos with optimal early morphokinetic parameters (t2, s2, t5, tSB, tEB) and late developmental events (compaction, morulation, and blastulation) had better implantation rates than those who had suboptimal ranges. However, due to few studies available with mostly retrospective data, the validity of these findings and their generalizability for clinical practice needs to be further assessed. Prospective studies with larger sample sizes are needed to determine whether using TLM for embryo selection in endometriosis improves pregnancy and live birth outcomes.

Endometriosis and mental health disorders: identification and treatment as part of a multimodal approach

Endometriosis is a disease marked by more than just pain and infertility, as it transcends the well-characterized physical symptoms to be frequently associated with mental health issues. This review focuses on the associations between endometriosis and anxiety, depression, sexual dysfunction, and eating disorders, all of which show a higher prevalence in women with the disease. Studies show that pain, especially the chronic pelvic pain of endometriosis, likely serves as a mediating factor. Recent studies evaluating genetic predispositions for endometriosis and mental health disorders suggest a shared genetic predisposition. Healthcare providers who treat women with endometriosis should be aware of these associations to best treat their patients. A holistic approach to care by gynecologists as well as mental health professionals should emphasize prompt diagnosis, targeted medical interventions, and psychological support, while also recognizing the role of supportive relationships in improving the patient's quality of life.

Exercise-Induced Fluid Retention, Cardiac Volume Overload, and Peripheral Edema in Ultra-Distance Cyclists

Introduction

Ultracyclists expose themselves to extreme physical challenges. This study aimed to elucidate the effects of ultracycling on electrolyte and fluid balance and investigate the potential occurrence of peripheral edema.

Methods

A total of 4 clinical visits were performed before, during, and after a 6-day bicycle ride in 13 ultracyclists (5 female, 8 male) including serial laboratory analyses of blood and urine, bioelectrical impedance, and echocardiography. Throughout the ride, participants continuously tracked fluid intake, measured extremity circumferences daily, and self-tested urinary electrolytes using a point-of-care testing device. Portrait photos were judged by 20 physicians for occurrence of facial and eyelid edema.

Results

Participants covered a mean distance of 1205 km and 19,417 vertical meters. From baseline to day 6, body weight remained stable (P = 0.479); however, body composition changed with increasing total body water (TBW) (+1.98 l ± 1.37, P = 0.003) and plasma volume (+18.86 % ± 10.7, P < 0.001). A significant increase in N-terminal pro brain natriuretic peptide (NT-proBNP) (+297.99 ng/l ± 190.42, P < 0.001) until day 6 indicates concomitant cardiac volume overload. Swelling of face and eyelids peaked on day 5 (both P ≤ 0.033). On recovery, changes partly resolved. Although urinary sodium concentration showed a nadir on day 4 (-32.18 mmol/l ± 23.88, P = 0.022), plasma osmolality (+5.69 mmosmol/kg ± 5.88, P = 0.004) and copeptin (+38.28 pg/ml ± 18.90, P < 0.001) increased steadily until day 6.

Conclusion

Ultracycling over multiple days induces extracellular volume expansion, peripheral edema, and cardiac volume overload. Renal sodium and water retention is likely contributing to this condition.

High concentration of first-measured HCG after embryo transfer is associated with subsequent development of pre-eclampsia

RESEARCH QUESTION

Are outlier high values of first-measured human chorionic gonadotrophin (HCG) following embryo transfer related to pregnancy complications, specifically pre-eclampsia?

DESIGN

This retrospective cohort study screened 3448 women aged 18-45 years who underwent IVF between 2014 and 2019 and evaluated 614 women who had an intrauterine pregnancy following single embryo transfer (SET), 423 of whom had a live birth. Pregnancy and birth outcome information was available for final analysis in 280 cases. The setting was a university-based IVF centre. HCG was measured at a standardized time after the embryo transfer and the values correlated with adverse pregnancy outcomes associated with poor placentation.

RESULTS

Women with first-measured HCG in the highest quintile had a higher incidence of pre-eclampsia than those with lower HCG concentrations (odds ratio [OR] 4.08, 95% confidence interval [CI] 1.41-11.82) even after controlling for age, body mass index, parity and type of embryo transfer. Additionally controlling for embryo stage at embryo transfer did not change the results (OR 3.97, 95% CI 1.37-11.46). No differences were found in the incidence of fetal growth restriction.

CONCLUSIONS

This is the first known report that links high first-measured HCG after SET to an adverse pregnancy outcome. If confirmed by future studies, initiation of preventive interventions at a very early stage of pregnancy merits further evaluation in this cohort of patients.

Preoperative application of the Enzian classification for endometriosis (The cEnzian Study): A prospective international multicenter study

OBJECTIVE

To assess the diagnostic performance of preoperative application of the Enzian classification (cEnzian) using surgical findings as reference standard.

DESIGN

A prospective international non-interventional study.

SETTING

Twelve endometriosis centres in four European countries (Austria, Germany, Switzerland and Czech Republic).

POPULATION

1062 women with endometriosis surgery.

METHODS

Extent of endometriosis was preoperatively classified using the cEnzian classification based on gynaecological examination and/or transvaginal ultrasound (TVS) and/or magnetic resonance imaging (MRI). After subsequent surgery, the surgeon classified the intraoperative findings using the Enzian classification.

