Unexplained recurrent pregnancy loss and unexplained infertility: twins in disguise

STUDY QUESTION

Is B-cell CLL/lymphoma 6 (BCL6) endometrial expression, a surrogate biomarker of endometriosis, elevated in women with unexplained recurrent pregnancy loss (uRPL) and unexplained infertility (UI) compared to fertile subjects?

SUMMARY ANSWER

Endometrial BCL6 expression is elevated to a similar degree in women with uRPL and UI compared to fertile controls.

WHAT IS KNOWN ALREADY

Endometriosis has been linked to the genesis of endometrial progesterone resistance and to specific nuclear proteins, including endometrial BCL6. BCL6 overexpression (immune histologic score > 1.4) has been strongly associated with poor reproductive outcomes in IVF cycles in women with UI. Our previous data have demonstrated an accuracy of 94% for diagnosing endometriosis, and BCL6 protein is elevated in the decidua of women with uRPL.

STUDY DESIGN SIZE DURATION

In this case-control study, at a tertiary university teaching hospital, 110 samples (control n = 28; uRPL n = 29; UI n = 53) from pathological archives were analyzed. Timed endometrial biopsies were obtained between 2 January 2002 and 31 December 2016.

PARTICIPANTS/MATERIALS SETTING METHOD

LH-timed endometrial biopsies were obtained from women with UI, uRPL (two or more consecutive losses) and normal fertile subjects during the mid-secretory phase of the menstrual cycle. Endometrial BCL6 protein levels were compared in women with UI and uRPL and fertile controls using western blot analysis and immunohistochemistry (HSCORE).

MAIN RESULTS AND THE ROLE OF CHANCE

The mean age of the uRPL group was significantly higher than the others [mean (SD)] control = 32.7 (2.6); uRPL = 35.8 (3.7); UI = 32.7 (4.4); P = 0.002, ANOVA]. Seventy-nine percent of women in both subfertile groups (uRPL and UI, 65 out of 82) displayed elevated BCL6 protein levels. From these, a subset of cases with abnormal BCL6 went to laparoscopy and endometriosis was found in 9 out of 11 cases of uRPL and in 20 out of 21 cases of UI. Median BCL6 HSCORE for controls versus uRPL and UI was significantly different [median (interquartile); control = 0.3 (0.02 to 0.5); uRPL = 3 (1.9 to 3.6); UI = 2.9 (1.6 to 3.1); P < 0.0001, Kruskal-Wallis]. A significant trend in the association between the degree of infertility (fertile, uRPL and UI) and the HSCORE level (negative, medium and high) was found (P < 0.001; x 2 for trend). Western blot of representative samples from each group demonstrated similar findings based on protein levels in the whole endometrium. After running ANCOVA analysis for age difference, the BCL6 difference among groups was still significant (P-value < 0.0001).

LIMITATIONS REASONS FOR CAUTION

We studied subjects with two consecutive pregnancy losses rather than the definition adopted in Europe of three losses. The findings may lack external validity in other clinical settings (e.g. low prevalence of endometriosis).

WIDER IMPLICATIONS OF THE FINDINGS

Based on the data presented here, we postulate that the degree of BCL6 expression may represent a continuum of progesterone resistance and response to inflammation that occurs in women with endometriosis, yielding different degrees of infertility, from uRPL to UI.

STUDY FUNDING/COMPETING INTERESTS

This study was supported by NICHD/NIH R01 HD067721 (SLY and BAL), by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior: Grant 99999.003035/2015-08 (BAL) and by CAPES/PROAP (RFS). Two authors (BAL, SLY) have licensed intellectual property for the detection of endometriosis. Dr Bruce Lessey is an unpaid scientific Advisor for CiceroDx. The other authors report no conflict of interest.

Medical or surgical treatment before embryo transfer improves outcomes in women with abnormal endometrial BCL6 expression

PURPOSE

To evaluate the effect of medical or surgical treatment prior to embryo transfer in women with elevated endometrial BCL6 expression and suspected endometriosis in a prospective, cohort study design at a university-associated infertility clinic.

METHODS

All subjects had at least 1 year of unexplained infertility (UI) and each prospectively underwent endometrial biopsy and immunostaining for the oncogene BCL6, prior to embryo transfer during an assisted reproductive technology (ART) cycle. To be included, subjects had to have an abnormal BCL6 result, defined by elevated HSCORE ≥ 1.4. Women that were pre-treated with laparoscopy or medical suppression with GnRH agonist (depot leuprolide acetate; Lupron®, Abbvie, Inc., Chicago, IL) for 2 months were compared to a group that went untreated (controls). Endpoints included implantation rate (IR), clinical pregnancy rate (CPR), and live birth rate (LBR), and as well as cycle characteristics. Miscarriage rate were also compared between treatment and control group.

RESULTS

Women in each group had similar characteristics. Those treated by medical suppression and those undergoing laparoscopy for endometriosis had a significantly higher LBR, (5/10; 50%; 95%CI 23.7 to 76.3%) and (11/21; 52.4%; 95%CI 32.4 to 71.7), respectively, compared to controls (4/54; 7.4%; 95%CI 2.9 to 17.6). An absolute benefit of 44.2% (16/31; 95%CI 24.6 to 61.2) and a number need to treat of 3 for those that received treatment (medical suppression and laparoscopy), compared to no treatment. Miscarriages were significantly more common in the control group.

