Prevalence and confounders of chronic endometritis diagnosed using CD138 in patients with recurrent implantation failure

OBJECTIVE

This retrospective study aimed to investigate the prevalence of chronic endometritis, diagnosed using CD138 immunohistochemistry, among infertile women and to assess the association between chronic endometritis and recurrent implantation failure (RIF).

METHODS

In total, 266 patients who underwent hysteroscopy due to infertility between 2019 and 2020 were included in the analysis. Of these, 136 patients with RIF and 130 non-RIF patients were included in the study. CD138 immunohistochemistry test results, blood biomarkers (including natural killer cells, white blood cells, and the lymphocyte-to-neutrophil ratio), and data on pregnancy outcomes were obtained. If the CD138 test yielded a positive result, the patients received antibiotic treatment.

RESULTS

The overall proportion of CD138-positive patients was 32.7% (87/266). The CD138 positivity rate was not related to the number of cycles with implantation failure. In the RIF patient group, no significant associations were found between CD138 positivity and peripheral blood markers. The clinical pregnancy rates were similar between infertile women treated with antibiotics for chronic endometritis and those without chronic endometritis.

CONCLUSION

To improve the pregnancy rate in infertile patients, it may be helpful to combine CD138 testing with other laboratory tests and administer antibiotic treatment if the result is positive.

Risk Factors for Infertility in Korean Women

BACKGROUND

Female infertility is a crucial problem with significant implications for individuals and society. In this study, we explore risk factors for infertility in Korean women.

METHODS

A total of 986 female patients who visited six major infertility clinics in Korea were recruited from April to December 2014. Fertile age-matched controls were selected from two nationwide survey study participants. Conditional logistic regression after age-matching was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of each risk factor for infertility.

RESULTS

Women with a body mass index (BMI) < 18.5 kg/m² had 1.35 times higher odds of infertility (OR, 1.35; 95% CI, 1.03-1.77), while those with a BMI ≥ 25.0 kg/m² had even higher odds (OR, 2.06; 95% CI, 1.61-2.64) compared to women with a normal BMI (18.5 kg/m² ≤ BMI < 25 kg/m²). Ever-smokers exhibited 4.94 times higher odds of infertility compared to never-smokers (95% CI, 3.45-8.85). Concerning alcohol consumption, women who consumed ≥ 7 glasses at a time showed 3.13 times significantly higher odds of infertility than those who consumed ≤ 4 glasses at a time (95% CI, 1.79-5.48). Lastly, women with thyroid disease demonstrated 1.44 times higher odds of infertility compared to women without thyroid disease (95% CI, 1.00-2.08).

CONCLUSION

Female infertility in Korea was associated with underweight, obesity, smoking, alcohol consumption, and thyroid disease.

A Successful Live Birth From a Vitrified Oocyte for Fertility Preservation of a Patient With Borderline Ovarian Tumor Undergoing Bilateral Ovarian Surgery: A Case Report

This article reports the live birth of a healthy newborn using vitrified-warmed oocytes from fertility preservation before ovarian surgery. The patient in our case underwent two cycles of controlled ovarian stimulation before laparoscopic bilateral ovarian cystectomy for endometriosis, and a total of 23 mature oocytes were vitrified. After surgery, her pathologic reports revealed a serous borderline tumor and endometrioma. Fifteen months after her second surgery of laparoscopic right salpingo-oophorectomy and left ovarian cystectomy owing to recurrence, she had been married by then, and three of the frozen oocytes were thawed for intracytoplasmic sperm injection. These oocytes were cryopreserved for 2.5 years. All three were fertilized, and two grade-A cleavage-stage embryos were transferred. A singleton pregnancy was achieved, resulting in the delivery of a healthy baby boy at 39.3 weeks of gestation. Oocyte cryopreservation is an effective method for fertility preservation prior to ovarian surgery when ovarian function decline is predictable.

Thiol-yne click crosslink hyaluronic acid/chitosan hydrogel for three-dimensional in vitro follicle development

