The Predictive Value of Serum ß-HCG Levels in The Detection of Ectopic Pregnancy Sixteen Days after Embryo Transfer: A Cross-Sectional Study

BACKGROUND

To detect the predictive value of beta human chorionic gonadotropin (β-hCG) levels 16 days post embryo transfer (ET) regarding detection of an ectopic pregnancy (EP) in assisted reproductive technology (ART) cycles.

MATERIALS AND METHODS

In this cross-sectional study, we reviewed the database of Royan Institute from January 2011 to December 2014 and from January 2017 to December 2019 retrospectively. All cases with positive β-hCG levels sixteen days after ET were screened (n=4149). The pregnancies with oocyte or embryo donation and the multiple pregnancies based on the first ultrasound were excluded. All eligible singleton pregnancies with documented serum β-hCG levels at Royan institute laboratory (n=765) were included and then classified according to the type of pregnancy: EP (n=189) or non-EP (n=576). The data of the treatment cycle was extracted from the patients' files. A receiver operating characteristic (ROC) curve was used to detect the predictive power of the first measurement of β-hCG level in distinguishing EP from ongoing pregnancy in the ART and intrauterine insemination (IUI) cycles separately. Sensitivity, specificity, area under the ROC curve and 95% confidence intervals (CI) were calculated for each of the estimates.

RESULTS

The mean levels of β-hCG 16 days after ET were remarkably higher in the ongoing pregnancy group than the EP group (1592.35 ± 87 IU/L vs. 369.69 ± 50.61 IU/L, P<0.001). The β-hCG thresholds predictive of ongoing pregnancy were 278 IU/L as the most suitable cut-off to predict viable pregnancy with a sensitivity of 72.8%, a specificity of 67.5%, a positive predictive value of 77.8%, standard error of 0.02, and a confidence interval of 73.8- 81.7%. However, this relationship was not found in IUI cycles.

CONCLUSION

Based on these findings, if β-hCG levels 16 days after ET are below 278 IU/l, close follow-up is recommended, until either the diagnosis of EP or miscarriage is established.

Human Chorionic Gonadotropin monotherapy for the treatment of hypogonadal symptoms in men with total testosterone > 300 ng/dL

Purpose

The 2018 American Urological Association guidelines on the Evaluation and Management of Testosterone Deficiency recommended that 300 ng/dL be used as the threshold for prescribing testosterone replacement therapy (TRT). However, it is not uncommon for men to present with signs and symptoms of testosterone deficiency, despite having testosterone levels greater than 300 ng/dL. There exists scant literature regarding the use of hCG monotherapy for the treatment of hypogonadism in men not interested in fertility. We sought to evaluate serum testosterone response and duration of therapy of hCG monotherapy for men with symptoms of hypogonadism, but total testosterone levels > 300 ng/dL.

Materials and Methods

We performed a multi-institutional retrospective case series of men receiving hCG monotherapy for symptomatic hypogonadism. We evaluated patient age, treatment indication, hCG dosage, past medical history, physical exam findings and serum testosterone and gonadotropins before and after therapy. Descriptive analysis was performed and Mann Whitney U Test was utilized for statistical analysis.

Results

Of the 20 men included in the study, treatment indications included low libido (45%), lack of energy (50%), and erectile dysfunction (45%). Mean testosterone improved by 49.9% from a baseline of 362 ng/dL (SD 158) to 519.8 ng/dL (SD 265.6), (p=0.006). Median duration of therapy was 8 months (SD 5 months). Fifty percent of patients reported symptom improvement.

Conclusions

Treatment of hypogonadal symptoms with hCG for men who have a baseline testosterone level > 300 ng/dL appears to be safe and efficacious with no adverse events.

Comparison of First Trimester Screening for Down's Syndrome Using Free Beta-Human Chorionic Gonadotropin and Pregnancy-Associated Plasma Protein-A Levels between Spontaneous and IVF Pregnancies at 12 Weeks of Gestation

Background

In some previous studies, it was shown that first trimester screening tests produce equivocal results in in vitro fertilization (IVF) pregnancies. The purpose of this study was to compare free beta-human chorionic gonadotro- pin (β-hCG) and pregnancy-associated plasma protein-A (PAPPA) levels between single normal and IVF pregnancies during 11 to 13 week (+ 6 day) of gestational age.