CONCLUSIONS

Women with suspected endometriosis and aberrant endometrial BCL6 expression have worse reproductive outcomes following embryo transfer, including a high miscarriage rate, poor IR, and low LBR and CPR compared to cycles pre-treated with medical and surgical management.

Endometrial BCL6 testing for the prediction of in vitro fertilization outcomes: a cohort study

OBJECTIVE

To evaluate endometrial BCL6 expression as a prognostic biomarker for IVF outcome in women with unexplained infertility (UI) before ET.

DESIGN

Prospective cohort study.

SETTING

University-associated infertility clinic.

PATIENT(S)

Women with UI for >1 year.

INTERVENTION(S)

We studied women with UI who underwent testing for endometrial BCL6, in an LH-timed midluteal phase biopsy and completed an IVF cycle and ET.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate (PR) and live birth rate per transfer was compared for women positive or negative for BCL6 expression. An abnormal BCL6 result was defined by an histologic score (>1.4).

RESULT(S)

Women with normal and abnormal BCL6 and those who conceived or not had similar characteristics. Women with low levels of BCL6 expression had a significantly higher clinical PR (11/17; 64.7%; 95% confidence interval [CI] 41.3-82.6) compared with women with abnormal (high) BCL6 expression (9/52; 17.3%; 95% CI 9.3-30.8). These results yield a relative risk of 0.267 (95% CI 0.13-0.53; P=.0004) for those with normal BCL6 expression, an absolute benefit of 47.4% (95% CI 22.5-72.0). Live birth rate was also significantly higher in women with low BCL6 expression (10/17; 58.8%; 95% CI 36.0-78.4) compared with women with abnormal BCL6 expression (6/52; 11.5%; 95% CI 5.4-23.0). The relative risk was 0.19 (95% CI 0.08-0.45; P=.0002), yielding an absolute benefit of 47.3% (95% CI 21.8-67.8).

CONCLUSION(S)

Aberrant BCL6 expression (histologic score, >1.4) was strongly associated with poor reproductive outcomes in IVF cycles in women with UI.

Laparoscopic surgery improves pregnancy outcomes in women with suspected endometriosis with or without pathological confirmation

PURPOSE OF THE INVESTIGATION

To verify whether histologic confirmation of endometriosis impacts fertility outcomes.

MATERIALS AND METHODS

Women with unexplained infertility (UI) underwent laparoscopic excision or ablation with CO2 laser or electrocautery of all suspected endometriotic lesions, followed by clinical treatment between January 2007 and December 2013; pregnancy (> 12 weeks) within 12 months of monitored cycles was the main outcome measured.

RESULTS

Women with histological confirmation (n = 74) did not differ from those not confirmed (n = 29) with age, body mass index, gravidity, parity, ovulation induction protocol, and past duration of infertility. Pregnancy outcome was similar in both groups (39/74 vs. 15/29-p = 0.9--Chi-square) and there was no statistical difference in time to conceive/deliver (p = 0.7) between groups.

CONCLUSIONS

There is no difference in fertility outcomes in women with UI, whether or not suspected endometriosis is confirmed pathologically.

Endometrial receptivity defects during IVF cycles with and without letrozole

BACKGROUND

Our aim was to study ways to improve IVF success rates in women with suspected endometrial receptivity defects.

METHODS

We conducted a retrospective cohort study examining the effect of letrozole (aromatase inhibitor) on integrin expression as a marker of endometrial receptivity. We compared IVF outcomes in 97 infertile women who had undergone ανβ3 integrin assessment by immunohistochemistry in mid-luteal endometrial biopsies. Of 79 women undergoing standard IVF, 29 (36.7%) lacked normal integrin expression. Eighteen other women with low integrin were studied after receiving letrozole during early IVF stimulation. An independent set of ανβ3 integrin-negative patients (n = 15) who had undergone repeat endometrial biopsy for integrin testing while taking letrozole were re-evaluated.

RESULTS

Clinical pregnancy and delivery rates were higher in women with normal ανβ3 integrin expression compared with those who were integrin negative [20/50 (40%) versus 4/29 (13.8%); P = 0.02 and 19/50 (38%) versus 2/29 (7%); P < 0.01, respectively]. In 18 women who received letrozole early in IVF, 11 conceived (61.1%; P < 0.001) compared with integrin-negative patients who did not receive letrozole. In integrin-negative women who were rebiopsied on letrozole, 66.7% reverted to normal integrin expression. Positive endometrial aromatase immunostaining using a polyclonal antibody was a common finding in infertile patients compared with controls.

CONCLUSIONS

Lack of endometrial ανβ3 integrin expression is associated with a poor prognosis for IVF that might be improved with letrozole co-treatment. Prospective studies are needed to confirm and extend these findings but the data suggest that aromatase expression may contribute to implantation failure in some women.

Creation of a neovagina by the Vecchietti procedure in a patient with corrected high imperforate anus

BACKGROUND

Vaginal atresia is often associated with high imperforate anus. Because the commonly used methods of surgical vaginal creation (eg, McIndoe, intestinal segment interposition) may adversely affect urinary and fecal continence, the less-invasive Vecchietti procedure was selected for a young adult with a successfully corrected high imperforate anus.

METHODS

A 21-year-old was born with a high imperforate anus, vaginal atresia, right hemi-uterus, and left renal agenesis. A colostomy was done at birth, a pull-through procedure at 9 months, and a stoma closure 3 months later. At age 13, an obstructed and dilated right hemiuterus and fallopian tube were resected. A laparoscopic version of the Vecchietti procedure was used for creation of a neovagina.