There is a great deal of potential for in vitro follicle growth to provide an alternative approach to fertility preservation. This strategy reduces the possibility of cancer cells re-exposure after transplantation, and it does not require hormone stimulation. Adopting a three-dimensional (3D) culture method helps preserve the architecture of the follicle and promotes the maturity of oocytes. In order to maintain follicle morphology, enhance the quality of mature oocytes, and facilitate meiotic spindle assembly, the current work aimed to develop the 3D in vitro preantral mouse follicle culture method. Thiolated chitosan-co-thiolated hyaluronic (CSHS) hydrogel was designed to evaluate the effects of biomaterials on ovarian follicle development. Isolated follicles from mouse ovaries were randomly divided into alginate (Alg) as a 3D control, thiolated hyaluronic acid (HASH), and CSHS groups. Single follicle was encapsulated in each hydrogel, and performed for 10 days and subsequently ovulated to retrieve mature oocytes on day 11. CSHS hydrogel promoted follicle survival and oocyte viability with maintained spherical morphology of follicle. Matured oocytes with normal appearance of meiotic spindle and chromosome alignment were higher in the CSHS group compared with those in the Alg and HASH groups. Furthermore, CSHS increased expression level of folliculogenesis genes (TGFβ-1, GDF-9) and endocrine-related genes (LHCGR, and FSHR). With various experimental setups and clinical applications, this platform could be applied as an alternative method to in vitro follicle culture with different experimental designs and clinical applications in the long-term period.

Multidisciplinary Shared Decision Making for Fertility Preservation in Young Women With Breast Cancer

PURPOSE

Fertility preservation (FP) is an important issue for young survivors of breast cancer. Although international guidelines recommend pre-treatment fertility counseling for women with breast cancer, there is no standardized protocol or referral system for FP in South Korea. There are also barriers to discussing FP that make patient-centered decision making difficult. This study aimed to develop a shared decision making program for FP and compare the rates of FP procedures between the usual care and shared decision making groups. We hypothesized that multidisciplinary shared decision making for FP would increase the rate of FP procedures and patient satisfaction.

METHODS

The multidisciplinary shared decision making for FP in young women with breast cancer (MYBC) is a multicenter, clustered, stepped-wedge, randomized trial. A total of 1100 patients with breast cancer, aged 19-40 years, from nine hospitals in South Korea, will be enrolled. They will be randomized at the institutional level and assigned to usual care and shared decision making groups. Four institutions, each of which can recruit more than 200 patients, will each become a cluster, whereas five institutions, each of which can recruit more than 50 patients, will become one cluster, for a total of five clusters. The shared decision making groups will receive multidisciplinary programs for FP developed by the investigator. The primary outcome is the rate of FP procedures; secondary outcomes include fertility results, satisfaction, and quality of life. Outcomes will be measured at enrollment, treatment initiation, and the 1-, 3-, and 5-year follow-ups after starting breast cancer treatment.

DISCUSSION

A multidisciplinary shared decision making program for FP is expected to increase fertility rates and satisfaction among young patients with breast cancer. This study will provide the evidence to implement a multidisciplinary system for patients with breast cancer.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05139641. Registered on December 1, 2021.

The effect of growth hormone on ovarian function recovery in a mouse model of ovarian insufficiency

Objectives

To evaluate the effects and mechanisms of action of growth hormone (GH) in the recovery of ovarian function in ovarian insufficiency induced by cyclophosphamide (CP) in a mouse model.

Materials and methods

After inducing ovarian insufficiency by administering 400 mg/kg of CP intraperitoneally to 6-week-old ICR mice, the mice were divided into four groups (control, CP, 1 mg/kg GH, and 2 mg/kg GH) with 10 mice in each group. GH was administered a week later for 7 days. Five mice from each group were sacrificed the next day, and their ovaries were collected for histological examination. The remaining mice were superovulated for in vitro fertilization (IVF). The terminal deoxynucleotidyl transferase dUTP-nick end labeling assay was performed to detect apoptosis. Masson's trichrome staining was used to analyze the degree of fibrosis. To quantify angiogenesis, CD31 immunohistochemistry was performed. Angiogenesis-related gene expression profiles were assessed using quantitative reverse transcription polymerase chain reaction.

Results

CP induced the loss of non-growing (primordial and primary) follicles while GH significantly protected primordial follicles and increased follicular quality. The CP group showed a decrease in fertilization and blastocyst formation rates in IVF. In contrast, the GH treatment group showed dose-dependent enhanced IVF outcomes. Furthermore, GH treatment decreased apoptosis and stromal fibrosis and increased angiogenesis. Many genes involved in angiogenesis, especially Leptin (Lep), platelet endothelial cell adhesion molecule 1 (Pecam-1), and angiogenin (Ang) were up-regulated in the GH treatment groups.

Conclusion

GH treatment may promote the recovery of ovarian function in ovarian insufficiency induced by the administration of CP via decreasing apoptosis and stromal fibrosis and upregulating Lep, Pecam-1, and Ang genes.