Materials and Methods

In this observational cohort study, 300 consecutive single IVF pregnancies and 700 single normal pregnancies were enrolled at about 11-13 week + 6 day gestational age and levels of free β-hCG and PAPPA were compared between the groups.

Results

The results demonstrated that PAPPA (P=0.026) was significantly lower and β-hCG (P=0.030) was signifi- cantly higher in IVF pregnancies. The other factors including nuchal translucency (NT) and crown-rump length (CRL) and demographic characteristics did not significantly differ between the groups (P>0.05).

Conclusion

This study showed that PAPPA levels are lower but free β-hCG levels are higher in single IVF versus normal pregnancies. This finding could be related to different placentation in intracytoplasmic sperm injection (ICSI) technique because of alterations in oocyte cytoplasm. Therefore, these markers may need to be adjusted in assisted re- productive technology (ART) conceptions. Further research should be done to obtain optimal cut-off for these markers in first trimester screening for detection of Down syndrome in ART pregnancies.

hCG - related molecules and their measurement

Measurements of human chorionic gonadotropin (hCG) synthesized by trophoblast cells is a powerful tool of pregnancy monitoring. It was showed that similarly to pregnancy also trophoblastic and nontrophoblastic malignancies produce variety of hCG molecules. In urine and serum of both pregnant women and tumors patients a fifteen various forms of hCG, such as: regular hCG, hyperglycosylated hCG and predominant hyperglycosylated hCG free β, were identified. These forms might be useful in order to recognize between physiological and pathological pregnancies as well as cancers. Even the presence of these different hormone variants is well documented the commercially available biochemical tests detecting hCG failed to identified and distinguish among these forms. Especially hard is to identify glycan chains linked to heterodimer. Thus, a detailed analysis of hCG-related molecules produced during physiological and pathological condition, together with a new tests development are needed.

Supposed pituitary-production of human chorionic Gonadotropin induced by androgen deprivation therapy

INTRODUCTION

The main cause of slightly elevated human chorionic gonadotropin (HCG) after successful treatment of male germ cell tumors is considered to be pituitary-derived HCG. It is well known that pituitary-derived HCG is frequently detected in postmenopausal women. We evaluated the status of serum HCG in men with elevated gonadotropins, which were induced by androgen deprivation therapy, using commercially available assays.

MATERIALS AND METHODS

We enrolled 44 patients with prostate cancer, who underwent luteinizing-hormone releasing hormone agonist treatment. We measured serum follicle-stimulating hormone (FSH), serum luteinizing hormone (LH), serum total HCG, serum free HCG-β subunit, and urine total HCG 3 times per patient, on the day of treatment initiation, the next day, and 3 months after.

RESULTS

On the day after treatment initiation, serum and urine HCG was detected in 61% and 73% of patients, respectively. Markedly strong correlations were observed between serum/urine HCG and FSH/LH. In particular, receiver operating characteristic curve analysis indicated excellent area under the curve (0.977, 95% confidence interval 0.951-1.003)) for serum HCG-detectable LH. At the cutoff value of 21.07 mIU/mL for serum HCG-detectable LH, the sensitivity and specificity were 96.7% and 95.3%, respectively. Serum HCG-β was not detectable at any times in any patients.

CONCLUSIONS

Suggested pituitary-derived HCG can be frequently detected in patients with elevated gonadotropins, and there is a firm association between HCG detection and gonadotropin levels.

Extremely Rare Case of Bilateral Pure Primary Non-Gestational Ovarian Choriocarcinoma

Background

Germ cell tumors of the ovary constitute less than one percent of ovarian tumors worldwide. Choriocarcinoma arising de novo from the ovary is very rare and only occasionally reported in the literature. Herein, we report a case of bilateral non-gestational pure primary ovarian choriocarcinoma that was confirmed by beta human chorionic gonadotropin (β-HCG) levels and histopathology.