RESULTS

After the patient had been in the hospital for 2 days, traction was gradually advanced every other day in the office. At 2 weeks postoperatively, the bead was removed revealing a 7-cm vagina. Further elongation was achieved using the Frank method, while continence remained intact.

CONCLUSION

The Vecchietti procedure is an attractive, minimally invasive alternative for creation of a neovagina in patients at risk for compromise to their vesico-anorectal continence.

Effect of short-term diet and exercise on hormone levels and menses in obese, infertile women

OBJECTIVE

To improve serum metabolic and endocrine measures known to influence fecundity.

STUDY DESIGN

Twelve infertile, obese women were enrolled in a 12-week program of diet and exercise. Subjects underwent baseline testing for estrone (E1), estradiol (E2), testosterone (T), luteinizing hormone (LH), follicle-stimulating hormone (FSH), thyroid-stimulating hormone (TSH), prolactin, fasting leptin, dehydroepiandrosterone sulfate (DHEAS), C-reactive protein (CRP) and total cholesterol. Glucose and insulin levels were measured fasting and 2 hours after a 75-g glucose load. Subjects attended three 1-hour exercise sessions per week and received instructions for a 1,200- to 1,300-kcal/day diet. Serum tests and body mass index (BMI) were remeasured after 12 weeks. Intermenstrual intervals were also recorded. At 24 weeks, subjects rated compliance with diet and exercise. Main outcome measures included change in serum variables, BMI and intermenstrual interval.

RESULTS

BMI, total cholesterol and E1/E2 ratio significantly decreased over 12 weeks (mean difference +/- SEM, 2.06 +/- 0.51 kg/m2, 25.91 +/- 4.33 mg/dL and 0.7 +/- 0.22, respectively). No significant differences were noted for all other measures. Ten of the 12 subjects (83%) showed menstrual improvement, with 8 becoming eumenorrheic.

CONCLUSION

Favorable metabolic and menstrual changes are possible in obese, infertile women after 12 weeks of diet and exercise.

Refuting the net risks test: a response to Wendler and Miller's "Assessing research risks systematically"

Earlier in the pages of this journal (p 481), Wendler and Miller offered the "net risks test" as an alternative approach to the ethical analysis of benefits and harms in research. They have been vocal critics of the dominant view of benefit-harm analysis in research ethics, which encompasses core concepts of duty of care, clinical equipoise and component analysis. They had been challenged to come up with a viable alternative to component analysis which meets five criteria. The alternative must (1) protect research subjects; (2) allow clinical research to proceed; (3) explain how physicians may offer trial enrolment to their patients; (4) address the challenges posed by research containing a mixture of interventions and (5) define ethical standards according to which the risks and potential benefits of research may be consistently evaluated. This response argues that the net risks test meets none of these criteria and concludes that it is not a viable alternative to component analysis.

Equipoise and the duty of care in clinical research: a philosophical response to our critics

Franklin G. Miller and colleagues have stimulated renewed interest in research ethics through their work criticizing clinical equipoise. Over three years and some twenty articles, they have also worked to articulate a positive alternative view on norms governing the conduct of clinical research. Shared presuppositions underlie the positive and critical dimensions of Miller and colleagues' work. However, recognizing that constructive contributions to the field ought to enjoy priority, we presently scrutinize the constructive dimension of their work. We argue that it is wanting in several respects.

Trust based obligations of the state and physician-researchers to patient-subjects

When may a physician enroll a patient in clinical research? An adequate answer to this question requires clarification of trust-based obligations of the state and the physician-researcher respectively to the patient-subject. The state relies on the voluntarism of patient-subjects to advance the public interest in science. Accordingly, it is obligated to protect the agent-neutral interests of patient-subjects through promulgating standards that secure these interests. Component analysis is the only comprehensive and systematic specification of regulatory standards for benefit-harm evaluation by research ethics committees (RECs). Clinical equipoise, a standard in component analysis, ensures the treatment arms of a randomised control trial are consistent with competent medical care. It thus serves to protect agent-neutral welfare interests of the patient-subject. But REC review occurs prior to enrolment, highlighting the independent responsibility of the physician-researcher to protect the agent-relative welfare interests of the patient-subject. In a novel interpretation of the duty of care, we argue for a "clinical judgment principle" which requires the physician-researcher to exercise judgment in the interests of the patient-subject taking into account evidence on treatments and the patient-subject's circumstances.

Regulating the market in human research participants

Lemmens and Miller critically examine "finder's fees" and other recruitment incentives issued to physicians for successfully referring patients to clinical trial investigators.

Fiduciary obligation in clinical research

Bioethics is currently witnessing unprecedented debate over the moral and legal norms governing the conduct of clinical research. At the center of this debate is the duty of care in clinical research, and its most widely accepted specification, clinical equipoise. In recent work, we have argued that equipoise and cognate concepts central to the ethics of clinical research have been left unnecessarily vulnerable to criticism. We have suggested that the vulnerability lies in the conspicuous absence of an articulated foundation in moral and legal theory of the physician-researcher's duty of care to the patient-subject. We have repeatedly suggested that the requisite foundation is in the ethics of trust and the law of fiduciaries.

Curiously, despite the absence of a published thorough exposition of our position, some have preemptively criticized our suggestion that the relationship between physician-researcher and patient-subject is fiduciary. Others have offered their own accounts of the implications of fiduciary law for the relationship.