Fertility Preservation in Young Women With Breast Cancer: A Review

Fertility preservation is a major concern in young patients diagnosed with breast cancer and planning to receive multimodality treatment, including gonadotoxic chemotherapy with or without age-related decline through long-term endocrine therapy. Most breast cancer patients undergo multimodality treatments; many short-term and long-term side effects arise during these therapies. One of the most detrimental side effects is reduced fertility due to gonadotoxic treatments with resultant psychosocial stress. Cryopreservation of oocytes, embryos, and ovarian tissue are currently available fertility preservation methods for these patients. As an adjunct to these methods, in vitro maturation or gonadotropin-releasing hormone agonist could also be considered. It is also essential to communicate well with patients in the decision-making process on fertility preservation. It is essential to refer patients diagnosed with breast cancer on time to fertility specialists for individualized treatment, which may lead to desirable outcomes. To do so, a multimodal team-based approach and in-depth discussion on the treatment of breast cancer and fertility preservation is crucial. This review aims to summarize infertility risk related to currently available breast cancer treatment, options for fertility preservation and its details, barriers to oncofertility counseling, and psychosocial issues.

Microbiology of Human Follicular Fluid and the Vagina and Its Impact on in Vitro Fertilization Outcomes

PURPOSE

The present study aimed to identify microorganisms in follicular fluids and to investigate their association with in vitro fertilization (IVF) outcomes.

MATERIALS AND METHODS

This study was conducted as a prospective study of 49 infertile females undergoing IVF/intracytoplasmic sperm injection cycles between 2013 and 2016. Paired follicular fluid and vaginal secretions were collected on the day of ovum pick up and were cultured to detect microorganisms.

RESULTS

Fifteen women (30.6%) had no microorganisms in follicular fluid or vaginal swabs, 23 (46.9%) had microorganisms on vaginal swab alone, 3 (6.1%) had microorganisms in follicular fluid alone, and 8 (16.3%) had microorganisms in both follicular fluid and vaginal swabs. The same microorganisms were detected in both the follicular fluid and vaginal swabs of three women, while different microorganisms were detected between follicular fluid and vaginal swabs in five women. Follicular fluid microorganisms were not associated with embryo quality or clinical pregnancy rates during IVF cycles. However, significantly decreased implantation rates (9.1% vs. 29.4%, p=0.031) and clinical pregnancy rates on embryo transfer day 5 (0% vs. 83.3%, p=0.048) were observed in the group that was positive for vaginal pathogens.

CONCLUSION

Follicular fluid contains microorganisms that can differ from those in the vagina of the same women; however, they do not appear to be associated with embryo quality or clinical pregnancy rates in IVF cycles. In contrast, vaginal pathogens were found to be associated with worse implantation rates and clinical pregnancy rates in IVF cycles.

Sperm DNA fragmentation in consecutive ejaculates from patients with cancer for sperm cryopreservation

Objective: This prospective consecutive study investigated the variation in sperm DNA fragmentation (SDF) in multiple semen samples from patients with cancer.Methods: Eighty-one patients with various cancers underwent multiple semen collections on 3 consecutive days for sperm cryopreservation prior to cancer treatment. A commercial Halosperm kit was used to measure SDF. Within- and between-subject coefficients of variation were estimated via random-effects analysis of variance to assess the consistency of semen parameters and SDF. Intraclass correlation coefficients (ICCs) were calculated to assess the magnitude of the between-subject component of variance relative to the total variance.Results: The volume of semen in the day-2 and day-3 samples was significantly lower compared with the day-1 sample. Most parameters showed high ICC values, suggesting that within-subject fluctuations were small relative to the between-subject variability. The highest ICC values were identified for the SDF (ICC, 0.68; 95% confidence interval [CI], 0.45–0.84) and semen volume (ICC, 0.67; 95% CI, 0.45–0.84).Conclusion: Our findings showed that repeated ejaculates from patients with cancer had stable SDF levels.

Correlation of oocyte number with serum anti-Müllerian hormone levels measured by either Access or Elecsys in fresh in vitro fertilization cycles

Objective

The aim of this study was to assess the correlation of oocyte number with serum anti-Müllerian hormone (AMH) levels measured by two automated methods (Access or Elecsys) in fresh stimulated in vitro fertilization (IVF) cycles.

Methods

In this retrospective study at a university hospital, data were collected from 243 fresh stimulated IVF cycles performed from August 2016 to December 2020. The serum AMH level was measured by Access in 120 cycles and by Elecsys in 123 cycles. The cut-off of serum AMH for prediction of poor responders (three or fewer oocytes) or high responders (15 or more oocytes) was calculated by the receiver operating characteristic curve analysis.