MAIN OUTCOME MEASURES

Sensitivity, specificity, PPV, NPV, LR⁺ , LR^- and accuracy were calculated. Conditional frequencies of intraoperative Enzian codings and the corresponding 95% confidence intervals were computed for each preoperative coding and visualised in plots.

RESULTS

Although overall consistency of cEnzian and Enzian was poor (35.14%, 95% confidence interval 32.26-38.03), high specificities and negative predictive values (NPVs) of the cEnzian compartments could be demonstrated. Looking at the individual parts of the Enzian classification, the poorest diagnostic performance was detected for compartment B and the highest PPVs were found for category 3 lesions (>3 cm), independent of the compartment.

CONCLUSIONS

Using the Enzian classification in a non-invasive setting is a useful tool providing us with an 'at a glance' summary of the diagnostic workup regarding deep endometriosis with high specificities and NPVs. An attempt to merge the two new endometriosis classification systems (#Enzian and AAGL 2021) seems reasonable taking into consideration the respective advantages of each other.

Predicting success of intrauterine insemination using a clinically based scoring system

Purpose

To develop a predictive score for the success of intrauterine insemination (IUI) based on clinical parameters.

Methods

We performed a retrospective cohort study evaluating the homologous IUI cycles performed at a single university-based reproductive medical center between 2009 and 2017. The primary outcome measure was pregnancy, defined as positive serum human chorionic gonadotropin (hCG) 12–14 days after IUI. Predictive factors for pregnancy after IUI were identified, and a predictive score was developed using a multivariable continuation ratio model.

Results

Overall, 1437 IUI cycles in 758 couples were evaluated. We found a per cycle pregnancy rate of 10.9% and a cumulative pregnancy rate of 19.4%. In a multivariable analysis, the probability of pregnancy was negatively associated with female age ≥ 35 years (OR 0.63, 95% CI 0.41–0.97, p = 0.034), endometriosis, unilateral tubal factor, or anatomical alteration (OR 0.54, 95% CI 0.33–0.89, p = 0.016), anti-Mullerian hormone (AMH) < 1 ng/ml (OR 0.50, 95% CI 0.29–0.87, p = 0.014), and total progressive motile sperm count (TPMSC) < 5 mil (OR 0.47, 95% CI 0.19–0.72, p = 0.004). We developed a predictive clinical score ranging from 0 to 5. Following 3 cycles, couples in our cohort with a score of 5 had a cumulative probability of achieving pregnancy of nearly 45%. In contrast, couples with a score of 0 had a cumulative probability of only 5%.

Conclusion

IUI success rates vary widely depending on couples’ characteristics. A simple to use score could be used to estimate a couple’s chance of achieving pregnancy via IUI, facilitating individualized counseling and decision-making.

Rates of severe complications in patients undergoing colorectal surgery for deep endometriosis-a retrospective multicenter observational study

INTRODUCTION

Surgical experience and hospital procedure volumes have been associated with the risk of severe complications in expert centers for endometriosis in France. However, little is known about other certified units in Central European countries.

MATERIAL AND METHODS

This retrospective observational study included 937 women who underwent surgery for colorectal endometriosis between January 2018 and January 2020 in 19 participating expert centers for endometriosis. All women underwent complete excision of colorectal endometriosis by rectal shaving, discoid or segmental resection. Postoperative severe complications were defined as grades III-IV of the Clavien-Dindo classification system including anastomotic leakage, fistula, pelvic abscess and hematoma. Surgical outcomes of centers performing less than 40 (group 1), 40-59 (group 2) and ≥60 procedures (group 3) over a period of 2 years were compared.

RESULTS

The overall complication rate of grade III and IV complications was 5.1% (48/937), with rates of anastomotic leakage, fistula formation, abscess and hemorrhage in segmental resection, discoid resection and rectal shaving, respectively, as follows: anastomotic leakage 3.6% (14/387), 1.4% (3/222), 0.6% (2/328); fistula formation 1.6% (6/387), 0.5% (1/222), 0.9%; (3/328); abscess 0.5% (2/387), 0% (0/222) and 0.6% (2/328); hemorrhage 2.1% (8/387), 0.9% (2/222) and 1.5% (5/328). Higher overall complication rates were observed for segmental resection (30/387, 7.8%) than for discoid (6/222, 2.7%, P = 0.015) or shaving procedures (12/328, 3.7%, P = 0.089). No significant correlation was observed between the number of procedures performed and overall complication rates (r_Spearman  = -0.115; P = 0.639) with a high variability of complications in low-volume centers (group 1). However, an intergroup comparison revealed a significantly lower overall severe complication rate in group 3 than in group 2 (2.9% vs 6.9%; P = 0.017) without significant differences between other groups.

CONCLUSIONS

A high variability in complication rates does exist in centers with a low volume of activity. Major complications may decrease with an increase in the volume of activity but this effect cannot be generally applied to all institutions and settings.

O-155 What strategies help patients cope with endometriosis in everyday life: a doctor's perspective

Endometriosis is an enigmatic disease characterized by chronic pain and infertility and associated with a diminished quality of life.  While surgery, pain medications and hormonal treatments are the mainstays of treating endometriosis, patients are increasing seeking complementary therapies to help them cope with their symptoms in everyday life.  Too often, clinicians caring for women with endometriosis are at a loss when it comes to discussing or recommending such alternative therapies, as they are not part of typical western medical training.  

