Premature ovarian failure

PURPOSE OF REVIEW

To summarize current knowledge about premature ovarian failure (POF) with an emphasis on recent developments regarding its management.

RECENT FINDINGS

The incidence of POF is increasing largely due to improved survival rates of cancer patients treated with radiation and chemotherapy. Delayed diagnosis and management of POF leads to suboptimal outcomes. Anticipation and early detection of this condition in high-risk women by means of ovarian function testing, followed by early institution of appropriate management could improve outcomes. Choice of strategies should vary depending on the age of onset, associated symptoms and fertility aspirations of the individual, and should change with the patient's advancing age.

SUMMARY

Early assessment of the individual's risk of developing POF, development of a strategic management plan, and timely commencement of infertility and hormone deficiency treatment, together with counselling in an integrated management plan should improve both the short and long-term health of those with POF.

Testosterone for peri- and postmenopausal women

BACKGROUND

: The value of adding testosterone to hormone therapy (HT) for the management of peri- and postmenopausal women is controversial and has not been systematically reviewed.

OBJECTIVES

: To determine the benefits and risks of testosterone therapy for peri- and postmenopausal women taking hormone therapy.

SEARCH STRATEGY

: We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (1st November 2003), The Cochrane Library (Issue 2, 2003), MEDLINE (1966 to 1st November 2003), EMBASE (1980 to 1st November 2003), Biological Abstracts (1969 to 2002), PsycINFO (1972 to 1st November 2003), CINAHL (1982 to 1st November 2003), and reference lists of articles. We also contacted pharmaceutical companies and researchers in the field.

SELECTION CRITERIA

: Studies that were randomized comparisons of testosterone plus hormone therapy versus hormone therapy alone in peri- or postmenopausal women.

DATA COLLECTION AND ANALYSIS

: Two review authors assessed the quality of the trials and extracted data independently. Where it was necessary, the corresponding authors of eligible trials were contacted for additional information. For dichotomous outcomes Peto odds ratios and 95% confidence intervals were calculated. For continuous outcomes non-skewed data from valid scales were synthesized using a weighted mean difference or standardized mean difference. If statistical heterogeneity was found, a random-effects model was used and reasons for the heterogeneity were explored and discussed.

MAIN RESULTS

: Twenty-three trials with 1957 participants were included in the review. The median study duration was 6 months (range 1.5 to 24 months). Most of the trials were of adequate quality with regard to randomization and concealment of allocation sequence. The major methodological limitations were attrition bias and lack of a washout period in the cross-over studies. The pooled estimate from the studies suggested that the addition of testosterone to HT regimens improved sexual function scores for postmenopausal women. A significant adverse effect was a decrease in high-density lipoprotein (HDL) cholesterol levels. The discontinuation rate was not significantly greater with testosterone therapy (Peto odds ratio 1.01, 95% confidence interval 0.76 to 1.33) than with HT alone. There was insufficient evidence of a treatment effect for perimenopausal women or for other outcomes.

AUTHORS' CONCLUSIONS

: Only a limited number of studies could be pooled in the meta-analyses. This limited the power of the meta-analysis to provide conclusions about efficacy and safety. However, there is evidence that adding testosterone to HT has a beneficial effect on sexual function in postmenopausal women. There was a reduction in HDL cholesterol associated with the addition of testosterone to the HT regimens. The meta-analysis combined studies using different testosterone regimens. It is, therefore, difficult to estimate the effect of testosterone on sexual function in association with any individual hormone treatment regimen.

Ovarian Leydig cell tumor in a peri-menopausal woman with severe hyperandrogenism and virilization