Results

For the two automated methods, the following equations were derived: total oocyte number=2.378+1.418×(Access-AMH) (r=0.645, p<0.001) and total oocyte number=2.417+2.163×(Elecsys-AMH) (r=0.686, p<0.001). The following combined equation could be derived: (Access-AMH)=0.028+1.525×(Elecsys-AMH). To predict poor responders, the cut-off of Access-AMH was 1.215 ng/mL (area under the curve [AUC], 0.807; 95% confidence interval [CI], 0.730–0.884; p<0.001), and the cut-off of Elecsys-AMH was 1.095 ng/mL (AUC, 0.848; 95% CI, 0.773–0.923; p<0.001). To predict high responders, the cut-off of Access-AMH was 3.450 ng/mL (AUC, 0.922; 95% CI, 0.862–0.981; p<0.001), and the cut-off of Elecsys-AMH was 2.500 ng/mL (AUC, 0.884; 95% CI, 0.778–0.991; p<0.001).

Conclusion

Both automated methods for serum AMH measurement showed a good correlation with oocyte number and good performance for predicting poor and high responders in fresh stimulated IVF cycles. The Access method usually yielded higher measured serum AMH levels than the Elecsys method.

Ovarian Tissue-Based Hormone Replacement Therapy Recovers Menopause-Related Signs in Mice

PURPOSE

In women, menopause manifests with a variety of symptoms related to sex-hormone deficiency. Supplementing steroid hormones with pharmacological drugs has been widely practiced. However, considering the possible complications associated with artificial hormone therapy, studies have been conducted to find an alternative to pharmacological hormone replacement therapy. Accordingly, this study aimed to evaluate the efficacy of tissue-based hormone replacement therapy (tHRT) for treating post-menopausal signs and symptoms.

MATERIALS AND METHODS

CD-1 mice were ovariectomized, and the ovaries were cryopreserved. Following artificial induction of post-menopausal osteoporosis, cryopreserved ovaries were subcutaneously autografted, and indexes related to bone health were monitored for 12 weeks. Bone mineral density (BMD), bone mineral contents (BMC), total bone volume (BV), and body fat mass were measured by dual energy X-ray absorptiometry. Uterine atrophy was assessed histologically, and bone microstructures were imaged by micro-computed tomography analysis.

RESULTS

Regardless of the number of grafted ovaries, the BMC, BMD, and BV values of mice that underwent ovary transplantation were better than those that did not undergo transplantation. The uteruses in these mice were thicker and heavier after auto-transplantation. Furthermore, the bone microstructure recovered after tHRT.

CONCLUSION

Recovery of menopause-related bone loss and uterine atrophy was achieved through tHRT. Ovarian tissue cryopreservation and transplantation may be applicable not only in patients wanting to preserve fertility but also in sex hormone-deficient post-menopausal women.

Ovarian tissue cryopreservation and transplantation for fertility preservation

Background: As the number of cancer survivors has increased with advancements in cancer treatment, fertility preservation has become a treatment goal. Ovarian tissue cryopreservation (OTC) and transplantation (OTT) has made great progress over the past few decades. It has become the treatment of choice for fertility preservation in adolescents or patients in urgent need of chemotherapy. However, it is considered to be experimental compared with oocyte or embryo cryopreservation in some countries. Nevertheless, OTC and OTT is regarded as the more ideal method for fertility preservation in that it can also restore hormonal functions.Current Concepts: Currently, over 200 live births have been reported worldwide after OTC and OTT, proving the excellence of the technology. However, before its application in clinical settings, some challenges, including cryoinjury, ischemic injury, and cancer cell reimplantation, should be overcome. For cryoinjury, studies are underway on protocol improvement with the addition of agents such as antifreeze protein during cryopreservation. For ischemic injury, various agents have been studied to promote angiogenesis or revascularization. Furthermore, studies are underway on artificial ovary or xenotransplantation for fertility preservation in an effort to avoid cancer cell metastasis.Discussion and Conclusion: OTC and OTT is a clinically applicable option for fertility preservation. To set OTC and OTT as an established method for fertility preservation, further research is necessary to overcome the current challenges.

The voiding VAS score is a simple and useful method for predicting POUR after laparoscopy for benign gynaecologic diseases: a pilot study