Case Report

Our case is of a middle-aged multiparous female who presented with amenorrhea for three months. She underwent an evaluation with ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI), which revealed bilateral bulky solid adnexal masses. Based on an increased blood level of the beta human chorionic gonadotropin and a histopathological examination, the diagnosis of bilateral non-gestational pure primary ovarian choriocarcinoma was made.

Conclusions

The imaging findings were found to be specific for bilateral non-gestational pure primary ovarian choriocarcinoma.

Intravenous neutralization of vascular endothelial growth factor reduces vascular function/permeability of the ovary and prevents development of OHSS-like symptoms in rhesus monkeys

Background

Ovarian hyperstimulation syndrome (OHSS) is a disorder associated with elevated serum VEGFA following chorionic gonadotropin (hCG) exposure in controlled ovarian stimulation (COS) cycles in women. In this study, we tested the effect of intravenous VEGFA neutralization on OHSS-like symptoms and vascular function in rhesus macaques during COS cycles.

Methods

Monkeys (n = 8) were treated with 3 COS protocols and assigned randomly to groups as follows: 1) COS alone (Control,n = 5); 2) COS + VEGF mAb Avastin 19 ± 5 h before hCG (Avastin pre-hCG; n = 6); 3) COS + Avastin 3–4 days post-hCG (Avastin post-hCG; n = 4); 4) COS + Simulated Early Pregnancy (SEPn = 3); or 5) COS + SEP + Avastin (SEP + Avastinn = 3). Follicles were aspirated 36 h post-hCG, fluid was collected from one follicle for analysis of steroid and vascular hormone content. Remaining follicles were aspirated, and luteinized granulosa cells (LGCs) cultured for 24 h. Ovarian/uterine vascular flow (VF) and blood volume (BV) were analyzed by contrast enhanced ultrasound (CEUS) before hCG bolus and 6–8 days post-hCG bolus/time of peak SEP response. Ovarian permeability to albumin was analyzed by Dynamic Contrast Enhanced-MRI (DCE-MRI) post-hCG.

Results

Abdominal fluid was present in 4/5 Control, 2/6 Avastin pre-hCG, and 3/4 Avastin post-hCG females. Neutralization of VEGFA before hCG reduced ovarian VF, BV, and permeability to albumin (P < 0.05), while only ovarian VF and permeability were reduced in Avastin-post hCG group (P < 0.05). There was no effect of Avastin on ovarian vascular function during COS + SEP. VEGF levels in follicular fluid were reduced 78-fold by Avastin pre-hCG, and LGCs exposed to Avastin in vivo also released 4-fold less VEGF into culture media (P < 0.05). Culture medium of LGCs exposed to VEGFA neutralization in vivo had lower levels of P4 and ANGPT1, and an increased ratio of ANGPT2/1 (P < 0.05). Uterine VF was reduced by SEP + Avastin in the basalis/junctional zone (P < 0.05).

Conclusions

Avastin treatment before hCG prevents the development of symptoms associated with ovarian hyperstimulation syndrome. In vitro data suggest neutralization of VEGFA alters expression of other vascular factors typically induced by hCG in the luteinizing follicle. Neutralization of VEGFA action alters the vascular function of the basalis zone of the uterus during simulated early pregnancy, indicating a potential effect on embryo implantation.

Electronic supplementary material

The online version of this article (doi:10.1186/s13048-017-0340-5) contains supplementary material, which is available to authorized users.

A Clinical Experience of Ectopic Pregnancies with Initial Free Intraperitoneal Fluid

INTRODUCTION

Extra-uterine pregnancy or Ectopic Pregnancy (EP) is a major health problem for pregnant women, presenting as a potentially life-threatening emergency in the first trimester. There are three major options for the treatment of EP: expectant management, surgical treatment and medical management. The presence of free intraperitoneal fluid in EP-diagnosed patients is crucial for treatment planning and evaluation.

AIM

To compare the outcomes of both the expectant man-agement and medical treatment with methotrexate (MTX) in ectopic pregnancies with free intraperitoneal fluid.