Assisted reproductive technology (ART) in the upstate: reducing the risks of multiple births

Multiple pregnancies from ART procedures are all too common. Efforts to reduce high-order multiple pregnancies will require both social and medical reforms. In lieu of a legislative agenda to reduce multiple pregnancies in the United States, efforts must come from the personnel within the individual ART clinics. The approach to the problem includes accepting a lower pregnancy rate than otherwise might be obtainable, if the observed rate of high-order multiple pregnancies is above a certain threshold. Expanding the opportunities for ART reimbursement will ultimately address this problem in the United States, but until then, it is a problem that will not go away without commitment and resolve.

Flexible versus rigid intrauterine insemination catheters: A prospective, randomized, controlled study

OBJECTIVE

To prospectively compare pregnancy rates for couples undergoing IUI by a single healthcare provider with random assignment to either rigid (Tomcat; Kendall Sovereign, Mansfield, MA) or flexible (Soft Pass; Cook, Spencer, IN) catheters.

DESIGN

Randomized, controlled study.

SETTING

Tertiary care infertility practice.

PATIENT(S)

One hundred infertile women enrolled from a single infertility practice who met the inclusion and exclusion criteria for IUI were enrolled. Of the 100 patients, 95 underwent ovarian stimulation before IUI: 35 with clomiphene citrate alone, 60 with clomiphene citrate combined with a single dose of gonadotropins.

INTERVENTION(S)

Timed IUI was performed with either rigid (Tomcat) or flexible (Cook) insemination catheters.

MAIN OUTCOME MEASURE(S)

Pregnancy rate per cycle.

RESULT(S)

No differences were noted between groups for the following: age, length of infertility, day-3 FSH level, number of prior IUI cycles, total motile sperm count, days of abstinence, infertility diagnoses, insemination ratings, and stimulation protocols. No difference in pregnancy rates was observed between rigid and flexible catheter groups.

CONCLUSION(S)

There is no statistically significant difference between flexible and rigid catheters for IUI.

Protecting communities in pharmacogenetic and pharmacogenomic research

The existing EELS literature has usefully identified the scope of ethical issues posed by pharmacogenetic and pharmacogenomic research. The time has come for in-depth examination of particular ethical issues. The involvement of racial and ethnic communities in pharmacogenetic and pharmacogenomic research is contentious precisely because it touches upon the science and politics of studying racial and ethnic difference. To date, the ethics literature has not seriously taken account of the fact that such research impinges upon the interests of communities, and that taking such interests seriously requires that we both protect and empower communities in research. We propose a framework that rests upon the recognition that communities are heterogeneous human associations and differing policies are appropriate for differing communities. Community consent and consultation and community consultation alone are neither appropriate nor required for all pharmacogenetic and pharmacogenomic research. Rather, application of these policy protections must take into account particulars of both planned research and the communities involved.

Will the real Charles Fried please stand up?

In response to the preceding commentary by Jerry Menikoff in this issue of the Journal, the authors argue that Fried's central concern is not that randomized clinical trials (RCTs) are conducted without consent, but rather that various aspects of the design and conduct of RCTs are in tension with physicians' duties of personal care to their patients. Although Fried does argue that the existence of equipoise cannot justify failure to obtain consent from research subjects, informed consent by itself does not supplant ill subjects' rights to personalized judgment and care embodied in Fried's equipoise.

Short-term calcium supplementation has no effect on biochemical markers of bone remodeling in early postmenopausal women

INTRODUCTION

This study was designed to assess changes in biochemical markers of bone remodeling in early postmenopausal women receiving calcium supplementation.

MATERIALS AND METHODS

In a randomized cross-over study of eighteen weeks duration, the effect of a 6-week calcium supplementation (1000 mg calcium carbonate) on biochemical markers of bone resorption (collagen type I cross-linked C- and N-telopeptides) and bone formation (osteocalcin, total and bone-specific alkaline phosphatase), and total serum calcium was assessed in 27 early postmenopausal women.

RESULTS

While total serum calcium levels increased significantly due to calcium supplementation (p<0.05), biochemical markers of both bone resorption and formation remained virtually unchanged.

CONCLUSION

In contrast to other investigations, there was no significant short-term effect of calcium supplementation on biochemical markers of either bone resorption or formation.

Rehabilitating equipoise

When may a physician legitimately offer enrollment in a randomized clinical trial (RCT) to her patient? Two answers to this question have had a profound impact on the research ethics literature. Equipoise, as originated by Charles Fried, which we term Fried's equipoise (FE), stipulates that a physician may offer trial enrollment to her patient only when the physician is genuinely uncertain as to the preferred treatment. Clinical equipoise (CE), originated by Benjamin Freedman, requires that there exist a state of honest, professional disagreement in the community of expert practitioners as to the preferred treatment. FE and CE are widely understood as competing concepts. We argue that FE and CE offer separable and, in themselves, incomplete justifications for the conduct of clinical trials. FE articulates conditions under which the fiduciary duties of physician to patient may be upheld in the conduct of research. CE sets out a standard for the social approval of research by institutional review boards. Viewed this way, FE and CE are not necessarily competing notions, but rather address complementary moral concerns.

Bone remodeling and bone mineral density during pregnancy

INTRODUCTION

The effect of pregnancy upon the maternal skeleton is not fully understood. The information that has been gathered by recent studies is conflicting with regard to overall loss or gain of bone during pregnancy. The aim of the present longitudinal, controlled study, therefore, was to investigate the effect of pregnancy on lumbar spine, wrist, and hip bone mineral density, and to describe bone remodeling during pregnancy as indicated by biochemical markers of both bone resorption and formation.