The aim of this study was to identify an appropriate scoring system for predicting postoperative urinary retention (POUR) after gynaecological laparoscopic surgery for benign disease. We analysed 99 patients who underwent gynaecological laparoscopic surgery for benign disease. All patients were asked to complete self-administered questionnaires, including the International Prostate Symptom Score (IPSS), voiding visual analogue scale (VAS), and Brief Pain Inventory-Korean version. Of the 99 patients, 27 (27.3%) experienced urinary retention at least once, while 72 (72.7%) did not. The preoperative and postoperative IPSS scores were not associated with the development of POUR. However, the voiding VAS score was significantly lower in patients that developed POUR (p = .014). In conclusion, our results show that the voiding VAS score is a simple and useful method for identifying patients at risk of POUR after gynaecologic laparoscopic surgery for benign disease. IMPACT STATEMENTWhat is already known on this subject? Postoperative urinary retention (POUR) is an often underestimated complication defined as inability to void during the postoperative period despite a full bladder. Undetected POUR may lead to complications such as urinary tract infection, bladder distention, and bladder dysfunction. Routine assessment of POUR by bladder ultrasonography in all surgical patients places a larger workload on the nursing staff.What do the results of this study add? Among the self-scoring assessment tools, the voiding VAS provided the most accurate reflection of POUR in patients undergoing gynaecologic laparoscopic surgery for benign disease.What are the implications of these findings for clinical practice and/or further research? As laparoscopy is the most widely employed surgical procedure in gynaecology, our findings could have significant implications for postoperative care in daily clinical practice.

Effect of human peripheral blood mononuclear cells (hPBMCs) on mouse endometrial cell proliferation: a potential therapeutics for endometrial regeneration

OBJECTIVES

The persistently thin endometrium is a major cause of repeated implantation failure; however, there is no definite treatment for it yet. This study aimed to confirm the potential of human peripheral blood mononuclear cells (hPBMCs) as a therapeutic agent for endometrial regeneration.

DESIGN

Experimental study Participants/Materials, Setting, Methods: To assess the in vitro effect of hPBMC, the human primary endometrial epithelial cell lines SNU-685 and SNU-1077 were co cultured with or without 1×10^5 hPBMCs for 24 hours. To evaluate the in vivo effect, either 1×10^5 hPBMCs in PBS or PBS alone were injected into the left uterine horn of NOD-SCID mice, and the right untreated uterine horn was used as control.

RESULTS

Co-culture with hPBMCs stimulated significant proliferation in both SNU-685 and SNU-1077 cell lines (p=0.002 and 0.044, respectively). Moreover, treatment with hPBMCs significantly increased the thickness in all parts of the endometrium compared with that in the untreated control uterine horn (proximal: 1.69±0.19 vs. 1.00±0.10, p=0.009; middle: 1.51±0.14 vs. 1.00±0.12, p=0.010; distal: 1.72±0.22 vs. 1.00±0.12, p=0.003, respectively). Compared with the PBS injection group, the hPBMC injection group had significantly thickened endometrium in the middle (P=0.036) and distal segments (P=0.002) of the uterine horn. Immunohistochemical analysis revealed the presence of exogenously injected hPBMCs in the uterus of recipient mice. hPBMC-recipient mice had cyclic uterus with normal histology in the endometrium.

LIMITATIONS

hPBMCs were not applied directly to a mouse model with thin endometrium, so further study is needed.

CONCLUSION

The beneficial effect of hPBMCs on endometrium may suggest their clinical feasibility for the safe treatment of infertile patients with persistently thin endometrium.

Impact of BRCA mutations and hormone receptor status on reproductive potential in breast cancer patients undergoing fertility preservation

OBJECTIVE

To identify whether the BRCA mutations and hormone receptor status affect the ovarian reserve and ovarian stimulation outcomes in breast cancer patients undergoing fertility preservation.

METHODS

A total of 117 women diagnosed with breast cancer who were referred to the fertility preservation clinics at Seoul National University Bundang Hospital and Seoul National University Hospital between September 2012 and July 2019 undergone ovarian stimulation for oocyte retrieval. Basal characteristics including age, BMI, basal AMH, basal FSH, and fertility preservation outcomes such as the number of retrieved oocytes and mature oocytes were compared retrospectively.

RESULTS

BRCA1 mutation was noted in 25 women, and BRCA2 mutation was observed in 35 women. Positive estrogen receptor status was noted in 87 women, and positive progesterone receptor status was noted in 69 women. HER2 was positive in 55 women, and 19 women were diagnosed with triple-negative breast cancers. The number of total oocytes retrieved was lower in patients with BRCA mutation (8.3 ± 5.4 vs. 15.3 ± 8.7, p = .002). The number of mature oocytes retrieved was also lower in BRCA carriers (4.7 ± 4.2 vs. 8.7 ± 7.9, p = .025). Triple-negative breast cancer (TNBC) patients were younger than non-TNBC patients (30.3 ± 4.8 vs. 33.9 ± 5.0, p = .007). The rate of mature oocyte rate was higher in TNBC patients (68.6%±20.6 vs. 52.5%±29.7, p = .037).