MATERIALS AND METHODS

This retrospective cohort study inclu-ded a total of 91 ectopic pregnancies with or without rupture in which the women had initial free intraperitoneal fluid and were haemodynamically stable. Serial β-HCG measurements were used to assess the outcome of expectant management and medical treatment with MTX. For the statistical analysis, the SPSS statistical software package, version 22.0 (Chicago, IL, USA), was used. For the quantitative variables that were not distributed normally, the Kruskal-Wallis test and the Mann-Whitney U test were performed for the evaluation of differences between the groups.

RESULTS

It was observed that the success rate with expectant management was 81% (initial β HCG concentration 626±443 mIU/mL). With a single dose of MTX, it was 76% (initial β HCG concentration 2124±1647 mIU/mL) and with a total single or double dose of MTX, it was 88% (initial β HCG concentration 2252±78 mIU/mL) from among EP with or without rupture in women with initial free intraperitoneal fluid during diagnosis. There was no significant difference between the groups with regard to ultrasonography findings.

CONCLUSION

Expectant management or medical treatment with methotrexate should be the first line treatment for ectopic pregnancies with initial free intraperitoneal fluid, albeit with rupture, in patients who are haemodynamically stable, along with β-HCG follow-up.

Mid-trimester maternal serum HCG and alpha fetal protein levels: clinical significance and prediction of adverse pregnancy outcome

CONTEXT

Maternal serum human Chorionic Gonadotropin (hCG) and Alpha Fetal Protein (AFP) were originally introduced to detect trisomy 21 and neural tube defects. However, in the absence of aneuploidy or neural tube defects, mid-trimester maternal serum hCG and/or maternal serum AFP associated with adverse pregnancy outcomes. Pregnancies with unexplained mid-trimester elevation in maternal serum hCG and/or maternal serum AFP, are at increased risk for pregnancy complications resulting from placental insufficiency.

EVIDENCE ACQUISITION

Mid-trimester maternal serum hCG>2.5 MoM associated with an increased risk for pregnancy complications including: late fetal loss, gestational hypertension, preeclampsia, intrauterine growth restriction (IUGR), preterm delivery and intrauterine fetal death(IUFD). Mid-trimester maternal serum AFP levels >2.5 MoM are thought to reflect a defect in placentation and associated with an increased risk for pregnancy complications including: late fetal loss, gestational hypertension, preeclampsia, IUGR, preterm delivery and IUFD.

RESULTS

Combined mid-trimester elevation in maternal serum hCG and AFP levels suggest a more complex type of placental pathology. They have stronger association with pregnancy complications including: late fetal loss, gestational hypertension, preeclampsia, IUGR, preterm delivery and IUFD.

CONCLUSIONS

Mid-trimester maternal serum hCG or AFP levels alone cannot detect all pregnant women with increased risk to develop pregnancy complications. Multiparameter testing of placental function in mid-trimester (maternal serum hCG and AFP screening, uterine artery Doppler and placental morphology) may allow us to identify women with increased risk to develop severe placental insufficiency and pregnancy complications. However, future prospective studies are needed to confirm the prognostic significance of multiparameter testing of placental function in mid-trimester.

Pleomorphic carcinoma of the lung with high serum beta-human chorionic gonadotropin level and gynecomastia

Although gynecomastia is a well-defined paraneoplastic syndrome in patients with non-small cell lung cancer, the association with pleomorphic carcinoma has not been reported. A 50-yr-old man presented with bilateral gynecomastia and elevated serum beta-human chorionic gonadotropin (βhCG) level. Chest tomography showed a mass in the right middle lobe. Right middle lobectomy and mediastinal lymph node dissection were performed. βhCG levels decreased rapidly after surgery. Histological examination revealed pleomorphic carcinoma with positive immunostaining for βhCG. Serum βhCG levels began to increase gradually on postoperatively 4th month. Computed tomography detected recurrence and chemotherapy was started. After second cycle of chemotherapy, βhCG levels decreased dramatically again and tomography showed regression in mass. Patient died 6 months later due to brain metastasis. βhCG expression may be associated with aggressive clinical course and increased risk of recurrence, also βhCG levels may be used to evaluate therapy response in patients with pleomorphic carcinoma.