MATERIALS AND METHODS

Thirty healthy women (15 subjects seeking pregnancy and 15 non-pregnant controls) were studied. Bone mineral density (BMD) was measured by dual-energy x-ray absorptiometry before conception and within 2 weeks after parturition. Markers of bone resorption (urinary cross-linked type I collagen N-telopeptides, serum type I collagen C-telopeptides) and bone formation (total and bone specific alkaline phosphatase, osteocalcin), and total serum calcium were analyzed before, during (once in each trimester), and after pregnancy.

RESULTS

During pregnancy, BMD decreased significantly by 3.4+/-4.1% at the lumbar spine and 4.3+/-3.9% at the trochanter, while there was a slight but significant increase in BMD at the proximal 1/3 of the forearm (1.3+/-1.9%). Total hip and femoral neck BMD did not change significantly, nor did total and ultradistal forearm BMD. Bone resorption increased during pregnancy with peak levels in the third trimester (N-telopeptides) or post partum (C-telopeptides), respectively. The increase in bone resorption was accompanied by a significant decrease in serum calcium in the third trimester. Markers of bone formation showed a biphasic pattern with decreases from baseline to the first (total and bone specific alkaline phosphatase) or second trimester (osteocalcin), respectively, followed by a significant increase in the third trimester and post partum. There was no change in any parameter in the control group throughout the study.

CONCLUSION

In conclusion, pregnancy is characterized by high bone turnover with resorption preceding formation. During the first and second trimester bone remodeling is uncoupled. Serum calcium decreases as bone resorption peaks in late pregnancy. There are significant decreases in bone mineral density at sites rich in trabecular bone, such as the lumbar spine and the trochanter.

The human subjects trade: ethical and legal issues surrounding recruitment incentives

Over the past 5 years, a series of articles in leading American newspapers has revealed the extent to which the conduct of clinical trials may be affected by inducements offered by corporate research sponsors and accepted by some unscrupulous physicians. The cases described were disturbing. They involved physicians engaged in excessive “enrollment activities” in exchange for money. Some of these physicians perpetrated fraud, falsifying their recruitment records in order to increase their profits. Others ignored exclusion criteria designed to ensure the safety of subjects and the validity of research results, referring their patients to research investigating treatments for conditions from which they did not suffer. One of the articles reports that physicians focusing exclusively on commercial research regularly divulge annual incomes upwards of $1,000,000 with profits in excess of $300,000. Two physicians accumulated well over $10,000,000 through clinical trials activities in less than a decade.

Walking the moral tightrope: respecting and protecting children in health-related research

Special moral, regulatory, and scientific questions surround the inclusion of children in health-related research. These questions arise from a fundamental moral tension between the obligation to expose children to research participation to ensure that they share in the benefits that arise from it and the obligation to protect them from the harms associated with their inappropriate involvement in research. This tension is felt in the development of moral and regulatory frameworks for the protection of child research subjects and in the implementation and interpretation of these frameworks by institutional review boards (IRBs).

Acute ureteral obstruction following transvaginal oocyte retrieval for IVF

Transvaginal, ultrasound-guided oocyte retrieval has become the gold standard for IVF therapy. Despite a low reported complication rate, here a case is reported of acute ureteral obstruction following seemingly uncomplicated oocyte retrieval. Prompt diagnosis and ureteral stenting led to rapid patient recovery with no long-term urinary tract sequelae. Ureteral injury needs to be included in the differential diagnosis of a patient presenting with pelvic/abdominal pain following oocyte retrieval.

Morphometric analysis of primordial follicle number in pigtailed monkey ovaries: symmetry and relationship with age

We previously described a modern, three-dimensional counting method for determining primordial follicle (PF) numbers in primate ovaries using a combination of fractionator and physical dissector techniques. The purposes of our current study were 1) to apply our method to describe intraindividual differences in PF numbers between ovaries and 2) perform a linear regression analysis of age versus mean PF number per ovary. Ovaries from 16 pigtailed monkeys (Macaca nemestrina) age 0.85-12.5 yr were examined. Both ovaries were available from 11 subjects. The difference between ovaries ranged from 2% to 22% (mean +/- SD, 10 +/- 7%) and was not statistically significant. Regression analysis of data from all 16 subjects displayed a log-linear relationship according to the equation log N(a) = 4.8542 - 0.0714(age) where N(a) is the number of PF at a given chronological age. The fit for this model was highly significant (r(2) = 0.73, p </= 0.0001). Extrapolation of the model suggests that there are 71 483 PF in each ovary at the time of birth. We conclude that right and left ovaries differ little and that PF numbers follow a log-linear rate of decline during the reproductive years in this species.

Late-onset hematometra and hematosalpinx in a woman with a noncommunicating uterine horn. A case report

BACKGROUND

Noncommunicating uterine horns are rare, occasionally presenting with functional endometrial cavities. Surgical removal of the noncommunicating horn is commonly performed to prevent endometriosis in these patients.

CASE

A 41-year-old woman with a unicornuate uterus and noncommunicating uterine horn presented with a three-month history of right-sided pelvic pain. She had previously undergone multiple assisted reproductive technique attempts with superovulation and supraphysiologic serum estradiol levels and no apparent symptomatology or evidence of hematosalpinx during laparoscopy. Shortly after completing a donor oocyte recipient cycle, she developed acute right-sided pelvic pain. Diagnostic laparoscopy and subsequent laparotomy confirmed a right hematosalpinx and hematometra of the noncommunicating horn, with stage III endometriosis.