This lecture will review the evidence behind –or lack thereof—for many commonly sought therapies for endometriosis to enable physicians and clinicians to better counsel their patients.  Topics to be addressed include: is there any benefit to special diets for endometriosis and endometriosis-associated pain? ; is there a role for physical activity or specific exercises in improving symptoms?;  are yoga and meditation effective in helping women cope with endometriosis? ; are there specific phytotherapies that improve symptoms? ; has acupuncture been shown to help women cope with endometriosis symptoms? ; are there complementary therapies that improve fertility?

In addition, based on clinical experience in treating with women with endometriosis, the importance of setting shared goals and expectations for treatment and supporting patients in their plans for attempting pregnancy and fulfilling the wish for a child will be discussed.

Phrenic nerve paralysis after bipolar electrocoagulation of endometriosis of the diaphragm: case report and mini review

Objective

To present a case of persistent postoperative elevation of the right hemidiaphragm after bipolar electrocoagulation of diaphragmatic endometriosis, highly likely because of collateral thermal damage to key branches of the phrenic nerve, and review the literature on diaphragmatic endometriosis, focusing on operative treatment.

Design

Case report and mini review.

Setting

Single university-based interdisciplinary endometriosis center.

Patient(s)

A 33-year-old nulliparous patient, initially presenting with right-sided shoulder and back pain accompanied by severe dysmenorrhea and diarrhea. Written consent for the use of anonymized data and images for research purposes was obtained.

Intervention(s)

Laparoscopic surgery with bipolar electrocoagulation of multiple superficial endometriotic lesions on the right hemidiaphragm and excision of bilateral deep infiltrating endometriosis on the sacrouterine ligaments.

Main Outcome Measure(s)

Outcome and complication of surgical treatment of diaphragmatic endometriosis.

Result(s)

Three weeks after surgical treatment, the patient complained of exertional dyspnea and pain in the right flank. Imaging showed a postoperative elevation of the right hemidiaphragm, which did not resolve over the following 6 months. We suspect collateral thermal damage to key branches of the phrenic nerve after bipolar electrocoagulation of extensive superficial diaphragmatic lesions.

Conclusion(s)

During laparoscopic treatment of diaphragmatic endometriosis, bipolar electrocoagulation should be used sparingly and with caution to avoid potentially damaging the phrenic nerve.

Dubious effects of methadone as an "anticancer" drug on ovarian cancer cell-lines and patient-derived tumor-spheroids

BACKGROUND

The opioid agonist D,L-methadone exerts analgesic effects via the mu opioid receptor, encoded by OPRM1 and therefore plays a role in chronic pain management. In preclinical tumor-models D,L-methadone shows apoptotic and chemo-sensitizing effects and was therefore hyped as an off-label "anticancer" drug without substantiation from clinical trials. Its effects in ovarian cancer (OC) are completely unexplored.

METHODS

We analyzed OPRM1-mRNA expression in six cisplatin-sensitive, two cisplatin-resistant OC cell-lines, 170 OC tissue samples and 12 non-neoplastic control tissues. Pro-angiogenetic, cytotoxic and apoptotic effects of D,L-methadone were evaluated in OC cell-lines and four patient-derived tumor-spheroid models.

RESULTS

OPRM1 was transcriptionally expressed in 69% of OC-tissues and in three of eight OC cell-lines. D,L-methadone exposure significantly reduced cell-viability in five OC cell-lines irrespective of OPRM1 expression. D,L-methadone, applied alone or combined with cisplatin, showed no significant effects on apoptosis or VEGF secretion in cell-lines. Notably, in two of the four spheroid models, treatment with D,L-methadone significantly enhanced cell growth (by up to 121%), especially after long-term exposure. This is consistent with the observed attenuation of the inhibitory effects of cisplatin in three spheroid models when adding D,L-methadone. The effect of methadone treatment on VEGF secretion in tumor-spheroids was inconclusive.

CONCLUSIONS

Our study demonstrates that certain OC samples express OPRM1, which, however, is not a prerequisite for D,L-methadone function. As such, D,L-methadone may exert also detrimental effects by stimulating the growth of certain OC-cells and abrogating cisplatin's therapeutic effect.

Abstract 947: Effects of methadone on ovarian cancer cell-lines and patient-derived tumor-spheroids

Background: D,L-Methadone exerts analgesic effects via the mu opioid receptor, encoded by OPRM1 and therefore plays a role in chronic pain management. Although the use of this opioid-receptor agonist as an anti-cancer drug is deemed controversial, this drug is gaining popularity in Europe as an “off-label” therapy despite insufficient research to support its benefits. In preclinical glioblastoma and leukaemia cell culture models D,L-methadone showed apoptotic and chemo-sensitizing effects. Its effects in ovarian cancer (OC) are completely unexplored.

Methods: We analysed the OPRM mRNA expression in six cisplatin-sensitive, two cisplatin-resistant OC cell-lines, 192 OC samples and 12 non-neoplastic control tissues. Pro-angiogenetic, cytotoxic and apoptotic effects of D,L-methadone were evaluated in OC cell-lines and four patient-derived tumor-spheroid models.