The authors report a case of Leydig cell tumor in a 46-year-old woman who first presented with severe clinical hyperandrogenism and associated complex medical history. Investigations revealed markedly raised serum concentrations of testosterone (28.3 nmol/l) and free androgen index (54.4), whereas sex hormone binding globulin, random cortisol, androstenedione, 17-hydroxyprogesterone and dehydroepiandrosterone sulphate concentrations were all within the normal range. Transabdominal ultrasound and computed tomography scan of the pelvis and abdomen showed a slightly bulky right ovary, but no other abnormalities. An ovarian source of androgens was suspected and surgery was arranged. Following a three-year history of defaulting appointments due to agoraphobia, she underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and intraoperative selective ovarian venous sampling. Histopathological examination revealed a 2 cm Leydig cell tumor within the right ovary. Successful intraoperative ovarian venous sampling demonstrated significantly elevated testosterone levels (>260 nmol/l) from the right ovarian vein. Hyperandrogenaemia normalized post-operatively. The patient showed significant regression of clinical signs and symptoms, including the anxiety disorder. Clinical presentation, biochemistry and imaging modalities should allow to detect androgen-secreting ovarian tumors, while selective venous sampling should be reserved for patients whom uncertainty remains. The present case confirms that androgen-secreting ovarian tumors represent a diagnostic and therapeutic challenge. They have to be considered in the differential diagnosis of severe hyperandrogenism even in peri-menopausal women. Although selective venous sampling is of diagnostic value, however, its impact on future management should be considered on individual basis.

Characterizing the endometrium in unexplained and tubal factor infertility: A multiparametric investigation

OBJECTIVE

To characterize endometrial development in unexplained and tubal factor infertility.

DESIGN

Prospective study of 20 women with unexplained infertility, 22 with tubal factor infertility, and 21 fertile controls in the midproliferative, periovulatory, and midluteal phases of the menstrual cycle.

SETTING

Reproductive Medicine Department of St. Mary's Hospital, Manchester, United Kingdom.

PATIENT(S)

Women awaiting assisted conception.

INVESTIGATION(S)

Serum hormone assays, transvaginal ultrasound, Doppler, and midluteal endometrial biopsies.

MAIN OUTCOME MEASURE(S)

Serum levels of E2, P, and LH, endometrial ultrasound morphometry, uterine and subendometrial artery Doppler, and endometrial histology and biochemistry.

RESULT(S)

Women with unexplained infertility demonstrated significantly reduced uterine artery flow velocity in all phases, significantly elevated uterine and subendometrial artery impedance in the periovulatory and midluteal phases, and significantly reduced endometrial texture in the midproliferative phase. Women with tubal factor infertility demonstrated significantly reduced uterine artery flow velocity, without a concomitant increase in impedance, and significantly greater expression of endometrial glandular and luminal keratan sulphate.

CONCLUSION(S)

Unexplained infertility is associated with a profound impairment of endometrial perfusion that might be amenable to treatment by perfusion enhancers. Tubal factor infertility is associated with endometrial developmental defects that might be corrected by salpingectomy. Endometrial ultrasound and Doppler studies are likely to become a vital tool in the investigation of infertility.

The impact of assisted hatching on live birth rates and outcomes of assisted conception: a systematic review

BACKGROUND

During the past decade in the UK, only one in six cycles of assisted conception has resulted successfully in a live birth. Assisted hatching (AH) has been proposed to improve outcome. This systematic review of randomized controlled trials addresses primary outcomes of live birth, clinical pregnancy and embryo implantation.

METHODS

Trials on post-fertilization disruption of the zona pellucida were identified from the Cochrane Controlled Trials Register, MEDLINE, EMBASE and published bibliographies. Outcomes were analysed using random effects meta-analysis, sensitivity analysis, sub-grouping and meta-regression.

RESULTS

Of 23 included trials recruiting 2572 women, only six reported live birth data. AH had no significant effect on live birth (OR 1.21, 95% CI 0.82-1.78). There was a significant benefit of AH on clinical pregnancy (OR 1.63, 95% CI 1.27-2.09), especially in the sub-group of women with previous failure of assisted conception (OR 2.33, 95% CI 1.63-3.34). Meta-regression suggested that AH might be more useful in older women. Implantation data were not considered valid for statistical analysis. The methodological quality of included trials was sub-optimal.

CONCLUSIONS

AH probably enhances clinical pregnancy, especially in women with previous failure of assisted conception treatment and in older women; however, trials were of poor quality and so may be biased. Better quality trials reporting live birth are required to confirm any positive effects on the 'take-home-baby rate'.

Effect(s) of assisted hatching on assisted conception (IVF & ICSI)

BACKGROUND

Failure of implantation and thus conception might result from inability of the blastocyst to escape from its zona pellucida. Artificial disruption of this coat has been proposed as a method of improving the success of assisted conception.

OBJECTIVES

To determine whether assisted hatching of embryos facilitates live births, clinical pregnancy and implantation and whether it impacts on negative outcomes (such as miscarriage).