CONCLUSIONS

Our study demonstrated that BRCA carriers with breast cancer had comparable ovarian reserve to non-carriers but the response to ovarian stimulation was lower. We also observed that oocyte maturity was higher in TNBC patients, however age might be a confounding factor of this result.

Effects and safety of COVID-19 vaccination on assisted reproductive technology and pregnancy: A comprehensive review and joint statements of the KSRM, the KSRI, and the KOSAR

Humanity is in the midst of the coronavirus disease 2019 (COVID-19) pandemic, and vaccines—including mRNA vaccines—have been developed at an unprecedented speed. It is necessary to develop guidelines for vaccination for people undergoing treatment with assisted reproductive technology (ART) and for pregnancy-related situations based on the extant laboratory and clinical data. COVID-19 vaccines do not appear to adversely affect gametes, embryos, or implantation; therefore, active vaccination is recommended for women or men who are preparing for ART. The use of intravenous immunoglobulin G (IVIG) for the treatment of immune-related infertility is unlikely to impact the effectiveness of the vaccines, so COVID-19 vaccines can be administered around ART cycles in which IVIG is scheduled. Pregnant women have been proven to be at risk of severe maternal and neonatal complications from COVID-19. It does not appear that COVID-19 vaccines harm pregnant women or fetuses; instead, they have been observed to deliver antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to the fetus. Accordingly, it is recommended that pregnant women receive COVID-19 vaccination. There is no rationale for adverse effects, or clinical cases of adverse reactions, in mothers or neonates after COVID-19 vaccination in lactating women. Instead, antibodies to SARS-CoV-2 can be delivered through breast milk. Therefore, breastfeeding mothers should consider vaccination. In summary, active administration of COVID-19 vaccines will help ensure the safe implementation of ART, pregnancy, and breastfeeding.

Clinical efficacy of dual trigger with human chorionic gonadotropin and a gonadotropin‐releasing hormone agonist for women undergoing fertility preservation

Purpose

To determine the optimal maturation method to increase the yield of mature oocytes, especially for cancer patients with fewer chances of fertility preservation (FP) before gonadotoxic therapy.

Methods

A total of 373 cycles in 293 patients undergoing controlled ovarian stimulation (COS) for FP using a gonadotropin‐releasing hormone (GnRH) antagonist protocol were enrolled. The control group (n = 225) received 250 µg of recombinant human chorionic gonadotropin (rhCG) while the study group (n = 148) received 250 µg of rhCG and 0.2 mg of triptorelin for triggering. Subgroup analyses were performed for stimulation cycles with diminished ovarian reserve (DOR; anti‐Müllerian hormone (AMH) levels <1.1 ng/ml, n = 86), with endometrioma (n = 104), or with breast cancer and endometrial cancer using 5 mg of letrozole during the COS cycles (n = 84).

Results

There was no significant difference in the baseline characteristics or the number of total and mature oocytes between the two groups. Subgroup analyses for women with endometrioma or DOR showed similar results. However, the dual trigger group had a significantly higher number of mature oocytes than the rhCG trigger group in breast and endometrial cancer patients using letrozole during the COS cycles (6.9 ± 6.0 vs. 4.6 ± 3.6, p = 0.034). The maturation rate was higher in the dual trigger group, although the difference was not statistically significant (59.3 ± 26.7 vs. 50.0 ± 28.0, p = 0.124).

Conclusions

Dual triggering can be an efficient maturation method to maximize the yield of mature oocytes in breast or endometrial cancer patients using letrozole‐combined GnRH antagonist protocol for FP.

The Experience of Fertility Preservation in a Single Tertiary Center in Korea

OBJECTIVE

Oocyte (OC), embryo (EC), and ovarian tissue cryopreservation (OTC) are options for fertility preservation (FP) before going through gonadotoxic cancer treatment, or anticipated fertility decline in benign ovarian diseases, or for planned OC. The aim of this study is to report outcomes of FP in a single tertiary hospital in Korea.

METHODS

This is a retrospective study of OC, EC, and OTC cycles. All patients who visited or were referred to the infertility clinic at the Department of Obstetrics and Gynecology for the purpose of FP between 2010 and October 2021 were included.

RESULTS

A total of 564 controlled ovarian stimulation cycles were conducted in 416 women. Three hundred fifty-seven women underwent 494 OC cycles. Most patients were diagnosed with breast cancer (22.4%), followed by endometriomas (21.9%), and then by planned OC (20.7%). Cases of OC have increased over the years, peaking at 109 cycles in 2019 compared to one in 2010. Fifty-nine women underwent 70 EC cycles, and breast cancer (50.8%) was the most common indication. Repetitive OC and EC cycles were undergone in 92 and 9 women, respectively (mean number of repetition, 1.37 and 1.19 times in OC and EC, respectively), yielding a maximum number of 33 oocytes or 23 embryos being cryopreserved per patient. The utilization rate was 3.1% (11/357) in OC and 16.9% (10/59) in EC. Twenty-six women underwent OTC, and gynecologic cancer was the most common indication (9/26, 34.6%). One woman had the cryopreserved ovarian tissue retransplanted and successfully generated embryos.