Results: OPRM1 was transcriptionally expressed in 69% of OC-tissues and in five of eight OC cell-lines. D,L-methadone exposure significantly reduced cell-viability in five OC cell-lines irrespective of OPRM1 expression. D,L-methadone, applied alone or combined with cisplatin, showed no significant effects on apoptosis or VEGF secretion in cell-lines. Notably, in two of the four spheroid models, treatment with D,L-methadone resulted in significantly enhanced cell growth (by up to 121%), especially after long-term exposure. This is consistent with the observed attenuation of the inhibitory effects of cisplatin in three spheroid models when adding D,L-methadone. The effect of methadone treatment on VEGF secretion in tumor-spheroids was inconclusive.

Conclusions: Our study demonstrates that certain OC samples express OPRM1, which, however, is not a prerequisite for D,L-methadone function. As such, D,L-methadone may exert detrimental effects by stimulating the growth of certain OC-cells and abrogating cisplatin's therapeutic effect.

Citation Format: Heidelinde Fiegl, Judith Hagenbuchner, Michael J. Ausserlechner, Christiana Kyvelidou, Beata Seeber, Sieghart Sopper, Irina Tsibulak, Verena Wieser, Julia Roessler, Elisabeth Reiser, Kaisa Huhtinen, Olli Carpén, Walther Parson, Christian Marth, Alain G. Zeimet. Effects of methadone on ovarian cancer cell-lines and patient-derived tumor-spheroids [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 947.

Diagnosis and Treatment of Endometriosis. Guideline of the DGGG, SGGG and OEGGG (S2k Level, AWMF Registry Number 015/045, August 2020)

Aims The aim of this official guideline published and coordinated by the German Society of Gynaecology and Obstetrics (DGGG) in cooperation with the Austrian Society for Gynaecology and Obstetrics (OEGGG) and the Swiss Society for Gynaecology and Obstetrics (SGGG) was to provide consensus-based recommendations for the diagnosis and treatment of endometriosis based on an evaluation of the relevant literature. Methods This S2k guideline represents the structured consensus of a representative panel of experts with different professional backgrounds commissioned by the Guideline Committee of the DGGG, OEGGG and SGGG. Recommendations Recommendations on the epidemiology, aetiology, classification, symptomatology, diagnosis and treatment of endometriosis are given and special situations are discussed.

Beta endorphin in serum and follicular fluid of PCOS- and non-PCOS women

PURPOSE

To compare the concentrations of beta endorphin in serum and follicular fluid (FF) of PCOS- and non-PCOS women. Secondarily, to investigate associations between beta endorphin and other parameters.

METHODS

Fifty-nine women undergoing in vitro fertilization (IVF) were included in the study. Sixteen were stratified to the PCOS group using the Rotterdam criteria. The remaining 43 women served as controls. Follicular fluid was collected during oocyte retrieval and peripheral blood sampling was performed on the same day. Beta endorphin concentrations in serum and follicular fluid, serum levels of insulin, glucose, LH, estradiol and progesterone were measured. Additionally, testosterone was measured before starting the stimulation protocol.

RESULTS

There was no difference in beta endorphin levels between PCOS- and non-PCOS women. The concentration of the peptide was higher in serum than in FF, likely due to collection of FF after ovulation induction and corresponding to the early luteal phase. We found a significant correlation between the number of mature Metaphase II (MII) oocytes retrieved and beta endorphin concentration in FF. In women with biochemical hyperandrogenemia, beta endorphin levels in FF correlated with testosterone levels.

CONCLUSION

Beta Endorphin concentrations in serum and FF do not differ between PCOS- and non PCOS-women undergoing IVF. However, together with sex hormones, beta endorphin might play a key role in oocyte maturation.

Marked improvement in the success rate of medical management of early pregnancy failure following the implementation of a novel institutional protocol and treatment guidelines: a follow-up study

Purpose

To analyze the success rate, time to passage of tissue and subjective patient experience of a newly implemented protocol for medical management of early pregnancy failure (EPF) over a 2-year period.

Methods

A retrospective chart review of all patients with early pregnancy failure primarily opting for medical management was performed. 200 mg mifepristone were administered orally, followed by a single vaginal dose of 800 mcg misoprostol after 36–48 h. We followed-up with our patients using a written questionnaire.

Results

167 women were included in the present study. We observed an overall success rate of 92 %, defined as no need for surgical management after medication administration. We could not identify predictive values for success in a multivariate regression analysis. Most patients (84 %) passed tissue within 6 h after misoprostol administration. The protocol was well tolerated with a low incidence of side effects. Pain was managed well with sufficient analgesics. Responders to the questionnaire felt adequately informed prior to treatment and rated their overall experience as positive.

Conclusion

The adaption of the institutional medical protocol resulted in a marked improvement of success rate when compared to the previously used protocol (92 vs. 61 %). We credit this increase to the adjusted medication schema as well as to targeted physician education on the expected course and interpretation of outcome measures. Our results underscore that the medical management of EPF is a safe and effective alternative to surgical evacuation in the clinical setting.