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (26 November 2002), the Cochrane Controlled Trials Register (Cochrane Library Issue 2, 2002), MEDLINE (1996 to February 2003), EMBASE (1980 to February 2003) and reference lists of articles. Authors were contacted for missing and/or unpublished data.

SELECTION CRITERIA

Trials were identified and independently screened by two reviewers. Randomised controlled trials of AH (mechanical, chemical or laser disruption of the zona pellucida prior to embryo replacement) versus no AH that reported live birth, clinical pregnancy or implantation rates were included.

DATA COLLECTION AND ANALYSIS

Qualitative assessments and data extraction were performed independently by two reviewers. Outcomes were extracted as rates and combined using random effects meta-analysis, sensitivity analysis, subgrouping and meta-regression where appropriate.

MAIN RESULTS

Twenty-three randomised controlled trials (2572 women) were included. There was no significant difference in the odds of live births in the AH compared with control groups (6 RCTs; OR 1.21, 95% CI 0.82 to 1.78; 161 births from 523 women). Women undergoing assisted hatching were significantly more likely to achieve clinical pregnancy (722 clinical pregnancies in 2175 women, OR 1.63, 95% CI 1.27 to 2.09), however the studies were heterogeneous. Implantation data were difficult to analyse due to the practice of replacing multiple embryos in individual women. The trials provided insufficient data to investigate the impact of assisted hatching on several important outcomes, including monozygotic twinning, embryo damage, congenital and chromosomal abnormalities, and in vitro blastocyst development.

REVIEWER'S CONCLUSIONS

There is insufficient evidence to determine any effect of AH on the 'take-home-baby rate' of assisted conception. There are also very few data regarding miscarriage rates and other adverse events. This prevents us from extrapolating the impact of AH on live births from our finding of improved odds of clinical pregnancy.

Mosaic characteristics of human endometrial epithelium in vitro: analysis of secretory markers and cell surface ultrastructure

Specific terminal carbohydrate structures and mucin-associated glycans increase in expression within the human endometrial epithelium during the secretory phase of the menstrual cycle but exhibit wide intercellular variation. We postulated that variation in glycosylation between cells would produce differences in the glycocalyx and result in complex mixtures of cells bearing different combinations of glycans. MUC-1 mucin, keratan sulphate and fucosylated lactosaminoglycans were examined in epithelial gland fragment cultures with antibodies (HMFG1, 5D4) and a lectin (Dolichos biflorus agglutinin). The glycocalyx was examined by transmission and high resolution scanning electron microscopy. The data were related to patterns of expression seen in vivo. The MUC-1 mucin was expressed relatively uniformly in culture, but heterogeneity was evident in mucin sialylation within the epithelial cell population. Double labelling of gland explant cultures for combinations of fucosylated lactosaminoglycans, keratan sulphate and MUC-1 demonstrated cells expressing all combinations of these markers. Ultrastructural examination confirmed remarkable intercellular variation in the glycocalyx. Though the human endometrial epithelium is relatively morphologically homogeneous, these observations reveal complex variations of cell surface glycosylation between neighbouring cells and suggest that secretory function might vary in a similar fashion.

Fecundity in the modern city: a comparison of couples attending antenatal clinics in Manchester (UK) and Melbourne (Australia)

To determine the characteristics of couples with resolved subfecundity and to compare these findings in two geographically distant centres, a self-reporting questionnaire was completed by a sample of women attending six antenatal clinics in Greater Manchester, UK and five antenatal clinics in Melbourne, Australia. A total of 2158 pregnant women, 1106 from Manchester and 1052 from Melbourne participated in the study. The prevalence of subfecundity (proportion of women who failed to conceive current pregnancy within 12 months of unprotected intercourse) and demographic and medical factors potentially related to subfecundity were measured. The samples from the two cities had similar medical characteristics, but several socioeconomic and cultural differences were detected. Characteristics which independently correlated with decreased fecundity were increasing parental age, previous pregnancy, previous miscarriage, maternal smoking before conception and low socioeconomic status. Increased body mass index was also a significant, independent predictor of decreased fecundity, but in the Melbourne sample only. Subfecundity was found to be influenced by a combination of parental and socioeconomic factors as well as previous pregnancy. The factors identified were similar in two modern industrial societies in very different geographical locations, only their relative importance differing between Australia and the UK.