CONCLUSION

OC, EC, and OTC are possible options for preserving fertility, and these opportunities should be provided for women at risk of fertility decline or those who are eager to protect their future fertility. This is the first report on long-term FP outcomes in a single tertiary center in Korea. We expect that there will be more cases over the years and more women returning to use their gametes or embryos for pregnancy.

Utility of Blood Markers for Predicting Outcomes of Fertility Preservation in Patients With Breast Cancer

This study aimed to investigate the usability of blood markers for predicting controlled ovarian stimulation (COS) outcomes in patients with breast cancer undergoing fertility preservation (FP). In total, 91 patients with breast cancer who had undergone COS using a letrozole-combined gonadotropin-releasing hormone (GnRH) antagonist protocol before chemotherapy were enrolled retrospectively in a single tertiary hospital. FP outcomes were compared in terms of the mean platelet volume (MPV), MPV/platelet count (PC), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR). The cutoff values for obtaining 10 or more mature oocytes as favorable prognoses were obtained for each parameter, and the COS outcomes were compared based on the cutoff values. The optimal cutoff levels for MPV and MPV/PC were 10.15 [sensitivity: 90.0%; specificity: 45.1%; AUC: 0.687; 95% CI (0.563, 0.810)] and 0.41 [sensitivity: 65.0%; specificity: 67.6%; AUC: 0.682; 95% CI (0.568, 0.796)], respectively. The oocyte numbers did not significantly differ with respect to the cutoff values of NLR, PLR, and LMR (p > 0.05). However, the total number of acquired and mature oocytes were significantly lower in the group with MPV<10.15 than in that with MPV≥10.15 (8.0 ± 5.1 vs. 12.6 ± 9.1, p=0.003; 4.0 ± 3.7 vs. 7.3 ± 6.3, p=0.002, respectively). Similarly, considering the cutoff of MPV/PC as 0.41, the low-MPV/PC group showed a significantly lower total oocyte yield than the high-MPV/PC group (9.5 ± 7.1 vs. 13.1 ± 9.1, p=0.048), whereas the number of mature oocytes showed similar patterns with no statistical significance (5.3 ± 5.4 vs. 7.3 ± 6.1, p=0.092). From logistic regression analysis, age, anti-Müllerian hormone (AMH) level, MPV, and MPV/PC≥0.41 were found to be significant factors for the acquisition of 10 or more MII oocytes (p=0.049, OR: 0.850; p<0.001, OR: 1.622; p=0.018, OR: 3.184; p=0.013, OR: 9.251, respectively). MPV or MPV/PC can be a reliable marker for predicting FP outcome in patients with breast cancer. Protocols to acquire more mature oocytes, such as the dual-trigger approach, could be recommended for patients with breast cancer with MPV<10.15. Furthermore, a higher dose of gonadotropins was considered to obtain more oocytes in patients with MPV/PC<0.41.

Promotion of angiogenesis toward transplanted ovaries using nitric oxide releasing nanoparticles in fibrin hydrogel

Transplantation of ovary is one method of facilitating fertility preservation to increase the quality of life of cancer survivors. Immediately after transplantation, ovaries are under ischemic conditions owing to a lack of vascular anastomosis between the graft and host tissues. The transplanted ovaries can suffer damage because of lack of oxygen and nutrients, resulting in necrosis and dysfunction. In the technique proposed in this paper, the ovary is encapsulated with nitric oxide-releasing nanoparticles (NO-NPs) in fibrin hydrogels, which form a carrying matrix to prevent ischemic damage and accelerate angiogenesis. The low concentration of NO released from mPEG-PLGA nanoparticles elicits blood vessel formation, which allows transplanted ovaries in the subcutis to recover from the ischemic period. In experiments with mice, the NO-NPs/fibrin hydrogel improved the total number and quality of ovarian follicles after transplantation. The intra-ovarian vascular density was 4.78 folds higher for the NO-NPs/fibrin hydrogel groups compared to that for the nontreated groups. Finally,in vitrofertilization revealed a successful blastocyst formation rate for NO-NPs/fibrin hydrogel coated ovaries. Thus, NO-NPs/fibrin hydrogels can provide an appropriate milieu to promote angiogenesis and be considered as adjuvant surgery materials for fertility preservation.