Localization of TrkB and p75 receptors in peritoneal and deep infiltrating endometriosis: an immunohistochemical study

BACKGROUND

The roles of the neurotrophins NGF (Neurotrophic growth factor) and BDNF (brain-derived neurotrophic factor) in neuronal growth and development are already known. Meanwhile, the neurotrophin receptors TrkA (tropomyosin related kinase A), TrkB, and p75 are important for determining the fate of cells. In endometriosis, this complex system has not been fully elucidated yet. The aim of this study was to evaluate the expression and location of these neurotrophins and their receptors in peritoneal (PE) and deep infiltrating endometriotic (DIE) tissues and to measure and compare the density of nerve fibers in the disease subtypes.

METHODS

PE lesions (n = 20) and DIE lesions (n = 22) were immunostained and analyzed on serial slides with anti-BDNF, -NGF, -TrkA, -TrkB, -p75,-protein gene product 9.5 (PGP9.5, intact nerve fibers) and -tyrosine hydroxylase (TH, sympathetic nerve fibers) antibodies.

RESULT

There was an equally high percentage (greater than 75 %) of BDNF-positive immunostaining cells in both PE and DIE. TrkB (major BDNF receptor) and p75 showed a higher percentage of immunostaining cells in DIE compared to in PE in stroma only (p < 0.014, p < 0.027, respectively). Both gland and stroma of DIE lesions had a lower percentage of NGF-positive immunostaining cells compared to those in PE lesions (p < 0.01 and p < 0.01, respectively), but there was no significant reduction in immunostaining of TrkA in DIE lesions. There was no difference in the mean density of nerve fibers stained with PGP9.5 between PE (26.27 ± 17.32) and DIE (28.19 ± 33.15, p = 0.8). When we performed sub-group analysis, the density of nerves was significantly higher in the bowel DIE (mean 57.33 ± 43.9) than in PE (mean 26.27 ± 17.32, p < 0.01) and non-bowel DIE (mean 14.6. ± 8.6 p < 0.002).

CONCLUSIONS

While the neurotrophin BDNF is equally present in PE and DIE, its receptors TrkB and p75 are more highly expressed in DIE and may have a potential role in the pathophysiology of DIE, especially in promotion of cell growth. BDNF has a stronger binding affinity than NGF to the p75 receptor, likely inducing sympathetic nerve axonal pruning in DIE, resulting in the lower nerve fiber density seen.

Afamin serum concentrations are associated with insulin resistance and metabolic syndrome in polycystic ovary syndrome

BACKGROUND

High plasma concentrations of the vitamin E-binding protein afamin have been previously shown to be associated with insulin resistance and metabolic syndrome. We set out to determine whether the concentration of afamin in the serum of women with polycystic ovarian syndrome (PCOS) is elevated in relation to the presence and severity of insulin resistance (IR).

METHODS

This cross-sectional study looked at 53 patients with PCOS and 49 non-PCOS patients. IR was diagnosed as a HOMA Index >2.4 and confirmed with a three-hour glucose tolerance test. Serum concentrations of afamin were determined using enzyme-linked immunosorbent assay (ELISA). Clinical characteristics, hormone and metabolic parameters were correlated to afamin concentrations.

RESULTS

Serum concentrations of afamin did not differ between women with PCOS and controls. When separated according to the presence of IR a significant difference in median afamin levels was seen between PCOS with IR and PCOS without IR (73.06+/-27.36 mg/L and 64.25+/-17.41 mg/L, p = 0.033). No difference in afamin levels was detected when comparing the few controls with IR and the controls without IR (76.20+/-27.96 mg/L and 60.44+/-21.03 mg/L, p = 0.235). On univariate analyses, afamin serum concentrations significantly correlated with BMI, triglycerides, HOMA Index, and AUC-Insulin. On multivariate linear regression analysis, only triglyceride concentration was seen to be an independent predictor of afamin. Subjects with metabolic syndrome had higher median afamin concentrations than did those without metabolic syndrome (77.43+/-28.60 mg/L and 65.08+/-18.03 mg/L, p = 0.010).

CONCLUSIONS

Elevated afamin concentrations are associated with the presence of metabolic syndrome in young women and may potentially serve as an independent predictor for the development of metabolic syndrome in at-risk women, especially those with IR.

Dynamics of anti-Müllerian hormone during controlled ovarian stimulation

AIM

To evaluate the dynamics of anti-Müllerian hormone (AMH) during controlled ovarian stimulation (COH) and to correlate changes in AMH to age, estradiol (E2) levels, and the presence of polycystic ovary syndrome (PCOS).

METHODS

Data were retrospectively collected from women presenting for COH in the outpatient clinic of a university hospital between January and July 2011. Concentrations of AMH and E2 during COH with gonadotropins for in vitro fertilization (IVF) (n = 68) and clomiphene or low-dose gonadotropin stimulation cycles (n = 27) for intrauterine insemination were evaluated. Percentage change in AMH and E2 from pre-stimulation values was calculated. Dynamics of hormonal changes were analyzed using non-parametric tests. Correlations between changes in AMH and E2 were analyzed with Spearman correlation.

RESULTS

During IVF stimulation, AMH declined steadily from pre-stimulation values. No significant change in AMH dynamics was observed during clomiphene or low-dose stimulation cycles. Percentage decline in AMH during IVF stimulation correlated with rise in E2 at all time points.