Human ovarian granulosa cells and follicular fluid indices: the relationship to oocyte maturity and fertilization in vitro

The study investigates the correlation between oocyte maturity and fertilization and a variety of hormonal parameters in follicular fluid and ovarian granulosa cells. A methodology for purification of granulosa cells from contaminating blood cells is also established. A total of 63 follicular aspirates were collected at oocyte retrieval from 30 women superovulated using the long luteinizing hormone-releasing hormone (LHRH analogue)/human menopausal gonadotrophin regimen. Oestradiol, progesterone, testosterone and human chorionic gonadotrophin (HCG) were quantified in follicular fluid and granulosa cells were immunostained for human chorionic gonadotrophin. Immunopurification of granulosa cells from contaminating blood cells was performed. HCG in follicular fluid was significantly high in follicles yielding immature (grade 3) oocytes (P=0.002); there was no correlation with fertilization. Aspirates from follicles containing mature (grade 1) oocytes and oocytes that subsequently fertilized had significantly more granulosa cells immunobound to HCG (P < 0.001, P=0.02). Moreover, the immunomagnetic purification technique provided >98% pure population of granulosa cells. The data demonstrate that HCG in follicular fluid and on granulosa cells may help to predict oocyte maturity and fertilization. Furthermore, immunomagnetic beads provide a reliable procedure for the purification of ovarian granulosa cells.

Indices of differential endometrial: myometrial growth may be used to improve the reliability of detecting endometrial neoplasia in women on tamoxifen

The aim of this study was to test the hypothesis that the use of indices of differential endometrial: myometrial growth may be a non-invasive method of improving the reliability of detecting endometrial neoplasia in women on tamoxifen. Thirty postmenopausal women were involved in this prospective study. Nineteen had been treated with tamoxifen for 2 years or more, and eleven were age- and ponderal index-matched controls who had never been exposed to tamoxifen and who were non-smokers. Transvaginal ultrasonography and color Doppler imaging were performed, to measure the length, anteroposterior diameter, uterine sagittal area, endometrial thickness and uterine blood flow (using the pulsatility index and the resistance index as measures of uterine blood flow impedance). The anteroposterior diameter: endometrial thickness ratio and product, and the saggital area: endometrial thickness ratio and product were used as indices of differential endometrial: myometrial growth. The predictive values (sensitivity, specificity, positive and negative predictive values) of each index were calculated using established criteria. For the purpose of analysis the women were allocated to three groups: controls (group 1); women on tamoxifen without endometrial neoplasia (group 2) and women on tamoxifen who developed endometrial neoplasia (group 3). The mean age was similar in the three groups as was the duration of tamoxifen treatment in groups 2 and 3. Analysis of the decision matrix based on increased endometrial thickness (> 5 mm) alone revealed good sensitivity (100%) and negative predictive value (100%) but poor specificity (46.15%) and positive predictive value (26.32%). However, when the indices of differential endometrial: myometrial growth were taken into consideration, the sensitivities and negative predictive values were similar but the specificities and positive predictive values were significantly improved, indicating an improvement in the reliability of predicting the development of endometrial neoplasia.

Abnormal expression of integrin alpha 6 beta 4 in cervical intraepithelial neoplasia

We have used subunit-specific monoclonal antibodies (MAbs) and immunohistochemistry to examine the distribution of integrin alpha 6 beta 4 in normal ectocervical epithelium and various grades of cervical intraepithelial neoplasia (CIN). Antibodies were first characterised by immunoprecipitation from two surface-labelled tumour cell lines. Monoclonal antibody G71 was found to precipitate integrin beta 4 from BeWo but not T47D cells, while other anti-beta 4 antibodies precipitated beta 4 from both cell lines. Both G71 and an antiserum to the C-terminal peptide of beta 4 precipitated free beta 4 from surface-iodinated BeWo cells. Neither antibody recognised truncated beta 4 chains observed at approximately 160 kDa. These data suggest that different isoforms of beta 4 are expressed in different tumour cell lines, and that there may be a pool of beta 4 at the cell surface that is not complexed to alpha 6. In normal cervix, both the alpha 6 and beta 4 subunits occur at the basal surface of the basal cell layer. In CIN, the distribution is markedly altered, with strong expression of alpha 6 and beta 4 in the upper cell layers of the ectocervical epithelium. All 40 cases of CIN that were studied exhibited this alteration. Furthermore, the extent of extrabasal staining appeared to correspond with the grade of CIN. The form of integrin beta 4 recognised by antibody G71 also appears in the upper cell layers in CIN, but it shows a more restricted distribution than the normal isoform.