CONCLUSION

Consideration of prophylactic resection of a noncommunicating uterine horn with a cavity should be considered in an asymptomatic, reproductive-age patient with this rare müllerian anomaly.

Correlation of reproductive aging with function in selected organ systems

OBJECTIVE

To compare day 3 FSH levels with biomarkers of aging in other organ systems in healthy, older, reproductive age women.

DESIGN

Cross-sectional pilot study.

SETTING

Healthy volunteers in an academic, tertiary care center.

PATIENT(S)

Healthy, regularly cycling women aged 40 to 45 years divided into two groups: those with normal day 3 FSH levels and those with elevated day 3 FSH levels.

INTERVENTION(S)

Blood and urine collection with blood pressure measurement, pulmonary function testing, bone densitometry, and skin biopsy.

MAIN OUTCOME MEASURE(S)

Comparison between groups for serum creatinine, albumin, glucose, hematocrit, DHEAS, fasting insulin, low-density lipoprotein cholesterol, and triglyceride levels; creatinine clearance (CrCl); forced expiratory volume in 1 second; forced vital capacity; bone density at the wrist, hip, and lumbar spine; and mean dermal thickness.

RESULT(S)

Hematocrit and CrCl values were significantly lower in the group with high FSH levels. Creatinine clearance also was significantly negatively correlated with FSH level. After Bonferroni adjustment for multiple testing, all measures were no longer different at the P < or = 0.05 level.

CONCLUSION(S)

Aging of the hypothalamic-pituitary-ovarian axis may parallel aging in other organ systems. Further longitudinal analyses are necessary to ascertain whether these measures will predict reproductive reserve before irreversible dysfunction occurs.

An accurate, simple method for unbiased determination of primordial follicle number in the primate ovary

Previous investigations of primordial follicle (PF) number in primate ovaries have used biased, model-based techniques that require correction factors based on assumptions regarding cell size, orientation, and shape. We sought to apply several techniques from the "new stereology" to obtain unbiased number estimates. This method involves a hierarchy of systematic random sampling combined with the physical disector and fractionator techniques. The method readily allows the estimation of the coefficient of error (CE) of each sampling level as it contributes to the observed variance of the overall number estimate. We examined one ovary from each of five pigtailed monkeys (Macaca nemestrina). The mean number of PF was 15,735 +/- 6214 (mean +/- SD). The mean CE for the individual number estimates was 0.085, contributing minimally to the inter-individual coefficient of variation (CV) of the primordial follicle numbers (CV = 0.395). The correlation between age and PF number was not significant (r = -0.74, p > 0.1). The total time taken to count the 100-200 PF necessary per ovary was 4-5 h. We conclude that this method produces reliable, unbiased estimates with measurable and acceptable accuracy in a robust, efficient manner.

Ovarian follicular development and the follicular fluid hormones and growth factors in normal women of advanced reproductive age

Reproductive aging in women (a physiological decline in the function of the hypothalamic-pituitary-ovarian axis) is an infrequently investigated and poorly understood biological phenomenon. Although menstrual irregularity and anovulation are known to precede the menopause, normal women in their fifth decade experience a profound decrease in fertility while still experiencing regular menstrual cycles. To further our understanding of the physiological changes associated with reproductive aging, this study examined the spontaneous development and function of ovarian follicles in normal women, aged 40-45 yr. The subjects were women (n = 21), aged 40-45 yr, who had regular 25- to 35-day ovulatory menstrual cycles, were not infertile, had no medical problems, and met specific criteria for weight, diet, and exercise. The controls were normal women (n = 20), age 20-25 yr, who met the same criteria. The subjects were monitored with daily hormone measurements [LH, FSH, estradiol (E), progesterone (P), and inhibin] and pelvic sonograms from day 1 of their study cycle until the dominant ovarian follicle reached a mean diameter of 15 mm and/or a serum E level of 550 pmol/L or higher was attained. At that time, 10,000 U hCG were given, and a transvaginal sonographic follicle aspiration was performed 32 h later. The follicular fluid (FF) was collected, stored frozen at -70 C, and later analyzed for E, P, testosterone (T), androstenedione, inhibin, insulin-like growth factor I (IGF-I), and IGF-II. The number of cycle days to aspiration was lower (11.6 vs. 15.6 days; P < 0.001) and the early follicular phase mean FSH and mean E levels were higher (9.3 vs. 6.6 mIU/mL and 305 vs. 160 pmol/L; P < 0.01) in the older (O) group compared to the younger group. There was a strong trend toward higher FF mean E (2280 vs. 1931 nmol/L) and lower FF mean T (978 vs. 2361 pmol/L) levels in group O. The E/T ratio was significantly higher (5253 vs. 2408; P < 0.03) in group O. In group O, the mean FF P levels were increased as well (25.1 vs. 18.8 micromol/L; P < 0.01). The serum mean IGF-I (153 vs. 226 ng/mL; P < 0.001) and FF mean IGF-I (113 vs. 158 ng/mL; P < 0.02) levels were significantly decreased in group O. There were no differences between groups in serum or FF IGF-II or inhibin levels. Whether reproductive aging is an intrinsic ovarian process or the ovary is simply responding to exogenous influences, the ovary in general and its follicles in particular are the primary site of the effects of aging. Ovarian follicles in older ovulatory women have some unique features: 1) the follicles are the same size as those in younger women, but form more rapidly; 2) secretion of E and inhibin is not compromised; 3) the concentrations of steroids in the FF are indicative of a healthier follicle, i.e. increased P levels and higher estrogen to androgen ratio; and 4) serum and FF levels of IGF-I are decreased, but there are no differences in IGF-II levels.