CONCLUSIONS

The observed phenomena contribute to an improved understanding of AMH expression and its role in the follicular development. Our data support the concept that AMH is produced by secondary, preantral and small antral follicles in the early part of stimulation and declines as these follicles are recruited into dominant growing follicles.

Does obesity interfere with anastrozole treatment? Positive association between body mass index and anastrozole plasma levels

INTRODUCTION

The efficacy of adjuvant endocrine treatment with aromatase inhibitors (AIs), inhibiting the conversion of androgens to estrogen in adipose tissue, might depend on the overall volume of adipose tissue. However, little evidence is available regarding the pharmacokinetic behavior of AIs in women with obesity. The aim of this study was to investigate the interaction between body mass index (BMI) and anastrozole treatment as well as estrogenic activity.

PATIENTS AND METHODS

A total of 216 postmenopausal patients with early-stage breast cancer who were receiving AI treatment with anastrozole constituted the final sample included in the analysis. During a regular 3-month after-care check-up, sociodemographic and clinical data and BMI were assessed. Blood samples were collected during routine blood testing. Measurement of AI plasma levels was performed by liquid chromatography-tandem mass spectrometry. Follicle stimulating hormone (FSH) and estradiol were measured within the routine blood examination.

RESULTS

A median anastrozole plasma concentration of 34.7 ng/mL (mean, 37.4), with a large interindividual variability, was observed (SD, 15.1; range, 5.4-86.5). After age adjustment, it was found that anastrozole plasma concentrations significantly increased with BMI (r = 0.241; P = .001). Anastrozole serum concentrations in women with obesity (BMI ≥ 30) exceeded those of women with normal weight (BMI ≤ 25) by 25%. Women with excess weight had lower mean FSH levels, indicating higher estrogenic activity, compared with women with normal weight.

CONCLUSION

This study indicates that BMI is a vital factor in anastrozole metabolism, as measured by anastrozole plasma concentration and FSH levels. Further research is mandatory to clarify results on the association of obesity and AI treatment efficacy to allow adapting AI treatment accordingly.

Analytical characterization and clinical evaluation of an enzyme-linked immunosorbent assay for measurement of afamin in human plasma

Background

Comparative proteomics has recently identified afamin, the newest member of the albumin gene family, as a potential biomarker for ovarian cancer. The aim of this study was the analytical and clinical evaluation of a sandwich enzyme-linked immunosorbent assay for the determination of afamin in human plasma.

Methods

We evaluated precision, linearity, and detection limit of the assay, analyte stability and biological variability, determined reference values and quantified afamin concentrations in various diseases.

Results

Within-run and total coefficients of variation were < 10%. The method was linear across the tested measurement range. Detection limit was 7 mg/L for the assay. The analyte was stable for 24 h at room temperature, for 48 h at 4 °C, and for at least one year at − 20 °C and − 80 °C. The reference change value for healthy individuals was 24%. Age- and sex-independent reference values in healthy blood donors were 45–99 mg/L (median 68 mg/L). In the clinical assay evaluation afamin plasma concentrations were modestly decreased in patients with heart failure. Patients with pneumonia or sepsis exhibited markedly decreased afamin plasma concentrations. However, patients with chronic renal disease or chronic obstructive pulmonary disease showed no difference in afamin plasma concentrations as compared to healthy individuals. Correlation analyses revealed an inverse association between afamin and inflammatory biomarkers.

Conclusions

The afamin assay meets quality specifications for laboratory medicine. The results of the clinical assay evaluation revealed novel insights with respect to afamin as a potential negative acute phase protein and should encourage further studies.

•

The aim of this study was the analytical and clinical evaluation of a human afamin ELISA.

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The afamin assay meets the needs of quality specifications of laboratory medicine.

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Afamin exerts a good in vitro stability which is important of preanalytical issues.

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The RCV was 24% and reference values in healthy blood donors were 45–99 mg/L.

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We revealed novel insights with respect to afamin as a potential negative acute phase protein.

Accurate screening for insulin resistance in PCOS women using fasting insulin concentrations

The aims of this cross-sectional study were to evaluate the relative agreement of both static and dynamic methods of diagnosing IR in women with polycystic ovary syndrome (PCOS) and to suggest a simple screening method for IR. All participants underwent serial blood draws for hormonal profiling and lipid assessment, a 3 h, 75 g load oral glucose tolerance test (OGTT) with every 15 min measurements of glucose and insulin, and an ACTH stimulation test. The prevalence of IR ranged from 12.2% to 60.5%, depending on the IR index used. Based on largest area under the curve on receiver operating curve (ROC) analyses, the dynamic indices outperformed the static indices with glucose to insulin ratio and fasting insulin (fInsulin) demonstrating the best diagnostic properties. Applying two cut-offs representing fInsulin extremes (<7 and >13 mIU/l, respectively) gave the diagnosis in 70% of the patients with high accuracy. Currently utilized indices for assessing IR give highly variable results in women with PCOS. The most accurate indices based on dynamic testing can be time-consuming and labor-intensive. We suggest the use of fInsulin as a simple screening test, which can reduce the number of OGTTs needed to routinely assess insulin resistance in women with PCOS.

Ultrasonographic assessment of skin thickness in patients with PCOS - a case-control study

OBJECTIVE

To measure skin thickness in patients with polycystic ovary syndrome (PCOS) in comparison to controls and to examine a possible association with sex steroids, body mass index, lipid profile and hyperinsulinemia.