Expression of the vascular endothelial growth factor receptor, KDR, in human placenta

Vascular endothelial growth factor (VEGF) is a heparin-binding growth factor known to act directly on vascular endothelial cells by promoting cell proliferation and permeability. To date, 3 structurally related cell surface receptors for VEGF, Flt-1, Flt-4 and KDR, have been identified and shown to be human type III receptor tyrosine kinases. The establishment of a vascular network is crucial to the development of the placenta and occurs through both angiogenesis and vasculogenesis. The signals controlling these processes are unclear. Immunohistochemical and in situ hybridisation techniques have localised VEGF in the trophoblast layers and VEGF binding to placental vascular endothelial cells and haemangioblasts has been shown, suggesting a role for VEGF and its receptors in development of the vascular network. In this study we have used specific antibodies to localise KDR and endothelial cells in 1st and 3rd trimester human placenta. The staining showed a colocalisation of KDR with endothelial cells and haemangioblasts. No staining of trophoblast cells was observed, but strong staining of the endothelial cells was seen in the villous stroma adjacent to areas of trophoblast proliferation.

Human chorionic gonadotrophin and steroid concentrations in follicular fluid: the relationship to oocyte maturity and fertilization rates in stimulated and natural in-vitro fertilization cycles

The study investigates the relationship of follicular fluid steroids and human chorionic gonadotrophin to oocyte maturity and fertilization rates in stimulated and natural cycles. Oestradiol, progesterone, testosterone and human chorionic gonadotrophin were quantified in 129 samples of follicular fluid and the progesterone:oestradiol ratio calculated. Both stimulated cycles (short and long luteinizing hormone-releasing hormone/human menopausal gonadotrophin regimens) and natural cycles were compared. A total of 60 women were studied, 20 in each group. In the natural cycles, testosterone was significantly lower in follicles with intermediate oocytes (P = 0.015). Both oestradiol and testosterone were significantly lower in stimulated cycles compared to natural cycles (P = 0.032 and P = 0.034 respectively). In the ovarian stimulation cycles, the progesterone:oestradiol ratio was significantly higher when oocytes fertilized (P = 0.052). Moreover, in the stimulated cycles, oestradiol and human chorionic gonadotrophin were singnificantly lower in the short protocol compared to the long protocol. The data demonstrate that the hormonal milieu of the follicle is altered in down-regulated stimulated cycles to varying degrees, depending partially on the type of protocol used. Furthermore, the progesterone:oestradiol ratio, rather than individual hormone concentrations, may be a useful predictor of the fertilizing capacity of the oocytes.

Cell adhesion molecules on the oocyte and preimplantation human embryo

The presence of cell adhesion molecules on human oocytes, early embryos, and pre-hatched blastocysts was examined by indirect immunofluorescence and compared to the distribution found on first trimester villous placenta with the same antibodies. Six integrin subunits (alpha 3, alpha V, beta 1, beta 3, beta 4, beta 5) were observed consistently throughout preimplantation development. Evidence was also obtained for the presence of integrin subunits alpha 2, alpha 4, alpha L, beta 2, and beta 7 on a small number of oocytes. A more restricted developmental analysis of E-cadherin, ICAM-1, NCAM, and VCAM-1 demonstrated that these cell adhesion molecules are also present on oocytes and early embryos. L-selectin was detected on oocytes but was not found on 8-cell embryos. The oocyte and early blastomeres have complex surfaces in which the integrin and CAM families are represented.

Comparative analysis of motility characteristics of Percoll-selected spermatozoa populations from fresh and cryopreserved semen

The proportion and quality of motility of spermatozoa in normozoospermic ejaculates were assessed using computer-assisted semen analysis. The ejaculate was split and the motility re-assessed following separation on a Percoll gradient with or without cryomedium and cryopreservation. Cryopreservation caused a significant decrease in the proportion of motile spermatozoa and in their velocity and amplitude of lateral head displacement. The initial decrease in the proportion of motile spermatozoa was found to be in part an effect of the cryomedium. The use of Percoll gradient separation did not initially change these effects but after 4 h incubation differences in velocity and amplitude of lateral head displacement between samples were no longer evident. Percoll-selected, cryopreserved spermatozoa had both a stable proportion of motile spermatozoa and a stable velocity for at least 48 h, whereas in fresh spermatozoa populations, similarly separated using Percoll, the proportion of motile spermatozoa had decreased by 24 h and the velocity was lower at 48 h. Percoll preparation is an effective method for the selection of motile spermatozoa from cryopreserved semen which, after a short incubation, have similar motility characteristics to fresh spermatozoa.