Circulating levels of growth hormone, insulin-like growth factor-I and growth hormone binding protein in normal women of advanced reproductive age

OBJECTIVE

Women experience an age-related decline in fertility despite regular ovulatory cycles and normal production of ovarian steroids. Growth hormone and IGF-I are both reported to decline with age, and there is evidence that both hormones promote intraovarian actions of gonadotrophins. The purpose of this study was to characterize circulating levels of GH and IGF-I in normal, older reproductive age women with ovulatory cycles.

DESIGN

Prospective, controlled.

PATIENTS

Twenty-eight regularly cycling older (n = 16) and younger (n = 12) women were recruited for daily blood sampling throughout a menstrual cycle.

MEASUREMENTS

Serum obtained from daily blood sampling was analysed for LH, FSH, oestradiol (E2) and progesterone (P). Serum obtained from frequent sampling during the admission was analysed for pulsatile GH secretion. IGF-I and GH binding protein (GHBP) were also measured in subsets of the two age groups.

RESULTS

All subjects exhibited normal patterns of LH, FSH, E2 and P consistent with ovulatory cycles. There were no differences between the two age groups in integrated 24-hour GH secretion or in GH pulse amplitude or frequency. There were no differences in GH secretion between the early follicular and miduluteal phases when data were combined for the two subject groups. Plasma concentrations of IGF-I were significantly lower throughout the cycle in the older women. There were no significant differences in levels of GHBP across the cycle or between the two age groups.

CONCLUSIONS

IGF-I decreases with age in women without identifiable changes in the amount or pattern of GH secretion or in circulating GHBP concentrations. Decreased IGF-I production may be related to decreased ovarian gonadotrophin sensitivity in older reproductive age women.

The usefulness of a urinary LH kit for ovulation prediction during menstrual cycles of normal women

OBJECTIVE

To assess the predictive value of monitoring urine LH at home using a rapid, colorimetric enzyme immunoassay test (Ovuquick) once every evening.

METHODS

Twenty-six strictly defined normal women with no history of infertility were enrolled in studies involving urine LH tests. Each subject had transvaginal sonography and serum LH tests performed two times per day beginning in the middle of a normal menstrual cycle. All subjects performed urine LH testing at home every evening. The time of the peak serum LH measurement was considered the surge. Ovulation was determined using sonographic criteria with confirmation by normal luteal-phase progesterone levels (3 ng/mL or greater). Two clinically relevant intervals were determined: interval I, time from peak serum LH to positive urine LH, and interval II, time from positive urine LH to follicular collapse by ultrasonography.

RESULTS

All 26 cycles examined were ovulatory, based on sonographic and progesterone level criteria. The mean time (+/- standard error of the mean [SEM]) for interval I was 2 +/- 2 hours (95% confidence interval [CI] -2 to 6). The mean time (+/- SEM) for interval II was 20 +/- 3 hours (95% CI 14-26). Positive predictive values for follicular collapse within 24 or 48 hours after positive urine LH testing were 73 and 92%, respectively.

CONCLUSION

Urine LH testing every evening is a reliable method of predicting ovulation within the ensuing 48 hours.

Endoglucanase A from Cellulomonas fimi in which the hinge sequence of human IgA1 is substituted for the linker connecting its two domains is hydrolyzed by IgA proteases from Neisseria gonorrhoeae

The hinge in IgA1 and the linker in endoglucanase A (CenA) are quite similar. The IgA1 hinge is 18 amino acids long and contains only proline, threonine and serine. The linker in CenA is 27 amino acids long and contains only proline, threonine and a single serine. IgA proteases from Neisseria gonorrhoeae cleave Pro-Ser and Pro-Thr bonds within the IgA1 hinge sequence, but they do not attack CenA. When the linker sequence of CenA is replaced with the hinge sequence of IgA1, the hybrid polypeptide is susceptible to the N. gonorrhoeae proteases. It is cleaved within the hinge sequence at the same sites as IgA1.

alpha-Putrescinylthymine and the sensitivity of bacteriophage phi W-14 DNA to restriction endonucleases

The modified base alpha-putrescinylthymine (putT) in phi W-14 DNA blocks cleavage of the DNA by 17 of 32 Type II restriction endonucleases. The enzymes cleaving the DNA do so to widely varying extents. The frequencies of cleavage of three altered forms of the DNA show that putT blocks recognition sites either when it occurs within the site or when it is in a sequence flanking the site. The blocking is dependent on both charge and steric factors. The charge effects can be greater than the steric effects for some of the enzymes tested. All the enzymes cleaving phi W-14 DNA release discrete fragments, showing that the distribution of putT is ordered. The cleavage frequencies for different enzymes suggest that the sequence CAputTG occurs frequently in the DNA. Only TaqI of the enzymes tested appeared not to be blocked by putT, but it was slowed down. TaqI generated fragments are joinable by T4 DNA ligase.