Predictive value of sperm motility before and after preparation for the pregnancy outcomes of intrauterine insemination

Objective

This study aimed to investigate sperm motility and its changes after preparation as predictors of pregnancy in intrauterine insemination (IUI) cycles.

Methods

In total, 297 IUI cycles from January 2012 to December 2017 at a single tertiary hospital were retrospectively analyzed. Patient and cycle characteristics, and sperm motility characteristics before and after processing were compared according to clinical pregnancy or live birth as outcomes.

Results

The overall clinical pregnancy rate per cycle was 14.5% (43/297) and the live birth rate was 10.4% (30/289). Patient and cycle characteristics were similar between pregnant and non-pregnant groups. Sperm motility after preparation and the total motile sperm count before and after processing were comparable in terms of pregnancy outcomes. Pre-preparation sperm motility was significantly higher in groups with clinical pregnancy and live birth than in cycles not resulting in pregnancy (71.4%±10.9% vs. 67.2%±11.7%, p=0.020 and 71.6%±12.6% vs. 67.3%±11.7%, p=0.030, respectively). The change in sperm motility after processing was significantly fewer in the non-pregnant cycles, both when the comparison was conducted by subtraction (post-pre) and division (post/pre). These relationships remained significant after adjusting for the female partner’s age, anti-Müllerian hormone level, and number of pre-ovulatory follicles. According to a receiver operating characteristic curve analysis, an initial sperm motility of ≥72.5% was the optimal threshold value for predicting live birth after IUI.

Conclusion

Initial sperm motility, rather than the motility of processed sperm or the degree of change after preparation, predicted live birth after IUI procedures.

Levonorgestrel-Releasing Intrauterine System Use in Perimenopausal Women

The levonorgestrel-releasing intrauterine system (LNG-IUS) is a highly effective contraceptive method that has several noncontraceptive benefits. It has been used in various gynecological conditions, such as heavy menstrual bleeding, dysmenorrhea, and endometrial hyperplasia. During the perimenopausal period, hormonal fluctuations occur, and there is a high tendency for the development of several benign gynecologic diseases. Therefore, the use of LNG-IUS in perimenopausal women might be more beneficial than in women belonging to other age groups. Moreover, the insertion of LNG-IUS during the perimenopausal period could confer endometrial protection during estrogen replacement therapy. In this review, we discuss the use of LNG-IUS in perimenopausal women.

Operative and Obstetric Outcomes after Single-port Laparoscopic Myomectomy: A Retrospective Single-center Analysis of 504 Cases

STUDY OBJECTIVE

To analyze the obstetric and operative outcomes of 504 cases of single-port laparoscopic myomectomy (SPLM).

DESIGN

Single-center retrospective study.

SETTING

A tertiary university hospital.

PATIENTS

A total of 502 patients (504 SPLM procedures) who underwent SPLM for symptom relief or growing myomas between October 2009 and April 2020.

INTERVENTIONS

Data on patient demographics, operative variables (estimated blood loss, hemoglobin decrease, operation time, perioperative complications, and postoperative hospital stay), and obstetric outcomes (the surgery-to-pregnancy interval and birth-related outcomes) were obtained from medical records and analyzed.

MEASUREMENTS AND MAIN RESULTS

The mean age of the patients was 40.6 ± 6.6 years. The patients had had an average of 2.3 ± 2.2 myomas removed; the largest myoma size was 6.8 ± 2.4 cm. The mean operation time, postoperative hemoglobin decrease, and postoperative hospital stay duration were 112.9 ± 45.3 minutes, 1.7 ± 1.1 g/dL, and 2.2 ± 1.4 days, respectively. The overall rate of postoperative complications was 7.7% (39/504), and the common complications were transfusions (16/504, 3.1%) or wound problems (15/504, 3.0%). Conversion to multiport or open myomectomy was required in 0.8% of the cases (4/504). A total of 376 women were of child-bearing age, and 56 attempted to become pregnant after surgery. The mean interval from surgery to pregnancy was 15.6 ± 12.2 months. The obstetric outcomes were pregnancy (42/56, 75.0%), live birth (39/56, 69.6%), and miscarriage (2/56, 3.6%). One pregnant woman was lost to follow-up. The 39 live births predominantly involved full-term delivery (36/39, 92.3%), mostly through cesarean section (36/39, 92.3%). No postpartum complications were reported. The 2 most common obstetric complications were preterm labor (7.6%) and gestational diabetes (5.1%).

CONCLUSION

SPLM seems to be an effective procedure with good operative and postoperative obstetric outcomes for women with myomas who require surgery and may wish to subsequently become pregnant.