Review of the organized support network for infertility patients in licensed units in the UK

In acknowledging that 'counselling is generally recognized as beneficial', the Human Fertilization and Embryology Authority (HFEA) Code of Practice requires that all infertility units provide counselling facilities to be available for patients. In this study, we intended to evaluate the support and counselling services made available by the licensed units in the UK. A questionnaire consisting of 30 questions was designed and sent to every licensed treatment unit in the UK. The data were coded on a nominal scale and, using a data entry program, loaded onto a computer. Using the Statistical Package for the Social Sciences program, a non-parametric frequency analysis was performed. Associations were examined with cross-tabulations and chi 2 analysis. A total of 62 units (61.4%) responded to the questionnaire, from both the private and National Health Service sectors. Of these, 95% have their own counsellor, most of whom (84%) practised on the premises. One-third of these counsellors had a dual role, mainly as nurses, social workers or in administration; 98.6% were trained in counselling, with only 28% having either the Certificate or Diploma in Counselling. One-third (32.2%) of centres charged for counselling, with only 13 units indicating their charges. The majority of centres (78.8%) do not actively follow-up patients after counselling and one-quarter (25.5%) did not have a specific counselling room. Over two-thirds (68.4%) of centres described their support network as adequate. The results of this survey suggest that, although the requirements of the HFEA Code of Practice are being adhered to reasonably well, overall patient uptake of counselling is low.(ABSTRACT TRUNCATED AT 250 WORDS)

CD44 is expressed throughout pre-implantation human embryo development

The cell surface glycoprotein CD44 has been demonstrated in a variety of cell types in embryonic and adult tissues. We have established that CD44 is present on human oocytes, cumulus cells, early embryos and pre-hatched blastocysts by indirect immunofluorescence. We have also shown that CD44 is present on 8-11 week placental stroma cells, but not on the trophoblast. These findings demonstrate that CD44 is present throughout preimplantation development, and that down-regulation occurs on the embryonic surface after implantation.

Ovulation induction and endometrial steroid receptors

The endometrial morphology, endometrial steroid receptors and serum steroid hormone concentrations have been studied in 22 infertile women participating in an in-vitro fertilization, gamete intra-Fallopian transfer programme, including nine cases following treatment with gonadotrophin-releasing hormone analogue/human menopausal gonadotrophin/human chorionic gonadotrophin. All patients had normal ovulatory function before treatment and satisfactory response to ovulation induction. Endometrial biopsies were taken in spontaneous and treatment cycles on the fourth day after ovulation had been detected by ultrasound scanning, when endometrial receptors were measured using immunohistochemistry. Histological examination of biopsies in spontaneous cycles showed the majority (20/22) to be 'in-phase', while in two cases luteal phase defect was diagnosed. After ovulation induction, all the biopsies were still morphologically 'in-phase', although a significant reduction had occurred in the nuclear receptor level in both the glands and stroma for both progesterone receptors (gland P = 0.030, stroma P = 0.012 using microscopic analysis; gland P = 0.020, stroma P < 0.001 using a cell analysis system) and oestrogen receptors (gland P = 0.017, stroma P = 0.002 using direct microscopic analysis). This suggests that a reduction in steroid receptors in the endometrium occurs after ovulation induction in the presence of supraphysiological amounts of steroids, which is not associated with detectable morphological changes.

Endometrial differentiation in the peri-implantation phase of women with recurrent miscarriage: a morphological and immunohistochemical study

OBJECTIVES

To study endometrial differentiation in the peri-implantation phase of women with recurrent miscarriage and to compare the results with endometrium of normal fertile women.

DESIGN

A prospective study of endometrial specimens precisely timed from the LH surge, using traditional histologic dating (Noyes' criteria), quantitative histologic measurement (morphometric analysis), and immunohistochemical techniques.