DNA synthesis in Pseudomonas acidovorans infected with mutants of bacteriophage phi W-14 defective in the synthesis of alpha-putrescinylthymine

Normal levels of the hypermodified pyrimidine, alpha-putrescinylthymine, which is formed from hydhydroxymethyluracil at the polynucleotide level (Maltman et al., J. Virol. 34:354-359, 1984), are not required in bacteriophage luminal diameterW-14 DNA for the DNA to serve as a replicative template in luminal diameterW-14-infected cells.

Polypeptide synthesis directed by bacteriophage phi W-14 and by mutants defective in DNA synthesis

The latent period of bacteriophage phi W-14 is approximately 65 min when the doubling time of its host, Pseudomonas acidovorans, is 85 min. Host protein synthesis is shut off relatively slowly, stopping approximately 25 min after infection. There are several phases of phage-specific polypeptide synthesis during the latent period: early polypeptides appear within 10 min after infection; middle polypeptides start to appear between 10 nd 30 min; late polypeptides appear after 30 min. The lengths of time for which individual polypeptides are synthesized vary widely. Several late polypeptides do not appear in the virion. DNA replication is not required for late gene expression. The hypermodified pyrimidine, alpha-putrescinylthymine, appears not to be required in both strands of the DNA duplex for transcription.

Formation and possible functions of alpha-putrescinylthymine in bacteriophage phi W-14 DNA: analysis of bacteriophage mutants with decreased levels of alpha-putrescinylthymine in their DNAs

The DNA synthesized in the nonpermissive host by the noncomplementing mutants am36 and am42 of bacteriophage phi W-14 contains about half the wild-type level of alpha-putrescinylthymine (putThy) and a correspondingly greater level of thymine. The mechanisms whereby thymine nucleotides are excluded from replicating DNA are functional in both mutants because neither of them incorporates exogenous thymidine into DNA. It is proposed that (i) in wild-type phi W-14, the conversion of hydroxymethyluracil to putThy at the polynucleotide level is sequence specific, but that to thymine is nonspecific; and (ii) in the mutants, the sequence-specific recognition is impaired so that more thymine and less putThy are formed. The thymine-rich DNA can be packaged into phage particles. In the case of am42, the phage particles are morphologically indistinguishable from and have essentially the same polypeptide composition as wild-type particles. However, the DNA molecules they contain are about 11% shorter than those in wild-type phage, am42rev4, a revertant of am42, contains DNA with about 70% of the normal level of putThy; these molecules are about 3% shorter than wild-type DNA. The properties of am42 and am42rev4 are consistent with the suggestion that putThy facilitates the very tight packing of phi W-14 DNA (Scraba et al., Virology 124:152-160, 1983). It also appears that the putThy content of phi W-14 DNA can be reduced by no more than 30% without adversely affecting the production of viable progeny; for example, the burst size of am42rev4 is about 25% of that of the wild type.

Isolation and preliminary characterization of amber mutants of bacteriophage phi W-14 defective in DNA synthesis

Of 42 amber mutants of bacteriophage phi W-14, 6 were defective in DNA synthesis. Three of the mutants synthesized DNA in the nonpermissive host, but were defective in post-replicational modification of the DNA. The DNA synthesized by two of these mutants, am36 and am42, contained more thymine and less alpha-putrescinylthymine than did wild-type DNA; that synthesized by the third mutant, am37, contained the normal amount of thymine, no alpha-putrescinylthymine, and hydroxymethyluracil. The properties of these mutants suggested that the presence of the normal amount of alpha-putrescinylthymine in phi W-14 DNA was essential for the production of viable progeny. Three of the mutants, am6, am35, and am45, failed to synthesize DNA in the nonpermissive host. These mutants were analogous to the DNA off mutants of T4. Nonpermissive cells infected with DNA off mutants accumulated dATP, dGTP, dCTP, and hydroxymethyl dUTP, but not dTTP or alpha-putrescinyldeoxythymidine triphosphate, confirming that both thymine and alpha-putrescinylthymidine in phi W-14 DNA are formed from hydroxymethyluracil at the polynucleotide level. The synthesis of phi W-14 DNA is unusual because (i) thymine is formed from hydroxymethyluracil at the polynucleotide level, (ii) the hypermodification forming alpha-putrescinylthymine is essential, and (iii) thymine and alpha-putrescinylthymine must be made in the correct proportions. Complementation tests showed that the mutants defined three genes involved in DNA polymerization and two genes involved in post-replicational modification.

Aminoglycoside monitoring program

An aminoglycoside monitoring program (AMP) using pharmacokinetic variables is described. The AMP was established in one patient-care pharmacy that served 69 medical/surgical beds. The pharmacists received a two-hr instructional course designed to refamiliarize them with basic pharmacokinetic concepts and the practical application of these concepts. A form was developed to assist monitoring. From data recorded on the form, pharmacists calculate ideal body weight, creatinine clearance, predicted rate of elimination, half-life, volume of distribution, serum peak (Cmax) and serum trough (Cmin) concentrations, dosing interval, and maintenance dose. Aminoglycoside therapy is evaluated and assessed daily based on whether or not: (1) predicted Cmax or Cmin concentrations are above the recommended concentrations, (2) predicted Cmax or Cmin are below the recommended concentrations, or (3) actual serum concentrations are necessary before a dose assessment is made. The pharmacist notifies the physician and records any recommendations concerning aminoglycoside therapy. Within the first year of the program, 304 patients were placed on tobramycin or gentamicin therapy; for 21% of them, dosage recommendations were made to the physician. The AMP provides the hospital pharmacist with an opportunity to use aminoglycoside pharmacokinetic theory in everyday practice.