METHODS

Thirty patients with confirmed PCOS were compared to thirty-two women presenting for infertility workup. Skin thickness was measured using high-resolution ultrasound in a standardized area, blood samples were collected once at presentation.

RESULTS

Patients with PCOS showed a statistically significant thicker skin than women in the control group (0.95 mm (±0.093 mm) versus 0.85 mm (±0.077 mm, p < 0.0001)). LH, estradiol, testosterone, the free androgen index, triglycerides, cholesterol, LDL-cholesterol and body mass index were significantly increased in PCOS - patients. No correlation between hyperinsulinemia and skin thickness was seen.

CONCLUSIONS

PCOS - patients showed a greater skin thickness in comparison to women without PCOS. This might be due to proliferative effects of sex steroids such as estrogens and testosterone and metabolic derangements on skin thickness.

Female fertility loss and preservation: threats and opportunities

BACKGROUND

Ovarian aging and cytotoxic treatments are the most common causes for fertility loss in women. With increasing numbers of young female survivors following cytotoxic cancer treatments, the issue of fertility preservation has assumed greater importance.

METHODS

We review the literature on the causes of female fertility loss as well as the recent advances in fertility preservation options and strategies that might be of interest to oncologists. Currently, several methods and techniques exist for fertility preservation of female patients with cancer including embryo freezing, ovarian protection techniques, oocyte cryopreservation, ovarian tissue cryopreservation followed by autotransplantation, and recently in vitro culture of ovarian tissue, follicles, and oocytes. Each method or technique has advantages and disadvantages related to current success rate, required delay in cancer treatment, sperm requirement, and risk of reintroducing cancer cells.

RESULTS

To date, embryo freezing is the only established method successfully and widely used for fertility preservation of female patients with cancer. The other methods are promising but still considered experimental.

CONCLUSION

Patient awareness, physician knowledge, early counseling, costs management, international registry, interdisciplinary networks, and research development are necessary to improve the current care in the field of female fertility preservation.

Impaired body image in patients with multiple sclerosis

OBJECTIVE

Despite the growing research on body image disturbances in chronically ill patients, reports of such disturbances in patients with multiple sclerosis (MS) are scarce. The aim of this study was to assess the occurrence of different aspects of body image disturbances in patients with MS, taking into account the disability status as well as depressive symptoms.

MATERIALS & METHODS

Forty patients with MS and 28 healthy controls were investigated with questionnaires assessing attractiveness/self-confidence, accentuation of external appearance, worries about possible physical deficits, sexual problems, vitality and depressive symptoms. In MS patients, medical parameters like the expanded disability status were assessed too.

RESULTS

In comparison with healthy controls, the MS patients, being although only mildly disabled and in a quite stable mood, reported significantly higher worries about physical deficits, described a significantly worse body appraisal and significantly more sexual problems. While female MS patients predominantly suffered from worries concerning physical deficits and feelings of being less attractive, sexual problems were of particular concern in male MS patients.

CONCLUSIONS

Even mildly impaired MS patients who are not markedly depressed have to deal with problems of body image. Improvement of body image perception in MS patients taking gender-specific differences into account represents a promising area of future psychological research.

Polymorphism in vitamin D-binding protein as a genetic risk factor in the pathogenesis of endometriosis

CONTEXT

Previous studies have implicated a deficiency in the inflammatory response in women who develop endometriosis. The specific immunological deficits have not been completely elucidated.

OBJECTIVE

Our objective was to identify differences in protein expression in serum that might shed light on the pathophysiology of endometriosis.

DESIGN AND SETTING

This cross-sectional study of women undergoing laparoscopy between 2003 and 2005 took place at a university medical center.

PATIENTS

Patients included consenting women age 18-49 yr undergoing surgery for pain and/or infertility or elective tubal ligation. Women with acute or chronic medical conditions were excluded.

INTERVENTION

Blood was collected preoperatively.

MAIN OUTCOME MEASURE

Proteomic analysis of serum was done using two-dimensional difference gel electrophoresis.

RESULTS

We found 25 protein spots with a significant difference in abundance between women with endometriosis and controls, including acute-phase proteins and complement components. The abundance of vitamin D-binding protein was higher in all endometriosis pools by a factor of approximately 3 compared with the control pool (P < 0.02). Analysis of specific allele products using nano-scale liquid chromatography-electrospray ionization-mass spectrometry indicated that it was the GC*2 allele product that was in greater concentration in serum pools, as well as in single validation samples, in women with endometriosis (P = 0.006). In contrast to the GC*1 allele product, which is readily converted to a potent macrophage factor (Gc protein-derived macrophage-activating factor), the GC*2 allele product undergoes practically no such conversion.

CONCLUSIONS

We speculate that the inability to sufficiently activate macrophages' phagocytotic function in those carrying the GC*2 polymorphism (more prevalent in endometriosis) may allow endometriotic tissues to implant in the peritoneal cavity. Future studies evaluating specific vitamin D-binding protein polymorphisms as a risk factor for endometriosis in larger populations of women are warranted.