RESULTS

Fifteen of 25 (60%) subjects in the recurrent miscarriage group had retarded endometrial development in the peri-implantation period as monitored by morphometry. The recurrent miscarriage group showed reduced levels of four mucin-related secretory epitopes, and greater reductions were associated with morphological retardation. Normal differentiation was observed in all of the 14 subjects in the control group.

CONCLUSIONS

Women with idiopathic recurrent pregnancy loss may be divided into two distinct subgroups on the basis of their endometrial response in the peri-implantation period. Precisely timed endometrial biopsy should be incorporated in the investigation of recurrent miscarriage.

Expression of two isoforms of CD44 in human endometrium

The distribution of the cell-surface adhesion glycoprotein CD44 in human endometrium was examined by immunofluorescence using six monoclonal antibodies to epitopes common to all forms of the molecule, and by reverse transcription-polymerase chain reaction (RT-PCR). Immunoreactivity was observed throughout the menstrual cycle in stroma, vessels, glandular, and luminal epithelium. Variations in staining intensity were observed, especially in the epithelial compartment. CD44 was also expressed strongly by decidualized stromal cells of first-trimester pregnancy. No systematic variation of immunoreactivity was observed with stages of the normal cycle, but a fraction (25%) of the specimens lacked reactivity in the epithelium. To determine the molecular size of the epithelial isoform, an immunoprecipitation technique was developed using surface-radioiodinated, detergent-extracted glands. This indicated the presence at the cell surface of a single dominant CD44E species with an approximate molecular mass of 130 kDa. RT-PCR was used to investigate the isoforms present in whole endometrial tissue, isolated gland fragments, and Ishikawa endometrial carcinoma cells. Complementary DNA produced from total endometrial mRNA was PCR-amplified across the splice junction between exons 5 and 15. Transcripts corresponding to the hyaluronate receptor CD44H as well as a larger isoform were identified. CD44H was absent, or very scarce, in cDNA from purified gland epithelium. In contrast, Ishikawa cells expressed this form abundantly. The glands and Ishikawa cells also expressed CD44E containing sequences encoded by exons 12, 13, and 14. These data demonstrate the presence of CD44 in human endometrium and decidua, and show that different isoforms of CD44 are associated with tissue compartments in which different functional roles can be anticipated.

The endometrial cell surface and implantation. Expression of the polymorphic mucin MUC-1 and adhesion molecules during the endometrial cycle

The cell surface mucin MUC-1 is present in endometrial epithelial cells and their associated apical glycocalyx and is also released into gland lumens as a secretory product. MUC-1 mRNA and core protein are found at low levels in the proliferative phase of the cycle, but their abundance increases after ovulation. Endometrial MUC-1 has been found to carry sialokeratan sulphate chains and these show a dramatically increased abundance in cells and secretions in the post-ovulatory phase of the cycle, reaching a maximum in secretions 6-7 days after the LH peak. The apical epithelium also contains adhesion receptor molecules of the integrin and CD44 families. MUC-1 is large and highly glycosylated and probably extends farther from the cell surface than these 'conventional' glycoprotein receptors. It has the potential to inhibit sterically receptor-mediated cell-cell adhesion. However, it is also possible that MUC-1 displays specific (e.g., glycan) recognition structures for the initial attachment of the blastocyst or that the embryo may create a specialised microenvironment in which to implant.

Endometrial structure after superovulation: a prospective controlled study

OBJECTIVE

To demonstrate the effect of superovulation using a GnRH agonist (GnRH-a) and hMG and hCG on endometrial structure.

DESIGN

Prospective, case-controlled study.

SETTING

Tertiary referral assisted reproduction unit in an academic department.

PATIENTS

Eleven women undergoing GIFT or IVF, without ET.

INTERVENTIONS

All women were treated with a long stimulation regimen using the depot GnRH-a Goserelin (ICI, Macclesfield, United Kingdom) and hMG and hCG.

MAIN OUTCOME MEASURES

Comparison of endometrial biopsy specimens taken 4 days after ovulation in an unstimulated cycle with specimens taken 4 days after oocyte recovery, using standard dating criteria and morphometric analysis.

RESULTS

There was no difference in endometrial glandular development as assessed by either standard criteria or morphometric analysis.

CONCLUSIONS

Superovulation preceded by pituitary down regulation is not associated with abnormal endometrial glandular development, even though supraphysiological levels of E2 and P are induced.