Leydig-cell-tumor of the ovary that responded to GnRH-analogue administration - case report and review of the literature

Progressive hirsutism can be a symptom of an androgen-producing tumor, especially in postmenopausal women. We report a case of a 58-year-old woman who complained of progressive hirsutism, nervousness, irritability, anxiousness and an increased libido. Examination showed an unusual redness of her head, décolleté, palms and soles of her feet. Basal laboratory tests revealed a profound elevation of testosterone levels (7.5 microg/l) and normal levels of androstendione, dehydroepiandrosterone-sulfate, 17alpha-hydroxy-progesterone and thyroid-stimulating hormone. Also remarkable was that her red blood count, hemoglobin and hematocrit values were elevated while erythropoietin was within normal limits. Functional laboratory tests ruled out heterozygous C21-hydroxylase deficiency and showed a moderate insulin resistance on the oral glucose tolerance test. Transvaginal ultrasound revealed a slightly hyperdensic area of 6 mm in the left ovary. Magnetic resonance imaging showed a contrast medium-accumulating area of 2 cm in the left ovary. Since the patient was initially reluctant to undergo surgery, a GnRH-analogue (triptoreline) was administered VIA intramuscular injection once per month for two months and testosterone levels were lowered to less than one third of the initial level (2 microg/l). Surgery was eventually performed with laparoscopic bilateral salpingoophorectomy, hysteroscopy and uterine curettage. The histologic examination revealed a Leydig cell tumor in the hilus and stroma of the left ovary. Postoperatively testosterone levels dropped dramatically and instantly into the normal range. Within months, the red blood count and hematocrit levels were within normal limits. The patient's face became more feminine, the redness of her face and hirsutism regressed. Her anxiousness and nervosity resolved and the insulin sensitivity improved. In this paper, polyglobulia, the metabolic and psychological changes due to hyperandrogenism are discussed, as well as the phenomenon that the tumor responded to a GnRH-analogue. Such a response implies that the tumor is either under gonadotropin control or that GnRH analogues have direct effects via receptors on tumorous Leydig cells.

Proteomic analysis of serum yields six candidate proteins that are differentially regulated in a subset of women with endometriosis

OBJECTIVE

To identify potential novel biomarkers that differ between subjects with and without endometriosis and that might aid in developing a noninvasive, serum-based diagnostic test.

DESIGN

Case-control evaluation of a diagnostic test.

SETTING

University medical center.

PATIENT(S)

Consenting women of reproductive age undergoing laparoscopy for indications of pain, infertility, elective tubal ligation, tubal reanastomosis, or other benign indication.

INTERVENTION(S)

Diagnostic laparoscopy and peripheral venipuncture.

MAIN OUTCOME MEASURE(S)

Concentrations of low-molecular-weight proteins in serum; surgical staging of endometriosis.

RESULT(S)

Six proteins were found that were differentially expressed between those with and without disease and that had good diagnostic properties. Taken together in a two-step diagnostic algorithm, we were able to diagnose 55% of subjects, with 99% accuracy as to the status of disease. Further combining this algorithm with that derived by our previous study of serum putative markers (monocyte chemoattractant protein-1, migration inhibitory factor, leptin, and CA-125) improved our diagnostic capability to 73% of subjects, with 94% overall accuracy.

CONCLUSION(S)

This study is the critical first step in the identification of potential novel biomarkers of endometriosis. Future identification of the proteins and further validation in a second population is needed before applying these findings in clinical practice.

Panel of markers can accurately predict endometriosis in a subset of patients

OBJECTIVE

To evaluate whether a combination of putative markers of inflammation and CA-125 could serve as a multiple-marker screening test for endometriosis in a heterogeneous population of patients.

DESIGN

Case-control evaluation of a diagnostic test.

SETTING

University medical center.

PATIENT(S)

Consenting women of reproductive age undergoing laparoscopy for indications of pain, infertility, elective tubal ligation, tubal reanastomosis, or other benign indications.

INTERVENTION(S)

Diagnostic laparoscopy and peripheral venipuncture.

MAIN OUTCOME MEASURE(S)

Serum concentrations of interleukin-6, tumor necrosis factor-alpha, macrophage migration inhibitory factor, macrophage chemotactic protein-1, interferon-gamma, leptin, and CA-125 measured by using ELISA assays; surgical staging of endometriosis.

RESULT(S)

Concentrations of the seven markers were compared between the 63 women with surgically confirmed stage II-IV endometriosis and 78 women who were surgically confirmed to be free of endometriosis. The individual diagnostic performance of each of the markers, based on receiver operating characteristic curves, was poor. When combinations of markers were evaluated by using classification tree analysis, a three-marker panel of CA-125, macrophage chemotactic protein-1, and leptin could diagnose 51% of subjects as to the presence of endometriosis with 89% accuracy. A four-marker panel of CA-125, macrophage chemotactic protein-1, leptin, and macrophage migration inhibitory factor could diagnose 48% of subjects with 93% accuracy. The remaining subjects would have no definitive diagnosis on the basis of the algorithm and would need to undergo standard evaluation.

CONCLUSION(S)

This large study evaluates the combined use of putative serum markers for the diagnosis of endometriosis, rather than the use of each singly. Using the serum concentration of four markers in a two-tiered decision rule, nearly half of the subjects in this population would have been diagnosed (and could have avoided surgery) with 93% accuracy.